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