South Sudan: With brain injuries, it's not luck that counts - it's preparation

When Tomas arrived in South Sudan, he found he was missing one bit of surgeon’s kit. Here he explains how the instruments he ordered mainly as a precaution meant the team had a chance to save a young boy’s life.

*WARNING*: This blog contains graphic images of surgical procedures, which may be distressing to some readers.

When I was checking on the surgical instruments we had here on my arrival, I didn’t find a single complete set.
The set I was looking for was a craniotomy set: instruments for opening the skull during brain surgery – a manual drill, a cutter, a wire saw. 
I asked our pharmacist, who knew exactly what I was after and was able to arrange everything.
If we had ordered these instruments through an international order, they would take at least six months to arrive. But because the pharmacist found them in a warehouse in Juba, South Sudan, I had them at my disposal in fourteen days.

Sharp as razors

Milling cutters are sharp as razors. They can get through the skull after a couple of rotations.
This speed - it's completely new! When necessary, four holes can be drilled in the skull in a moment.
It makes me think back to Afghanistan, where it took me over fifteen minutes to drill one hole. Yes - fifteen minutes.

Statistically speaking, during the whole existence of this hospital, there had been only one head surgery performed.

I presented the new instruments to the great interest of the entire surgical team. We discussed how they were used (unfortunately, only in theory).
Then we professionally sterilised them and placed the whole set in the vestibule (which is a simple closet).
I was convinced that I wouldn’t use it. 

Our craniotomy patient

Statistically speaking, during the whole existence of this hospital, there had been only one head surgery performed.
How long had the hospital been here? Four years? Six years?
Today I used the brand new set. We did a craniotomy.
He came to our primary health care centre in Mayom this morning.
Usually at around 9 am, our colleagues at Mayom refer the patients who need more complex care to our hospital in Agok. The journey takes three hours.
The boy arrived at the health centre five minutes before the convoy departed.
He arrived walking, accompanied by his mother. Apparently he had fallen while climbing a tree and was unconscious for several hours.
This was five days ago. The dirty wound on his right temple bears this out. 

A race against time

Someone once told me they thought time runs more slowly in Africa. Not in this case. Here we apparently race against time.  
The international nurse and paediatrician in Mayom correctly decided to refer the boy to our hospital. Along the way he was falling unconscious.

There’s a voice in my head telling me: Don’t wait! What are you waiting for?

When he arrives at our hospital, he is agitated. We can't manage to calm him down, not even with high doses of benzodiazepines.
Finally, we examine the wound with our anaesthesiologists: open fracture. Or a fissure on the right temple.  Both pupils responsive and symmetrical.
Objectively, there is no reason to intervene yet. Without an X-ray or a CT scan, I'm not able to come up with a better diagnosistic than basic neurological examination.
But as I examine him there’s a voice in my head telling me: Don’t wait! What are you waiting for?

Making a choice

I’m not waiting for anything. I listen to the voice in my head.
Experience tells me that when compared to the brain cell that works exclusively on the basis of scientifically explainable medical data, that inexplicable inner voice is usually right.

I have to discuss it with the MAM – the medical activity manager. He’s a very experienced GP. So it’s a substantive and quick debate with him. He agrees.
In thirty minutes after the decision has been made we start with anaesthesia.


I’m glad I don’t have to deal with his hair - local boys here regularly shave their heads, just as I did after my arrival, to finally stop sweating from my head. Our patient has done his recently.  
First I cut out the edges of the initial wound; I clean it and stitch it.
And then I find out that the wound is badly placed; I’m not able to do any of the planned skin flaps. The flap of skin I would aim to expose the skull bones with would risk becoming necrotic due to the insufficient blood supply.  
More staff arrive at the operating theatre, including two members of the international team, and with them looking on I gradually cut ten centimetres of what I just stitched in order to lengthen the wound and make use of the existing incision.
Good start!
Tomáš and the team perform surgery on their young patient.

Tomáš and the team perform surgery on their young patient. Photo: Tomáš Šebek/MSF.

Fortunately, the surgery continues as I wish.
After I drill four holes into the skull with the participation of the completely wide-eyed audience of the operating room, I start to saw a little square on the cranial bone.
I hear smacking lips around me. In local dialect it means something like: Oh, cool!

Respect to my inner voice

After the removal of the bone, a I feel a huge relief.
Yes, his dura mater (a thick membrane that surrounds the brain) is deeply perforated by his own bone fragments. And underneath, there’s a huge blue subdural haematoma (a bleed on the brain) shining through.
You would say: why would I be relieved at my patient’s misfortune? I’m happy because despite the basic diagnostic tools and with all the respect to my inner voice, I was right in this diagnosis.
I remove another part of the bone in order to make space for opening the dura. It’s been about thirty minutes since we started.
Then I have to stop for an hour because of eight square centimetres.
Tomáš and the team during the craniotomy.

Tomáš and the team during the craniotomy. Photo: Tomáš Šebek/MSF.

In these eight square centimetres I’m trying in vain to stop extensive bleeding from damaged brain tissue.
Trying to catch something that has the consistency of pudding with the tweezers.
That’s exactly what this part of the brain looks like because of the bleeding: like mush.  

"Wait and every bleed will eventually stop"

In the end, I rely on an old surgical rule: wait and every bleed will eventually stop.
After an hour, millimetre-sized movements and occasional use of electrocauter in the brain tissue, it all really stopped.
It’s dry. I’m closing.
And because damaged dura won’t do, I’m suturing a transplant from the fascia (connective tissue) of the jaw muscle.
It’s closed.
The staff look satisfied. There’s an unprecedented atmosphere in the operating theatre. I always experience that when I operate on the brain.

"Cranial surgery is team work"

Guys want me to extend my stay in Agok. They want to learn this.
I explain that cranial surgery is team work.
Both anaesthesiologists have done the biggest part, and they will continue doing it in the next few hours.
The rest is down to some kind of local god.
The surgical team in Agok, South Sudan, celebrate their first successful craniotomy.

The surgical team in Agok, South Sudan, celebrate their first successful craniotomy. Photo: Tomáš Šebek/MSF.

We move the patient from the operating theatre to the recovery room. We don’t have a ventilator.
We unplug him from the Ambu bag, but we keep him intubated. An unprecedented thing for a European observer, but I’ve seen dozens of such patients since I’ve been with MSF. The international staff anaesthesiologists will get used to it in in a while.
We give him Midazolam (a sedative medication) so he doesn’t take the tube out of his throat. But we give him just enough of it to make sure that his respiratory centre still broadcasts signals. Because with sedatives, it’s a game of millilitres.
Sometimes the boy sits, opens his eyes or, by contrast, stops breathing. And a pulse oximeter (which monitors how much oxygen is in the blood) is screaming.
The anaesthesiologists and I divide the shifts to keep an eye on him.
I sit with him till midnight.

Local gods

The story about operating on the boy’s head is spreading through the entire hospital. Colleagues ask questions. And the patients already know about it too.
When I’m walking through, they show me visible respect. I’m trying to be invisible.
There’s a grasshopper jumping on the floor of recovery room. And there’re also those malarial mosquitoes flying. It’s so hot that you’re almost dying. There’s a radio transmitter and diluted Midazolam on the table in front of me.
A nurse is monitoring his vitals and suctioning. His mother is sitting on the bed. She’s a bit angry about what we keep doing to her son.
We’ve tried to explain the fact that we need to keep him under sedation, but she’s understandably worried.
She tells me that evening that she would like to give him some food. I have a suspicion that she wants to give him rice through the endotracheal tube… Otherwise she’s helpful.
She helps us keep him calm on his bed when he’s waking up and midazolam hasn’t started to work yet.
I’m observing the grasshopper.
Right at this moment, there’s also a big rusty ant walking across the floor.
The mother gets angry every time I go to check on her son. Our translator explains me that she’s angry because of the way I look at him all the time!
It’ll be midnight soon. I feel sleepy.
The anaesthesiologist hasn’t arrived yet.
I think of handing the shift over to the local god, because I too need to lie down sometimes…