Lauralee in Lankien

The rain in the wet season is like nothing I have ever seen before. Huge drenching droplets of water. A deluge. And when it is not raining, the air is still full of moisture. Everything is damp most of the time, the towels, the sheets, my mattress, my clothes. The inside of my tukul smells like an old damp sock.

The condition of the airstrip in rainy season is an ongoing concern. It can be either “Landable”, “Wet landable”, or “Unlandable”. Today we are unlandable. The plane, carrying my reinforcements, will have to try again tomorrow.

Strangely, I do not feel disturbed; I have already decided that I am going home.

I want to quit, resign, throw in the towel, end it, go home. I want it to be over. I feel broken. I am tired of working with a skeleton team and being woken up at night. I cannot sleep at all now and I don’t know why. Larium? Sleep Deprivation? Stress? Heat? All of the above?

My project coordinator sits me down and calmly and patiently tries to inject some sanity into my thinking. But the thought of going home is starting to take hold in my head and it feels like an immense relief.

The full team returns tomorrow.

The sky in the morning is dark and threatening. Big thunderheads in the east, a sure sign that rain is on the way. Once the wind starts the rain will soon follow. I am a wreck from worrying about the woman with the twins and the lack of sleep. If you think that I am over reacting, you have clearly never been involved in an obstetrical disaster. I have, the memories are still ripe; they remain long after all the warm fuzzy feelings of the normal deliveries are forgotten. I pray that it will not rain till after the plane has come and gone. I look at the sky repeatedly during morning rounds, every time I stick my head out of a tukul, I check.

And finally the roar of the plane, the sound of the children screaming and running to the airstrip. The plane is coming! The patient and her caretaker are already waiting there. I hustle myself over as well.

Little droplets of rain start while the plane is still on the ground. A group of men lift the patient into the fuselage. The pilot knows the score and quickly pulls up the ladder, closes the doors and makes a quick retreat. The condition of the airstrip will deteriorate rapidly once the heavy rain starts. No one wants to get stuck on the ground in Lankien!

The plane roars down the airstrip just as the skies are opening up.

I go to the IPD at midnight, 3 am and 6 am to check on the woman with twins. By morning her contractions have diminished, they are only mild and irregular now. A false start. I am immensely relieved and pray that she will hold on till tomorrow when the plane comes. I listen to the baby/babies with the Doppler, order some more IV fluids and start antibiotics. If she starts into active labor there is nothing I can really do, except watch impotently as the disaster unfolds. I check on her periodically during the day and pray for good weather for tomorrow. We are into the rainy season now when the condition of the airstrip becomes tenuous and we are often ‘unlandable’.

6 p.m. Saturday: The patient is 9 months pregnant with twins. She has been having painful contractions since early this morning and she says she has been leaking fluid. She already has five living children at home. I place my hand on her abdomen to assess her contractions. You can feel her contractions, but her belly is so huge and taut it is difficult to assess their strength. I press firmly with my right hand, just above her pelvis, to feel for the baby’s head. There is nothing that feels like the hard ball of a head, in fact I can feel a small little baby part just above her pubis. Heart sink.

The Doppler confirms the presence of a fetal heart. But is it one or two?

I examine her internally. She is about 4 centimeters dilated and her membranes are bulging; the bag of waters tightens up considerably with each contraction like a balloon about to burst. I feel around gingerly to avoid breaking the bag. What I feel confirms my worst fears. It is a small part behind the bag, not the large hard globe of a head, but a small part that feels like a foot. Or even a hand or a knee? I can’t tell what it is, but I am sure it is neither a head nor a bottom.

Normally with a head first position the large diameter of the head opens the birth passage for the rest of the baby. Even when the bottom presents first, it is relatively large and round and prepares the way for delivery. But this! This foot/hand/elbow/knee? The baby/babies will get stuck. Or the cord will come down first and choke off the their blood supply. This is an obstetrical disaster waiting to happen. At home I would call the obstetrician for a Caesarean Section and the story would probably have a happy ending. But here!

I get on the phone with the medical coordinator in Loki. There is a plane on Monday that could transport her to Nasir, another MSF project, for a C-section. Monday looks a long way away.

Malaria is on the rise in Lankien. The numbers say so. Yesterday, I took one of my rare forays outside of the compound and realized why. The compound is rapidly becoming an island in a swamp. Pools of water are collecting everywhere. This is great for watching long legged marsh birds but it is terrible for malaria rates. Pools of stagnant water allow the development of the female Anopheline mosquito, the insect vector of malaria.

There are four species of malaria parasite but only one is of any real importance in this part of Africa, Plasmodium falciparum. In addition to causing simple malaria characterized by fever and headache, P. f. also causes severe life-threatening disease. Globally there are 1-2 million deaths from malaria every year; 90% occur in Africa south of the Sahara. Virtually all deaths are from P. falciparum.

Deaths from malaria are only the tip of the iceberg. There is a vast base of underlying morbidity associated with malaria: recurrent fever, anemia in children and pregnant women, low birth weight, and brain damage from cerebral malaria and low blood sugar.

Basically this is how it works: An infected mosquito bites you. She has several thousand malaria parasites in her salivary glands and injects about 30-100 into you. The parasite goes quickly to your liver where it multiplies explosively, leading to 10,000 to 30,000 malaria parasites. At least 5.5 days later, the parasites are then released into your blood stream where they enter red blood cells and start to multiply again, killing the red blood cell in the process. An infected red blood cell eventually bursts and the parasites are then free to invade other red blood cells. And around and around. The thing that makes the Plasmodium falciparum so much more dangerous than other species of malaria parasite is its ability to stick to the lining of small blood vessels in vital organs such as the brain.

For those who would like to know more about what MSF is doing about malaria, here is a link.

Malaria is a huge complicated global health problem. Two of the big players in fighting malaria are The Global Fund and WHO’s Roll Back Malaria:

• http://www.theglobalfund.org/en/about/malaria/
• http://www.rollbackmalaria.org/

The sting of a scorpion must be excruciatingly painful. Anyone who has ever had one says so, and the patients who come to the IPD, well, grown women cry!

The treatment is an injection of local anaesthetic and painkillers.

There are a lot of scorpions in Lankien. You see them around the compound sometimes; it is best to watch your step, always use a flashlight and check your shoes when you get up at night to go to the latrine.

Scorpions have eight legs and a long tail that contains the sting. Most of the time they only cause temporary symptoms (hours to days) at the site of the bite, but in children they can cause serious illness and even death. One father told us a terrible story: A scorpion bit his newborn child shortly after she was delivered onto the blanketed floor of the family tukul. The child died within an hour of her birth.

This is a scorpion that I found just outside the latrine.
I ruthlessly squashed it with my sandal after the photo.

A teenager with spinal TB and a draining sinus.

An elderly woman with a stroke.

A baby with a scalding burn on his penis.

Another child with a burn on his left hand and forearm.

A man with brucellosis

A child with an abscess in his right thigh.

A child with suspected meningitis.

A baby with an infected foreskin

A teenaged girl with Kala Azar.

A child with severe asthma.

A man with a femoral fracture. We rig up traction with a wooden plank, a rope, a pulley and a bag of stones.

All the people with gunshot wounds need new dressings.

A woman with post partum sepsis comes in at 1 in the morning.

We have ruptured out (run out) of IV metronidazole and injectable ampicillin.

I am starting to get a sore throat. Merde.

Yesterday I had a date to call my husband on the satellite phone at 7pm Sudan time, 12-noon Brampton time. It was our 7th wedding anniversary. Exactly 7 years ago yesterday, we got married in a small white chapel in Kleinburg, Ontario. The 43-year-old bride had the audacity to wear white and her soon to be husband looked quite distinguished in a blue suit and a new tie. After a long, complicated 10-year courtship, I suspect family and friends heaved a secret sigh of relief.

Yesterday was uncharacteristically quiet here in Lankien; at least it was until exactly one hour before my phone date. At 6pm I was summoned to come quickly, another gunshot wound to the chest.

The bullet had entered just next the young man’s nipple and emerged soon after on the other side. It had continued on into his upper arm, shattered the bone, and blasted out the lateral side; every hole was successively larger that the one before. The exit wound smelled terrible and was oozing
green pus. It had not entered into the chest cavity though, making management infinitely easier than when a bullet enters lung and large blood vessels!

I was back at the compound by 7pm for my phone date. I left the base nurse to finish dressing the wound.

"Happy Anniversary, sweetheart." I heard myself say into the satellite phone, and then, " No, just a regular day, nothing special. How was your day?"

‘We are guilty of many errors and many
faults, but our worst crime is abandoning the
children, neglecting the fountain of life.
Many of the things we need can wait.
The Child cannot.
Right now is the time his bones are being
formed, his blood is being made and his
senses are being developed.
To him we cannot answer "Tomorrow".
His name is "Today".’

Gabriela Mistral
- Nobel Prize-winning poet from Chile