Monday, June 4, 2012

South Sudan: Level Three Threats

South Sudan’s recent appearance in the news prompted me to post this series recounting my experience operating on the Nile riverbank in 2007.
The operating room is better known as the operating theatre in most of the English-speaking world. Cool, huh? Room is pretty boring. Wouldn't we all prefer to perform in a theatre, perhaps in a ruffled shirt and cape a la Shakespeare? 

Lo, suffering patient, have bullets rent thine flesh? Tell me, then, where thou most hurtest?

In my first two days, we received six gunshot victims. One had been hit just above the elbow. His skin had exploded, splitting in three long strips which spilled dead muscle and bone chips. We had no x-ray machine, so initial assessment meant flipping and flopping the deformed limb to estimate the location of the fracture. In the operating theatre, which was an inflatable tent, I washed grime out of the exit wound, and stuck a couple  fingers in the mess to get the lay of the land.

War surgery and orthopedics were both out of my usual scope of practice. So, I was improvising - because that's what you do when you're the only doc in hundreds of miles.

You reach in the exit wound and push the muscle around, far from the shattered proximal humerus (different patient).

You’re feeling the pectoralis, playing it careful, scooping out dead meat and blood clot two fingers at at time to prevent infection. Ouch. You feel a bone shard cut through your rubber glove and your epidermis. Your blood mixes with the patient’s. You sigh and look at the young man, calculating his HIV and Hepatitis odds. You feel a little like hanging up your scalpel and coming home. You remind yourself that you calculated these risks in calm circumstances months ago. You tell yourself it’s fun learning orthopedic anatomy on the job. Of course you’re going to gash yourself now and then! And obstetrics? You never did a C-section in your whole residency – of course you’re gonna enter a bladder or two! Sure, you’re helping these people!

Between cases, I sit drinking water, trying to dry the sweat out of my scrubs. A nurse comes into the OR tent. She’s never been in here before. She looks serious.

Have you heard of the problem in the maternity ward? she asks.


I came to inform you.


The C-section from last night. Her husband just came onto the ward. He is very angry. He says he did not give permission for her surgery.

Consent? The patient gave consent. We saved her baby.

I know that, and you know that. But I wanted to inform you…Anyway, it has been difficult to explain to the husband.

I’ll come explain it, after the next case.

Perhaps you had better not, she says.


The husband is drunk and carrying a large stick. There are two other men with him. They were threatening people in the maternity ward and asking for the doctor who cut his wife.

I slump in my chair. (I have been told that a C-section is considered a failure of motherhood. A man disgraced by a C-section-having wife may return said wife to her father and demand full recompense of the cows paid in dowry.) What price does a surgeon pay for performing surgery not authorized by the head of household? Is the angry husband a tribal chief? Mayor of Bor Town? Is there a mob of irate Sudanese charging the guards of our hospital gate? Am I safe in an inflatable operating suite, or in the canvas and bamboo fortress of the mission compound? Is the man carrying a stick because he checked his AK-47 at the gate? My next thought is of home.

 The nurse leaves. I am alone in the operating tent. Hanging against my belly like a moist sponge is my passport/money pouch. I’m subconsciously assessing my readiness for flight. My South Sudan travel pass is in the pouch. We carry our passes at all times since a Polish volunteer was arrested a few days ago for walking Bor’s dirt road without his pass. The pouch also carries photos from home. I unstick them from one another and transport myself to my backyard where my wife and child are face to face laughing at one another. I try to keep my mind there, in my own backyard, safe.

The scrub assistant, John, then appears. He tells me not to worry, that the man’s anger will pass. His manner is truly comforting, as he understands the situation – the context – better than I. He also knows that Akot, the nurse in charge of the operating theater, is taking care of business in a culturally-appropriate way.

Akot and John have been at my side working long hours at local wages in the operating theater. They never complain, though we operate at the pace of a visiting surgeon trying to finish as much work as possible in a sea of surgical candidates. They are proud of their work.

Akot is almost fifty. I don’t know how he became such a phenomenal nurse since nearly all his adult life was spent as a soldier in a civil war. But I am glad that this nurse is acting as a warrior on my behalf. I learn later that Akot, catching wind of the drunk, stick-wielding, doctor-hunting trio, marched alone to the maternity ward, disarmed the men, called them stupid and ungrateful in front of all the new mothers and babies, and shoved them out the hospital gate. He returned, wordless, to finish the day’s operating schedule.

After a couple of local gunfire incidents (see upcoming missives) Bor Town was put under curfew. No activity in the streets sundown till sunrise. Hospital employees were being beaten on their way to work. A soldier who didn’t speak the local language would stop a nurse in dawn light, they would exchange useless words, and a rifle butt would break the language barrier.

This put some pressure on the operating schedule toward the end of the day. I’d squeeze in a quick case in the afternoon, we’d run into some snag (no sterile gauze, blood donor has wandered off, etc.) and now I’m sewing like Betsy Ross on the Third of July. Getting home, for me, was a matter of darting across one dirt road. But that road was seeing more and more boots every day, and the OR staff had much farther to walk.

On the day of my scheduled departure, our field coordinator placed a satellite call to headquarters about my plane ride – the first leg of six in my long trip home. He was calling to find out when to expect the Cessna. There was no answer – in South Sudan mission headquarters. He then called on short-wave radio. The only staff member at headquarters was a radio operator. The whereabouts of the rest were unknown. The streets had been seized by an early morning convoy. All movement was prohibited, said a megaphone. Information trickled in throughout the day. A city-wide spot-check for weapons held the town in a complete shutdown, including the pilot hired to collect me. Staff were all okay, though confined to wherever they happened to be when megaphone man rolled in.

I had grown accustomed to late planes. Nearly every one leaving Bor was delayed – cows on the landing strip, mud on the departure strip, plane needed elsewhere to transport a patient, etc. So I made rounds again, then cracked a beer. Our chief logistician, a jolly Congolese man of limited English, found me drinking at lunchtime and asked about my plane. I explained the situation at our headquarters.
The instability is, is, is…It is coming, said the man from the Congo.

I couldn’t imagine more disheartening words from a guy whose home country is the only place more destitute and violent than the one I was trying to depart. My plane came two days later. You know you’ve been in a sketchy place when you kiss the ground after your plane lands – in Nairobi. I arrived in Phoenix to start my new job two days late.

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