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