Habib asked the first adult he met whether there was anyone in the village with medical skills He realized a hospital was out of the question, but a qualified doctor, or perhaps someone who could deliver babies and deal with routine injuries might be able to help.
He was directed to a large house with a well-kept garden, surrounded by a high wall and wide, solid timber gates. The man who lived there was a doctor.
When they arrived at the house, the doctor’s wife came to the door.
Habib introduced Carla as a friend, and explained that Carla’s sister had become seriously ill with appendicitis, during their trip to visit relatives in Chino Kharote. Carla said nothing, but nodded meekly under her Burqa.
Max remained outside the gates, keeping an eye out for pursuers.
The woman told Habib that the doctor had just left to help at the hospital in Kabul. There had been an armed attack on the police, because of a prison escape. The Taliban were also involved in the fighting, although they were not the original attackers. Many people had been injured or killed, so everyone was on the lookout for the perpetrators.
The doctor was expected to return tomorrow evening.
Habib thanked the woman and left with Carla, to consider their next move. They met Max outside the big gates and were about to discuss their options when Anita cried out in agony, “I think my appendix may have ruptured, you have to get help immediately, please hurry”
There was now no option to discuss. They all climbed into the Cruiser and drove into the doctor’s compound.
The doctor’s wife came out in an agitated state. She had guessed who her visitors were and had just made a telephone call to a Taliban leader, informing him where the fugitives were.
“We need to use your doctor’s surgery at once, my sister believes her appendix has ruptured, and we need to operate immediately,” explained Carla. “Please help us, we don’t intend to harm you in any way.”
Realizing the visitors would not leave until they had operated on their colleague, and that keeping them in the house would assist the Taliban, the woman showed Carla and Max to the small operating room, pointing out where everything for the operation was kept.
“How are we going to do this then, Max? Anita will certainly die if we don’t get on with it.”
“I only have a general knowledge of the procedure” Max replied. “I don’t mind the cutting, tying off and stitching, but I haven’t a clue about the drugs and the anesthetics, or what materials to use.”
Carla replied confidently, “Well, I can remember the details from when I worked in our local hospital. I don’t think the open appendectomy procedure will have changed since then, so I can set things up and guide you.
“I was allowed up in the gallery, when they went through every step to a couple of students, as they worked on a patient in the Operating Theatre.
“The difficulty is in administering the right anesthetic and dealing with complications.”
“Ok then,” said Max. “Habib and I will get Anita onto the table while you set things up. Ether would be the safest anesthetic for us to use; it is easy to apply and there is less risk than with chloroform, but it does make the patient prone to vomiting. I expect the doctor will have some for animals and for minor operations, to keep the cost down.”
Carla set about gathering the surgical instruments, different suture types and saline drips etc. as she ran through the whole process in her mind.
With Anita’s help, Max and Carla eased off her clothes. They were concerned that the pain which had suddenly reduced, was coming back and was now more generalized to her whole abdomen. It was a bit like a lanced boil, once the pus runs free the pain drops, but the pus trapped in the abdominal cavity was now inflaming the abdomen, and peritonitis or blood poisoning was developing rapidly.
Carla explained, “The first thing we must do is set up a drip of saline and second-generation cephalosporin antibiotic.
“Then, we scrub up and we clean around the site of the incision on Anita’s abdomen, using this iodine solution applied by swabs.
“You need to make an incision here” and she drew a line on Anita’s belly with a marker pen.
“Start with a shallow cut, down to the first layer of muscle to find the exact direction the muscle fibers run, retract the skin, and split along them. Only go down to the surface of the lower muscle, because the fibers run in another direction; and we must retract the upper muscle and finally split the lower muscle.
“You will have to be extremely careful how deep you cut, because a fraction too deep and you will perforate the underlying abdominal contents.
“Cut through the peritoneum to expose the abdominal contents and find the appendix. Then lift the appendix and cecal base above the incision, on her belly, to work on it.
“That is the overview.”
Max nodded grimly, he was fully aware that Anita would soon be dead if he did not operate, but the moment he started operating, her life was in his hands. If she died then, he would be her murderer.
“We need to put Anita under now,” said Carla. “I will keep an eye on her blood pressure. I have to make sure it does not drop, because it could indicate a bleed or that she has breathed in too much ether, but on the other hand, too little ether and she will come round in agony from the cutting.
“Sorry Anita, you were not supposed to hear that.”
Anita murmured, weakly, “just get on with it, you seem to know what you’re doing, right now I am dying anyway.”
With everything in place and Anita deeply unconscious, Max set to work under Carla’s watchful eye. The bleeding was alarming at first, but Carla kept the site clear with suction and swabs, so Max could concentrate on the task before him. It was so intense working on an actual living body, where a slip or innocent mistake would certainly lead to the death of this woman they had come to rescue.
Max had opened up the abdominal cavity and could immediately smell that the appendix had ruptured. Pus and fecal matter was oozing from the swollen, mid finger sized, flaccid appendage, though it hadn’t dropped into the abdominal cavity.
“We need to get this appendix clamped off immediately, and then deal with the arterial supply which runs in the mesoappendix, while I suck out the pus and enteric contents and wash out the abdominal cavity with saline,” Carla directed.
She handed Max the clamps and showed him where to place them, and how to separate the base of the appendix from the mesoappendix.
Carla thoroughly cleaned up all the fluid in the abdomen, and was confident there was nothing more she could have done. She checked the number of swabs and instruments before pronouncing it was time to close Anita up.
Carla then explained the final stage. “First we have to close up the peritoneum with absorbable sutures; this holds the abdominal contents in place when we individually close the two layers of muscle, and skin.”
Max was relieved that everything had progressed without a hitch so far including the closing up, and although fiddly, it was quickly done. Finally, they covered the wound with sterile dressings.
Carla was concerned about the pain Anita would experience from the surgery, when she came round. It was not just that the pain would be unpleasant, but it would cause the muscles in the abdomen to tense and make the pain worse, possibly the wound would break open, and many other undesirable effects.
She remember that tramadol added to the drip was a possible solution and that tomorrow morning, when Anita could start drinking, she could take meloxicam, an analgesic and anti-inflammatory tablet.