Surgery in South Sudan: the bald surgeon

Tomas discusses surgeries, head shaving and landmines: his account of a normal day in South Sudan.

We go for a run, intentionally avoiding where we ran into dogs the last time. Despite this, we end up running into a fight between three nasty-looking mutts. They growl and bark at each other, and at the villagers who cluster around them. The villagers are trying to protect us, which is touching. Learning from their example, we pick up some stones just in case. The dogs reluctantly, but nimbly, move on. We thank the villagers.
This morning I struggle with my meditation.
The previous night, I admitted a patient  whose left leg had been shot that afternoon - I don’t know the details or the reasons.
I wanted to operate on him as fast as possible.
He was already lying on the table when we found out that our external fixation set wasn’t sterilised. So no surgery for now.
Tomáš in the operating room with colleague Anitha.

Tomáš in the operating room with colleague Anitha. Photo: Tomáš Šebek/MSF.

Doing ward rounds, I sent our healed patients to the parking lot to take their bus home. They stood in the sun for an hour, only to return because their departure was rescheduled for tomorrow.
I’ve been requesting a HIV test for one patient for four days. Every time I ask, it’s like I asked for it the first time. 
I start to become grouchy and make a profound "mmmmmmhhhhmmm…" sound.
Eventually, Anitha and I place the external fixator on the man's shot leg. Fractured at a right angle from the tibia. We perform plastic surgery, a reverse sural lobe. 

Loop sigmoideostomy

A sixty-year-old man comes to the hospital. He was shot in his abdomen in 2014, and back then we made a temporary intestinal aperture (stoma). This is when part of the intestine is diverted through a small hole in the abdomen, through which urine or faeces is removed while part of the bowel is healing.
He hasn’t had time to come to see us till now.
Now he has finally come, he's only brought the outpatient charts. They are so tattered and faded that we can hardly read them.
We discover that the stoma is a “loop sigmoideostomy” - in other words, it’s on the top of the sigmoid colon. There should be two openings - one leading to the functioning part of the bowel, and the other to the rectum. There’s only one. 
Normally we would operate to attach the two openings to each other, so the healthy bowel is connected to the rectum again. The only thing we can do for this patient is pray to find the rest of the rectum somewhere deep in the pelvis.

"What are we going to do?"

We thank the previous surgeon for keeping a consistent record in this patients' chart! 
We have no equipment  to find out what part of the rectum remains there. We don’t even have any examination methods available. We guess it’s probably in the midline of his abdomen, and begin the surgery.
After a while of searching and threading the entire digestive tract through the small intestine bridge to the right side, we find out that the sigmoid colon has really does seem to resulted in what's called 'terminal stoma'. We are surprised that it hasn’t knotted yet.
There’s absolutely nothing in the pelvis minor - Anithe, what are we going to do?
The first idea is to close the abdomen and refer the patient somewhere else, where they’ll try to connect the rectum with stapler – a special surgical stitching instrument. Of course, we don’t have one of those here.
Anitha mid-procedure.
Anitha mid-procedure. Photo: Tomáš Šebek/MSF.
No, we've already cut him open. We have time, there’s no other emergency. And of course, a bit of our surgeons' pride is at stake.
Most importantly, we may be the only option for the patient. Who knows if someone else would take care of him?
So I plunge into the pelvis.
Gradually, deep down and retroperitoneally (in the back of the abdominal cavity) I find the hidden rectal stump.
When I manage to loosen it after a while, it is just long enough.  
I hand the reins to Anitha who disconnects the stoma from the skin and starts to stitch those two ends of separated intestine together. I’m glad that she’s doing this - after all, her eyes are ten years younger than mine.
There’s a floor lamp illuminating my back with faintly yellow light. Another lamp with sharp white LEDs is shining right to our faces. It’s usually dark inside abdomens.
Anitha stitches it very well!
We irrigate and drain it.
Give me five! Chalas, tamam!

Bald surgeon

Could you cut my hair?
How much?
Well, first I’ll try to shorten it with the clippers. And then you’ll tell me if that’s okay.
The first set of clippers isn’t working.
But I bought two-for-one and they were very cheap. My barber recommended the model to me. Cheap, but American original. The second one doesn’t have the right extension for shaving head. So, number three...
I’m bald-headed in 10 minutes.
Anitha cut my hair. She had some objections that I’ll be less attractive. Between choosing attractiveness and the fact that my head won’t sweat that much, I’m definitely choosing the second option.
The last time I was bald, I was eighteen. When we were having dinner at home I had to sit at the table with my hat on.  I think that if I had dinner with my parents today, they would force me to wear a hat again…

Snakes, dogs and landmines

In many places across South Sudan there’s unexploded munition (bombs, mines, grenades, rockets and others). Very often, they are hidden in the ground and people are powerless against them. The most vulnerable are playing children.

Daily life in Agok.

Daily life in Agok. Photo: Tomáš Šebek/MSF.

Supposedly landmines have been here since the first Sudanese civil war, which took place in the eighties. Groups of British and Dutch mine removal specialists have been and gone in the past several years, clearing the land of mines.
Apart from the fact that during the dry season mines can be quite visible, they don’t move. Or do they? During the rainy season they swim in the mud as if they were swimming in the water. So it can happen that a road that had initially be cleared of mines can get mined again.
The only one hundred percent safe place in Agok is allegedly the main street. The beaten paths around tukuls are around ninety per cent safe, but only during the dry season.
So not only snakes and dogs, but also landmines.
One of the locals joined us on our run until the bus terminal station. From there on, he used public transport. 

Read Tomáš's post in the original Czech here.