Four emergency transfers and five lives (Part Two)

Correction: in blog 19 I described 4 emergency transfers with five lives at stake. Sadly, I learned today that one of these patients died yesterday on October 11. And thus, three out of our five patients who were emergently transferred in the last week lived.

Correction: in blog 19 I described 4 emergency transfers with five lives at stake. Sadly, I learned today that one of these patients died yesterday on October 11. And thus, three out of our five patients who were emergently transferred in the last week lived.  Two patients died - one a newborn and the second death was our 4th transfer, a patient named Souh. I will tell you about Souh, below.

Note: all patient names have been changed or shortened to protect confidentiality.

"At one point during one of our meetings the minister [of foreign affairs for Sudan] had expressed his fascination with "you MSF fellows and ladies. Why do you do it" he asked. I replied immediately, "Because we can"."

-James Orbinski, "An Imperfect Offering"

Because "we can" is an important reason why I am an MSF volunteer. We can save lives, we can alleviate suffering and we can help restore dignity of those living in danger. It is within our grasp. It is possible. We have doctors, nurses, surgeons, drugs and equipment, logistics, coordinators, radios and Land Cruisers. We are willing and ready to operate in places others are not willing to be present. We take calculated risks to our own personal safety and well-being to be here. We realize our endeavor is not perfect, but nonetheless we are in constant pursuit of improved professional and compassionate medical care. Because we can.

Case three: Thursday October 8, 14:00 PM

Simon my team-leader and I were back on the road to Maitikoulou after transferring our patient Felicite to Markounda (and then Boguila) for emergency surgery. We were tired but satisfied things had gone smoothly. We had got to spend a night and morning in Markounda, which for me is paradise  compared to Maitikoulou. I was scanning some MSF radio channels (Spain and France) in complete boredom in the 2nd MSF car in our convoy.  Simon's car stopped ahead of us. He got out and asked me if I had heard all the talk over the high-frequency radio about a sick MSF staff member. I had not. I felt a bit embarrassed I had been fooling around and not heard the call. My bad.

It turned out there was a concern regarding an MSF staff member with a possible stroke. I immediately knew who it must have been - Sara - one of our female nurses I had been attending to for the past 2 days with a severe, but resolving headache. This MSF nurse's headache was not classic for an aneurysm which had leaked or ruptured in that it was not the worst of her life and did not develop suddenly like a bolt of lightning (but unfortunately as well, most ruptured aneurysms don't present "classically" - classic medical presentations are for textbooks and do always occur in real life). But it was a bad headache. I had treated her for malaria, sinusitis and a migraine headache, but the thought of a ruptured aneurysm lingered in the back of my mind.

When I first encountered this nurse, I seriously thought about medically evacuating her, but since she rapidly and consistently improved each time I visited her in her, I thought we could monitor her improvement in our project. Plus, you cannot evacuate everyone who falls sick - it just occurs too frequently that someone falls sick and the vast majority get better. Just before I evacuated Irene, I had visited Sara, our sick nurse. Sara was getting better, eating and having less pain.

On the road at Mainojo health clinic, Simon and I called our medical coordinator on the Thuraya satellite phone. My suspicion that it was Sara who was sick was unfortunately correct. She had fallen unconscious on Friday October 9 at 13:00 in the afternoon. Our American expat nurse-practitioner Kathryn had already gotten approval from the capital to begin evacuating Sara out of Maitikoulou. Sara was having seizures and could not be aroused. Simon and I quickly made plans for me to take one MSF car and evacuate Sara to Markounda, where we could hopefully fly her out on the first flight possible. This would mean I could not return to Maitikoulou as planned.

When Kathryn brought Sara by car, the diagnosis was correct. Sara was in a comatose state. I rubbed my knuckles deep into her sternum but there was no response. We hastily changed staff and kept Sara in the same car. With Papa Eli - our best driver - we drove like hell to Markounda. Collete, one of our national staff nurses sat in the back of the car with Sara. She softly sang. Papa Eli - who is also a pastor with the Catholic Church prayed and asked for blessings as he drove as fast as he could without endangering us or bystanders. We reached Markounda and I immediately examined Sara. She was completely paralyzed on the right side of her body and the left side of her face, and could not speak. I phoned the medical coordinator in the capital city and he informed me that he had arranged an air evacuation on a United Nations plane the next morning. I thanked the medical coordinator Martins for his fast action.

The night for Sara passed smoothly and without incident. The MSF national staff were obviously very concerned and one of our employees openly thanked us for taking care of the national staff so seriously. In the morning, Sara's flight departed without incident to the capital. We had lost from our project a fantastic bedside nurse, a trusted colleague and a friend.

Lindsay our American log and I got back to the base. I felt nauseated, guzzled a liter of water and organized a second doctor's rounds in the inpatient ward. The first round in the morning was rushed due to the need for Dr. Honore, our local national staff doctor in Markounda, to prepare to take Sara on the plane. Him and I did a quick tour so I could find out who was really sick or complicated.

As I headed to the ward, Lindsay announced that believe it or not, there was an emergency transfer request from Maitikoulou.

Case four: Saturday Oct. 10, 11:30 AM

Souh, age 45 from southern Chad arrived in Maitikoulou the night before. He had severe abdominal pain, fever, and vomiting. His abdomen was bloated and with clear signs of peritonitis. Peritonitis indicated that his intestines had ruptured somewhere and fecal matter was inside his usually sterile abdomen, causing an intense and excruciatingly painful inflammatory reaction. Kathryn, our clinically sharp nurse-practitioner and I talked on the satellite phone. She was 100% convinced this man needed surgery, and I 100% believed her based on my experience of her spot-on clinical ability.

I called the medical coordinator in the capital - he approved the transfer. Then logistics arranged the transfer. Frank, our German project coordinator here in Markounda approved the movement, and Lindsay the American logistician drove out to meet the Maitikoulou MSF cars. She radioed me as she approached. The patient wanted to sit up and she wondered if that was OK. I told her let the patient do whatever he wants in order to get comfortable.

The MSF coordination team in Bangui was not in favour of moving the patient all the way to our surgical site in Boguila. They had security concerns. They advised that I make a quick decision when Souh arrived whether I could stabilize him here in Markounda or if he truly had to be moved out right away to Boguila. Good copy - I could do that.

When Souh arrived he looked terrible. I got 6 other men and we carried Souh out of the car to the reanimation room. He had no blood pressure. I could not feel his radial or his carotid pulse. His respirations were labored and far too fast. I quickly hung two bags of intravenous fluid to try and boost his blood pressure. I listened to his abdomen with my stethoscope - no bowel sounds - a bad sign. His skin was oven hot and his abdomen was bloated and excruciatingly tender to the lightest touch. I gave Souh an antispasmotic medication, a pain killer and medication to stop vomiting. I told the men to get him back in the car right away. I ran off to find Frank and tell him Souh had to go.

Frank and I called the medical coordinator in the capital again. I told him Souh will die if he stays here overnight. The movement to Boguila was  approved. Once more, I told Lindsay the logistician to just drive like hell, bumps or no bumps in the road.

Lindsay got back to Markounda on Sunday afternoon October 12. She had bad news. Souh had died. The Boguila team had taken Souh to the operating theatre, where they found a ruptured appendix. Afterwards the patient did poorly and despite aggressive attempts to keep him alive with potent medications to raise his blood pressure, it did not work.

We all agreed the attempt to save Souh's life was unquestionably worth it. What efforts we made exist in a complete vacuum of any other actors to try and help this man. Sadly enough, we were his only chance.

And why do we do it? Because we can.

Warm wishes from the Central African Republic,

Raghu Venugopal