Afghanistan: mission two, day three – From the airport straight into the abdomen and then into the head

"It’s the beginning of March and I am back in Kunduz. I’m starting to write the fourth part of the never-ending story of my travels with Doctors Without Borders."

It’s the beginning of March and I am back in Kunduz. I’m starting to write the fourth part of the never-ending story of my travels with Doctors Without Borders.

Yesterday at the airport in Kabul was amusing. The morning info to be ready at the gate of the base at 7:30 am sounded quite optimistic for the flight to Kunduz. When, after five minutes of driving, I was deposited at the airport, the current info said we would be leaving at 9 am. Things started looking worse. The temperature was just below zero, snowing, me in two T-shirts, standing in the chilly yard.

BeechCraft is the usual aircraft MSF fly with in Afghanistan. We arrived at the hangar, chucked our bags into the luggage space, sat down in the deep freeze masquerading as a plane and together with Sany, who is the  logistics manager, we eagerly watched out for  the two guys who were to fly it. One of them introduced himself in perfect English as the captain, the second one summed up in excellent Irish English that if this aircraft was to crash in Afghanistan, then the breathing masks wouldn’t really be that necessary. The engines started, giving us a little warmth, the plane taxied from the parking stand to the holding area, then taxied back, the engines were switched off – damn guys – low visibility, we’d have to wait `… 

It stopped snowing at two in the afternoon, the plane was swept clean with brooms, English, Irish, taxiing, and a surprising take-off!

The view from the flight Kabul to Kunduz © Tomáš Šebek

The view from the flight Kabul to Kunduz © Tomáš Šebek 

We landed in Kunduz at about half past four. The sky was clear and we could drive off straight from the apron. I feasted my eyes on fresh green grass, which grows here on otherwise bone dry sand dunes. Here and there I saw the white blossoms of apple trees, a few farmers scraping about in the soil. The spring had come… And then my telephone started to ring somewhere after the sign for Kunduz.

"Hi, this is doctor Safi, is that Stevenson?"

"No, this is Tomas, we’ve just exchanged the phone at the airport."

"Oh, OK then, hi, come to the hospital, we’ve got a guy with a bullet wound in the abdomen."

"Do you need me? I’m travelling to the house right now…"

"Yup." Clunk.

I apologised to the crew for making a detour and from the airport I jumped straight into an abdomen. I could not have wished for a better start to the mission and I mean it seriously. I hate formal introductions probably even more than saying goodbye.

The guy had got hit once, the entry wound was in the epigastric region above the stomach, FAST - a rapid ultrasound examination to evaluate the torso for bleeding - negative, stable, abdomen soft. I hesitated a bit, but the indications were there. I asked for another X-ray of the chest and stomach and went to explore the new layout of the theatres which they had built since the last time I had been here. 

On my way I saw familiar faces. We smiled at each other; they didn’t only offer me a hand to shake but treated me as a friend. Tom, he is one of us, it’s great, you've come again. This is what I like about second missions, the returns.

The bullet fragments on the X-ray suggested that the shot trajectory had led tangentially, finishing somewhere outside of the abdominal cavity. Out here apart from the head you can forget about a CT scan and fuzzy ultrasound is bugger all use. At least I made a mini laparotomy (an incision through the abdominal), checked the insides, sewed it up, removed a few gettable bullet fragments, put a drain in and in a few minutes it was all done.

Fine. So should I go to unpack? Then a dry message from the emergency came near the end of the procedure: we were admitting a child with a hole in its head. Well not yet then, I’m not going to unpack.

I was shaving his head and again and again I felt pissed off. Why these children? It didn’t look very dramatic from the outside, a small skin wound on the left side of the forehead running towards the vertex. But as I touched it gently I discovered a spongy area instead of the bone, exactly matching the CT image I’d seen. It was closer to the middle line than I expected. I was concerned about the venous sinus there. If opened, the operation would be over in double quick time… Instead of the standard incision from the vertex down across the head over the impression, as we had been taught by neurosurgeons in Cologne, Germany, I chose skin flap, because it was just more suitable right there and then for that type of fracture.

The cranial CT scan © Tomáš Šebek/MSF

The cranial CT scan © Tomáš Šebek/MSF 

After pulling back the skin flap with galea (a tough layer of dense fibrous tissue which covers the upper part of the cranium), I could see soft puffs of brain tissue lying amidst bone fragments. At a greater number than I had ever seen in any patient before. I very carefully removed the fragment, which was buried deepest in the brain and then I contemplated the strategy of how to prise out the rest of the imbedded pieces so as not to cause more havoc than had happened during the accident. At that point I didn’t feel much like trepanning with a manual drill.

I prised out all of the fragments in the end, immersed them in saline for further use, and started investigating the hole in the brain tissue, ending in about a five centimetre torn dura mater (a thick membrane that is the outermost of the three layers of the meninges that surround the brain and spinal cord). There was quite a lot of diffuse bleeding. The last haemoglobin of the boy had been really low and currently we had no blood. But I was patient, sometimes it is better to just keep drying and wait.

I rinsed the brain with a Janet, which is a big syringe. I had been doing this since my first craniotomy in Haiti. It looks brutal and yet it is very friendly to the brain tissue. I didn’t poke in it anymore; I am still in awe of the organ where man dwells. I was thinking if I should return the loose bone fragments in there. Obviously, I feared the upcoming swelling of the brain and I didn’t want to obstruct it at a place where it would be a smaller nuisance than near the respiratory centre on the medulla.

In the end I decided to shape the four largest bone fragments making them almost round and placed them loosely on the dura mater like buttons. In addition I just drilled through and sewed them to the edges of the intact parietal bone ( the bones in the human skull which, when joined together, form the sides and roof of the cranium). Finally, I hermetically sealed the skin over them. I finished all of it within an hour. I am faster, more precise, I have it better thought-out and technically more refined. And it isn’t thanks to being really clever or talented. Practice, practice, practice. That’s what makes us better.

I said my goodbyes and departed for the base, where I was unpacking until one at night, washed my hair which was totally caked in dust, then had 24 hours worth of food - breakfast, lunch and dinner all at once. And then I slept.