Doctor's casebook: Treating Monrovia's wounded II

Helping Liberians is 'worth the risk'

Andrew Schechtman of charity Medecins Sans Frontieres has been witnessing the tragedy unfold in the Liberian capital, Monrovia. He has sent parts of his diary to BBC News Online.

When a door slams, I jump thinking it to be a mortar shell exploding in the distance.

The sporadic bursts of gunfire during the day are not so worrisome.

Most of the bullet injuries we've seen have been from falling bullets. We never hear the gunfire before the bullets fall.

I assume that they must be fired from too far away to hear.

This also leads me to believe that bullets that I hear being fired will most likely land somewhere far off. Following the logic, I feel safer when I hear the gunshots.

I don't know if this logic holds true or if it is a desperate attempt to find a pattern, to find predictability, to find an illusion of safety amidst the chaos.

No heartbeat

The newborn baby boy faced an uphill battle from the beginning.

His mother had been in the earliest stages of labour when two minimally-trained birth attendants tried to assist with his birth.

Despite the fact that her cervix had only dilated to two centimetres instead of the required 10, they climbed on her and pushed on her uterus.

Doctors are discharging people who have nowhere to go

They put instruments inside her and ruptured her bag of waters, trying to hasten her labour.

She arrived at our hospital after two days of their earnest but misguided interventions, burning with fever and bleeding from her vagina.

When we examined her, her cervix was still only two centimetres dilated but was now also swollen.

Listening with the fetoscope pressed against her uterus, we couldn't hear the baby's heartbeat.

Our fear was that the baby was dead in the womb. The limitations of the fetoscope, a very basic stethoscope-like device which was essentially just a hair better than putting ones ear directly to the woman's belly, left some hope for the baby.

He could have been alive and we just didn't hear his heartbeat. We started our patients on strong intravenous antibiotics to combat the infection and gave her drugs to induce labour.

Improvised oxygen mask

Six hours later, her fever was down and the baby was delivered. He was a beautiful little baby boy but hadn't tolerated the intrauterine ordeal well.

He came out floppy and blue. We resuscitated him as best we could and he improved.

He became a little less blue and his breathing slowed to a normal rate. I started him on the same strong antibiotics I had his mom on and initiated a sugar water infusion since he was too weak to start breast feeding.

We had recently received an oxygen extractor for our hospital and he would be the first patient to benefit from it. The oxygen extractor creates oxygen from the air using electricity and is quite practical in settings where oxygen tanks are hard to come by.

We improvised a baby-sized oxygen mask by cutting up a plastic one litre bottle and hooked him up to the machine.

He seemed to be getting better. The blueness receded almost to the point where one could say he was starting to look a little pink. Along with our oxygen extractor, we had also just gotten a pulse oximetre, a device that can read the oxygen level in the blood when clipped on a finger.

We tested our baby boy and his response to the oxygen. His oxygen level was 78%. This was not good. A normal oxygen level is over 94%. This baby needed an intensive care unit.

This baby needed to be put on a ventilator. He needed the oxygen pumped into his lungs until the antibiotics could kick in, until his little body could mount its own immune response against the infection he'd contracted in his mother's womb.

But there is no neonatal intensive care in Monrovia. There is no ventilator. He died an hour later. We had done all we could.

Tears

Fatu (not her real name), a 20-year-old woman, was brought to our clinic from the nearby community of West Point.

She had been raped the night before by an armed man.

In a private examination room with the presence of a female escort, she calmly shared with me the details of her attack as the tears quietly ran down her face.

Liberians have nowhere safe to flee to

Four armed men wearing masks grabbed her and threatened to shoot her. One fired his gun into the air overhead.

She fell to her knees and begged him not to kill her. He dragged her to a place that people had been using as a toilet and threw her to the ground.

He held his bayonet over her, threatened to kill her, and raped her.

I examined her and completed a legal report I gave to her in case she had the opportunity to prosecute her assailants in the future.

This was not likely. She didn't know who had attacked her and there is no functioning system of law in Monrovia.

'Pay yourselves'

The streets now are filled with armed men, boys recruited to fight, given weapons, and provided little if any training.

These are not professional soldiers. These are ill-disciplined boys with guns.

To compound the problem, these recruits are not paid for their work. Instead, they are encouraged by default to "pay themselves."

This means grabbing whatever goods of value they can get their hands on, looting from the civilian population, businesses, aid organizations, and sometimes from each other.

The general lawlessness that this promotes has led to a lot of rape.

State-of-the-art

I gave her single dose preventive treatments for all the treatable venereal diseases - gonorrhoea, chlamydia, trichomonas, and syphilis.

I gave her a course of post-coital (commonly called "morning-after") contraception to prevent pregnancy. Perhaps most importantly, I educated her about and started her on an antiretroviral drug combination for preventing of HIV infection.

She had survived a horrible experience.

I was glad I was able to offer her state-of-the-art medical care in the aftermath to minimise the chances that her tragedy would be compounded by a sexually transmitted disease, an unwanted pregnancy, or Aids.

I gave her care that I think was as good as that which she could have received in most emergency rooms back home in the United States. I think she deserved at least as much.

Andrew Schechtman's first casebook