Band-Aid for a Broken Leg

by Damien Brown

  ‘Mr Feldman,’ says my colleague. ‘Eighty-two years old. Type-two diabetic, day one post-elective revision of coronary artery bypass grafts. He arrived from theatre last night. Three grafts: L.I.M.A. to L.A.D., S.F.A. to O.M. one, radial to R.C.A.’

  We look at Mr Feldman. Mr Feldman beeps but says nothing. He lies still, bathed in the sterile white of fluorescent tubes as twenty-one degrees of climate-controlled air falls with a gentle shush from vents above.

  My colleague continues. ‘No intraoperative issues. He’s been stable overnight. Inotrope requirements are coming down—milrinone off at six this morning, noradrenaline still weaning—and he remains fully sedated. There’s a fair bit of ooze from his chest drains though. We checked his coags and gave some F.F.P. earlier, but there’s still ooze.’

  ‘I.N.R.?’ asks the senior, an Intensive Care specialist.

  ‘One point one.’

  ‘A.P.T.T.?’

  ‘Normal.’

  ‘Have we given any factor seven?’

  ‘No,’ replies my colleague. ‘We thought we’d wait until you saw him.’

  The specialist logs into the laptop on the table beside the patient’s bed, enters two passwords and swipes an ID card, then scrolls through lab results. Pages of them. He turns next to read through the nursing charts, then examines Mr Feldman—or at least the things going into or out of Mr Feldman, that is, because there’s little to be gained from examining Mr Feldman himself: he’s still unconscious, heavily sedated and on a ventilator. Instead, a bank of monitors behind him displays the waveforms and acronyms of his essential parameters, while the chest X-ray taken of him an hour ago shows his lung fields and cardiac outline, confirming as well the position of the many tubes that spaghetti their way into and out of him—endotracheal and nasogastric tubes, a four-lumen central venous catheter, and two chest drains. (Three peripheral catheters are not shown.) A row of steel sutures is also visible on the radiograph, the discrete loops and knots arranged in a vertical row that hold the divided edges of his sternum together. Small metal bows, it seems, on Mr Feldman’s new gift: another lease of life at eighty-two years of age.

  The specialist kneels down. He regards one of the drainage bags leading from the chest, and looks up. ‘This all collected since midnight?’

  My colleague nods.

  ‘We should give it then,’ he says. ‘Let’s give the factor seven.’

  He nods my way.

  I nod his way.

  ‘Yeah, let’s give it,’ he says.

  ‘Now?’ I ask.

  ‘Yes.’

  ‘One vial?’

  He nods again.

  I ruffle papers. Lift them up, check the back, but I’ve got no idea where I’m supposed to write. There’s a mountain of charts clipped to the desk. As I flick through the paperwork the others watch me, and I wonder if this is what Manuel felt like when I questioned him on the rounds about quinine and saline infusions. ‘Sorry, but where?’

  ‘Here,’ says my colleague. ‘Infusions go here, stat doses there.’

  ‘Cheers.’

  ‘Got it?’

  ‘Think so. How much are we giving again?’ I ask.

  ‘One vial.’

  I write it up. Mr Feldman’s designated nurse for the next twelve hours goes to the drug room to fetch it, and I quietly ask my colleague what factor seven is. It’s been eighteen months since I last worked in a large Australian hospital—time spent doing that Tropical Medicine course, then the stints in Thailand and Angola—so as suspected, I’m well out of touch. And this drug is one I’ve not used before, either.

  ‘It’s a pro-coagulant,’ explains my colleague. ‘We give it a fair bit to these post-graft guys here. Great for persistent ooze but it’s a couple of thousand bucks a vial, so better to check before you give it. And don’t drop any!’

  I nod. The specialist meanwhile fiddles with the ventilator and suggests other numbers to an appreciative audience, but he lost me minutes ago. So I look around, take stock of our surroundings and tune out for a moment, because the room we’re standing in is the very epitome of modern medicine. Near us, eleven other Mr Feldmans rise and fall in their neighbouring beds to the demands of their ventilators, and it’s clear that no expense is to be spared in the management of any of them—the consultant just asked for a second vial of factor seven, and I’d spent enough time in these departments as a student to know that we’ll hang on to patients for weeks, months if necessary, scanning, medicating, operating, dialysing, weaning, intubating, haemo-filtering, catheterising, transfusing and referring them, stopping only when, should they unfortunately not recover, a very clear point of no return has been crossed. Decisions will not ever be based primarily on finances or a lack of resources. No credit card details will be sought, nor insurance plans relied upon, and no young mothers will be palliated for breast cancer in a tent. It’s the opposite in nearly every respect to Mavinga; a comparatively bottomless pit of resources, but it’s not at all a system I resent. On the contrary, it’s a level of care I would want for my family, and that I believe everyone should have the right to access. The problem now is that working here, after being in Mavinga, is a glaring, uncomfortable reminder of the disparities between here and there.

  What a cliché, though, this difficulty in readjusting! And how thoroughly I begin to fulfil it. No less when the predictability of the years ahead dawns on me. I’d taken this job before going to Mavinga, the intention having been to complete my specialty training in Emergency Medicine as soon as I got back here (the Intensive Care job is part of that), but the program is five more years. Five very structured, very limiting years, all of which will need to be spent in Western hospitals.

  A few months later I rotate to the Emergency department. It’s an interesting job, a role that certainly can’t be described as boring, and one that I enjoy for the most part. But while MSF are again in Angola helping with another cholera outbreak, I’m dealing mostly with paperwork, referrals and nursing home transfers, and that reliable staple of the many night shifts: drunks. Some of whom are delightfully entertaining. Others, not quite so.

  ‘We picked him up fighting in the laneway, doc,’ a police officer tells me one typical Saturday night. I stand in the ambulance bay with security, contemplating how to deal with the hundred kilograms of intoxicated fury behind the door of the wagon. ‘He’s goin’ nuts in there. We used the spray a couple of times, but he just went crazier. Amphetamines, I reckon. He didn’t even blink. Cut his head during the scuffle, so now he’s bleeding.’

  I sigh. ‘How many guards we got?’

  ‘Three.’

  ‘Okay. Cindy, can you draw up some midazolam? Full vial. We’ll give it to him as he comes out the door,’ I say. A routine I know well.

  ‘No way,’ says the policeman. ‘You’ll need to give it to him in there. We gotta sedate him before he comes out. We can’t have him loose out here.’

  Great news. There’s no way we can send a female nurse in there, so it’ll have to be me along with the officers and security guards (who, it must be said, have the more difficult job in the department on nights like these). I try reasoning with the man first, for what it’s worth. You never know your luck. ‘We’re just here to help you, mate,’ I say. ‘We need to stop that bleeding, that’s all, then we’ll leave you in peace. You can sleep when we’re done and we won’t bother you again. Promise. We’ll bring you something to eat if you want. You hungr—?’

  ‘Fuuuuuuck yooooouuu!’ the roar from the back of the van.

  ‘Mate, either way we need to have a look. There are two ways we can go about this. It’s your choice. Seriously, it’ll be much easier if—’

  ‘This is police brutalidy! I know my . . . my fucken . . . my . . .’

  ‘Your rights?’

  ‘Yeeaah.’

  I’d laugh, if only I wasn’t responsible for this man’s care. I turn to one of the two officers. ‘Is his head bleeding badly?’ I ask.

  He nods.

  ‘Cindy? We g
ood to go?’

  She nods.

  ‘Security?’

  They nod.

  ‘Officers?’

  They nod. We don gloves and goggles and get the door, and I think: I’d rather deal with malaria for free than this for a decent salary.

  Obviously not all is like this in the department. Most patients are great to deal with and there are plenty of seniors around to help. I’m just not sure how much more of what I’m learning here I can apply to the field.

  • • •

  By mid-year I’m trawling the aid worker websites—just browsing, I assure myself—and hoping for someone to talk sense into me. I have coffee with a specialist in the hospital who’s spent years in the field, and ask for his advice: should I finish the training program or return to the field?

  ‘Go back to the field,’ he says. ‘It doesn’t get any easier to do it. You’ll climb the ladder here and set yourself up nicely, but in five years you’ll have a hundred more reasons why you can’t leave. You’ve got broad, generalist skills. If you really want to do that work again, go.’

  I contact MSF to see what jobs are on the horizon—just browsing, I continue to assure myself—but they have plenty. We correspond increasingly over the following months, and the possibility of a one-year contract with their emergency response team comes up. It’s extremely tempting. More so when I receive an email from Andrea, who’s thoroughly enjoying the new volunteer position she’s taken in west Africa.

  Meanwhile, things at home begin to make even less sense at times than in Mavinga. Mum calls to tell me that she’s just taken the family dog to the vet and that he wants to prescribe a new medication—

  ‘Anxiety pills,’ she says. ‘Apparently he’s got an anxiety disorder of sorts.’

  ‘The dog?’

  ‘Ja. Some sort of nervous tremor.’

  —and after another weekend of Emergency department night shifts I stand red-eyed at the supermarket checkout, drunk with fatigue and my scrubs soiled, watching an overweight kid have a tantrum because his mum bought him that chocolate bar, not the other of the twenty varieties he wanted, and I wonder how he’d feel about therapeutic milk up his nose instead.

  But such comparisons are futile. Naïve at best, self-righteous at worst.

  Nothing more annoying than the person at the dinner table who notes how many kids could have been vaccinated in lieu of your latte—I’ve long since realised things aren’t quite that simple—yet here I sit, later in the year, tuning out when colleagues speak of new cars and property renovations, recalling instead images of re-thatched roofs and re-mudded walls, and I wonder what happened to our staff, or José with the burns . . .

  Bugger it. I’m in. No point agonising over the inevitable.

  ‘Two years,’ I tell MSF. ‘I’d like to commit for two years, maybe longer depending on how things go.’

  Almost immediately I’m offered my first choice for a posting, a project for malnourished children. They forward details of the large feeding centre where a hundred severe cases are currently being treated as inpatients, several thousand more as outpatients. Various documents arrive: nutrition guidelines, job descriptions, vaccination requirements, and then this: Survival Guidelines During Abduction.

  The job’s in Somalia. It’s my dream position, in my nightmare destination. The security situation there is dire, with ongoing clan warfare, no effective government for over a decade, and now a fundamentalist Muslim insurgency as well. It’s not a project I’d have dreamed of considering in the past, but I think of the nutrition ward in Angola, and of how rehabilitating those children seemed to me the epitome of humanitarian intervention—an imperative, even.

  ‘You won’t leave the compound at all,’ explains an MSF senior via email. ‘You’ll be escorted in an armed convoy to the hospital compound, and you’ll live and work there. Armed guards will always be present.’ (An exception for MSF, who normally don’t allow guns within their projects.) ‘Any signs of trouble, and we’ll pull you straight out. We take security very seriously, but you do need to understand that this area is unstable, and that we can neither foresee nor prevent every possibility. As a volunteer, the decision to go is entirely yours.’

  I do my reading. Not lightly, I make my decision. I put my property into storage and say teary goodbyes, then head again for a briefing in Sydney. In Switzerland I sign security documents and a Proof of Life form, and for the next two weeks mull over it anxiously in an old hotel room in wintry Geneva, delayed by human resources issues. When I finally arrive in Kenya, I’m nervous, excited, outright frightened, but keen to just get there and start. The MSF driver picks me up at Nairobi airport to take me for my briefing at the regional offices, the last step before Mogadishu, but when I arrive there I see only solemn faces, not the cheery Welcome To the Project I’d known previously.

  ‘You Damien?’ they ask.

  ‘Yes.’

  They direct me to take a seat. ‘We’ve got bad news,’ says the French project coordinator. ‘You won’t be going to Somalia for a while.’

  Jesus, after all that?

  ‘Why?’ I ask.

  Three MSF workers were murdered in Somalia that morning, he says. A targeted attack, only metres from their compound.

  First glimpse of Mavinga, Angola, from above. Bone dry, and only mud huts in sight.

  The laundry section of the Cubia River, Mavinga, just after the first rains.

  Delivery of supplies by an old Russian transport plane, Mavinga. Goods are being loaded directly into our vehicle—a mine-proof, ex-military machine. The living compound can be seen to the right.

  The Outpatient waiting area, Mavinga Hospital.

  Patients queue for a lunch of maize and beans, Mavinga Hospital.

  The backyard of Mavinga Hospital. The main wards are to the left, Maternity at the rear and tents for our long-term residents to the right. The town’s choir was visiting on this day, singing for one of its unwell members.

  One of Mavinga’s many makeshift classrooms, this one in the bombed-out remains of an old building.

  The girl with the beer-bottle doll. A tuft of black hair is jammed into the top of the bottle, it has no eyes, and the label is still on.

  A young boy carrying water from the river, Mavinga.

  With the relatives of a woman who’d just survived major surgery, Mavinga.

  A mother cradles her severely unwell child in Intensivo, our ‘intensive care’ unit. He is malnourished, his hair is thinning and the increased effort of breathing is seen at the front of his neck.

  The same child after two months of treatment.

  An unwell infant receiving IV antibiotics, Mavinga.

  A young girl at the end of her treatment for malnutrition, sporting a beard of high-energy biscuit crumbs.

  This patient was in a coma for over a month in Mavinga Hospital. He finally woke up during my last days, albeit with a degree of brain damage. His carer—a good friend, he’d told us, not the patient’s brother as we’d thought—never left his side.

  A group of the Angolan medical staff, Mavinga Hospital.

  Waiting patiently for hours near our compound in Mavinga in the hope of receiving a free blanket, a bucket, a piece of soap and some biscuits during a one-off distribution.

  A hastily-formed camp for Internally Displaced People (IDPs) in Eldoret, Kenya, providing sanctuary for those who’ve fled widespread post-election violence in the region.

  Posing with local children, Mozambique.

  Locals cross a flooded landscape, carrying their few belongings to higher ground.

  Kids play on the remains of a crashed plane along the edge of the Sobat River, Nasir, South Sudan.

  Surgical ward, Nasir Hospital.

  Locals fill their water containers from one of the hospital’s clean-water outlets, Nasir.

  Posing in front of a hut in the town of Wudier, South Sudan.

  Net fishing in the Sobat River, Nasir.

  Kids from the TB treatment village make the
most of a rain-soaked compound, moulding toys from abundant clay.

  A blind, elderly man in Nasir, carrying the sum total of sight-aids available to him: a stick, the other end of which was pulled by a young relative.

  The tragedy of malnutrition. A young girl recovers in our small re-feeding unit, Nasir.

  Staff and patients chatting outside the surgical ward in Nasir. The six parallel lines of scarification across the foreheads of several of the men are called gaar.

  A sunset in Nasir, silhouetting the conical tops of a cluster of tukuls.

  What came to be my daily exercise in Nasir: lifting and throwing the kids who’d request this—and with increasing frequency, too.

  Two young siblings and one fantastic haircut, South Sudan.

  14. NET FISHING ON THE ZAMBEZI

  The service takes place on a blustery afternoon in a leafy park of Nairobi, Kenya, just days after the explosion. The hundred expats working with MSF in Somalia are hastily evacuated—my room-mate at the guesthouse has only the clothes he’s wearing and a laptop, everything else still in Somalia—and all attend. It’s a sad, sobering event.