Surgery in South Sudan: Let's not confuse the baby's back with its bottom...

31 May 2017

The only thing I see beyond the pharyngeal flap is pus. I take a laryngoscope and suction unit from the anaesthesiologist. I can't get further than ten centimetres below the laryngeal flap. Not even with a nasogastric tube for children. There’s a blockage. A traditional healer had previously cut off her palatine uvula to heal her chronic cough. She stopped coughing. But she also stopped eating and drinking. He closed her pharynx - or more precisely the upper part of her esophagus. If I only had an endoscope here. Or perhaps even better, Magda – a gastroenterologist from my home hospital. But I don’t. I'm a surgeon alone in the field. Sometimes we need someone to take our hand.
 
 
We take a patient needing a skin transplant to the operating room.
 
When the patient lies down, the nurse discovers that the electrodermatome set (a device for removing of the top layer of skin used in transplants) is not charged.
 
- Should we postpone the operation for tomorrow, Tom?
 
- No. Do you have the Humby knife?
 
(A Humby is like an adjustable longitudinal penknife, and isn't powered by electricity like the electrodermatome is.)
 
- We do have it…
 
- Give it to me!
 
And I’m already cutting and transplanting.
 

Dreadful things

 
The mother of this young lady with the cut-off palate doesn’t understand how dreadful the healer's actions were. I have to patiently explain everything so she doesn’t turn to him again instead of letting us help her daughter.
 
Education is one of the main problems in such situations. You have no idea how great an advantage it is to be educated compared with other parts of the world.
 
I draw it for her. That seems to be the best way to make it understandable for her compared to my thirty-minute explanation with translation.
 

How will we explain that we may have to amputate? 

 
Meanwhile, to perform a gastrostomy (a procedure that will allow us to introduce food directly into the stomach) I need the permission of my bosses here in Agok, in Juba, the capital of South Sudan, and in the MSF HQ in Geneva. We need to open her abdomen, create a small hole in the stomach, then stretch a urinary catheter (the only one we have) through the hole, to inflate the balloon and eventually start to feed her. 
 

A difficult message

Another patient from Mayom comes to the emergency room.

His leg is so severely swollen that his muscles under the fascia (a sheet of connective tissue that envelops the muscles) are dying. We call it compartment syndrome. He needs a fasciotomy, an incision of the connective tissue to relieve the pressure on the muscles.
 

A patient in Agok hospital's surgical department.

A patient in Agok hospital's surgical department. Photo: Tomáš Šebek/MSF.

 
After getting spinal anaesthesia from our anaesthesiologist, he decides to hurriedly leave us and tries to languidly walk from the operating room. This is obviously not possible.
 
We call an interpreter. We take him to the vestibule and talk to him. Finally he agrees to the operation, but only on the condition that the translator goes with him to the OR. 
 
When we operate his muscles are already dead and a fasciotomy is not going to help him much.
 
How do we explain that we may have to amputate his leg? That I don’t know.
 

I smile, they smile

In a while there’s another patient coming to the ER – an eleven-year-old boy. He got run over by a car, outside the hospital. Round here there's no traffic, a car passes by maybe every ten minutes. They tell me that his mother called him and he ran under the only, widely passing car.
 
It looks like a comminuted fracture of the left femur (that's when the bone has splintered in more than two places), probably with rotational shifting. We don’t have an X-ray.
 
We move quickly to do the repositioning and stabilise the boy before he bleeds to death from the open wound on his thigh. I give him morphine and a place a plaster splint over the pelvis. He stops crying after a while.
 
When I’m doing the final bandage I look around - there are twenty faces of his relatives staring at me from different parts of the divider.
 
I smile. They smile.
 

Back or bottom?

While I scrub in, boiling water flows from the tap. The water tanks are on the roof and you can’t regulate the African sun.
 
When I scrub in for another caesarean section in the evening, the water is lukewarm.
 

Manoeuvring the baby's head is not easy at all. I struggle for a while.

 
The mother is 24 years old; the child is in its 30th week.
 
The decision to perform a caesarean was made because she has eclampsia. This is a condition where the mother is in life-threatening situation because of possible high-pressure brain swelling.
 
I get in in a couple of seconds and make contact with the baby's back. 
 
Silly me! What show up first seems to be the baby's bottom!
 
But turns out it is its back, so I accidentally pull out his right hand. Luckily I don't dislocate or break his clavicle.
 
Manoeuvring the baby's head is not easy at all. I struggle for a while. If the baby was bigger, I’d be screwed. I’m glad the baby’s out!
 

Mary

 
I walk through the hospital in the evening and I meet Mary.
 
She’s been here three months. Broken right femur.
 
She refused stabilisation with the external fixator, she refused the traction and she’s been lying with plaster on for a couple of weeks. We take off the heavy cast.
 
The thigh is not healed. I feel motion, maybe pseudo-arthrosis? Literally that means 'false joint' - where the fracture does not heal, and won't without more intervention.
 

Mary.

Mary. Photo: Tomáš Šebek/MSF.

 
I do a thigh tube. It’s a bit of a local procedure, but I have it mastered. By tonight, Mary will be walking with crutches. I’m happy.
 
I give crutches to a grumpy eight-year-old boy as well. He started to walk only when I gave him one of the foam balls for beginner tennis players. (I brought some little things for the children here.)
 
 

Read Tomáš's post in the original Czech here.

 

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