“Emergency in maternity!”
The call pierces an otherwise silent period on the MSF radio.
I immediately head towards the ward, oblivious as to the situation I may encounter.
Anything is possible in Old Fangak.
First, to describe the context: Old Fangak is around 500km north of Juba, the capital of South Sudan. It's a swamp region with a population of around 50,000 people, most of whom fled to the area during the civil war because the remote location conferred relative safety.
With the tenacious mud consuming the runway, the MSF plane is unable to land
There aren’t any roads to Old Fangak. During the rainy seasons, when the runway turns to mud, three helicopter flights and a boat trip are required to travel here from the capital.
In Old Fangak, MSF run a small hospital.
Blood on their shoes
I swiftly move to the maternity ward. On arrival, I see the midwife has blood on their shoes. This isn’t an unfamiliar sight when encountering a midwife during the day, however I can read from their facial expression that the situation is serious.
I am advised that the patient has delivered a healthy baby. However, the placenta is retained inside the uterus.
This little one is just metres from her mother who is now fighting for life
Two midwives correctly tried to remove the placenta, however it is completely adherent, and the patient is now haemorrhaging. There is a river of blood flowing over the front of the bed, only partially captured by a nearly full bucket below.
Within a moment of my arrival, the patient loses consciousness.
In total contrast, out of the corner of my eye, I see the perfect newborn baby lying under the warmer. No doubt waiting for the first cuddle and feed, this little one is just metres from her mother who is now fighting for life.
Crammed into the tiny delivery room, the temperature must be approaching 40°C. Sweat is pouring from all staff, safety glasses are fogging minutely.
We will not stop treating her, we will not withdraw support
We squeeze fluid into drips in each arm and I start the mother on a potent medication that raises blood pressure. This medication must be carefully titrated. In this low resource setting I count the drops per minute to infer infusion rate.
Within ten minutes of resuscitation commencing the patient starts to groan. She is regaining consciousness.
I call the name Nyame, waiting to see if the woman will open her eyes. In the local Nuer language, Nyame is a polite way to refer to another. For the remainder of this post, I will use the name Nyame for this patient.
She desperately needs blood
Nyame’s condition requires surgical support. We don't have those facilities in Old Fangak, so we immediately send a senior MSF staff member to begin the referral process to transfer her to another hospital.
In the meantime, Nyame now desperately needs blood.
If Nyame does not survive, what will be the future for her children?
We don’t have a blood bank; to find donors we rely on patients’ families. I ask that all of the family members gather urgently. I walk into a room of around ten people and can tell from the mood that they are unaware of the events that have just unfolded.
It is at this point that I explain that Nyame is in critical condition.
The optimistic intrigue for news about the new baby is replaced with intoxicating grief. I learn that Nyame has five children and is the primary caregiver.
If Nyame does not survive, what will be the future for her children? The sheer implications cannot be comprehended at this point; rapidly I steer the conversation to requesting that the family members locate multiple people willing to donate blood.
Over the next few hours while we continue to resuscitate Nyame, family members line up to provide a sample to identify if they are a compatible blood group.
Multiple MSF staff work in synchrony to ensure the process is expedited.
Out of many willing donors, we find three matches. The matching donors are screened for transmissible diseases and connected to drips to start donating blood.
At this point we are well into the night.
We manage to yield one-and-a-half litres from the donors. As Nyame begins to receive the blood, we can progressively reduce the potent blood pressure medication.
Every possible avenue
Throughout the night I remain in the hospital, checking the few parameters available and making adjustments where appropriate. Multiple relatives camp in the same room.
Despite being in the small hours of the morning, not a single person is sleeping.
While I remain in the hospital a team of MSF personnel work to find a way to get Nyame the surgery she desperately needs.
I check the clock and realise I have been in the hospital for 26 hours and with Nyame for 18 hours
With the tenacious mud consuming the runway, the MSF plane is unable to land. In this context, options are limited.
As dawn breaks, we still do not have a means to transfer Nyame to a hospital with surgical capacity. Exhaustion is now matched with concern. I know that the MSF coordination team within the project and in the capital will be pursuing every possible avenue.
I check the clock and realise I have been in the hospital for 26 hours and with Nyame for 18 hours. I handover to another MSF doctor and take some rest.
We will not stop
At the point of waking, I learn that the haemoglobin (or level of blood) in Nyame's body is falling. As a result the team has had to increase the dose of blood pressure medication.
Nyame has no visible blood loss, so we do an ultrasound. This shows that her uterus is expanding.
As the sun starts to set, we hear the most amazing news
This is not a welcome development, it means that Nyame is haemorrhaging into her uterus.
We are now close to 24 hours post-delivery, yet we do not have a means to refer Nyame to another hospital.
I update the family and explain that there is a high chance that Nyame will not survive, however we will not stop treating her, we will not withdraw support.
As the sun starts to set, we hear the most amazing news.
The International Committee for the Red Cross (ICRC) will provide a helicopter to transport Nyame to Juba. In Juba, MSF will arrange and fund the surgical care.
I cannot even begin to express my gratitude.
I know that diverting ICRC’s helicopter to Old Fangak will be costly, interrupt their operations and must be logistically challenging. There aren’t exactly spare helicopters in South Sudan.
Humanitarian workers from multiple organisations worked together for one purpose, to reduce disease and suffering.
The earliest the helicopter can arrive is midday tomorrow. While we do not have any more blood to provide Nyame, we have hope on our side.
Due to her unstable condition, another MSF doctor remains next to Nyame throughout the night.
We are all invested
Early in the morning we prepare for Nyame’s departure.
A transport medication pack is assembled, and mobile monitoring equipment is tested. The role of medical escort is allocated to one of our brilliant South Sudanese nurses.
I meet with the nurse and run a rapid tutorial about how to manage in the air and treat possible issues which may emerge. This nurse has never been in this situation before and I can only hope that the tutorial and my basic written guide is sufficient.
Managing Nyame's precarious condition in the air is a monumental task and would not be easy even for a veteran critical care flight nurse.
News of Nyame’s imminent departure rapidly spreads.
I estimate that thirty people are outside the maternity department, everyone wanting to offer a hand. Four are allocated to carry the stretcher, two to medical equipment and one carries Nyame’s newborn.
We walk down to the MSF boat to almost a guard of honour from MSF staff and relatives. We are all invested.
The ICRC helicopter is waiting at the airstrip. Seats are removed to make way for Nyame’s stretcher. I rig up a makeshift IV pole to the ceiling of the helicopter canopy.
We check Nyame’s vital signs and make final adjustments to the infusions. The doors are closed, the engine is fired, and the blades of the helicopter begin to spin.
We all watch as the aircraft rises and flies towards the horizon. Family and MSF staff remaining on the ground shake hands and congratulate one another for their roles.
Even though Nyame's plight is not over, joy gives way to an overwhelming sense of pride. Humanitarian workers from multiple organisations worked together for one purpose, to reduce disease and suffering.
This is why we are here.
A life saved
Over the coming days, we frequently refresh our email, eagerly awaiting an update.
Eventually we learn that Nyame had a successful surgery to remove her uterus. Nyame is now recovering well and is expected to return to Old Fangak in the coming week.
Nyame is alive and Nyame’s children still have their mother because of the commitment, passion and generosity of many.