Fieldset
South Sudan: Learning to find comfort in loss

When 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's deteriorating condition. It was a one-and-a-half-year-old girl, severely malnourished and now acutely stuffy, gasping for breath.

Apparently, the child had severe pneumonia. Her basic condition was already so bad that her resistance was probably minimal before she was infected.

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

This 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 prove sufficient.

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 step 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, it makes me gloomy.

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 and I am not allowed to walk.

During the rollercoaster ride in the landcruiser 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 a manual breathing balloon to blow oxygen into the lungs. I ask her to connect the balloon to the oxygen concentrator.

In the meantime, I myself am looking for a better fitting mask, 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 lead to an improvement of the treatment.

Unfortunately, it doesn't take us much further.

15, 2, 15, 2

Time passes ...

We give adrenaline, continue with chest compressions, blow oxygen into the lungs with the balloon, 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, feeling as concentrated as possible with my fingers in the neck looking for the carotid arteries, 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 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 with which she wordlessly expresses her empathy.

To be honest, it is not necessarily the lost life of this girl that saddens me, more the despondency about what lies ahead…

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