Day 12: Midnight Trepanation of the Skull

"I do not like quiet periods. It means that something is going on. In the ICU three out of the four beds are vacant. The doctors in the emergency room stare at the wall, not a molecule of air is moving in the hospital… It is clear, that something terrible is about to happen!"

During the day I am just dilly-dallying with nothing concrete to do. I am releasing the boy who was shot through the heart from the hospital. The patient with the torn liver is also finally going home and all other laparotomy patients are healing surprisingly well. The people here are robust…

Time passes slowly and there’s time for an afternoon trip to the base. Perhaps today I’ll even manage to join the group that aims to spend an hour in a local “pub”. I am working my way through the department and my last stop is in the emergency room. They have a little girl there following a car accident.

She suffered a severe impairment of consciousness, bleeding from the left ear, a comminuted [splintered] fracture of the skull, a fracture of the left humerus [upper arm] and an open fracture of the tibia [shin].  Finally I discover that she also has a totally unstable pelvic fracture and that if nothing is done about it immediately she will die… In the end everything turned out for the best, but it was this that started the onslaught that I had been expecting all day!

Trepanation of the skull. So here it is!

There was then an ageing man of about 50 years old. It was a few hours after a serious car accident before they managed to drag him here. He is in a coma, but to me the brain does not seem too screwed up. We have some sort of manual here that was put together by neurosurgeons and neurologists who understand these things. It has pictures designed specifically for idiots such as myself. The X-rays and the subsequent CT showed a fracture on the left side in the area between the temple and the top of the head – an impression. I suggest a craniotomy and surprisingly everyone agrees. They say that during the year long existence of the hospital, no one else had done it here. They say we do have the equipment though, so hooray!

Xray showing the skull impression Tomas operated on. © MSF

Xray showing the skull impression Tomas operated on. © MSF

Our mission in Kuduz is to help people, if possible, to do no harm and mainly to train local staff. Together with the local orthopaedist, Dr. Samsoor who’s on duty, we are opening-up the man’s head. I’m already an expert on skin incision. We find the impressed area and clean it immediately. We will need to drill holes into the head. I am showing my Afghan colleague how to make the first one. Because we’re both decent drillers, we don’t have any problems with the manual drill and smoothly puncture it twice. I then show him a trick where I slip a saw beneath the bone and then to cut it. Carefully we remove the fragments of fractured bones and rising from beneath is the dura mater [the membrane that separates the skull from the brain] which is fortunately intact.

When we have a hole of about 8 to 10 cm, it is solved. No more bone pushing on the brain. I pluck up my courage and stick a needle in just beneath the dura mater to suck out at least some of the bleeding that is coming from beneath there. If I were sure that we could successfully close this entire wound and that the risk of infection would be minimal, I would close that dura mater straight away and then flush it thoroughly. But I’m not sure, so we leave it closed. Samsoor obviously enjoyed it, he was puncturing and drilling like crazy. He definitely enjoyed the special taboo that accompanies head injuries and surgery!

When we are closing it, we carry out some very minor plastic surgery and make a skin flap so that we can close it as effectively as possible.Seven minutes before the end of the surgery all the lights go off for a few minutes… This time the backup generator does not even kick in and since it is eleven at night and it’s dark outside it’s dark as hell in here My colleague actually finishes the sewing thanks to the LED lights from three mobile phones. It’s quite touching that here we are struggling in these conditions in the light of these modern ‘candles’. It feels like a convergence of people and of nations.

Liver 2.0

Before I have completed the head surgery, they bring in a patient who has been shot. The bullets have gone through the right hypochondrium [upper abdomen] and it emerged in the left frontal area of the chest. It will be a mess in there, probably another damaged liver. As Samsoor has started struggling with an open femur fracture in the next room, this time I’ll work by myself, alone. It is half past eleven at night.

Again I cut it through the centre and just to the right under ribs. There’s a hole in the liver the size of a cow, again the liver almost in two halves, and again ounces of dark blood in the abdomen. I had plenty of practise from my last patient with a torn liver,, so this time I quickly stick dozens of pieces of gauze under and behind the liver and with a beautiful, sharp – and also the largest – skin needle that I have, I proceed to connect the left lobe of the liver to the right one. Normally a special needle is used for this and usually three surgeons are working on it together over a period of hours.  I have sewn the liver together in twenty minutes.

With my left hand I raise the chest while pumping out blood, while with the right hand I sew and add new stitches using a needle that I’ve placed on the liver. The left hand of the nurse helping me keeps the liver away from the diaphragm and he cuts using his right hand. This is it. Everything works. I even have a splendid view of the surgical field. I’m not afraid. It has become routine!

With the liver sorted I continue my reconnaissance of the terrain. His stomach is also cut in two. I carry out B1 anastomos – simply cutting off the dead parts and sewing the live ones together. I then stop the bleeding from the interstitial suspension. The spleen is ok, as are the intestines. After an hour the fight is over. While I’m washing my elbows that are covered with blood, Sergio the anaesthesiologist comes to announce in a resigned manner that in the Emergency Room there is a patient with a puncture wound to the abdomen. It is one o’clock in the morning

When I arrive in the Emergency Room there are already two stabbed people … We don’t finish-up until 2:30 am. I came to the hospital the morning before at 7.45 a.m. Since then I’ve had nothing to eat, nothing to drink and haven’t even been to the toilet.