In Praise of General Surgeons

An interesting aspect of the work in Juba was that our patient population was finite. In Aweil, there is an essentially infinite number of potential malaria and malnutrition patients (and I’m sure my colleagues there sometimes feel like it IS infinite – they are apparently completely overwhelmed at the moment, more so than in any recent year). The program in Juba, though, was set up for one purpose: To treat people with injuries related to the flare-up in communal violence in early-mid July. Since the flare-up was relatively quickly contained, and has not, happily, recurred, our pool of potential patients was “capped” a few weeks ago at a limited number. I think, in the end, we treated between 50 and 60 people.

This meant that, when I arrived, the surgeon (“Dr. Dave”) already knew all the patients, each of whom had by now had his or her initial intervention (wound cleaning – bullet removal – initial stabilization of broken bones – etc.). So we had a very clear idea of the exact work remaining – what everyone needed before we left and turned to program back over to our partner NGO.

The list included 3 skin grafts, 3 “ex-fixes” (pinning of thigh fractures that would otherwise have to spend 6 weeks in traction – see my previous post, “Bones”), one exploration of an infected abdominal wound in a woman whose bowels had been destroyed by a bullet but who was hanging in there way longer than anyone had thought she would, and many cleanings of deep, infected bullet, machete, and grenade wounds. (The little girl with the injured arm I have often mentioned was a special case. She was injured not in the July flare-up, but in early August, when some soldiers having a disagreement had the brilliant idea to start shooting at each other (don’t get me started on the idiocy of filling your country with ill-trained, irregularly paid, undisciplined young men with lethal weapons). She arrived literally a couple of hours before we were due to leave the compound for the last time and turn over care to the other NGO. We ended up taking care of her just because there was no one else who would.)

The greatest pleasure of the week was simply watching “Dr. Dave” do his work. He was an Army surgeon for 24 years, which probably prepares you for anything. Also, it must be said, surgeons in general are just very skilled people. Whatever the problem or need, skin graft or pus-filled wound, abdominal exploration or pediatric amputation, Dave dived in and did it, with what seemed to me exemplary authority, speed, efficiency, and thoroughness. “I tend to be a somewhat more aggressive debrider than the surgeon working here before” he remarked, reaching deep into a thigh wound to pull out pieces of dead bone which, left in place, would have prevented the site from ever healing. “Ex-fixes are fun,” he said, screwing a long metal rod into a femur. Two of the skin grafts had to be done with a particularly medieval instrument – essentially, a cross between a cheese slicer and a carving knife. You put it on the “donor” site, usually the person’s thigh, and just – start sawing away! The thin layer of skin to be transplanted comes out between the blade and a metal guide, just like a slice of Havarti. Dave wrestled with it until he had the grafts he needed. I will give myself a small shoutout here, for managing to keep the people on whom this was being inflicted comfortable – but to be honest, once I’d gotten the spinal (so EASY in a land where almost no one is obese!), my only real job was keeping them schnockered enough on ketamine that they didn’t look down at what was being done to them and start freaking out.

Dave also spent the week being a sort of logistical mastermind – when I arrived, there was no more “ex-fix” hardware at the site, and one of the skin grafts he had to do was just too big to manage with our 1^st-Crusade-era equipment (it would have taken many, many hours). Over the next few days, Dave, our pharmacist, and one of the OR nurses scoured other MSF projects and arranged transport, by car and by plane. By Friday, we had both enough ex-fixers AND an electric dermatome (skin-graft-harvester), and were set up to finish all the planned major surgeries before the Monday-morning handover.

Which we did, by early afternoon Sunday. Learning just afterwards that the girl with the shot-off arm had arrived. The next morning, while I was getting ready to fly out, Dave and my replacement operated on her, too, managing to remove all the damage before it spread into her shoulder muscles (extremely good news). I can’t say how she will fare in the long run, but by the time they left on Tuesday, she was as well as anyone could have imagined, as anyone could have made her given the condition she arrived in, and had a real path to recovery. More good work from Dave.