Four emergency transfers and five live (Part 1)

"Humanitarianism is about more than medical efficiency or technical competence. In its first moment, in its sacred present, humanitarianism seeks to relieve the immediacy of suffering, and most especially of suffering alone"

"Humanitarianism is about more than medical efficiency or technical competence. In its first moment, in its sacred present, humanitarianism seeks to relieve the immediacy of suffering, and most especially of suffering alone"

- James Orbinksi, "An Imperfect Offering".

Note: all patient names have been changed to protect confidentiality

As a physician and as an MSF volunteer, I exist to serve the most ill. In emergency medicine, my specialty in Canada, this is our goal as well. The last week here in Maitikoulou has been a difficult one, with many emergency transfers, some under difficult circumstances, but all with the aim to  preserve individual human lives - for which MSF exists.

Many of our medical interventions here in CAR aim to serve the population at large at a public health level. These efforts include vaccination, mass screening for sleeping sickness, distribution of bednets, antenatal care and supporting remote health posts which are the most basic and also most accessible first line of medical care for the population of CAR. But at the same time, MSF exists to manage, case by case, the sickest patients that come to our attention on a daily basis. At the same time, us as the medical attendants, also often fall sick as occurred this week out here in the bush,  and we must care for each other.  Here, there is no health care except MSF.

Let me tell you about 4 emergency transfers in one week. Five lives were at stake and four out of five of the patients lived.  One patient died.

Case one: Saturday October 3, 8:30 AM.

Irene, age 18, had been in labour 26 hours before she came to my attention. I had just finished giving a training to the national staff on the approach to managing diarrhea. Dr. Placide, the national staff doctor, told me about Irene. It was her first pregnancy and the baby had become obstructed in the lower birth canal. Earlier, medications to augment her contractions had failed, and the child was still alive as Dr. Placide said he could hear a fetal heart rate. The mother was exhausted. I performed an ultrasound and saw the fetal heart rate was present and at a normal rate. I could not use suction to remove the child since there was too much swelling around its head. Such obstructed labours need a cesarean section - something I cannot do, much to my frustration.  At 11 AM after multiple clearances from my team leader, project coordinator and medical coordinator, we evacuate out Irene. I knew that even if the baby died we had to at some point remove the fetus from the mother or else she could face multiple complications, including death.

We had to stop many times on the road since Irene and her own mother, not accustomed to the Land Cruiser, vomited a lot. I give them both anti-emetic medications, lied them side-by-side as comfortable as possible and eventually put her mother in a care front seat. Nothing really helped. Irene cried out in pain as we tried to avoid holes in the dirt road but inevitably hit many. Each bump is like a punch to the chest when you are lying on the floor in the back of a Land Cruiser. At Dokabi, or "Delta-Kilo" as we call it, we did a "kiss" with the Markounda team MSF cars. Lindsay, a wonderful, cheerful American logistician, and Hilaire, a top-notch and gentle national staff nurse, took over the transport and care of the patient.

Two days later by email I learned Irene had receive a cesarean section and she was alive. Her baby was alive as well, but was not breast-feeding. I had Irene's family called to the hospital and gave them the news. However, on Wednesday October 7 I had to inform Irene's family that the baby had died but the mother was still alive.

As I write this blog I am actually at our base, in Markounda, due to other emergency transfers. Yesterday October 10 I actually found Irene in the in-patient ward here, as I was doing the patient rounds. Irene was on her way back to Maitikoulou. She lay quietly in a bed. As she speaks only M'Bai she could not communicate with anyone since no one here speaks M'Bai. They speak Sango here. She was alone as well, her own mother gone. I found Irene with a high fever and intense abdominal pain. I talked to her in my few words of M'Bai and started her on medications for an intra-abdominal infection. She is not out of the woods yet.

Case 2: Thursday October 8, 4:05 PM.

Felicite, age 24 was on the ground moaning on the steps of the out-patient department. In my experience, the Chadians and Central Africans I attend to do not lie on the dirty floor unless they are quite sick. I was exhausted after sleeping very little the night before trying to save a 2 year old boy with cerebral malaria who ended up dying after my best efforts over 3 days. I had just repaired the hand of a daily worker who suffered a partial amputation of his finger after it went into a saw. I had no energy left. I saw Felicite on the ground and the best I could honestly do was ask our national staff nurse, Hebert to attend to her, admit her and tell me if he had any concerns. Hebert is an outstanding nurse with almost military discipline and promptness. I ask him to do many things and he does them without question and with exceptional reliability.

Hebert was concerned and notified Dr. Placide, our national staff doctor. Dr. Placide in turn felt the patient had a ruptured ectopic pregnancy. When I examined Felicite it was clear she had peritonitis (a 'surgical abdomen') and needed immediate emergency surgery. But the time of the day was late. Too late. To confirm the diagnosis, I had the nurses insert a bladder catheter and do a urine pregnancy test. It was positive. I performed an ultrasound exam and transabdominally I could see a classic black sliver of fluid between Felicite's kidney and liver - presumably blood from a ruptured ectopic pregnancy now bleeding into her abdominal cavity. I then did a transvaginal ultrasound exam as I have been trained to do in Canada. I could not see any evidence of a pregnancy where it is supposed to be - in the uterus.

With all the information we had at this point, a key series of events again unfolded to authorize an emergency movement of this patient to surgical care. I sweated and paced while awaiting a phone call back to hear if we would get permission to move her. Back home, within 30 minutes, she would be in an operating theatre. Here, I was potentially being asked to stabilize her for another 18 hours, which is when she would arrive at our surgical site, if a movement was only permitted the next day. I was concerned Felicite would die. A mother of 3 children and a wife.

Thankfully, permission to transfer Felicite was granted. As this was transpiring, we hastily tried to find a blood donor. Felicite was A+ - only two other blood types were possible. Unfortunately, the first two men who volunteered to give their blood tested positive for hepatitis. Thankfully, a third donor was found and his blood tested negative for any infections and we hung the blood along with multiple other medications from the roof of the Land Cruiser and started our movement to Markounda.

On the way, we passed Felicite's village. They all lined the dirt road and blocked the passage of the cars. They wanted to exchange her husband as the guarde de malade for Felicite's sister in law. No problem, we made the switch. Mommas and poppas looked into the car and talked to Felicite. They said things to me I could not understand. I am sure they realized with five infusion bags hanging (including one with blood) from the roof and three intravenous lines inserted in Felicite's arms that we were doing our best to save her life. I said to them we are going to Markounda and then Boguila. I think they understood that as well. It was touching to see her whole village lining the road as we took her out.

Like all patients in pain, Felicite suffered on the long 5 hour drive. Each bump and twist, she moaned and cried out. I had not brought any pain medications in the scramble to get her loaded, transfused and treated with other medications. Jacob, a truly loving and gentle secourist, had volunteered to come on this transfer with us after working for 12 hours in the in-patient ward. I wanted him since I trusted him and he could speak M'Bai to the patient and explain to her what was happening. Each lurch and crash of the car into ruts and bumps, Jacob and I held the medication bags thrashing about in the back of the car. Jacob held the patient's shoulders and I held her right hand. We tried to comfort her and warn her when a big bump was coming.

I was getting seriously car sick and did not need to be in the back of the car anymore to keep an eye on the patient.  I knew well she was OK since she moaned every few minutes. I moved to the front seat of the car. Along the road, armed military personnel stopped us. They quickly realized what we were doing and allowed us passage. Anyone could see we were trying our best to save someone's life.

When we got to Markounda, I re-examined Felicite. She was still critically sick, but it was night and we could not move further due to security concerns. I arranged for a bed for Jacob beside Felicite. I was starving and ate some Plumpy Nut usually used for the malnourished children. The nurses gave me a bed in the adjacent examination room but since I am so afraid of mosquito bites I chose instead to sleep in the ward with the patients under a bednet.

At 3 AM I was woken by the crying of children and the nurses who wanted my help for a child with cerebral malaria. The 3 year old girl was dying, I knew it. It is sad but now I know well the breathing of a child who is soon going to die. They gasp and the side of their mouth opens as if you were trying to show your canine teeth to someone. I had the nurses call the local national staff doctor, Dr. Honore, who had attended to the child for 3 days. I had just been through this kind of case all night just yesterday. I started the child on antibiotics, gave diazepam and glucose to stop the seizures, and began oxygen (a useful intervention I don't have in the bush in Maitikoulou). Dr. Honore arrived and agreed with my treatment and agreed the child would likely soon die.

The crying of the children in the ward kept me up. I need to sleep. So I took some blankets and slept on the dinner table at the old expat house, now used as a storage facility. I could have gone to the expat house and slept in a proper bed, but I was not going to leave Felicite without my constant medical attention.

At 5:15 AM the sun woke me up and I radioed Lindsay, the base logistician, and she arrived with two MSF Land Cruisers. We loaded Felicite in the car. I told Lindsay to just drive like hell out of here. Lindsay radioed me 30 minutes into her journey to our sister project, where we could do surgery. She said they forgot some medical equipment. No matter, I said, just keep driving. This woman needs a surgeon and nothing else. Felicite entered the operating theatre at about 8 AM. She survived.

This is what MSF is for.

Warm wishes from the Central African Republic,

Raghu Venugopal