the HF radio crackles beside me. a guard is resting his head on the desk in front of it. every minute or so, he lifts it and calls into the mic:
“mobile, mobile for alpha bravo, over… mobile for alpha bravo, over…”
we have sent a patient, urgently, to the nearest surgical hospital 3 hours away. when they arrived, they were told that there would be no surgical cases accepted, and suggested another hospital, 4 hours away. it is well past dark, and outside of a hospital in northern sudan, in the back of a car, a woman in labour and in need of surgery is waiting to see if they change their mind, or if she will have to drive in the black night 4 more long hours on a dangerous road. we are sitting by the HF radio waiting for the same news. there has been no contact recently from the driver. we are not sure how to interpret this.
“mobile, mobile for alpha bravo, over…”
we were talking the other night about the msf life. country to country, crisis to crisis, six months here, two there, on and on and on. there are a few of us who are doing our first mission with MSF. others have done several. maurizzio, our field coordinator, is of the latter group. he said that when he was proposed the mission in abyei, his second in sudan, he was doing some research and came across my blog. after reading, he decided not to come. he recognised too many things from his previous mission. thankfully, for all of us, he changed his mind, and relented.
he was speaking the other night that after you do one mission, and you go back home, you are ruined. there is a distance between you and others that is irreconcilable, things that you cannot share. when you try, the people you talk to either cannot place themselves there, or they realize they don’t want to know after all. the larger the rift becomes. you arrive home, exhausted, longing for familiar comforts you thought you missed, but after a short time, no matter how hard the previous mission was, you feel the pull. if at least to be around people who have known a similar world.
i have just returned from the hospital. i was called in a few hours ago.
“doctor james? this is hospital. we have sick child. girl. 5 months. high fever. diarrhea. breathing problem.”
“alright, hospital. can you do a paracheck, give the child 80 mg of paracetamol, and some cool cloths… do you copy? …good… is the child drinking?”
“no.”
“ok, start a cannula, …weigh the child and write the name down. …and i will be there in a few minutes… do you copy?”
“doctor james… i… ummm… i use bag for breathing now…”
“i’m coming. over and out.”
where is the driver? no driver. i grab my stethoscope, and jog 480 paces. i arrive through the gate, people are standing in front of me, waving outpatient cards. i brush past them to the nursing room. a young mother wearing a bright yellow veil is holding a limp 5 month old child whose eyes are sunken, and half open. her small chest rises and falls with last breaths. two nurses are bent over one tiny, dangling arm that has a latex glove tied above its elbow, poking needles through soft skin, looking for veins.
they can find none. no veins, no intravenous. (mohammed, can you use the bag again… no, like this, smaller breaths… no… do you hear that sound? it means there is no seal… you know what… i’ll do it… tell the guard to start the generator for the oxygen machine). no gas for the generator. (ok, prep the leg, the left one. with betadine. perfect. great. ok, take the bag. smaller breaths. push when she breathes. no, make a seal…). i open the intraosseus cannula, landmark a little less than a cm below the tibial tuberosity, on the flat part of the shin just below the knee, twist and twist and twist until it pops through the thin shell of bone. marrow flows back freely into the clean water of the syringe and i flush it smoothly back. the fans in the nursing room start to spin. i ask for fluid, and antibiotics. the child’s head hangs loosely on my knee. she vomits, and breathes it in. (suction please.)
last breaths are like this:
………hu…………..siiigghhh………..hu………..siiiigghhhh…………hu……………………….hu………………………………
so, instead, i am blowing in tiny, tiny breaths through a tiny, tiny mask. i barely have to squeeze the bag, her lungs are so small. small, and full of crackles. three times my stethoscope dangles down and touched my knee, and three times i feel a small pearl of hope, thinking it was her hand. i looked down, her arm hangs loosely by her side. i stay there for three hours.
i think i would still be there if her breathing didn’t worsen, but it did. she was tired, her muscles burning and inefficient from the lack of oxygen, full of lactic acid. when i would stop, instead of taking a breath, all she could manage was a grimace, a shrug of her small shoulder.
i placed an oxygen mask over her cheeks and pulled it gently snug. i put my stethoscope on her chest, and heard her heart count quietly down.
5………(hu)……4………(hu)……3………(hu)…………2…………………………….1……………..
i don’t think that i will end up ruined, but there are certain things that are going to be tough to share. things that would make poor dinner conversation (hey, have you ever heard an infant’s heart stop? don’t you think it is like the silence must be after a train wreck, deep in the forest? once the metal has stopped creaking? like all this activity, and then this final vacuum in place of all the sound?). i can imagine meeting people on the street, and being asked how my “trip” was. (……you know the feeling, when you are confined to the compound, and you and your colleagues are sitting underneath a tin roof, listening for the cracks of gunshots, but all you can hear is the rain, and then someone decides to make an apple pie, and how happy you all feel for something else to anticipate?).
it was fine. it all was fine.
i cleaned up the emergency room, the nursing room, watched the family close the baby’s mouth with gauze. i saw some outpatients. i took a seed out of a little girl’s nose. i walked back to the compound alone. i went to the kitchen for a glass of water. andrea, the nurse, came in to see me.
“is everything ok at the hospital? is the baby ok?”
“ummm… no… she’s dead.”
“are you ok?”
“yep, i’m good.”
“you know, you don’t have to keep everything right here,” she said, and pointed to her sternum.
“i know,” i said.
usually, as a doctor at home, it is rare to have one of these experiences, but when you do, you often bear it with others. another doctor, or nurses whom you know. you sit, and talk about it. it doesn’t make it go away, but it diffuses some of the weight. so, just now, from the kitchen, i walked over to the log tukul, and started typing this. instead of keeping it here, in my sternum, i am going to put it right here:
.X.
still no news from the car. we are all quite anxious.
i don’t mean to burden anyone unnecessarily, but this is what happened tonight, just now, i am freshly back. the part of me that normally edits these stories out doesn’t want to do it today.
i am grateful for this forum. not only does it allow me to place X’s, but it also means that when you meet someone you know on the street, and they have just gotten back from something like this, and you say, “so, how was it?”, and they say “fine. it was fine.”, you will know. good night.
“…austere as the Sudanese landscape, this book has poetry in it along with pain…” – The Washington Post
A riveting read; thank you for sharing James. Share as much as you can; knowledge breeds understanding.
I’ve often felt that I missed my calling, felt that I was supposed to be where you are, but now I’m not so sure, the hollywood msf is about a million miles away from the reality of msf. The reality of death up close and personal, the sadness, the solitude, the time. I’m not sure if most could do what you do. But, although the slowness of time in your msf world resounds in every word you write, you are at least aware of each passing moment. Awareness is hard to find in North American society. Instead, we are impatient, we drive too fast, talk too fast, walk too fast, all the while not noticing that life is passing us by.
Baked goods……beer…Amsterdam…and a 96-hour bar crawl…..!!! Rich I think perhaps the writing medal should go to you…there is no doubt your words probably distracted James from his current task at hand…more than anyone elses…..
A 96-hour Amsterdam pub crawl…I shudder at the thought that there’s anything left of you to type with…
Bro,
Kenny, Liza, Julia and I just got bak from Queen’s Day in Amsterdam. It’s brilliant and we’ll have to go some day. There seems to be a very strong desire for more UN intervention in Darfur among the people of European Union, and the issue had far more regular press than anything you (don’t) see here. Not that I had much opportunity to read, since my hands were mostly full of baked goods, beer and poorly folded maps. It’s an easy city to navigate, but not by sight, since everything looks like it should be a landmark. I think we ate one sit-down meal, and instead opted for the 96 hour bar crawl. A special kind of endurance for which there are no medals.
James,
I deeply respect what you do. Myself, I would be swallowed up by fear. I read your blog often and I am grateful to you for reminding me there is a bigger world out there. By putting your experience into words you are challenging me to think about how I should use my education to improve life for others rather than only thinking of myself.
Dear James,
Your writings are inspiring…amazing….take good care and return safely.
George
i won’t try to understand but i will say that i am sending warm thoughts northwards in hope they find you.
I am not naive enough to think I can comprehend or fully appreciate the intense physical and emotional complexities of your experience J…Frankly I’m not certain I want to….But perhaps…we should all glimse a few of the true tragedies of life…if only so that we hopefully appreciate what we can are given and not take for granted what we have in North America….As an anesthesiologist I have always…’avoided’…pediatric cases as much as possible…knowing…I would probably not ‘survive’ having to hear those last breaths…Perhaps I am a coward…Your words…posts…thoughts and feelings…have given me reason……to pause….and rethink…..and I thank you…….T
Sometimes ‘fine’ is the only answer you can give to someone who doesn’t and never can understand the complexities of where you have come from. After 3 years of living back in Britain, it is still a kneejerk answer. Such is the bittersweetness of re-entry – bitter because you will never be the same again, yet so sweet because you know that despite all the frustration you feel at people’s ignorance, the preciousness of those memories is worth it all.
James,
I am an ER nurse in Canada, in such a wealthy country. I am grateful for all its "problems". How does one respond to you? Do you need someone to listen? To have experienced it? To offer solace or prayers? What do you need to get through this?
God grant me the serenity…
Dear James:
Thank you for sharing your heart and your experiences. Your writing is beautiful, particularly so when the part of you that normally edits is absent.
It is an honour and a privilege to share your experiences through your words.
Toby
Calgary, AB
You are correct in stating that a rift exists when you go home, after braving it somewhere way outside of your comfort zone. But it can go away with time. And this blog is a big part of that. Readers who don’t know you personally, like me, can send you support in intangible ways. Your people back home can have a greater appreciation for those things that you don’t want to talk about–at least not until/ if ever you are ready.
Let us know what happens with the car.
It is Tuesday morning in Abbotsford, BC and my life is changed after reading your blog. Thank you so much for the work you are doing, but especially for sharing your heart. You are bringing such blessings; I honour you and your passion. Thank you for the gift of describing the difficulties of "re-entry" — this is all part of my world, our world and we need to understand, be compassionate and supportive and allow things to change because we care. I am with you.
James,
just by writing the harsh truths so beautifully you are preparing those of us back "home" to understand the realities that volunteers like you experience.
I have a hard time hearing them (I admit to spilling a few tears for every child you mention) but I would not miss a single one of your posts
!
Pour it out here – we are listening!
Patricia
Such a brave person, you are doing such a wonderful thing. I am so inspired by your writings. I am speechless. Keep going…
Stay safe
Georgina
James, I was riveted to the screen while reading this latest entry and left near speechless. On one hand really sad, on the other inspired, No doubt, there will be many adjustment for you to make upon your return, but I’m certain that those who have been following this blog will be a little closer to understanding. Thanks for doing what you are doing and thanks so much for sharing. I look forward to seeing you back in TO and hope you remain well until then.
Be safe…chin up.
bro, amazing… don’t know what else to say. we are anxiously awaiting the next chance to see you, to talk aimlessly about nothing and the depths of our hearts with you, to sit in silence drinking a beer with you.
missing you.
loving you.
I love your comment Xuan Wen. I believe that Dr. Maskalyk will write a book and it will be much better than that other book.
I am in the Canadian Military, and even tho I have never served in a theater of war, friends have. Their responses to those ‘how was it’ questions were eerily similar to your desription.
SO you are not alone and there are some people who you talk to when you come home who, may not know, but have some idea.
you are making a difference.
Hello Doctor James,
My name is Xuan, and I am a high school student from Toronto. I’ve been following your blogs for the past while and they’ve been nothing short of a thousand brilliant butterflies fluttering away from the same tree at the same moment in time. Your days in Sudan have inspired me to pursue my medical asiprations beyond the confines of the OR, and instill humanity in the exact science that is medicine today.
I was wondering if I could possibly translate your blog into Chinese and post it, with full citation and recognition of your original work, on a large chinese website so that youth from the extremely media-censored China can also experience the same harsh realities that you face in Sudan so that they, too, may be inspired to bring about change to the world.
By the way, you should consider coming back and publishing all of this into a book. You’re loads better than the last doctor-turned author that I had read. LOADS.