Six Months in Sudan (25 page)

Wow. Our water tank is filthy. Everything is square. The clothes washing sink and that stupid metal table. Was that worth the fight? The cleaner hates me because I took it into my tukul without asking. It was MSF’s table. Whatever. Should just smash it.

I wonder when the foundation of the new office is going to be finished. It looks like a mosquito farm. Can’t they clear the dirt away? It just makes mud. Last week with the hole in the kitchen. Dust was everywhere. Oh, look, someone stacked dirt to make a little ramp. The satellite antenna is crooked. Tim and I …

I step into the kitchen. The guard has delivered our morning package of bread in newspaper, the pieces on the outside black from the ink.

A piece of bread. I wonder if that ink is bad for you. Not as bad as cigarettes, so who cares. I wonder if there is some Nutella left. I wonder whose it is. Everyone eats it. Sarah sent me some. That’s a mess. Don’t think about that.

What am I thinking about? A billion things at the same time. A billion blind pathways.

Quiet.

I open the lid of the freezer.

An orange. One left. So what. I’ll get another later. Nutella. Sarah. No. Bread. Cigarette? No. Yes. After lunch. See if it tastes good. Maybe I’ll stop.

I take the Nutella from the rack at the top of the freezer, grab the orange with my other hand, let the freezer door slam shut.

Ants in the sugar. Shake them out. Wonder if their brains live on glucose like ours. Probably.

I unscrew the Nutella jar, and take a spoon from our cutlery can. Beside it is a sink full of dishes, dashes of blue wash powder by its edges.

They use that powder for clothes. I wonder if it’s safe to eat. So slippery. I should do the dishes. Corrugated metal roof. Hot in here. No breeze. Plastic over the windows. Tear a corner open.

I pick up the jar of Nutella, the spoon, the orange, and sandwich a bottle of water under my arm.

Why do I always need to make one trip? I wonder what that means about me. Something. Beer bottles with candle wax on them. We’re supposed to take those back. Should we? We said we would. I wonder what they do with them.

I step out of the kitchen and onto the flat ground. The compound is quiet.

Where is everyone? Plants. Wish the generator was off. What am I supposed to do? Cigarette. No. Write something. Shoulda washed my hands.

I walk back to my plastic table, set my food and water down. The orange rolls off the crooked table and lands lightly in the sand.

I pick it back up, blow it off, and start to peel it. I turn
Ulysses
back over and notice that its binding glue has melted from the heat and pages are coming loose from the spine. I tug at one and a section fifty pages deep slides free.

With satisfaction, I stand up and walk the thick book over to the garbage can and drop it in. I return to the table, peel a section of orange, tilt back my chair, and look up at the sky.

14/05: half.

at this point in the story, the character’s eyes are closed nearly all the time. despite the fatigue, sleep eludes him. he is replaced with a half-ness, a part of him awake, part of him not. at night he sleeps in fits. he approaches dreams, but never arrives.

this morning, while walking to work, at the corner, the one with the half-buried tire, the character saw a mini cyclone pick itself up off the road. it whirled dervishly in widening ellipses, then blew itself into a closed green door, opening it. his eyes met those of the man seated behind it who calmly stood from his chair and closed it again, as if cyclones came knocking all of the time. the character thought to himself, who needs dreams when days are so extraordinary?

i am more than halfway through my mission, and am overdue for a break. though my time in ethiopia was more about tuberculosis than rest, it did allow me to step away from abyei. so i delayed a vacation partly because i wanted a true experience, to spend my full time in the field, to arrive at all the important points in the mission so that i could better understand them. i have discovered that fatigue, however, is like the personal experience of illness. though being sick is valuable, particularly as a physician, because it increases one’s empathy, only a fool would court it. so too exhaustion.

but, here it is. a halfness. i remember talking with friends about how i could manage to work, during my residency, 30 sleepless hours in the hospital, leave it to sleep, then return. i explained that the last thing to go was my capacity to perform medical duties. i could sort out a high potassium at five in the morning. what i lost was my ability to offer the patient something beyond the task. i would walk in, inject the proper drugs in the correct amounts into their iv, mumble something neither of us understood, then stumble out to do something else.

the tiredness i feel now is different. it has been a slow erosion. bits of sand have ground me down. i can still recognize the best things in the day, but am just not able to participate in them fully. half.

some members of my team have suggested that i not take call, that we have enough staff to make it possible. i have thought about it, but i think i would miss it. often, it makes up the best part of my day. i get to meet someone, someone new, listen to their story and feel their anxiety. i get to touch their child’s forehead, then quietly listen to his heart. and sometimes, i get to put my hand on the father’s shoulder, tell him that everything is going to be all right, and i get to feel the coolness of his relief.

one of my friends told me that once, when she was having a personally difficult time (someone in her family was sick and her relationship was crumbling), she poured herself into her general practice. the more she worked, the more patients would stop on the street and say “hello, doctor soandso,” the more they would send flowers. not only was she caring, she was being cared for. of course, in the end, this was not an equitable relationship, not the true contact someone needs to feed their bruised spirit, and after several months, she burned out.

i will not, though i can feel the heat. i can understand it better. i am due for a break in 16 days. i started counting yesterday.

M
OHAMED AND I ARE
sitting beside Aweil, watching her play. The woman who has unofficially adopted her, a relative of a child who was in the feeding center, sits close by wearing a new necklace. We have been paying Rebecca to stay in the hospital with Aweil and she seems to be spending the money wisely. I have never seen her drunk and Aweil is wearing a new red polka-dot dress. It is likely she has some children at home, and is using some of the money for them. I don’t care. Marco has agreed to continue the arrangement for now, and each time I suggest to Rebecca that Aweil could probably continue TB treatment at home, she says her home is too far away. I never press.

We have sent word about Aweil to the military area where we last knew her father to be. So far, we have not seen him. Our discussions about her care have been exclusively with this woman, and we are reluctant to complicate things any further. Mohamed and I are in no hurry to take her from our daily routine.

To our other side is a mother with her starving child lolling in her lap, his eyes half open, hands taped over so he cannot pull at the feeding tube in his nose. He probably couldn’t manage the strength anyway. Today he hasn’t been able to muster anything but a thin cry.

His story is typical. Already malnourished, his mouth last in line for whatever small amount of food the family could afford, he got diarrhea. What little energy he had left, to tug at his mother’s skirt, to cry from hunger, to hold his head up to be fed, was washed away.

Her child mewling and taped, tubes in his nose and his arm, the mother sits embarrassed. I’m not sure if it is because it marks the tenuousness with which her family is hanging on, ten hands scrabbling to find purchase, or if it makes evident her necessary neglect of this child in favor of the others. I wish I could talk to her, I wish Alfred’s English was better. When I walk past and she looks at the ground, I could say, “I know what you were trying to do. I do. You were trying to save as many as you could.”

We can’t know how many children die in the mud tukuls because the family cannot afford to bring them to the hospital. The only thing
we know is how difficult it is to get them better once they do. Diarrhea is a killer. It runs children dry. The work it takes to keep their machinery turning with the desert outside and the one inside becomes too much. They creak to a stop.

I don’t have the necessary investigations to determine what the terminal cascade of events is. Could be a problem with potassium. They lose it in their diarrhea, become hypokalemic. Or their kidneys fail from having to work so hard with such little fluid. Could be acidosis, the pH of their blood so low that the proteins in it unfold, their cargo bobbing uselessly a million cells away from where it is needed. Could be all three. Or none.

Aweil shakes a rattle of beads at me. I try to take it, but she won’t let go. She grins.

On rounds earlier today, I pulled down the boy’s lower lid. It was white from anemia. I remembered talking with someone in Ethiopia (a month ago, two?) about how many malnourished children they saved with transfusions. Today we are trying it.

The mother agreed to donate. Ismael drew some blood from her this morning, and we are trying to drip it into a small vein in the back of her son’s hand. We are running it slowly. If we give the blood too quickly, it can overwhelm his homeostatic system, the extra volume filtering into his lungs.

I hand Aweil to Mohamed, stand up, and dust off my scrubs. I take the small bell on my stethoscope and put it on the boy’s chest. His mother stares. I feel the taptaptap of his heart before I hear it. It’s the size of a cherry. I listen to his lungs. Clear.

I unwrap the cool towel that we have wrapped around the blood bag and look at the drip set hanging below it. A thick clot hangs from the filter.

This is the second time today we have tried this, the second time it has clotted. I went over the process with Ismael after the first failure, made sure he added the correct amount of anticoagulant. He did. I went back at lunch to try and find an answer in a book. Ismael did the same. We found none. Brian is gone. We’re unlikely to get a response from Geneva in time.

Shit. Maybe the intravenous is too small. Or it’s too hot outside. Perhaps it affects the heparin. If we store it somewhere too warm …

The boy’s breathing is getting faster. I’ve seen it this way a dozen times by now. If you do something as simple as put in an IV, worse an intraosseous, sometimes if you even turn the kid over to wipe at the diarrhea, they spiral. They cry, and that withdrawal of energy, from the pain and the distress, puts them into debt and they die.

I stop the IV. The mother looks up at me.

“Mohamed, can you tell her that the blood is too thick, that it won’t flow?”

While he is translating to her, I go to the front to find a nurse. I find one hunched over the desk trying to read our orders, then drawing up medicines into unlabeled syringes that litter the desk.

“How do you know which syringe is which?” I ask.

He looks at me and smiles. “I remember.”

“Right. You know the baby with the blood transfusion?”

“I know.”

“It’s clotted. Not working. Can you take it down and put in a saline lock?”

“Yes. Right now.”

He leaves the room and I sit down on the blue metal chair behind the desk. My foot bumps against something. It is the cardboard box we use to hold all of the charts from all of the patients that leave the hospital each month. It is nearly full.

I lift it onto the desk and take the top chart. It is for a patient who died last night. One of two. She was a young woman who came in with a sudden fever and a headache. We treated her for both malaria and meningitis. Her fever never left, and in the past forty-eight hours, she drifted in and out of consciousness. Mohamed was on call last night and he told me that the nurses called him at four in the morning to say her blood pressure was 220 over 140, and as he prepared to come into the hospital, they called back to tell him she died.

Probably a brain abscess. No way to know for sure. I have scrawled at the top, as a diagnosis, “FEVER.” When I tally the births and deaths at the end of the month, hers will be classified under “Other.”

The next chart is in sequence. It is that of a man who also died last night. He started feeling weak a few days ago and saw a local doctor, who gave him some antibiotics. He continued to worsen. His weakness became so profound he could not walk, and by the time he rolled through our doors, he was having trouble breathing.

Mohamed saw him last night, on call. The man started to vomit, and inhaled some of it. He stopped breathing shortly after. Guillaine-Barré, probably. Could be botulism, I guess. Myasthenia gravis. On the top of his chart I write “WEAKNESS.” Other.

I start to comb through the charts, remembering the people through their scribbled stories at the tops of their pages.

Oh yeah. This one. Little boy, came in with a sore throat. Seemed to be all right, but got worse. Didn’t respond to antibiotics, stopped eating. Breathing became noisy. We finally transferred him to Heglig, where they airlifted him to Khartoum. I heard he died on the tarmac. “SORE THROAT.”

Mansood. His chart is thick. He was here for months and never got any better. The caregiver we hired worked for a while, but after she found out I was treating him for TB, I never saw her again. I checked on him a few days ago. His eyes were still and unblinking, the skin on his face taut, his last expression a toothless grin. On the windowsill of his room was a stack of foil Plumpy’nut packages and three or four half-finished sodas swimming with ants. “WEAKNESS.”

“MALARIA.” “MALARIA.” “PNEUMONIA.” “SNAKE BITE.” “MEASLES.” “FEVER.”

“GRENADE WOUND.” The boy’s mother finally came back, and we transferred him for an amputation. Don’t know if it happened, or where in the world he is.

I put the old charts back in their box and start going through the active ones, the ones on the desk, to make sure I haven’t missed a stool or urine sample.