David Elliott: Trauma surgery in South Sudan - drunken soldier, bullet wounds, saving a 5-year-old girl

By David Elliott

Editor’s note: In last Sunday’s Commentary, Dr. David Elliott, a Richmond trauma surgeon and an Army veteran, wrote about his arrival and first two days in war-riddled South Sudan, as part of a Doctors Without Borders team working in Juba, that country’s capital city. Today, we feature the second and final installment of his story. To read last week’s column, go to Richmond.com^[1].

My third day in Juba started with a hurried breakfast of toast and French press coffee, guzzled as quickly as the gin the night before. I had convinced my colleagues to start early to maximize our operating time, so we packed our Land Cruiser and headed out just after sunrise to the UN’s Jebel refugee camp, where we’d set up our Operating Theater (OT) and recovery area.

We encountered few South Sudanese other than wild dogs, who felt confident sleeping in the boulevard’s potholes. A nation the size of Texas, South Sudan has less than 100 miles of paved roads, most of them in Juba. We were finding most of them questionably paved, at best.

We arrived at our Quonset hut trauma center a little after 8 a.m. and set to work immediately. As our logistics crew cranked up the generator and Denis, our French anesthetist, got our first patient ready for surgery, I made rapid rounds on the ward.

Although my one laparotomy patient had died the day before, my other 40-plus patients appeared OK. Most were lobbying to be next up for an operation, as they had been languishing for more than a week with pain and infection — casualties of the recent upsurge in violence in the long-running civil war in South Sudan.

Given their dire circumstances, they maintained a good sense of humor. They especially got a good laugh at my wretched attempt to speak their tribal language: “Chewa-leedy?” (what’s your name?); “Winny beh-zhah?” (where is your pain?); “Gheer buda wally” (dressing change today).

The strong coffee had renewed my motivation and stifled my blue funk from the prior evening, when I had learned that my laparotomy patient had died just hours after the abdominal surgery for his multiple gunshot wounds.

My enthusiasm was luckily infectious. Alice, our OT nurse, Denis, the French anesthetist, and our refugee nursing recruits also stepped up the pace. We started working like a well-oiled machine, and dispatched six major surgical procedures before 2 p.m. Morale was greatly enhanced when our new air-conditioner finally started cranking out cold air in the OT.

I’d have to treat Marc, our head of mission in South Sudan, to a Tusker tonight for fulfilling his promise about the air-conditioning, which is as rare as diamonds in South Sudan. Tuskers — African beer — were free for us expats with MSF (Médecins Sans Frontières/Doctors Without Borders), so it wasn’t much of a treat.

I started the day’s surgery by cleaning out an infected gunshot to a patient’s upper arm. However, the next case gave me shivers: a single gunshot through both thighs and the scrotum. No bones were fractured, but the infected scrotal injury was extensive. Luckily, none of the “family jewelry” required sacrifice.

The next three cases were gunshots to the upper thigh, causing compound fracture to the femur in each patient. I placed traction pins under anesthesia in their tibial bones, then hooked each up to traction on the ward. We had no calibrated weight for traction, so we weighed out 15 pounds of sand in plastic buckets for each and used that instead. Next, a quick break for water hydration and a peanut butter sandwich, stuffed in my pocket after breakfast that morning.

***

My last operation of the day piqued my anxiety: another abdominal exploration, on a young woman I will call “Nyabol” (her name changed for confidentiality).

I knew I could do the surgery, but could our staff keep her alive overnight? Given her multiple gunshots, I had no alternative.

Nyabol’s abdominal injury was minimal: only two holes in her small intestine, reparable with a few simple stitches. Then I excised a small gunshot entrance wound above her knee, and encountered, to my chagrin, an ugly complex fracture of the lower femur. No simple solution here.

I cut away the dead tissue, and then constructed an external fixator connecting the upper femur to the tibia — a metallic TinkerToy-like frame of pins, rods, and clamps to stabilize the fractured thigh.

We still had an hour before mandatory departure at 3 p.m., after which it was considered too dangerous to travel through the city back to our safe house. That gave us adequate time to watch our post-op patients in the Recovery Room and to evaluate a half-dozen new admissions, additional casualties brought in by relatives when word got out about our Jebel camp trauma center.

The commute back home was interrupted unexpectedly at an army checkpoint. The government soldiers, ethnic adversaries of the civilian refugees we cared for in the UN camp, knew what MSF was doing there.

The two soldiers, one obviously inebriated, harassed our South Sudanese driver for minor discrepancies on his driver’s license. Thomas, our boss at the Jebel camp, got out of the Land Cruiser and argued with the soldiers’ commander, who had walked over to assess the situation.

It became tense when the drunk soldier, armed with a loaded Kalashnikov, began screaming and shoving his finger into the chest of Thomas and our driver.

Luckily, cooler heads prevailed and, after 45 minutes, the commander allowed us to proceed back to the expat house. I was impressed by the calmness and restraint shown by Thomas; no doubt my surgeon’s temper would have started an international incident.

Back at our house, we had an early dinner of samosas and spaghetti. As the darkness of the Juba night set in, reinforcements arrived: Dr. Asoshi from Japan, another experienced MSF surgeon who would help me churn through the complex wounds still facing us in the camp. He told us all just to call him “Sushi” for short.

Thomas didn’t received any phone calls, so I kept my fingers crossed that all the patients we operated on had survived.

***

Medical care and expertise in South Sudan is critically limited. The country boasts neither medical nor nursing schools — and rare university graduates.

Many speak English, but few of our nursing staff knew at first how to run IV fluids, calculate and administer medication dosages, or even take blood-pressure measurements.

MSF provided education and training as part of medical care, and our staff was getting a crash course in life-saving trauma care that should enable them to keep their friends and relatives alive.

On the fourth day of our commute to the Jebel camp, Sushi and I discussed the urgency of our sickest patients and shared stories of our prior missions as we bounced and weaved for 40 minutes along Juba’s pothole-strewn excuse for roads.

Disembarking at the Quonset hut in the Jebel camp, we set to work immediately. With two surgeons, work became more manageable: one of us rounded while the other began surgery. One of us could also perform minor wound and fracture procedures in the ward’s wound-care tent.

Over the next three weeks, the commute, surgery, and patient care, which at first seemed so precarious, became routine — never dull, never impersonal, but standardized to the point where we expats became efficient, the South Sudanese staff proficient, and the patients accustomed to the daily regimen in their temporary home.

Patient cots were placed inches apart, making rounds difficult and the spread of disease problematic, but it maximized the number of patients we could help as our census swelled above 60.

The close quarters produced support and good friendship between patients and their caregiver families, and, combined with my humorous attempts at speaking their language, made for enjoyable morning rounds that sometimes made me feel like a stand-up comic. I felt I had done a poor job if I didn’t at least get a few rounds of belly-clenching laughter.

We also received reinforcements of equipment, essential since we rapidly depleted stores of surgical gauze, IV saline, and antibiotics. Additional external fixator parts enabled us to convert all five of our femur fracture patients from traction (necessitating six weeks of strict bed rest) to the “TinkerToy” frames that enabled them to walk.

Arrival of an electric dermatome enabled us to harvest skin from patients’ legs and transplant it to complex open wounds to expedite skin closure.

We even received a dental kit, allowing me to operate on a patient with a gunshot to the face: the bullet had fractured his mandible (jawbone), making his entire lower face wobbly and preventing wound-healing.

I stabilized it by wiring his jaw to his upper teeth, using thin wire and dental instruments. This was nonetheless problematic since a) I had never received a single minute of dental training in medical school or surgical residency; and b) this gunshot victim, like many South Sudanese, suffered from poor oral hygiene and only had five teeth in his entire mouth, three of which were loose!

Then came the last 48 hours of our mission, when MSF’s agreement with the UN camp management and the Quonset hut’s previous tenants reached expiration.

***

Dr. Sushi had already flown home to Japan, and I made final arrangements to discharge our last inpatients. At 2:30 p.m. on our penultimate full working day, in walked a distraught couple holding a very gravely ill little girl.

“Nyalora” had been playing with her sister near their home in Bentiu, 300 miles away, when a stray bullet from nearby fighting struck her in the arm. Her sister ran to get help, but it took two days for her family to find her, collapsed under a bush, in shock from heavy blood loss.

Over the next three days, they wandered the countryside, carrying her in their arms, looking for someone to provide their daughter with medical care. Finally they came upon the International Red Cross, who put Nyalora and five of her family members on a plane and brought her to Juba. Then she was brought to us.

This five-year-old girl had been in shock for six days. Her hemoglobin was 2.5: thinner than cherry Kool-Aid.

Her right arm was dead: the bullet had fractured the arm and severed the artery just beneath the shoulder, and, without blood supply, gangrene had set in. As the infection appeared to be advancing above the shoulder, she really required immediate surgery, but our security rules still required us to leave the camp at 3 p.m. — I could do nothing until morning.

In the last minutes before leaving, I gave detailed instructions to the refugee nurse in charge to give Nyalora blood transfusions, administer antibiotics, and convince her parents to sign a consent to amputate her arm the next morning.

I crossed my fingers that our nighttime hospital staff had learned sufficient Western medical care over the past month to keep little Nyalora alive overnight, but, honestly, I harbored little hope I would return the next morning to find her among the living.

Imagine my surprise when I returned to find her both alive and out of shock. The night staff had amazingly convinced the family not only to consent to surgery, but to donate blood for her as well. All five donated a unit; she was transfused three. The antibiotics had halted the progression of gangrene, although I knew that was only temporary.

On my last full day in the Jebel trauma center, I performed one final operation: amputating Nyalora’s arm at the shoulder.

She recovered quickly, walking and eating by the next morning, which was fortunate, since we had to close down our hospital by noon.

Those last few hours in our Quonset hut I spent double and triple-checking Nyalora for bleeding or infection (there was none), saying goodbye to all the remaining patients and staff — and celebrating with Nyabol, my long-standing patient with the complicated knee and abdominal injuries, as she took her very first steps on her fractured leg.

***

We made our final commute from the Jebel camp back to our expat house in a convoy — one vehicle carrying us expats, one all our equipment, and one with Nyalora and her family, for whom Thomas had arranged follow-up inpatient care at a willing and competent Juba facility.

En route, Thomas and I reflected on what our little trauma center had accomplished in the past month.

I read from our OT log: we had performed more than 200 major surgeries on the 76 patients that had passed through our tent-flaps. Three had died. Most of the others would have died if MSF hadn’t been there for them.

It might seem like a drop in the bucket: 73 lives saved out of a total population of 12 million South Sudanese. That’s how MSF works: one life at a time. Over time it adds up.

Soon thereafter, my mission in South Sudan ended and I returned home. Thomas kept me informed that Nyalora made a full recovery. In my nine missions with MSF, this was the shortest, but to me it most dramatically demonstrated why Doctors Without Borders exists: being there when someone needs you; saving a life when no one else will; the fine line between life and death.

It was also the riskiest mission I’ve been on, but worth every second of danger and discomfort. It made me realize that the greatest rewards in life result when we rise up from our comfortable existence and take a risk, a bold step, for the benefit of others.

Nyalora’s parents certainly risked everything they had, wandering the South Sudan wilderness for three days for the sole purpose of saving their daughter’s life. In a nation beset by poverty and brutality, they displayed the type of courage, perseverance, and humanity we could all emulate.

References

1. ^{^} Richmond.com (Richmond.com)