February 20, 2013

MSF nurse Emma Pedley describes the trials—and triumphs—of a difficult day in the MSF hospital in Nasir, South Sudan.

South Sudan 2012 © Brendan Bannon

A woman and her child at the maternity unit in MSF's hospital in Nasir. The basket is the traditional way for Nuer mothers to carry their children.

Emma Pedley is a British nurse working on community outreach projects with Doctors Without Borders/Médecins Sans Frontières (MSF) in Nasir, South Sudan. Read her MSF Field Blog here.

Some days it’s just not your day. Today opened that way—a fidgety and restless night’s sleep precluded waking to an uncharacteristically overcast morning. I’m stiff and sore as I crawl out from under my mosquito net and yawningly make my way to the river tukul for my my morning yoga. This small hut is so-named because it is raised up a few feet on stilts and thus affords a pleasant view of the river a few feet beyond the compound fence. Today the river is as sullen as the sky though, a dull stony gray—as above so below—and as I look over towards the east I see that the cloud cover is concealing the sunrise that I normally love to begin my day watching. Yoga this morning is brief and perfunctory—more mechanical then meditative—and I still have uncomfortable kinks in my back when I head to the breakfast table. Grump.

As if to add insult to injury one of the bats in the toilet tukul poops on my head just before I leave for the office.

The outpatient department (OPD) is the same as ever when I arrive there at nine—full, busy, and, as always, just teetering along the edge of chaos. A couple of the senior staff on both the MSF and ministry [of health] side are on leave at the moment, so I’ve somewhat uncomfortably taken on a general floor management role that I feel vastly under qualified for, but am muddling my way through anyway. I walk past the registration queue and deliver a few boxes of Paracheck to the laboratory. These things are pretty amazing—a single drop of blood onto the test strip and, just like on a pregnancy test, a small watermark creeps up the viewing window and within five minutes you have your result. One visible line: negative. Two visible lines: congratulations, you’re malarious!

The challenges come thick and fast today—medication in the dispensary has run low, patient registration cards have run out, three people have forgotten their pens . . . oh bother, I forgot to bring the spare ones. I take a deep breath and step over the squalling children in the Therapeutic Feeding Center to borrow from its stock. Here, however, a new set of issues assail me: some of the Ready-to-Use food that we dispense for the kids seems to have gone missing. My heart sinks. I take note of the numbers and then head out again, the new problems playing on my mind. A couple of cases are brought to me:

-Teenager, sky-high fever—clothes off, cold water sponging, paracetamol, Paracheck for malaria. Next.

-Another fever. Same treatment. -A snake bite victim. “How long ago?” I ask. Over a week. Most likely a dry bite then, no envenomation. Not emergency but still a potential infection risk. Tetanus booster, oral antibiotics, dressing room.

-A toddler is bought to me—a vague history of vomiting and slight fever. No diarrhea. No urine today either.

Huh?

My ears prick up—in this heat, even a short period of vomiting can make young children life-threateningly dehydrated. No urine is not good—and given that there are no such things as nappies here, infant urine is generally a hard thing to miss, although it’s happened before that an older sibling had already dealt with a wet baby that day without telling mum.

I take a look at the proffered child—a bit lethargic, not playful, but still vaguely interested in breast feeding. So some liquid is getting in at least. I undress the copious layers of clothing and gently pinch the skin on the belly to check for turgor. If it springs back, great; if it’s slow we need to treat urgently. It’s slightly delayed—but not terribly so. So, moderate but not severe dehydration by our protocols. The Paracheck for malaria was negative. I um and ah—It’s always best not to site an IV unnecessarily if we can coax the child into taking oral fluids. I elect to treat here rather than sending the family to the already-busy MSF emergency room (ER). Can we keep trying breast milk and rehydration solution here in the OPD for a couple of hours first? I’d feel better if we definitely saw urine. And if the kid’s hot then keep all those clothes off him!

There’s a chatter of translation. The mother nods her assent and is led off to the stabilization room. I’ll check back in an hour.

As I turn away, pondering my decision, I thump my shoulder hard into the solid metal dispensary door. A feature of life here is that if you trip or hit something, no matter how clumsy and blatantly self-inflicted the injury, the Nuer people around you chime in with profuse apologies. Given the crowded location and my very audible yelp of pain a loud chorus of “Oh Sorry! Sorry! Sorry sister. So sorry!” sets up all around me, which is gorgeously sweet and yet mortifyingly embarrassing.

I rub my smarting shoulder and smile through slightly gritted teeth at the needlessly woeful and apologetic faces around me. No one and nothing to blame here but my own lack of coordination!

The rest of the day passes in much the same fashion. Cases and patients are passed rapidly before me and I prioritize the best I can—tallying drug consumption, trying to deal with overprescribing, anticipating low stock for the next day. I plan the week’s immunization schedule with the ministry official and congratulate the registrars on triaging well. I take a peek at the dehydrated baby as I pass. Looks like he’s breastfeeding a bit—good.

The early cloud cover has long cleared and by afternoon the sky is clear and the sun is punishingly bright, as if to make up for its earlier absence. It’s easily mid-thirties today [about 95 degrees Fahrenheit]. Squinting into the light is giving me a headache and my shoulder throbs so I chase back some ibuprofen with the last blood-warm dregs of my bottle of water.

Heavy heat, heavy head, heavy heart. I miss my senior staff.

Before I know it it’s 5:00 pm and as I start to wearily gather all my things together into the Land Cruiser one of the consultants trots up to me to remind me about the baby still in the stabilization room.

What baby? There have been dozens.

The one you wanted to pass water. Oh, that baby.

Not one but three hours have flown by since I first saw that child.

For a tired girl I pick up an impressive turn of speed on my way to the stabilization room and only narrowly escape repeating my earlier trick of careering full-tilt into the door. The baby is flaked out on the bed next to mum. Despite apparently feeding earlier he hasn’t taken much breast milk. Hard to tell how much of the rehydration solution he has drunk and how much he’s wearing from the soggy state of his t-shirt. The blanket and trousers however remain stubbornly dry. Crap. I recheck the skin pinch. No worse, but definitely no better either. Double crap.

Right, into the car with them. I’m not even going to waste time trying to site an infant cannula [a tube inserted into the body for the delivery or removal of fluid] and start an IV; they are tricky at the best of times and a thumping head is not the best of times. Let’s just get to the MSF ER.

As we rattle back over the uneven roads to the hospital I’m panicking internally and right now, with the tight band of headache pressing round my skull, I feel like I’m not thinking straight and my mind heads straight for worst-case scenarios. What if that kid does have concurrent malaria? Diagnostically the quick Parachecks aren’t 100 percent infallible, but at MSF the microscopy blood films are . . . What if this drowsiness isn’t just from dehydration, but from low blood sugars? What if the mother was right—what if that child really hasn’t passed urine all night as well as all morning as well as all afternoon? What if he really didn’t take any of that rehydration solution? What if I’d taken the other option and sent him straight to the ER? What if, what if, what if . . . ? Despite my training and qualifications I feel so, so unprepared for parts of this job sometimes—not so much professionally, but experientially, emotionally . . . unprepared for the heat . . . my heart feels leaden inside me and I’m barely holding back tears as I berate myself.

We arrive at the compound and pull up outside the Emergency Room. Running around to the back of the Land Cruiser, I take the sleeping child from his mother’s arms to carry him into the ER. Somehow during the short journey the mother has bundled the child back up into all his clothes again! He’s now wearing a long-sleeved cotton top, a big fleecy jumper, and matching trousers and a blanket. It’s 35 degrees here, for heaven’s sake! I plonk myself onto a bench by the ER and start undressing him again. As I unwind the blanket, the child rouses and starts crying—a weak, fitful cry that health care workers know and dread—the cry of a child with scant energy reserves left to cry with.

My heart sinks a little further, and I start tugging a little faster at the child’s clothes. His head lolls back mid-wail and on catching a glimpse of the pale and unexpectedly unfamiliar face above, his eyes suddenly flip into focus on me.

The crying pauses . . . I pause . . . the startled black eyes below unblinkingly regard the worried brown ones above. A few heartbeats and a few hundred years pass . . . and suddenly the little man in my arms is crying—and I mean proper crying—a lusty, full-lunged bawling with all the might and main he can muster, and I feel like I’ve never heard a more beautiful sound in my life, because any child that can cry that hard is OK, not 100 percent OK, but OK nonetheless. My heart feels like it’s going to burst with relief. And then there is a sudden warmth spreading across my lap and I jump up startled, still cradling the now half-naked yelling baby, watching the dampness seep across his trousers and mine and it's OK. He’s passing urine, lots of urine—fantastic, amazing, brilliant amounts of wonderful urine that I’ve scared out of him that tell me that the kidneys are working perfectly, and the urine is streaming down my arms and legs and puddling at my feet and the baby is crying and the mother is clucking and fretting at the urine on me and I’m laughing because I’m so relieved, and I’m laughing so hard because who knew a crying baby peeing all down me could make me so, so happy? And then without knowing quite why I’m crying too and my heart is bursting wide open, and all the stress is pouring out and there are tears pouring down my cheeks and the urine is still pouring down my arms and they all mean the same thing—the baby is OK, I’m OK, everything is going to be OK.

The damp baby is passed over to the bemused ER staff with a somewhat garbled handover. This much urine? He’ll be just fine.

I clean off by the simple expedient of sticking my fully clothed arms and legs under the outside tap—blissful coolness!—and squelch my way back to the expat house.

A colleague joins me later out in the darkness at the back of the compound where I’m drinking beer spread-eagled out on the ground, staring at the constellations overhead. “Calm down,” he tells me. No need to be so intense. Stay focused. No one fails in their first month. This is followed up with some wryly insightful experiences from his first few missions.

I smile ruefully up at the stars. Sage advice, indeed. I remember receiving similar advice when I first arrived. Who knows, I might actually manage to follow it sometime soon.

But for now, I’m just happy to lie here on the floor in the darkness looking out into the universe, which never fails to bring me peace and perspective. The unfaltering points of starlight are joined by hundreds of fireflies above me, and for a while the familiar lines of Orion and Gemini are blurred with dozens of dancing stars around them.

Stars. Fireflies. Peeing babies. My heart feels wide open again. I breathe.

And I’m happy.