The best laid plans

So it’s my birthday weekend.

So it’s my birthday weekend. My birthday is actually Monday, but that is a universally crap day to celebrate anything, so I had planned to spend the weekend beforehand generally lazing around: have a lie-in, maybe do some yoga with Michelle (my project coordinator) and have a cake bake-off with Stefan (our techlog). Maybe drink a beer or two. Nothing too taxing.

Apparently nothing too realistic either, because the way the weekend has panned out has been somewhat different! I’m learning it’s a little risky to plan too far ahead here…

Let’s go back to 6:30am on Saturday morning when I was abruptly woken up by Michelle banging on my tukul door…

Thump, thump. “Emma… Emma! I need to talk to you…”

I stagger sleep-drunk out of my tukul, rubbing my eyes and unaccountably anxious that somehow I have managed to do something wrong during the night. My drowsiness vanishes rapidly as I’m told that there have been reports of fighting in a nearby village with multiple wounded in villages downriver. I need to be ready to get in a boat with a small team to retrieve patients within the hour. I’m telling you, it’s better than a triple espresso waking to news like that.

The compound is filled with expats in varying states of dress and alertness, carrying everything from toothbrushes to sat phones and emergency medical kits as we all scramble to prepare for whatever the day ahead is bringing. The logisticians are kitting out the boats and starting the generators early; the surgeons (of whom happily we have two at present as they are in their ten-day handover period – Christina our incoming first mission surgeon is in for a baptism of fire) are preparing to call in the operating theatre (OT) team; Michelle is fielding phone calls and trying to get accurate reports of how many injured we need to prepare for.

By 7:10 I am on the first boat heading downriver where we find our first casualty already headed our way in a dugout canoe – a  six-year-old with a horrific wound to his abdomen. Christina and I elect to “scoop and run” rather than try and treat on scene – we’re only ten minutes away from the hospital.

The tiny shell-shocked mother and another small son climb into the MSF boat and huddle on the floor and the boat speeds back. I have my hand on the cloth holding this child’s intestines in and I have a queer sick feeling in my stomach. Not from the wound – I’ve seen worse – but from the visceral fear of the weapon that caused this much damage to this small a person. I know – rationally, intellectually know – that the gun is nowhere near. It’s hours and miles away, but still… the sick feeling lingers.

We arrive back at the hospital and the child is handed over to the waiting team on the river bank and whisked to the OT. With barely time to draw breath we are en route back downstream, with both boats this time, to the village an hour or so away that we are told has the highest concentration of casualties. The river is gorgeous at dawn – the air in our faces is cool, we are surrounded by greenery and birds erupt up from the water as we whizz past. It’s hard to be blind to the beauty but harder to forget our purpose.

MSF South Sudan

The boats turn down a small tributary of the main river and into a large shallow lake. There are some frustrating but vaguely comic moments as both boats repeatedly run aground on the concealed mud flats and Stefan resorts to climbing overboard and towing us through the worst sections. As we approach the village we can see a large crowd gathered by the water’s edge.

The next half hour is nothing short of sheer pandemonium. Triage and treatment is near impossible in the melee of distressed and vociferous families, so we scoop and run again – six patients in one boat, three in the other. All women and children. The wounds, as far as we have been able to assess, are terrible: one child is bleeding persistently and worryingly from a thigh wound; the woman nearest me has both heels blasted off, with shattered leg bones clearly visible.

My earlier nausea has gone now and I’m thankful for the years of training that help me to push some of these emotions down and deal with the urgency of here and now. There’s a price to pay of course – whatever you push down will surge up again at some point. But for now I’m just glad that we are here to offer help and hope to these people.

Michelle’s phone beeps. She grimaces as she looks down at the message on it, then relays to me that the first boy from this morning hasn’t survived surgery. I feel like something has taken my heart and twisted it tightly. Despite our efforts we were too late for that child. I’m impatient to get back to the hospital so we can get these people the treatment that they need and avoid any more needless deaths.

We arrive back at the hospital. In the two hours since we left it has been transformed. Ruth, who has taken over coordinating, and the rest of the medical team have worked some miracles. The two most severe patients are offloaded straight to the surgery teams in the OT. The emergency room (ER) has been rearranged as a receiving and triage station. The inflatable OT tent that has been waiting for use during building refurbishment is ready to do service as a temporary pre-surgical ward. Blankets and beds are ready and waiting, IV fluids are hanging ready to go. Tun Thiha, our Burmese log admin, is hurrying past with a cold chain box full of tetanus vaccine. An extraordinary amount of national staff are here as well on their day off, staffing the pre-surgical ward and translating for the doctors in the ER.

I turn on a tap to wash my hands and note that the water pressure in the taps seems low – I mention it and within minutes someone is scaling the water treatment tower to check the levels and pump more from the borehole. The energy here is amazing.

My nursing OCD takes over briefly when I get into the chaotic ER and I spend time collating notes and drug cards neatly into files – with this much happening at once, it’s all too easy for patients’ cards to get mislaid or muddled. And mini-muddles are definitely happening! At one point I lose track of the keys to the central pharmacy where all our medical stock is kept. The OT needs gauze. Um, I already gave them gauze? Not that gauze, I’m informed, bigger ones! I narrowly escape running round like a headless chicken to find a logistician to break into the pharmacy for me when Erik, our Dutch doctor, calmly takes the keys from round his neck and hands them to me with a beatific smile. I could hug him. Extra gauze, extra IV fluids, extra soap. Call staff to work the next 24 hours in the pre-surgical ward. Juggle for staff cover elsewhere. Extra gloves, extra morphine, extra iodine. Go, go, go.

At about lunchtime Michelle brings a smartly-dressed smiling Nuer woman to me – she is a nurse who is visiting her family in Nasir from Australia and wants to volunteer her services during the emergency. Local registered nurses are like gold dust here, female nurses more so, and volunteers nigh on unheard of. I DO hug her, and then delightedly introduce her to the intensive care unit where the first patients are arriving after their surgery. Talk about a godsend.

At 3 pm we receive news of wounded men at another village upriver. Stefan and I grab the emergency box and head towards the boat again. Azat, who is to be our techlog when Stefan leaves, joins us. The emergency box feels suspiciously light in my hands. I pause and then run back to the ER and fill my shoulder bag with IV fluids and cannulas. We don’t have far to go this time, only 15 minutes upriver, but it turns out that we are ahead of the game here – the men we find at the riverbank shake our hands enthusiastically and inform us that four patients are en route to the village but are still almost an hour inland where we can’t reach them. We exchange looks and resign ourselves to wait.

At first the enforced respite is almost annoying – when you’ve been going at a million miles a minute all day, it’s hard to change gears. But we rest by the river bank and take a breath. We are in an area with a fair amount of military in it and there’s a skeleton of a jeep that we sit in for a bit while I phone Michelle and tell her we’re going to be a while. Men wander past with spears and guns. I regard the weapons surprisingly calmly. For all my initial fear at the gunshot wound this morning, I feel no threat here. We are wanted. MSF’s reputation long precedes us as individuals here and they know that we will treat them for their medical needs without questions or judgement. Not for the first time today I feel a bubble of pride well up inside at being a part of it all.

A few hundred metres away some shots ring out. Happy shooting, I’m told by the men sitting under the tree with us. Into the air, not at anyone. Hmm, slightly reassuring I guess.

Our patients arrive eventually, borne on the shoulders of their companions, and I sort through them. One minor wound, three severe. Face, abdomen, knee. Pints of congealed blood and flies. I put a hand to their wrists and it only takes a few seconds to assess that they are all tachycardic from their blood loss. I cannulate and hang IVs to replace the lost fluids while Stefan sorts through the growing group around us to extract healthy-looking men who are willing to be blood donors.

At one point I look up from putting a patchwork dressing onto one man’s chest and am mildly perturbed to see the now huge crowd around me veritably bristling with guns and spears. A distinctly adolescent-looking individual is brought to me as a potential blood donor and I shake my head and regretfully explain that we need bigger, older men to be able to take a decent donation from. As the translation is done a ripple of laughter spreads through the men and they slap their legs and pinch their biceps to show how big and strong the rest of them are. The boy smiles as he is shoved back through the crowd and other men shoulder their way forward smiling. I grin back and tell him to eat more. Maybe next year!

After a litre of fluid each, the pulses of my patients are slower and stronger and I deem them ready for transport. The river is still low and the banks steep but somehow, surefootedly, they are carried to the boat on stretchers and loaded on. I skid somewhat unsteadily down the gravelly sides and join them on board.

As we travel I am hit by a sudden tiredness. Not just body-tired, although I am that too, but soul-tired from witnessing the outcomes of all the violence. This is when the emotions hit in.

The hospital is still busy when we get back but there’s a steadiness to the pace now – more of a sense of settling in for the marathon than the sprint. We have received 19 patients with gunshot wounds in total, and although the next few days may see a few walking wounded arriving, we devoutly hope that the initial rush of severe cases is over.

The expat team straggle together in the compound as it gets dark and flop into chairs. Cold Pepsis are poured, plates are piled with food – I finally have my long awaited beer! – and the team share their experiences of the day. Hectic but good appears to be the general consensus. We are all exhausted. Most of us started the day tired after a long week and I wasn’t the only one planning a low-key weekend. The surgeons still have to check on their post-ops, and poor Tommy, who spent most of the day in the ER, is scheduled to be on-call tonight. Michelle, who started receiving phone calls in the wee small hours of last night, is on the phone again updating the MSF country capital team on the day’s events.

Worn out though we are, there are few complaints. This is what we are here for after all. And we would do it all again tomorrow if we had to.

But for the moment we're not planning anything...