Friday, December 29, 2006

Pus Surprise

I can feel my heart start to beat a little faster in anticipation. My mouth starts to water and I hope I don't drool. The suspense is killing me! Every time I see someone with some kind of rag draped over a body part or waddling in like a sore cowboy after a long ride wearing nothing but a wrap draped around the waist, I can't help but wonder, what gross thing am I going to get to cut open or take out next?

Friday, it's an eight-year-old boy from Kélo. The father brings him in his arms. The right leg is draped in an army green rag that was probably a shirt at one point. The air gets a little thicker and I'm glad for my cold that dampens the odors. I quickly pull out the strip of paper to cover the exam table. The rag is hanging wet and limp. As soon as the boy is put down I regret having brought him into my office as the paper is starting to soak up whatever foul liquid is oozing from whatever it is under that "bandage." I hurriedly pick him back up myself and take him outside to the gurney where I gingerly lift up the cloth to reveal...

Saturday night, it's a quiet shake from my wife. Sarah's on night duty and I am feeling drugged from fatigue. The last two weeks we've been doing 2-3 surgeries a day and it's taking it out of me. She's saying something about a teenager who has no lung sounds on one side. I seriously can't wake up. I'm trying but it's like I took a sleeping pill. I mumble something about sticking a needle in over the rib and seeing if there's liquid or air making the lung collapse. I tell her if there's air to come get me, if liquid than I'll see him in the morning. I wake up early Sunday morning wondering what I'll find as I walk over to the hospital in the coolness and stillness of an early African morning...

Monday, two guys waddle into my office wearing only skirts. They've both come from far away. I can hardly contain my excitement as I ask them to lie down on the exam table and fumble with the knot attaching the cloth skirt to their waist. As I slowly un-wrap it to look I find just what I was expecting...

Tuesday, I operate on a woman who'd come in the Thursday before. She had a cloth wrapped around her mid-abdomen. She'd been sick for a month with pus draining from a small hole (fistula) in her belly button. As I am poised with my scalpel after the pre-op prayer, I wonder what I'll find inside. I quickly slice down from her belly button to her pelvis. To my surprise, I find...

Wednesday, Sarah comes running up to me with an amazed grin on her face. "James, you have to see this guy's arm. It's three times the usual size." I walk into the clinic and see an elderly man with whitening hair and beard on his rugged face lying moaning on a stretcher on the floor. His left arm is wrapped in a rag that at one time ages ago was probably white. From finger tips to mid upper arm I can see nothing. The upper arm to the shoulder is swollen to three times the size of the other arm. As I grab some gloves and bend over to unwrap it and take a look I have a feeling I might find... sure enough, as I snap off the gloves and order him to surgery...

One of the glorious benefits of working in a bush hospital is the phenomenon of pus surprise. No matter how often I see it. No matter how often I suspect it. No matter how often I have to really search for it... I always find it. Seek and ye shall find is my motto for tropical pus explorers. It is usually deeper than you think... but it's always there. But why this rush when I suspect it or the anticipation when I suspect it's there hidden under some rag? Maybe I'm weird, but few things bring instant gratification like liberating some imprisoned pus.

The boy's leg is a fungating, purulent mass surrounding his entire lower leg with the exception of his foot which is swollen and edematous. I take him to surgery, wrap a blood pressure cuff around his upper thigh and slice down to his tibia. I then cut up his tibia taking off his patellar tendon from the bone. That opens up his knee joint where I cut through the ligaments and menisci exposing his patellar space. There is barely a drop of blood anywhere thanks to the tourniquet. I divide and tie his vessels and cut through his sciatic nerve. I then slice down leaving some muscle for the flap. Israel lifts off the leg under the drape while I attach the patellar tendon to the posterior cruciate ligament. I then suture the flap closed and put a dressing and ace wrap on. While I didn't get to directly liberate pus, I did get to cut it off.
Three days later he's already up on crutches moving around on his own. Sarah has been giving him books to read and crayons to draw and he is quite smart and a talented artist. He talks almost nonstop without fear. The only time he expressed any reserve was after I took the dressing off and was going to replace the bandage. In a tiny, timid voice he begged "please, not too tight, it hurts."

As I enter the OR, Sarah has already prepared the young man for his chest tube. I infiltrate around the ribs between his nipple and his armpit. I slice down to muscle and then poke up and over the rib with a curved clamp. I feel the pop. I see the stream of liquid pus squirt up. Most severely, I am almost floored by the pungent force of the odor that escapes with the pus geyser. I smell plenty of body fluids and odors in my work but this one I can barely take. It's not that I feel nauseated, I just feel like I really don't want to breathe that one more second. I try to hold my breath as I grab the large bore chest tube with the clamp and push it in over the rib and into the pleural space. I then attach the drainage chamber and suture the tube in place. The damage has been done, though, and I think I have never attached and wrapped a chest tube in place faster in my life before bursting out for a breath of fresh air. The block isn't the same for days, despite our best efforts at deodorizing.

Tuesday, I operate on the two skirt-wearing gentlemen. Out of the first, I take a newborn-baby-sized hydrocele with his testicule and cord ensemble. It's the only way for a man to really experience the joys of childbirth as we push the hydrocele out of the incision into the air I almost expect to hear a baby's cry. The joy is about the same for either. The second, I cut into his scrotum, expecting the same pleasurable result only to realize it's actually an extremely large hernia. Changing strategy mid-operation, I open up his inguinal canal but with the size of the defect and sac I'm obligated to take out his testicule and cord as well. Well, it's almost as good as pus!

Unfortunately, as I follow the fistula down from the woman's umbilicus I find it leads to the bladder which is filled with friable tumor which I scrape out as much as I can. I know that this is a very advanced cancer that I can do nothing about so I'm forced to close up and give the family the bad news. Sometimes the surprise is a bad surprise...especially when there's something besides pus. If you find pus, you can usually do something about it. If you find cancer...
I lift off the rags from the man's arm. The whole arm is three times the usual size. The skin on the back of his hand is like the bladder from a basketball that is half-filled with water. It pokes in and bounces out as if there's nothing but liquid inside. His skin is peeling off in many places and in others is like wet cornmeal that crumbles off when rubbed. He has blisters in spots and holes leaking pus in a few spots. We inject Diazepam and Ketamine to put him under and I incise down the back of his wrist. Yellow and red liquid seeps out. I extend the incision towards his shoulder with scissors. The skin is thin and like rubber with nothing attached underneath all the way to the elbow. There is just a little yellow jello like substance that melts away with pressure like a jellyfish caught on the beach on a hot summer day. I find what used to be muscle or fat but is now just a fibrous mass the consistency of sponge cake which dissolves into pus when my fingers dig into it searching for the limits of the infection. I pull up mats of this spongy pus leaving anatomy I haven't seen since cadaver lab in Gross Anatomy my first year of med school. All the superficial veins are intact and thrombosed. A fine net of superficial nerves remains draped over the veins. All the tendons and aponeuroses are exposed on the back of the hand leaving skin covering the fingers like an inverted weight lifter's glove. When I finish debriding the wound it extends from the base of the fingers to above the elbow and half way around the circumference of the arm on both sides. The other side of the arm, while swollen, doesn't appear to be necrotic or pus-filled.

We wrap up the arm in diluted bleach soaked lap sponges and wrap it tightly with an ACE wrap before letting off the blood pressure cuff tourniquet. There is some brisk bleeding near the elbow that I compress while sending Siméon to get a sand bag. A family member soon comes with a piece of cloth filled with a few kilos of sand that I place over the bleeding part to compress it and we take him out to his bed.

I'll never forget the pleasant sensation of feeling my fingers dig into that mass of necrotic fat and muscle squeezing out the pus along the length of the man's arm. To get all that nastiness out is a source of great satisfaction. I pray that with dressing changes and powerful antibiotics we'll be able to save his arm by liberating his pus surprise!

James

Darkness II

One minute I'm eating my Danish tuna pasta salad garnished with circles of fresh green pepper and the next I can't even see my hand in front of my face. Then, silence abruptly descends as the motor driving the generator is shut off. With the increasing silence, the sounds of mourning increases as well. The wails and shrieks and moans that have become all too common and yet still cut deep into my psyche with their piercing hopelessness come from directly behind our house.

It must be our neighbors. It must be the family of Allawaye, the father of "Naked Boy" and "One Armed Boy", our little neighbors with self-explanatory names (although "Naked Boy" has recently transformed himself into "T-shirt and Sometimes Pants Boy"). Allawaye's third wife's little one-year-old was recently hospitalized for meningitis and treated with a full course of IV Chloramphenicol. At discharge, the fontanel was normal, there was no fever, and the child was breastfeeding and otherwise acting cured. Three days later, the child came back seizing and with a tense fontanel. The H. flu bacteria infecting his little cerebral spinal fluid was resistant. We had no other good alternative but did what we could.

Last night, David came to talk to me.

"Allawaye's wife came to the gate with the child insisting on going home. I told them to wait until morning."

This morning, I enter the peds ward and see Allawaye with two of his wives including the mother of the child with meningitis. The mother looks down the whole time and has a scowl on her face. The baby is breastfeeding... an improvement from two days ago when I was forced to put in a feeding tube. The fontanel has become less tense. I start to explain to Allawaye that while the baby is still sick and could die, there are some positive signs. Just then the other wife pipes up with a low, vicious voice and an evil glare. The nurse translates her Nangjere. She insists on going home. The child isn't better. Our treatments haven't worked. It's time to consult the witchdoctor.

I make her leave and continue to explain to Allawaye why I think the child should stay in the hospital. He seems to understand and agrees to finish treatment. The mother of the child continues to act like we're trying to torture her child by asking him to stay.

I offer to pray for the child and they accept. I'm desperate for God to prove that it's not some witchcraft that is making the child sick (although, I guess one could say all sickness originates with our enemy, the devil). I ask that God continue to heal the child. We've done our best but with the limit in our arsenal of antibiotics we need a miracle.

Now, in the crying, wailing, and yelling coming from next door I'm afraid God has once again not intervened.

Siméon told me this evening another related tall tale.

On Friday, a boy from lie presents with a leg wound "treated" for 18 days at the Kélo Hospital. All I see is a fungating mass encompassing his entire lower leg between the knee and ankle. The foot is swollen and the eight-year-old is in obvious pain. We take him immediately to surgery.
His leg is doubled up in contractures from weeks of not moving so I prop up the leg with rolled up towels after giving him his spinal anesthetic. He is naturally afraid, but curious at the same time. I feel his eyes on my every movement. I put on my sterile gloves and attach sterile towels around the legs, leaving just the knee exposed. I'm about ready to start, but then Israel asks if I'm going to let the boy watch. I look over and see him still staring at me in wonder tinged with anxiety.

I ask for a sterile drape as well so that the surgical site can be hidden from the boy's view. Israel pumps up the blood pressure cuff around his thigh to 260 and then I pray before starting. I imagine in my head the two flaps I want to create and then slice down to bone across the anterior tibia. I retract up the skin flap with forceps and slice up the bone cutting off the patellar tendon from its attachment. I then enter the knee joint and cut across the menisci and the ligaments. There is no blood thanks to the tourniquet. The only things holding the leg on now are the popliteal blood vessels, the sciatic nerve and the posterior muscles. I dissect a little around the vessels and clamp and tie them off before cutting them loose along with the nerve. I then slice inferiorly to leave a muscle flap and have Israel pull off the leg from under the drape. He tosses it in the trash as I sew up the two flaps and wrap an Ace bandage around the wound.

As I'm about to leave the OR after the boy has been taken out and we've cleaned up, I pause over the trash can. It's in the middle of the floor filled with plastic IV bottles, tubing, tape, gauze, plastic drapes and an upside down, normal looking foot sticking straight out like someone has been dumped in there upside down. I'm reminded of Samedi's tale during the time of Dr. Kip when they did a ton of amputations and dumped the body parts in a pit behind the hospital. One day, after a rain, a woman came running into the compound screaming that someone had drowned in the now water-filled pit. All she saw was a foot sticking out and was sure there had to be a body attached somewhere in the water. I get the same feeling now as I stare down at the bottom of the boy's foot so recently attached to a living body.

Now, for the tale: apparently, Siméon had to listen to this boy talk and talk all day long the following day. He wouldn't keep quiet and told Siméon how his leg got infected. His dad sent his mom away shortly after he was born and married another woman. According to the boy, the woman is a sorceress who transforms herself into a cat. A few months ago, she had it out for the boy so she became a cat and bit his leg which subsequently got "poisoned" and that's why it didn't heal and had to be cut off. It was natural since it had been cursed by his witch stepmom.

The problem is, these stories are not uncommon. Most people's idea of cause of disease here is that it's witchcraft and someone has "poisoned" them or cast a spell on them or performed some sorcery against them. Therefore, usually some sort of "traditional" treatment has been tried before they are brought to the hospital in the throes of death. Then, the hospital is blamed when the patient dies.

As I sit in the darkness listening to my neighbors trying to appease the spirit of the departed child, dead from meningitis, I feel frustrated and hopeless. How can one fight against not only the forces of physical disease in a resource poor setting, but against the forces of ignorance and the forces of darkness? It seems sometimes that they want the person to die to prove that they were right that it was some witchcraft and that our medicines are useless. I've seen people go out of their way to discourage a patient and tell them they're going to die and after I've spent so much time trying to get them to be encouraging and hopeful, when the person finally does die, largely in part to the psychological attacks of their family, they go out of their way to say "I told you so. I knew they would die, but you kept insisting they had a chance. See, I was right and you were wrong." Nothing that I've experienced here comes close to that for discouraging.

After lighting a kerosene lamp to bring a little light to the darkness of my room, I pull out my Bible. Finally, I find what I'm looking for, but in a surprising place: right after the most famous verse in the Bible, John 3:16. "This is the verdict: Light has come into the world, but men loved darkness instead of light because their deeds were evil." John 3:19.

Yes, I can understand a little God's dilemma. He can't "mess with free will" (as he says in the movie "Bruce Almighty"). In other words, Satan has an advantage: he can use fear, force, superstition, manipulation, coercion, brutality, etc. God can't. And because I've aligned myself on God's side, I can't use those things either. As much as I'd like to take some parents by the neck and shake them until they realize they need to bring their kids to the hospital when they first become sick rather then when they're on death's door, I can't. I have to try to persuade them. But, I've found it amazingly true that men (and women) really do love the darkness rather than the light... and it's so frustrating realizing there's nothing one can do about it except continue to fight, even if it seems like a losing battle, to continue to fight, because who knows, maybe one or two will see the light and come out of the darkness...

James

Thursday, December 28, 2006

Darkness

One minute I'm eating my Danish tuna pasta salad garnished with circles of fresh green pepper and the next I can't even see my hand in front of my face. Then, silence abruptly descends as the motor driving the generator is shut off. With the increasing silence, the sounds of mourning increases as well. The wails and shrieks and moans that have become all to common and yet still cut deep into my psyche with its piercing hopelessness come from directly behind our house.

It must be our neighbors. It must be the family of Allawaye, the father of "Naked Boy" and "One Armed Boy", our little neighbors with self-explanatory names (although "Naked Boy" has recently transformed himself into "T-shirt and Sometimes Pants Boy"). Allawaye's third wife's little one year old was recently hospitalized for meningitis and treated with a full course of IV Chloramphenicol. At discharge, the fontanel was normal, there was no fever and the child was breastfeeding and otherwise acting cured. Three days later, the child comes back seizing and with a tense fontanel. The H. flu bacteria infecting his little cerebral spinal fluid was resistant. We had no good other alternative but did what we could.

Last night, David comes to talk to me.

"Allawaye's wife came to the gate with the child insisting on going home. I told them to wait until morning."

This morning, I enter the peds ward and see Allawaye with two of his wives including the mother of the child with meningitis. The mother looks down the whole time and has a scowl on her face. The baby is breastfeeding...an improvement from two days ago when I was forced to put in a feeding tube. The fontanel has become less tense. I start to explain to Allawaye that while the baby is still sick and could die, there are some positive signs. Just then the other wife pipes up with a low, vicious voice and an evil glare. The nurse translates her Nangjere. She insists on going home. The child isn't better. Our treatments haven't worked. It's time to consult the witchdoctor.

I make her leave and continue to explain to Allawaye why I think the child should stay in the hospital. He seems to understand and agrees to finish treatment. The mother of the child continues to act like we're trying to torture her child by asking him to stay. I offer to pray for the child and they accept. I'm desperate for God to prove that it's not some witchcraft that is making the child sick (although, I guess one could say all sickness originates with our enemy, the devil). I ask that he continue to heal the child. We've done our best but with the limit in our arsenal of antibiotics we need a miracle.

Now, in the crying, wailing and yelling coming from next door I'm afraid God has once again not intervened.

Siméon told me this evening another, related tall tale.

Friday, a boy from lie presents with a leg wound "treated" for 18 days at the Kélo Hospital. All I see is a fungating mass encompassing his entire lower leg between the knee and ankle. The foot is swollen and the eight year old is in obvious pain. We take him immediately to surgery.

His leg is doubled up in contractures from weeks of not moving so I prop up the leg with rolled up towels after giving him his spinal anesthetic. He is naturally afraid and curious at the same time. I feel his eyes on my every movement. I put on my sterile gloves and attach sterile towels around the legs leaving just the knee exposed. I'm about ready to start, but then Israel asks if I’m going to let the boy watch. I look over and see him still staring at me in wonder tinged with anxiety.

I ask for a sterile drape as well so that the surgical site can be hidden from the boy's view. Israel pumps up the blood pressure cuff around his thigh to 260 and then I pray before starting. I imagine in my head the two flaps I want to create and then slice down to bone across the anterior tibia. I retract up the skin flap with forceps and slice up the bone cutting off the patellar tendon from its attachment. I then enter the knee joint and cut across the menisci and the ligaments. There is no blood thanks to the tourniquet. The only things holding the leg on now are the popliteal blood vessels, the sciatic nerve and the posterior muscles. I dissect a little around the vessels and clamp and tie them off before cutting them loose along with the nerve. I then slice inferiorly to leave a muscle flap and have Israel pull off the leg from under the drape. He tosses it in the trash as I sew up the two flaps and wrap an Ace bandage around the wound.

As I'm about to leave the OR after the boy has been taken out and we've cleaned up, I pause over the trash can. It's in the middle of the floor filled with plastic IV bottles, tubing, tape, gauze, plastic drapes and an upside down, normal looking foot sticking straight out like someone has
been dumped in their upside down. I'm reminded of Samedi's tale during the time of Dr. Kip when they did a ton of amputations and dumped the body parts in a pit behind the hospital. One day, after a rain, a woman came running into the compound screaming that someone had derowned in the now water-filled pit. All she saw was a foot sticking out and was sure there had to be a body attached somewhere in the water. I get the same feeling now as I stare down at the bottom of the boy's foot so recently attached to a living body.

Now, for the tale: apparently, Siméon had to listen to this boy talk and talk all day long the following day. He wouldn't keep quiet and told Siméon how his leg got infected. His dad sent his mom away shortly after he was born and married another woman. According to the boy, the
woman is a sorceress who transforms herself into a cat. A few months ago, she had it out for the boy so she became a cat and bit his leg which subsequently got "poisoned" and that's why it didn't heal and had to be cut off. It was natural since it had been cursed by his witch stepmom. The problem is, these stories are not uncommon. Most people's idea of cause of disease here is that it's witchcraft and someone has "poisoned" them or cast a spell on them or performed some sorcery against them. Therefore, usually some sort of "traditional" treatment has been tried before they are brought to the hospital in the throes of death. Then, the hospital is blamed when the patient dies.


As I sit in the darkness listening to my neighbors trying to appease the spirit of the departed child, dead from meningitis, I feel frustrated and hopeless. How can one fight against not only the forces of physical disease in a resource poor setting, but against the forces of ignorance and the forces of darkness? It seems sometimes that they want the person to die to prove that they were right that it was some witchcraft and that our medicines are useless. I've seen people go out of their way to discourage a patient and tell them they're going to die and after I've spent so much time trying to get them to be encouraging and hopeful, when the person finally does die, largely in part to the psychological attacks of their family, they go out of their way to say "I told you so. I knew they would die, but you kept insisting they had a chance. See, I was right and you were wrong." Nothing that I've experienced here comes close to that for discouraging.

After lighting a kerosene lamp to bring a little light to the darkness of my room I pull out my Bible. Finally, I find what I'm looking for, but in a surprising place: right after the most famous verse in the Bible, John 3:16. "This is the verdict: Light has come into the world, but men loved darkness instead of light because their deeds were evil." John 3:19.


Yes, I can understand a little God's dilemma. He can't "mess with free will" (as he says in the movie "Bruce Almighty"). In other words, Satan has an advantage: he can use fear, force, superstition, manipulation, coercion, brutality, etc. God can't. And because I've aligned myself on God's side, I can't use those things either. As much as I'd like to take some parents by the neck and shake them until they realize they need to bring their kids to the hospital when they first become sick rather then when they're on death's door, I can't. I have to try and persuade them. But, I've found it amazingly true: men (and women) really do love the darkness rather than the light...and it's so frustrating realizing there's nothing one can do about it except continue to fight, even if it seems like a losing battle, to continue to fight, because who knows, maybe one or two will see the light and come out of the darkness...

James

Der

I'm walking back from the hospital. I've just finished late Sunday morning rounds and plan on doing some emails or computer work. I see André standing by the gate. I waltz up and ask him what's going on. He's dressed in a light blue and white full jogging suit like he's about to head out
to warm up for some match.

"We're going to Der to visit Daniel. We haven't seen him in awhile and we heard he was deathly sick. Pierre, David and I are going as soon as David gets here."

Daniel is one of the teachers at our school. I instantly am impressed I should go. The words of my late brother, David, come to mind: "do what's important, not what's urgent." I decide this is important.

I put on my swimming suit and a t-shirt and grab the keys for the truck.

Pierre, André, Doumpa and David pile in and we head across Béré till we find a narrow, sandy track out of town heading more or less west. We go until we hit water.

"It only gets worse," remarks David, "We'll be up to our knees at least. Everything is flooded this year." There's no room to turn around but I try anyway and immediately get stuck in the thick mud of the adjacent rice field. The guys easily push me out but I decide I'll just have to back out when we get back. Little did I know how hard that would prove to be. We tumble out and I lock up.

The day is beautiful. The sky is blue like a Pacific atoll on a calm day. Billowy white clouds add character making the sky seem infinite, yet so close. The sun brings out the warm greens of the vast fields of tall, orderly rice waving in the gentle breeze in neat, but not perfect rows. The
water is warm under my feet and the sandy bottom almost makes me believe I could be near the ocean and that I should hear the crash of waves at any time.

Small fish and tad poles swim in schools around our legs and through the rice fields. Tiny, delicate dragonflies with fluorescent green heads and fluorescent blue tails flit across the surface of the water covered trail as larger, uglier dragonflies ply the air between the heads of rice. Dark, bug-like animals scoot with coordinated flaps of their legs across the sandy bottom...dragonfly larvae according to David.

Sparrow-sized, pudgy, bright red or yellow "millet eaters" chirp and dart from patches of scrub bushes on slightly elevated "islands" in between the flooded fields. The sand gives way to a black silt. The clay makes turns our march into a slick situation. I almost fall several times. We head out into the rice fields where at least walking on the grasses makes it less likely we'll slip.

The water gets deeper. I'm wading up to my thighs. The path/river takes a bend around an "island" and I finally see the village poking their thatch roofed heads above the tall heads of millet and between the mango trees. Smoke rises from several cooking fires. I reach a dry path and put my shoes back on.

David, Doumpa and I wait up for Andre and Pierre and then we march through the village till we find Daniel's house at the other side. It has been blown down in the last rain. When it rains it pours! We finally catch up with him at this mother-in-law's.

Apparently, he became dizzy and weak while out working in the fields. Then he couldn't move his legs and arms because they just cramped up. He thought he was going to die. All his family and friends came by but refused to pray for him because he's been going to the Adventist Church. "Pronounce the name of the Evangelical Church of Chad or we won't pray for you," they said. So he did. He was very confused though, wondering why Christians wouldn't pray for other
Christians just because they were from a different denomination. I wondered the same thing out loud to him.

After all, at the Adventist Hospital we pray for all our patients whether Adventist, Evangelical, Muslim, Animist, Atheist, Pagan, whatever. His two daughters are sick now, too. So we convince him to come back with us. I put the four year old on my shoulders and wade back through the water until it gets shallower and shallower and arrives back at the truck. We've gone two
kilometers each way through the flooding.

After waiting again for Andre and Pierre we start backing up. There is no problem until we almost get to the dry sand when suddenly the engine revs and the car slows down as the
right front sinks.

I get out to look and see that apparently the hard sand is only about a foot thick under which is a liquid soup of muddy sand. We work for an hour or so without even the slightest movement of the truck. I call Rich Hoyt again to see if he can pull me out. I can't get a hold of him. I try Sarah, nothing. Andre finally calls Enock, the guy who's building our staff housing who agrees to go search for Rich. David heads off on foot since it's getting dark and he needs to start the generator at the hospital and start his shift as night watchman. We are about to head off on foot
ourselves when we see and hear a motorcycle followed by a Land Cruiser. They've come!

Rich comes to check things out on foot and then returns to the Land Cruiser to turn it around and back up to pull us out. He ignores the rule he'd taught me last time he pulled me out and backs into a field to turn around. Now he's stuck too!

Enock heads off to the Evangelical Church of Chad of Béré #7 to round up manpower. We wait around getting eaten alive by mosquitoes the size of small vultures. It's night and the beauty of the day has fast faded. I’m starting to get frustrated. Then, I remember that I felt impressed to come, that this was important and that I have a choice as to my reaction to a situation. Instead of getting mad, Rich and I go apart and talk. Apparently, he's had a horrible weekend and this just tops it off. But, he's amazingly upbeat. I am able to unburden some of my hard times from the past week and I realize that this bad situation has given us both a chance to debrief that we
wouldn't of had otherwise. We pray together and then the crowd arrives.

With the arms, legs and backs of 21 people, the Land Cruiser is fairly easily pushed back onto the road. Rich doesn't want to risk getting closer to us to pull us out so he goes to where the road is solid. Then, with a lot more effort but no less enthusiasm, the 21 lift the back of the truck out of the holes onto more solid ground and then push the truck out of it's front tire pits as I gun the engine for all it's worth in low four-wheel drive reverse! I get about 100 feet when the left side of the truck sinks again into the mush. This time the 21 man force just pushes the truck to the right out of the hole and I wind the engine out until I’m on solid ground! What a great feeling! (although, I don't think I want to drive again for awhile...at least until the rainy season is over!)

James

Ramadan

My horse seems very tired. I have such a love-hate relationship with him. One day he seems like he's the best horse around and the next, I wonder if I shouldn't sell him. Ever since Sarah's horse chased him around until he tried to jump over a six-foot fence and dislocated his knee and broke part of his pelvis, he just hasn't been the same. Now that they're both castrated, they get along fine...but the damage is done.

Sarah and Israel are far ahead. They are both riding bareback on Sarah's horse who has boundless energy. My horse can't even walk right. Every once in a while, when I get too far behind, I make him trot to catch up but it's like pulling teeth. Sarah's horse has to be held back to keep from galloping the whole time and mine won't even do a slow trot.

But the day is beautiful and we are headed out to an Arab village to celebrate the end of Ramadan, the Muslim month-long fast. The sun is out, the sky is a deep bleu with billowy white clouds, and there is a cool breeze. Our sandy path takes us through endless fields of meter high waving deep green rice divided by rows of tall grasses swaying in the wind. There is still water on much of the path but the water table is descending rapidly as the rains have mostly come to an end.

The horses eat like pigs and are constantly turning their heads to the sides to sweep, gather and tear of luscious heads of rice. They are in perpetual search of food and never cease to eat even at night. Eat like a pig? Forget it...eat like a horse is the true saying to describe a glutton!

We pass through the Nangjere section of Kouloum Goumdah accompanied by the usual cries of "Nassara lalé, nassara lalé" wrung from the throats of a thousand kids. Soon we exit the Nangjere part and enter open fields. The arab village is not really a village but rather a few small huts scattered around a huge central cattle enclosure. The Nangjere are cultivators and the Arabs are herdsmen. The cows are all out to pasture now. We wind through some huts
until Ahmat comes running to meet us.

The staccato, ritualistic Arabic greetings commence.

"Al salaam alekum"

"Wa alekum al salaam"

"Kikef?"

"Afe tayybin"

"Afe, bet afe?"

"Al hamdullilah"

"Machallah"

"Kullo afe"

"Kullo, machallah"

"Al hamdullilah!"

Ahmat leads us through the village to his small mud brick hut. The "fancy" mud brick hut is where is mom lives while to the side is a rounded hut made in the style of a tent with wood bent over in curves covered by cow skins with a low, three-foot high door in one side. Inside is a bed made of curved, twisted sticks with a cotton mattress covered by layers of ornate Arabic rugs. The dirt floor is meticulously swept and to the side there are piles and piles of cheap, metal pots with brightly painted designs wrapped around the top. Outside is a half fence of "sekos", woven reed mats, with a large wooden mortar and pestle for pounding millet into flour. A long, pointed Arab knife in a leather sheath hangs inside the door by an equally covered long machete.

Ahmat takes us to a shelter outside the door of his mom's hut. Four large, twisted branches have been stuck in the ground with cross pieces covered with mats making a three walled enclosed resting spot. On the ground are woven reed mats covered with Arabic rugs. We are invited in as the round of Arabic greetings repeats itself with Ahmat's wife and mother.

As we lounge on the mats, Ahmat's wife brings us tea and some "Beignets", or flour donuts cooked in peanut oil. Our day is spent like this, greeting people who come to welcome us, drinking tea from time to time, eating small things here and there (millet paste, rice with a tiny bit of meat sauce, etc.)

Sarah goes into Ahmat's mom's hut and Israel and I stay outside. The chief of the village comes and we get into a conversation with a visiting Arab who'd been treated at our hospital about why Muslims shouldn't drink alcohol and why he should quit if he wants to be a good Muslim. I ask him if he can imagine standing before Allah on judgment day with a glass of "Argyle" (millet wine) in his hand. He looks horrified and then laughs as it sinks in.

At 3pm we head over to the cattle enclosure where they have cleared off some brush to make a place for the horse races. Of course, Sarah is hyped up to enter. We are some of the first to arrive but there are already 3-4 Arabs with their horses all decked out in brightly colored ribbons around the neck and along the sides. The horses are prancing as they are whipped with short pieces of rope. They all have metal bits in their mouths and are in constant motion as their rides try to control them.

I can imagine their thoughts as they see Sarah ride up, a woman on an old castrated horse with only a rope around it's nose and no fancy accoutrements. The son of Abdoulaye, an elder in the village who had been treated for weeks in the hospital for an abscess on his hand, offers to race Sarah to start of the ceremonies.

Sarah pulls up next to him and they take off together in a slow walk to the end of the cleared off patch. There is quite a contrast. Sarah's horse is calm and easily controlled while the son of Abdoulaye his constantly tugging at the reins and whipping his horse to keep him in line. The horse is bursting with energy and there is no doubt that he will win.

Finally, they are just specks on the horizon about 300 meters away. Suddenly, they both jerk their horses around and they take off at a tremendous gallop. They are moving so fast that they rapidly regain size in a blur of legs and frothing mouths. The son of Abdoulaye is standing up in the stirrups not moving at all but seeming to glide towards us as his horse releases all his pent up energy.

Sarah has a white veil tied as a scarf around the top of her head that is streaming behind her along with her long curly red hair. The speed of the horses is actually frightening as they quickly approach without slowing down in the slightest. Finally, they both tug back and reluctantly,
fighting all the way the horses are brought to a halt as the crowd scatters wondering if they might get trampled. And, to the embarrassment of all, except me and Israel, Sarah has
won!

The races continue until sundown interrupted from time to time by herds of cattle coming in for the night. Crowds of little boys wearing new Arabic robes and crowds of girls wearing new dresses and veils play to the sides. Fires are started in the cattle pen to ward of insects. Sarah races a few more times and then we go back to Ahmat's.

Ahmat requested that we bring the Jesus film with us. He'd seen part of it once when he came to visit. He is HIV-positive and was treated for two months in the hospital for TB and continues to come to visit from time to time as he made a lot of friends. It was he who helped us get the horses. So when Sarah showed him part of the Jesus film in Arabic he was very impressed and came three mornings in a row before the feast of the end of Ramadan to remind us to bring the film.

So, we set up a sheet over the side of the shelter, hook up the generator to the projector and show the Jesus film in Arabic. Most of them don’t understand standard Arabic and their reactions are kind of funny. When they see donkeys, goats, cows, horses, etc. the kids get so excited and shout out the names. When they see some apples, they shout out "Mangos!" When they see old white people it seems to be the most hilarious thing they've ever seen...white people look so funny to them.

At the end, I ask Ahmat if he understood since they speak Tchadian Arabic and the movie was in Saudi Arabian Arabic. Ahmat says he understood everything and now he knows that "Issa" is the "grand marabout", or traditional healer. So, as I lie under the stars that night before falling asleep I wonder how much did he get out of it? Only Allah knows.

James

Thursday, December 7, 2006

A Photo Tour from the Bere Bunch 2006

Loading up truck in NdJ upon arrival. Where do all 6 of us sit , James???
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View of country side on way to Bere’ – not much to see – Tchad is FLAT and Dry
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Our home – Bere’ Adventist Hospital Dorm – for the next 10 days.
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Bere’ Village Homes
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Our work begins – new home for James and Sarah with guest quarters attached
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View inside when we arrived – rather rough. We hired local muscle to help – they did good.
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Jamie - installing plumbing
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Tasks – Rick mixing concrete
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Peter doing electrical work – where are the inspectors? – Oh, Peter is an inspector back home!
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Kelli’s ultrasound student.
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View inside new home when we finished
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Most of us slept in mosquito-proof (hopefully) tents on the porch or in the yard.
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Friday night on the front porch – ‘Jammin’ with James and Jamie
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Everyone joins the Jam session – Sarah with many friends
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Our work is done. Headed back to NdJ and home – but first – where’s the bridge – a barge?
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Everyone gets thirsty in Tchad – even the truck
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A warm sunset to reflect the warm hearts we have for Bere’
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Wednesday, December 6, 2006

We’re back home - -

In fact we’ve been home for a few days now. All of us struggling with getting our body clocks back to match our local time zones. But let us back up a little.

After 9 days of very hard work, we were able to hang up the shovels, put down the saws, pack away the tools and get ready for Sabbath – our second Sabbath in Bere’. The Lord knew what he was doing when he asked us to rest one day out of seven. Six days of labor had made all of us very tired. Along with missing our families, we were ready to come home.

Unfortunately, we were missing one thing – a method to get back to the airport. James had gone to NdJ for meetings, and on the return, the truck had some mechanical difficulties which forced James to remain in NdJ an additional day for repairs. So instead of James returning to Bere’ on Friday afternoon, he left NdJ Sabbath morning. He was able to stop along the way at one of our churches and attended SS and Church.

This was a miracle provided by God because when he stopped, he noticed a leak in the radiator of the truck. Upon further inspection, a large hole had formed and was expelling water and stream at a goodly rate.

James was able to jam a piece of rubber into the hole, but that was only a temporary fix. Every few miles he would have to stop, find a source of water (well, ditch, what ever), fill his drinking bottle and pour it into the radiator. The rubber plug was getting looser, so James and the other rider in the truck began chewing all the gum they could find and then jam that into the hole.

Well, a trip that should take between 7 and 8 hours actually took close to 15 hours. There were 6 very happy people to welcome James back to Bere’ – until we discovered why he was so late.

Upon further inspection, it was determined that the radiator would not survive a return to NdJ in its present shape, so a search was commenced to find suitable radiator fixit ‘stuff’. Yes – we were not in a position to be selective – anything that might hold was considered. But once again, the Lord provided for our needs – at the time of our need.

All of us had been in the closet looking for things all week long and none of us spotted the ‘radiator gunk’. This is a special sealant designed specifically for leady radiators. Was it there all week? We don’t know. Was it there when we needed it most – absolutely!

Jamie – our resident truck repair man to go along with his electrical and plumbing skills once again rose to the occasion. He mixed up the compound and in a matter of minutes had plugged the leak. We let it sit overnight and upon complete inspection in the morning found that for the most part the leak had stopped. But would it stand under pressure of a 200 mile drive in the heat and rough roads? Well, the Lord does not take a person so far and then drop him - - neither did He provide for us the radiator gunk only for it not to work. Oh, we took extra water with us in the truck, and we did add about 2 liters half way to NdJ, but we made it to the airport in good shape.

We even were able to get past the highway guards who gave us such a hard time the week before. This time, we learned that a little sugar goes a long way. It turns out the guards had a healthy sweet tooth and offerings of candy, gum and other such items was all that was needed for quick passage through the checkpoints.

In NdJ we went directly to TEAM for a quick shower and on to the airport because we had been informed that the rebels from the East where on the outskirts of NdJ. You know how news travels and how bad news usually gets blown all out of proportion. Well, that was the case here, but we did not know for sure and were not in a position to question conventional wisdom – so all 6 of us took our last Chadian shower in record time – and were off to the airport to wait out the ‘rebel attack’ and be in position to board the first plane out of NdJ.

We were able to spend quality time – 9 hours worth - in an airport with no place to eat, one bathroom without the necessary paper products for either end of the body, hard chairs, no air conditioning, and people going to and fro speaking a language we did not understand. But once again, the Lord provided us with a safe refuge and at 11:55pm (on time) our Air Bus 320 lifted off the runway and we were away from suspected danger and one our way home.

An overnight flight to Paris brought us to the City of Light in the Dark at 6am. And Paris was still foggy and rainy – just as we had left it the week before. We did find a place to purchase some snacks for breakfast. We ate as we discussed our week’s adventure. Each of us took time to record our impressions on Video that will become part of the official record of Bere Team’s adventures in Tchad.

Peter departed before the rest of us as he went a different way back to Seattle. We boarded our plane at the appropriate time and then we waited and waited for it seemed that not only was our truck from Bere’ to NdJ in need of repair but so was our plane from Paris to New York.

After a 45 minute wait we were once again airborne ‘over the pond’ to our home – the USA.

Due to our delay in Paris, we missed our last connection to Orlando. You see, the Lord had us wait at the airport in NdJ, so we would be in good practice to wait at JFK. We experienced another long wait – this time roughly 7 hours (but with all the pleasures of ‘home’ such as clean bathrooms, air conditioning, food, English speaking people. Our 8:30pm flight was full, but we all made it back to Orlando by 11pm and were finally in familiar surroundings and the loving arms of family.

Have we recovered - for the most part yes. Have our body clocks returned to be in sync with the local time – for the most part yes. Did any of us catch Malaria – not that we know of for we faithfully took our medicines while there and then gladly accepted the final treatment that James prescribed for us.

Are we ready to go back to Bere’? Not at this moment, but give us a few weeks or a month or two and then ask us again.

God was, is and is always good. He took care of our needs - - not necessarily our wants (we wanted ice cubes in Bere’, but they did not materialize). But through His blessing, we were able to accomplish pretty much everything we had hoped to and for all we know, the things that did not get finished – well, they were not in God’s plan to begin with.

So family and friends, thank-you for supporting us on our mission. Thank-you for understanding why we did call home more often. Thank-you for accepting that we wanted to go to bed early when we got home and seemed to get up way before the time we should. And thank-you the most for loving us, for caring about us and for keeping us in your prayers.

So long for now.

May God Bless us all.

The Bere Bunch 2006