Band-Aid for a Broken Leg

by Damien Brown

  In my second week I’m booked on a charter back to Sudan, but Nasir won’t be my next destination—not for a week or two yet. MSF have scheduled the closure of a nearby outreach project due to population movements and they’d like me to go. ‘You’ve done this before,’ says a senior, ‘so it’s better that you do it,’ which is like being told you’re good at breakups.

  I argue the decision, but arguing with management is something I’ve been doing too much of lately. I’d had issues with the way aspects of the Mozambican mission were run and made it well known, and my new supervisor now hits a raw nerve: I’m putting personal frustrations ahead of the project’s needs. It’s an assertion that makes me wince. I’d throw the insult back, tell him that I’ve seen a handful of good, experienced field workers walk away from the organisation for no other reason than being messed around repeatedly, and significantly, by Human Resources, but there’d be no point. I’d only validate his assertions.

  So I go. I fly into the small village with another nurse. I spend a few glorious days living like a camper in an old hut, see some patients, walk the village with staff and thoroughly enjoy my time. Then, give employees their last salaries, dispense medical supplies, take down the flag and pack four of the sicker patients into the plane with us, and return to Nasir. Desperate to just stay put.

  • • •

  ‘Doctor!’ calls the guard, as our LandCruiser pulls up at the gates. Steffi just flew out—I saw her on the airstrip, no time for a handover. ‘Come now,’ he says. ‘For the feeding centre.’

  I leave my bags and walk across the yard, step through the low doorway of the mud-walled feeding centre. Heidi’s kneeling with one of the Sudanese health workers beside a young patient near the side wall, the family watching over her shoulder.

  ‘Look,’ she says. ‘Look at this. They carried her in a minute ago, like this.’

  I crouch next to the young girl. I’ve not seen her before, but I know well those eyes. I saw them in Angola. Big, white, dinner-plate eyes, sunken in a face that’s too big for such a skinny body, a face that belongs to someone seventy years older with its wrinkled skin. ‘Wizened,’ the textbooks call it.

  ‘Eight kilograms,’ says Heidi. ‘Eight kilograms, at three years old. She’s eighty-six centimetres tall.’

  The girl’s too short for her age (stunted, due to chronic under-nutrition) but even accounting for this lower height she’s markedly too light (wasted, due to acute malnutrition). Not that there’s a need for charts in her case.

  She sits up from the sheet on the floor where Heidi’s started treatment and squats like a frog, her knees splayed, mewling listlessly. I haven’t seen a child this ill since Mavinga. Not even close. Nothing like this ever presents back home, and my heart sinks and my head rages as I think of the audacity that this still occurs.

  She won’t sit still. She has none of the loss of appetite I’d expect for this late stage. She grabs the cup of rehydration solution and gulps it in one go, but it’s far too much for her body; she pukes it instantly, but wants more anyway. I gently pry the cup from her and she looks accusingly at me with those big eyes. Her head bobs, it’s disproportionately large on her bony frame. We quickly move her to Inpatients because Joseph and the team there are better equipped to manage her.

  Joseph’s worried when he sees her.

  We insert an IV line and let her drink limited amounts. We give antibiotics, glucose and a small bolus of fluid, but even after six months in Angola the management of these children petrifies me. We’re walking a tightrope with their treatment, with little margin for error, because three conditions interplay and overlap in this little girl right now. Each is potentially fatal, and each requires a slightly different approach. Malnutrition is one, and a severe one, but she’s also got diarrhoea so is likely dehydrated. Managing these two can be contradictory. Malnutrition requires extremely cautious rehydration in order to not overfill her, which could put her weak heart into failure as it struggles to pump this sudden fluid load around. Dehydration, on the other hand, can lead to shock and cardiovascular collapse due to a lack of fluid, and therefore requires the opposite: appropriate filling. Add to this her high fever, cold hands and rattly sounding chest, and she’s quite possibly in septic shock—a third condition, also mandating prompt fluids.

  So we commence management with extreme care.

  ‘Two monthses,’ says Joseph, talking with the mother. ‘She has been sick for two monthses. Now she also has diarrhoea for one week. Very much diarrhoea.’

  ‘They from Nasir?’

  ‘Yes. But they never come’d to Outpatients. They were seeings the traditional doctor. He gave them medicines, and they tried to buy other medicines from the markets but did not have money.’

  The traditional healer should see this.

  We reassess her constantly. We’ll soon know if we’ve pushed it too hard or not hard enough. We wait for her to make urine and for her peripheries to warm up, listening carefully to her chest to make sure she doesn’t fill up too quickly. I gently pinch her skin between thumb and forefinger but it remains loose, crumpled black tissue paper. Joseph mixes up a fresh batch of the ReSoMal solution, and as he opens the sachet I think, How strange that we live in a world where a product range needs to be designed, created and sold for the sole purpose of treating the starving. The packet even has its own logo.

  The little girl’s diarrhoea is copious. Perhaps more so now that she’s drinking again. Her bowels unload an impossible amount of fluid from her body every few minutes, so we cautiously give her replacement. We add extra when she has a bowel motion, but as fast as we put fluids into her she loses them.

  By late evening her diarrhoea seems to slow, as does her vomiting. Her blood sugars are okay and she looks fractionally brighter. Joseph has already worked hours overtime so heads home and is replaced by his evening colleague, Deng, and the pair of us run through the girl’s management plan together. Heidi’s meanwhile still in the nutrition centre because there are twenty-something other patients that need attention in there, and at some point later I quickly head back to the expat compound to grab a drink and something to eat. I still haven’t unpacked.

  I stop outside.

  I look over the fence, at the cracked-earth plains spreading for miles beyond the river. Above it all, a thin crescent of a moon glows; a silver hammock slung lazily between two stars. There’s an immense beauty in the starkness of it all, this place, and this eerie silence. I’m utterly entranced by Sudan.

  And intimidated.

  17. WEEK FROM HELL

  The guard calls me back to the assessment room within half an hour. I run in but this time there’s a young boy lying on the bed.

  ‘Where’s the girl?’ I ask.

  ‘Who?’

  ‘The girl. Where is she?’

  ‘Back to the Nutrition,’ says Deng. ‘When this boy come’d, we moved her. Gatwech is looking after her. With Heidi.’

  ‘Is she all right?’

  ‘What?’

  ‘She okay?’

  ‘Same.’

  The boy’s a year old and in much the same state as the girl. Fragile, wasted, desperately fatigued. Why the two severe cases in one night? Is there an outbreak of something? Jesus—is this normal for South Sudan?

  His father and three other men sit in silence on the wooden bench along the deep-red wall when I walk in. His mum stands quietly by his side. She looks up meekly at me, says nothing. Deng gathers equipment as I examine the boy. He’s worse than the girl. Not drinking at all, no appetite, and I try to insert an IV line in the back of his hand but miss the little vein and his eyes don’t even flicker. Big eyes for such a little body. His face looks peaceful though his chest is heaving.

  I put on a pair of gloves and prepare a nasogastric tube so we can at least start giving fluids, and Deng explains the procedure to mum who then holds her son’s head still. I grasp the tube, push the tip back, through his nose and down his throat, and he cries only weakly. His disapproval i
s feeble. He doesn’t even have the energy to fight me. It’s a worrying sign.

  The tube doesn’t go in properly. I pull it out and his tired eyes dart between mine and his mum’s as he silently sobs. Why are you doing this?, he must be thinking.

  Sorry little man. We gotta do it again.

  I hate doing this.

  We try the other nostril. A dab of lubricating jelly on the tip of the tube and then insert it horizontally, all the way to the back, pushing with a little more force as it curves around the bend at the back of his nose into his nasopharynx. He gags. I push a little harder and the tube suddenly slides easily, down the length of his oesophagus. Deng hands me a large syringe and I fix it to the free end of the tube. A draw back on the plunger confirms the placement as gastric fluid refluxes into the chamber. We tape the end to his cheek and give ReSoMal down it, then a small amount of milk. Deng performs a malaria test. Passers-by are watching from the doorway. It’s now pitch dark outside, and the generator’s humming life into the two bulbs hanging from the roof but there’s still not enough light in here, never enough light in these places.

  I set up again for an IV. The little boy passes copious amounts of green diarrhoea with an effortless gurgle, and it oozes like a little green tidal wave across the plastic surface of the examination table. His mum reaches over, mops it with the hem of her blue shawl. She doesn’t even blink. Only a mother would do that.

  Deng holds a torch as I retry for an IV, and more green foulness oozes from the boy’s body, spreads across the table but my hands are occupied and I watch as it drips onto the floor next to me. I won’t wear sandals to night calls anymore.

  The line goes in. We give fluids and antibiotics, but his diarrhoea keeps flowing. He becomes sleepy. We add dextrose to keep his blood sugar levels up and give extra fluid whenever he passes diarrhoea, and I lose track of time. Ten minutes, six hours—it all feels the same. Eternal moments of watching, standing, and waiting; of doing nothing, then re-examining him and adjusting his infusion, but according to the chart we did that only two minutes ago. Always feels like we’re not doing enough. What we should do is rig up monitors, adjust oxygen and reset alarms, insert half as many central lines as Mr Feldman had going into him in ICU and then yell for X-ray because this is an imminent code-blue, people, on a one-year-old—

  Deng’s lamp is running flat. It’s rechargeable, but it needs the sun. Not a great invention for busy nights. He excuses himself and retrieves the one from the surgical ward.

  The boy’s diarrhoea won’t settle. We keep giving fluids but for all we give even more shit comes out. Green filth, burbling from his little body. Impossible quantities for such a small boy. I draw up more ReSoMal, and the health worker from the feeding centre comes in.

  ‘Doctor?’

  I look up.

  ‘The little girl has died.’

  I nod.

  ‘The mother will take the body. In the morning. Is this all right?’

  I nod again.

  ‘There is no father to help bury it. Only a brother, but he is away. So can it stay here?’

  Okay.

  For hours the little boy stays much the same. We don’t leave the room. His diarrhoea settles and we recheck his fluid status, and some time later he actually starts to sip from a cup if we prop his head up; a small but clear improvement. I re-check everything—his IV line, his tube, the quantities, my notes. What we’re doing is right. I draw up a plan for Deng: what to give every fifteen minutes, what to do each time he has a bowel motion.

  I head back to the compound. I’ll come and check on the boy soon, but right now I need a quick bite, a drink, I need to put my head down for a bit because I didn’t sleep much before that outreach closure yesterday and this morning’s ward round begins in a couple of hours from now, and I’m going to have to start from scratch reviewing all those new patients again.

  The guard calls me.

  Jesus, I fell asleep?

  I run to the assessment room.

  Two dead children, lying on the table.

  The little girl from the feeding centre and the new little boy, just there, right as you walk in. Like two mannequins. They don’t look real. Not old enough to be dead, I think, but I’m forgetting where I am.

  I walk over to them and their eyes are open. Not peaceful, not anything, just glazed and expressionless. Their bodies lie side by side on the plastic surface and the boy’s mother is silent, the whole family silent and the generator off and I hear only the noisy breathing of a sick infant next door, and Deng carries over the other portable lamp which is also fading and shines it onto the bodies. I walk to where the mum of the little boy is kneeling at the foot of the table and she looks up at me pleadingly, waiting for me to say something. Surely she knows?

  I listen to her son’s chest as a formality. No heartbeat, no breath sounds. I try to shut his eyes but they don’t stay closed, and I wonder why they put the two children together like this, naked, it makes no sense.

  I try again to close his eyelids with a soft sweep of my fingers but they remain open. I turn to the mum with the same stupid look of resignation I’ve had on my face far too many times in these places, and I don’t say anything, just look at her, and she grabs my hands and sobs into them. The family on the bench start crying too, so I just stand, don’t move, never knowing what to do because I’m no better at these moments than that very first time this happened in Mavinga.

  The mother stands up and begins pacing. Her sobs build, becoming wails. ‘Ayoy ayoy ayoooooooooy . . .!’ she screams. I’ve not ever heard people yell like this before. Strange that cries should sound different in different places.

  ‘Deng, please tell her I’m sorry.’

  ‘Yes?’

  ‘Tell her I’m sorry. Tell the family.’

  ‘It’s okay—we gave it before.’

  I try again but he doesn’t understand me. ‘Is that what you called me for?’ I ask him.

  ‘Yes.’

  ‘No other problems in here?’

  ‘No.’

  ‘I’m sorry about all of this, Deng.’

  ‘What?’

  ‘Nothing. But Deng, could you please cover the bodies next time?’

  ‘Yes?’

  ‘The bodies. Can we not leave them like this? And not just near the entrance.’

  I turn to walk out but he asks me for boxes. ‘For the bodies,’ he says. ‘We are losing many blankets. It is better we use boxes.’

  ‘Which boxes?’

  ‘From the pharmacy.’

  ‘The ones for packing?’

  ‘Yes—like for the medicines. The medicine boxes.’

  I get the key to the pharmacy from the small shelf in my hut and fumble around in the room, retrieve two empty cardboard boxes.

  I return to the ward with two little coffins.

  And walk back to the compound.

  And go to bed.

  • • •

  Morning, and I’m back on the ward just hours later. Self-consciousness engulfs me like a dark cloud as I walk in. The children died just around the corner, beneath this same roof. There are no doors, no privacy. Everyone here knows what happened. Everyone would’ve heard the crying. And I wonder now what the patients think when I come to see them: This new doctor—two patients dead on his first day! My God, whatever you do, don’t take what he prescribes . . .!

  Joseph’s waiting for me. He heard about what happened. ‘Very sad,’ he says, ‘but today I have maybe happy newses. I think maybe we should start with this ones, yes?’

  I couldn’t agree more. I follow him to the far corner of the ward, a free-standing brick building that’s a replica of the surgical unit—same high tin roof, same white walls painted dark red along their lower half, only this is longer and houses a dozen or so extra beds. Thirty-something patients are in here—men, women, adults and children, all together, all languishing in the diabolical heat. Most will go outside shortly to lie on the dirt in the shade of the eaves.

  ‘Yo
u have met Elizabeths?’ asks Joseph, whose English, aside from a tendency towards the plural form, is excellent. ‘You know, Elizabeths, with the HIVs?’

  I do. She’s in a bed at the back right corner of the room. She’s a thin, frail woman in her mid-twenties, with a halo of short black hair. A bright red dress drapes from her bony shoulders like the lining of a sagging, broken tent, and she sits up on her cotton throw-down as we approach. She ideally should have been started on anti-retroviral therapy for HIV when she was admitted two weeks ago, but she doesn’t meet our criteria for therapy; according to the guidelines, she lives too far from town and is consequently at a high risk of defaulting.

  ‘We have spoken withs her,’ says Joseph, ‘and today she is saying that her family will move. Before, she didn’t wants to move, but now she does. She is getting sicker. She wants treatments.’

  Elizabeth stares intently, looking from side to side at us while we discuss her future. Joseph speaks with her in Nuer, a lilting tonal language with soft-sounding consonants and none of the distinctive ‘clicks’ of the Xhosa I’d heard around me in Cape Town.

  ‘She knows this will be forever?’ I ask, looking at Elizabeth. ‘And that she must take it daily? She knows that she’ll need to see John regularly?’ John’s the supervisor of our small HIV unit, and one of only two members of our Sudanese staff with formal qualifications, having trained as a nurse in Juba. Joseph and the others attended only basic health courses.

  ‘Yes,’ says Joseph. ‘She knows. John and me talked with her.’

  ‘Great!’ I smile. ‘Then let’s get the treatment started! I see no reason to wait.’

  Joseph translates, and now just look at that: the widest grin you’ve ever seen, and a red dress. There’s not much more to her, really. She’d be thirty kilograms at most. I’m really looking forward to seeing her through this treatment, too; I’ve not treated patients with anti-retrovirals previously, although the manual is currently top of the pile at my bedside.