Band-Aid for a Broken Leg

by Damien Brown

  ‘You go.’

  ‘Fuck that!’

  ‘But it’s your turn.’

  ‘No chance! No way am I going that far.’

  —because we’re not entirely sure about the ground where it’s ended up. The airstrip to our left is free of mines, the collection of huts further along is fine, and we can see no Perigro, Minas! signs in the foreground, but our map on the office wall has this area marked as being off-limits. We think it’s safe; to the north of the airstrip are the bulk of those de-mining grids I’d seen, and we’re now to the south. As well, bridges, water collection points and fruit trees are more likely to have been danger areas, but there are none of these features ahead of us. And none of the donkeys grazing here seem to have any injuries, either, but before we can agree on who’s going to retrieve the ball a group of young kids have run over anyway—‘CUIDADO!’ we yell, ‘BE CAREFUL!’—and had a kick of it among themselves before kindly throwing it back.

  By mid-afternoon we’ve exhausted all extracurricular activities. Paperwork is what we’ve defaulted to. And it’s now, with the temperature rapidly dropping, that it’s best to head out.

  As with previous days off, the market will be our ultimate destination, even if Toyota was right: there’s little of interest to buy. People-watching is the real reason we go, because the same piles of donated clothing and cheap goods (candles, batteries, soap, cigarettes, handheld radios, hair beads and Western-styled wigs) clutter the shelves of the three dozen ramshackle stalls, while the town’s meagre food supplies, sold on the outskirts, are a sobering sight. Here, women and girls kneel behind paltry quantities of stock spread on cloths before them—little mounds of maize, dry biscuits, small piles of okra, a few tubers, maybe some oil or cans of fish. How the town feeds itself with this we’re not sure. Ironic then that the only other goods we’ve come across being sold, aside from beer, are diamonds. As fanciful as that sounds, we’ve now been approached twice by men offering handfuls of the uncut gems, taken presumably from the large alluvial deposits to our north. The stones look merely like broken glass, but there’s every chance they’re genuine; the trans-border trade is still thriving in the region, although the prospect of time in an Angolan prisão has so far kept us from investing in it.

  So the market it is. I charge my camera. Put a few Angolan kwanzas in my pocket, change batteries on the walkie-talkie and let the hospital guard know. We’ll leave in fifteen minutes, we decide, except that Sergio’s at the office door right now, describing what I suspect will be my alternative arrangements. Surgery.

  • • •

  For three weeks we’ve not taken a major case to theatre here. Potential candidates have been managed medically, albeit not always with Roberto’s agreement, but Sergio now leads me to see a young woman who unequivocally needs an operation. This worries me greatly. Not so much her condition—likely appendicitis. More, the conditions under which we’re about to operate.

  The theatre is a small brick room attached to Maternity, where the only hints of modernity are a handheld pulse-oximeter and halogen lamp. A car battery powers the latter. Two shelves of medical supplies, a steel operating table and a curtained window account for the rest of the fittings, and a crack in the wall allows for some ventilation.

  I enter and find the anaesthetist setting up in the room. Veronica’s her name. She normally works with Andrea in the pharmacy, sometimes also on the wards as an enfermeira.

  Veronica looks a little nervous.

  ‘Have you done this before?’ I ask her.

  ‘A few times,’ she says, meekly.

  ‘What training have you had?’

  ‘One of the other doctors showed me,’ she says. ‘And I use this chart on the wall.’

  ‘What anaesthetic do you use, Veronica?’

  ‘Ketamine.’

  ‘And what else?’

  ‘Just ketamine,’ she says. ‘We only have ketamine.’

  This is a problem. I’ve given the drug in emergency departments as a sedative and painkiller for minor procedures, and vets use it widely for surgery on animals. It’s an illicit party drug, too; Special-K, it’s called, taken for its dissociative and hallucinatory effects. But for use as the sole anaesthetic, in open abdominal surgery? I’m not convinced.

  Roberto’s here. Sergio had called him earlier and now takes me to see him. He’s squatting in the doorway of a small shed behind the adults’ wards, watching something simmering over coals at the centre of the space. He looks up.

  ‘Novo Doctor,’ he notes unenthusiastically. He returns his attention to the coals.

  ‘How are you, Roberto?’

  ‘Bom.’—Good.

  ‘Good. Have you seen this woman?’

  He nods, watching the coals.

  ‘And?’

  He thinks it’s appendicitis, he tells me. I tell him I agree. He says nothing.

  ‘So what now?’ I ask.

  ‘We will take it out.’

  ‘Okay.’

  He stares quietly at the coals.

  ‘When?’ I ask.

  ‘Soon.’

  ‘Okay.’

  Another awkward pause. Sergio walks off.

  ‘Uh, have you done many of these appendicectomies before, Roberto?’

  He stares at me, saying nothing.

  ‘Is that a yes?’

  He continues staring. I take it as a yes.

  ‘Good,’ I say. ‘So, do we do it now?’

  ‘As soon as the steriliser has finished,’ he says.

  ‘Sim. Okay. But what steriliser, by the way?’

  ‘This one.’

  ‘Which one?’

  He nods towards the large pot simmering above the fire.

  ‘That’s the steriliser?’

  ‘An autoclave, Novo Doctor,’ he corrects me. ‘Sim. This is an autoclave.’

  Jesus Christ! Our steriliser is a pot on top of a fire?

  My anxiety levels ramp up as he asks me how I thought we’d cleaned the instruments, but I really hadn’t considered it at all, hadn’t needed to until now. But that’s the least of the issues, just the start of it, because an hour later we’re standing in theatre, scrubbed and gowned, only an iodine-bronze square island of the young woman’s belly visible below us and the rest of her covered by a sea of sterile green drapes, when Roberto turns to the woman’s husband—the husband’s in theatre, too!—to ask him for permission to proceed.

  ‘Sir,’ Roberto says. ‘We are going to start cutting now, okay?’

  Sofia had forewarned me about this, although seeing it is no less surreal. The patient’s husband is sitting not far from us, on a wooden stool; a farmer, dressed awkwardly in green surgical scrubs, about to watch us open his wife’s belly. ‘It’s a security thing,’ Sofia had explained. ‘It’s important the family know exactly what’s going on in theatre, in case something goes wrong. They won’t operate without the relatives there.’

  Four others are crowded into this room, too. Veronica and her enfermeira assistant; Agostinho, the surgical assistant; and Andrea, who’s kindly offered to help me.

  The husband smiles, nodding his permission to begin.

  Roberto lifts a scalpel from the tray of steel instruments to his side, then re-examines her belly and feels the anatomical landmarks. Satisfied, he makes a firm, straight, midline incision below her navel. The layers of her abdominal wall cleave neatly under the pass of his blade; black skin, yellow globules of fat, beef-red muscle, each in turn. Roberto pauses briefly to allow Agostinho to tie off oozing blood vessels, then opens the abdominal cavity itself with a pair of scissors. I feel a little easier about my decision. He seems to know what he’s doing. Gently, he slips the gloved fingers of his right hand into her abdomen and feels around for a moment. He removes his hand and extends the incision slightly, then re-explores the cavity and retrieves a loop of bowel.

  ‘Her appendix,’ he states, pointing out the finger-like diverticulum. He reinserts his hand. Kissing noises fill the air as moist organs slide against e
ach other, sloshing and slurping while he probes. ‘Her ovaries,’ he declares next, pointing to the relevant structures.

  I nod in agreement.

  ‘Which ones do you want us to take out?’ he asks, voice somewhat muffled by his surgical mask.

  ‘Sorry?’

  ‘Which of these, Novo Doctor, do you want us to take out?’

  ‘Say what, Roberto?’

  ‘Her appendix, Novo Doctor, or her ovaries? Which would you like me to remove?’

  Did I just hear wrong? I look to Andrea, who’s standing beside Veronica, but she’s equally wide-eyed, which only confirms it.

  ‘You serious, Roberto?’

  He is.

  My low-grade sweat of background unease shifts gear into a full-scale tropical deluge. ‘You’re the surgeon,’ I stammer. ‘This is your decision, no?’

  It traditionally is.

  ‘I’m not a surgeon,’ he says. ‘You know this.’

  ‘Are you kidding me?’

  ‘I’m a surgical clinico. I do the cutting. You are the doctor, so you must decide what her diagnosis is, and what is normal or not normal in her belly. Now, are you happy with her appendix and ovaries?’

  The words resonate in my head like a guilty verdict being delivered in a bad courtroom drama. Roberto drops a clamp back onto the tray; it clangs, bounces, echoes like a judge’s gavel and I can’t believe what we’re doing in here. Christ, it’s hot in here—Andrea, is it hot? This surgical garb is killing me. I want to adjust my mask, I need a little air. My God, Andrea, what the hell are we doing in this town! I glance around the room and try to gather my thoughts as I look to the husband, his face one of simple humility as he stares back, implicit in his expression the enormous trust he’s placed in us. Beside me is Agostinho, comfortable, relaxed, adeptly tying off oozing vessels; watching me from across this open belly is Roberto, wearing the confidence of a man relieved of the burden of decision-making for the time being. To my right, Veronica’s sweating as she corrects the position of the simple plastic Guedel device in the patient’s mouth to help her breathing—like a big plastic straw, really—but the patient begins to gurgle so Veronica tries again, then introduces a suction catheter to the patient’s mouth to clear the airway secretion, and now she’s hopping—Andrea, she’s fucking hopping!—and a loud clank commences beneath the table so I drop my head to look below and see her stomping energetically on a small metal foot-pump to generate suction for the tube. This is utter insanity! I want out, we need to close this woman up as soon as possible but gleaming ahead of me on a bronzed belly is the soft whiteness of her two ovaries . . .

  ‘Uh, my God, Roberto,’ I stutter. ‘Her ovaries look completely normal. Let’s leave them in.’ I’ve assisted and watched enough operations to know what normal looks like, and her ovaries look fine.

  Roberto agrees. ‘Then we will just remove the appendix,’ he states.

  What—we’re bargaining for body parts now?

  ‘Hang on, Roberto. Let’s look at it again.’

  He gently returns the ovaries via the incision and isolates the appendix. Although rupture is not imminent, it’s definitely inflamed. I agree with Roberto—we should remove it. He nods and turns to address the patient’s husband, who’s still sitting on the stool against the back wall. ‘Come here, sir,’ he says. ‘But do not touch anything.’

  The man approaches and peers over Roberto’s right shoulder. Roberto lifts the small, finger-like structure as the husband regards the tissue with a detached fascination, not in the least bit squeamish. I’ve seen medical students faint over far less—and this is his wife! The husband nods his approval.

  ‘Good. You can take your seat again, sir,’ Roberto tells him, and that’s where the man stays: on his stool, quietly, in his scrubs, watching two strangers debate the fate of his wife’s organs over her open abdomen.

  Roberto then performs an appendicectomy—not the fastest, but more importantly a competent one. I’m immensely relieved. The three of us assist with closing each layer of the abdominal wall, then dress the wound and carry the woman to Intensivo. The ketamine wears off quickly.

  The husband’s thrilled with our work.

  ‘You did the right thing, Novo Doctor,’ says Roberto, as we head to the side room to get changed.

  I nod, still rattled by what I’ve seen.

  ‘You did,’ he repeats.

  I sincerely hope so. More, I hope that the young woman recovers. And that we never, ever, have to operate on someone again.

  8. FIGHTING CUBANS

  The low sun ignites the first clouds I’ve seen in the five weeks since I arrived, colouring them deep reds and hot pinks: a pair of woolly lips, pouting as they kiss a cool sky. It’s the first hint of rain. A promise that the world here may not be brown and dusty forever, and that this town may soon be able to feed itself properly. We’re now entering the ominously titled hunger gap—the period between the exhaustion of the last harvest and the arrival of the next—and the spread at the market is looking more worrying each day, the land even drier.

  Pascal’s busy with Toyota as I enter the hospital, working on the awning above the waiting area. They’ve been checking the compound roofing lately, but this area appears to get more than its share of attention. My suspicion is it has something to do with the triage clerk beneath it.

  ‘Why are you up there again?’ I ask Pascal.

  ‘What?’

  ‘Weren’t you up there last week?’

  ‘Maybe,’ he smiles.

  ‘She’s far too busy to flirt with you guys,’ I stir, nodding towards the attractive young clerk. The first of the day’s hundred outpatients are queuing in front of her desk, an unimpressed child crying beneath the weighing tree to her right.

  Pascal shakes his head. ‘Just fixing the canvas.’

  ‘This canvas gets very loose, Novo Doctor,’ laughs Toyota. ‘The wind can make it very loose.’

  I’m not convinced. But either way, whether they’re flirting or not, I still envy Pascal his job. I’m not sure how to manage the hospital. Of the three thousand volunteers MSF sends out annually, around half won’t undertake a second stint. The reasons are varied and include, among others, family and career commitments, volunteering with a different organisation, disillusionment, or simply having been overwhelmed. And as I now enter the assessment room to join the team for the Monday handover, the start of my second month here, I empathise fully with this latter group. I’m in over my head.

  Twenty of us squeeze onto the wood benches, uncomfortably cold. Woollen hats are pulled low and lab coats cinched tightly, and everyone has a cough—dry air and smoky huts ensure this. The light in the room is gloomy, the mood equally so. And the smell: burned flesh. It’s inescapable. Both doors are wide open and our twenty bodies huddled together, but still we smell it. Still we breathe it. And still my stomach churns from it. The source of this is a man lying in Intensivo behind us, who’d arrived two days ago with charred expanses of skin after having fallen into a fire. These black eschars cover most of his lower body, and they’re crisp and hard, like bark on a human tree, and they all need to be removed. Without doubt we should fly this man out. His chances of survival here are minimal and we’ve spoken with him about it, but he lives on the Christian mission just outside town and has no money for treatment in the city. No way to get back, either. He wants to be with his family, he says, even if we could find a way to send him and arrange for treatment. Here, people from the mission can visit him, and his wife and young daughter can stay beside him. He wants that more than any treatment.

  Carrying through the rank air this morning is the sound of moaning, although not from the man with burns. It’s from the next bed, where the patient I’d performed the lumbar puncture on two weeks ago is becoming increasingly delirious. Just yesterday I found him tied to his bed with gauze bandages; the staff had done this to stop him lashing out, although by evening he’d become too drowsy to do anything of the sort. When I last checked on him during the
night, two other patients shared that tiny room as well; one, the young woman with the ulcerated breast cancer, recovering from her severe infection; the other, an infant boy who’s no longer here. Literally. He was carried home hours ago, wrapped in blankets by a distraught family.

  ‘Bom dia,’ begins Senhor Kassoma, drawing my attention away from Intensivo. He’s standing at the front, dressed immaculately as always, this morning in neat blue shirt, grey trousers, old business shoes, and a floppy denim beach hat—his solution for a cold bald head. He nods to the attendees and opens his black journal, then begins recounting last Friday’s supervisor meeting. First up, last month’s statistics. He goes through all of them—admissions, deaths and deliveries—and delves next into the minutiae: numbers of chickenpox cases, and what exactly was stolen from our big delivery. People soon nod off. I try not to—Roberto’s directly across from me—although the five health workers huddled to my right are long gone, rocking back and forth like white-breasted budgies about to fall off their perches as they succumb to the Snooze-Jerk-Wake cycle. I smile, but not for long.

  To my immediate left, wedged between myself and Sergio, is Adolfo. Adolfo’s a soft-spoken, competent clinico in his late thirties, and uncle to that boy who’d mysteriously gone blind. The two of us spent much time with the boy but despite advice from the specialist in Melbourne we still couldn’t diagnose him (I suspect it was a brain tumour), so last week Adolfo made the decision to take the boy home. This week, Adolfo’s staring at his shoes. The boy died a few days ago.

  Behind Adolfo, propping himself against a wall, is Manuel, another of the clinicos. Although genial, Manuel is jittery and nervous, flitting confusedly around the wards like a jumpy butterfly as he makes repeated mistakes with patients. He’s by far the least capable of the health workers so I’ve made it my goal to coach him. We’ve started meeting twice a week in private to revise the basics, but only yesterday—my fourth Sunday, and ostensibly a day off—I came past and found him about to administer unprescribed, frankly dangerous quantities of IV fluids to two children. He’d read the wrong protocol—the one for someone a mere sixty kilograms heavier than the children were—yet next week Manuel’s supposedly running this place at night.