As most people realize, AIDS is a huge problem in Africa. At first I didn't think it was that big a problem here but as it turns out that's just because people don't want to know, don't get tested, and if they are seropositive everyone hushes it up because to them its a death sentence and the health care workers feel like there's nothing to do either.
I felt the same way at first because all I saw were advanced cases who ended up dying.
Now I've started to identify and work with a group who I've tested because of various risk factors or exam findings (or often when they come with a kid at the end stage then I identify the parent as HIV +) This group is healthy and I've discovered that there are things we can do.
1. We can educate to prevent transmission (fidelity, if there are several wives and some are negatif...condoms, etc)
2. We can treat pregnant mothers to prevent transmission to the newborn (if we have the medicines which we hope to soon...transmission can also be reduced by elective c-section) We are trying to start a program to test pregnant women for HIV (very rarely done here)
3. We can see them at regularly scheduled monthly visits for routine physical exams and lab tests to identify and treat infections early
4. We can identify and treat Tuberculosis or give primary prevention with Isoniazid
5. We can provide emotional and psychological support...especially if they end up abandoned by their families (as unfortunately happens only too often)
And, if we can identify a group that is trustworthy and comes to regularly scheduled visits and is reliable we could hopefully start some of them on Anti-retroviral therapy (anti-HIV meds) if we could find some donors or if the government comes around to decreasing the cost.
We have somehow found a little hope on this dark continent that is at the point of an epidemic. Pray for us and if you can in anyway give us other suggestions or help in any way...
Monday, May 17, 2004
What I wish...
Tout le monde,
Well, here's to disappointment. If you expect this to be inspiring or moving, please just delete and move on. All I can think of now is what I wish was different about the situation I'm in. Basically this is going to be one big "poor me" session. Here's my wish list:
1. One night to not have to sleep in my own sweat (or someone else's), to be cool enough to cover up and snuggle down in my own comfortable bed. While I'm at it how about sleeping inside instead of out on the porch because it's even hotter inside.
2. One day without having to eat rice, beans or lentils. One day where all I eat is fresh stuff (fruit, salad, yogurt, a sandwich,...)
3. One afternoon at the beach. One surf session even if there are no waves. I just want to paddle out and sit on my board and feel that anticipation that no matter how flat it is a great wave with my name on it is about to roll in. If it could be cold where I had to where my wetsuit and my fingers were so cold afterwards I couldn't hardly get out of the wetsuit or zip up my pants...that'd be sweet...
4. One meal without flies...
5. Grass...one day without staring at, walking on, and breathing dust.
6. Air conditioning
7. Flushing toilets all the time
8. Electricity just one full day when I could plug in my computer when I needed to use it or turn on the fan or listen to music besides 6:30pm to 10pm.
9. Water I could drink from the tap. One shower when I could just throw my head back and drink up some cold fresh water straight, unfiltered, un-partially-refrigerated-with-old-cabbage-smell-on-the-bottle
10. One day of speaking only English with everyone I met...no French, no Arabic and definitely no Nangjere.
11. One day when I could actually have at my disposal all I needed to make the diagnosis.
12. One ICU stay for one patient so one patient who should live...could.
13. One consult with a specialist, any specialist I wanted.
14. One day when I could give the patients all they needed without worrying about whether they'd paid for it or not.
15. One day when I could trust that what I'd ordered would actually be done by the nurses as I ordered it.
16. One of mom's home cooked meals.
17. A game of hoops...with a few weeks ahead of time to get back in shape for it.
18. One day without seeing armed soldiers.
19. One day without being stared at.
20. One hour of privacy without kids standing outside my windows staring in.
21. One trip to town in anonymity without hearing one single "NASARAH"...
22. A vehicle I could take anywhere I wanted, anytime I wanted.
23. One church service with music that moved me.
24. One email session without bugs on the screen.
25. One less trip to N'Djaména for administrative business.
26. One hospital administrator so I didn't have to be it.
27. One guy friend I could just hang out with, shoot hoops with, laugh with, etc...Sarah's great but she is just a GIRL after all.
(I guess that's a good place to stop...27...where have I heard that number before?)
Paix et tranquilité á tous...et que tous vos reves soivent realisés...
Well, here's to disappointment. If you expect this to be inspiring or moving, please just delete and move on. All I can think of now is what I wish was different about the situation I'm in. Basically this is going to be one big "poor me" session. Here's my wish list:
1. One night to not have to sleep in my own sweat (or someone else's), to be cool enough to cover up and snuggle down in my own comfortable bed. While I'm at it how about sleeping inside instead of out on the porch because it's even hotter inside.
2. One day without having to eat rice, beans or lentils. One day where all I eat is fresh stuff (fruit, salad, yogurt, a sandwich,...)
3. One afternoon at the beach. One surf session even if there are no waves. I just want to paddle out and sit on my board and feel that anticipation that no matter how flat it is a great wave with my name on it is about to roll in. If it could be cold where I had to where my wetsuit and my fingers were so cold afterwards I couldn't hardly get out of the wetsuit or zip up my pants...that'd be sweet...
4. One meal without flies...
5. Grass...one day without staring at, walking on, and breathing dust.
6. Air conditioning
7. Flushing toilets all the time
8. Electricity just one full day when I could plug in my computer when I needed to use it or turn on the fan or listen to music besides 6:30pm to 10pm.
9. Water I could drink from the tap. One shower when I could just throw my head back and drink up some cold fresh water straight, unfiltered, un-partially-refrigerated-with-old-cabbage-smell-on-the-bottle
10. One day of speaking only English with everyone I met...no French, no Arabic and definitely no Nangjere.
11. One day when I could actually have at my disposal all I needed to make the diagnosis.
12. One ICU stay for one patient so one patient who should live...could.
13. One consult with a specialist, any specialist I wanted.
14. One day when I could give the patients all they needed without worrying about whether they'd paid for it or not.
15. One day when I could trust that what I'd ordered would actually be done by the nurses as I ordered it.
16. One of mom's home cooked meals.
17. A game of hoops...with a few weeks ahead of time to get back in shape for it.
18. One day without seeing armed soldiers.
19. One day without being stared at.
20. One hour of privacy without kids standing outside my windows staring in.
21. One trip to town in anonymity without hearing one single "NASARAH"...
22. A vehicle I could take anywhere I wanted, anytime I wanted.
23. One church service with music that moved me.
24. One email session without bugs on the screen.
25. One less trip to N'Djaména for administrative business.
26. One hospital administrator so I didn't have to be it.
27. One guy friend I could just hang out with, shoot hoops with, laugh with, etc...Sarah's great but she is just a GIRL after all.
(I guess that's a good place to stop...27...where have I heard that number before?)
Paix et tranquilité á tous...et que tous vos reves soivent realisés...
Sunday, May 9, 2004
La guerre...et la paix
War and Peace could've been written here in Tchad...except not much about peace. It's just routine to here in the morning report of the activities of the "Gard" that a woman came in who'd been beaten by her husband, or her brother or uncle, or her husband's other wife, or her sister, etc. As I mentioned before, about a month ago, tribal warfare broke out in N'Djaména near where the Busl brothers were staying as a whole quarter was shut down by armed police shooting tear gas and bullets while inside the warring members bludgeoned each other with clubs, machetes, bush knifes, tools, bicycles and anything else they could get there hands on and swing at someone. That same week a man was walking near the Busl's house and was jumped on by thugs from a tree who knifed him and left him for dead. The next morning he was still alive surrounded by curious onlookers who when asked why they didn't help him shrugged and said, "we don't know him." Another was stoned to death on a close side street. You remember well the knife fight that happened inside our own hospital right outside the door where I was trying to take care of an infant with Tetanus and another with seizures from severe Malaria.
So, where's the peace? Not yet. This last Thursday I was suddenly called from rounds by shouting. Our chauffeur, Bichara, had just driven up outside the halfway built hospital wall. He'd been out with the district vaccination program at the same time as some of the agricultural community decided to retaliate for what they felt was an unfair decision in a land dispute with the arab nomad cattle traders. A bunch went to the nearby Gendarmerie and when the Gendarmes pulled out their guns one tried to wrest the rifle away only to be shot in the stomach. Then the other Policemen went crazy leaving at least two dead and multiple wounded. All this happened right in front of Bichara who then helped load five wounded into the back of our pickup and bring them to the Bere Adventist Hospital. By the time I arrived a huge crowd had gathered as usual to gawk. Dr. Eric Davy and Dr. Cathy Castillo are visiting from Ventura where I trained so it was just like being in residency...except we were unloading dirty Tchadians with blood soaked clothing from the back of a beat up truck instead of a well equipped ambulance with paramedics who'd already started IVs and applied dressings. No, this was raw carnage, the casulties of war straight from the battlefield.
I quickly questioned the wounded--who were all conscious--where they were injured (at first I thought they'd all been stabbed as knifings are more common here) and three had been hit in the legs, one in the belly and the last in the arm. Blood smeared the bed of the truck as I commandeered several staff to bring stretchers and take away the one shot in the stomach first. All seemed pretty stable on first look and listen to heart and lungs before being carried away. We actually had gloves which was a bonus.
We took Belly Boy to the OR while I grabbed IV catheters, tubing and IV fluids from the Pharmacy. Eric had just taken one shot in the leg to the Salle de Gard (ER). He was bleeding pretty profusely and looked like the bullet had gone through the femur shattering it. Anatole was with him and they were in good form so I moved on. In the Minor Procedure room we had two others who'd been shot in the leg. On the procedure table was a man who'd been shot through the front of the thigh bursting out the back of his knee with some fat and a shredded nerve or tendon hanging out. He couldn't move his foot and was writhing in pain as Cathy washed out the wound. Dr. Claver was there assessing the other who'd been shot in the hamstrings but seemed to not have hurt anything serious.
I went into the OR. Belly Boy had a soft belly, a fast heart rate, a normal blood pressure and a bullet hole entering his right lower quadrant of his abdomen exiting his right posterior flank. I started an IV quickly and started fluids pouring in, shot him up with antiobiotics and Valium, arranged the instruments, scrubbed and about 25 minutes after his arrival I opened his abdomen. I sliced from sternum, around belly button and down close to his pelvis. The small intestine came pouring out but there was no blood or fecal material. I fished around his lower belly identifying a hematoma where the bullet had passed by without entering his abdomen. Then I checked carefully the colon, appendix, liver, spleen and finally ran the small intestine from end to start without finding any injuries. I then sewed the fascia and skin closed and unscrubbed.
While he woke up I went to check on the others. The two in the minor procedure room had IVs running, antibiotics in and dressings in place. They were sweating like crazy in the stuffy tin roofed chamber so I had them moved to hospital beds and went to see the one in the ER. Eric had placed a sandbag on his leg to stop the bleeding but the table was still covered. We lifted off the sandbag, removed the dressing, packed it with gauze in the small anterior hole where the blood was pouring out of and placed a pressure dressing with the sandbag again. We snagged a bed from the medicine ward, rolled it outside under the porch and moved the patient there while a crowd of about thirty gathered around to see what the three "Nasara" docs would do. Since we don't have any equipment for traction or orthopedic surgery (nor an xray for that matter) we placed a plaster cast around his lower leg, tied a rope around it, looped it over the end of the bed and lashed the sandbag to it. The leg was out to length and didn't look rotated so we left it assuming it was reduced. The pressure dressings had managed to stop the bleeding.
I'm starting to wonder why I said it was ok for Cathy and Eric to come. It had been so calm here with just some nice easy malaria cases, a couple of hernias, etc. The first night they arrived was right when I'd decided to take a young man to surgery who had severe pelvic pain with peritoneal signs and vomiting I thought was either vomiting or appendicitis. Unfortunately, Eric scrubbed with me and it transformed from and easy appendectomy to a Sigmoid Volvulus (when the last part of the colon twists around itself causing obstruction and compressing the blood supply sometimes causing gangrene) requiring a partial bowel resection and reanastamosis. Even more unfortunately, due to lack of appropriate post-op care he died two days later. We have no ICU, not enough nurses, and not a good system to make sure the patients family get the treatments prescribed so the nurses can give them. For example, IV fluids and antibiotics where not bought and therefore not given for the first 24 hours. Afterwards, I donated a few and even bought some antibiotics for him but it was too late and he died of sepsis and dehydration. It can be very frustrating and discouraging when it's something so "simple" over there but so "complicated" here.
But seriously having colleagues here has been great. Docs I can trust, consult and conspire with and discuss things with. Not to mention Cathy's a chef and Eric is my surfing buddy who taught me how to catch waves two years ago when we were working together at the Ventura County Medical Center. He even brought a surfing video! It's good to be inspired even though I'm in a country without a coast about as far as one can get from the ocean. Eric also shares my passionate hatred of the rooster who wakes us up every morning way too early. He actually pegged it yesterday with a well aimed shoe thrown from where he was sleeping on the porch.
I've been learning some Danish as Sarah and her mom talk constantly in that little known tongue. For example, Gootmorn means good morning. Tak means thank you. "Coon Girl" means could do (and has become Sarah's new nickname)!
So, Sarah and I headed out to the river yesterday. Me on the pedals, her relaxing easily on back. I'm so out of shape and the bike's tires are flat. Needless to say I was struggling. The over 100 degree weather didn't help. Sweat was pouring off. My thighs were burning...and my butt...let's just say that a bike seat here is really a torture device. Lona's oldest son and one of Pastor DeGaulle's sons caught up to us and passed us easily...you can tell I was working hard and getting no where.
We finally arrived. It was so good to plunge into that muddy, warm water. I gave a bried introductory swimming lesson to DeGualle's son and went off to play in the current. As I rested under the shade of the opposite bank, my feet and legs in the water still, Lona's son called and asked where Sarah was. I didn't see her. I got a little nervous when Lona's son yelled back that he thought she'd headed downstream. He and I took off. The stream got shallow quick and we crossed and climbed the footpath to the side. Up ahead the stream wound around a corner with grassy banks sticking into the meandering stream in between volcanic rock and scrub trees leading to the African plain. No sight of Sarah. We rounded another corner and there she was. She was striding nonchalantly in the ankle deep but wide stream with here long curly red hair flowing and her bright white skin reflecting the sun off her baby blue bikini. All along the banks were scores of very dark, curious children. Ahead was a ford where groups of Arabs gathered in long robes and turbans while similarly attired boys herded cattle across. Sarah seemed to be oblivious to the stir she was creating.
I ran up to her and joined her as we passed the groups of Arabs (who I'm sure approved of her "modest" clothing). We continued around the bend as she asked some of the kids if there was deep water and they said it was just ahead. We had to detour to the bank as a boy running along above the stream warned us of fishing line marked with white plastic waving in the breeze off of sticks stuck in the sand. He also said there were hippos ahead so we decided to stop. I faced downstream on my back and she faced upstream on her tummy. We just sat and talked as I stared at her thinking how improbable all this was to be in the middle of a stream in Africa with a beautiful redhead surrounded by Arabs. I turned around on my belly and but my arm around her. She had goosebumps (from the cold not from me...) and we sat and talked for about half an hour watching huge cargo trucks gun it across the ford followed by pickups packed with turbaned arabs splashed, sprayed, spun and twisted across. The cattle were sometimes obstinate running from the water just right before entering sending the arab boys running and shouting and waving their sticks. Finally, as the sun started to go down we had to go back...uneventfully (except for my almost dying trying to pedal the 7 kilometers while being completely out of shape).
War and Peace...
So, where's the peace? Not yet. This last Thursday I was suddenly called from rounds by shouting. Our chauffeur, Bichara, had just driven up outside the halfway built hospital wall. He'd been out with the district vaccination program at the same time as some of the agricultural community decided to retaliate for what they felt was an unfair decision in a land dispute with the arab nomad cattle traders. A bunch went to the nearby Gendarmerie and when the Gendarmes pulled out their guns one tried to wrest the rifle away only to be shot in the stomach. Then the other Policemen went crazy leaving at least two dead and multiple wounded. All this happened right in front of Bichara who then helped load five wounded into the back of our pickup and bring them to the Bere Adventist Hospital. By the time I arrived a huge crowd had gathered as usual to gawk. Dr. Eric Davy and Dr. Cathy Castillo are visiting from Ventura where I trained so it was just like being in residency...except we were unloading dirty Tchadians with blood soaked clothing from the back of a beat up truck instead of a well equipped ambulance with paramedics who'd already started IVs and applied dressings. No, this was raw carnage, the casulties of war straight from the battlefield.
I quickly questioned the wounded--who were all conscious--where they were injured (at first I thought they'd all been stabbed as knifings are more common here) and three had been hit in the legs, one in the belly and the last in the arm. Blood smeared the bed of the truck as I commandeered several staff to bring stretchers and take away the one shot in the stomach first. All seemed pretty stable on first look and listen to heart and lungs before being carried away. We actually had gloves which was a bonus.
We took Belly Boy to the OR while I grabbed IV catheters, tubing and IV fluids from the Pharmacy. Eric had just taken one shot in the leg to the Salle de Gard (ER). He was bleeding pretty profusely and looked like the bullet had gone through the femur shattering it. Anatole was with him and they were in good form so I moved on. In the Minor Procedure room we had two others who'd been shot in the leg. On the procedure table was a man who'd been shot through the front of the thigh bursting out the back of his knee with some fat and a shredded nerve or tendon hanging out. He couldn't move his foot and was writhing in pain as Cathy washed out the wound. Dr. Claver was there assessing the other who'd been shot in the hamstrings but seemed to not have hurt anything serious.
I went into the OR. Belly Boy had a soft belly, a fast heart rate, a normal blood pressure and a bullet hole entering his right lower quadrant of his abdomen exiting his right posterior flank. I started an IV quickly and started fluids pouring in, shot him up with antiobiotics and Valium, arranged the instruments, scrubbed and about 25 minutes after his arrival I opened his abdomen. I sliced from sternum, around belly button and down close to his pelvis. The small intestine came pouring out but there was no blood or fecal material. I fished around his lower belly identifying a hematoma where the bullet had passed by without entering his abdomen. Then I checked carefully the colon, appendix, liver, spleen and finally ran the small intestine from end to start without finding any injuries. I then sewed the fascia and skin closed and unscrubbed.
While he woke up I went to check on the others. The two in the minor procedure room had IVs running, antibiotics in and dressings in place. They were sweating like crazy in the stuffy tin roofed chamber so I had them moved to hospital beds and went to see the one in the ER. Eric had placed a sandbag on his leg to stop the bleeding but the table was still covered. We lifted off the sandbag, removed the dressing, packed it with gauze in the small anterior hole where the blood was pouring out of and placed a pressure dressing with the sandbag again. We snagged a bed from the medicine ward, rolled it outside under the porch and moved the patient there while a crowd of about thirty gathered around to see what the three "Nasara" docs would do. Since we don't have any equipment for traction or orthopedic surgery (nor an xray for that matter) we placed a plaster cast around his lower leg, tied a rope around it, looped it over the end of the bed and lashed the sandbag to it. The leg was out to length and didn't look rotated so we left it assuming it was reduced. The pressure dressings had managed to stop the bleeding.
I'm starting to wonder why I said it was ok for Cathy and Eric to come. It had been so calm here with just some nice easy malaria cases, a couple of hernias, etc. The first night they arrived was right when I'd decided to take a young man to surgery who had severe pelvic pain with peritoneal signs and vomiting I thought was either vomiting or appendicitis. Unfortunately, Eric scrubbed with me and it transformed from and easy appendectomy to a Sigmoid Volvulus (when the last part of the colon twists around itself causing obstruction and compressing the blood supply sometimes causing gangrene) requiring a partial bowel resection and reanastamosis. Even more unfortunately, due to lack of appropriate post-op care he died two days later. We have no ICU, not enough nurses, and not a good system to make sure the patients family get the treatments prescribed so the nurses can give them. For example, IV fluids and antibiotics where not bought and therefore not given for the first 24 hours. Afterwards, I donated a few and even bought some antibiotics for him but it was too late and he died of sepsis and dehydration. It can be very frustrating and discouraging when it's something so "simple" over there but so "complicated" here.
But seriously having colleagues here has been great. Docs I can trust, consult and conspire with and discuss things with. Not to mention Cathy's a chef and Eric is my surfing buddy who taught me how to catch waves two years ago when we were working together at the Ventura County Medical Center. He even brought a surfing video! It's good to be inspired even though I'm in a country without a coast about as far as one can get from the ocean. Eric also shares my passionate hatred of the rooster who wakes us up every morning way too early. He actually pegged it yesterday with a well aimed shoe thrown from where he was sleeping on the porch.
I've been learning some Danish as Sarah and her mom talk constantly in that little known tongue. For example, Gootmorn means good morning. Tak means thank you. "Coon Girl" means could do (and has become Sarah's new nickname)!
So, Sarah and I headed out to the river yesterday. Me on the pedals, her relaxing easily on back. I'm so out of shape and the bike's tires are flat. Needless to say I was struggling. The over 100 degree weather didn't help. Sweat was pouring off. My thighs were burning...and my butt...let's just say that a bike seat here is really a torture device. Lona's oldest son and one of Pastor DeGaulle's sons caught up to us and passed us easily...you can tell I was working hard and getting no where.
We finally arrived. It was so good to plunge into that muddy, warm water. I gave a bried introductory swimming lesson to DeGualle's son and went off to play in the current. As I rested under the shade of the opposite bank, my feet and legs in the water still, Lona's son called and asked where Sarah was. I didn't see her. I got a little nervous when Lona's son yelled back that he thought she'd headed downstream. He and I took off. The stream got shallow quick and we crossed and climbed the footpath to the side. Up ahead the stream wound around a corner with grassy banks sticking into the meandering stream in between volcanic rock and scrub trees leading to the African plain. No sight of Sarah. We rounded another corner and there she was. She was striding nonchalantly in the ankle deep but wide stream with here long curly red hair flowing and her bright white skin reflecting the sun off her baby blue bikini. All along the banks were scores of very dark, curious children. Ahead was a ford where groups of Arabs gathered in long robes and turbans while similarly attired boys herded cattle across. Sarah seemed to be oblivious to the stir she was creating.
I ran up to her and joined her as we passed the groups of Arabs (who I'm sure approved of her "modest" clothing). We continued around the bend as she asked some of the kids if there was deep water and they said it was just ahead. We had to detour to the bank as a boy running along above the stream warned us of fishing line marked with white plastic waving in the breeze off of sticks stuck in the sand. He also said there were hippos ahead so we decided to stop. I faced downstream on my back and she faced upstream on her tummy. We just sat and talked as I stared at her thinking how improbable all this was to be in the middle of a stream in Africa with a beautiful redhead surrounded by Arabs. I turned around on my belly and but my arm around her. She had goosebumps (from the cold not from me...) and we sat and talked for about half an hour watching huge cargo trucks gun it across the ford followed by pickups packed with turbaned arabs splashed, sprayed, spun and twisted across. The cattle were sometimes obstinate running from the water just right before entering sending the arab boys running and shouting and waving their sticks. Finally, as the sun started to go down we had to go back...uneventfully (except for my almost dying trying to pedal the 7 kilometers while being completely out of shape).
War and Peace...
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