Death

It's early in the morning. I can't sleep even though it was a late night. I keep thinking back to yesterday. What could I have done differently? Why did it turn out the way it did?...

It started off innocently enough: a breakfast of potatoes and eggs hurriedly eaten so I could run off the make worship at 7:30. Andre read from the Psalms and we discussed being able to tell God everything we're thinking...even if it's nasty stuff like wanting bad things to happen to people and being extremely frustrated and confused. I guess that's what I've been doing since last night...

The report of the overnight guard nurse was uneventful. One kid admitted with Malaria. No problems with the hospitalized patients.

We pray and head off to work. Pediatrics is always first on the list for rounds. Now, instead of being depressing walking into a small dark room with dirty walls and floors littered with mats, wire charcoal cooking baskets, pots and pans and variously brightly colored cloths covering patients lying on mattressless metal beds with metal mesh as a base, now we walk into a brightly painted ample ward with fish, hippos, huts and horses painted on the walls along with colorful sketches done by some of the kids.

The first one is a 9 month old with Malaria. Doing fine, starting to breastfeed again, heart not beating too fast. The next is similar but anemic. Already transfused once, she's doing better but still has a really fast heartbeat and is somewhat pale. I'd ordered a repeat Hemoglobin on her yesterday which the parents still haven't done. Then there's the kid with an infection in the bone of his leg that had lasted four months. We'd unroofed the infected bone, left drains in and casted the leg to support the weakened bone. He seems to be doing better...at least his appetite has increased and there's hardly any liquid in the drains and it doesn't smell like it did at first. The next one is a 4 year old with Malaria and four different parasites in his intestines. He's fine and we send him home. We also send home a 6 year old with severe scoliosis who'd broke his ribs playing soccer...I guess he doesn't know he's supposed to be handicapped. The final patient is a little girl with burns on her abdomen and both thighs who had been treated at home for two weeks with a traditional goat hair paste and then came to us mostly healed but with a few infected places that now are almost completely closed after dressing changes and antibiotics. She's also our resident artist and has the cutest shy smile ever. She helps us as usual by carefully taking off her bandages to let us see the wounds.

Then, off to see the adults with their variety of post-partum, Malaria, diabetic foot post amputation of toes, and Koko, who will soon be the reason I am up typing this email.

Koko has been sick for 2 months. He came to us when I was in Denmark about to get married and was treated for Malaria. At the time he'd already been losing weight for one month. He then when to Kélo and was treated for Malaria once, then hospitalized later and treated for Malaria and Amoebas. Then, he came back on Thursday of last week and was treated for Malaria again and then Typhoid Fever. I just saw him for the first time Sunday. Yesterday was Monday. He's thin and somewhat wasted. It's his stomach that bothers him. Yesterday he was eating a little but his stomach was swollen and very tender. He had bowel function. Overnight his bowel function stopped and he started vomiting a lot. He looks bad. His stomach is bloated and doughy and filled with air but soft and tender all over but not extremely so. I suspect perforation from Typhoid or Tuberculosis or HIV with something else even weirder...I'd thought about operating on him yesterday and I think the same today...I'm uncomfortable with it though, he might die during surgery in his weakened state...but will it give him his only chance?

So I just order a CT Scan and get an Infectious Disease and Surgery consult (oh wait, I must've drifted off to sleep there and been dreaming...)...Instead I ask everyone to leave and ask him if he's ever tested positive for HIV. He says he's never been tested. We don't have any tests right (except for emergency blood transfusions) now but he says he does want to be tested if they become available. After getting the CT, ultrasound, and extensive lab test results back I...(wake up, James...) I decide he has something that needs to be operated on and even if he doesn't survive the surgery I'm pretty sure he won't survive if I don't operate. I don't feel comfortable with the decision but then decisions here are rarely simple as we don't have much to work with except clinical signs and a gut instinct...

I move on to consultations where I see a plethora ranging from constipation to hypertension to loss of appetite to testicular mass to miscarriages with products of conception needing to be pulled out to lipomas to hemerroids to Malaria to infertility to too much fertility (two women come in wanting tubal ligations: one has 8 kids, the other 9). I also spend some time supervising the nurse doing consultations and teaching the nursing student. My desk is piled with books that I have to consult frequently.

Andre passes me and says, "Make sure that guy you want to operate on doesn't die during surgery." Thanks, André, I'll be sure to remember that. Why would he say that anyway?

I finally make it home at 3pm for a lunch of fresh millet cinnamon bread and rice with one of Salomon's famous sauces. Sarah, Nathan and I play a few rounds of Rummy to while away the time. We're supposed to have a Managing Committed meeting but no one shows up.

At 6pm we bring Koko to the operating room, prep him, give him Ketamine, open his skin and find a seriously thickened peritoneum and a balled up mass of small intestine stuck together and to the abdominal wall. A thick greenish fluid comes out. Everything is covered with white dots. Tuberculosis. I free up some of the adhesions, irrigate well, leave in two drains and close up. He's doing fine. We wait for him to wake up. Pulse is fine. Blood pressure is fine. Oxygen saturation is fine. We have no cardiac monitor. He doesn't want to wake up. His kidneys have stopped putting urine into his catheter bag. His heart rate slows. His O2 sat drops. We have nothing really. We start bagging him and doing CPR. His O2 sat comes back. We give him the couple of medicines we have: Atropine and Bicarbonate. No pulse. Nothing. We do CPR for 20 minutes. He's dead. André's a prophet.

We pull out his drains, IVs and catheter. I call in the Guard Nurse who gets the head of the family. About 50 people are waiting just outside. They go to get a car to take the body. Nathan, Sarah and I wait with the body. Nathan offers me some Oreos. I accept. I'm drained and sickened. They finally come. As soon as they pull up the wailing and howling starts. Women flailing their arms and crying "Whoooo Whoooo whooo" and "Baaahooooh, baaaahhhhooooo"! I'm suddenly scared. I slink off in the moonless night to the small side gate as the truck piles high with many live bodies and one dead one. I watch from a distance in the dark. It's creepy. There are drum beats and slowly distancing primal howls and wails. I go back and eat some sauce and rice...I talk to Andre...apparently everyone but me knew Koko was HIV positive...I sleep fitfully...

James

I'm back!

I'm back. I've been nervous. What can I expect? I've been in the cold, north, developed world for one month now. What will it be like in the hot, dry, desert of poor Tchad? Will it be hard to readapt?

I descend from the Air France plane onto the runway in N'Djam�na. I'm excited. The air is cool and dry with that distinctive Tchadian odor (not a bad one) that first caused me to feel that Tchad was where I was supposed to go so long ago when I first came here in November of 2002. I'm thrilled to hear Tchadian Arabic again as I wait for my passport to be signed and easily grab my luggage. Of course, this time I'm not alone as I've come back to Tchad no longer a batchelor.

I don't know if there really is a change or just my own perspective has changed, but it seems N'Djam�na is less dirty and there is more of a hopeful atmosphere in the air. There are more foreigners on the streets now. Things seem more available in general. On the way down to Bere all the police checkpoints have disappeared. The road to B�r� has started to be graded to make up for the damage caused by the transport trucks during the rainy season. The hippos are still there. The barge across the Tandjilé River has become a bridge again as the water level has dropped. The sign saying "Bienvenue � Bere" hasn't changed. There's the white water tower and before you know it we are back.

I find that everything is familiar. I have truly come home. Good, bad, ugly, warts, quirks, frustrations, joys, beauty, simplicity, filth, all the contradictions that Bere is, it is still home now.

The peace lasts only a short time. At first, everyone is just thrilled and excited to have Sarah and me back. There are congratulations all around on the wedding. Life is good. But, then slowly but surely everyone starts to realize they don't have to be responsible any more, the Doctor/Administrator is back. I swore that this time I wouldn't let them stress me out. However, little by little people subtly place their problems, grievances and other things before me...I wouldn't mind if it wasn't a constant barrage of things that people could handle and have been handling fine in my absence. The place didn't fall apart when I was gone, it functioned fine and there were even a lot of improvements. The fence around the housing has been started, the rehab of the clinic building continues to advance (the roof is on and most of the ceiling redone), the TB ward has been repainted, latrines were built. So why now does everyone seem helpless and overjoyed at the prospect of dumping any and every little problem in my lap?

Andre, who I've been counting on and has come through in my absence as acting administrator suddenly can't do anything without coming and asking my permission first. His report for our AHI committee was poorly prepared and confusing and just downright wrong and unreflective of the actual financial situation. The lab guys come to me yesterday to say they've started having to wash and reuse the slides since they are out...of course, they didn't bother to mention they were getting low. The government has been out of HIV tests for two months now as apparently they are selling them on the side to make a profit leaving us helpless in the face of the epidemic.

And of course, there are the medical challenges. A boy comes in with a swollen face, legs and belly from losing protein from his kidneys (nephrotic syndrome) caused by Malaria. We treat the Malaria and start him on something that might help his kidneys. Two days ago I come to see him for the first time since I was in N'Djam�na for AHI board meetings and as he goes to pull off his shirt so I can listen to his heart and lungs he starts having problems. At first we laugh because he has intertwined his two shirts so his arms are trapped. Then, we realize he's having problems because he's having a generalized siezure.

He's finished treatment for Malaria and hasn't had a fever so it's probably not that or another infection. It could be sodium or calcium or other metabolic disturbances but are lab can't perform any of the tests that would be reflex in the states. Of course, we have not CAT Scan or MRI. So I just give him some valium, assume it's low sodium because one of the nurses gave him a diuretic while I was gone as I notice. I give him an oral sodium rich mixture to be given when he wakes up and pray. It's a helpless feeling. I don't know if I'll see him the next morning.

The next patient in our newly painted peds ward is a 12 year old with a wound on his leg for four years. The x-ray shows massive deformation of the femur from infection in the bone...it's into the knee. Chances of saving the leg are poor.

Then Rahama mentions that the boy who I thought we'd miraculously saved last year is draining from a similar wound in his leg. He'd fallen from a mango tree shattering his jaw and giving him an open femur fracture. We'd wired his jaw, cleaned out and immobilized his femur. His jaw had healed normally and it appeared the leg had too. Now apparently the openness of the fracture had let in an infection that has now manifested itself. Very discouraging...we'd wanted to send them to a higher center but they'd refused just as they refuse to come in now...

Then, there's the girl who'd been burned two weeks ago and just came in covered with a goat hair paste. Fortunately, surprisingly that paste works pretty well and most of the burns had healed. Only a small section behind and in front of her left thigh is infected and needs more "standard" wound care. She's doing well.

Another difficult case: a girl who had a longstanding Parotid gland abscess that now has developed into a fistula leaking digestive juices. They won't go anywhere else. What do I do?

Not to mention the three women who came in Saturday. One with the placenta covering the opening of her uterus so the baby can't come out. Of course, the baby's already dead and her hemoglobin is 4 (normally over 12). We operate...she does well but another dead baby is always discouraging. Of course, I come out of surgery just to find another woman with the umbilical cord hanging out and the baby also already dead...she delivers the corpse a few hours later. Only one woman, a tiny 14 or 15 year old Arab nomad, delivers a live baby. We have to cut an episiotomy and bring the baby into the world with a vacuum attached to its head to suck it out. The baby comes out screaming and is completely alive in every way as if to spite the death that has been so ominously hanging around.

We have the staff over to see pictures of the wedding. There's a picture of me swinging off a playground rope in Madrid. I jokingly say that this is a picture of a monkey we saw. Koumabas says "Ah bon?" (really?) The funny thing is, he's serious. Everyone laughs and explains it's really me. Later on, there are pictures of Sarah and me in the Paris Airport stuffing grapes in our cheeks and lips just to be silly. I say again that this is a monkey we found in the airport. Amazingly, Koumabas again says seriously "Ah bon?" Everyone is incredulous. "Koumabas, it's the doctor!" "Ah bon?" says Koumabas...it's hard not to survive when you have moments like that...

Like it or not...I'm back!

James