Today’s Solutions: July 25, 2024

Ode presents an exclusive book excerpt from Six Months in Sudan: A Young Doctor in a War-Torn Village, by Dr. James Maskalyk.

Ode Editors | June/July 2009 issue

“What’s his hemoglobin?” I ask.
“Six,” Mohamed says.
“Six? Shit.”
I look down at Manut. His eyes are wide and worried. Today is the day we have to change the dressing on his leg. We’ve done it every couple of days since the grenade accident earlier this month. I was hoping that we could do this one under general anesthesia, using ketamine, so I could fully explore his wound, dissect some of the torn muscle away and see if his bone is intact.
A hemoglobin of 6 is too low for me. If he vomits and inhales it, or if he gets laryngospasm from the ketamine, a rare complication, the oxygen level in his blood will fall, and there’s not a lot of hemoglobin in him to keep it up. We had tested his mother as a possible blood donor shortly after he arrived. She has hepatitis C. We tested Manut too. I looked at his result and could see a few clumps of antibodies near the margins of the test’s blue circle. Weakly positive. He likely received the virus from her during delivery.
I asked his mother if she knew of anyone nearby who would be able to donate. She did not. The boy’s father is far away, and she tried to send a message to him, but heard nothing. No one else in Abyei was willing. People here fear giving blood, believing that once it is given, it is gone forever. I explain that it will grow back, that it is like their hair, but cannot convince them.
She wanted to go and find his father herself, but had no money. She tried for days to borrow some but could not. Finally, Mohamed gave her the dinars she needed. She said she would be back in two days. She has been gone for five. Traditional beliefs here are strong, and we struggle for legitimacy.
There are two health providers in town, both competing for patients with our hospital. One is a medical assistant who charges patients for his services, which, regardless of the problem, include an intramuscular injection of benzathine penicillin, one of quinine, and an infusion of normal saline. Patients believe that intramuscular injections are superseded only by intravenous ones in their potency and are often unhappy when they receive pills from us, and completely dissatisfied if they receive nothing at all.
The other show in town is a traditional healer. I haven’t taken the time to meet him yet. I would like to. It would be better to have a relationship with him so he knows when to send people to the hospital. As it is, frustrated mothers leave the feeding center because of the slow growth of their children and visit his tukul. He either blesses them and sends them on their way delighted, or keeps them until they fall more and more sick. Near death, they come to the hospital and die, sullying further our reputation.
“Well, I guess we’ll have to do it with local. You want to grab him, Mohamed? I’ll open the theater.”
Mohamed lifts Manut up from under his arms. The boy whimpers, terrified.
I open the lock to the operating theater and lay a plastic sheet on the operating table. Mohamed enters behind me and sits Manut on top of it. He starts to cry.
“Nonononono . . .”
He wasn’t this upset last time. Mohamed tries to comfort him in Arabic, then shakes his head. Manut speaks only Dinka. I leave the room to find Alfred. He is sitting at the front desk, arms folded, eyes closed. I tap him on the foot and he starts awake. He follows me into the theater.
“Alfred, explain to him that we need to look at his leg, and we will be as gentle as we can. Okay?”
Alfred speaks to the boy softly.
“Nonononononono . . .”
Mohamed and I prepare the necessary dressings and syringes full of local anesthetic.
“Mohamed, do you know the maximum dose of lidocaine? It’s 5 milligrams per kilogram. This boy is 20 kilograms, so 100 milligrams, right? Ten cc’s. Shit. Is that right?” It doesn’t seem like very much.
We try to get Manut to lie down. He refuses, wailing.
“Alfred, tell him there is no choice. You know what, just hold him. Yeah, like that.”
I remove the splint from his leg and Mohamed pours some sterile water over it, loosening the caked dressing. More crying.
“What is he saying?” I ask Alfred.
“Nonsense,” he says.
I glance through the open mesh window into the feeding center. A feeding center mother is peering through, concerned.
“Shut that, will you, Alfred?”
Mohamed starts unwrapping the dressing. The boy sits up, trying to stop him. Alfred thrusts him down.
“Tell him he is being very brave. Brave like a man.”
Mohamed has unwrapped nearly all of the dressing. The last bit remains adhered to Manut’s flesh. Mohamed rips it away. Scream. I look at his wound. A hole the size of a golf ball in the anterolateral part of his shin, rimmed with brown, rotting tissue, and at its base, gleaming splinters of bone.
Mohamed starts injecting lidocaine through the periphery of the wound.
“Maybe if this doesn’t work, we can try a Bier’s block,” I say.
The 10 cc’s are quickly used. I try to lift Manut’s leg by his toe. It bends at the wound like a tape measure stretched too long. He screams. Completely broken. No union.
“Well, he probably needs an amputation. We can transfer him if his mother ever comes back.”
Mohamed and I set about trying to clean the dead tissue from the wound, but the lidocaine is not effective. Manut begs us to stop in a language Alfred is not bothering to translate. It is clear to all of us. We’re almost finished. Manut sits up with tears in his eyes, his hands in praying position.
“All right. That’s enough. That’s enough.” Mohamed tries to wiggle free an ochre fragment of bone. Scream.
“Tell him it’s over, Alfred.” I walk around the end of the bed so I am close to his face. I look him in his eyes. “You are a very brave boy. When your father comes I am going to tell him how strong you were.”
Manut’s lips quiver as Alfred translates. He looks away.
“Alfred, if you can help Mohamed finish the dressing, I’m going to make a phone call.”
I leave the operating room and hurry from the hospital towards the compound. The wind gusts dust in swirls. I clang through the gate, duck into the admin tukul. Tim is sitting at his desk.
“Hey, do you have the sat phone?” I ask.
“Yup. Here. Who are you calling? I need to write it down.”
“Your girlfriend.”
“Oh. Say hello for me.”
“I’m calling our new medco. He’s supposed to be in Khartoum this week. Finally. And he has tons of tropical health experience. I’m psyched.”
I punch the numbers into the sat phone. It’s my first time using it. We are allowed a free ten- minute call on our arrival in the field, but I haven’t taken it yet.
“Hello. Hello? Hey, this is James, the doctor in Abyei. How are you? What is Khartoum like these days? Uh-huh… Uh-huh… Ha. So not much has changed. Hey, you have someone new in the office now, the medco from Geneva, right? Is he in? Can I talk to him? Great.”
I move underneath the tamarind tree. Scattered empty pods crunch under my feet.
“Hello, Paul! Welcome to Sudan! It’s James, the doctor from Abyei. Thank you. Trying my best. Listen, I have a question for you. Sorry to hit you with business right away. I just finished debriding the wound of a young boy who probably needs general anesthesia for me to do a proper job. In fact, he probably needs internal fixation or an amputation. Grenade wound. Yeah. Long story short, he’s very anemic. We’ve looked for donors, but the usual, no one will give except his mom. But she has hep C. And so does he weakly positive. Uh- huh. So, my question. My assumption is that he got it from her. Yeah, no scars or anything. If I give him her blood, is it possible that she has a higher viral load or something, or if he contracted it elsewhere, might I be giving him a more virulent strain? Could I be making him worse? You know, ‘First, do no harm.'”
The generator roars to a start. I glare at the guard and move farther away.
“Okay . . . right. That makes sense. They’re both in their latent phase. Cool. Okay. I’ll do it if necessary. Well, I must say, it’s good to have you here. I’ve been figuring stuff out with textbooks, or by contacting Geneva. They’ve been trying, but they have so many different countries and . . . What’s that? Oh. Really. No way. Shit. Well, I guess you have to do what you have to do. Uh- huh. Well, thanks for talking to me. Okay. Good luck to you too. Bye.”
I duck into Tim’s tukul and plug the phone back in.
“Was it good for her too?” he asks.
“The medco just told me he’s leaving.”
“What? Why?”
“I don’t know. Something about the office being a mess, no records. Whatever.”
“Man. That sucks.”
“Tell me about it.”
He holds up his hand and counts on his fingers. “No medco, no logco, no head of mission, no logistician . . . um . . .”
“No admin,” I say.
“No doctor.”
We shake our heads.
“What are we doing here again?” I ask.
“Sometimes I don’t know.”
“I mean, why not two hundred kilometers . . . that way.” I point over my shoulder. “There’s probably a hospital just like this one, maybe even worse.”
Tim shrugs, turns back to his payroll sheets. I leave his tukul and pass under the tamarind tree. The generator shakes noisily behind me and from it, the thick smell of oil. Each week we get an email from Geneva with vacant positions around the world. There are always several in Sudan, and lately, many in Abyei. I don’t know why. Perhaps experienced people are fatigued from the long civil conflict, maybe most of them have already worked in the country and know how difficult it is. Or they know something else I don’t.
I pass through the compound’s open gate and walk back to the hospital. I don’t want the work to be easy. I would feel I was in the wrong place if it was. I just want to know that of the many fights out there, this is a good one.

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