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...
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