ER

Twice now, we’ve gotten huge numbers of injured people from vehicle accidents. Things are difficult in a hospital made of poles and plastic sheeting in the best of times, but with an influx of 15 to 20 injured people at night, it can get ugly fast. Luckily Emir (our doctor) is really good at handling situations like that. The team works together really well, and we all know our specialties well and how to anticipate problems, so it’s exciting, but not utter pandemonium,

The first one came a few weeks ago with no warning. The Physician Assistant on duty at the hospital called on the radio around 9 or 10 pm as we were all getting ready for bed. He said he had 14 newly arrived cases at the Emergency Room and that there was another car coming. The accident that injured all these people was due to a big truck running off a bridge and plunging into a creek. We never really got a credible report of what happened, but the rumor going around was that 7 people were known to be dead at the accident scene, and that 4 more bodies were pulled out of the creek in the morning. When Emir got the call, I went to Lilian’s room and told her Emir would probably want her help. Then I went to get on the radio and talk with the camp guards. Our hand-held radios are at their limit of reception, so it helps a lot to have an operator at the main radio at base who can relay messages. Because the radio room is next to the Field Coordinator’s room, she also got up. So the medical people gathered up supplies like extra gauze, gloves, and tetnus vaccine and headed out. Emir used the big open space of the outpatient clinic waiting room as a triage area, and then moved patients through our single ER one at a time. There are electric lights in the ER, but not in the triage area, so I imagine there was a fair amount of scrambling for flashlights and batteries. One great decision Emir made was to have me immediately get a taxi waiting at the hospital. After his initial assessment, he loaded the taxi with the worst cases who needed the least stabilization and sent them to Ganta. So within 15 minutes, he’s already gone from 14 patients to 11. We ended up sending a second taxi that night with more patients.

Last night around 5:30 pm, we got a call that an accident had injured 30 people nearby and we were asked to go pick up the patients. We don’t run an ambulance service, so we have to say no to those requests. But sometimes there are extenuating circumstances, so we keep our mind open. Getting one call about 30 injured people jolts you to attention, but also makes you ask, “is that real information, or a rumor?” So you start asking around, emphasizing that what you heard in unconfirmed, etc. Due to turnover on both sides, we don’t have really great contact info for UNMIL and Civpol (the UN-operated civilian police service). We did find a number for a Merci person in Nimba. They have an ambulance that sometimes drops patients at our hospital, so I asked them to go see what was going on beyond Bahn where the accident reportedly was. I was also
tracing the progress of one of our vehicle home from Lepula, and I realized too late to warn them that they would be passing the accident site. Luckily, they found the injured people and poor Jerome (outreach/bush nurse) found himself in the middle of about 200 Liberians freaking out and all wanting a ride to Saclepea on the MSF car. He assessed the patients and chose the 2 that he could take. Unfortunately, by the time Jerome was on the scene and could give us accurate information that would have allowed us to send a car to help him, it was too late to send a car because they don’t drive outside of Saclepea at
night. So Jerome did the best he could with the space he had.

At base, we scurried around gathering supplies. It was clear that we learned a lot from last time by how well organized people were. I realized I had all the stuff I needed easily available to make a lighting system in the triage area, so I went along with the medical staff carrying all my lights and cables. I grabbed one of the watchmen and started setting up the lights. They were ready about 30 seconds before Jerome arrived with his patients. Like last time, I arranged to
have a taxi standing by. Everything went smoothly, too smoothly. Of course because we were so well prepared, the 30 patients didn’t really materialize. After Jerome arrived with his two patients, another truck came carrying quite a few more patients. The head PA arrived from town, and had picked up a number of other medical staff he’d seen in central town along the way. There was almost one PA per patient, which made the assessments go fast. The injuries were minor, or at least not the super-dramatic open femur fractures that are the real nightmares.

When we got home, Emir thanked me for the lighting system, and said it made a real difference. I’m now considering how to arrange for the emergency lighting system to be ready to deploy for the future. I think I will add a plug to the electrical system nearby and then stockpile the lights, extension cord, and power strip in a box at the base. I’ll probably put some instructions in it, because the problem is that there’s a chance that by the time I have it ready to use, there will be no more emergencies. The next log will need it someday and have to figure it out on the fly. Hopefully marking it clearly and putting the instructions in will help.

“Jeff is BRAVE!”

Today we had a little excitement in the compound. The storekeeper came to me really agitated. He said that he’d gone in the food store to check that things were ready to deliver food on Monday. But when he opened the door he found a big snake. He showed me that it was as big as his forearm. Now, we have snake scares from time to time. It results in a frenzy of activity, as all the expats run for digital cameras, and the Liberians who grew up in the bush get their slingshots, cutlasses and sharp sticks ready, and all the city boys from Monrovia scream like girls. I tend to try to steer clear of the circus and watch the country boys to make sure that the snake is dispatched swiftly and safely.

First, a word on MSF Nimba Project snake policy. The policy is, “we kill them”. As an addendum to the policy, we let the watchmen eat them if they want. The problem with the snakes is that only some of them are poisonous, but those that are, are really poisonous. In fact, they are so poisonous, the treatment protocol for snakebite is, “if they are alive when they get to the hospital, treat the symptoms because he’ll survive anyway”. (With a little imagination, you can figure out the other half of that “if”.) Since not all of them are deadly, it’s not fair to kill them all. But the problem is that finding someone in the heat of the moment who knows if a snake is safe to leave in the compound is impossible. So every snake sighting turns into a snake hunt.

So Isaac reports a snake. We have an hour or so before sundown. Isaac is not really hot on snakes, but I can tell from the way he is acting that this is a serious snake, over a meter. The other ones we have killed have been a meter tops, sometimes only 50 centimeters. The problem with the food store is that there are pallets, and so there are lots of snake hiding places. There are several rooms, but right now we know which room it is in, so we need to act fast and take advantage of the knowledge. The food store won’t be safe until we find and kill the snake. The other problem with a food store is that even the best food store has a few mice, and mice are snake food. So it’s not like the snake is going to just mosey on out of the snake buffet without a little help from a cutlass.

As I said, when the circus atmosphere takes over, I do my best to watch and see how I can keep it reasonably safe. I try to follow the lead of the person who decides what to do and then starts doing it. We checked to see if James the watchman was around, because he’s the great hunter. He usually steps up to the challenge of all the hunting needed in the base. Alas James was not going to be on duty until after dark, and it was clear that I needed to find another hunter. Luckily a driver/watchmen named Diago stepped up to the plate and started poking
under the pallets with a long stick. We called for a flash light and tried to look in from the doorway. Diago couldn’t do much with the stick form the doorway. This is when things stalled. Diago didn’t have any more ideas, and I was left holding the flashlight.

One of the things I learned in log school is that the key to effective leadership is to keep people thinking that there’s always something you know how to do that they don’t, and that they should listen to you. Usually, bravado and a smooth tongue can maintain the proper level of respect. Sometimes however, you can’t fool the crowd and you actually have to show some real leadership instead of just bluffing. I realized this was one of those rare moments. So, in I went, flashlight in hand.

The nice thing about pallets of food all lined up in a warehouse is that they form a grid underneath them. When you are on your knees looking under them with a flashlight, they line up in rows and columns. You can eliminate a lot of territory by working your way through the place checking rows and columns. So I worked my way in looking for the snake, crawling on my hands and knees. About halfway through the room I found a tiny piece of the snake, luckily just a piece out of the middle. Not too intimidating. And it was easy to tell where I would find the rest. So I screwed up my courage and checked the next row, and there it was. It was really big. Way bigger than any we’d seen before. Isaac was right, and I was glad we’d found it. But now I had a problem… how to kill it. I
regrouped outside and explained what I’d seen to Diago. With more information, Diago was willing to come inside with me. First though, he cut the stick down, using the cutlass expertly. He made it into a spear, even going so far as to take off the little knots on the edge so it could slide through the pallets easily. Either that or he was just trying to kill time tpo avoid going back in the building with me. When the stick was as ready as it would ever be, we returned to the warehouse and I shined the light while he got ready to stick the snake. The sharp stick is not to kill it, but to hold it in one place, it turns out. Once he was lined up, he poked it against the back wall with a quick thrust and the snake got very angry, very fast.

I hopped up and started moving boxes. Richard the radio operator jumped into the act and helped me tunnel towards the snake. We had to remove about 12 boxes to get to it. The first few were no problem, but the closer I got to the bottom of the stack and the snake, the more careful I had to be to grab the box and get out of there. Diago held the snake firmly and we exposed it. Adolphus came in with a cutlass for the kill. The snake was whipping around and Adolphus was trying to cut it’s head through the slats of the pallet, which is not easy. I was yelling for a second stick, since it turned out that Diago didn’t have very good control of the snake after all. The snake foolishly lined his head up
with the slats for a second and Adolphus finished it off with the front of the cutlass, which is squared off. The blade came down between two slats of wood like a guillotine, and the snake was in two pieces. Happily the head only had a few inches of body attached, which made it unable to move much. The rest of the body was going all over the place, but without the head, there’s nothing to be afraid of.

This is the part of snake killing that gets scary. The problem is that the Liberians like to poke at and otherwise taunt the head, and the head of the snake is still intent on killing someone, body or none. So you have to clear out until they crush the jaw, and then it’s a bit safer. So I ran for cover, mostly because the whole thing was really creeping me out by that point and I just wanted to get the heck away. Diago held up the body, and it was as tall as him… over 1.70 meters. It even had a mouse in it’s belly, making it look all the more gruesome. Many pictures were taken. Diago was proud to be in most of them.

Afterwards, as all the adrenalin was draining away I gave all my fellow snake killers a well deserved soda and toasted them all. Richard commented in his Liberian way, “Jeff is BRAVE! No one would go in to find the snake, but Jeff did!”. I ought to be able to get some mileage out of that for a few weeks! Then I’ll have to climb up on a roof and adjust an antenna or do something else dramatic to impress the locals. Tough crowd, these logistics staffers.

Toys for TFC

The TFC is the Therapeutic Feeding Center, where severely malnourished patients can be fattened up. This is significantly harder than it sounds since it turns out that human bodies do not take well to severe starvation. As you put in fluids and carbohydrates, the body needs to adjust and deal with the new chemical balances. You can kill a person by feeding them. So the medicine in the TFC is actually a specialty, like urology or proctology, but less icky. Unfortunately for all the malnourished people in Africa, it is also a rare specialty, so we here in Saclepea are just sort of doing our best to run the TFC according to the books the experts in Europe wrote and sent to us. There’s a certain amount of “if it works, don’t change it”, which is OK, but can be dangerous if things aren’t actually working, but you don’t understand what’s happening enough to be able to tell.

Of course, when you have clinically malnourished people in a community you’ve got to first ask the question, “why aren’t they eating?” It’s better to take a public health perspective and solve that problem first, lest 100 more people arrive next week on the verge of death. Of course, there are entire NGO’s organized around that question. When you are writing proposals to the funders, it’s called “food security”. As an aside, making sense of the whole vocabulary of NGO’s is like walking in a house of mirrors with a blindfold on. Like any other essentially political activity, it all changes every decade or so based on the direction of the political winds. There is a sign in a little tiny village on the way to Lepula that says, “Building capacity in maternal mortality and child survival”. This in a village without a school, and a literacy rate that is probably less than 25%. Wouldn’t it be better if the sign said, “Helping mothers and kids to not die”? Or if the money used to pay for the sign was used instead to help mothers and kids to not die? Just a thought.

Anyway, MSF doesn’t do Food Security. We just fix people who are malnourished and hope someone else will make it so that less of them come to us, so we can close down the TFC and get on with more pressing issues, like teaching Quiplu the dog to fetch. (not gonna happen, it seems)

Our TFC has only kids in it. This is a reflection of the current context in Liberia. Children are ending up malnourished in Liberia due to a number of reasons, but rarely is the reason “there’s no food to eat”. This might seem surprising, but consider some other possibilities. A lot of children who are three right now were conceived during the war. I don’t know about you, but the next time I’m in a war, I’m not planning on starting a family. Some of these 3 year olds are the products of rapes, or less violent but still unwanted sex (for instance, sex as a survival strategy, in order to get food, or protection). These children are unwanted, and there is no orphanage system in Liberia to help the mothers deal with them, so some mothers are overwhelmed and de-prioritze the unwanted children among the others who are products of happier times. Another possibility is that these are children of 15 year old orphans, who are missing the family structure of mothers, grandmothers, and aunts who might be able to explain nursing and child rearing to them. It takes a tiny amount of time for a healthy child with diarrhea who stops eating to get malnourished. Also, due to the poor state of health care here, mothers could have an undiagnosed condition that keeps them from producing enough milk, like dehydration and anemia due to low level malaria infection. If we had some Food Security experts here, they could drive up in shiny new Land Cruisers and give us a snazzy PowerPoint presentation explaining which of these factors are at work here. I suppose they are doing that in some UN meeting, but it’s not my problem.

Now that I have you totally depressed, I should get back to the topic: Toys for the TFC. We are working on improving and decentralizing our TFC in order to align our project with the current winds that are blowing through the relief industry. By shifting towards outpatient therapeutic feeding, you can cover many more children with the same amount of money. This is a good thing, but it requires that Susan, our fieldco, figures out what’s currently happening in the TFC and then makes a plan to change it. She started reading the MSF nutrition books and found out that after a child is out of the severe malnutrition phase, it is a good idea to stimulate them with toys. This is actually head-slappingly obvious when you see the TFC, which is a place where the patients and the caretakers sit for 12 hours and basically do two things, eat and wait (the other 12 hours are spent in the night TFC ward, where they do three things: eat, wait, and sleep). The waiting is for the next meal. So clearly this would be a good place to have some toys.

About this time I realized that my mom sent the long balloons you can make balloon animals out of in a care package. (She does weird things like that. Of course, I’m the weird kid who thanked her for the balloons, then asked for a pepper grinder. We clearly deserve each other.) So I made some balloon animals, and they were a big hit. I need to teach the other expats how to do that, so that we can keep a constant supply of balloon animals coming into the TFC. Mom has already airlifted an emergency supply of balloon animals to Geneva, which will arrive when Susan gets back from Geneva.

The problem with the balloon animals is that they pop. So I started thinking about wood toys. On Sunday, my only day off, I try to schedule some work with my hands that is not mind work. Sometimes it is fixing little things that I notice are broken during the week. This weekend, I decided to make wooden toys. I started off with a Land Cruiser pull toy, which was a great success. Then I moved to building blocks, which were too much trouble to cut out of the hard tropical wood we have here using the hand saw. So after only 6 of those, I moved on to blocks with holes and a spindle to stack them on. That went pretty well. So with an afternoon of work, I had three prototypes. We took them in to the TFC on Monday, and they were popular. The MSF Land Cruiser pull toy has not made it’s debut because the paint was still drying. I noticed tonight that it is dry, so Jerome can draw on the MSF logo, and some other details to make it a Land Cruiser. I think the snorkel will have to go on, as it is very distinctive. I put a big HF antenna and tuner on it, which is a trademark of NGO cars here. The HF radios can communicate hundreds of kilometers, even out in the bush, so we use them to stay in touch instead of trying to use VHF repeaters on towers like a fleet of vehicles might do back in the US. The HF antennas are really distinctive, and are easy to model with a little wire. You just strip the insulation off the top part to be the antenna and leave the insulation on the bottom to be the tuner. Et viola!

I just realized that the sticks in the forest next to our compound would make really excellent Lincoln Logs, but I’m not sure that the kids are old enough for that type of toy. Perhaps some sort of coconut-based rattle would be nice. I don’t know how to get a coconut with only water inside. The coconuts here have lots of white flesh, which will rot if I just drain the water. This will take some thinking.

After I exhausted myself making toys with the hand tools our carpenters use all day effortlessly, Hugo mentioned that the construction site has power tools. So this weekend, Hugo and I will set up an assembly line and maybe get Jerome to help us make some more toys for the TFC. It should be a fun weekend project!

One more quick thing. Ever wonder where the big advertising banners go when the campaign is over? Like the kind in Times Square? Well, it turns out they end up in Liberia on top of trucks as tarps. Normally, they are probably inside out, advertising boring stuff like soap to the bags of rice inside. But the other day one caught my eye. Remember the Dove Soap ads with the real women, not stunning supermodels on them? Just a bunch of nice ladies standing around in their bras and panties? Well there is a truck on the road in Nimba with them on it, and the driver chose to put them right side out, so that the Dove women are riding along on top of the truck. Certainly required a doubletake!

Learning the Lingo

Hello from the middle of a huge rainstorm. It has been threatening to rain all day, and getting muggier and muggier, so it is nice that the rain and the cool breezes have finally come. It means, of course, that when I am done writing this and try to send it, it will fail because the satellite signal is blocked, but this is a small inconvenience to trade for the cool breeze coming through the office.

After a couple months in Liberia I have mastered enough of the lingo to be accepted as a native speaker of English, instead of an incomprehensible foreigner. Likewise, I usually understand people, even when they are talking to others instead of directly to me. Liberians with long experience working in NGOs know how to speak English to foreigners, and will occasionally translate for us. The key difference is a combination of word choice, grammar, and word endings. In casual Liberian English, the word endings are gone, making it pretty hard to reconstruct what word from standard English they meant. When it comes time for a Liberian to write down a word, if they don’t know the spelling and choose to write it phonetically, you can actually SEE that the end of the word is completely lost. The grammar used by casual Liberian speech is the simpler grammar found around the world. This version of English is like the welding or masonry or carpentry of the developing world. A little rough around the edges, but exactly what is needed to get the job done, and nothing more. And in case that sounds condescending, remember that I love the engineering of the developing world, where everything is out where you can see how it works, and any parts that are not needed broke and were removed years ago. This is casual Liberian English, and it works great. Most educated Liberians can switch into standard English in a heartbeat, and they know they need to do so to make themselves understood to foreigners.

Like everywhere where English is spoken, there are local words, or much more confusing to an outsider, local meanings for standard English words. One fun one is the verb to embarrass, which means to disrupt, make untidy, or annoy. When I first got here I asked Roger to arrange to have a huge pothole filled because the water in it was always messing up the cars as they came and went from the compound. As the waste water from the small lake was going to cross someone else’s property, he wanted to get permission from the mayor, and took me along. He said, “we want to drain the puddle because it embarrasses our vehicles”. Another funny example was a message that came over the radio one night: “Please bring diesel fuel to the hospital to waste around because there are driver ants that are embarrassing the patients.” In Liberian English, to waste is to spread something (however wastefully or frugally). A man clears land then wastes rice seeds over it. We wasted a whole lot of diesel fuel on the ants that night, let me tell you. In the morning, I told the storekeeper what we did and he carefully wrote on the stock card, “8 gallons of diesel fuel for ants in hospital”.

Everything is justified to the last dollar and gallon around here. I spent an enjoyable few minutes the other day looking for an accounting code to list the LRD 20 (about 50 cents US) that I spent on a pair of bowls for feeding the dog and cat. I settled on “expat residence expenses” reasoning that Quiplu is pretty much one of the expats now, and Dude the cat only ever eats, as far as we can tell, if we put something dead in a bowl for him. I keep explaining to him that American cats would love the opportunity to eat the kinds of moths and bugs he
has here, but he just walks away.

Back on the topic of Liberian words for a second… “Fine” is used like “uh huh” when someone else is talking… so if they are saying something you generally agree with you utter a string of “fine”, “fine”, “fine” sotto voce along with them to show you are following them. This is pretty distracting until you get used to it, but now I do it some when listening to Liberians. Hopefully, like getting into the wrong side of a car when I try to drive it, this will be an easy habit to drop when I get home.

Today I got Lilian and Desma to cut my hair. The guys in town do an OK job of cutting hair, but I just wanted a buzz cut and Hugo brought what a Liberian would probably call a shaving machine (anything mechanical is called a machine, like the pumps and generators), so I decided to get my hair cut at the MSF barbershop. A good time was had by all, and I cleverly scheduled my shower right after the haircut, so the little pieces of hair that were stuck to my sweaty skin are all gone now. Ick.

When you are the administrator, there are a thousand places to sign your name every day. The same holds true for a logistician, who approves expenditures of the material variety. So as a log/admin, I have about two thousand signatures to do a day. I’ve learned the benefit here of carrying a distinctive pen. It doesn’t need to be expensive or anything, but everyone knows now what my pen looks like, and if I start to leave their desk and it is still there, they call me back for it. It is absolutely incredible to consider it, but I am still using the same pen today that I was using when I got here, over 2 months ago. I’m beginning to worry that it will run out of ink, and I will have to train everyone what my new pen looks like. My current pen is a promotional one I got from Telenor at the Humaninet Demonstration Day in June that’s got puppy teeth marks on the end from Kat. I was looking at it closely during a really boring staff meeting (yes, even in Africa you can’t escape boring meetings) and it turns out it is Swiss-made, which is fitting, as I work for MSF Switzerland.

Update: It turns out that I did in fact run the pen out of ink, which is a first in my life, I think. I had a troublesome few days until I settled on a new pen with the help of Marina, who had brought an amazing collection of pens with her from an aunt. She was supposed to be giving them to children, but she gave one to me too. Marina also brought a special pen for me from Barcelona after her training session, but I immediately lost that one, which made me very sad. Getting attached to pens in the bush is not an effective use of the finite energy available for emotions.

My work is completely under control right now. That’s not to say that it won’t careen dangerously out of control on Monday morning with broken radios, lost vehicles, and water and food shortages. But on Saturday evening, I sat down to have a beer and de-stress and realized I wasn’t stressed. The accounting closed on time, and no money is missing (though I had some really big scares this month, which taught me to be more careful about everything I learned the first month). The health post rehab project in Diallah is going great. WFP assures me they will be delivering food next week, as long as I get this stupid report done tonight and take it to them in the morning. And I moved a radio over from one car to another, giving us 3 cars for use in the bush again, since last week I found out one of our bush cars needs major transmission work and is no longer allowed outside of Saclepea. On Saturday evening I did have one little fly in the ointment, which is that the front sway bar on one vehicle has broken loose and needs to be fixed. Luckily, that part of the suspension breaks the most around here, so just by looking at it, I could tell it will be a 2 hour fix. I
adjusted the Monday morning vehicle plan, and we’ll get it fixed right up.

The condition of the roads is increasingly bad. But everyone says that this rainy season wasn’t as bad as last one because we have had lots of small storms with lots of sun in between instead of days and days of slow rain. It turns out what’s needed to maintain an African dirt road is not machinery or rocks, but sun. As long as the roads get enough sunlight to cook them back into hard clay from mud, everything pretty much repairs itself. The villagers have a system set up where each village is responsible for cutting the bush away from the road to ensure it gets enough light. No amount of sun fixes bridges, however. This week we had two trips interrupted by broken bridges. At one of the bridges, our driver worked most of the day to get a commercial truck off the broken bridge using his MSF vehicle and it’s tools. Then he took the mobile clinic team back to base to spend the night. The next day they made it to the mobile clinic site beyond the place they were stuck the first day. People understand here if you miss an appointment out in the bush. Sometimes you just can’t get through.

With the arrival of a new expat, Desma from Kenya, we got a delivery of mail from home. I got some stuff from my mom and some mix CD’s from a friend in Rome. Thanks Kristin! Kenneth and Dima, who were the log and nurse here before Lilian and I got here sent a care package for the team too. It includes the Rough Guide to West Africa, so I will start reading up on Ghana and plan my vacation which is coming up in a month. The guidebook includes no info at all on Liberia and Ivory Coast because they were at war when it was published. But it’s OK, we already know the best bars in Saclepea!