Signing off and going to ground

Sitting in a coffee shop in the international terminal at Istanbul Airport with Fleur de Lis playing in the background. Surreal does not begin to describe the mental turmoil.

Wednesday was a day of seeing post-op patients. A rewarding way to finish up in Darkoush. This was followed by the expected protracted (that doesn’t appear grammatically correct but I will plead sleep deprivation and hypoxia) farewells before the journey home began. Due to the military activity in Damascus and Jisr al-Shagour and resultant increase in border security on the Turkish-Syrian border, time spent at the river crossing was kept to a minimum.
My wish to cross an international border in a makeshift raft at dusk by moonlight was fulfilled.

The start of a series of layovers began in Antakiyya / Antioch. Removing the Syrian mud, running water showers and no sleep. Red eye flight to Istanbul. Then Cairo and home.

Steve Jobs sums p some of what is bustling around in the post Syria vacuum:

“Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose. You are already naked. There is no reason not to follow your heart”.

There will be no mortar fire at night. No gunfire in celebratory panache. No heavily armed guards.

I will be back at work soon after I touch down in Mzanzi so will be going to ground and flying below the radar for a while. On resurfacing, the torrent of photos will be unleashed.

Ma’a salama

مع السلامة

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The brief respite has ended

The heavily charged atmosphere was palpable last night when I arrived home. An Air Force MiG had bombed a town 40km to the south.

This was a stark contrast to the morning of wandering round the old city, walking on the stone roads leading to the ancient Roman baths. The bustling activity through the narrow convoluted alleyways. (Early morning walkabout at the expense of breakfast).

As we start to wind down our time here, the caseload of operations that need to be done before we leave is climbing significantly. The three year old with flexure contractions on her hand, the shattered humerus, the septic shoulder fracture following a mortar blast. Alternatives for them are to cross the border into Turkey (escaping out of Syria is the difficult part for them) and going to a Turkish hospital. Then they are placed on a waiting list. Some of the outcomes that I have seen thus far have been suboptimal. Both operated and missed cases / incorrect diagnoses.

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Bittersweet War

War lends itself to experiences. Most of the medical breakthroughs we are embracing in trauma / acute medicine is as a result of knowledge gained during war time. It lends itself to the development of new techniques, more effective algorithms and more efficient patient care. It allows us (me) to come here and do numerous operations that i would normally wait years to do. It allows o e to operate without the burocratic burocracy and lethargy that permeates government sector work in South Africa. War allows one to sit in the evening and unwind with a group of men, not allowing a language barrier to intervene. With no sounds of shells exploding the ambiance tends towards the surreal. Sharing photos of the ruins of the Byzantine Palace that I visited en route to work and the houses in the small alley-ways that are relics from the Ottoman Empire transports one away from the stark reality.

They are at war. There is an imminent danger of them being killed, either by mortar fire at home or the frontline. Some even face the prospect of being shot on site by the very ones entrusted to protect them.

They are at war and we get to benefit. Yet they still welcome us with warmth and open arms.

20130423-233010.jpgHard at work.

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Theatre waiting lists.

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Gunship driving past the hospital.

It’s a simple life

So I find myself sitting at midnight with eight other middle aged men, minimal shared spoken language dialogue, conversing for a couple of hours. There are no family members, they have all been moved out of Darkoush and are either in the refugee camps or in neighboring Turkey. The interactions are all animated, the laughter following a successful mime is infectious. The ‘chai’ (Arabic sweet tea) flows constantly, the air thick with smoke. No bombs were heard. For a couple of hours of everyone in the room indulged in an escapism and thought of things other than the war (or revolution as is the PC term here).

Jet fuel being prepared in the morning

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Transport of kings

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Gunfest?

What seemed to be a start to a normal day with plans to venture off into the town for a walkabout with my camera (armed guard and translator in tow) was anything but normal.

Arriving home at close on midnight with Al Jezeera (spelling?) blurting out updates on bombings in the Middle East and USA intermingled with English Premier League updates. Our hosts had brought out some of the armory that was present in the house. The ever present Kalishnikov; the 9mm handgun; the shotgun and various other ‘light’ weaponry.

This was the day of challenging operative cases and even more challenging work conditions. At about mid morning there was a volley of semiautomatic fire directly outside the hospital followed by a patient carried with obvious signs of being bound and assaulted. That was not the problem. The problem was the group of bodyguards (fan-club?) who insisted on accompanying him into Casualty. Hospital guards, aware that the medical team was not that comfortable with level of personal protection armament (Syrians who are at war – ie everyone here- carry a weapon around like the average individual carries around a cell phone) attempted to keep the fan club outside. This attempt at separation lead to repeated arguments which were heated and animated ( including one walking stick brandishing elderly gentlemen assaulting the door to punctuate his point of view). However no one used their gun / semiautomatic to intimidate or threaten anyone.

Combine the above with more than 250 rounds of semiautomatic fire at the entrance to the hospital to celebrate ( the patient was a high level military leader who had been captured by outlaws?) the freeing of the patient.

The hospital was whittled down to a skeleton staff for a couple of hours while fears were allayed, people calmed and tears dried. Needless to say the stories are flying…

Anyway. This morning I find out if I get to stay a few extra days.

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Leader of the Military Counsel explaining the hospital issue.

Penultimate day in the zone

The excitement from yesterday is that there was any. At least there wasn’t anything big and dramatic. My rewarding case of the day (the were numerous, but the first and most memorable) was doing a fusion on a fourteen year old. Normally not a procedure I would consider for someone that young, but for a growing boy to be dependent on crutches due to the pain following a mortar attack on his house. He will be almost back to normal in six weeks.

As there was no major drama (I hesitate to say only gunshot wounds and shrapnel injuries), people started to focus on the small things. Then proceed to blow them out of proportion. Describing them as ‘First World’ issues seems apt. Debates over cupboard space, who gets to do what and in what order. When there are a multitude of newly arrived blast injuries, the minor issues are mute.

This is probably a natural progression as people (medical team personnel) struggle with living in a state of constant alertness. The adrenalin is ever present. Similar to developing a tolerance to heroin, the rush in a trauma setting makes the mundane, routine and equally essential non emergent tasks less appealing. Unless one can dramatise the issue.

As can be expected, friendships are forming, people’s idiosyncrasies are noted, tolerated to varying extents and invariably laughed at over dinner or in the ride back to our host houses. The warm (bucket) shower and lights are appreciated when arriving home late at night. The implication is that the host gets up at 10pm to start the generator and fire up the boiler before making tea and entertaining the motley crew while we take turns in the single bathroom.

Walked down the road during the day yesterday during a quiet period and walked past a cafe. The Pepsi and snacks were visible behind the window display of guns and rifles. All made in Turkey and ranged from USD120 to USD150. No background checks.

20130419-152331.jpgCoffee break across the road.

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20130419-152549.jpgMy translator, Walmaa.

Post script: (Lunchtime addition) Will write later about the celebratory gunfight outside the hospital. No injuries, a reasonable amount of adrenalin.

Palm trees in Paradise

This is my view this morning while awaiting the coffee to brew.

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There needs to be a more descriptive word for the process by which the coffee is prepared here because brew does not adequately describe a process that results in a small espresso sized cup filled ith the upper two-thirds of über coffee like extract and one third sludge that would terrify a dredger.

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Yesterday we the first day of all systems go in the team. Two theatres ran concurrently, four teams went to surrounding clinics.

The clinic I was posted to (with a GP) was situated in Alhamaneh (pronounced Hamania). Based in a vet clinic (!) we saw approximately 70 patients. We managed to escape the frenetic activity in the afternoon to go and visit the neighboring town of Jacobina.

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20130417-163349.jpgSyrian army tank.

Bombed churches. Burnt out tanks. Holes in pavements. Appartments with two meter holes in the wall.

The remains of the house of the 14 year old boy that I had seen earlier, macerated foot and on crutches, saw where he had been when when the town was being shelled.

Drove home through the mountains. Incredibly scenic transitioning from olive and fig plantations to riverine terrain.

Philosophical meandering from last night.
People are fixated on fighting and wars. Individuals travel significant distances to work in a war zone to help the victims of a two year war. Local residents enduring hardships, intermittent electricity, limited food supplies and constant bombardment and sniper fire (over the two year war). What do people discuss at night: how one religion is wrong, that its necessary to not be tolerant of other religions before they take over.

20130417-163709.jpgMark Deacon, myself and Abd Apteek (photographer for Al Jezeera)

20130417-164100.jpgmortar shell from the day before.

20130417-164528.jpgSupper from our hosts.

And they continue to fall

Our journey started from the same hotel as yesterday. The route to the border the was a little less traditional. Started in a generic taxi. Deteriorating roads aided the transition to our next mode of transport which was reminiscent of a thirty year old Massey Ferguson tractor. Baggage took up over half of the trailer so the sixteen passengers were relegated to the remainder of the Diesal soaked space with stragglers perched precariously on the baggage. The road seemed to be an oscillating mix of potholes and mud. Passengers an luggage alike were transferred piecemeal to an oversized bathtub for the penultimate leg. The final leg was a high speed race to Darkoush.

The hospital, our own purpose built two story building (converted from a house three months ago) has seen a significant number of patients already. Trauma related to the fighting a few days ago has mostly been treated. Outpatients / Casualty required some focused work to clear the queues.

Tomorrow we start with theatre cases.

There were two brief episodes of shells falling today. The jovial nature and gay abandon which some people approached the security issues of working in a wad zone disappeared incredibly quickly. I think it was by the second loud “thunderclap”. With wanting to appear too harsh the gay abandon was replaced with rite outs indignation. Fortunately those are in the minority.

This precipitated a couple of challenging episodes of accommodation exchanges. The dynamics of balancing socially and culturally acceptable sleeping arrangements with people faced with the prospect of not being able to sleep due to perceived security issues. Enough said.

The tea drinking session with the owner of the house was far more entertaining. Only one person present was bilingual in Arabic and English. Then the freedom fighter and relative of the owner arrived. The conversation naturally progressed to aspects of the war, from underlying philosopies to pictures (on his mobile phone)of guns,
Victims (not sparing any age nor favoring any gender). His perspective is a little different to of us as
he has lost most of his friends.

Photos to follow tomorrow. I need some sleep so my patience with people (read colleagues) is optimal.

-p

Getting closer

20130415-001857.jpgAppropriate graffiti. Johnny, myself, Mark & Hannes posing next to some graffiti on the back streets of Hatay.

Today security issues prevented us from crossing the border and by the time everything was sorted, the fading light was against us. (Short version: walking four kilometers in the dark while crossing No Mans Land seemed to be less than ideal and conjured up images reminiscent of the scenes out of a World War I attrition warfare movie).

Everything seems to be more promising for Monday morning.