“This is complete 'field anaesthesia'”

Birsen blogs about her first days in Agok, a town in the Abyei Special Administrative Area, which is a disputed area between Sudan and South Sudan. The health system in the region has been badly affected by years of conflict, and MSF is supporting the hospital there.  


I'm on board one of the UN's small aircraft approaching Agok. The plane will soon land and my first assignment with MSF will begin. I have no idea what to expect despite all the preparation, briefings and information I have been furnished with over the last few weeks. 
I'm thinking: I can cope with pretty much everything, but can I really cope with what is expected from me? I am an anaesthetist. But I am the sort of anaesthetist who's used to practising in a developed part of the world; lavished and spoiled with all sorts of equipment and choice. Can I really deliver my job in an environment with so many limitations? I am a bit scared - I can't deny it. 
The landscape below is red. I realise Agok is a big cluster of sun-washed huts. My project manager who's travelling with me points out the hospital to me. A huge wave of excitement rushes through me. The plane lands with a trail of high dust behind.

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Soon we were welcomed by some staff wearing MSF t-shirts. It wasn't long before we were surrounded by children who obviously claimed the runway as playground. They are playful but shy, barefoot. 
Then a familiar sight of MSF Toyota four-wheel-drive arrives. I've seen these cars with their classic 'No Weapons' signs in the media so many times, but now I am about to get into one... 

I'm really curious about the operating theatre and can't wait to see what it looks like...

It's a short drive to the compound and soon I find myself in the 'living tukul'. This is a large cone-shaped hut that is used as a living room for MSF staff. The team is very welcoming. I meet the operating team and have a tour around the compound. But I'm really curious about the operating theatre and can't wait to see what it looks like.
Then, here we are. The only theatre in the compound. It's just as hot in here as it is outside! I immediately spot a couple of flies inside. Somebody grabs the insecticide and there’s a well-practised fly chase. And there, mission accomplished. 
The operating theatre is a plain room. I look around and fail to identify the anaesthetic machine. To my horror I realise; actually there isn't one. It's a shock! No anaesthetic machine, no ventilator, no capnography, no ECG monitor, no infusion pumps, no volatile agents, no defibrillator, no LMAs to keep a patient’s airway open, no other laryngoscope other than a few McCoys, no bougie (a device that helps with intubation), no intubating stylets, no Propofol, no arterial line, no CVC lines, no USS, no nerve stimulator. This is complete 'field anaesthesia'.

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All I have is some ETs (tubes for maintaining an airway), McCoys (but only two sizes), a couple of Ambu-bags, face masks, portable oxygen concentrator with a maximum flow of five litres, a weak portable suction, pulse oxymeter, blood pressure cuffs, a monitor, some endotracheal suction catheters. The exact list of drugs I have is: Ketamine, Thiopentone, Suxamethonium, Atracurium, Neostigmine, Midazolam, Morphine, Ephedrine, Atropine, Adrenaline 1:1000, Paracetamol, Diclophenac, some antibiotics, Hydralazine, Oxytocin, Lignocaine 1%, Bupivacaine 0.5 % plain, IV fluids.

The only way we can get blood is by donation from relatives.

We have Haemocue and a portable BM device. But the laboratory is non-existent. None of the blood tests can be done here. So no FBCs (Full Blood Counts – a test which can check for conditions like anaemia), no U&Es to look at kidney function, none of it! There's a small fridge in the lab for blood. But the only way we can get blood is by donation from relatives.
The surgeon starts giving me an insight into the type of cases they tend to receive. This is a hospital that provides emergency and urgent care only. But I'm buried in private thoughts; I have to learn a great deal from the current anaesthetist before he leaves... My experience with Ketamine is limited...
So, it's going to be hand ventilation for a laparotomy, major trauma, some of the emergency C-sections. I am going to have to use my clinical judgement for the delivery of safe anaesthesia as I have no monitor other than a stethoscope, Sats probe (a blood oxygen monitor) and the blood pressure cuff. I realise that without the equipment I'm used to, it feels like I've gone back in time. This is overwhelming!
It's soon obvious that we treat all ages for a wide range of problems, including newborn babies. The exception seems to be complicated neurosurgery as we're missing a craniotomy set.
The surgeon sounds incredibly competent. He's a trauma surgeon from the USA. Over time I found out that his skills ranged from thyroidectomy (for when the thyroid is compromising the airway), bowel surgery, skin grafts for burns, penile surgery, gynaecological procedures, C-Sections and many other procedures. I have a good rapport with him from the outset; which is reassuring. I think he must have noticed my perplexed face and was evidently trying to be supportive.

I need a cool drink to clear my head. I need breathing space where I can formulate the kind of anaesthesia I can possibly give here with what I have.

It's incredibly hot and humid. I need a cool drink to clear my head. I need breathing space where I can formulate the kind of anaesthesia I can possibly give here with what I have. This is by far the biggest challenge in my career. Did I mention that there won't be any ODP (an anaesthetic assistant)?! I'm all by myself. How can I possibly constantly hand ventilate and yet attend to the other needs of the patient? I really can't see the solution to this, but the project has already been running for some time, so there must be one.
A few hours after my arrival I'm told we have an emergency laparotomy. I'm jet-lagged and incredibly tired but I want to see this. I follow the anaesthetist. He draws Ketamine, Morphine and Suxamethonium. No Atracurium!
It's the appendix. The whole thing to extubation takes a half hour. I guess limited paralysis is a good idea as awareness is a real danger. The patient wakes up stable, and pain free. I'm amazed!

Despite exhaustion, I feel so elated... 

From there on it's an intense experience for me. Soon I begin my practice doing many sedations for minor surgeries. But it isn't long before I find myself having to deal with high-risk patients going for high-risk procedures. With no alternative I soon adapt my practice to work with the limited resources. I become an expert in the art of using Ketamine for the majority of cases. 
I also have to do something that I couldn't have imagined doing before – on a number of occasions I had no choice but to hand-ventilate patients after their operations for many, many hours, taking the role of a ventilator in order to stabilise them for successful extubation. Despite exhaustion, I feel so elated every time this has worked out. But of course, a crushing feeling of frustration and helplessness for the unlucky ones has never left me for one minute.


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