The longest day...

Hello,

I'm on the road to Bere again. It has been a grueling and psychologically draining three days in N'Djamena. There's a reason why Tchad was voted the world's most corrupt country in 2005. I spent three days shuffling from bureau to bureau, from office to office, getting papers, having letters signed, arguing, bargaining, yelling, manipulating, threatening, shaming, pleading. Finally, I was so discouraged I just wanted to get on a plane and leave. We had found a donor willing to treat the AIDS patients in our district with anti-retroviral medications. For a year and a half we had tried to get the authorization to import. Finally, they had arrived and I was blocked by greedy, money hungry, grasping hands all around wanting a piece of the pie. No one cared that the meds were to be given away free. No one cared that it was to help their country. Finally, through the intervention of some friends and God, we got the medicines out of airport warehouse and now I'm on the road back to the hospital.

Sarah and I had slept the night in K�lo after arriving late. Now, the sun has just come up. The air is cool. The sky is an early morning bluish gray. There are mounds of fluffy clouds stacked like pancakes and the sun is shining its rays in a descending pyramid from a hole in the clouds. The road is red. The bush is green. The millet is starting to push through the earth. The goats and pigs are tied up. The bicycles are just getting on the road with their cargo tied on back: anything from fuel to sacks of charcoal to live animals to people. The women are starting the daily walk to and from the well with huge pots and basins balanced easily on their heads as their bodies sway with a rhythm only possible for someone who has carried heavy weights on his skull for years.

The evidence of vigor and life and courage and hardiness and strength and newness and hope is all around. I feel the weight of the last week slip from me and I feel excitement course through my veins as I think of what we can do now for the most marginalized of Africans, the AIDS patient.

Little do I know that this day will not end until well after midnight.

I pull into the hospital compound, run in for a quick shower, change into scrubs, and head over to the hospital for worship. It is 7:30 a.m.

By 8:00 a.m. the waiting room is already packed full of patients and I'm on my way to see the hospitalized ones. There is one mother that Samedi had done a c-section on who is doing well. I send her home. A young man with an intestinal obstruction also operated on by Samedi during my stay in N'Djamena is passing gas so I advance his diet. A man with an infected testicule taken out by Samedi three days ago is sent home.

I come up to a 17-year-old Arab boy. He is skin and bones except for an amazingly distended abdomen. I tap it with my fingers and it resonates like a bouncing basketball in an empty gym. I fill out the operation order sheet and send the family off to pay for surgery. We then approach Jacques, the man whose leg I had amputated through the knee a week ago. His wound is foul-smelling and pus-filled with black, dead muscle hanging out the ends. I send him off with Samedi to the OR to be debrided.

I continue on to Pediatrics. The one-month-old we'd done a laparotomy on last week has a wound dehiscence with part of his intestine sticking out. I prepare him to go back to the OR as well. I finish with the other patients and go to see Samedi. He has Jacques on the bed, knocked out with Ketamine.

He shows me that there is pus all the way up his thigh that he is squeezing down and out through the stump of the amputation. We haul him into the main operating room, tie a tourniquet around his upper thigh, and prepare him for surgery.

I pull on the gloves, put on the drape, and grab a large scalpel between my fingers. Samedi prays and I slash down his mid thigh to bone. I continue cutting quickly all around 'til I cut through the main artery and vein which I then clamp and tie off. I grab the small hand saw and as Samedi retracts the muscles out of the way I saw through his femur. I close the bottom part of the muscle flap leaving the top and entire skin wound open for dressing changes. As we finish, our med student, Aaron, goes out to get the gurney but comes back quickly to say there's a women there having seizures as the nurses desperately try to find an IV and take her vital signs.

I pull off my gloves as Samedi, Sarah, and Aaron clean up and find the other gurney to take Jacques back to his bed. The women is in her early twenties and is pregnant with her fourth child. Her blood pressure is 160/110 and she is combative. We can't find the baby's heart beat. We give her magnesium and take her directly into surgery.

A few minutes later I pull out a baby girl. As her head pops out of the abdominal incision she starts to gasp and her arms start to move. I suction out her nose and mouth, clamp and cut the umbilical cord, and hand her off the Sarah who soon has her screaming that beautiful newborn "I'm alive and not sure I like it" wail. I close up the uterus, fascia, and skin, and go out to see a few patients while the OR team takes the patient out, cleans up, and prepares for the next patient.

The Arab boy's family hasn't yet paid so we take in the one-month-old with the wound dehiscence. I open up the wound a little more to find the extent of the wound breakdown. Then, Samedi pushes in the intestines and holds them in while I put a nice big suture bite through skin, fascia and peritoneum and slowly bring the wound back together. The baby is so tiny that even with skin and fascia and peritoneum together the layer is only a few millimeters thick. I finish and put a sterile dressing on.

After seeing all the outpatients I finally go home at 4:30pm and eat for the first time since 6:00am that morning. I'm exhausted. Fortunately, the Arab family hasn't paid yet as I'm too tired to even think of doing another operation.

At six, Samedi comes to the house to say he's going to Kelo in the morning. I get a little nervous as the Arab boy needs to be operated on and without Samedi, it'll be very difficult. No one else really has much experience with assisting on big cases. I ask Samedi if he'll go see the family with me. They say they have sent someone to get a cow to sell in the market and they'll get us the money Saturday. Can't we just do it now? I think he needs it urgently as his belly is really bloated and he is already wasting away. I look to Samedi and he nods. We call in the team and take him to the OR.

As I stand after the prayer poised to cut I wonder what I'll find: a sigmoid volvulus? Small bowel obstruction? Tumor? Mass of worms? Nothing I imagine is close to what I find.

I cut carefully down from his rib cage to below his belly button. The skin is thin and he has no fat. Before I know it I'm in the abdomen and I see a huge, shining white mass: an immensely distended colon! I open the belly completely and find that his colon is the size of a six foot long boa constrictor who has just had several nice big meals. Starting from his rectum the Sigmoid stretches up all the way to his stomach and then back again to the bottom of his pelvis and then the descending colon starts which is the same size and goes up to his spleen where the football sized intestine continues over to under his liver where suddenly it gets a little smaller. His small intestines are completely flat like a pile of small tapeworms piled in the center of his otherwise massive abdominal cavity.

I have to remove his colon. It looks like the rectum is ok so I start at the sigmoid and start to clamp, cut and tie off the blood vessels. He is so malnourished that the arteries and veins are easily identified due to the absolute lack of fat. After over four hours of careful dissecting, cutting, clamping, and tying I have an over six foot piece of colon out on the table filled with air and stool weighing well over 20 kg. I have Aaron take plenty of pictures as I hold it up like a fisherman holds up a prize deep sea catch.

I then free up the corner of the part of transverse colon that is left and bring it down to reattach it to the rectum. It is so bizarre to look in a two foot abdominal incision on a now almost empty cavity. I put in a drain and close up the fascia and skin. I attach suction to the drain and watch his belly descend to a massively concave emaciated state that matches perfectly the rest of his malnourished body. We finish a little before 1:00 a.m.

I go home, eat some beans and rice, drink a liter of juice, take a shower, and hit the sack. I'm asleep before my head hits the pillow.

James