Six weeks in South Sudan

Six weeks in South Sudan
Birsen Gaskell is a doctor who been practising anaesthesia and intensive care in the UK since 2008.

When she was younger, she fantasised about becoming an astronaut, air force pilot or writer, but now considers herself lucky and privileged to be practising medicine.

As a person who takes a strong interest in humanitarian crises, she recently joined MSF. Her first mission was in April, for six weeks, in Agok, a disputed area between Sudan and South Sudan. It involved providing secondary emergency health care for the general and displaced population with high infant and maternal mortality rates, poor sanitation and poor immunisation. Birsen provided anaesthetic care and training for the local staff, as well as overseeing the surgical activities involved (approx 50 procedures per week, on top of emergency operations).  Here, she tells JAP about her experience with MSF.

“This is complete ‘field anaesthesia’”

I’m on board one of the UN’s small aircraft approaching Agok. I’m thinking: I can cope with pretty much everything but can I really cope with what is expected from me? I am the sort of anaesthetist who’s used to practicing in a developed part of the world; lavished and spoiled with all sorts of equipment and choice. Can I really deliver my job in an environment with so many limitations?

The landscape below is red. I realise Agok is a big cluster of sun-washed huts. The plane lands with a trail of high dust behind. It’s a short drive to the compound and soon I find myself in the ‘living tukul’ (a large cone shaped hut that is used as a living room for MSF staff). But I’m really curious about the operating theatre; I can’t wait to see what it looks like.

Inpatient department; in Agok, South Sudan, MSF is running an 130 beds hospital in an area where there is no other hospital. MSF provides secondary healthcare to the population of Agok and the surrounding area. MSF provides ITFC, IPD and Intensive care, TB and HIV, maternity, neonatology and emergency surgical services. Most of these are unavailable within 80km radius of the hospital. The main pathologies that MSF treats are malaria, respiratory tract infections, diarrhoea, and severe malnutrition. Credit: Pierre-Yves Bernard/MSF

Inpatient department; in Agok, South Sudan, MSF is running an 130 beds hospital in an area where there is no other hospital. MSF provides secondary healthcare to the population of Agok and the surrounding area. MSF provides ITFC, IPD and Intensive care, TB and HIV, maternity, neonatology and emergency surgical services. Most of these are unavailable within 80km radius of the hospital. The main pathologies that MSF treats are malaria, respiratory tract infections, diarrhoea, and severe malnutrition. Credit: Pierre-Yves Bernard/MSF

The operating theatre is a plain room. I fail to identify an anaesthetic machine. To my horror, I realise there isn’t one. What’s more, there’s no ventilator, no capnography, no ECG monitor, no infusion pumps, no volatile agents, no defibrillator, no LMAs to keep a patient’s airway open, no other laryngoscope other than a few McCoys, no bougie, no intubating stylets, no Propofol, no arterial line, no CVC lines, no USS, and no nerve stimulator.

All I have are some ETs, McCoys (two sizes only), a couple of Ambu-bags, face masks, portable oxygen concentrator with a maximum flow of five litres, a weak portable suction, pulse oxymeter, blood pressure cuffs, a monitor, some endotracheal suction catheters. The exact list of drugs I have is: Ketamine, Thiopentone, Suxamethonium, Atracurium, Neostigmine, Midazolam, Morphine, Ephedrine, Atropine, Adrenaline 1:1000, Paracetamol, Diclophenac, some antibiotics, Hydralazine, Oxytocin, Lignocaine 1 per cent, Bupivacaine 0,5 per cent plain, IV fluids.

We have Haemocue and portable BM device, but the laboratory is non-existent. None of the blood tests can be done here. So no FBCs, no U&Es to look at kidney function, none of it! There’s a small fridge in the lab for blood. But the only way we can get blood is by donation from relatives.

This is a hospital that provides emergency and urgent care only. But I’m buried in private thoughts: my experience with Ketamine is limited… So, it’s going to be hand ventilation for a laparotomy, major trauma, some of the emergency C-sections for example! Then it’s all guess work with maintenance of anaesthesia… I am going to have to use my clinical judgement for delivery of safe anaesthesia as I have no monitor other than a stethoscope, Sats probe and blood pressure cuff. It feels like I’ve gone back in time. It’s soon obvious that we treat all ages for a wide range of problems, including newborn babies. The exception seems to be complicated neurosurgery as we’re missing a craniotomy set.

A few hours after my arrival I’m told we have an emergency laparotomy. I follow the anaesthetist. He draws Ketamine, Morphine and Suxamethonium. No Atracurium! The patient is breathing and the surgeon doesn’t mind this. It’s the appendix. The whole thing to extubation takes a half hour. I guess limited paralysis is a good idea as awareness is a real danger. The patient wakes up stable, and pain free and I’m amazed!

Surgery of a 3 year old boy who was burned at the abdomen. The majority of cases are burns caused by domestic accidents, gunshot wounds, traumas, and infections that follow injury or snake bites that have not been treated early enough and require amputation. Credit: Pierre-Yves Bernard/MSF

Surgery of a 3 year old boy who was burned at the abdomen. The majority of cases are burns caused by domestic accidents, gunshot wounds, traumas, and infections that follow injury or snake bites that have not been treated early enough and require amputation. Credit: Pierre-Yves Bernard/MSF

Soon I begin my practice doing many sedations for minor surgeries. But it isn’t long before I find myself having to deal with high-risk patients going for high-risk procedures. With no alternative, I soon adapt my practice to work with the scarcity of resources. I become an expert in the art of using Ketamine for the majority of cases.

I also have to do something that I couldn’t have imagined doing before – on a number of occasions I had no choice but to hand-ventilate patients after their operations for many, many hours, taking the role of a ventilator in order to stabilise them for successful extubation. Despite exhaustion, I feel so elated every time this has worked out. Nevertheless, if you ask me, a crushing feeling of frustration and helplessness for the unlucky ones has never left me – not for one minute.

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