GIDEL, Sudan — The outdoor church service deep in the all-but-inaccessible heart of Sudan’s Nuba Mountains begins early, before the sun’s heat becomes too difficult to bear.
The congregation sings as they wait. Then the priest arrives, swinging incense as he walks down the sandy aisle beneath a canopy of interweaving neem trees.
Among the worshippers is Tom Catena, a 49-year old New York-born missionary doctor, who bends his shaved head in prayer.
"Dr. Tom," as everyone in the area calls him, is the only surgeon at the only hospital in a region the size of Philadelphia, and where a seemingly endless civil war touched-off again two years ago.
On any given day, there are hundreds of patients — many of them war wounded — in the busy hospital wards, or on the beds that spill into corridors and the tarpaulin-covered verandahs.
Catena came here as an aid worker in 2008 to treat things like malaria and malnutrition. But since the war kicked off in 2011, there has been scant letup in the injuries from ongoing government airstrikes, against both rebels and civilians alike.
“All of a sudden we went from doing elective surgery to trauma,” Catena said of the night the violence resumed in 2011.
“We converted into a MASH unit overnight,” he said, using the acronym for a mobile army surgical hospital, which serves as a fully functional hospital in a combat zone.
Back then, almost every foreign aid worker fled. But for Catena, that was never an option.
He learned to amputate limbs, clean out dirt-filled wounds, cut away dead flesh and set shattered bones.
“It was like a scene from hell, there was blood all over the place,” he said. “It was a horror show.”
According to a special ledger of war wounded kept by the hospital, the last two years have seen over a thousand wounded brought in, the youngest a nine-month-old girl, the oldest a 75-year-old man.
The ongoing air raids are producing particularly gruesome injuries, Catena said.
“Antonov bombs are huge, and when they hit the ground they explode and the shrapnel — big chunks of metal — fly out and tear through whatever they come in contact with,” he said. "They tear apart limbs, rip through the abdomen, take somebody’s head off, take off an arm.”
Catena has worked in Africa for over a decade. But despite the years abroad, his accent and vernacular remain unmistakably New York, his delivery rapid-fire.
He grew up in Amsterdam, New York, one of six children born to Catholic parents.
While studying mechanical engineering at Brown University in Rhode Island, he fell in with an evangelical group and decided then to become a missionary.
Catena’s expressions of faith are light and infrequent, but his religious beliefs, he says, lie at the core of everything he does.
In Gidel, Catena’s life has shrunk to the size of the hospital compound and the nearby Catholic mission. Each morning shortly after dawn Catena, in his green surgical scrubs, walks across a seasonal riverbed to a little church. He says the rosary as he goes and attends mass before beginning work at the hospital.
More from GlobalPost: South Kordofan: Sudan’s latest humanitarian disaster
Ward rounds, outpatient consultations and surgeries leave barely time for lunch. He finishes as the sun sets, and goes to bed in a cement-floored single room next to the hospital. The following days repeat themselves.
“I got so used to this being normal here but I miss family, friends, companionship, someone I can talk to who understands what the heck I’m saying, who I can talk to about American football, about life in my hometown 20 years ago,” he said.
Occasionally he is able to visit his family in New York — he has had only three breaks in the last five years — but suffers the inevitable culture shock of return to a place so different.
In the US earlier this year, he found himself standing in front of the drink display at a sandwich shop, paralyzed by the choices available.
After a few weeks, he was back treating the sick and wounded in Gidel, a place of oppressive heat without electricity, roads or running water.
“We had amputations, guys who were shot in the abdomen, guys with unsalvageable wounds,” he said of some of the more heady days of the conflict.
“Another one was shot in the ankle, blown to bits, hanging off by a little thing — and he’s walking around,” he said. “Your confidence level goes way up when you start working with these cases: you know what you can and can’t do.”