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