Fieldset
Day 8: Postponed Walk

A homemade grenade explosion causes a horrific injury resulting in Tomas the surgeon having to postpone the much anticipated hike.

Until now, we had not been allowed to walk to the hospital but today there was the first opportunity to go on a hiking trek through Kunduz to the hospital. Five of us were going. One of them was myself and I felt OK about that. It had been in preparation for months with the help of some of the locals so that everybody was 100 per cent certain that no one would be shooting our arses off.

Wake-up call at 6:00, I brush my teeth, go to the toilet and have breakfast. I was looking forward to the morning walk through Kunduz which was due to start at 7:00. At 6:35 we have a phone call: “We’ve had an explosion,”

“Shit,”  I say.

“Exactly,” The doctor’s voice responds on the other end. “With an unstable home-made grenade; injured pelvis, possibly blood in the abdomen so please come, okay?”

Abdominal surgery in Afghanistan MSF

A home-made grenade stuck between the buttocks…

That’s not the song name of some hard-core start-up band. It’s the reality of this morning. When I arrived at the hospital – by this time we were really hurrying – the patient was already in the operating theatre. In the place where the right hip should’ve been he had a hole the size of a gate that led into the abdomen. As soon as I opened up the abdomen, waves of dark venous blood came rolling out. This time it was not be a torn liver, judging by the direction of the explosion. On the X-ray I also saw small fragments impaled throughout the whole pelvic area.

The intestines are good, both the large and the small so I take a look at the spleen. Then I see it. The entire retroperitoneum (the area between the abdomen and spine) has been lifted-up. There it’s really bleeding. As soon as I make a hole in it a jet of blood sprays onto my chest. When I open it up properly the blood tsunami continues. From three minutes of suction there are two litres of pure blood in the suction flask. I don’t think he will survive this.

I can’t see anything, the pump does not manage to remove the blood fast enough and I’m sweating like a pig. I wrap one cloth over the top of the area that’s bleeding the most and another under it and SQUEEZE, Mr. Assistant, SQUEEZE! This alleviated the blood flow enough that what we had been searching for appears below the vacuum pump. Oh My God! Almost two centimetres of the common pelvic vein is ripped. This vein is garden hose calibre. I scroll through my brain to the relevant chapter and decide that we will sew it up.

Sweat was pouring off me like raindrops. It dropped off me everywhere, even inside my glasses but especially into the open abdomen. My hands however remained absolutely calm. At moments like this they always cease to belong to me; they work independently and I look down on them from above, just watching. The shaking comes later, after many long minutes have gone-by. Stitch by stitch, with a fine needle and using thread that’s nearly invisible, I sewed the mess together.

We went through the abdomen and we removed just a single piece of shrapnel, otherwise, nothing really. We went through everything twice; I hope we didn’t miss anything. My fist would have fitted into the hole in his side. I have a big fist, it doesn’t fit into my mouth and I have a big mouth! Anyway, enough of the measurements!

He was bleeding from everywhere; his torn buttocks, the ilium bone that is blown off and from which most of the blood flowed. Unfortunately, we can’t stop this bleeding and we didn’t have any wax for the bones. So it was a case of washing-out, removing the plastic cap from the grenade, putting gauze inside and tamponing the bleeding. He was stable, with a haemoglobin level of 42, so we put him in the ICU.  I felt a kind of temporary victory until the evening, when I actually saw him after six transfusions. He was quite calm, hardly restless at all so we’ll see in the morning…

Painful rounds

Here in Afghanistan you have to accept the fact that you cannot do everything, and certainly not all of it at a 100% level. Adapting to that takes a week or two. I’m almost there, but it still bothers me when I see how some patients have been treated before they arrive at the MSF hospital: wires pierced where they shouldn’t be, people with rotted limbs because nobody did a fasciotomy after they had been shot in a limb. They have more antibiotics than you could stuff into an ox but those who need them don’t get any. During rounds we have 60 beds so we only have time for just two minutes with each patient. One has to focus on what matters the most and leave the rest to Allah.

Before rounds we receive a general report that begins with a safety report by my colleague Purdel. He reports that the situation in Kunduz is quiet and activity is normal. The Security Level is one, which is the lowest. Then, however, he reports that several people have been killed in the vicinity, a few mass casualties on the roads and a murder. I cannot imagine what level two is like! Nor how many levels this scale has, for God’s sake!