Kulluku,
Al-salam alekum...anina afe...al hamdu lillah...
It's kind of strange. I only really get close to patients if they have problems severe enough to keep them hospitalized for a long time. There's Marty, the fisherman bit by the hippo. We still keep in touch. It seems every time I go to swim at a certain spot I see him. Last Saturday, he stopped by to give Sarah and I some fish he'd caught. Apparently, he's back fishing the lake with the hippos. But that friendship was at the cost of excruciating daily dressing changes on a two-foot long, 6 inch deep wound on his derriere.
Gai, the tall, lanky young man with one lung also sees us often at another swimming hole we frequent. He's usually off hunting with his bush knife but stops to say hello. He stops by the hospital from time to time as well and we're always glad to see him. He became our friend because of living with a chest tube for weeks, undergoing a thoracotomy with second chest tube and being hooked up to a crude suction machine every night when the power came on.
Then there's Freddy whose father refused amputation, who we did deep dressing changes deep into his thigh on for months and who ended up dying but not before finding a place in our hearts.
The list could go on and on...people brought into our lives through painful circumstances and suffering who somehow change us and become part of us through the process.
Currently, there's Suzanne and Yvonne. After a year of virtually no wound infections we were faced with two consecutive c-sections that turned into catastrophic post-op pus nightmares. Suzanne came first. Hers was a simple routine c-section except that the child was difficult to resuscitate and died 2 days later. She had a normal post-op course but then came back a week later with a little pus coming out of her wound, diarrhea and a distended abdomen.
She was started on antibiotics by the nurse, found to have malaria, treated for malaria and started to improve. I saw her a day later and opened the wound up more as there appeared to be a little abscess inside. Overall, she was doing well, walking and eating.
15 minutes after I opened the wound her husband came running to find me and said she'd had a huge diarrheal episode. I came in to find her standing in a puddle of foul smelling fluid. When I asked her she said it'd come from her wound. I took off the dressing and saw some fluid coming out.
We went to the OR to explore and ended up having to open her up in the midline as we found her entire abdomen filled with pus and inflammatory debris. She was left with a huge inverted T-shaped wound with the skin open in the midline and the entire wound down to the uterus open at the base.
She's been here over 6 weeks and has recuperated nicely with only a small portion of her wound still to close. Unfortunately, she has developed a nasty bed sore on her sacrum. But she and I and her mom (named Sarah) and my Sarah have all become fast friends. They don't speak French and I don't speak Nangjere but our non-verbal communication is enough to show that we're happy to see each other and that she has grown as fond of us as we have of her. They joke that Sarah needs to give me more back rubs as I work to hard...both probably true.
Just a few days after Suzanne came in with her wound infection, Yvonne came in with almost exactly the same thing. You'll remember that she is the woman infected with HIV who gave birth to twins by c-section. Her wound wasn't as extensive so I put drains in and we're doing dressings on the existing wound.
We helped them get formula from the Catholics so they wouldn't get HIV from the mom's breast milk. They did fine for about a month and we grew quite fond of them. In fact, they named one James and when I told them my twin brother was named David they named the other one David. David was the stronger one. James developed some abscesses on his head and was treated with some antibiotics. He was smaller and frailer from the beginning.
Yvonne's 3 year old son has started hanging out with the kids at church and basically has made himself a regular on campus. Her ten year old daughter helped us cut tree limbs and cooks and cleans for Yvonne here at the hospital.
Yvonne had a couple of setbacks but has pulled through. She developed a partial bowel obstruction which was resolved with one day of antibiotics, IV fluids and a nasogastric tube. A second one was cured with watching, waiting and prayer. She came to church last week and gives God thanks that she's recovering. The past two days she was well enough to walk to the market and back.
Unfortunately, David and James developed diarrhea and got Malaria. In a strange parallel to my own life, David (the stronger one), died after two days while the weaker James pulled through and is doing fine. It has been truly a bizarre sort of d�j� vu all along with Yvonne, James and David...but it has been a joy as well. I guess now I have two twin Davids to look forward to seeing in heaven...
James
Tuesday, April 26, 2005
Friday, April 15, 2005
No title
My living room in Béré is simple. There are holes in the ceiling over the table in the corner. In the rainy season we put pots on the table to collect the drips. The table is covered with fake plants, a kerosene lantern, a laptop computer, a satellite phone, a calendar, a box with corks, a clay pot with notes inside from people who've borrowed money and a straw basket woven locally and filled with pens, rubber bands, paper clips and various other odds and ends.
A woven wicker wasted basket sits to the side. A metal file cabinet with no door and a few shelves has been converted into a bookshelf containing Christian books in French, a Tchadian Arabic dictionary and grammar book, CDs, DVDs, Surfing magazines and a few odds and ends like Don Quixote in the original Spanish, A Tale of Two Cities, Perspectives on the World Christian Movement, The Gospel According to Biff--Christ's Childhood Pal, and Spanish playing cards.
In the corner are three African drums of various sizes, a guitar case, a car battery, a rusty machete, a broom, sandals and a few odd clay pots. A wicker couch covered with a curtain, a small table in the other corner, 4 chairs and a coffee table complete the furnishings. Two bush knifes, a Safari hat and various postcards adorn the otherwise bare, white walls.
Out the front door comes the sounds of an old typewriter being painstakingly tapped by André on his porch across the courtyard. A metal, rebar frame on the verandah houses a sagging, limp mosquito net. The cement railing has chipped paint and many missing blocks leaving some suspended virtually in mid air.
Out the side window one hears the sounds of twittering birds, scratching chickens and the mumbling of kids at play. A bare dirt yard has piles of raked weeds and leaves ready for burning and smoldering piles and ashes from this morning's burnings. Several guava trees have cracked leftover bricks arranged in something resembling circles around their trunks so they can be watered. An old clothesline is currently bare of its usually brightly colored African clothes or drably colored hospital scrubs. A rooster and a hen with her chicks scratch at the base of the newly watered trees.
The recently constructed wall is made of locally fashioned and fired mud bricks with sand-heavy mortar up to about 3 feet high where a thick, chain-link fence takes over. The heads of children are barely visible on the other side where they have gathered to drink from the hose draped over the bricks and through the chain-link to the outside. Some sort of game with a small deformed ball is being played to the side. An older boy rides by on a rickety bike with a hundred pound sack of rice tied to the back.
Behind the kids is our neighbor's stack of newly fired bricks. The mud bricks were assembled in a rough pyramid with holes on the outside layer and underneath where sticks were shoved and lit. All night long the family and neighbors gathered around the warm glow until morning brought a blackened outside crust housing bright red fired bricks within. The neighbors' mud brick, thatched houses weathered by years of rain rest just behind almost seeming a part of the natural landscape unlike our cement and tin roofed behemoths and rude metal fencing.
The elementary school is a few hundred yards off the corner of our fence, abandoned now in the hot, 120 degree afternoon. Everything seems oppressed by the heat. Even the air seems afraid to move lest it start to sweat or expend too much energy in providing its wind. The only thing unrestrained by the heat is the universally boundless energy of the kids, one of whom hangs casually off the chain-link while the rest have changed games slightly, now tossing the ball in the air in a circle with who knows what objective.
A man walks out of the hole in the neighbors wall serving as a door, leading three cattle. The cattle have huge, floppy humps between their shoulders and 2-3 foot long curved horns. A chain or rope through the nose allows these otherwise unpredictable steers to be guided even by a child. The man leads them off for some undetermined task:� perhaps hauling wood, carrying bricks, pulling a cart, or just to be watered and grazed.
In the kitchen, Sarah sits at her desk with white lace curtains behind her. She is intently flipping through pages scratching her neck with a pen. Her hair has been pulled up tightly and she wears a tank top in a vain attempt to escape some of the heat. A rooster crows. Ephraim calls for his papa. A boy runs past the fence with a stick pushing a rolling metal lid. The briefest of winds evaporates the sweat running down my back providing temporary refreshment.
The hospital is quiet but at any moment that dreaded clap-clap could appear on the porch in the form of a scrub-wearing, white-coated nurse calling me forth from my malaria-induced reverie back into the world of the Béré Adventist Hospital...
James
A woven wicker wasted basket sits to the side. A metal file cabinet with no door and a few shelves has been converted into a bookshelf containing Christian books in French, a Tchadian Arabic dictionary and grammar book, CDs, DVDs, Surfing magazines and a few odds and ends like Don Quixote in the original Spanish, A Tale of Two Cities, Perspectives on the World Christian Movement, The Gospel According to Biff--Christ's Childhood Pal, and Spanish playing cards.
In the corner are three African drums of various sizes, a guitar case, a car battery, a rusty machete, a broom, sandals and a few odd clay pots. A wicker couch covered with a curtain, a small table in the other corner, 4 chairs and a coffee table complete the furnishings. Two bush knifes, a Safari hat and various postcards adorn the otherwise bare, white walls.
Out the front door comes the sounds of an old typewriter being painstakingly tapped by André on his porch across the courtyard. A metal, rebar frame on the verandah houses a sagging, limp mosquito net. The cement railing has chipped paint and many missing blocks leaving some suspended virtually in mid air.
Out the side window one hears the sounds of twittering birds, scratching chickens and the mumbling of kids at play. A bare dirt yard has piles of raked weeds and leaves ready for burning and smoldering piles and ashes from this morning's burnings. Several guava trees have cracked leftover bricks arranged in something resembling circles around their trunks so they can be watered. An old clothesline is currently bare of its usually brightly colored African clothes or drably colored hospital scrubs. A rooster and a hen with her chicks scratch at the base of the newly watered trees.
The recently constructed wall is made of locally fashioned and fired mud bricks with sand-heavy mortar up to about 3 feet high where a thick, chain-link fence takes over. The heads of children are barely visible on the other side where they have gathered to drink from the hose draped over the bricks and through the chain-link to the outside. Some sort of game with a small deformed ball is being played to the side. An older boy rides by on a rickety bike with a hundred pound sack of rice tied to the back.
Behind the kids is our neighbor's stack of newly fired bricks. The mud bricks were assembled in a rough pyramid with holes on the outside layer and underneath where sticks were shoved and lit. All night long the family and neighbors gathered around the warm glow until morning brought a blackened outside crust housing bright red fired bricks within. The neighbors' mud brick, thatched houses weathered by years of rain rest just behind almost seeming a part of the natural landscape unlike our cement and tin roofed behemoths and rude metal fencing.
The elementary school is a few hundred yards off the corner of our fence, abandoned now in the hot, 120 degree afternoon. Everything seems oppressed by the heat. Even the air seems afraid to move lest it start to sweat or expend too much energy in providing its wind. The only thing unrestrained by the heat is the universally boundless energy of the kids, one of whom hangs casually off the chain-link while the rest have changed games slightly, now tossing the ball in the air in a circle with who knows what objective.
A man walks out of the hole in the neighbors wall serving as a door, leading three cattle. The cattle have huge, floppy humps between their shoulders and 2-3 foot long curved horns. A chain or rope through the nose allows these otherwise unpredictable steers to be guided even by a child. The man leads them off for some undetermined task:� perhaps hauling wood, carrying bricks, pulling a cart, or just to be watered and grazed.
In the kitchen, Sarah sits at her desk with white lace curtains behind her. She is intently flipping through pages scratching her neck with a pen. Her hair has been pulled up tightly and she wears a tank top in a vain attempt to escape some of the heat. A rooster crows. Ephraim calls for his papa. A boy runs past the fence with a stick pushing a rolling metal lid. The briefest of winds evaporates the sweat running down my back providing temporary refreshment.
The hospital is quiet but at any moment that dreaded clap-clap could appear on the porch in the form of a scrub-wearing, white-coated nurse calling me forth from my malaria-induced reverie back into the world of the Béré Adventist Hospital...
James
Saturday, April 9, 2005
More death... and darkness
Suddenly it's pitch black. Not a new occurrence, it happens every night around 8pm or so. Shortly thereafter there is also quiet as the generator shuts down. For some reason, though, it is darker than usual. Like being in a cave, turning off the flashlight and trying to see your hand in front of your face. We sit patiently waiting. Someone lights a match...
But what about the darkness in my soul, the blackness squeezing out any light from my soul?
Death has struck again. If you've wondered where that dark hooded guy with the sickle over his shoulder hangs out in his spare time...it's Béré.
I'm standing on the porch talking to two teenagers. They have come before seeking help with science homework. They've taken us to their church a few Sundays ago. They have come tonight just to talk. It's a Friday night. They wonder if I'll go to Lai tomorrow to see the President of the Republic who'll be there to inaugurate the bridge linking B�r� and Lai. Andre walks up. "Our president is dead." At first, I think he means the President we've just been talking about. He soon clarifies, "the president of our Mission."
I met Pastor Herimanana at an HIV conference last October in Bamenda, Cameroun. A down to earth guy, he had a real heart for the sick and hurting, especially those suffering from HIV/AIDS. At the time, we'd been half a year without a leader of our Mission here in Tchad. I couldn't help but think how cool it'd be if he could come to Tchad. I knew he'd be supportive of our hospital and provide honest, strong leadership. To my happy surprise, a few months ago he was named as the president of the Tchad Mission.
Thursday, he finished his visa paperwork in Yaound� and was on his way to Douala to catch his flight to Tchad when the driver lost control and he was killed on the highway.
Andre kept hitting his hand with his other hand crying out "c'est pas possible, c'est pas possible!" Looking at me he said, "the devil really must hate us here in Tchad." I had to agree.
The darkness descends.
I hear in morning report today that the little Arab boy with the burn on his chest wasn't doing well. His mom "bugged" the night nurse three times to go get the "Nasara" meaning me. We all had a good laugh.
On rounds, Sarah comes up and says the boy is yellow all over...jaundice...and his belly is hard. I'll be to see him in 5-10 minutes when I finish with the other patients.
5 minutes later I hear a small child scream and wail. I look outside. The cute little sister of our young patient is running around, throwing her self on the ground with the most heart-rending cries. A nurse comes to say the boy has died.
He's been with us for weeks. He'd been recovering. He'd come in dehydrated after a month of home treatment for burns on his chest, arms, hands and feet. Friday, he was a chubby, happy baby. His two little sisters are the cutest ever and love to play with Sarah and hang all over their doting dad. He always brings crackers in his pockets where even the littlest one knows to find them before he can even get his ritual Arabic greetings over with.
A large group of brightly clad Arab women in veils cry--sometimes sounding like laughter but one look at the face makes the distinction--and prepare to take away the corpse. The oldest little sister bangs her head on the ground tears streaming down her cheeks as a nurse tries to keep her from hurting herself by placing her head in the absorbent lap of an aunt...
And the baby? Now, he's a cooling body lying on his back, eyes staring into nowhere...into the darkness...
I return to rounds and stare blankly at the floor for awhile. None of the patients or staff says a word. They must wonder what's the problem, people die all the time, it's a part of life...a part I just can't get used to.
A few minutes later, the Financial Manager of our Health District comes in. He pulls me aside to inform me that our newly appointed "Chef" of the infant vaccination program died yesterday of AIDS. Also, Dagal, the nurse in charge of supervision of the health centers on my arrival who'd recently been relocated to Lai, also died of AIDS. Two of our colleagues in the same day. Yeah, I'd had my run-ins with Dagal, but at the same time I'd hear him occasionally mention God as if his life was a tug of war between two warring factions for his life...who knows who won in the end...it would appear the darkness of his reckless lifestyle...but God only knows...
I stumble on, groping, in the darkness...I find a little light, enough to finish rounds and head to the office where a letter awaits me in the hands of Andre.
Rahama has asked for a 5 day leave of absence to take her husband to see one of the more powerful witch doctors in the area for his eye problem. After some discussions with Rahama and Samedi I find myself walking through the dusty streets, past the mud brick houses of Anatole and Samedi, around the corner near the big mango tree, through the hole in the mud wall and onto the mat under the large shade tree in Rahama's courtyard.
Kemkoye invites us to sit. We do. Samedi and I are wearing matching light blue scrubs and Kemkoye has a brightly colored shirt on. His face is an expressionless puzzle. Thinking back, I wonder if I've ever seen anything not approaching a blank stare on that face. I start the conversation.
I tell him I must warn him that not only is he unlikely to find a lasting solution to his problem, but that he is messing with dangerous, and real, forces of darkness. Is it worth it, even to find a little relief? Or as Someone said years ago, to gain the world and lose one's soul? The mask stares past me. The red, cloudy eye pierces into some corner far away. He hedges and bets never changing the expressionless tone of his voice.
He says he can't afford to go to the Ophthalmologist. I offer to have him come with us in two days to N'Djaména...free of charge. Then, I mention having just seen that Doctors Without Borders has some Ophthalmologists in Kousseri, Cameroun, just across the border. I'll take him there personally I say. He doesn't want to be convinced. Samedi says a few words. Half an hour later we leave with him at least "considering it".
At 2pm, I see Rahama. She enters the office, face a storm cloud of darkness. Abruptly, she spurts it all out. He insists on going to the witchdoctor. She must go with him. She rises to go. She says she's at the breaking point of discouragement...her face shows it. She is hopeless. She says I should pray "beaucoup". As the door is about to close behind her she turns and says, "C'est entre vos mains, maintenant" (it's in your hands now) and without a look behind her she heads off into the increasing darkness of a sunny day.
I find myself that afternoon curled up in a ball on my mattress on the floor in the corner of my room. Music coming from the computer across the room tries to soothe my mind...in vain. The pillow is wet...not just sweat this time...but tears flowing from sobs of an uncomprehending soul desperately seeking answers from the one spot he's at least got a few in the past...Tossing and turning, I cry out in the midst of this present darkness...
James
But what about the darkness in my soul, the blackness squeezing out any light from my soul?
Death has struck again. If you've wondered where that dark hooded guy with the sickle over his shoulder hangs out in his spare time...it's Béré.
I'm standing on the porch talking to two teenagers. They have come before seeking help with science homework. They've taken us to their church a few Sundays ago. They have come tonight just to talk. It's a Friday night. They wonder if I'll go to Lai tomorrow to see the President of the Republic who'll be there to inaugurate the bridge linking B�r� and Lai. Andre walks up. "Our president is dead." At first, I think he means the President we've just been talking about. He soon clarifies, "the president of our Mission."
I met Pastor Herimanana at an HIV conference last October in Bamenda, Cameroun. A down to earth guy, he had a real heart for the sick and hurting, especially those suffering from HIV/AIDS. At the time, we'd been half a year without a leader of our Mission here in Tchad. I couldn't help but think how cool it'd be if he could come to Tchad. I knew he'd be supportive of our hospital and provide honest, strong leadership. To my happy surprise, a few months ago he was named as the president of the Tchad Mission.
Thursday, he finished his visa paperwork in Yaound� and was on his way to Douala to catch his flight to Tchad when the driver lost control and he was killed on the highway.
Andre kept hitting his hand with his other hand crying out "c'est pas possible, c'est pas possible!" Looking at me he said, "the devil really must hate us here in Tchad." I had to agree.
The darkness descends.
I hear in morning report today that the little Arab boy with the burn on his chest wasn't doing well. His mom "bugged" the night nurse three times to go get the "Nasara" meaning me. We all had a good laugh.
On rounds, Sarah comes up and says the boy is yellow all over...jaundice...and his belly is hard. I'll be to see him in 5-10 minutes when I finish with the other patients.
5 minutes later I hear a small child scream and wail. I look outside. The cute little sister of our young patient is running around, throwing her self on the ground with the most heart-rending cries. A nurse comes to say the boy has died.
He's been with us for weeks. He'd been recovering. He'd come in dehydrated after a month of home treatment for burns on his chest, arms, hands and feet. Friday, he was a chubby, happy baby. His two little sisters are the cutest ever and love to play with Sarah and hang all over their doting dad. He always brings crackers in his pockets where even the littlest one knows to find them before he can even get his ritual Arabic greetings over with.
A large group of brightly clad Arab women in veils cry--sometimes sounding like laughter but one look at the face makes the distinction--and prepare to take away the corpse. The oldest little sister bangs her head on the ground tears streaming down her cheeks as a nurse tries to keep her from hurting herself by placing her head in the absorbent lap of an aunt...
And the baby? Now, he's a cooling body lying on his back, eyes staring into nowhere...into the darkness...
I return to rounds and stare blankly at the floor for awhile. None of the patients or staff says a word. They must wonder what's the problem, people die all the time, it's a part of life...a part I just can't get used to.
A few minutes later, the Financial Manager of our Health District comes in. He pulls me aside to inform me that our newly appointed "Chef" of the infant vaccination program died yesterday of AIDS. Also, Dagal, the nurse in charge of supervision of the health centers on my arrival who'd recently been relocated to Lai, also died of AIDS. Two of our colleagues in the same day. Yeah, I'd had my run-ins with Dagal, but at the same time I'd hear him occasionally mention God as if his life was a tug of war between two warring factions for his life...who knows who won in the end...it would appear the darkness of his reckless lifestyle...but God only knows...
I stumble on, groping, in the darkness...I find a little light, enough to finish rounds and head to the office where a letter awaits me in the hands of Andre.
Rahama has asked for a 5 day leave of absence to take her husband to see one of the more powerful witch doctors in the area for his eye problem. After some discussions with Rahama and Samedi I find myself walking through the dusty streets, past the mud brick houses of Anatole and Samedi, around the corner near the big mango tree, through the hole in the mud wall and onto the mat under the large shade tree in Rahama's courtyard.
Kemkoye invites us to sit. We do. Samedi and I are wearing matching light blue scrubs and Kemkoye has a brightly colored shirt on. His face is an expressionless puzzle. Thinking back, I wonder if I've ever seen anything not approaching a blank stare on that face. I start the conversation.
I tell him I must warn him that not only is he unlikely to find a lasting solution to his problem, but that he is messing with dangerous, and real, forces of darkness. Is it worth it, even to find a little relief? Or as Someone said years ago, to gain the world and lose one's soul? The mask stares past me. The red, cloudy eye pierces into some corner far away. He hedges and bets never changing the expressionless tone of his voice.
He says he can't afford to go to the Ophthalmologist. I offer to have him come with us in two days to N'Djaména...free of charge. Then, I mention having just seen that Doctors Without Borders has some Ophthalmologists in Kousseri, Cameroun, just across the border. I'll take him there personally I say. He doesn't want to be convinced. Samedi says a few words. Half an hour later we leave with him at least "considering it".
At 2pm, I see Rahama. She enters the office, face a storm cloud of darkness. Abruptly, she spurts it all out. He insists on going to the witchdoctor. She must go with him. She rises to go. She says she's at the breaking point of discouragement...her face shows it. She is hopeless. She says I should pray "beaucoup". As the door is about to close behind her she turns and says, "C'est entre vos mains, maintenant" (it's in your hands now) and without a look behind her she heads off into the increasing darkness of a sunny day.
I find myself that afternoon curled up in a ball on my mattress on the floor in the corner of my room. Music coming from the computer across the room tries to soothe my mind...in vain. The pillow is wet...not just sweat this time...but tears flowing from sobs of an uncomprehending soul desperately seeking answers from the one spot he's at least got a few in the past...Tossing and turning, I cry out in the midst of this present darkness...
James
Friday, April 8, 2005
Scroti
"I just don't get it, why would anyone want to keep something like that at home?" Lona echoed all our thoughts. I mean, really, I ask you, how could one let one's scrotum get like that. Maybe a little bulge, but 3 liters!!!
I was called in as usual in the middle of the night for the emergency. It just started hurting yesterday. You never had any problems before? No, it just came on suddenly. No vomiting? No. What then? Pain, it hurts.
There is something strange about a man lying on an exam table wearing nothing but a wrap around skirt looking like he's hiding a small animal between his legs. As he gingerly lifts up his skirt I see a two-football sized scrotum emerge into view.
The first trick is to figure out if it's a hernia with intestines and other abdominal stuff inside or if it's just a hydrocele (a collection, often massive, of liquid around the teste that doesn't usually communicate with the abdomen) caused mostly by small parasites called filaria. I just stared in awe. I mean, we often make jokes about the size of the hydroceles that we see here, but this one takes the cake! Obviously, this didn't happen over the last few days. In fact, on further questioning he says it's been years! I ask you, would you...I don't get it...
We hospitalize him and schedule surgery during which we remove 3 liters of straw colored fluid then hack off a 10 inch hunk of scrotal skin with hydrocele attached, suture the rest around back of the testicule and somehow manage to get the rest sewed back together. Afterwards, it is far from aesthetically pleasing, but at least he can wear his skirt without bulging and walk without waddling bowlegged.
The next guy I wished was a hydrocele. His scrotum was only about a football size. This had been sudden...at least this episode. It all came out and he started vomiting and writhing in pain. He's had a hernia operated on years ago on the same side that had recurred over the last two years. He'd always been able to get it back in before but not now.
The scrotum was bulging at the inguinal area with bowel sounds audible and even the shape of the intestines visible through the skin. We knocked him out with Ketamine and Valium but soon realized it wasn't going back in. We rushed him to the OR and slashed a diagonal down across the mass, dissected into the hernia sac and found small intestine, cecum (large bowel) and appendix inside. All of them were looking a little dusky from being strangulated. Even then it wouldn't go back in. Finally, we had to cut the hernia bigger which pinked up the intestine and allowed it to finally be pushed inside after which the hole was closed.
For our third sac of the week, we have a young man with only a small half a football sized hernia suddenly that evening at 6pm. He came to us at 11pm. I was exhausted already and didn't want to have to operate that night. I gave him many good drugs. I pushed, I manipulated, I massaged, I wrung, I forced, I dripped great, big piles of sweat all over him, I twisted and pried and prodded until my hands, arms and fingers were cramping. I didn't see any progress after an hour. I prayed. I continued in desperations. I didn't feel I had the strength. Slowly, I felt wiggling and heard some gurgling. It started to go in. I persisted 20 more minutes and with the help of the nurse it finally went in. What joy to feel that final sucking in and see the scrotum normal (a rare site here)!
A running joke here is my famous saying, "that's the beauty of the scrotum". Kind of sarcastic in a way, but even something as gnarly and nasty as the scrotum does have its amazing qualities. When one cuts into the scrotum, the skin and muscles contract up to close the wound almost making stitches superfluous. But in the face of the above cases, I ask you, is there really such a thing? And wouldn't you seek help sooner if it was you...seriously...wouldn't you?
James
I was called in as usual in the middle of the night for the emergency. It just started hurting yesterday. You never had any problems before? No, it just came on suddenly. No vomiting? No. What then? Pain, it hurts.
There is something strange about a man lying on an exam table wearing nothing but a wrap around skirt looking like he's hiding a small animal between his legs. As he gingerly lifts up his skirt I see a two-football sized scrotum emerge into view.
The first trick is to figure out if it's a hernia with intestines and other abdominal stuff inside or if it's just a hydrocele (a collection, often massive, of liquid around the teste that doesn't usually communicate with the abdomen) caused mostly by small parasites called filaria. I just stared in awe. I mean, we often make jokes about the size of the hydroceles that we see here, but this one takes the cake! Obviously, this didn't happen over the last few days. In fact, on further questioning he says it's been years! I ask you, would you...I don't get it...
We hospitalize him and schedule surgery during which we remove 3 liters of straw colored fluid then hack off a 10 inch hunk of scrotal skin with hydrocele attached, suture the rest around back of the testicule and somehow manage to get the rest sewed back together. Afterwards, it is far from aesthetically pleasing, but at least he can wear his skirt without bulging and walk without waddling bowlegged.
The next guy I wished was a hydrocele. His scrotum was only about a football size. This had been sudden...at least this episode. It all came out and he started vomiting and writhing in pain. He's had a hernia operated on years ago on the same side that had recurred over the last two years. He'd always been able to get it back in before but not now.
The scrotum was bulging at the inguinal area with bowel sounds audible and even the shape of the intestines visible through the skin. We knocked him out with Ketamine and Valium but soon realized it wasn't going back in. We rushed him to the OR and slashed a diagonal down across the mass, dissected into the hernia sac and found small intestine, cecum (large bowel) and appendix inside. All of them were looking a little dusky from being strangulated. Even then it wouldn't go back in. Finally, we had to cut the hernia bigger which pinked up the intestine and allowed it to finally be pushed inside after which the hole was closed.
For our third sac of the week, we have a young man with only a small half a football sized hernia suddenly that evening at 6pm. He came to us at 11pm. I was exhausted already and didn't want to have to operate that night. I gave him many good drugs. I pushed, I manipulated, I massaged, I wrung, I forced, I dripped great, big piles of sweat all over him, I twisted and pried and prodded until my hands, arms and fingers were cramping. I didn't see any progress after an hour. I prayed. I continued in desperations. I didn't feel I had the strength. Slowly, I felt wiggling and heard some gurgling. It started to go in. I persisted 20 more minutes and with the help of the nurse it finally went in. What joy to feel that final sucking in and see the scrotum normal (a rare site here)!
A running joke here is my famous saying, "that's the beauty of the scrotum". Kind of sarcastic in a way, but even something as gnarly and nasty as the scrotum does have its amazing qualities. When one cuts into the scrotum, the skin and muscles contract up to close the wound almost making stitches superfluous. But in the face of the above cases, I ask you, is there really such a thing? And wouldn't you seek help sooner if it was you...seriously...wouldn't you?
James
Heat
I have never known what heat was. I thought that maybe living in Florida qualified me as an expert. Maybe visiting the deserts of southern Cal or living on the Amazon. I imagined that maybe after a year in sub-Saharan Africa I had some kind of idea about being hot. But now, I know. There is a reason why Béré is in the part of Africa called the Sahell.
Imagine. Over 130 degrees Fahrenheit. A cool evening is 96 degrees inside. Sweat is your constant companion. In surgery, with the air conditioner running full blast you soak your scrubs and drip sweat onto your patient despite your best efforts at sterile technique. Drinking water becomes your obsession. You feel a strong desire to fall to all fours and join the goats at the salt lick. Sleeping is an impossibility as you must flip your pillow every half hour to let the soaked side dry out. The stillness of the night with its hanging heat and dust weighs you down.
The newly remodeled clinic building is a little cooler with its aluminum roof instead of galvanized steel. Running the generator during the day instead of at night lets us use the ceiling fans which bring a little relief. Amazingly, a hand crafted clay jar makes our drinking water at least not hot, and comparatively cool. No fridge means food doesn't last. But one doesn't feel like eating anyway.
Sarah manages to find some ice in the vaccine fridge today and I have a brief epiphany of joy as the ice cold water flows into me. The only other true ecstasy is the couple of minutes after a surgery of placing my sweat soaked face and hair in front of the air conditioner about 5 inches from the vents and letting the cool air pour over me until the generator is shut off...and it's back, suffocatingly, unrelieved by wind or night...the searing life that is the Sahel in Béré...
James
Imagine. Over 130 degrees Fahrenheit. A cool evening is 96 degrees inside. Sweat is your constant companion. In surgery, with the air conditioner running full blast you soak your scrubs and drip sweat onto your patient despite your best efforts at sterile technique. Drinking water becomes your obsession. You feel a strong desire to fall to all fours and join the goats at the salt lick. Sleeping is an impossibility as you must flip your pillow every half hour to let the soaked side dry out. The stillness of the night with its hanging heat and dust weighs you down.
The newly remodeled clinic building is a little cooler with its aluminum roof instead of galvanized steel. Running the generator during the day instead of at night lets us use the ceiling fans which bring a little relief. Amazingly, a hand crafted clay jar makes our drinking water at least not hot, and comparatively cool. No fridge means food doesn't last. But one doesn't feel like eating anyway.
Sarah manages to find some ice in the vaccine fridge today and I have a brief epiphany of joy as the ice cold water flows into me. The only other true ecstasy is the couple of minutes after a surgery of placing my sweat soaked face and hair in front of the air conditioner about 5 inches from the vents and letting the cool air pour over me until the generator is shut off...and it's back, suffocatingly, unrelieved by wind or night...the searing life that is the Sahel in Béré...
James
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