by Damien Brown
Maternity
Twenty-six vaginal deliveries, two stillbirths and four miscarriages, documented in meticulous detail by Nene, the head Angolan midwife. I’ll pass the report on to Andrea, along with that for the dispensary, the other major department she looks after.
Dispensary
A long list of items given out or used this past month, including six thousand amoxicillin tablets, fifteen thousand paracetamol tablets, one thousand de-worming tablets, and fifteen hundred malaria treatment packs. They’re also requesting five pens and a new torch. Are they serious? Could we possibly use this many tablets in a single month? This surely needs looking into.
Laboratory
A summary of tests performed. Two hundred stool smears, forty urine tests, fifteen hundred malaria tests, and a handful each of hepatitis B and C, HIV, and syphilis tests, and blood-typing for transfusions—the latter being single-use kits from Europe.
Surgical outpatients
The first I’ve heard of such a department. I double-check the name, flick the paper over, but it seems right. According to this, twenty-eight abscesses were drained, five plaster casts applied and a hundred-and-something wounds dressed in there. Says also that twenty-three teeth were removed. We’re pulling teeth? Here? This place I’m going to have to find.
Tuberculosis program
Nine patients who live at home, and who return fortnightly for their medical review, new pills and a food ration to encourage their compliance. One, an elderly man, is currently living in our isolation ward—a pair of small rooms at the far corner of the front hospital yard. I’ve not met the others, but according to this, one of them died: a forty-two year old woman.
Surgical theatre
Operations performed last month: one Caesarean section, one appendicectomy, one hernia repair, and a leg amputation. No deaths.
Inpatient unit
The source of my ongoing difficulties, this unit, and one overseen by Sergio. Says here that two hundred and ninety-one patients were admitted last month, two-thirds being for malaria. Six patients died; three from malaria, and one each from TB, eclampsia, and pneumonia.
All of which begs the question: How to manage this? These numbers are staggering, no less given our limited resources. In an emergency department back home I’d see ten patients in a shift. Here, we have sixty-five on the ward—each of whom needs to be reviewed daily—and another hundred coming through Outpatients.
Most of the local health workers seem pleasant, at least from what I can tell via translations, although Sergio and Roberto remain difficult to work with. Sergio had wandered off on that first afternoon and busied himself with paperwork for a couple of days, but has since returned—grudgingly. Roberto’s been far more direct. He’s not missed a ward round, and continues to argue the case for operating on the woman with cancer even though the MSF surgeon has agreed with me via email: she’s far beyond any hope of cure, likely to die either during or shortly after surgery. As per universal medical ethics, we’re to First do no harm.
Roberto doesn’t see it this way. ‘How can you not at least try to help her?’ he implores, in full view of her relatives and other patients. Quoting the advice from Geneva only provokes him. ‘And where then is this man?’ he asks. ‘Am I not the one operating in Mavinga?’
I take some comfort in the recovery of the young boy with cerebral malaria, who’s now sitting up and picking at a bowl of maize. And from the man who’d killed the leopard, who can be seen showing off his bandaged limbs to an entranced audience outside the men’s ward. But overall I’m lost in that place. I’m thoroughly out of my depth, and I haven’t mentioned those malnourished children. Three new admissions joined the nine already on the ward this week, and treating them is like trying to combine intensive care with homoeopathy. Drug dosages are minuscule (even the quantity of specially formulated milk they’re given has to be exact, just so, not too little and absolutely not too much) and their progress is measured in grams each day. For some, a dozen grams makes for a significant improvement. For others, a few vomits or bouts of diarrhoea can be catastrophic. It’s frightening. The entire hospital is frightening. And I’ve got a hundred and sixty-something days left in there. But right now our cook, Dominga, is calling us for lunch.
• • •
Tim’s at our plastic dining room table, re-reading a month-old newspaper. I take a seat opposite him. Andrea’s not here yet, but Pascal returns moments later from a trip in our vehicle, a large, mine-proof, ex-South African military personnel carrier. He’s been to inspect the water point, a series of taps through which the town’s only clean water is distributed. It’s another site of interest on any walk; a constant queue of people wait out front of it, empty buckets under arms, while others carrying full containers stream out the other end. One hundred and twenty thousand litres are carried out like this each day, a bucket at a time atop the heads of women and children. The project is run and maintained by Pascal and his logistics team of around a dozen Angolan men, Toyota included, who are known collectively as the ‘logs’, and who are responsible for all the maintenance, construction, communications and supply aspects of the project.
‘Two police officers pulled us over on the way back today,’ gushes Pascal, standing at the dining room doorway. He has a mildly frantic appearance when he speaks, his wild eyes caught between an explosion of unkempt hair and a wispy goatee. He’s immensely entertaining, even if I can’t understand much of his Spanish-Portuguese mix. Tim clarifies. ‘Toyota was driving the truck,’ Pascal tells us, ‘and the police asked for his licence. So Toyota laughs. He asks them who has a licence in this place anyway—does anyone?—but the police make him get out of the truck. So now we’re on this dirt road just five hundred metres from here—I mean, how far is this fucking water-project anyway? A kilometre?—and there is no car in any direction, no cars all week in any direction, and we stand on the sand next to the truck when a donkey cart goes past with kids on the back of it, these kids poking the donkey with a stick every now and then—like this!—slower than walking speed, and Toyota asks the police if the kids have a licence to drive that. So then the police start getting funny with him, because even these two officers don’t have a car—I mean, they walked across the road to pull us over, because our thing does what, twenty kilometres an hour on this shitty road? So I try to apologise and make it all right, but Toyota—he knows them well, he told me afterwards—he stirs these guys. The police say we should know that Jamba is the only one on the team with a valid licence, but then Toyota points to Jamba, who’s sitting in the back seat, and teases him, saying that Jamba is an alcoholic these days so he thought it was safer if he drove. So now Jamba and Toyota are in hysterics, and I’m trying hard not to be disrespectful to the police, but I mean, these cops don’t even have tickets or anything—what were they going to do?’
‘Shoot you,’ notes Tim.
Pascal contemplates this.
‘Seriously. They’d all be ex-soldiers.’
‘Okay, maybe this is a possibility,’ laughs Pascal. ‘But by the end they were laughing. But I mean, what the fuck—we drive twice a week for ten minutes, and now we get stopped for licence checks?’
He pulls up a chair, looks into the three pots on the table. ‘This is it?’ he asks. ‘Peas? And pasta?’
Tim looks unfazed. ‘Probably.’
Pascal heads to the kitchen. He seems troubled when he returns. ‘There’s nothing else in there. Dominga still here?’
‘Gone home for lunch.’
‘But this can’t be right. Peas? On pasta? And look at this,’ he says, running a spoon through one of the pots. ‘Never mind malaria—we will all die of heart attacks before we leave!’
He may well be right. Dominga’s fondness for oil knows no bounds. Today, pasta glistens in a viscous lake of orange. Yesterday it was chicken, bobbing in the same. The day before, heavily fried goat.
‘If you want variety,’ says Tim, ‘we’ll need to come up with new recipes for her. She’
s only been cooking a few weeks. Before that she was the hospital cleaner.’
Andrea joins us, also not overly impressed with lunch. She’s looking a little ruffled, too, having been up most of the night with a delivery. Isabella flew out hours ago.
‘You guys can say all you want,’ says Tim, ‘but believe me, you’ll be wishing for peas with tomato sauce when the wet season arrives. It’s only been a week now since our last food delivery. Wait until the rains begin. Wait until flights get cancelled, and it’s been three weeks since the last flight. Then you will dream of peas and—’
WHOOOOMFFFFF!!!
A noise we feel as much as hear.
What the fuck was that?
Windows rattle and dust drifts from the roof as my adrenal glands swiftly dump a year’s supply of the hormone into my circulation.
Jesus—is this an attack?
A dense silence follows.
Tim asks Pascal to turn up his walkie-talkie. We sit. Frozen. No chance that sound was the de-mining team—we hear their controlled detonations most mornings but they’re never this close. Or loud. This is something else.
‘Tim?’
‘Wait,’ he says. ‘We stay here for instructions. If it’s a mine, we don’t respond first. If it’s an attack, no fucking way.’
I’d been cautioned in briefings that landmines are deliberately arranged in clusters in order to maximise casualties. The would-be rescuer risks the same fate as the victim. Only the HALO Trust’s de-mining technicians are to respond to blasts in town, and we’re to provide backup when called. If this is a landmine.
A long moment passes. We stare wide-eyed at each other. Someone suggests that maybe there’s an innocent explanation for all this but that’s unlikely: a thin pall of smoke rises from behind our wood-pole fence. The walkie-talkies suddenly burst into life and several voices speak at once. Police, de-miners, the army—all say it wasn’t them. The chatter settles and we hear screaming from behind our fence. It quickly gets louder.
‘Tim?’
‘HALO Trust,’ crackles the radio. ‘We’re en route. We can see the site—centre of town, near hospital end . . . Some casualties.’ A pause. ‘Uh, beside the main road. Access is definitely safe. MSF—come in.’
‘MSF here.’
‘Proceed to site immediately.’
Andrea and I grab the emergency medical kit from the entrance. Pascal grabs more handsets. We run out the gate following Tim but there isn’t any need to go to the scene because before we can get even fifty metres a crowd of Angolans are heading towards us, some with injured people slung over their shoulders, and they’re heading straight for the hospital. Christ. It’s the real thing.
We change direction and run back to the hospital. People pour in behind us, straight into the small assessment room, but there’s only one bed in here so they lie the injured on the floor.
A young girl bleeding from her cheek.
A man bleeding from his neck.
A woman, crying, laid down in the corner.
Others arrive. They sit against the wall and people step around them and shout, more squeeze in, this room is far too small—
‘Wait!’ I call to Tim. ‘Tell them to stop bringing people in here. We’ll see them outside. In the yard.’
—but they keep coming in, now a man with a bloodied shirt that’s torn open, and the ferric smell of wet blood is strong in the little room so we need to assess people quickly. Carlos runs in with two enfermeiras, and I ask him where the rest of the staff are. He says they’ve all gone home for lunch.
‘All of them?’
‘Yes.’
Jesus, what timing!
‘We need to clear beds quickly. Let’s put the intensivo patients in the tent,’ I say. ‘We’ll see the injured in Intensivo. And in here. No, outside. There’s too many. Okay, no—let’s triage them outside, under the tarp. No more in here.’ The staff stare confusedly at me. I’m speaking English. I’ve forgotten any Portuguese I know. Andrea and Tim come over and explain.
More people rush into the room. It’s impossible to tell who’s injured and who’s not, and there’s more blood on the floor from someone.
‘Pascal—can you get some stretchers and set them up outside?’ I ask him. ‘And bags of fluid. In the cupboard, there. Lay out bags of fluid. And bandages—’
A woman with a red headscarf yells, and I break off although I have no idea what she’s saying. One of the enfermeiras has stopped to bandage a small hand injury. ‘No!’ I say. ‘Tim—tell her we need to assess everyone first. We’ll treat later. Ask her to set up IVs.’
Another young boy arrives, bleeding from the scalp, then another boy with a facial laceration. Police rush in. The woman with the red headscarf is still yelling and she grabs me—
‘Pascal!’ I call. ‘Can you send someone in the car to fetch the clinicos from wherever they are. And—’
Wait, is that blood on the woman’s head? Is all that blood? I pull off her headscarf to check but I can’t see an injury, and she won’t follow me next door so with no respect for privacy the enfermeira and I lift up her dress and look at her limbs and torso to make sure we’re not missing a serious injury. We’re not. We think she’s yelling for her child so the enfermeira takes her outside.
Health workers run back from lunch and recognise many of the injured—family members, neighbours, friends—and head straight to them. Everyone begins doing their own thing, seeing patients anywhere and bandaging injuries and getting suture kits to sew lacerations.
‘No one is to treat minor injuries yet,’ I ask Tim to relay. ‘We’ve got to do this systematically. All non-injured, wait on that side. Only injured on this side. One relative can stay with them. First thing is to check vital signs and make sure no one’s bleeding heavily. Anyone with an injury gets an IV line inserted. Everyone else must stay out of that room—’
No one listens.
People are frightened and in shock and want their relatives seen immediately. More spill in through the gate, the front yard is boiling with people. Pascal returns with Toyota and a handful of the logs and we use them as crowd control, but the clinicos are still doing their own thing in the yard, the front room, against the outside walls, so Andrea and I walk between all patients to quickly assess wounds. A basic triage for major incidents: who needs immediate intervention, who can wait a little while, who can safely wait hours? We make a first pass around the yard then back into the assessment room, but by the time we’ve finished our staff have moved patients—
‘Where’s that boy with the facial injury gone?’
—and there are new faces everywhere. We start again.
Back outside. Through all the rooms. The yard. Within minutes we think we’ve seen everyone. If no more patients arrive we’ll be okay; most injuries seem minor—facial and limb lacerations that appear dramatic as blood seeps onto light clothing or trickles down faces, but that are easily manageable. Two people have chest injuries but their breathing sounds normal and blood pressure is good—for the moment. They could have life-threatening internal injuries, but who knows how deep the wounds go, or into what, because we don’t have an X-ray out here, so for now we’re just going to have to—
Shouting at the gate. Two policemen arrive, carrying a colleague who’s slumped and dragging his feet. We lead them straight through to Intensivo but the injured policeman refuses to sit. He’s slurring and lashes out confusedly at his colleague, and I stand dumb as the two colleagues wrestle him to the bed and remove the gun from his belt. We pull his hat off and examine his head but find only a small injury, about half a centimetre long at the back. ‘Was there metal?’ I ask. ‘Any shrapnel?’
‘Everywhere,’ says Andrea, speaking with the police. ‘They think it was a grenade.’
How to treat a head injury here? I’ve seen pictures of burr holes drilled into skulls to relieve certain types of clots on the surface of the brain. I watched a neurosurgeon perform it in theatre—once. But out here? I don’t think the man’s
a candidate anyway. It’s the wrong type of injury. ‘Where’s Roberto?’ I ask. ‘We need him!’
‘Injured,’ says Carlos, tending to someone new behind me. ‘One of our enfermeiras saw him. The guard has gone to fetch him.’
Jesus Christ, the one man in Mavinga who can deal with this stuff is injured?
We restrain the policeman to insert an IV. We give some diazepam to sedate him, then antibiotics for the wound. Andrea heads back outside. Carlos shows me the patient he’s dealing with, a boy of about ten with an open jaw injury. He’s lying on his own and looks impossibly calm, no tears, and he nods when we tell him we’re going to rinse the wound to have a better look. I inject local anaesthetic and Carlos pours saline through the entry wound, a long jagged gash above the left jawline, but Carlos stops abruptly when smaller bone fragments from the boy’s mandible begin flushing from a second laceration beneath his mouth. No way we can manage this out here. Carlos applies bandages and gives antibiotics. We’ll come back to him.
Back outside. Andrea’s dealing with a man who has a cut to the side of his neck, and I see Roberto limping towards her. We help him to the stairs outside the assessment room, sit him down and roll up his trousers where they’re torn. ‘It’s small,’ he says of the gash to his right lower leg. ‘Show me the patients.’
‘Roberto, we should—’
‘Leave it.’
Pascal finds him a crutch. Andrea and I show him around, and maybe half an hour passes without more people arriving. Things seem to be settling. All staff are back and now working systematically. Only two patients appear to be severely injured—the policeman, now losing consciousness, and the young boy with the jaw injury—and all others have relatively minor injuries: that neck laceration, a breast wound, several limb and facial lacerations, and two men with chest wounds.
We organise the beds that are needed. We give antibiotics and tetanus cover and spend the remainder of the afternoon exploring wounds, trying to assess their depth and retrieve shrapnel, but without X-ray it’s largely a fishing expedition. Hard to tell how many fragments there are, or how deep, so we retrieve them where we can; for others, we leave the wounds open but bandaged, hoping the metal will extrude itself in coming days.