Surgery in South Sudan: Facing death

Surgeon Tomas blogs about an emergency surgery on an eighteen year old girl in South Sudan.

Content note: this post mentions suicide. Please take care while reading.
In total desperation, I push another dose of diazepam into her vein. Her masticatory muscles ease off from contracting for at least for couple of seconds. I insert an airway tube in between her teeth. When I take it out, she clenches - and my finger gets stuck between the airway and her teeth. It’s a nasty pain. I’m helpless under current circumstances, but she's in much more pain than I am. The girl is as tense as a bow, especially her back. Her fists are clenched. She vainly struggles to breathe when having those terrible muscle contractions. This is the moment when muscles are fighting against their own body. And that causes death…
In the evening, children with malarial fevers start to come into the hospital in ten minute intervals. We admit six of them within an hour.
Fortunately, none of them were in critical condition - that would have been a disaster in such a short period of time.
These kindergarten kids, aged from one to three years, are placed in our stabilising unit deep down in the desert of South Sudan. We give them antimalarial drugs and infusions for the dehydration caused by diarrhea and vomiting. We test their blood sugar, because it can rapidly drop during malaria.
I’m making an effort to get familiar with the subject so that I’m not just standing around these patients and asking my colleagues stupid questions. 
When I’m kneading dough for Friday’s pizza, they call me back.

Attempted suicide

An eighteen-year-old girl is lying on the ICU bed.
God knows why she tried to kill herself.
She got poisoned by some kind of local make-up, reportedly very toxic. And then she went to hang herself on the roof.
Her father cut her off and brought her in. They’ve been on the road since one o’clock. It’s seven now.

Cannulation. Photo: Tomáš Šebek/MSF.

The girl is confused, disoriented, aggressive and desperately stiff.
While others are struggling with cannulas, I’m trying to examine her and secure the airway. It’s impossible - her teeth are clenched as if they were glued together.
I’m done struggling when I find the vein. Five milligrams of diazepam relaxes her entire body in a second.
We can insert another cannula and secure the airway. She doesn’t need to be ventilated for now, as her oxygen saturation (percentage of oxygenated blood cells) is excellent.
Gastric lavage was unsuccessful and it’s not possible to insert a gastric tube. After we stabilise her we put her to bed.

Wake-up call

Our pizza didn’t turn out very well; the dough is burned on the top and not baked at the bottom.
I’ll be sick. But I’m gonna eat it anyway. I’m going to bed.
At night I wake up after midnight and my throat is completely dry. A fan is blowing air straight to my mouth. It’s the second time I've got a cold because of that.
My muscles and joints hurt. A sniffle. A cold.
William, one of our clinical officers, calls me at 4:30 am.
"Tom, that girl is desaturating. Oxygenation of her red blood cells is low." 
I gradually get up from bed and I go to the stabilisation unit. Saturation at 60 percent! Damn, such a wake-up call!
She is tetanic, sweaty, shaking, restless. Another two milligrams of diazepam and her neck relaxes, allowing her airway to open fully.
Her mother had put a pillow under her head, which caused her her airway to close. In three minutes we have a 100 percent saturation.
I tell her mother to keep an eye on her open airway, and no pillow. Then I go to bed.

What keeps us going

Originally I wanted to oversleep.
Screw today’s ward round! I feel sick.
But every doctor knows that there’s a higher power above us. We have too much responsibility, and a really terrifying prospect that we won’t be where we are needed makes us keep going.
I get dressed and prepare very strong and very sweet tea (like the Afghans do), then head for the office next to the stabilisation unit.
A little patient before being released home.

A little patient before being released home. Photo: Tomáš Šebek/MSF.

Around the complex, you can hear desperately loud gasps from the girl whose lungs are trying to ventilate, despite the tetanic (spasming) muscle resistance.
After a while, I go to check on her.
Pulse oximeter not measuring. When I position it right, it announces her saturation levels are lower than 50 percent. Damn it!
I mobilise Melanie, the head nurse from Switzerland. She’s great!
I need an airway tube, ambu bag, adrenaline, diazepam, infusion and most importantly some help because the girl is fighting us really hard in her seizure.

"I didn't cry then. But I'm crying now, writing this"

It’s not helping anymore.
I can feel her extremely tense cheek muscles with my fingers. With the last aperture in the airway tube, I remove a huge amount of mucus with a manual suction pump.
Her mother is holding her legs and knows that it’s over.
Her sister is holding her hands and she knows it as well.
They both start quietly crying. (I didn’t cry. I’m a trained professional. But I’m crying now, when I’m writing this).
I don’t know if it’s a physical symptom of sickness or if it’s my soul hurting. I feel like I’m gonna throw up.
And here it is. Her respiratory rate is gradually lowering. Her body is getting released. Her heart is stopping beating, there’s no pulse on major arteries.
When she becomes floppy I start resuscitating. Heart massage, ventilation of her airways that are already loosened.
There’s white foam literally spattering from her mouth with each compression of the thorax. Adrenalin.
We all know that we cannot defeat this death - but we do our best and attempt resuscitation for thirty minutes.

My soul hurts

She probably got poisoned by some kind of curare?
Today we could have really used equipment we simply didn't have: muscle relaxation drugs, a laryngoscope for inserting the endotracheal tube, and a ventilator to help her breathe before the tetanic spasms subsided.
We didn't have any of it.  We cannot blame ourselves for anything.
Who knows why she tried to commit suicide. Maybe she was raped? Unfulfilled love?
I don’t know if this death is just.
I do the quick ward round. In order to amuse all the patients and relatives who witnessed this terrifying situation, I take a picture of an “abuba” - that is, a grandmother of one of our little patients.
People smile.
I apologise to my colleague and I go to my tukul. I don’t know if it’s a physical symptom of sickness or if it’s my soul hurting.
I feel like I’m gonna throw up.

Mercedes Unimog

In the evening I go to see the Mercedes Unimog.
While during the dry season we refer patients to Agok in a typical MSF land cruiser and it takes three hours, during the rainy seasons we use Unimog trucks.
I have a driving license for the Unimog. But I’m not an authorised person here, so I cannot drive it.
However, walking around it and sitting behind the steering wheel made me feel good today.
Me behind the wheel of the Mercedes.

Me behind the wheel of the Mercedes. Photo: Tomáš Šebek/MSF.

It’s a real car and I think it’s perfect for trips in one’s old age. I add it to my wish list.
I water the flowers before I go to bed. A previous inhabitant of my tukul planted some plants so it would be a pity if they faded.
Maybe if everybody planted a tree here, we would stop the drying in Africa.
Standa Havlíček, our pharmacist, used to say that it’s one of the official world plans.

Read Tomáš's post in the original Czech here.