Band-Aid for a Broken Leg

by Damien Brown

  What I read is that cattle are not merely a source of wealth. Rather, the Nuer’s daily routines and seasonal migrations revolve entirely around the herd’s needs, with the animals said to be utterly doted upon. Only rarely are they eaten, and almost every part or product derived from them is traditionally put to use—even urine for hair washing, and the ash of dung for teeth brushing. Men compose songs about their favourite beasts and are said to be able to recite the ancestry as if they were relatives, and there’s a significant spiritual component to the animals, too, with beasts being dedicated to the ghosts and spirits of ancestors—becoming wandering shrines, in essence. It’s an entirely cattle-centric view of the world, perhaps best summed up by the Nuer word for foreigners, Jur, which means ‘entirely cattle-less’. Easy then to see why they’d risk death defending their herds.

  What I see, though, when standing at the end of the victims’ beds each morning, is petty squabbling among armed men, who’re willing, despite decades of hardship, to risk not only their lives but also those of innocent bystanders—for animals. It’s not my role as a foreigner, and particularly not as a health worker, to question such things. I know this; the practice has been going on for thousands of years, albeit without guns, and is part of the culture. Yet I do question it. More each day, as I review the consequences of it all on the ward.

  Thomas turns back to me. The brother’s adamant, he says. There can be no amputation.

  I go to the office and try again for a plane, but they can’t send it.

  I talk to the surgeon in the other project, but all he can suggest is to get the patient out.

  I feel ill.

  We set up theatre, then carry him over. The clan follow and wait outside. I’m still not sure what I’m going to do. If we leave him, he’ll die. If we amputate, there’ll be consequences. I’ll just have to try to trim away the spreading infection again.

  We lie him on the table. Paul runs the generator. Gatluak, the surgical assistant, prepares the instruments, and Heidi draws up the anaesthetic. I scrub and don gloves and gown, and while I’m prepping his leg with iodine and musing aloud as to whether things could possibly get any worse, the question is answered with a resounding ‘YES!’ when Heidi gives the first dose of ketamine and his throat clamps and he stops breathing.

  I drop the iodine and run to beside his head where Heidi’s apologising furiously. She gave the right amount; this is a rare but known side effect. She hands me the laryngoscope to look down his airway and to try to secure it with a tube but a herd of wild horses couldn’t pry open his mouth right now, it’s clamped so tight and the oximeter beeps faster as his blood oxygen concentration drops and it’s already below ninety per cent Jesus in a couple of minutes it’ll be in his boots and he’ll arrest and we’ll have no chance of getting him back.

  I can’t ventilate him. I discard the laryngoscope fuuuck there’s no one to call for—

  Back to basics.

  First principles.

  A rubber bag and mask.

  It’s all we need to move air.

  Nothing.

  Like trying to blow hard through a blocked straw.

  ‘Seventy per cent,’ says Heidi. ‘Oxygen is seventy.’

  Christ.

  Everything so slow.

  Diazepam . . .

  Diazepam has muscle-relaxing effects and we don’t have any other drugs that could be of use right now so I ask Heidi to inject a couple of vials into him to relax the spasm in his throat and jaw, but I can still barely move air through his lungs—

  ‘Oxygen’s sixty per cent.’

  —so we just empty more vials into him because the side effect of too much diazepam, to stop breathing, seems an ironic and irrelevant one at the moment, Jesus what am I doing in this place, this man’s family are outside the theatre waiting for him to come out and I have no doubt in my mind that they’ll lose their minds if I walk out and say that he just died but the good news is that the leg’s still on, we didn’t perform an amputation, and I inflate-deflate the rubber bag as hard as I can while the diazepam runs into his veins. His oxygen level is now so low that the machine’s stopped trying to calculate it and I’ll be honest that a part of my mind is trying to work out how we’ll get to the boat from the operating theatre and downriver without going past the clan if we screw this up because I can’t comprehend what those younger guys will do, because if Gatwech threatened me for merely pulling him up over a missed teaching session, then imagine what’ll happen if this guy doesn’t—

  Air starts to move fractionally more easily.

  ‘Sixty-five!’ says Heidi.

  I can feel the spasm in his throat relaxing.

  ‘Seventy!’

  His oxygen levels slowly come up . . . ‘seventy-five’ . . . and maybe we won’t have to leg it for the boat after all . . . ‘seventy-nine per cent . . . no, it’s eighty-two per cent!’ . . . I suspect that now we’re out of the woods, and it’s probably been only five minutes, this whole ordeal, but my scrubs are soaked with perspiration.

  It becomes gradually easier to ventilate him. His levels climb to the nineties, which is where they stay. For the next hour Heidi and I stand with the rubber bag to assist his breathing as the drugs wear off, and we call Paul to set up the oxygen concentrator to help his breathing. There’s clearly no way I’m going to be able to do anything about this leg now. We just re-dress the wound and fashion a new cast.

  As the patient wakes up we move him back to the surgical ward. He seems to be okay. The family are oblivious to the near-disaster and actually quite happy with the look of his new cast, so I head to the office to call Loki again and upgrade the flight request from urgent to Get The Fucking Plane Here Yesterday status because this has now become a security situation as much as anything else. And when I finally go to bed, I become transiently but deeply religious, more even than when I board these small planes out here, and pray that the airstrip isn’t too muddy in the morning.

  And, for reasons more selfish than I should admit, that he actually survives the night.

  20. THE ASSASSIN

  The rain holds off the next morning. It’s still cloudy, but Paul checks the airstrip at dawn and thinks it’ll be fine. We radio Loki. They send the plane, and I stare anxiously at the dark clouds brooding to the north, would blow them away if I could because the plane can still turn back, but they stay put and the flight lands safely. The patient and one relative are evacuated. A couple of hours later I phone the surgeon receiving him, and he agrees that the leg is beyond salvage. He’s a Congolese man, though, so I can only hope that the family will respect a fellow African’s opinion more. He’ll let me know.

  And we were lucky, it seems. In coming weeks rains of almost biblical proportions regularly batter the town, causing frequent flight cancellations (more cases need transfer but none are as urgent), although I do enjoy listening to the storms. Especially since moving into a bedroom in the old missionary house. I sleep better knowing the walls aren’t water-soluble.

  By mid-June the river’s visible from our kitchen window, lapping not far from the top of the banks—the same banks on which our compound is built. The current is swift, sweeping clumps of water weeds silently west along the muddy surface, and the dugout canoes that ferry people and goods across it are now carried hundreds of metres downstream during just the short crossing. Beyond the far bank, what was until recently an endless expanse of dry land is now a large, shallow lagoon pooling alongside the river, its surface broken by a series of low islands and peninsulas on which lush grasses are already thriving. And all this is within just a month of the first rains. It’s testimony to how completely flat this region is; although water levels in the Sudd’s channels rise by only a metre and a half in the wet, even this small change will lead to a quadrupling in the size of swampland. Many Nuer will now move from the lowland cattle camps of the dry season to their higher, wet season villages, planting sorghum and maize in anticipation of an October harvest.

  ‘Does it ever flo
od in here?’ I ask Amos. It’s the Tuesday of my ninth week. He’s heaping plastic spoons of instant coffee into a mug, just beside me in the kitchen.

  ‘It does,’ he laughs, and he’d know. He’s worked in these South Sudan projects for much of the last five years, returning home every few months to spend time with his family in Kenya. ‘Sometimes, the water will come right in here. Right into the compound.’

  ‘Seriously?’

  ‘Oh yes! You will be living in those boots, my friend. Get used to them!’

  I grab a biscuit and jump the low windowsill into the bats’ room—one of two entrances to our main corridor—then head through and wait outside the shower for my turn, sitting on one of the large food storage containers. Paul soon comes around the corner, his pants muddied and face a little off-colour.

  ‘Sick again, mate?’

  He nods.

  ‘Squirts?’

  ‘Yeah.’

  ‘Badly?’

  He shrugs. ‘Same as two weeks ago.’

  ‘I hope that’s mud on your pants, Paul.’

  ‘Not that bad,’ he smiles.

  Either way, it seems that Nasir’s Frequent Traveller Club is well and truly open for business this month, the isle if la’trine its exotic and only destination. Paul’s looking gaunt, having lost a noticeable amount of weight since I arrived. Amos is sick again, too, and I’ve now shed a handful of kilograms since Mozambique. We still can’t work out the source of all this. Amos is confident the water’s good, and I doubt that the problem’s coming from the hospital—Heidi’s in there all the time and never gets sick, and neither does Carol. It must be the kitchen. Washing dishes outside is going to have to stop. Paul and I agree that one of us should spend an afternoon with the cook to see if she’s washing her hands and where she’s getting water from.

  ‘I’ll get that proper sink installed by the end of the week,’ he says. ‘I’ve been meaning to do it. Hey, you ever noticed that none of the women ever get sick? Zoe, Carol, Heidi, Maya—they always seem fine. You ever seen any of them ill?’

  ‘Never, actually.’

  ‘Seems a little weird, huh? I mean, we’re all eating the same food, and—’

  ‘She’s trying to pick us off.’

  ‘Huh?’

  ‘The cook. She’s trying to get rid of us, Paul. You, me and Amos. Anwar’s gonna be next. Then Ben. You watch. She’s trying to take us out, all the men.’

  ‘Seems that way,’ he smiles. ‘Like an assassin, you reckon?’

  Exactly. Not that she’s necessarily causing the gastro—the multitude of flies and proximity of our dish rack to the latrine may have more to do with that, in fairness—but at the very least she’s ensuring that we don’t regain any weight. It’s an objective that’s accomplished using a series of unusual though apparently well-honed cooking techniques. Like the boiling of spaghetti, for example, to a paste that, when left to cool, moulds itself to a glutinous mass replicating the inner shape of the pot in its entirety, and that can only be pried from its crucible with a manoeuvre involving the sequential levering of a series of well-positioned spoons—not unlike removing a bike tyre from its rim. Or the frying of fresh meat into dark, mahogany-like pebbles, the ingestion of which harks back to a distressing childhood incident involving the accidental swallowing of a Lego block; or the transformation of freshly purchased Nile perch and its less palatable flatmate, the catfish, from appetising foodstuff into golden, oily goop. And then there’s the accompaniments. Just last night: canned chickpeas, boiled eggs and a jar of curry sauce, all served cold.

  Paul stares flatly out the nearby doorway, looking drawn. I ask him why all the mud on his pants; it’s now just before seven, even by his standards a little early to have been working for long.

  ‘Had to do some digging,’ he says.

  ‘For that new ward?’

  ‘For a grave.’

  I’d not expected that. ‘For the young boy?’ I ask.

  ‘Yeah. Father’s not around, so the mother asked us to help with the body. Said she couldn’t carry it.’

  ‘Sorry, mate.’

  ‘Yeah.’

  ‘The local guys couldn’t do it?’

  ‘I didn’t want to put it off any longer,’ he says. ‘Not in this heat. He’d been lying in that back room all night, you know? I though it’d be better to just get it done.’

  ‘I’m really sorry.’

  ‘Yeah, well.’

  The boy had been another far-too-late presentation to Nutrition, dying within minutes of arrival. His was our first death here for days. We’re still seeing plenty of sick patients, but nothing compared with the sustained tragedy of those first weeks. Nineteen deaths had occurred in total that first month, but we’d found no obvious pattern, no consistent underlying cause. Nevertheless, MSF’s regional medical coordinator is coming out from Loki in a couple of weeks anyway, to have a look at things.

  Paul’s still staring out the doorway. We stay quiet for a while, bathed in the grey light of an overcast morning. Some kids laugh beyond our fence. A bull bellows across the far bank, and in the background there’s the gentle lapping of the river; a soft, ceaseless gurgling.

  ‘The mother wouldn’t let go of him,’ he says, after a while. ‘I dug the hole and stood there, just waiting. She couldn’t let him go.’

  ‘Jesus, mate. I’m sorry.’

  ‘Yeah.’

  ‘You okay?’

  He says nothing. We sit quietly.

  ‘They really don’t know what to do, Paul. These mothers—it’s really sad. They stay at home too long, inadvertently feeding the wrong things, giving bad water, then they see those quacks at the market that sell them aspirin or any old rubbish and they buy it because they think if they’re paying it must be good. Then the traditional healer charges them a cow to make incisions or give herbs or remove a spell, and they pay it, and when it doesn’t work they bundle them in here, three in the morning, on the verge of death when it’s all too late.’

  Paul says nothing.

  ‘Mate, you okay?

  A long silence.

  ‘The sister,’ he says, after a while. ‘His little sister . . . she really clung on, too.’

  He removes his hat and walks off to his bedroom, and I think: Nine months ago he was a successful businessman living with his wife; today, he buried a child. I wonder how he’ll fare when he gets back. I wonder what he’ll say at the office when people ask. And I wonder too what happens if you do this often enough, if you spend year after year in the field, repeatedly living its unbeatable highs and unrivalled lows. Does your emotional barometer simply reset itself? Is it irreversible? Is there a line you cross, beyond which a ‘normal’ life at home becomes impossible? When you have to return to the field, simply because you don’t experience things to the same degree, for better or worse, back home? Like a Disaster Gypsy, maybe, just floating from one international crisis to the next . . .

  I worry that that’s where I’m headed.

  • • •

  More rain during the week, but not everyone is lamenting the mud. On the contrary. While adults grumble as they schlurp, skid and clog their way around town, kids are having a blast—and understandably so: several thousand tons of high quality, ultra-gooey, extremely mouldable play-dough has just presented itself for their unlimited use, and young imaginations aren’t short of ideas. I discover this while heading past the TB village on Saturday morning, frantically called over by the kids.

  ‘Khawaja!’ a young girl shouts, and I wave back, heading past her to the ward.

  ‘OI!’ she yells, stomping her right foot—what appears to be a rebuke aimed my way. ‘KHA! WA! JA!’ she calls again.

  I’ve been told. I change course and veer towards them, a trip very much worth it. ‘You built all this?’ I ask, in reply to which muddy little hands clasp big white ones, and excitedly, breathlessly, give the khawaja a tour of their play area: the construction site of a replica Nuer village.

  Football-sized tukuls have b
een styled from mud and clay—some remarkably detailed, others a little less convincing—and a group of boys are currently working on a thatched roof for one, trimming straw to length. And what good is any home, replica or otherwise, without a befitting entrance? None, of course—every six-year-old knows that!—so the larger tukuls have accordingly been given little stick doors, their twig ‘beams’ hitched side by side like the poles of a raft and bound together tightly with thread. Nearby, little mud people tend to their little mud animals, and transport options have even been provided by little cars with little straw axles and clay wheels that actually roll when pushed! The site is still very much a work in progress, though; lumpy foundations allude to forthcoming developments, and the dozen-strong work crew are still in a flurry of activity. And what a work crew: ignoring that a few of the younger plasterers have arrived without uniforms (completely naked, in fact) and that madam foreperson is directing it all without shoes (but wearing a bright orange dress, although her young sister has sourced shoes—a pair of adult-sized gumboots that I suspect have been borrowed from the medical ward) they’re as coordinated and efficient as any I’ve seen. It’s just delightful. I consider taking the day off to join them. Many of these kids are the children of TB patients, although a couple are unwell themselves. Either way, they’ve all been in this hospital longer than me, and as far as they’re concerned they own this place. I’ve come to know them all by greeting now (some prefer a high five, others a lift and a few just a hug, although a couple would please like to hold my hand), and today I’m expressly forbidden from heading to the wards until I’ve opened each of the doors, looked in every tukul, then tried all the cars.

  • • •

  Outpatients closes at lunch. By now all the inpatients have been reviewed, and Thomas, Joseph and I have attended to a dislocated shoulder—a satisfying and easy fix. This may be as quiet as things get for a while.