So, Lindsey and I were recently in Maban, Sudan. This is a little town along the border between South Sudan and Sudan. It was a pretty sleepy place until a year ago, when fighting broke out in the Blue Nile State of Sudan. This conflict epitomizes the heavy-handed approach that the Khartoum government has utilized against its own people in the marginalized border areas. I can attest to the intensity of this war, as I personally experienced aerial bombardment while working at Kurmuk Hospital last year. I helped to treat countless patients whose bodies were torn by sharp fragments of bullets and bombs. I lived the struggle to flee from a war zone. At one point I was forced to balance the desire to serve with the basic instinct for self-preservation. I opted with the latter and fled. Shortly after, the town of Kurmuk was captured by the Sudanese army.
The area around Maban has served as a location for refugee camps from the struggle in Blue Nile State. Refugee camps in Doro, Gendressa, Batil, and Jamam have offered the chance of survival to the hundreds of thousands who have fled with scarcely a shirt on their backs. The threat of bullets has given way to the less glamorous, but more potent threat of starvation. When I visit these camps, I see the misery of people living in horrible conditions, with a sheet of torn plastic over their head, eating food that we wouldn't feed our pets. I have to wonder how bad things would have to be to flee to a place like this.
Maban County Hospital was established when Dr. Evan Atar, the indefatigable Sudanese doctor at Kurmuk Hospital finally fled across the border with a handful of staff. He stayed longer than I did and barely got out in time. They were allowed to set up medical services in a health center, and thus began the work of caring for the health needs of refugees. The demands are overwhelming. There is the business of caring for malnourished kids, treating diseases like malaria and typhoid fever, establishing programs for treatment of tuberculosis, dealing with obstetric emergencies, etc. The work load is heavy and overwhelming. Dr. Atar doesn't complain. He just keeps plodding on, doing what he can to help people in need. You would think that the cumulative burden of dealing with human suffering on this scale would get him down, but he just smiles and does what needs to be done.
I've been at Maban Hospital a couple of times. This last time I went with my wife Lindsey, a Pediatrician. I helped out with the surgical problems. This includes things like hernias, abdominal emergencies, trauma, abscesses. There are also challenges like hydrocephalus, vesicovaginal fistulas, burn contractures, malignant tumors and many things that you just can't quite figure out. In short, you deal with whatever comes in the door and needs a scalpel. It is pretty exciting, as you have to be willing to do whatever needs to be done. Lindsey took care of kids with pneumonia, meningitis, typhoid, tuberculosis, malnutrition, anemia and the ever-popular malaria. During this particular period of time, we dealt with a lot of obstetric problems. We had a run of caesarian sections, in particular. These were mostly women from the refugee camps who were not able to safely deliver their babies. They were generally referred by other NGO's who managed health care in the camps. They did what they could, but when they needed surgery, they would load them in a Toyota Land Cruiser and bring them down a bumpy road and leave them on our doorstep. During a ten day period, we did twelve of them. This is a lot for such a little facility. They mostly came at night.
One case, in particular, stood out. We had finished up a long day and were eating dinner under the plastic canopy that served as a dining area. The food, though not gourmet fare, was plentiful. Even rice and beans tastes pretty good after a long, hard day. During these precious moments of down-time, the team enjoys a little humor and you find yourself laughing about the terrible things that took place that day. This includes things like having to perform an amputation and finding that the hospital doesn't have a saw that is sharp enough to cut through the bone. We laughed about the experience of having a live grasshopper land smack-dab in the middle an open wound during surgery. We chuckled about the fact that there was only one set of sterile drapes available for an emergency and that they were burned on the charcoal fire used for sterilization. At this point, the gates were opened and a vehicle from MSF drove in. An unkempt Belgian field worker informed us that he had brought an emergency case for us. It was a woman who was pregnant and had been bleeding for the past day. She had no blood pressure for a while, but after pouring in some liters of fluid, they got a blood pressure of about 50. This kind of qualifies as a bona fide emergency and we dropped our plates and ran.
Dr. Atar went off to find some OR staff. Karen and Lindsey and myself opened up the OR and found the last remaining sterile drape set. I went in search of the patient and found her lying on the ground in the maternity. She was breathing and had a thready pulse. We put her on a stretcher and carried her across the courtyard, stepping over pigs, goats and sleeping family members, and into the OR. The presumed diagnosis was placenta previa. This is a condition wherein the placenta implants over the cervix. It basically closes the door of the uterus and makes natural birth impossible. The bare area of the placenta is also prone to sudden and catastrophic bleeding, which is what had happened. The body can tolerate a lot of blood loss, more than you might think. At a certain point, however, there just aren't enough blood cells carrying oxygen to the tissues. You lose consciousness because the brain isn't getting oxygen. The chance of the fetus surviving in such a condition is low indeed, and the chance of the mother surviving isn't much better. This woman was lying in a bloody pool and was on the verge of death. I took a quick look with an ultrasound to confirm the location of the placenta. I saw that the baby was still alive, but just barely. The heartbeat was slow and it looked like it was just about to stop. We didn't have much time.
I put on some gloves and asked someone to pour betadine on the abdomen. One good thing about this situation is that you don't need much anesthesia. This patient was nearly unconscious. We gave a little bit of ketamine, gave an abbreviated prayer, and I cut. I've been in this situation before and I've learned to move pretty quick. In about thirty seconds, I had cut open the uterus and pulled the baby out. The other good thing about a patient who has no blood pressure is that they don't bleed. The baby came out like a ragdoll and I handed it off the field to Lindsey.
Doing surgery involves an element of focus. You drape off a little corner of the body and this becomes your world. Everything else disappears as you cut through the fascia and open up the uterus. When my hand was pulling out that baby's head, that task was the only thing on my mind. Total focus. As soon as I had sewn up the uterus, I lifted my head to reevaluate the situation. It was pandemonium. There were about ten people in the room. Lindsey and Jared were working on resuscitating the baby. There were efforts to secure oxygen and to keep vital equipment plugged in. Several people were working to secure additional IV access. There was one nurse squeezing an IV bottle to push the fluids in faster. Some people were trying to obtain vital signs and find appropriate resuscitation equipment. Some people were handing gauze pads and sutures to the surgical team. Several individuals simply did not know what to do and were standing around with a dazed look.
Something happened to that woman after we got the baby out. She stopped breathing and the monitor couldn't find a blood pressure. When I looked at the head of the table, she looked like she was dead. It was one of those situations where you have to make a difficult choice. In the most commanding voice I could muster, I gave the command for everyone on the team to stop working on the baby and to concentrate on trying to save the mother. We had to make a decision between the child or the mother. We chose the mother. If we hadn't we would have lost both of them. I broke scrub and we started ventilating the woman with a bag. We poured in fluids, drew up medications, and after a couple of frantic moments we got a weak pulse. After a few more minutes she resumed spontaneous respirations. This was a huge relief. In the back of my mind, I had a terrible vision of carrying two dead bodies out of the operating room. Only when we had a decent pulse on the mother, did I ask whether the child had ever started breathing. It hadn't. There was a feeble pulse for a while, but by this time it had stopped. It was a beautiful little body, perfectly formed and still warm.
By this time Dr. Atar was sewing up the woman's abdomen and we turned to the next urgent task; getting blood. Unless we got a few red blood cells in her, this woman wouldn't last long. Karen had gone to the lab and gotten some blood typing reagents. They were tucked in her armpit, as they had been stored in a freezer and were frozen solid. We had a short debate as to whether blood typing reagents will still work if they are frozen. I stuck a needle in her neck and obtained a small amount of watery blood. It had the appearance and consistency of very weak cherry Koolaid. I'm not a lab technician, but there are a couple of vital skills that you learn in the field. One is to do a blood type. I took one slide and put three drops of thin blood on it. Then I added the slightly defrosted reagents; Anti-A, Anti-B and Anti-RH. The first two did not agglutinate, but the last one did. O+! Good for me, as I'm B+. Bad for Karen, as that happens to be her blood type. No time for other tests. I didn't have to ask her. Karen sat down with a blood bag, put a tourniquet on herself and swabbed her arm. I found a nice vein and poked it. In about a minute we had a plump unit of blood.
There are a lot of nice liquids in this world. Milk is a good one. Water is nice. Oil has its advantages. Coke is great. At this point of my life, my favorite liquid was fresh, warm, whole blood. The Bible is right when it says in Leviticus, that "the life of a creature is in the blood." We poured in that unit and the life started coming back in this woman. It is such a simple thing, but the effect of giving a unit of blood in such a situation is profound. This woman started to focus her eyes and to respond to questions. She still needed more blood.
Getting blood in Sudan can be a real challenge. There is a genuine fear of donating blood, even for loved ones. People think that they will die if they give blood. We asked the family. One tall man in a filthy clothes, with nappy hair immediately said he would give. He said he was the girls father. Amazingly, he was the same blood type. He looked at me, and peered in the open door at the chaos within. He asked if his daughter was still alive, and we said yes. He never asked about the baby. I think he knew.
The father lay down and we drew his blood. It took three sticks with a huge needle to get a sufficient quantity of blood. He endured this without complaint and without flinching. Afterwards I thanked him and told him that he had done a good thing. This man smiled at me and thanked me for helping his daughter. He said something in Arabic to Dr. Atar, who also smiled. I asked him for a translation, and he said, "He says that he is prepared to even give every drop of his blood for his daughter. He says he is old, and has lived his life. He loves his daughter. He says that she is the future and she means everything."
We explained that mother was doing OK and that she would probably survive, but that the baby had died. They said that it was the will of God and that they accepted it. The dead baby was wrapped in a cloth and given to the grandmother. She cradled it and looked at it lovingly. She did not shed a tear. I left them there, two thin characters in filthy clothes, holding a sad little bundle.
The next morning, she actually looked petty good. We asked her how she was doing, and she responded "Great." Her hemoglobin was 3.2! The normal is 13. She was hungry and wanted to eat something. Sudanese women are tough!
I've been doing this work for a while. I've seen more than my share of suffering and death. Sometimes I get a bit callused. The work that I do is a drop in the bucket. I can help a person or two here or there, but sometimes the work can seem a bit futile. Occasionally I have an experience like this. You do the very best you can, and you can actually save a life, in the literal sense of the word. This woman was dying and she came back to life. Her name was Khadija. It is grueling work, sweaty and dirty. You can't do it without getting blood on your hands. You might even lose a little of your own blood. Even the victories are bittersweet. I can't get out of my head the vision of the grandmother cradling that perfect little body. What sticks with me, however, is the incredible nobility of the human spirit, even in the face of suffering. I remember the smile on this man's face, as he told me he was ready to give every drop of blood he had for his daughter. There was something redemptive in that, something that reminded me of One who gave every drop of his, just because he loved us.
Some stories have a nice little conclusion, but I can't really come up with one. Two days later we flew out of Maban. We'll probably never see Khadija again. The fighting is picking up again as the rainy season ends. This means a new influx of refugees will flood the area. With them will come their diseases, their emergencies, their suffering. Unsung heroes like Dr. Atar, Jared, Karen and Loralee will care for them in the best way they can. They will give their time, their effort, their tears and their blood. There will be some successes, but also many failures. They will struggle, like Sissyphus, wrestling to deal with one emergency, only to have another one show up on the doorstep. It is hard work, but it is good to see this stuff. It is good to put our hands to the work, and to share, on some level, with the suffering of this world. It is the work of the Good Samaritan and I think it is what we are called to do.