Six Months in Sudan

by Dr. James Maskalyk

  i am typing in the logistics tukul. i have just returned from the hospital. i got a call a few hours ago.

  “dr. james? this is hospital. we have sick child. girl. 5 months. high fever. diarrhea. breathing problem.”

  “all right, hospital. can you test for malaria, give the child 80 mg of paracetamol, and some cool cloths. do you copy? good. is she drinking?”

  “no.”

  “ok, start a cannula. weigh her and write the name down. i will be there in a few minutes.”

  “dr. james … i … um … i use bag for breathing now.”

  “i’m coming. over and out.”

  where is the driver? no driver. i grab my stethoscope, and jog 460 paces. i arrive through the gate, people are standing in front of me, waving outpatient cards. i brush past them to the nursing room. a young mother wearing a bright yellow veil is holding a limp 5-month-old. the baby’s eyes are sunken, half open, and her small chest rises and falls with last breaths. two nurses are bent over one tiny, dangling arm that has a latex glove tied above its elbow, poking it with needles, looking for veins. the child doesn’t flinch.

  they can find none. no veins, no intravenous. (yusuf, can you use the bag again … no, like this, smaller breaths … no … do you hear that sound? it means there is no seal … you know what, i’ll do it. tell the guard to start the generator for the oxygen machine.) no gas for the generator. (ok, prep the leg, the left one. with betadine. perfect. great. ok, take the bag. smaller breaths. push when she breathes. no, make a seal …)

  i open the intraosseous cannula, landmark a little less than a cm below the tibial tuberosity, on the flat part of the shin just below the knee, twist and twist and twist until it pops through the thin shell of bone. marrow flows freely into the clean water of the syringe and i flush it smoothly back. the fans in the nursing room start to spin. i ask for fluid, and antibiotics. the child’s head hangs loosely on my knee. she vomits, and breathes it in. (suction please.)

  last breaths are like this:

  so now i am blowing in tiny, tiny breaths through a tiny, tiny mask. i barely have to squeeze the bag, her lungs are so small. small, and full of crackles. three times my stethoscope dangles down and touches my knee, three times i feel a small pearl of hope, thinking it was her hand. i look down, and her arm hangs loosely by her side. i stay there for hours.

  i think i would still be there if her breathing hadn’t worsened, but it did. she was tired, her muscles burning and inefficient from the lack of oxygen, full of lactic acid. when i would stop, instead of taking a breath, all she could manage was a grimace, a shrug of her small shoulder.

  i placed an oxygen mask over her cheeks and pulled it gently snug. i put my stethoscope on her chest, and heard her heart count quietly down.

  i don’t think that i will end up ruined, but there are certain things that are going to be tough to share. things that would make poor dinner conversation (hey, have you ever heard an infant’s heart stop? don’t you think it is like the silence must be after a train wreck, deep in the forest? once the metal has stopped creaking? like all this activity, and then this final vacuum in place of all the sound?) i can imagine meeting people on the street, and being asked how my “trip” was. (… you know the feeling when you and your friends are cleaning up after some young mother dies and you can hear her baby cry and you’re all praying to yourselves, please don’t let anyone look me in the eye? you know that feeling?)

  it was fine. it was all fine.

  i cleaned up the emergency room, the nursing room, watched the family close the baby’s mouth with gauze. i saw some outpatients. i took a seed out of a little girl’s nose. i walked back to the compound alone. i went to the kitchen for a glass of water. paola came in to see me.

  “is everything ok at the hospital? i heard the call on the radio. is the baby ok?”

  “um … no … she’s dead.”

  “are you ok?”

  “yep, i’m good.”

  “you know, you don’t have to keep everything right here,” she said, and pointed to her sternum.

  “i know,” i said.

  usually, as a doctor at home, it is rare to have one of these experiences, but when you do, you often bear it with others. another doctor, or nurses whom you know. you sit and talk about it. it doesn’t make it go away, but it diffuses some of the weight. i don’t do that here. i figure everyone has enough of their own weights. so, just now, from the kitchen, i walked over to the log tukul, and started typing this. instead of keeping it here, in my sternum, i am going to put it right here:

  .X.

  still no news from the car. we are all quite anxious.

  i don’t mean to burden anyone unnecessarily, but this is what happened tonight, just now, i am freshly back. the part of me that normally edits these stories out doesn’t want to do it today.

  KNOCKKNOCKKNOCK.

  “Hmm?”

  “Dr. James? Hospital. Channel 6.”

  “’Kay.”

  The handset is below my bed. I sweep the cement floor for it. I have moved inside because of the rains.

  “Hospital, go ahead,” I mumble.

  “Dr. James, we have patient here.”

  “I’m not on call. It’s Mohamed tonight. Over.”

  “Dr. James. It is a gunshot. Over.”

  “Where is the patient shot?”

  “To the chest.”

  “I’m on my way. Over and out.”

  I turn my light on, pull my clothes from the line in the corner, walk to the front gate. I check my watch: 2 a.m. The driver is pulling his seat belt on as I step into the Land Cruiser.

  “Mustashfa,” I say, as if there were anywhere else to go. He nods.

  The guard opens the gate and we roll slowly past it, gravel crunching. The road is deserted. We turn right at the buried tire, pull past the military compound. It is quiet.

  We stop at the hospital gates. The driver makes a signal with his hand, asking if he should wait. I nod. He reclines his seat.

  There is no guard at the gate. Strange. I look around his desk. No sign.

  I head towards the emergency room. No nurses in the nursing room either. A mother on the central veranda raises her head from behind a mosquito net.

  The door to the emergency room is open. Inside is the security guard. And both the nurses. And four soldiers. Don’t know which side, don’t care. I glance at their hips. Unarmed.

  Wait. Five soldiers. One is on the bed, his shirt off, dressings on the left side of his chest and his left arm. Both are red with blood. An intravenous has been started.

  “Blood pressure?”

  A nurse checks a list in his hand. “Um … 100 over 60.”

  I open the intravenous line fully.

  “Heart rate, 90. Oxygen level, 98%. Respiratory rate, 16. Temperature, 97.5,” he proudly reads from his list.

  “Great. That really helps. Thank you.”

  I listen to both sides of the patient’s chest. Air entry bilaterally. Less on the left? I put my finger in the notch of his sternum and feel the hard roundness of his trachea. It is midline. The veins of his neck are flat. So far so good.

  I lift the dressing on his chest. In his mid-axillary line, to the left of the nipple, is a quarter-sized hole. I look elsewhere on his torso. No others. Odd numbers of bullet holes mean at least one is inside.

  I unwrap the gauze on his arm. A small entry wound on the lateral side of his triceps, a wider exit wound through the medial side. Three holes.

  “How many shots?”

  My nurse translates. Maybe two. I think the one in his chest is the one that passed through his arm, judging by the size of the wounds. The damage done by bullets designed to kill humans is different than ones we use to hunt animals. When we fire a bullet towards an animal, we hope to kill and eat it, not destroy it. The ones made to shoot people are designed to tumble and fragment after they penetrate the tissue, transferring as much energy as possible to the body, creating as large a hole as possible.


  There is a bullet in his chest, I’m sure of that. The entry wound in his ribs is small, which means the bullet must have yawed inside his chest, tearing up some lung. Could be anywhere though. Lodged in his heart. Neck veins flat. His spine. Is he moving his toes? Yes. I feel his abdomen. Soft. Diaphragm. Can’t tell.

  Trauma-room ultrasound and x-ray, chest tube, cross and type four units of blood, CT scan chest and abdomen. Call the surgeon for possible exploratory laparotomy to look for a diaphragmatic injury.

  I decide to give him some antibiotics, a tetanus shot, and put in a chest tube. His lung has surely collapsed, at least a bit, and it will be bleeding. If it’s not drained, the resulting inflammation from the clot will scar it.

  I take my hands off his abdomen. “Can you tell him I need to put a tube in his chest? Tell him it won’t hurt; I will give him medicines to make him sleep.”

  I leave the room as the nurse is translating and wind around the sleeping families cocooned in mosquito nets. I slide between the stacks of vaccine coolers left from the measles campaign and reach the metal pharmacy door. I open it, turn on the light. Lizards scatter.

  I take a scalpel, some sutures, a vial of ketamine, and shuffle through the chest tubes. They are all too small. I pick the largest. I mark what I’ve taken on a piece of paper, sign it, and leave it on the shelf, under the calculator.

  One of the soldiers has left, but the rest are still in the room. No one wants to miss any excitement. I ask them to go. One objects. He is the patient’s brother. I let him stay.

  I prep the man’s chest with iodine until it is clean, and prepare all of my instruments. Lastly I draw up the anesthetic.

  “Tell him this will make him sleep,” I say, and inject the ketamine into his intravenous. By the time I am finished putting on sterile gloves, the soldier’s eyes stop roving, and close. Beneath his lids, I can see his irises jitter back and forth. Ketamine works best in children, because they can manage better with the dream world it creates. Adults, as they emerge, can be disoriented and violent.

  I make an incision in his chest, over the sixth rib, through skin and muscle. I take a curved forceps and curl it over the bone, and with a pop, push it through the pleura and into his chest. I spread the forceps apart, widening the hole, and then insert my finger, feeling for a piece of lung that might be adherent to the chest wall. There is none.

  I slide the tube into the incision and guide it into his chest, directing it towards the back of his rib cage, cinch it with a thick suture, and tie it to his chest. I clean away the torn skin from the bullet hole, then wash it out and sew it shut. As I turn my attention to his triceps, he starts to moan. I give him more ketamine and with it, some Valium.

  I finish. As the nurses are dressing his arm, I open the door to let the other soldiers back into the room. They are asleep on the veranda.

  I ask the nurses to do another set of vital signs and begin to clean up the mess. I put the scalpel and the needles in a thick cardboard box, and bend to pick up the iodine-soaked dressings on the floor. Beside them is the bag I just attached to the chest tube. It is full of blood.

  How much.

  I pick it up. Easily 800 milliliters. Whoa.

  “Can this guy give blood?” I point to the brother.

  “He says no,” the nurse answers.

  “What? Why not?”

  “He says he is too tired.”

  “Well, that disqualifies everyone on the planet. Tell him that his brother is going to die if he doesn’t get blood.”

  “He says he had malaria.”

  “It doesn’t matter.”

  “He refuses.”

  “Ask the other ones.”

  “They say no.”

  “What the hell.”

  It’s four in the morning. I look at the bag of blood. Closer to 900 cc’s now.

  “Okay. Tell them they have to find someone who will give blood. They have an hour. Or he will die. And then start another intravenous and give him more saline. A whole bag.”

  The soldiers leave. The nurse turns to me.

  “He was shot by other soldier.”

  “Oh.”

  I leave the room to find the guard and use his handset to call compound 2.

  “Ismael, it’s James. I need you at the hospital. Blood transfusion.”

  He’s on his way. I call compound 1.

  “Marco. It’s James. Sorry to bother you. I need to do a transfer. Yeah, gunshot. No, don’t know the details. Shot by another soldier. His own side, I assume. Wait, let me ask … No. I was wrong. Not his own side. You’d better come. Over.”

  I’m more awake now. I stop for a second and listen. I don’t hear any gunfire. Wait. Is that—? It’s tough to hear over the generator. I step out of the front gate and look at the military compound. No lights. Quiet.

  Marco and Ismael arrive in the same car. There is no sign of the other soldiers yet. Ismael tests the wounded patient, still sleepy from the Valium. Marco and I start getting the car ready for transfer, hanging bags of saline and stocking it with medicines.

  The soldier’s brother arrives alone. He could find no one else and now agrees to donate.

  “Ismael, how much blood can we draw, maximum? A unit? Maybe take a bit more.”

  Ismael draws half a liter of thick blood from one brother and we start to drip it into the other. The night begins to lift. It is five-thirty and we can be on the road soon. We call in a driver and an extra nurse. We carry the patient to the Land Cruiser on a stretcher and lay him on a mattress in the back. There is now a liter of blood in the bag.

  I pull the nurse aside and write specific instructions on a piece of paper. How much of the medicines to give, how fast to run the fluid and the blood, how often to do vital signs.

  “Is it clear?” She nods. “Call me if there are any problems.”

  Dawn breaks. The driver fires up the Land Cruiser, and the guard opens up the gate. The car pulls slowly forward, then stops.

  At the gate is a small pickup truck filled with people. They are blocking the exit.

  Our driver honks. The pickup pulls farther ahead. An impasse. Our driver gets out of the truck, begins shouting loudly in Arabic. The guard joins him. The driver of the pickup backs out of the way, and our Land Cruiser pulls through the gate and down the road.

  The pickup enters the hospital grounds. Three men jump down from the back. I can see their uniforms now. Police. They reach into the box and pull out a heavy load that they carry between them. It is a body. They deposit it at my feet.

  The face of the man is blue and swollen. I reach down to his neck. He is cold.

  “He’s dead.”

  “They want you to say how he died,” the nurse beside me whispers.

  It is six in the morning now.

  “I can’t. I’m not a coroner. Tell them I’m only good with the living.”

  She translates. The policemen start speaking loudly.

  “They say it is the law.”

  “No.”

  Marco comes from the nursing room. The body lies between me and the police, forgotten. We argue overtop of it.

  “James?”

  “These guys want me to determine the cause of death of this man. He appears to be beaten around the face, but I can’t say for sure why he died. Broken neck, internal bleeding. I can guess, but we’ll just get in the middle of something. It’s a recipe for ending up in a Sudanese courtroom.”

  “I’ll take care of it. You go back to the compound and get some sleep.”

  The hospital is waking up. People shuffle underneath their mosquito nets, toss them open. A baby starts to cry.

  I grab my stethoscope and walk through the gate and almost bump into Mohamed. He has heard the entire story from Ismael.

  “James, why didn’t you call me for help?”

  “I didn’t think of it. I should have. Hey, can you do rounds today? I’m pretty tired. Wake me if there’s anything, okay?”

  He agrees, and I turn towards compound 1. Beyond it, t
he rising sun.

  Bright.

  03/05: cheap sunglasses.

  one of the most difficult things for me to accept in sudan is that everyone has better sunglasses than i do. well, not everyone. mostly old men. in my other life, i live in kensington market in toronto. when i am not working or running from one place to the next, i am wandering the streets of my neighborhood trying to soothe that one hollow part in my spirit that the right pair of sunglasses would fill.

  i don’t think this is a sign of inner discord, representing a broader sense of dissatisfaction with the universe. nor do i think i should be looking for sunglasses inside my own soul rather than in second-hand store windows or on the faces of old sudanese men. i know this because once i found the right pair. i bought them in new york on the street for ten bucks. they were like blue blockers, and on the bridge was a swordfish. with them on, the world was better. minty. i took them off only when necessary. last year, on my way to train with msf, sleep deprived and excited, i left them on the seat of a german taxi. as it took off, i felt a familiar ache.

  it is a grand leveling that msf, as part arbiter of my sunglass woes, placed me in a country with such a high density of cool ones. i could even begin to forgive their role in the loss of my perfect pair if i could track some down. when i was in khartoum last, i spent an afternoon with a driver going from place to place, souk to souk, looking for some. he would pull up to a stand with racks of fake gucci glasses and look at me hopefully. no, i would say, i want old man glasses. confused, he drove on.

  and now i am in abyei. the souk is full of carbon-paper stores. the one selling cigarettes, powdered milk, tomato paste, lighters, and biscuits abuts another selling cigarettes, powdered milk, tomato paste, lighters, and biscuits. there are two restaurants. at bashir cafeteria, one can take his chances with beans, goat, or if he is lucky, tomatoes. at the other, beans, goat, tomatoes. the worst part is, of course, the old man who takes your money has the best pair of sunglasses you have ever seen, but the market has none. i asked him one time where he got them. he smiled, and turned away. he could smell my desperation.