On the Way Home

I am out of Gogrial.  And now I am back in the capital city, Juba.  The internet here is not as good as it was in Gogrial.  The power comes and goes, with no apparent reason.  The infrastructure in Juba is not very good, and sometimes, barely adequate.  There is a lot of room for improvement.
It is always hard at the end of a mission.  There are many people with whom you have worked hard, sweated, and survived.  It is hard to say goodbye.  But it is time for the next chapter.
The people in the OT have been great.  Angelo and Alessio have been the OT techs.  Abdullahi was the anesthesia provider.  We had a great team.

Alessio on the left, Angelo in front

I wish them all well.  Things are improving in Gogrial, but the influx of refugees at the camps near the border is overwhelming.  They estimate over 200,000 now, and they keep coming.  The camps have had to be moved due to flooding.  What a mess.  I feel fortunate that I was in a relatively safe area.  The stress levels at the camps is very high.  Many ex-pats have had to end their missions early, because of high stress, and illness.  I guess I have been very lucky.  I give a great deal of credit to the people who do this work.  It is hard work, and not glamorous in the least.  But there are people who need the help.  And I am glad to be able to help.
It is overwhelming.  So I am reminded of the parable of the little boy and the starfish.  It goes like this.  A little boy was walking along the beach after the tide went out, and he saw thousands of stranded starfish.  So he picked up starfish, one after another and threw them back into the sea.  An old man was watching him.  The old man told the little boy, "There are too many to help.  It won't make a difference!"  The little boy looked at the old man, then threw a starfish back into the water.  He said, "It made a difference to that one!"
So we do what we can in the face of overwhelming suffering and need.  And we hope to make a difference.

The Operating Theater (OT)

The scrub sink and the door into the operating room

The preop and postop area in the tent

MSF has used inflatable tents in areas of emergency.  These can be erected rapidly, are fairly mobile, and are very functional.  The OT in Gogrial is an inflatable tent.  The inpatient units include a Surgical Ward, a Medical Ward, a Pediatric Ward, and a Maternity Ward.  These are in fixed buildings that were built in 2010, and will eventually be handed off to the local Ministry of Health once the Human Resources and infrastructure to man and maintain them are present in the local community.  It is then that MSF will back away from this project.  This should occur sometime around 2015, but no one is holding their breath.

Sunday Morning

It is Sunday Morning, and the camp is still quiet.  This is the start of my last week.  I will start the journey back sometime later this week.  Time for some updates.
The man who was stabbed with the spear (A Piercing) survived and was sent home.  He was actually quite grateful for our efforts.  He offered to share his tobacco with me.  The man with the AK47 wound to his arm continued to worsen.  His family wanted him sent somewhere else, so we tried.  We sent him to Turalei, but there was no surgeon there.  And he returned to us.  They went to a traditional healer, but again he returned to us.  The gangrene in his arm continued to worsen.  His family finally decided that he did need surgery when they could see the maggots crawling amidst the wounds.  Because they had waited too long, the infection had climbed up past his elbow, requiring us to amputate higher than we originally planned.  We proceeded with an upper arm guillotine type amputation because of the nature of his infection.  He now looks much better, and his sepsis, which I was very worried about, seems to be resolving.
There was an attack two days ago by Sudan.  Three villages near Aweil were bombed.  There were several injuries.  A pregnant women sustained injuries to her back.  She is still in Aweil, but will be transferred to us tomorrow for more definitive surgical care.  (There is not a surgeon in Aweil.)
There are two women in our Antenatal area that we are watching closely.  One was thought to have a transverse lie, and would likely need a c-section.  After a number of evaluations, we felt that the baby was vertex, but the size of the uterus was concerning.  She might have twins!  The other woman has what we think is polyhydramnios.  We do not have an ultrasound or other way of evaluating patients other than clinically.  She may need a section as well.
So, the adventures continue.  There is not really a break.  I am the only clinical doctor here.  There is a fill-in administrator, that we call the medical focal point (MFP) who is a general practitioner, but he doesn't do much clinically.  He has been here for three days.  His responsibilities are primarily administrative.
The camp is stirring, and it is time to make the rounds and see the patients in the hospital.

How to Have a Meeting

Every day we meet in the morning.  We go over everyone's position and area so that everyone understands what the plan is for the day.  The other day, there was a song about malaria.  Today the song was about diarrhea.  Probably not on the top ten for most artists, but I thought that it would be fun for people to see how our meetings are held.  The guy that is singing is really quite good.
http://www.youtube.com/watch?v=Iet_Eci-6yo&feature=plcp

No Bicycles, No Motorbikes, No Cats

This is a picture of the sign that is posted near our meeting area.

There are a lot of things that should not be allowed into the meeting area.  I find it pretty curious that they find it important to list these out.  What about the mosquitos, the snakes, the porcupines, the hyenas, and the lions?

What They Don't Teach You in School

It seems that during our training as physicians, certain things are stressed as true and important.  I'm sure that this remains true in most of the United States.  But there are times when these truths are bent.  I remember learning that an open fracture is considered an important thing.  Something that should be fixed and cared for immediately.  Here in South Sudan, and I'm sure other places around the globe, open fractures are just another bump in the road.

I was just asked to see a six year old boy who broke his leg almost a month ago.  He came from another MSF site where there were no surgical capabilities.  When he arrived we did a quick assessment.  There in the middle of his leg, sticking out of the skin, was a ragged bone.  His tibia!  He has been limping around on an open fracture of his tibia for nearly a month.  Some emergency, I thought.  So much for all that secret orthopedic knowledge.  What I was lacking was the experience in treating open fractures where the bone is sticking out of the skin, and has been for weeks, and the bone left inside the skin has started to heal.  So once again, we did our best.  I took him to the OT where I opened the wound a little bit, and cut out the bone that was sticking out.  Then we packed his wound, and made him a type of splint that would allow for further dressing changes, yet give him support so that he can maintain some mobility. I doubt that he will ever run in the Olympics, but then again, how many of us with normal leg bones really have?

Charles Dickens and Tusker Beer

The nights are long near the equator.  The sun goes down just after six, and comes up sometime around six.  There is no night life.  No TV or movie theaters.  No restaurants.  The evening meal looks just like the noon meal, except colder and older.  So I read.  And what I have with me is Charles Dickens A Tale of Two Cities.  It is much better to read this story now than when I read it in high school.  I remember liking it then, but I'm sure that I didn't get it.  However, it is much better now.  To enhance the experience, there is Tusker beer.  It is made in East Africa, and is named after the elephant which killed George Hurst, one of the original brewers.  I had been told that Tusker beer is a terrible beer.  But when it is the only beer, it is also the best beer served.  Charles Dickens doesn't seem to mind.  Because, it was the best of times, it was the worst of times ...  

A Piercing

They have been through a lot, these people of South Sudan.  Many have been displaced.  Many have seen family members perish violently.  Many have seen friends die.  It is very hard to put it all into context.  Most of it is hard to even imagine.

Notice the number spikes that are not visible above.

I had a hard time imagining what I saw last night.  A local Dinka man, a one time soldier, a one time pastoralist farmer came into our compound with a spear imbedded firmly into his body.  From what I could understand, the woman that he wanted to court into a marriage had chosen a different man.  This was the last straw.  This man had been through too much, and this was just one more thing that he didn't want to deal with.  But he did deal with it.  He took his Dinka spear and stuck it into his body as far as he could, as far as it would go.  And it went far.  We took him to the OT to see what we could do, knowing that he would probably die.  The spear, a fearsome thing, went through his lower chest and upper abdomen.  It pierced through his xyphoid, and went through and through the liver.  It glanced off of his heart, but did not obviously damage it.  It went all the way to his spine.  We wrestled it loose, by spreading out the damaged liver.  The large spikes on the spearhead seemed to anchor it to everything, damaging organs with every movement.  But we continued, and eventually freed the offending object.  We had no suction device, and essentially no cautery.  I pressed on both sides of the liver to try to stop the bleeding.  I held that pressure for minute after minute.  And the bleeding slowed, and then stopped.  We were able to start to close the incision.  This morning, he was alive.

Exit Wound Update

After the return of the man who had been shot by the AK47, we took him to the OT for re-evaluation of his wounds after he left the hospital for a traditional healer.  The family still did not think that the wounds were bad, until we showed them.  The wounds were grossly infected, and maggots wriggled in a couple of the wounds.  Pus, and an awful smell, seemed to come forth in waves.  It almost made me want to gag.  His hand is not salvageable.  In fact, his forearm is not salvageable.  I was hoping that we would be able to amputate below the elbow, to give him at least a usable 'hook' at the elbow joint.  We will not be able to do that.  The tissues are too far gone.  Tomorrow, if they consent, we will proceed with an amputation.  I just hope that the infection hasn't made its way up into the upper arm.

Exit Wounds

There is a man who, appearing violent, was shot, reportedly in defense.  The AK47 7.62 mm bullet that struck his arm entered near the elbow, travelled down the arm and exited just above his wrist.  Both bones of the lower arm were destroyed, and there is basically nothing but a few tendons and some skin attaching his hand to what is left of his arm.  He needs an amputation of his hand and lower arm.  When we initially evaluated him, he would only consent to debriding, or cleaning the area.  However, over the next couple of days, he has developed gangrene of this hand.  Again we discussed further surgery, but this time his family refused for him to go to surgery.  They recommended a traditional healer, and he left the hospital.  Today, I heard that he was back, and wants to go ahead with further surgery.  I'm not really sure how much we can save at this point.
The family dynamics of consent in this region are very interesting.  The family must all agree, and women are not allowed to consent for themselves, but must have their husbands give consent for them. We have learned that we cannot rush this process.  We just wait, sometimes knowing that the situation is becoming more and more grave.  It can cost a life.  But there are violent reprisals if we were to circumvent this process.  So we wait, and watch, and wait.  And hope for the best.

Cat in the Compound

On the MSF ex-pat compound, we have about four cats.  They are of the domestic kind, but are not very domestic.  We keep them here because they keep the number of snakes down.  Their lives are not always easy, either.  One of the smaller, younger cats was taken by a hawk, but fought bravely and escaped with a fall from the sky and an injured eye.  The hawk lost the cat, and the cat lost an eye.  She is now the one-eyed cat.  But she has compensated well.  She sits next to us sometimes, and will let us scratch her ears.

Neighbors

The MSF compound and hospital are on the south side of Gogrial.  I am told you can actually see it on GoogleEarth, but the flyby must have been one or two years ago, because not all of the new buildings are present.  We are, however, still in the neighborhood.  Grass huts surround the compound, which is fenced, and supposedly secured with guards.  This morning I met the neighbors.  Two children, who called to me. "Kawanja!"  I came over, and they let me take their pictures.  Getting photos of the Dinka people is difficult, and can be tricky.  I have had to let many great opportunities pass for reasons of safety.  But my neighbors said "good morning, how are you?" and wanted a picture.  Many of the children know some English, and want to try it out.  Primarily we hear greetings.  Sometimes we even get a smile back.  And this is from a people who do not readily smile.

A Mosquito Net Among Friends

It is malaria season in South Sudan.  It is the rainy season, and the pools of water make great breeding grounds for the mosquitos.  We are seeing severe malaria cases in the the MSF hospital.  Many of these patients would have died, and many may still die of the disease.  There are several forms of malaria, and the one that is endemic here, is the worst kind.  So to help fight the malaria, MSF along with many other NGO's have handed out thousands of mosquito nets.  Some of our workers recently did a series of site visits to see how many people were using the nets.  The findings were pretty interesting.  They were being used for fishing nets, and for protecting young plants.  Some were being used to trap ants.  Very few were being used as mosquito nets.  It is all very interesting.  A question of priorities, but this is Africa, and life seems to be pretty cheap at times.  It may be worth the cost of a mosquito net.  A few cents.

Abdulahi and Me

The core of the surgical team is the anesthesia provider and the surgeon.  We also have two OT nurses, and one somewhat in training.  Abdulahi is the anesthetist.  He is from Kenya, the northern province, and is of Somali origins.  He has a very positive attitude.  Despite the fact that our anesthesia machine does not work properly, it does not slow us down.  He hand ventilates all of the patients.  We do patients from newborns to adults, and he never hesitates.  When we are not in the OT, we help out on the wards.  Today we used a variety of salvaged materials to rebuild a suction machine to be used in the maternity ward.  It is amazing to me all of the combined ingenuity that is used in a project like this.  There is no Home Depot or Menards to scour.  Everything that is used has either been carried in or is adjusted and made to work.  Yesterday, we tried to rebuild some fans to be used for cooling the tents.  The wards are full of people with severe malaria and malnutrition, and we have had to place mattresses on the floor to have a place for everyone.  Sometimes there are enough sheets for the beds, and sometimes not.

100 Cows

Abdulahi, my anesthesia provider, and I were having tea and reminiscing over the day.  We were planning the next OT schedule, and reviewing improvements to be made.  The conversation migrated to family.  He is a Somalian Kenyan, which means that his heritage is Somali, but his tribe lives in the northern area of Kenya in a province called Somalian Kenya.  He showed me a picture of his 2 year old son and 4 month old daughter.  He plans on about six more.  I proudly showed him pictures of my children, Taylor and Kate.  He thought that Taylor looked strong, but when he saw Kate, he exclaimed, "she is worth more than 100 cows!"  This is quite a complement.  It implies not only beauty and strength, but talent as well.  Many of the average girls are only worth 50 to 60 cows.  But a good one is worth more than 100 cows.  I am so proud!

Giving me The Finger

There must have been a reason why parents from around the world tell you not to bite.  Firstly, usually a fellow human does not taste good.  Secondly, it can be taken as an insult in many cultures, and thirdly, it hurts, and can do some sort of damage.  If someone bites you, you should make sure that you take good care of the wound.  Keep it clean, or it could get infected.  When I was in Sri Lanka, one of the first cases of true gas gangrene that I saw was secondary to a human bite.  Yesterday, I met a woman who was bitten on the finger.  Although it happened several days ago, she seemed to think it was getting better.  But she finally came in to be evaluated when it didn't improve.  It's hard to know how she figured out that something was wrong.  The picture is what it looked like when I saw it.

Shortly after this picture was taken, she gave me the finger.  There was not much a struggle to get it removed.

The Operating Theater

It is Tuesday.  Yesterday we were locked down for the one year anniversary of the Independence of South Sudan.  That means that things were pretty closed down, except for emergencies.  This morning we did four cases in the Operating Theater (OT).  The theater is in an inflatable tent.  But it is actually pretty functional.  I have a great anesthesia provider from Kenya, and the operating room nurses are local Dinka guys.  They also translate for us.
The Independence Celebration went off without too much of a hitch.  We did not have any attacks that I know of, although there had been concern that violence could arise.  The youngest country in the world just turned ONE.  They have a long way to go.  But they are going.  We need to wait and watch.

In the Field

The drivers didn't make it all the way to Rumbek that first day.  They had to stop in Tonj for rest and get up early the day of our departure.  They arrived at 0900 ready to pack us out, but we noticed a flat tire which needed attention.  Luckily, two spares are carried on each of the two vehicles.  We loaded up and took off.  The drive was about nine hours of four wheeling over difficult roads filled with potholes at next to breakneck speeds.  We needed to move fast in order to get to Gogrial before night fall.  The military was on the move, and we feared multiple roadblocks once evening came.
There were soldiers along most of the road.  Some were real soldiers, and others were guys with AKs and no uniform.  It was difficult to tell who they sided with.  We saw many AK47s, SKSs, and Chinese copies.  There were soldiers from Libya who had been either hired or had chosen to help.  I wasn't sure who's side they were on.  We knew that we didn't want to get stopped.  So we kept moving.  Fast.  And hard.  And we made it.

http://www.youtube.com/watch?v=iyzCIPjY5uU

This is a brief shot at the ride.  What I later found out, was that this was the good part of the road.

A Kenyan, a Zimbabwean, and an Ethiopian Walk into a Bar

There are four of us here in Rumbek.  It is easy to recognize me.  I'm the white guy.  The rest of the team includes our Kenyan logistician, a Zimbabwean nurse, and an Ethiopian nutritional nurse specialist.  We sat at the small bar in Rumbek sipping on Tusker beer.  It was cold and good.  The meal that we just had was roast lamb, some sort of beef, and pieces of chicken grilled over an open fire.  There was also rice, and some sort of local tuber.  We can't complain about the food, at least not yet.  It sounds like the meat in Gogrial is primarily goat.  I should have thought to pack some of Lynch's famous Butt Rub spice mix.  There are very few vegetables available.  Dominic tried to buy some spinach seeds, but was not successful.  He would like to start a small garden for some greens.

Road Warrior

Because the UN helicopter could not deliver us to Alek to picked up by the MSF vehicles, we are now preparing to drive by road to Gogrial.  It is a long way.  The roads are very poor.  Because they are poor, it is routine to send two vehicles, in case one would get stuck.  I have been chosen to ride shotgun in one of the vehicles, while Dominic, our Kenyan logistician, will be in the other.  The plan is to try to get to Gogrial by nightfall.  I sure hope that we make it there.  If not, it will mean a night in the bush, which could be quite the experience.  If the rains don't come too hard, and the road isn't too washed, and the gas tank isn't too empty ... if, if, if.  But I trust in the LandCruiser.  I do get this vision in my head of old MSF photos; of LandCruisers being pushed and pulled by MSF workers, trying to get them out of the mud.  Of ropes around trees, and of people on the roofs of the vehicles giving directions to the drivers who can barely see through the splashing mud.  I want to have a bandana wrapped around my leg, a black leather jacket with a shoulder pad sewn into it.  And a limping dog next to me.  Mel Gibson, you got nothing on us.

Packing the Car

In the MSF Belgium compound, getting ready to move out.  The Toyota Land Cruiser is the vehicle of choice.  Note the nice snorkel for those rainy days and high rivers.

The Next Leg of the Trip

The situation in South Sudan is very interesting, very difficult, very confusing, and basically overwhelming.  I will try to go into some of those aspects of things in the future.
For right now, I want to tell about my limited travels.  I have been in Juba for several days as we get organized for the projects.  There are several projects going on, and two new emergency projects just getting started, as you can imagine, the place is crazy busy at MSF.  Today was the day that I was to leave Juba for Gogrial, my ultimate destination.  There are four of us traveling, but I am the only one going to Gogrial.  The others are going to projects in the near vicinity of Gogrial.
We boarded a UN plane at the now famous Juba International FUBAR Airport.  The plane is operated by the World Food Project through the UN.  We landed after a several hour trip in Rumbek, South Sudan.  The schedule was arranged so that we would catch a UN helicopter to get into Gogrial.  However, the weather in Alek, the town where the helicopter would land, was not friendly, and they cancelled the flight.  That left us with several strange options.  The UN flight coordinator thought that we may be able to get back to Juba, however, because of the upcoming Independence Day (for South Sudan), the next flight out would be late next week.  Or we could stay here in Rumbek, which didn't really sound very nice either.  So we called the Field Coordinator, and after a few minutes of discussion, told us to stay in Rumbek, and they would send a car (land rover.)  The trip by car is about 9 hours.  That meant that the driver would need to rest, and we needed to find a hotel.  So here I am now in Rumbek.  I have a tent to myself, a cot-like bed, a fan, and a shower.  The pleasant surprise is that I have a toilet that actually flushes.  Now to many of you that may sound like a strange thing to celebrate, but toilets in this part of the world are about as common as Bentleys are in Decorah.  How's that for a mixed metaphor.  The other nice thing about my tent, is that there is wireless internet, hence the update.  I have never heard of Rumbek, but a toilet and internet -- wow!!!  A cold beer and I will have the whole trifecta!

Into Africa

It is July 6th.  My journey started several days ago.  I flew from Madison to Chicago, then on to Brussels, where I had MSF briefings for several hours to help understand the context of the project, then on to Addis Ababa later that day.  There I met a fellow traveler named Lazarus, who was actually going to Juba, the capital of South Sudan.  I found out that he works with MSF Belgium, and we were going to the same office.  We flew from Addis to Juba.  Once at Juba International Airport, which makes it sound like an impressive place (its not!), I had the opportunity to pay $100 for a visa.  And please, the one hundred dollar bill (that's all they take) must be 2006 or newer.  I had heard this before setting out, and went to 2 local banks in town, neither of which had newer bills.  Luckily, I got through with a nearly perfect 2006 Ben Franklin.
And then the adventure started.

What Comes Next

On the 9th of July, 2011, South Sudan became a country.  It wasn't clean, although the proposed lines had been drawn up years ago by the British.  But those are just lines on a map, not on the earth.  It reminds me of what Arthur said to Merlin as he was allowed to see with the eyes of a hawk.  Merlin had asked him 'what do you see?'  and Arthur replied, 'I don't see any borders.'   These borders are just as difficult for  nomadic peoples to recognize.  So they argue about them, and sometimes fight about them.

There are oil reserves in South Sudan.  But there is no port.  To get the oil out of the country to be sold, requires a pipeline, and this pipeline goes through Sudan to the Port of Sudan.  Sudan has told South Sudan that it is OK to use the pipeline as long as they are willing to pay for its use.  Most pipelines in the area ask for about 1 dollar per barrel.  Sudan is asking for 38 dollars per barrel.  South Sudan thinks that is a bit too much, so to save money, they have stopped shipping oil.  However, oil is the primary means for South Sudan to make any money.  As a result, they don't have much money.  Which is not good for infrastructure.
About two weeks ago I was asked to go to South Sudan with Doctors Without Borders, to help with taking care of war wounded and others needing medical and surgical help.  So I will go.  It is tough.  The operating room is in a tent.  There are no real bathrooms.  There are latrine pits that require squatting over a hole.  The temperature is 120 to 130 degrees.  I'm afraid that it will make the heat of Sri Lanka seem like the north shore of Lake Superior.

Remember hearing of Darfur?  The Lost Boys of Darfur?  The genocide in Sudan?  2 million people dead?  4 million people displaced?  So here I go...