Water. 60% of the human body. Drink 5 liters a day and you can resist malaria. Dig down 15 feet by the side of your mud hut and you have a contaminated water source. Dig down 90 feet at your hospital and have pure water. A mango tree stays green in a dry, Tchadian wasteland by sending deep roots into that water reservoir producing the world's best fruit in the middle of literal hell on earth in sub-saharan African in March nourishing otherwise left-to-fend-for-themselves kids as long as they can throw stones at, climb precariously to pick without falling and breaking their jaw and femur, or pluck off the mangos using a bamboo rod with a hooked stick tied on the end.
Plip, plop. Can it be? Yes, rain. It never rains in March in Béré...except right before 16 foreigners arrive to camp out in your yard for 10 days having been assured by you that they don't have to worry about getting rained on...which they don't, having passed over a week surviving heat, dirt, packs of kids and limited food supplies. A hose, attached to the house, carries water half way to their building site allowing them to fill buckets and containers, put them in push carts and haul them off to mix with cement and sand to make mortar to place between home-fired mud bricks and start building a new church. After having all been diagnosed with Malaria in the last few days of their stay in Béré, all are overjoyed to have the water fall from the sky again--even if only for 10 minutes--the last night most of them will ever spend in a place like this.
(Is it any wonder God describes his presence as rain as I feel the influence of this group's dedication to prayer by a palpable lifting of the spiritual darkness in Béré...followed by a wakening from my sleep feeling a evil presence and sense of fear the night they leave...and at the exact time their plane leaves N'Djam�na...weird? Yes. True? Oui.)
During the three major operations performed during the group's visit sterile water mixed with salt flows through a tube and into a vein in the patients arm allowing him to be put to sleep for the surgery and survive it. The water then flows through his blood, is filtered in his kidneys and comes back out mixed with waste products in his urine. That same sterile salt water is poured into the wounds before closing, diluting the bacteria and preventing infections. The bloody, vomit covered OR floor is then doused with water and squeegyed down the drain. The instruments are washed with water and then sterilized with heated water under pressure in an autoclave.
I approach the river between Béré and Lai. I have 5 other foreigners inside the truck with me and 15 foreigners along with 3 locals outside in the back. They are covered from head to foot in red dust and diesel exhaust. We've just come from the bush church in Kalm� and are looking forward to refreshing ourselves with a swim in the water. As white bodies immerge in swimming suits to descend down the small cliffs to the tiny beaches along the river, we draw quite a crowd of gawkers...mostly children. I'm one of the first to crash down the sandy bank, rip off my shirt and plunge into the cool, flowing river. I feel it envelop me, cleanse me, cool me, free me, energize me. I pop to the surface and swim against the strong current the short distance to the shallow sandbar that is most of the river. I lay on the bottom with just my head sticking up fighting the swiftness of the water streaming past.
The others soon join me with a football and two frisbees which quickly brings a swarm of naked boys who find it obligatory to place and hand over the privates when standing but are otherwise free to be one with nature. The sandbar drops sharply to about 10 feet allowing spectacular diving catches of appropriately thrown footballs. Soon kids are swarming, splashing, diving, thrashing, clambering, jumping, yelling, catching, tossing awkwardly, smiling, laughing. Two older boys arrive and ask to be given the frisbees. I say we'll see.
Suddenly, in the frenzy, I notice the football still being tossed but no frisbees to be seen. I stop and yell. The yellow frisbee is quickly produced by one of the older boys. No one claims the red one but they say it was probably buried under the sand to be dug up later when we've left. We talk a lot. I suspect the older boys. We're all in the middle of the river standing in 1-3 feet of water. Most are naked so they've no place to hide it.
I see that the soccer ball of one of the older boys is drifting downstream off the sandbar into the current. He's yelling for one of the small boys near by to get it. No one moves. I make my move. I splash through the shallow water and dive off the sandbar. Swimming powerfully through the crisp flow of water I grasp the deflated soccer ball and swim slowly back upstream to the sandbar. He says thanks and reaches out for it. I say thanks and say I'll keep it until he finds the red frisbee. Then begins a stand off of over 1/2 hour. Everyone wants me to give up. I'm surrounded by locals who say they just want their ball and they have no idea who stole it. I say we'll just take their ball and leave. When they find the frisbee they can come to B�r� and get their soccer ball back. They don't realize how stubborn I am.
They threaten to stop our car from leaving. I say go ahead and try...I'll take you to court and I know all the government officials (not exactly true...but a nice bluff). Suddenly, I see one of the older boys in the 3 foot area of the sandbar. A young boy 5 feet away holds up the red frisbee while the older boy shouts out look he's found it. I say thanks and take the frisbee. Then, without giving back the soccer ball I swim across the channel to the rest of the group.
The tall boy who owns the soccer ball calls out for it. I know now for sure it's they who have stolen it. I ask him to come get it. He smiles sheepishly and refuses. They beg for awhile and then walk off. The little boys surrounding us confirm that they are the thieves and tell me not to give the soccer ball back. I give it to the one who tells me that and still wet from the swim jump back in to drive back to dry, dusty Béré where just beneath the surface rests enough water to irrigate the entire area and keep it green and productive year round...instead, we appear to be in a desert...by definition and area without much water...
James
Thursday, March 31, 2005
Friday, March 18, 2005
Twins
A million thoughts tumble and whirl through my head like the rocks and pieces of smashed bricks tossed by the kids outside. Just like the mango tree outside assaulted by the kids with their missiles, I feel under constant attack. If enough things are thrown your way, no matter how well you may be grounded, some are sure to hit and damage if not cause you to fall off entirely and crash through the leaves and branches to the ground. It's an incessant battering of small things that keep my mind in a jumble and my thoughts from differentiating between what's important and what's simply annoying and pointless.
A deep anger has surfaced over that the last couple days. I don't know why. It can't be explained by one thing. Maybe it's the million small demands everyday. Maybe the feeling of being used by your friend who is helping renovate your hospital. Maybe it's the insults hurled at you by the woman when you ask why they're stealing huge bags full of your mangos to then go and sell to you a few hundred yards away. Maybe it's the kids who steal your barbed wire and poop in your tool shed. Maybe it's the sheep spending the night under your window bleating and screeching their heads off. Or maybe it's simply the goat peeing like a racehorse right outside waking you up wondering what faucet has been opened right next to your mattress. Maybe it's the feeling of never being able to get away or have a moment to yourself when you're not being watched. Maybe it's the patients' lack of gratitude. Maybe it's the feeling of being in over your head and doing things to people that you're not qualified to do simply because there is no one else. Maybe it's the lack of directness. Maybe it's the gossip. Maybe it's the forced friendliness. Maybe...
Maybe it's the unexpected which one has come to expect...like the case that makes your anger disappear and reminds you why you are here...
The woman is severely pregnant. I say that because I've never seen a bigger pregnant belly on anyone...and she's not that big a woman. Of course, she doesn't really know how long she's been pregnant. The uterine height measures 43 cm. That means she either has too much fluid, too much baby or too many babies (twins). Without an ultrasound I'm just guessing, but I think I did hear two different heartbeats so my guess is on twins. Oh, did I mention she's HIV positive? We had identified her on normal screening a few months ago and had explained to her what that means for her pregnancy and child and how we can try to prevent her child from getting infected. She had been pretty regular in coming to prenatal visits but had been absent for awhile. Now she's huge.
Her cervix seems favorable so we decide to try and induce her labor. We start her on our protocol for prevention of mother to child transmission of HIV and start the induction. It doesn't work. We then schedule her for a c-section. She says she needs to go home and will come back later...she doesn't.
A week later, two nights ago, she comes back. I'm so dead asleep I don't even hear the night watchman knocking. It's Sarah who wakes me up. I step groggily to the door after fumbling for my head lamp in the dark. I ask David what's going on. He replies with the classic, "a case at the hospital..." I say I'll be right there.
As I walk over I enjoy probably my only moments of true silence and tranquility when I'm awakened at 01:00 am for an emergency. The air is cool and still. There is no moon and hardly any stars. It's pitch black. And there's no sound.
I arrive to find that it is the same woman who's come back in labor with the face of the baby as the presenting part instead of the normal back of the head. There's no question. The baby can't come out that way and a c-section will help prevent transmission of the HIV to the baby. I ask why she hasn't come back sooner for the surgery. She said she couldn't find the $40 to pay for it. Dimanche, the nurse on Garde duty, says that in desperation the woman has just told her the real story.
Apparently, she was the third wife of a man who died a year and a half ago of AIDS. As the third wife with only small children and the stigma of a husband dead of AIDS she was abandoned to care for her kids without help. As a result she's been selling herself to men for 50 cents each time. With 6-7 customers a day, even while pregnant, she is able to put food on the table. Suddenly, in the early morning of a dark Tchadian night all my confusion, anger and frustration disappears as a dose of cold reality makes things starkly clear in an instant.
We prepare immediately for surgery...as I enter the dark OR lit only by the weak light of my headlamp I feel very strange as the story unfolding resembles my own beginnings in many ways and yet is the extreme opposite at the same time.
March 29, 1973. A beautiful, tall 22 year old blond is in the hospital to deliver. The pregnancy has been uneventful. Now her labor has stalled. The doctor orders an x-ray (in the days before ultrasound's ready availability). When the doc gets the results he asks the young, nervous husband to step outside. As the door closes behind him he catches a phrase that causes his heart to skip. "Well, the X-ray doesn't show the entire abdomen, but there's at least two in there."
I grab a green cloth bundle. I open it carefully revealing two folded green surgery gowns and a drape showing their years of use and reuse. The instruments are peaking out from underneath. I open two sets of 8 1/2 gloves, a scalpel and four sutures (3 for the caesarian and one for tying her tubes) and fold them with sterile technique onto the instrument table. I set another pair of gloves, a spinal needle, a syringe with needle and a vial of lidocaine on another table...ready for the spinal anesthetic.
The doctor decides to do a c-section on the young woman with "at least two" as he labor has stalled and the x-ray reveals that it is a breech/vertex presentation with locking chins. The young woman is my mother. What must have been going through her mind that day almost 32 years ago as the doctors prepared her for surgery. Suddenly, instead of her first child she's faced with her first two kids at once...at least two. She doesn't know exactly how many she'll have when she wakes up from the anesthesia, but it'll be at least twins.
We bring the woman in, place the anesthetic and cut down quickly pulling out two screaming, vigorous twin boys in one of the few uncomplicated c-sections that we do here. As I wipe the first one down quickly to remove the HIV infected blood as quickly as possible I feel very weird, kind of detached as I think how such a simple thing might be the difference between life and a slow death from AIDS for him. That strange, normal, red blood all over the operating field and dripping onto the floor is filled with a strange thing that is not alive yet can quickly take over a body making it waste away into one of the most dreaded diseases of our day.
I walk back to the house post-op thinking of my own birth, the tragic death of my twin over 3 years ago, and the uncertain future of the two most recent twin arrivals on our planet resting in the care of their prostitute, HIV infected mom. I realize again, that maybe one reason I was brought here was for these untouchables, the outcasts of our day, the HIV infected person living in poverty in the third world. Already, they are most cherished patients even though currently there isn't much I do for them except to be sure that they feel the presence of a person who isn't afraid to touch them and has no fear of their disease or the person that carries it. I'm honest with them, I don't try to ignore their disease and I give them hope when everyone else has given up on them.
The next two days will be filled with exhaustion, rising frustration, unrelenting challenges, but for that moment I feel the presence of God giving me a purpose and reminding me of the reason I have been sent to this apparently God-forsaken place...
James
A deep anger has surfaced over that the last couple days. I don't know why. It can't be explained by one thing. Maybe it's the million small demands everyday. Maybe the feeling of being used by your friend who is helping renovate your hospital. Maybe it's the insults hurled at you by the woman when you ask why they're stealing huge bags full of your mangos to then go and sell to you a few hundred yards away. Maybe it's the kids who steal your barbed wire and poop in your tool shed. Maybe it's the sheep spending the night under your window bleating and screeching their heads off. Or maybe it's simply the goat peeing like a racehorse right outside waking you up wondering what faucet has been opened right next to your mattress. Maybe it's the feeling of never being able to get away or have a moment to yourself when you're not being watched. Maybe it's the patients' lack of gratitude. Maybe it's the feeling of being in over your head and doing things to people that you're not qualified to do simply because there is no one else. Maybe it's the lack of directness. Maybe it's the gossip. Maybe it's the forced friendliness. Maybe...
Maybe it's the unexpected which one has come to expect...like the case that makes your anger disappear and reminds you why you are here...
The woman is severely pregnant. I say that because I've never seen a bigger pregnant belly on anyone...and she's not that big a woman. Of course, she doesn't really know how long she's been pregnant. The uterine height measures 43 cm. That means she either has too much fluid, too much baby or too many babies (twins). Without an ultrasound I'm just guessing, but I think I did hear two different heartbeats so my guess is on twins. Oh, did I mention she's HIV positive? We had identified her on normal screening a few months ago and had explained to her what that means for her pregnancy and child and how we can try to prevent her child from getting infected. She had been pretty regular in coming to prenatal visits but had been absent for awhile. Now she's huge.
Her cervix seems favorable so we decide to try and induce her labor. We start her on our protocol for prevention of mother to child transmission of HIV and start the induction. It doesn't work. We then schedule her for a c-section. She says she needs to go home and will come back later...she doesn't.
A week later, two nights ago, she comes back. I'm so dead asleep I don't even hear the night watchman knocking. It's Sarah who wakes me up. I step groggily to the door after fumbling for my head lamp in the dark. I ask David what's going on. He replies with the classic, "a case at the hospital..." I say I'll be right there.
As I walk over I enjoy probably my only moments of true silence and tranquility when I'm awakened at 01:00 am for an emergency. The air is cool and still. There is no moon and hardly any stars. It's pitch black. And there's no sound.
I arrive to find that it is the same woman who's come back in labor with the face of the baby as the presenting part instead of the normal back of the head. There's no question. The baby can't come out that way and a c-section will help prevent transmission of the HIV to the baby. I ask why she hasn't come back sooner for the surgery. She said she couldn't find the $40 to pay for it. Dimanche, the nurse on Garde duty, says that in desperation the woman has just told her the real story.
Apparently, she was the third wife of a man who died a year and a half ago of AIDS. As the third wife with only small children and the stigma of a husband dead of AIDS she was abandoned to care for her kids without help. As a result she's been selling herself to men for 50 cents each time. With 6-7 customers a day, even while pregnant, she is able to put food on the table. Suddenly, in the early morning of a dark Tchadian night all my confusion, anger and frustration disappears as a dose of cold reality makes things starkly clear in an instant.
We prepare immediately for surgery...as I enter the dark OR lit only by the weak light of my headlamp I feel very strange as the story unfolding resembles my own beginnings in many ways and yet is the extreme opposite at the same time.
March 29, 1973. A beautiful, tall 22 year old blond is in the hospital to deliver. The pregnancy has been uneventful. Now her labor has stalled. The doctor orders an x-ray (in the days before ultrasound's ready availability). When the doc gets the results he asks the young, nervous husband to step outside. As the door closes behind him he catches a phrase that causes his heart to skip. "Well, the X-ray doesn't show the entire abdomen, but there's at least two in there."
I grab a green cloth bundle. I open it carefully revealing two folded green surgery gowns and a drape showing their years of use and reuse. The instruments are peaking out from underneath. I open two sets of 8 1/2 gloves, a scalpel and four sutures (3 for the caesarian and one for tying her tubes) and fold them with sterile technique onto the instrument table. I set another pair of gloves, a spinal needle, a syringe with needle and a vial of lidocaine on another table...ready for the spinal anesthetic.
The doctor decides to do a c-section on the young woman with "at least two" as he labor has stalled and the x-ray reveals that it is a breech/vertex presentation with locking chins. The young woman is my mother. What must have been going through her mind that day almost 32 years ago as the doctors prepared her for surgery. Suddenly, instead of her first child she's faced with her first two kids at once...at least two. She doesn't know exactly how many she'll have when she wakes up from the anesthesia, but it'll be at least twins.
We bring the woman in, place the anesthetic and cut down quickly pulling out two screaming, vigorous twin boys in one of the few uncomplicated c-sections that we do here. As I wipe the first one down quickly to remove the HIV infected blood as quickly as possible I feel very weird, kind of detached as I think how such a simple thing might be the difference between life and a slow death from AIDS for him. That strange, normal, red blood all over the operating field and dripping onto the floor is filled with a strange thing that is not alive yet can quickly take over a body making it waste away into one of the most dreaded diseases of our day.
I walk back to the house post-op thinking of my own birth, the tragic death of my twin over 3 years ago, and the uncertain future of the two most recent twin arrivals on our planet resting in the care of their prostitute, HIV infected mom. I realize again, that maybe one reason I was brought here was for these untouchables, the outcasts of our day, the HIV infected person living in poverty in the third world. Already, they are most cherished patients even though currently there isn't much I do for them except to be sure that they feel the presence of a person who isn't afraid to touch them and has no fear of their disease or the person that carries it. I'm honest with them, I don't try to ignore their disease and I give them hope when everyone else has given up on them.
The next two days will be filled with exhaustion, rising frustration, unrelenting challenges, but for that moment I feel the presence of God giving me a purpose and reminding me of the reason I have been sent to this apparently God-forsaken place...
James
Saturday, March 5, 2005
Chant
It starts out with a single haunting voice chanting out a rhythmic song in Nangjere...a gourd filled with seeds quickly picks up the beat and fills in with a soft shooshing like gravel on a beach tossed by the waves. After a few lines a drum made from a hollowed out log covered with still hairy goat skin picks up in an off-beat as all the voices begin to echo the words of the leader. Then a low thumping fills it all out hitting you right in the chest with an alternating deep boom boom boom and a higher pitched hollow knocking as a small boy beats a long, hollow square pyramid made of lead that he also raises up and down off the floor to change tones.
It's hypnotic and I'm exhausted. My body slouches forward. My elbows on my knees, my eyes close. My feet can't help tapping and my hands softly tap involuntarily even though they don't have the strength for a real clap. My head bobs slightly up and down as my thoughts drift back to this morning...
"Lona wants to see you about some Maternity patient," Sarah shakes me awake.
It's been a long night. My malaria smear was positive again yesterday and after my second dose of quinine I was afraid I'd mixed up meds and took a tranquilizer because I found myself fighting my way out of a dark hole that wanted to suck me down into its depths never to wake again. Then, some people came on motorcycles and began talking and eating loudly right outside our window. I was so groggy, however, I couldn't make sense of anything and thought they were patients coming to complain that we'd stolen the pumps off their bikes they'd left as surety for the payment of their hospital debts. I drifted in and out of my fogginess all night without really feeling rested. Lying in a pool of sweat doesn't help.
I get up, shower, and put on a pair of cords and a shirt. I grab the car keys as I plan on going to Kalmé to bring the church members to join us for our first communion since I've been here. Our pastor from K�lo arrived last night at well.
I see Lona as I enter the hospital and he tells me it's just a pregnant woman with Malaria who wants to go home after two days in the hospital. I agree. Apparently, Jean, the man whose hydrocele we took out had a fever. I check on him and he has a small wound abscess. I open it up and pack it. I head over to Peds to check on the Malaria kids.
I walk in to our one bright spot on campus with it's newly painted cartoons on the walls (thanks to Sarah and Becky). Little James looks at me with a mixture of curiosity and fear. He's one of the first baby's I delivered here and probably the first of several now to bear the strange name of James. He's doing fine and I send him home...
....I'm nudged back to the reality of a Nangjere worship service as a small girl in tattered rags climbs onto the crude wooden bench without a back. She nudges herself between Sarah and I and gives me the hugest, whitest grin ever. I'm soon back into my swaying trance as I can hear the sound of the motorcycle pulling up in my reverie...
Lona and I go over to find that one of the health centers has referred a pregnant woman with a breech presentation (the baby's in position to come out butt first). I check the heartbeat and it's slow...I check to see if it's maybe the mother's but as I do it slowly picks up till it's back to a normal fetus' 150-160/minute. The baby is obviously in distress. The abdomen looks a little weirdly shaped but I think it's probably just a really full bladder. I know we don‚t have much time to get the baby out if we want to save him.
I send Koumabas to find Samedi. Jacob is already there and Dimanche shows up to relieve Lona of night duty so he helps me get the woman on a stretcher and carry her quickly into the OR. Sarah arrives at that moment and I see Koumabas who says Samedi is on his way.
I grab one of the green wrapped Cesarian bundles and through it on the instrument tray table and unwrap it in sterile fashion. I open onto the table two pairs of sterile gloves, a scalpel blade and 3 sutures. Sarah has started the IV and is letting fluids run in quickly. Lona turns the woman over on her side and I open a syringe and spinal needle onto a sterile field made with a glove package. I wipe down the woman's back with Betadine. She can't really double over and has tensed her back muscles. This will be hard. I put on the gloves, draw up the lidocaine, find the intervertebral space and push in the needle. Thank God clear fluid comes out on the first try. I inject the anesthetic and pull it all out as Samedi (who's just arrived) turns the woman on her back and lowers the head of the bed.
I put in a urinary catheter and find pure blood...a ruptured uterus probably. I really know we don't have much time now if the baby is to live. I do a quick scrub, gown and glove, and drape the abdomen. I nod to Samedi. He prays in Nangjere and I grab the 22 blade scalpel and in two strokes am through the fascia down to muscle. I quickly cut the fascia with scissors than poke through the muscles with my fingers and pull them apart to the sides. I keep digging and pulling with my fingers until I enter the abdominal cavity. I find a baby's back. The uterus is torn in the lower anterior segment. There is a lot of clots but not much active bleeding.
I reach my hand down the baby's back to it's butt and raise it out. Then I swing out the legs one at a time and then pull out the body. Each arm is then delivered, a finger put in the mouth to keep the baby's chin on his chest and the head comes out easily. He's huge and broad shouldered. I clamp and cut the cord. He's limp. I hand him to Sarah. There is no cry.
I return my gaze to the woman and pull the uterus out of the belly onto the abdominal wall. I keep in the back of my mind waiting for a baby's cry...it doesn't come.
"Bag the baby," I cry. "Oxygen, oxygen, oxygen" Of course, we don't have any but at least by breathing in room air to the baby some oxygen will hopefully get into his circulation.
The uterus is torn down through the cervix and partially into the bladder. Fortunately, there's almost no bleeding as all the edges are covered with clot.
"Is there a heartbeat?" I yell to Sarah. "No, nothing, she replies."
"Keep bagging...Jacob, il faut stimuler l'enfant...frapper les pieds ou quelque chose comme éa..."
I suture the bladder together and then the cervix over it up to the muscular wall of the uterus...
"There's a faint heartbeat," Sarah calmly mentions. Dimanche has come in. She grabs the baby by his feet and swings him back and forth upside down while supporting his head and neck with the other hand. Still no cry.
"Keep going."
I cut off the clot till the uterine muscle starts bleeding again. I clamp the arteries and suture it closed.
"He wants to cry, he's sucking on the suction and he's opened his eyes." Still no cry.
I suture the peritoneum over the uterine wound and tie her fallopian tubes. I suture the fascia and skin and turn to the baby.
He's still floppy and with blotchy skin but he's staring, has a great heartbeat and starts to breath on his own. We smack his feet, rub his back, grind his sternum and rub his mandibular angles a few more times and then give him to his mom where he actually starts to breast feed a little...
The music continues to surge through me down all my nerves causing many involuntary motions. Sarah pokes me and says to look at Joseph. Our 60 year old grounds keeper with the wizened, white-scruffy-bearded face wearing a pink shirt and maroon pants is up dancing with arms raised right in the face of the percussionists working them into an even more profound musical experience. The chills go down my spine and arms to my legs. People may say it's just malaria but I sense a connection to something unseen...Sarah nudges me again. Andre is on stage with a massive smile on his face and one up raised arm pumping the air...tears well in my eyes as I sense that in this small place somehow we have touched something beyond our comprehension and that on the other side too they are rejoicing as somewhere close by a small life continues against all odds...
James
It's hypnotic and I'm exhausted. My body slouches forward. My elbows on my knees, my eyes close. My feet can't help tapping and my hands softly tap involuntarily even though they don't have the strength for a real clap. My head bobs slightly up and down as my thoughts drift back to this morning...
"Lona wants to see you about some Maternity patient," Sarah shakes me awake.
It's been a long night. My malaria smear was positive again yesterday and after my second dose of quinine I was afraid I'd mixed up meds and took a tranquilizer because I found myself fighting my way out of a dark hole that wanted to suck me down into its depths never to wake again. Then, some people came on motorcycles and began talking and eating loudly right outside our window. I was so groggy, however, I couldn't make sense of anything and thought they were patients coming to complain that we'd stolen the pumps off their bikes they'd left as surety for the payment of their hospital debts. I drifted in and out of my fogginess all night without really feeling rested. Lying in a pool of sweat doesn't help.
I get up, shower, and put on a pair of cords and a shirt. I grab the car keys as I plan on going to Kalmé to bring the church members to join us for our first communion since I've been here. Our pastor from K�lo arrived last night at well.
I see Lona as I enter the hospital and he tells me it's just a pregnant woman with Malaria who wants to go home after two days in the hospital. I agree. Apparently, Jean, the man whose hydrocele we took out had a fever. I check on him and he has a small wound abscess. I open it up and pack it. I head over to Peds to check on the Malaria kids.
I walk in to our one bright spot on campus with it's newly painted cartoons on the walls (thanks to Sarah and Becky). Little James looks at me with a mixture of curiosity and fear. He's one of the first baby's I delivered here and probably the first of several now to bear the strange name of James. He's doing fine and I send him home...
....I'm nudged back to the reality of a Nangjere worship service as a small girl in tattered rags climbs onto the crude wooden bench without a back. She nudges herself between Sarah and I and gives me the hugest, whitest grin ever. I'm soon back into my swaying trance as I can hear the sound of the motorcycle pulling up in my reverie...
Lona and I go over to find that one of the health centers has referred a pregnant woman with a breech presentation (the baby's in position to come out butt first). I check the heartbeat and it's slow...I check to see if it's maybe the mother's but as I do it slowly picks up till it's back to a normal fetus' 150-160/minute. The baby is obviously in distress. The abdomen looks a little weirdly shaped but I think it's probably just a really full bladder. I know we don‚t have much time to get the baby out if we want to save him.
I send Koumabas to find Samedi. Jacob is already there and Dimanche shows up to relieve Lona of night duty so he helps me get the woman on a stretcher and carry her quickly into the OR. Sarah arrives at that moment and I see Koumabas who says Samedi is on his way.
I grab one of the green wrapped Cesarian bundles and through it on the instrument tray table and unwrap it in sterile fashion. I open onto the table two pairs of sterile gloves, a scalpel blade and 3 sutures. Sarah has started the IV and is letting fluids run in quickly. Lona turns the woman over on her side and I open a syringe and spinal needle onto a sterile field made with a glove package. I wipe down the woman's back with Betadine. She can't really double over and has tensed her back muscles. This will be hard. I put on the gloves, draw up the lidocaine, find the intervertebral space and push in the needle. Thank God clear fluid comes out on the first try. I inject the anesthetic and pull it all out as Samedi (who's just arrived) turns the woman on her back and lowers the head of the bed.
I put in a urinary catheter and find pure blood...a ruptured uterus probably. I really know we don't have much time now if the baby is to live. I do a quick scrub, gown and glove, and drape the abdomen. I nod to Samedi. He prays in Nangjere and I grab the 22 blade scalpel and in two strokes am through the fascia down to muscle. I quickly cut the fascia with scissors than poke through the muscles with my fingers and pull them apart to the sides. I keep digging and pulling with my fingers until I enter the abdominal cavity. I find a baby's back. The uterus is torn in the lower anterior segment. There is a lot of clots but not much active bleeding.
I reach my hand down the baby's back to it's butt and raise it out. Then I swing out the legs one at a time and then pull out the body. Each arm is then delivered, a finger put in the mouth to keep the baby's chin on his chest and the head comes out easily. He's huge and broad shouldered. I clamp and cut the cord. He's limp. I hand him to Sarah. There is no cry.
I return my gaze to the woman and pull the uterus out of the belly onto the abdominal wall. I keep in the back of my mind waiting for a baby's cry...it doesn't come.
"Bag the baby," I cry. "Oxygen, oxygen, oxygen" Of course, we don't have any but at least by breathing in room air to the baby some oxygen will hopefully get into his circulation.
The uterus is torn down through the cervix and partially into the bladder. Fortunately, there's almost no bleeding as all the edges are covered with clot.
"Is there a heartbeat?" I yell to Sarah. "No, nothing, she replies."
"Keep bagging...Jacob, il faut stimuler l'enfant...frapper les pieds ou quelque chose comme éa..."
I suture the bladder together and then the cervix over it up to the muscular wall of the uterus...
"There's a faint heartbeat," Sarah calmly mentions. Dimanche has come in. She grabs the baby by his feet and swings him back and forth upside down while supporting his head and neck with the other hand. Still no cry.
"Keep going."
I cut off the clot till the uterine muscle starts bleeding again. I clamp the arteries and suture it closed.
"He wants to cry, he's sucking on the suction and he's opened his eyes." Still no cry.
I suture the peritoneum over the uterine wound and tie her fallopian tubes. I suture the fascia and skin and turn to the baby.
He's still floppy and with blotchy skin but he's staring, has a great heartbeat and starts to breath on his own. We smack his feet, rub his back, grind his sternum and rub his mandibular angles a few more times and then give him to his mom where he actually starts to breast feed a little...
The music continues to surge through me down all my nerves causing many involuntary motions. Sarah pokes me and says to look at Joseph. Our 60 year old grounds keeper with the wizened, white-scruffy-bearded face wearing a pink shirt and maroon pants is up dancing with arms raised right in the face of the percussionists working them into an even more profound musical experience. The chills go down my spine and arms to my legs. People may say it's just malaria but I sense a connection to something unseen...Sarah nudges me again. Andre is on stage with a massive smile on his face and one up raised arm pumping the air...tears well in my eyes as I sense that in this small place somehow we have touched something beyond our comprehension and that on the other side too they are rejoicing as somewhere close by a small life continues against all odds...
James
Tuesday, March 1, 2005
1 March 2005
I can't explain it except to say there are weird things in the world and forces of evil that try and mess with people's minds...
It started innocently enough. David gave sign-out to the team about what happened overnight. A few patients had fevers but overall all the hospitalized patients were doing well. Furthermore, he received no outside cases and had no deliveries until a woman showed up 20 minutes before we started morning report.
The woman had apparently been out walking in the dark to relieve her self and then fell after stepping in a small hole. The family found her several hours later and brought her in as soon as possible.
We finish by assigning posts to the staff for the day and praying. I grab my "doctor's bag" (an old army tan shoulder bag) and head off on rounds. We go to see the new patient first.
She's lying in bed on her back with coarse breathing. She appears semi-comatose with some drool coming out her mouth and a pool of urine under her. She moans and barely moves her extremities but otherwise is unconscious. Both pupils are normal and reactive. She has no evidence of trauma and on further questioning the family says she apparently fell beside the hole but it wasn't the hole that caused her to fall. Her vital signs and heart, lung and abdomen exams are normal.
I order a malaria smear and some other tests. I continue my work for the day while waiting for results.
Awhile later I get the malaria results back which are positive; all other tests are unremarkable. I order a quinine drip and go back to work.
At 1pm I go into the OR to repair a hernia on an elderly gentleman. As I am gowned up and about to start Zachary walks in to tell me that the woman has died. No one is surprised, apparently. Now the true story comes out.
The man I am currently operating on is the woman's brother. When he sold a cow to pay for the operation, she protested and said she wouldn't go and see him in the hospital if he used the money for the surgery. He left his village to come to B�r� yesterday in order to be at the hospital early. She had regrets later and went outside to follow him and be with him after the surgery. That's when, to no one's surprise she fell down and, shortly afterwards, died. That is what the people here expect to happen if you do something that you later regret...you'll die.
So, of course, the solution is to never regret anything. That's why I never hear apologies because it doesn't really matter what you do as long as your not sorry for it you won't be struck down by whoever it is you believe does the striking!
I'm slowly learning little by little why I feel frustrated...I'm in a serious culture clash...not just American-Tchadian, but my own personal cultural differences. If I do something I like to be thanked. I will stay up all night, be totally wasted, work while sick with Malaria, do whatever it takes if you'll only appreciate it. But the Nangjere language doesn't even have the word "thanks"...they've borrowed "merci" from the French but still rarely say it. And now I've discovered that while I easily forgive and forget, and will often apologize myself when wrong in an effort to reconciliate...here, that is not only culturally not done, but considered dangerous as one could die if he has regrets, apologizes or tries to make things up or reconciliate!
As they say in Nangjere, "Kai, Kai, Kai" or in French "�a, �a, �a"...or in English, "dude, what's up wid dat?"...
I somberly return to the dead woman's brother lying on the operating table, covered with a green drape, and continue the surgery, find the hernia sac, tie it off, close up the defect, suture the layers closed and clean up...will I never cease to be surprised by this place...?
James
It started innocently enough. David gave sign-out to the team about what happened overnight. A few patients had fevers but overall all the hospitalized patients were doing well. Furthermore, he received no outside cases and had no deliveries until a woman showed up 20 minutes before we started morning report.
The woman had apparently been out walking in the dark to relieve her self and then fell after stepping in a small hole. The family found her several hours later and brought her in as soon as possible.
We finish by assigning posts to the staff for the day and praying. I grab my "doctor's bag" (an old army tan shoulder bag) and head off on rounds. We go to see the new patient first.
She's lying in bed on her back with coarse breathing. She appears semi-comatose with some drool coming out her mouth and a pool of urine under her. She moans and barely moves her extremities but otherwise is unconscious. Both pupils are normal and reactive. She has no evidence of trauma and on further questioning the family says she apparently fell beside the hole but it wasn't the hole that caused her to fall. Her vital signs and heart, lung and abdomen exams are normal.
I order a malaria smear and some other tests. I continue my work for the day while waiting for results.
Awhile later I get the malaria results back which are positive; all other tests are unremarkable. I order a quinine drip and go back to work.
At 1pm I go into the OR to repair a hernia on an elderly gentleman. As I am gowned up and about to start Zachary walks in to tell me that the woman has died. No one is surprised, apparently. Now the true story comes out.
The man I am currently operating on is the woman's brother. When he sold a cow to pay for the operation, she protested and said she wouldn't go and see him in the hospital if he used the money for the surgery. He left his village to come to B�r� yesterday in order to be at the hospital early. She had regrets later and went outside to follow him and be with him after the surgery. That's when, to no one's surprise she fell down and, shortly afterwards, died. That is what the people here expect to happen if you do something that you later regret...you'll die.
So, of course, the solution is to never regret anything. That's why I never hear apologies because it doesn't really matter what you do as long as your not sorry for it you won't be struck down by whoever it is you believe does the striking!
I'm slowly learning little by little why I feel frustrated...I'm in a serious culture clash...not just American-Tchadian, but my own personal cultural differences. If I do something I like to be thanked. I will stay up all night, be totally wasted, work while sick with Malaria, do whatever it takes if you'll only appreciate it. But the Nangjere language doesn't even have the word "thanks"...they've borrowed "merci" from the French but still rarely say it. And now I've discovered that while I easily forgive and forget, and will often apologize myself when wrong in an effort to reconciliate...here, that is not only culturally not done, but considered dangerous as one could die if he has regrets, apologizes or tries to make things up or reconciliate!
As they say in Nangjere, "Kai, Kai, Kai" or in French "�a, �a, �a"...or in English, "dude, what's up wid dat?"...
I somberly return to the dead woman's brother lying on the operating table, covered with a green drape, and continue the surgery, find the hernia sac, tie it off, close up the defect, suture the layers closed and clean up...will I never cease to be surprised by this place...?
James
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