Fieldset
South Sudan: “Please start CPR, I'm on my way"

When MSF doctor Ayla Emmink answers a late-night emergency call to treat a critically ill young girl, she must prepare herself for all scenarios - including heartbreak

A rainbow over the MSF hospital at Mundri in South Sudan

"Doctor Ayla, Doctor Ayla for ER!”

It is the middle of the night, but I am wide awake as soon as I hear the radio next to me.

The call sounds urgent, I hear the panic in the voice of the duty clinical officer (this is a role similar to a physician assistant in other countries).

Even before I tried to fall asleep – which is a daily challenge given the extreme heat – I suspected my night's sleep would be disrupted by the radio…

The girl with pneumonia

Earlier in the evening, I was asked at the ER to come and assess a patient. It was a one-and-a-half-year-old girl, severely malnourished and now acutely congested, gasping for breath.

The child had severe pneumonia. But because of the malnutrition, her body's ability to fight off infection was probably minimal before the pneumonia took hold.

I play all possible scenarios in my head – preparing myself mentally for what I will find in the ER tents

Her poor general health made her chances of recovery considerably worse. I wondered if she had any other underlying conditions, or if there was another explanation as to why she was in such an extremely bad state. We gave her antibiotics and oxygen support. Although we tried our best to treat this girl, I was not convinced that it would be enough.

When I left the department here in Mundri, I wondered if the child would make it through the night.

Out into the night

I quickly wriggle out of the clammy, sweaty sheets and grab my handheld radio:

“ER, ER for Ayla, go ahead,” I say.

“Yes doctor! The girl is now in cardiac arrest, we need your help,” I hear.

Even though I sensed that this was about to happen, I have a heavy feeling about this.

ayla_treating_another_young_girl_for_a_respiratory_tract_infection_in_mundri_south_sudan.jpg

Ayla treating another young girl for a respiratory tract infection in Mundri, South Sudan
Ayla treating another young girl for a respiratory tract infection in Mundri, South Sudan

“Please start CPR as we trained, I'm on my way," I reply, getting dressed, then waking the driver up and asking him to take us to the ER as soon as possible. The distance is not great, but for safety reasons I have to take the car to the ER at night.

During the rollercoaster ride in the Land Cruiser on the extremely uneven dirt road, I play all possible scenarios in my head – preparing myself mentally for what I will find in the ER tents.

CPR

When I arrive, the team is already doing chest compressions. A nurse comes running with an ambu-bag - a bit of kit to blow oxygen into the lungs. I ask her to connect it to the oxygen concentrator.

In the meantime, I'm reaching for a mask that will better fit the tiny girl's face, so that we enclose her nose and mouth as best as possible during resuscitation. I take over the task for her airways and explain to the clinical officer and the nurse how to position the girl for optimal opening of the trachea.

I listen to the heart with my stethoscope, but as much as I want to hear it, it remains silent

My head is running at full speed, but I try to stay calm while explaining exactly where to place their hands for the chest compressions, how to fold their hands and what rhythm to follow.

At the same time, we go through the case again – her original condition on arrival, the treatment so far, the moment of deterioration, looking for missing information that could be the key to her treatment.

Unfortunately, there are no extra details, and our review doesn't take us much further.

15, 2, 15, 2

Time passes ...

We give adrenaline, continue with chest compressions, blow oxygen into the little girl's lungs. The nurse takes over the chest compressions.

We continue with the cycles: 15 compressions, 2 inflation, 15 compressions ... but no visible result.

Even after the second dose of adrenaline, we see no signs of improvement. In my head, I count the number of cycles that we have completed and I calculate how long we have been working…

I know we have to stop, that it makes no sense anymore.

I interrupt CPR to check the girl’s pulse, with my fingers at her neck looking for the carotid arteries, concentrating as hard as possible, but to no avail. At the same time, I listen to the heart with my stethoscope, but as much as I want to hear it, it remains silent.

No breathing, no heartbeat.

Nothing more to say

I look into the mother's eyes and know that I don't have to say anything anymore, that she already felt it. She was crying before we stopped CPR.

I carefully close the girl's eyes. Then I help the nurse prepare her for the funeral. We remove all infusion lines and cannulas tubes. We tie the girl's head, thumbs and toes together.

I compose myself and compliment the team for their quick response. I tell them they did a good job, despite the unfortunate outcome

Watching the parents carry the girl wrapped in a sheet, I see the first rays of light rise above the horizon and a new day begins. I put my hands on the shoulders of the nurse and the clinical officer who are standing side by side with me. I can't help crying about the early loss of this young life.

All three of us fall silent. Then, I compose myself and compliment the team for their quick response. I tell them they did a good job, despite the unfortunate outcome.

A cup of comfort

Back in the MSF house, the cook has already started her day shift and is preparing breakfast in the kitchen. She looks at me and knows enough, she doesn't have to ask me anything.

She pours me a cup of tea and pats my shoulder, wordlessly expressing her empathy.

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