the HF radio crackles beside me. a guard is resting his head on the desk in front of it. every minute or so, he lifts it and calls into the mic:

"mobile, mobile for alpha bravo, over... mobile for alpha bravo, over..."

the HF radio crackles beside me. a guard is resting his head on the desk in front of it. every minute or so, he lifts it and calls into the mic:

"mobile, mobile for alpha bravo, over... mobile for alpha bravo, over..."

we have sent a patient, urgently, to the nearest surgical hospital 3 hours away. when they arrived, they were told that there would be no surgical cases accepted, and suggested another hospital, 4 hours away. it is well past dark, and outside of a hospital in northern sudan, in the back of a car, a woman in labour and in need of surgery is waiting to see if they change their mind, or if she will have to drive in the black night 4 more long hours on a dangerous road. we are sitting by the HF radio waiting for the same news. there has been no contact recently from the driver. we are not sure how to interpret this.

"mobile, mobile for alpha bravo, over..."

we were talking the other night about the msf life. country to country, crisis to crisis, six months here, two there, on and on and on. there are a few of us who are doing our first mission with MSF. others have done several. maurizzio, our field coordinator, is of the latter group. he said that when he was proposed the mission in abyei, his second in sudan, he was doing some research and came across my blog. after reading, he decided not to come. he recognised too many things from his previous mission. thankfully, for all of us, he changed his mind, and relented.

he was speaking the other night that after you do one mission, and you go back home, you are ruined. there is a distance between you and others that is irreconcilable, things that you cannot share. when you try, the people you talk to either cannot place themselves there, or they realize they don’t want to know after all. the larger the rift becomes. you arrive home, exhausted, longing for familiar comforts you thought you missed, but after a short time, no matter how hard the previous mission was, you feel the pull. if at least to be around people who have known a similar world.

i have just returned from the hospital. i was called in a few hours ago.

"doctor james? this is hospital. we have sick child. girl. 5 months. high fever. diarrhea. breathing problem."

"alright, hospital. can you do a paracheck, give the child 80 mg of paracetamol, and some cool cloths... do you copy? ...good... is the child drinking?"


"ok, start a cannula, ...weigh the child and write the name down. ...and i will be there in a few minutes... do you copy?"

"doctor james... i... ummm... i use bag for breathing now..."

"i'm coming. over and out."

where is the driver? no driver. i grab my stethoscope, and jog 480 paces. i arrive through the gate, people are standing in front of me, waving outpatient cards. i brush past them to the nursing room. a young mother wearing a bright yellow veil is holding a limp 5 month old child whose eyes are sunken, and half open. her small chest rises and falls with last breaths. two nurses are bent over one tiny, dangling arm that has a latex glove tied above its elbow, poking needles through soft skin, looking for veins.

they can find none. no veins, no intravenous. (mohammed, can you use the bag again... no, like this, smaller breaths... no... do you hear that sound? it means there is no seal... you know what... i'll do it... tell the guard to start the generator for the oxygen machine). no gas for the generator. (ok, prep the leg, the left one. with betadine. perfect. great. ok, take the bag. smaller breaths. push when she breathes. no, make a seal...). i open the intraosseus cannula, landmark a little less than a cm below the tibial tuberosity, on the flat part of the shin just below the knee, twist and twist and twist until it pops through the thin shell of bone. marrow flows back freely into the clean water of the syringe and i flush it smoothly back. the fans in the nursing room start to spin. i ask for fluid, and antibiotics. the child's head hangs loosely on my knee. she vomits, and breathes it in. (suction please.)

last breaths are like this:

so, instead, i am blowing in tiny, tiny breaths through a tiny, tiny mask. i barely have to squeeze the bag, her lungs are so small. small, and full of crackles. three times my stethoscope dangles down and touched my knee, and three times i feel a small pearl of hope, thinking it was her hand. i looked down, her arm hangs loosely by her side. i stay there for three hours.

i think i would still be there if her breathing didn't worsen, but it did. she was tired, her muscles burning and inefficient from the lack of oxygen, full of lactic acid. when i would stop, instead of taking a breath, all she could manage was a grimace, a shrug of her small shoulder.

i placed an oxygen mask over her cheeks and pulled it gently snug. i put my stethoscope on her chest, and heard her heart count quietly down.


i don't think that i will end up ruined, but there are certain things that are going to be tough to share. things that would make poor dinner conversation (hey, have you ever heard an infant's heart stop? don’t you think it is like the silence must be after a train wreck, deep in the forest? once the metal has stopped creaking? like all this activity, and then this final vacuum in place of all the sound?). i can imagine meeting people on the street, and being asked how my "trip" was. ( know the feeling, when you are confined to the compound, and you and your colleagues are sitting underneath a tin roof, listening for the cracks of gunshots, but all you can hear is the rain, and then someone decides to make an apple pie, and how happy you all feel for something else to anticipate?).

it was fine. it all was fine.

i cleaned up the emergency room, the nursing room, watched the family close the baby's mouth with gauze. i saw some outpatients. i took a seed out of a little girl's nose. i walked back to the compound alone. i went to the kitchen for a glass of water. andrea, the nurse, came in to see me.

"is everything ok at the hospital? is the baby ok?"

"ummm... no... she's dead."

"are you ok?"

"yep, i’m good."

"you know, you don't have to keep everything right here," she said, and pointed to her sternum.

"i know," i said.

usually, as a doctor at home, it is rare to have one of these experiences, but when you do, you often bear it with others. another doctor, or nurses whom you know. you sit, and talk about it. it doesn’t make it go away, but it diffuses some of the weight. so, just now, from the kitchen, i walked over to the log tukul, and started typing this. instead of keeping it here, in my sternum, i am going to put it right here:


still no news from the car. we are all quite anxious.

i don't mean to burden anyone unnecessarily, but this is what happened tonight, just now, i am freshly back. the part of me that normally edits these stories out doesn’t want to do it today.

i am grateful for this forum. not only does it allow me to place X's, but it also means that when you meet someone you know on the street, and they have just gotten back from something like this, and you say, "so, how was it?", and they say "fine. it was fine.", you will know. good night.