Six Months in Sudan

by Dr. James Maskalyk

  His shirt is off, but his pants are still on. Coarse tread marks march over his thighs.

  “His lungs are good? What about his belly?” I ask.

  “Seems okay.”

  I feel his abdomen. It is soft. I put one hand on each side of his pelvis and push down. He screams.

  “He’s probably got a pelvis fracture. We should cut his pants off. You log-rolled him?”

  “Not yet,” Sandrine answers.

  “Let’s do that. We should give him some morphine first.”

  We turn him on his side, one person holding his neck steady, two others pulling him over. I feel along his spine. As I get down lower, he shouts in pain.

  “Maybe a lumbar fracture too,” I say. “Seems to be moving his feet okay. That’s good.”

  “Transfer?” she asks.

  “I don’t know. What do you think?”

  “We can.”

  “Maybe it’s all from his pelvis, I don’t know. It feels stable, but if not, the guy needs to be in traction or have surgery. Is there an orthopod at that other hospital, whateverit’scalled?”

  “Heglig,” Sandrine says. “Don’t think so.”

  “X-ray?”

  “Yes.”

  “Well, it’s probably worth a transfer, then,” I say.

  “Okay. We’ll do it.”

  “Are you cool here, Sandrine? Should I go help Mohamed?”

  “Yeah. That’s a good idea.”

  She leaves tomorrow. She is an infectious-disease specialist and has been here three months. Today she is on call. Yesterday we were both pulled in so many different directions, we had little chance to speak.

  On a nearby veranda, two of the rollover victims are lying on the ground, each attended to by soldiers in green fatigues. They are moving. I consider that a positive sign and walk past them to the emergency room.

  It is full. I can barely squeeze myself inside. On each of the two beds lies a soldier. One of them has a clean piece of gauze on his head. I pull it aside. An abrasion. I turn to the other bed and see Mohamed holding a cloth firmly down on the upper arm of the second patient. He and I met briefly during my whirlwind day. He is the other doctor in the mission, recently graduated from a medical university in Khartoum. He is young, brown skinned, with a smile full of bright, white teeth.

  “Mohamed, you okay?”

  “Oh, James. How are you, man?” he says, grinning.

  “Good. What’s up with this guy?”

  He takes the cloth away, and blood starts shooting from a large gash in the patient’s upper arm in a thin, red stream.

  “Okay, okay. Got it.”

  “I think it was the glass from the windshield,” Mohamed says.

  I feel the pulse in his wrist. It’s strong. “Hey, can you ask him to wiggle his fingers.”

  A flicker.

  “Make a fist.”

  A bit.

  “Thumbs up.”

  Nothing.

  “Ask him if he can feel me touch his hand.”

  No.

  “Radial nerve. His arm is fractured?”

  “Seems so.”

  “Any other injuries?”

  “No, I don’t think so,” Mohamed replies.

  “Well, I guess we’ll have to wash it out and sew it up. Splint it. I’ll look for the nerve, I guess. We have ketamine, right?”

  “Yes.”

  “If you get me some, I’ll start. It’s going to take a long time.”

  It does. Over an hour. His arm is broken in half. Thin spicules of bone keep snagging my glove, ripping it. I can’t find the nerve, can’t see enough of the bone to trace its route. I am reluctant to cut any farther. Sweat drips down my forehead and into my eyes. My stomach cramps, and it makes me feel nauseated. I wash out the wound, cut away the black pieces of crushed tissue, sew his triceps together, then close the skin. Lastly, with Mohamed’s help, I put him in a long arm-cast.

  I finish wrapping it and open the door. A man in military fatigues pushes quickly past.

  “Doctor. Tell us what is wrong.”

  “Well, sir, this man has some scratches on his head. He is going to be fine.”

  “Good.”

  “The other soldier has broken his arm, and has a large cut in it, at the break. I have cleaned it out and sewn it up. It’s possible he cut the nerve as well. Right now, he can’t move his hand. That might recover, but possibly not. Time will tell.”

  “You must take him to Khartoum.”

  These guys must be SAF.

  “Sorry?”

  “You have to fly him to Khartoum. He is one of our soldiers. He needs an x-ray.”

  “He doesn’t need an x-ray. The bone’s broken. I can see it. The rest of his arm is okay. These fractures usually heal very well.”

  “You said he can’t move his hand.”

  “I know. The nerve has been bruised or cut. He could use a neurosurgeon. But not urgently, not today. He can wait a few days.”

  The patient starts to groan behind me, his anesthetic worn off.

  “You must fly him to Khartoum.”

  Another soldier enters the room.

  “Listen. We don’t have a plane. We have a Land Cruiser. We can take people as far as three hours from here, to a bigger hospital, but only if it is going to save their life. And there is no neurosurgeon there. And we can’t take people to Khartoum. We simply can’t.”

  “Why are you refusing? I know you are going to take the civilian who was run over. Why won’t you help us?”

  I need to get out of the emergency room. I need some air.

  “Excuse me, excuse me.”

  I push past and step into the courtyard. The scene has settled. Bev has done her work well and only a few mothers of children in the feeding center remain. One of the injured men on the veranda is gone, and the other is sitting there, his leg bandaged, sipping tea.

  The soldiers follow me out.

  “Doctor, I don’t understand …”

  “I’ve explained things as clearly as I can.”

  “I think it would be best if you took our man somewhere he could get better help.”

  “I agree,” says a man who has come to join us from the veranda. His hair is gray, and he is wearing a large white tunic. “I think you should listen to this soldier here. You’re new. I understand that, and you don’t know me yet, but I am one of the leaders around here, and …”

  Bev turns the corner.

  “Bev. Can you help me out over here?”

  I take her by the shoulder, lead her a few steps away.

  “I mean the guy needs a neurosurgeon or an orthopod I’m not sure maybe a general surgeon can handle it but he would have to dissect the triceps away look for the nerve sew it up but it’s not that straightforward maybe in Khartoum I don’t know and these guys they’re all—”

  “James. I’ll take care of it. Gentlemen, come with me.”

  And with that, she leaves. The soldiers follow. My anxiety quiets. I walk back to the tent. Sandrine is scribbling out a referral note.

  “You okay?” I ask.

  “Yeah. You?”

  “Yeah, I guess. Some drama. Is it always like this?”

  “Not always.”

  “Wow. Anyway. I think Mohamed has taken care of the rest of the patients. I’ll make sure. If there’s nothing else, I’m going back to the compound. I feel kinda shitty. I’ll write orders for the guys in the emergency room.”

  “See you back there.”

  I stop in the nursing room and find an empty chart. I am not certain what drugs we have, or how best to order them. I grab a chart on the desk. It looks like the system is to make a full circle, or half-circle, depending on the dose, and draw them on a line that marks the time of day when I want them given. I turn to the cupboards, find some antibiotics and some morphine, and hand the rest of the orders to one of the nurses whose name I don’t remember.

  I leave down the hospital road, and the hot wind blows across the open field. I turn right at the corner, duck
at the cannon, left at the tire, and I’m back to the gate. I knock. The door opens, and I step past the guard. I walk through the compound and past the kitchen. Tim is sitting in the gazebo, smoking, the sat phone in his lap. He sees me and stands up.

  “How’s the hospital?” he asks. “Bev said someone pulled a knife?”

  “I didn’t see that. I was in the emergency room forever. I’m going to lie down. I ate something bad, I think.”

  “Right. See you later.”

  I duck inside the tukul. It’s like an oven. I poke my head outside the door.

  “Dude, are there any fans?”

  “Nope. Not enough power.”

  “’Kay.”

  I lie down on the mattress. My hips dig into the metal frame. I look up at the mosquito net, orange because of the copper dust. Beyond it is the peaked grass roof, and between its narrow strands, small lizards rustle around, trying to shake out an insect. I turn on my side and wrap the pillow around my head. It smells like sweat.

  22/02: made it.

  the luggage restriction proved not to be a problem. i had a fleeting fear that my undeclared kilos might send us hurtling towards the ground in a thin metal airplane shell, gasless, just because i wanted to haul ulysses around the world for the fifth time. it didn’t. the book now sits proudly on the windowsill of my tukul, fully confident that it will leave it as it came, its spine strong and unbroken.

  a dirty, dusty, rumbling landing later, and i was there. here. for those who don’t know exactly where abyei, sudan, is, i will draw a map. the X marks it.

  no X where

  right in the middle.

  i will spend some more time later talking about my hut, its 3-x-3-meter blank cement walls and its straw roof, how it captures heat so well, and … actually, i don’t think i will spend any more time on it. that’s pretty much it.

  i will talk more about the hospital, more about the team here, and how they seem the best kind of people.

  and more about abyei, the town. its braying goddamn middle of the night donkeys and barking middle of the night damn dogs, its people, and its dustdustdust.

  I AM SITTING IN THE GAZEBO, waiting for the morning meeting to begin, the one where we discuss the day’s activities. Tim is leaning on its low cement wall sipping from a coffee cup, his face to the morning sun. I can hear the soft voices of the people who live on the other side of our compound’s thin grass fence, murmurs I can’t understand. Shadows are long and the air is still.

  The medical team from compound 2, our national staff, are due to arrive soon. Like in most MSF missions, national staff make up the vast majority of employees. Nurses, cleaners, cooks, drivers, guards. Of the forty or so people who work for MSF in Abyei, only five of us are expats.

  Sandrine has gone to the hospital already to say her goodbyes. Her flight to Khartoum, and from there to Geneva, is due in a few hours. The plane will land just over … there. Just behind the hospital. Right where I landed, four days ago.

  She and I spent yesterday afternoon together. As we walked the hospital grounds, she introduced me to the patients that were now mine. They were difficult to keep straight, scattered as they were, some inside wards, others lying on the ground in the open air.

  The hospital is a collection of disconnected rooms. As you enter, from the hot hospital road, you walk along a corridor that is filled with patients fanning themselves with registration cards, waiting to be seen. Off to the side, to the right of the corridor, is the nursing room, a small room with a drug cabinet, a single patient bed, and a crowded desk full of patient charts and open bottles of pills. Past this is the small, dark emergency room.

  There are a half-dozen other patient suites. Most of the patients seem to pay no attention to our hospital structure. Their order of preference appears to be: veranda, hallway, courtyard, and, lastly, hospital ward. The rooms are hot, stagnant places. Little air gets through them and the light is poor. Contrast this with the veranda, which yesterday was packed with family members, breeze blowing through, people laughing like they were on the deck of a cruise ship.

  I remember, as a medical student, working in the emergency room for the first time, trying to make sense of what it contained. It seemed so large, so complicated; it was not a world, it was a separate universe. With time, it shrank. This place will too. Right now, its rooms and hallways form a maze full of people I cannot talk to, nor properly help.

  Yesterday, as we turned towards the back of the hospital, towards the two rooms reserved for patients with contagious tuberculosis, Sandrine pointed out a broken section of the skirting cement wall. An orange plastic barrier had been put into the gap. She explained that when MSF started working here, about nine months ago, government soldiers were living in the hospital. They had removed part of the fence that their military compound shared with the hospital and, with that, claimed Abyei’s most valuable resource as their own.

  One of the first things MSF did was declare that our presence in the hospital was conditional on their armed absence. We put up the orange plastic barrier, and it has stood since. The hospital was returned to Abyei. I thought that of all the good MSF might do here over the years, that would be the single greatest act.

  Sandrine pointed at a humming generator in the corner.

  “This gives us power for some of the day. It’s mainly used to cool the drugs in the storage room and the vaccine fridge. If you need it at other hours, for the oxygen concentrator or whatever, ask the guard to turn it on.”

  We passed a group of patients gathered around barrels set on a high wall.

  “There is no running water. Each day the UN trucks it in for us and we pump it into these blue barrels here. The orange ones are for washing hands. Lots of chlorine.”

  A room near the front held two small refrigerators and a shelf lined with reagents. A tall man in a lab coat was peering through a microscope.

  “Okay, here’s the lab. Hi, Ismael.” Ismael lifted his head, raised his hand. “Ismael is great, but there is only so much he can do with the tools. He can test for malaria, meningitis, TB, hepatitis, HIV … um … blood groups too. Oh, and urine and stool. I think that’s it. No electrolytes, no blood counts.”

  “Cultures? Blood, stool, sputum?”

  “No.”

  We turned the corner and stopped at a patient’s bed. The boy on it looked like bones glued to bones. Sandrine told me he had measles last month and showed up on the hospital’s door several days after. She handed me his chart. His fever hadn’t broken for four days. He glanced up at me as she told me his story, then looked back at the wall.

  “Where are his parents?” I asked.

  “Haven’t seen them,” she said. “He came alone.”

  She pointed to her right. “Almost forgot. In that room, the one that looks like a storage closet, is Mansood. He came in with a cellulitis, around his knee, about a month ago. He hasn’t been able to walk since. Mohamed will tell you more. He should know pretty much everyone too.”

  Next were the patients with measles. There were two of them, on the veranda, near the female ward, their mothers fanning them with pieces of cardboard. We moved on.

  “And this is the TFC. The malnourished kids are kind of mixed in with the general pediatric patients, but we try to keep them separate so we can organize feeds better. Paola is working on that.”

  The children in the feeding center drooped in their mothers’ arms. One or two had their hands wrapped in gauze so they couldn’t pull at the tubes in their noses, or at their intravenous lines.

  “It’s a struggle with the mothers. They wait until the last minute, when their kid is almost dead, to bring them to the hospital. Then, after a few days, when he’s no better, they want to leave.”

  She asked if I had any questions. Yes, I said. What am I supposed to do? Where do I start?

  She said it was up to me. There were no rules. She told me that once she left, I could talk to Marc. I told her he was gone. She seemed surprised. She promised to write me a full han
dover from London.

  We walked down the hospital’s hot, hot road towards the compound. Wind gusted sand across the empty football field. I asked Sandrine if she was happy to be going home. She said she wasn’t sure, that there were things she would miss. For the rest of the day, I watched her buzz around the compound excitedly, scarcely able to conceal her delight.

  As sad as I am to see her go, as much as I don’t look forward to being alone with this hospital to take care of, trying to figure out how to start or when to stop, I can’t disguise my interest in her tukul. Today I woke up early to pack up my few things and move them from Tim’s to the front of hers. It is not an elegant gesture, claiming someone’s tukul before it cools, but I want it. I want a place.

  I hear the buzz of voices. Here comes compound 2. It’s almost eight, time for the meeting. After it, I want to do some teaching. There’s Mohamed. I like him already. The night before, at Sandrine’s farewell dinner, he shyly showed me some pictures he was taking. One of a bird, a falcon, sitting statue-still on the top of a tukul. Another the fragile sliver of a new moon.

  “Good morning,” I say, standing up, and juggle my coffee into my left hand.

  “Good morning …” “Good morning …” They shake my hand, walk past me, and sit down to continue their conversation in Arabic.

  Bev comes from her tukul, cigarette in her fingers. “Morning, every body. We’ll start soon. We’ll wait a minute for Jean. There was a problem with the electricity in the hospital last night. We’ll see if he turns up.” She walks to the kitchen to grab a piece of bread.

  I sit on the makeshift couch, its back a futon mattress doubled on itself, Tim beside me. He has been an excellent tukulmate to this point. He said the same of me. Both were compliments to the other for not snoring. The only time we are in the tukul is when we try to sleep. It is too hot otherwise.

  More people filter in, men dressed in long-sleeved shirts, the women in traditional gowns, scarves wrapped around their faces. I take a mouthful of coffee and taste cardamom.