Thursday

It's hard to get out of my warm bed. The nights have been actually cool here lately and getting out on the cool cement floor is all the more difficult. I finally make a break for the bathroom and am thankful for one of the few luxuries we have here...hot showers. I dress in scrubs and head to the kitchen on the other side of the duplex for breakfast. Nathan gives me a chunk of eggs well cooked on account of their sketchy appearance on being cracked open. I also fry up some of Salomon's now stale bread dipped in eggs and cinnamon to form a sort of French Toast. The final element is the big bowl of local Arab milk turned into yogurt overnight mixed with fresh limes, bananas and sugar. The breakfast of champions and definitely not a "petit déjeuner"!

I walk over in the early morning haze to our temporary waiting room under the mango tree. Behind me is the skeleton of our clinic with it's roof and ceiling completely removed and all furniture and equipment moved to the main hospital ward. Pierre reads from Psalms, we pray, Samedi gives his report from "Garde" duty and we pray again. It's 8am and the day is about to begin.

I enter my temporary office, the midwife's office, and am bombarded by a foul smell that has been growing. We put out poison for the mice a few nights ago and everyone tells me they've all died in my office. I tell Ferdinand to pull of the two boards covering a pile of wires in the corner as that appears to be their nest. I grab my army shoulder bag that serves as my doctor bag and then am accosted by Koumabas for supplies from the main pharmacy. After giving him the syringes, needles and meds he needs I check in on Ferdinand who has discovered one dried, splayed out mouse high up in the wires and a fresh kill down below along with tons of plastic, papers and a former nurses surgical cap that the mice have used for their nest.

I head out to the wards. I see Anatole's child first whose mom prefers to be hospitalized on the porch instead of inside. They are all spread out on a variety of mats and Arabic rugs. The kid has malaria and still has a very rapid heartbeat but otherwise appears to be doing somewhat better despite vomiting a couple times. I go inside.

The unlighted wards are perpetually dim and filled with shadows. I visit Pediatrics first. One adolescent with cerebral malaria and possibly syphilis is ready to go home. A nomadic Fulabi child with malaria is also ready to be discharged. The little 6 year old with meningitis and resultant right sided paralysis has woken out of his coma today and started to eat a little soup. The young boy with the osteomyelitis of his femur from a long standing thigh abscess gets his Ketamine and dressing change with a diluted blend of Clorox. Little Angeline who has been with us for over 4 months with osteomyelitis of her tibia necessitating removal of part of the bone has finally closed her wound. I have the mom buy a roll of fiberglass casting so I can replace her windowed leg cast that has been supported for months with two sticks.

I move on to the adults. The first patient is a sad case of teenage pregnancy. She labored for 4 days at home before going to the health center where they let her labor one day more before referring her to the hospital. Instead of coming to the hospital she continued to labor 4 more days at home until she delivered a dead baby while shredding her cervix and bladder. When she finally came to the hospital 2 weeks after being referred she had a raging infection with dead tissue hanging out and a 10 cm tear in her bladder. Her infection has now been treated and we've tried two repairs on her bladder with restoration of almost completely normal anatomy. Unfortunately, there is still a little leak (vesicovaginal fistula) meaning she has no control over urination. Our other local doctor has been trained in repair of these types of fistulas and if he's ever around we'll see if he can help her.

The second patient is an adult with malaria ready to go home. Next up is a woman with a huge jaw abscess from neglected dental caries. She's doing better after 3 extractions and antibiotics. I move onto an elderly gentleman with a huge inoperable bladder tumor who we are providing palliative care to. Another woman with Malaria and some strange shoulder pain is fine except for the hypersensitive painful, unswollen shoulder that just won't get better no matter what treatment we try. Following is a man admitted last night with ascites and lower extremity edema. Questioning reveals a heavy drinking past so I assume it's cirrhosis and plan a paracentesis later to draw off a bunch of the fluid in his belly.

I head back to the office, stop to change a dressing on a man who'd passed under my knife for a finger amputation a couple weeks ago. Then I see Angeline and her mom who've paid for the new cast. I pull out the newly donated cast saw, hook up to the lab's small generator and tear through the old fiberglass. Jennie and Nathan then help me rub off the thickened old skin over her leg and wash her down. The leg kind of flops for lack of a completely formed new tibia. I then wrap her leg in cotton and apply the fiberglass cast from thigh to foot. She only cries a few times and then with sniffles gives me our traditional 5 or ten high fives.

Back to my now clean smelling, mice-free office for clinic. It's 10am. Five of my nine patients are HIV positive. Two of the girls are relatives of one of my patients who just died on Monday. All three have AIDS. The one who died was one who had the resources to buy anti-retrovirals and took it for 3 months without any improvement...in fact she steadily got worse. One of the girls I see today, Honorine, on the other hand, started ARVs at the same time and has been healthy since gaining over 14 lbs. It's good to see all of them as they are the patients I see often enough to actually have formed relationships with them. Honorine just finished her last ARV pill and doesn't have money to buy more. She is an orphan and has some property in Kélo left her by her mom. It will be sold the 20th...too late to buy the ARVs as even a day or two of missed treatment can allow the HIV to become resistant. I lend her the money and she takes off immediately for Kélo. It is her life.

I finish clinic at about 1:30pm and head to do the paracentesis on the man with the ascites. I stick a large needle and catheter in the left lower quadrant of his belly and the anticipated straw colored fluid flows out. I send some to the lab and let 4 liters drain off. As the fluid goes down I examine his belly and am surprised to find his liver quite enlarged rather than the shrunken one that one usually finds in cirrhosis. Also, the consistency of his abdominal wall is thickened and doughy. Instantly, another possible diagnosis enters my head...abdominal tuberculosis. If this is the case it is good for him as we can treat that while the end stage of cirrhosis has no cure and is universally fatal in less than a year. I put him on a two week trial of anti-tuberculosis meds just as Dimanche, the Garde, comes up to tell me there are two patients just arrived referred from the hospital in Kélo. Apparently their generator is broken.

I go to see the first at about 2:30pm. A young man who shows the wear and tear of a hard life is lying temporarily on one of the delivery beds. His hair is wild and sticking straight up like Buckwheat's. He has a deep old scar on his left forearm and various smaller scars scattered across his torso. According to the story he was gored by a bull yesterday evening at 5pm. His intestines popped out and he went to the hospital where they covered the intestines with betadine soaked gauze and gave him antibiotics and pain meds. He was then told to come to Béré. I look at his belly. It is soft with good bowel sounds. He has bowel function intact (he farts). I take off the dressing and see a 10cm portion of irritated small bowl already starting to adhere to the skin. I give him Valium and try to reduce it at bedside. He doesn't tolerate. We rush him to the OR where I inject Ketamine, prep and scrub and push the intestines back in. Clear, serosanguinous fluid comes out of the belly. By the angle of the wound it appears that he was gored almost parallel with the abdominal wall and it is unlikely that the intestines have been punctured. I leave a drain inside, close the fascia and leave the skin open with our famous diluted Clorox dressings. Interestingly, I didn't need the generator...

I go to see the next patient. It is 4pm. She is a young girl at 7 months of her first pregnancy. She has been bleeding for a day and has abdominal pain. I check for the fetal heartbeat; it is absent. There is minimal amount of bleeding and she is stable. I order IV fluids and plan surgery for 6:30pm when our generator comes on. I go home. I haven't eaten yet since breakfast.

I eat heartily of Salomon's excellent vegetable sauce over rice and relax of an hour and a half by watching "Step Into Liquid", a great surfing movie, on the computer.

At 6:30pm on the dot the generator comes on and I rush over where Samedi has already brought the patient to the OR and is getting her set up. We put in a urinary catheter, I give her a spinal anesthetic, we prep the abdomen, scrub, drape and then pause for prayer before cutting through the lower abdominal skin straight down to fascia. In less than 5 minutes the baby is out...premature and unfortunately dead. We find she has had a placental abruption where the placenta separates from the uterus before the baby is born. We close quickly and by 7:30pm I am back home and ready for seconds on Salomon's sauce.

After supper, at 8pm the lights go off. I gather with Nathan, Jennie, and Becky out on the porch under another fantastic, pitch black, star filled Tchadian sky. We pray and I feel a peace pour over me that cannot be described. Strangely enough, I am completely content. I go to sleep almost immediately afterwards...

James