Ladies and Gentlemen! Welcome to this next addition of "How to...in Tchad"
Tonight's topic is one that is very dear to all of our hearts and a constant source of revenue for our parent organization, the Bere Adventist Hospital: How to have a hernia in Tchad.
In order to have a really sizable hernia, one that is noticeable even when wearing pants (or one that requires you to give up pants and wear a skirt) one must ignore the hernia one's entire life. It is also helpful to come from an agriculture tradition requiring years of hard, back-breaking labor bent over in a rice field.
One should let it get so big that ones entire collection of small intestines and part of the colon should be able to fit inside if one makes an effort. Making that effort is much more easily achieved under the influence of the local brew. One has many to choose from: cochette (rice wine), arguile (millet wine with a touch of methanol), bili-bili (who knows what fermented in a tasty beverage) as well as your more exotic beer.
If one is going to be operated on, it is much better to wait until after a hard day of bargaining at the market and a serious evening imbibing. Then, through various silly manoeuvres only achievable when dead drunk, one is able to achieve that mass excursion of intestines, colon and sometimes bladder into the hernia sac.
This usually makes if very difficult to push back in (especially when one is draped over a bench with the last calabas of rice wine in hand). This delay allows for swelling of the intestines and sacs to occur leading to what's known as incarceration or strangulation, big words meaning that one will die if not operated on soon!
The best thing to do at this point is to call for your cousin, slash drinking buddy and have him spend your last penny on a motorcycle ride through the bush in the dark so that one can arrive after midnight at the hospital, drunk and penniless.
Not to worry, the surgeon may be groggy, grumpy and disgruntled to find you have nothing to pay with, are sloppily drunk and babbling on the ER table and are alone with an equally smashed and useless cousin, but he will be sure to operate on you to save your life. That way, you don't have to wait for surgery or maybe even pay for it. You never know, those white folks are such suckers!
After a nice, pleasant Ketamine induced dream with a nightmare awakening with all your inhibitions making you see all those things you've repressed and regretted over the years, you wake up on a bloody plastic sheet covered loosely with a hospital gown and an IV dripping into your arm. You start to feel some serious pain in your left groin. You look down and feel a bandage. Feeling lower you realize your left testicle is missing. None of your family has come yet and not only are you waking up from surgery but you have a hangover.
Oh, and that supposed benefit about not paying, the sneaky doctor has gone and left the hernia on your right unfixed so that you'll have to pay him before leaving or the same thing might happen again and suddenly it's looking like it might be better to just have it done electively!
Well, that's it, folks, thanks for tuning in. Next weeks How to...well you just might need a wheelbarrow to carry it in.
Sunday, December 9, 2007
Teenage pregnancy
She is, unfortunately, one of many. Fifteen years old. A child. Tiny. Married and pregnant with a huge baby. She has been in labor for days. This morning she finally went to a health center where they tried to extract the baby with a vacuum suction applied to the baby's scalp. When that didn't work they referred her here.
It is all too common. Women usually marry as teenagers. Not just among the Muslims, but among the Nangere. Some even get pregnant before having their first period. Children having children. Small children having large babies. They don't come out easy.
In the "modern world", a woman with a small pelvis and a baby who's head is too big to come out will have a c-section. Every pregnancy thereafter, she will have excellent pre-natal care with early ultrasounds to determine the exact dates of the pregnancy so an elective c-section can be performed when the fetus is mature enough and before labor begins. After 3-4 children, she will have a tubal ligation and live happily ever after.
In Tchad, a woman with a small pelvis and a big baby will have no prenatal visits. She'll work in the fields until labor starts when she will be transported to a mat on a dirt floor in a dark mud hut. There she will labor under the supervision of an older, experienced traditional birth attendant...sometimes for days. Then, like our girl, she may get to a health center or a hospital before dying. Often, she will be buried with her unborn child never having left the village.
Supposing, she does make it to a hospital. The well-meaning obstetrician or surgeon or generalist will do a c-section. Sometimes he saves the baby but he usually saves the mom. All is well and good. 4-5 days later, the woman goes home. 9-12 months later she is at term with her next pregnancy and labors at home. This time, her uterus has a weak spot at the area of the scar which hasn't even had time to fully heal. Maybe she'll make it finally to the hospital again for another c-section (depleting again the family's meager resources) but maybe she'll tear her uterus with the force of the contractions against the unyielding bones of her pelvis and she'll bleed to death internally.
If she does make it for the second c-section, the process will repeat itself until she is either dead or abandoned by her husband as being too much of a drain. Who wants a woman who can only have 3-4 kids anyway? A quarter to a half of them will probably die before the age of 5, so one must have at least 8-10 kids in order to have 4-6 alive into adulthood.
So, at the Bere Hospital, thanks to a technique considered brutal, archaic and cruel by the turned up noses of the western obstetrical ward, we prepare our 15 year old for a symphysiotomie.
We take her to the OR, attach her to the monitors. She has low blood pressure and a very fast pulse. We give her antibiotics, IV fluids and call for a blood transfusion.
The problem is, she has been abandoned by her husband and most of her family. Her mom already paid most of her money at the health center and then the rest to put her on an hour long motorcycle ride to the hospital. She only has five dollars. We can't let her die, so when the mother promises that the rest of the family are coming, we don't believe her for one instant but set her up for surgery.
However, now that she needs blood, we find her mom is not compatible and since there is no blood bank we rely on family members to donate. None of our volunteer staff is compatible either. We are forced to do our best.
We shave and prep the pubic area. I inject the local anesthetic. A urinary catheter has been placed. IV fluids are running. Heart rate is 140 and blood pressure 80/40. I slice down to the cartilage and with my other hand displacing the urinary catheter (and thus the urethra) inside, I slowly incise the fibers from top to bottom being careful not to enter the bladder or vagina. Abel and Simeon have the legs flexed and externally rotated. On cue from me, they spread the legs down and the pelvis pops open with a load "crack".
As blood gushes out of the wound, I stuff two gauze pads down to stem the bleeding. I then am forced to cut an episiotomie and apply our own vacuum delivery device to the head. She has no strength left to push and the baby's scalp won't hold the vacuum. The head still won't come out.
I ask Simeon to put some Oxytocin in the IV fluids and to open it wide up. Slowly, the uterus contracts and pushes the head out little by little as I gently tug with the vacuum on the baby's head. Finally, the head pops out with a gush of thick dark meconium (baby's pooped inside mommy). The neck is strangulated with a tight nuchal cord that I can barely slide over the head. Finally, the shoulders and arms slip out and the rest of the body slides out quickly.
I check the umbilical pulse. Nothing. The baby has been dead for a while. The placenta quickly follows thanks to the Oxytocin still running and her uterus forms up nicely. She's bleeding from where we cut her quite a bit. I stuff in a bunch of gauze sponges and then pull out the sponges from the syphysiotomie wound.
I irrigate the wound and close it in two layers. I then suture up the episiotomie. She continues to bleed. Simeon checks her hemoglobin: 5.1 g/dl. Very low. Still no blood for transfusion.
I check all inside and finally find a tear up around her urethra. When I suture it the bleeding finally stops. She is sweating and a little delirious. Heart rate still 140s and blood pressure 90/50 now after several liters of fluid.
We have no choice but to send her out to the ward and hope the family members come quickly.
That evening, at about 8pm, Liz comes to talk to me about several patients. She mentions that the girl has low blood pressure, a fast heart rate and now a fever of 40 Celsius. She is wavering in and out of consciousness and is sweating profusely.
I tell Liz to give her Chloramphenical (maybe she's septic from the prolonged labor) and IV Quinine (maybe she has malaria on top of it) and IV fluids (she is still volume depleted). After Liz leaves, I take a long drink of water and something impels me to go see her myself.
I find her like Liz said. She is almost in fatal shock. Only blood will help. I help Liz get the medicines and IV fluids going.
The mother keeps wringing her hands and asking "Loe ne mega?" "Loe ne mega?" What's going on? What's going on? I tell her "Koubra kang ddi" There is no blood. She runs off. Liz and I continue our work.
The mother soon comes back with the brother of the young man who we'd just amputated his leg. He's been with us for several weeks. He and another man say they are willing. The other man just gave a pint for his relative two days ago but is willing again. We find his blood isn't compatible.
Then we think of Allison, the volunteer at the Evangelical Mission who's staying with us for a week while the other missionaries (Rich and Anne) are in N'Djamena. We call her and both she and the brother of the amputee are compatible. People don't just give blood to non-relatives but this man is encouragingly different, going against the cultural pressure and ignorance we are surrounded with to save the life of a stranger.
After two units of blood, the next morning she is a different person. She is up moving around with normal vital signs and has eaten some porridge for breakfast. Her uterus is firm, the wounds look good and she is hardly spotting at all.
Liz comes in at 5 am the next morning to give her her Quinine and finds her cold and stiff. Four family members are around her and haven't noticed. Liz informs them and they begin the death wail immediately, bundle up the corpse and head home.
It is all too common. Women usually marry as teenagers. Not just among the Muslims, but among the Nangere. Some even get pregnant before having their first period. Children having children. Small children having large babies. They don't come out easy.
In the "modern world", a woman with a small pelvis and a baby who's head is too big to come out will have a c-section. Every pregnancy thereafter, she will have excellent pre-natal care with early ultrasounds to determine the exact dates of the pregnancy so an elective c-section can be performed when the fetus is mature enough and before labor begins. After 3-4 children, she will have a tubal ligation and live happily ever after.
In Tchad, a woman with a small pelvis and a big baby will have no prenatal visits. She'll work in the fields until labor starts when she will be transported to a mat on a dirt floor in a dark mud hut. There she will labor under the supervision of an older, experienced traditional birth attendant...sometimes for days. Then, like our girl, she may get to a health center or a hospital before dying. Often, she will be buried with her unborn child never having left the village.
Supposing, she does make it to a hospital. The well-meaning obstetrician or surgeon or generalist will do a c-section. Sometimes he saves the baby but he usually saves the mom. All is well and good. 4-5 days later, the woman goes home. 9-12 months later she is at term with her next pregnancy and labors at home. This time, her uterus has a weak spot at the area of the scar which hasn't even had time to fully heal. Maybe she'll make it finally to the hospital again for another c-section (depleting again the family's meager resources) but maybe she'll tear her uterus with the force of the contractions against the unyielding bones of her pelvis and she'll bleed to death internally.
If she does make it for the second c-section, the process will repeat itself until she is either dead or abandoned by her husband as being too much of a drain. Who wants a woman who can only have 3-4 kids anyway? A quarter to a half of them will probably die before the age of 5, so one must have at least 8-10 kids in order to have 4-6 alive into adulthood.
So, at the Bere Hospital, thanks to a technique considered brutal, archaic and cruel by the turned up noses of the western obstetrical ward, we prepare our 15 year old for a symphysiotomie.
We take her to the OR, attach her to the monitors. She has low blood pressure and a very fast pulse. We give her antibiotics, IV fluids and call for a blood transfusion.
The problem is, she has been abandoned by her husband and most of her family. Her mom already paid most of her money at the health center and then the rest to put her on an hour long motorcycle ride to the hospital. She only has five dollars. We can't let her die, so when the mother promises that the rest of the family are coming, we don't believe her for one instant but set her up for surgery.
However, now that she needs blood, we find her mom is not compatible and since there is no blood bank we rely on family members to donate. None of our volunteer staff is compatible either. We are forced to do our best.
We shave and prep the pubic area. I inject the local anesthetic. A urinary catheter has been placed. IV fluids are running. Heart rate is 140 and blood pressure 80/40. I slice down to the cartilage and with my other hand displacing the urinary catheter (and thus the urethra) inside, I slowly incise the fibers from top to bottom being careful not to enter the bladder or vagina. Abel and Simeon have the legs flexed and externally rotated. On cue from me, they spread the legs down and the pelvis pops open with a load "crack".
As blood gushes out of the wound, I stuff two gauze pads down to stem the bleeding. I then am forced to cut an episiotomie and apply our own vacuum delivery device to the head. She has no strength left to push and the baby's scalp won't hold the vacuum. The head still won't come out.
I ask Simeon to put some Oxytocin in the IV fluids and to open it wide up. Slowly, the uterus contracts and pushes the head out little by little as I gently tug with the vacuum on the baby's head. Finally, the head pops out with a gush of thick dark meconium (baby's pooped inside mommy). The neck is strangulated with a tight nuchal cord that I can barely slide over the head. Finally, the shoulders and arms slip out and the rest of the body slides out quickly.
I check the umbilical pulse. Nothing. The baby has been dead for a while. The placenta quickly follows thanks to the Oxytocin still running and her uterus forms up nicely. She's bleeding from where we cut her quite a bit. I stuff in a bunch of gauze sponges and then pull out the sponges from the syphysiotomie wound.
I irrigate the wound and close it in two layers. I then suture up the episiotomie. She continues to bleed. Simeon checks her hemoglobin: 5.1 g/dl. Very low. Still no blood for transfusion.
I check all inside and finally find a tear up around her urethra. When I suture it the bleeding finally stops. She is sweating and a little delirious. Heart rate still 140s and blood pressure 90/50 now after several liters of fluid.
We have no choice but to send her out to the ward and hope the family members come quickly.
That evening, at about 8pm, Liz comes to talk to me about several patients. She mentions that the girl has low blood pressure, a fast heart rate and now a fever of 40 Celsius. She is wavering in and out of consciousness and is sweating profusely.
I tell Liz to give her Chloramphenical (maybe she's septic from the prolonged labor) and IV Quinine (maybe she has malaria on top of it) and IV fluids (she is still volume depleted). After Liz leaves, I take a long drink of water and something impels me to go see her myself.
I find her like Liz said. She is almost in fatal shock. Only blood will help. I help Liz get the medicines and IV fluids going.
The mother keeps wringing her hands and asking "Loe ne mega?" "Loe ne mega?" What's going on? What's going on? I tell her "Koubra kang ddi" There is no blood. She runs off. Liz and I continue our work.
The mother soon comes back with the brother of the young man who we'd just amputated his leg. He's been with us for several weeks. He and another man say they are willing. The other man just gave a pint for his relative two days ago but is willing again. We find his blood isn't compatible.
Then we think of Allison, the volunteer at the Evangelical Mission who's staying with us for a week while the other missionaries (Rich and Anne) are in N'Djamena. We call her and both she and the brother of the amputee are compatible. People don't just give blood to non-relatives but this man is encouragingly different, going against the cultural pressure and ignorance we are surrounded with to save the life of a stranger.
After two units of blood, the next morning she is a different person. She is up moving around with normal vital signs and has eaten some porridge for breakfast. Her uterus is firm, the wounds look good and she is hardly spotting at all.
Liz comes in at 5 am the next morning to give her her Quinine and finds her cold and stiff. Four family members are around her and haven't noticed. Liz informs them and they begin the death wail immediately, bundle up the corpse and head home.
Monday, November 12, 2007
A parent's worst nightmare
I couldn't believe my ears. It was surreal. I didn't really feel any panic or anything, but I felt a calm, cold-blooded realization of what I needed to do.
My vacation was about to be cut short.
Ok, so you couldn't really call it a vacation, Sarah and I had come to the Koza Hospital as part of an exchange with Drs. Greg and Audrey who were now in Bere. We had now been in Northern Cameroun for just a day over two weeks but compared to Bere, it was a definite, much-needed break.
In those two weeks, I did 6 surgeries at Koza. Greg did 37 at Bere. I sat around all afternoon reading and watching movies while sipping cold drinks and eating homemade ice cream with a fan and a swampcooler as my constant companions while Greg and Audrey hardly saw the light of day and came home to Kerosene lamps and lukewarm tapwater.
This morning, I'd been woken out of my electric fan-cooled sleep by the nurse and ended up doing a crash c-section to save a distressed baby's life. Now, Greg's calm voice is speaking through my cell phone (yeah, even here in the African bush) telling me that one of our student missionaries (who we call Esther because there's just to many Sarah's) has severe abdominal pain and has vomited several times. Greg goes on to say that she has peritoneal signs and a positive Typhoid Fever test. She's been on IV fluids, antibiotics and morphine since yesterday. He doesn't know if she should be evacuated or what.
Fortunately, thanks to Gary Roberts' airplane, I have the luxury of saying, "I'll be right over, let me just quickly pack my bags and I'll see you in a few hours."
It's a Saturday morning and it's going to be a long day.
I quickly go over to the church right across from the house and find Yves, the administrator, to inform him of the situation. He is sitting on one of the front rows, so I drag him outside to break the news. He is understanding and wishes us bon voyage. After saying good-bye to Jacques and Calda, Sarah and I pack our bags and about 30 minutes after the phone call, Gary's wife, Wendy, is driving us out to the grass airstrip.
We take down the string "fence" Gary has guarded the plane with, detach the moorings, load up the barrels of fuel and our small backpacks, strap ourselves in and Gary fires up the single prop, we taxi (bump) across the grass and are soon banking sharply right en route to Garoua. An uneventful landing, flight plan and missed immigration agents (lucky for us since we didn't have visas) and we are heading to Moundou. Less than three hours from Koza and we land in Moundou where we have a little friendly discussion (heated argument) with customs ending in the usual way (laughs and hand pumping).
20 minutes, and a little flying lesson for James later we are circling Bere International watching Rich race down the airstrip on his motorcycle looking for goats, cows and soccer goal posts which could make our landing a little more bumpy.
"See that second path over the strip right before the little mound halfway down? That's where we'll try to put down in order to miss that little bump. We could circle around again, but this is faster..."
Gary says as my stomach gets left somewhere over to the right as be bank sharply left and downward towards the swath cut from the Chadian bush. Seconds later we are taxiing up to the quickly gathered crowd of mostly kids awaiting our arrival.
After the plane is unloaded, draped and secured and the watchmen posted, Anne kindly drives us over to the hospital in their Land Cruiser.
Greg is waiting for us dressed casually in jean shorts and a scrub top and large sandals. We go inside where the back room has been transformed into an intensive care of sorts with one patient, three doctors and three nurses, and multiple auxiliary staff (the other student missionaries) crowding around to help in any little way possible.
I slowly enter with my Sarah at my side. Esther (the other Sarah) gives us a weak, Morphine-influenced smile and says "hi". I ask her a few questions.
Apparently, her pain started yesterday morning early but she thought maybe it was just part of her monthly cramps. So she got on a motorcycle and took a little jaunt over to Kelo with a couple of the other volunteers. Curiously, the bumpy, bouncy ride did little to alleviate her pain. On her return, she had a typhoid test done which was sort of positive (they're sometimes hard to interpret and often have both false positives and false negatives). She was started on antibiotics and then IV fluids after she vomited. She had no urinary symptoms and bowel function was normal. She ate a little something at night. Her pain was equal on both sides of her pelvis. The pain increased with movement, tapping on the lower belly and "rebound tenderness".
Greg, Audrey, Sarah and I go to the next room to discuss what to do. She has evacuation insurance and with Gary's plane we could have her in N'Djamena maybe in time for the midnight, once-a-day flight to Paris. There is no hospital in Tchad I would prefer her to go to over ours (especially with Greg, a board-certified general surgeon there). We agree it could be typhoid fever, but that would usually have a longer course. While there are some atypical features I ask, "what if it is appendicitis"? In that case, she should be operated on ASAP, and an evacuation won't be fast enough to keep her from perforating with all the life-threatening complications. We continue to discuss, finally, I ask Greg, "If she was not a foreigner, would you operate on her." After a few moments, he says, "yes, I definitely would." So we are decided that if she chooses to stay in Bere, we'll open her up.
Now, Greg spends a long time explaining to Esther the options and she wisely calls her parents. With the time change, we at first only able to get through to her mom who wisely tells her that the decision is hers. Esther doesn't take long to say that here in Bere she is surrounded by friends and people she knows and the thought of flying to Europe (even accompanied by another of our volunteers who works in France and is leaving next week anyway) and being operated far away from anyone she knows, that thought scares her and she'd rather be operated on her in Chad.
So, the decision is made. Hans, Sonya and Christina go to prepare the OR and make sure everything is as clean and arranged as possible. Liz, Christina and Sarah prepare Esther for her operation.
Greg, Audrey and I wait just in the outer room of the operating block. Once the decision is made, I am anxious to get started. Greg calms me down. We'd already waited an hour or so for her to be able to talk to her father. At about 10pm we are finally ready to start.
I sit Esther up, wipe Betadine across her back, put on sterile gloves and inject a spinal anesthetic. We lay her down and Greg and I leave to respect her privacy while Audrey and the other girls prep the operating site and Audrey drapes her in sterile fashion. Greg and I scrub and when the all clear is given, enter the operating room. Contemporary Christian praise music is going in the background as Greg and I put on our gowns and gloves and Greg moves to the left side and asks for the scalpel.
We then pray officially once again (one of many continual prayers going up since our arrival) and we check to see if the anesthesia has taken effect. It isn't working completely, just giving her some warm tingling feelings in her legs, so Sarah gives her some Ketamine to go on top of her Diazepam and Greg slices from her pubis to just below her belly button.
As we enter the peritoneum, we get a small surge of liquidy pus from the pelvis. We know now, we've made the right decision. It just remains to be seen exactly what's the source. We irrigate and suction out the pus. As I retract, Greg examines the left tube and ovary, the uterus and then the right tube and ovary. Everything is completely normal. He moves over to the cecum and as his fingers work some inflamed tissue free, out pops a very angry appendix right about to burst. With a couple quick clamps, the vessels are clamped, cut and tied. The base of the appendix is then clamped and stick tied twice and sliced off. A lot more irrigation and suction and we close the fascia and skin. It's taken less than an hour, the anesthesia was completely uncomplicated and we take her home to the "ICU" 30 minutes praising God all the way!
If she had been evacuated, she would certainly have perforated either in Gary's plane or in the Air France plane. Amazingly enough, the best care available for her in the world at that moment in her life was found at the Bere Adventist Hospital.
(Story told with the permission of Sarah "Esther")
My vacation was about to be cut short.
Ok, so you couldn't really call it a vacation, Sarah and I had come to the Koza Hospital as part of an exchange with Drs. Greg and Audrey who were now in Bere. We had now been in Northern Cameroun for just a day over two weeks but compared to Bere, it was a definite, much-needed break.
In those two weeks, I did 6 surgeries at Koza. Greg did 37 at Bere. I sat around all afternoon reading and watching movies while sipping cold drinks and eating homemade ice cream with a fan and a swampcooler as my constant companions while Greg and Audrey hardly saw the light of day and came home to Kerosene lamps and lukewarm tapwater.
This morning, I'd been woken out of my electric fan-cooled sleep by the nurse and ended up doing a crash c-section to save a distressed baby's life. Now, Greg's calm voice is speaking through my cell phone (yeah, even here in the African bush) telling me that one of our student missionaries (who we call Esther because there's just to many Sarah's) has severe abdominal pain and has vomited several times. Greg goes on to say that she has peritoneal signs and a positive Typhoid Fever test. She's been on IV fluids, antibiotics and morphine since yesterday. He doesn't know if she should be evacuated or what.
Fortunately, thanks to Gary Roberts' airplane, I have the luxury of saying, "I'll be right over, let me just quickly pack my bags and I'll see you in a few hours."
It's a Saturday morning and it's going to be a long day.
I quickly go over to the church right across from the house and find Yves, the administrator, to inform him of the situation. He is sitting on one of the front rows, so I drag him outside to break the news. He is understanding and wishes us bon voyage. After saying good-bye to Jacques and Calda, Sarah and I pack our bags and about 30 minutes after the phone call, Gary's wife, Wendy, is driving us out to the grass airstrip.
We take down the string "fence" Gary has guarded the plane with, detach the moorings, load up the barrels of fuel and our small backpacks, strap ourselves in and Gary fires up the single prop, we taxi (bump) across the grass and are soon banking sharply right en route to Garoua. An uneventful landing, flight plan and missed immigration agents (lucky for us since we didn't have visas) and we are heading to Moundou. Less than three hours from Koza and we land in Moundou where we have a little friendly discussion (heated argument) with customs ending in the usual way (laughs and hand pumping).
20 minutes, and a little flying lesson for James later we are circling Bere International watching Rich race down the airstrip on his motorcycle looking for goats, cows and soccer goal posts which could make our landing a little more bumpy.
"See that second path over the strip right before the little mound halfway down? That's where we'll try to put down in order to miss that little bump. We could circle around again, but this is faster..."
Gary says as my stomach gets left somewhere over to the right as be bank sharply left and downward towards the swath cut from the Chadian bush. Seconds later we are taxiing up to the quickly gathered crowd of mostly kids awaiting our arrival.
After the plane is unloaded, draped and secured and the watchmen posted, Anne kindly drives us over to the hospital in their Land Cruiser.
Greg is waiting for us dressed casually in jean shorts and a scrub top and large sandals. We go inside where the back room has been transformed into an intensive care of sorts with one patient, three doctors and three nurses, and multiple auxiliary staff (the other student missionaries) crowding around to help in any little way possible.
I slowly enter with my Sarah at my side. Esther (the other Sarah) gives us a weak, Morphine-influenced smile and says "hi". I ask her a few questions.
Apparently, her pain started yesterday morning early but she thought maybe it was just part of her monthly cramps. So she got on a motorcycle and took a little jaunt over to Kelo with a couple of the other volunteers. Curiously, the bumpy, bouncy ride did little to alleviate her pain. On her return, she had a typhoid test done which was sort of positive (they're sometimes hard to interpret and often have both false positives and false negatives). She was started on antibiotics and then IV fluids after she vomited. She had no urinary symptoms and bowel function was normal. She ate a little something at night. Her pain was equal on both sides of her pelvis. The pain increased with movement, tapping on the lower belly and "rebound tenderness".
Greg, Audrey, Sarah and I go to the next room to discuss what to do. She has evacuation insurance and with Gary's plane we could have her in N'Djamena maybe in time for the midnight, once-a-day flight to Paris. There is no hospital in Tchad I would prefer her to go to over ours (especially with Greg, a board-certified general surgeon there). We agree it could be typhoid fever, but that would usually have a longer course. While there are some atypical features I ask, "what if it is appendicitis"? In that case, she should be operated on ASAP, and an evacuation won't be fast enough to keep her from perforating with all the life-threatening complications. We continue to discuss, finally, I ask Greg, "If she was not a foreigner, would you operate on her." After a few moments, he says, "yes, I definitely would." So we are decided that if she chooses to stay in Bere, we'll open her up.
Now, Greg spends a long time explaining to Esther the options and she wisely calls her parents. With the time change, we at first only able to get through to her mom who wisely tells her that the decision is hers. Esther doesn't take long to say that here in Bere she is surrounded by friends and people she knows and the thought of flying to Europe (even accompanied by another of our volunteers who works in France and is leaving next week anyway) and being operated far away from anyone she knows, that thought scares her and she'd rather be operated on her in Chad.
So, the decision is made. Hans, Sonya and Christina go to prepare the OR and make sure everything is as clean and arranged as possible. Liz, Christina and Sarah prepare Esther for her operation.
Greg, Audrey and I wait just in the outer room of the operating block. Once the decision is made, I am anxious to get started. Greg calms me down. We'd already waited an hour or so for her to be able to talk to her father. At about 10pm we are finally ready to start.
I sit Esther up, wipe Betadine across her back, put on sterile gloves and inject a spinal anesthetic. We lay her down and Greg and I leave to respect her privacy while Audrey and the other girls prep the operating site and Audrey drapes her in sterile fashion. Greg and I scrub and when the all clear is given, enter the operating room. Contemporary Christian praise music is going in the background as Greg and I put on our gowns and gloves and Greg moves to the left side and asks for the scalpel.
We then pray officially once again (one of many continual prayers going up since our arrival) and we check to see if the anesthesia has taken effect. It isn't working completely, just giving her some warm tingling feelings in her legs, so Sarah gives her some Ketamine to go on top of her Diazepam and Greg slices from her pubis to just below her belly button.
As we enter the peritoneum, we get a small surge of liquidy pus from the pelvis. We know now, we've made the right decision. It just remains to be seen exactly what's the source. We irrigate and suction out the pus. As I retract, Greg examines the left tube and ovary, the uterus and then the right tube and ovary. Everything is completely normal. He moves over to the cecum and as his fingers work some inflamed tissue free, out pops a very angry appendix right about to burst. With a couple quick clamps, the vessels are clamped, cut and tied. The base of the appendix is then clamped and stick tied twice and sliced off. A lot more irrigation and suction and we close the fascia and skin. It's taken less than an hour, the anesthesia was completely uncomplicated and we take her home to the "ICU" 30 minutes praising God all the way!
If she had been evacuated, she would certainly have perforated either in Gary's plane or in the Air France plane. Amazingly enough, the best care available for her in the world at that moment in her life was found at the Bere Adventist Hospital.
(Story told with the permission of Sarah "Esther")
Wednesday, October 24, 2007
Airborne
The Land Cruiser crashes through the six foot high millet over a windy bumby trail towards the airstrip.
It's a cool Chadian morning just after 6:00 AM.
Rich has picked up Dr. Bond, Sarah and I from the hospital and brought us out here with our pilot, Gary Roberts. We finally burst on to the airstrip with just a tinge of pink lining the wisps of clouds barely clinging to the night before being swept away by the new day.
The plane looks tiny against the backdrop of grassy airstrip hacked from the African bush. Using well placed whacks with long switches a few kids guide some scattered goats across the strip halfway down.
A single prop, four-seater, our plane is about to go international.
Bond is a little nervous and plies Gary with all kinds of questions about flight hours, how many accidents, how much fuel the plane carries, is he going to check if there's water in the fuel, etc. As Gary takes off the tarps and I help him unattach the tie downs Bond is trying to visually inspect the plane from top to bottom. Dressed in his sport coat and sporting wild black hair streaked with gray and the beginnings of a bushy mustache, Bond looks like India's version of Albert Schweitzer.
Finally, luggage weighed and packed, we squeeze ourselves in the fuselage and strap ourselves in.
The engine fires up sending in a burst of "air conditioning" through the open windows. Last minute checks in place, the windows close and Gary turns the plane around away from the sunrise. Gary then reopens a window and yells to the night watchmen to run ahead and pull the stick "goal posts" out of the strip/soccer field so we can take off.
When all is clear, a pull of the throttle lurches us forward and we quickly pick up speed as we bump and bounce across the airstrip and in no time we are airborne as Bere drops out from below us and we take a sharp turn over the trees to buzz the hospital.
It's amazing to see how really small our 20,000 strong village really is. Just a bunch of mudhuts so well camoflouged by the mango trees and millet patches that you can't hardly see anything until the tin roofs of the church, school and finally hospital come into view.
Seeing that tiny clump of trees with a few tin roofs jutting up it's hard to believe that anyone would want to be treated there much less that people would come as far away as Lake Chad and Abeche on the border of Darfur to be operated on in our collection of ragged buildings.
Soon we are crossing a patchwork quilt of rice, millet, peanut and sweet potato fields. The artwork is more of the style of Barcelona's Gaudi with natural lines of trails, islands of trees and a symmetry more geographic than geometric.
We soon pick up the Logone river and follow it's course. Along the banks we see the tiny beehive-shaped, rounded tents of the Arab nomads with herds of cattle and a few horses scattered along the banks. Periodically the glassy surface is broken by the smooth gliding of a wooden log canoe and it's fishermen on their way or already casting their handwoven nets in the shallow, fish-rich waters.
We follow the Logone up and finally see the Tandjile snake it's way up and join it's fast flowing waters right before Koyom and the Pentocostal Hospital. We buzz it's airstrip and notice it's unusable.
Then we pick up altitude, leave the Logone behind and the African plane becomes a distant network of fields, forests and tiny villages.
Finally, we pick up Tchad's other major river, the Chari and follow that all the way to N'Djamena where the Logone and the Chari become one.
One doesn't even notice N'Djamena till one is right on top of it. It's just a large village lost amongst the trees. If it wasn't for the occasional 5-10 story building and the bridge across the Chari and the fact that I knew that's where the Logone joins in I wouldn't have been sure it was N'Djamena. I don't think there is any other capital village in the world like N'Djamena.
The airport is right across the river and has a single runway. There are two other planes pulled up at the airport. We land easily and taxi up the the MAF hangar. Probably the world's smallest international airport (a fact proven later on when we land in Garoua, Cameroun's international airport).
After a few days getting visa's and wasting time trying unsuccessfully to talk to the appropriate authorities to get Gary permission to fly on a permanent basis in Tchad we take off for Cameroun.
Cameroun is unremarkable for about 30 minutes until we hit the national park at Waza where we scare off some herds of antelope and giraffes. I finally feel like I'm really in Africa although some Elephants and Lions would be nice, too.
As we approach Garoua we hit some mountains and Gary flies us between two flat topped plateaus in a valley. The descent combined with an approaching storm and the mountains makes for a bumpy ride that threatens to loosen the tenous hold on my breakfast that I'd been maintaining since N'Djamena.
Sarah had already let up a sickening vomit smell from the back seat. Fortunately, Gary kindly provided us with vomit bags for the flight.
I think it's hypoglycemia as we haven't really eaten well the last few days. We couldn't find any place to stay in N'Djamena until someone finally opened us up a dorm room that hadn't been cleaned in months and didn't have a kitchen. So we were forced to eat off the streets which is slim pickins in N'Djamena (we had to content ourselves with boiled eggs, french rolls and fish soup).
After an uneventful landing and take off for formalities in Garoua, we head into the mountains. The beauty of the rugged cliffs rising from the rich green valleys sprinkeled with fields of corn and millet and wizard hat-like pointed roofed huts is impossible to describe.
Gary calls Maroua Airport to check in and the controller is shocked to hear we're going to Koza since no one has landed there in over 20 years but Gary assures her that the airstrip has been repaired.
One mountain plateau is so broad we dreamed aloud of building a hospital and airstrip on top of it...and it is not exaggerating.
Finally, we climb the last pass and look into Koza's valley. We approach the airstrip. I get the idea Gary is going to land because he goes so low but he's running out of airway. At the last minute he cranks the throttle and whips up over the tree tops before banking hard left and back around. Apparently, he was only looking for cows and holes that kids have dug to find mice to eat.
We circle around again and make a very bouncy jungle strip landing without any problem in time to greet the crowd of kids running up followed by a gang of bikers. By the time we have stopped and started to tie down our two guardians are there with sticks keeping the kids a safe 2-3 feet away. The crowd is so thick it is literally a sea of smiling, laughing and waving faces.
Gary's wife Wendy drives up in Greg and Audrey Shank's pick-up truck and Sarah and my 3 week adventure at the Koza Adventist Hospital (before returning to Bere) is about to begin...
It's a cool Chadian morning just after 6:00 AM.
Rich has picked up Dr. Bond, Sarah and I from the hospital and brought us out here with our pilot, Gary Roberts. We finally burst on to the airstrip with just a tinge of pink lining the wisps of clouds barely clinging to the night before being swept away by the new day.
The plane looks tiny against the backdrop of grassy airstrip hacked from the African bush. Using well placed whacks with long switches a few kids guide some scattered goats across the strip halfway down.
A single prop, four-seater, our plane is about to go international.
Bond is a little nervous and plies Gary with all kinds of questions about flight hours, how many accidents, how much fuel the plane carries, is he going to check if there's water in the fuel, etc. As Gary takes off the tarps and I help him unattach the tie downs Bond is trying to visually inspect the plane from top to bottom. Dressed in his sport coat and sporting wild black hair streaked with gray and the beginnings of a bushy mustache, Bond looks like India's version of Albert Schweitzer.
Finally, luggage weighed and packed, we squeeze ourselves in the fuselage and strap ourselves in.
The engine fires up sending in a burst of "air conditioning" through the open windows. Last minute checks in place, the windows close and Gary turns the plane around away from the sunrise. Gary then reopens a window and yells to the night watchmen to run ahead and pull the stick "goal posts" out of the strip/soccer field so we can take off.
When all is clear, a pull of the throttle lurches us forward and we quickly pick up speed as we bump and bounce across the airstrip and in no time we are airborne as Bere drops out from below us and we take a sharp turn over the trees to buzz the hospital.
It's amazing to see how really small our 20,000 strong village really is. Just a bunch of mudhuts so well camoflouged by the mango trees and millet patches that you can't hardly see anything until the tin roofs of the church, school and finally hospital come into view.
Seeing that tiny clump of trees with a few tin roofs jutting up it's hard to believe that anyone would want to be treated there much less that people would come as far away as Lake Chad and Abeche on the border of Darfur to be operated on in our collection of ragged buildings.
Soon we are crossing a patchwork quilt of rice, millet, peanut and sweet potato fields. The artwork is more of the style of Barcelona's Gaudi with natural lines of trails, islands of trees and a symmetry more geographic than geometric.
We soon pick up the Logone river and follow it's course. Along the banks we see the tiny beehive-shaped, rounded tents of the Arab nomads with herds of cattle and a few horses scattered along the banks. Periodically the glassy surface is broken by the smooth gliding of a wooden log canoe and it's fishermen on their way or already casting their handwoven nets in the shallow, fish-rich waters.
We follow the Logone up and finally see the Tandjile snake it's way up and join it's fast flowing waters right before Koyom and the Pentocostal Hospital. We buzz it's airstrip and notice it's unusable.
Then we pick up altitude, leave the Logone behind and the African plane becomes a distant network of fields, forests and tiny villages.
Finally, we pick up Tchad's other major river, the Chari and follow that all the way to N'Djamena where the Logone and the Chari become one.
One doesn't even notice N'Djamena till one is right on top of it. It's just a large village lost amongst the trees. If it wasn't for the occasional 5-10 story building and the bridge across the Chari and the fact that I knew that's where the Logone joins in I wouldn't have been sure it was N'Djamena. I don't think there is any other capital village in the world like N'Djamena.
The airport is right across the river and has a single runway. There are two other planes pulled up at the airport. We land easily and taxi up the the MAF hangar. Probably the world's smallest international airport (a fact proven later on when we land in Garoua, Cameroun's international airport).
After a few days getting visa's and wasting time trying unsuccessfully to talk to the appropriate authorities to get Gary permission to fly on a permanent basis in Tchad we take off for Cameroun.
Cameroun is unremarkable for about 30 minutes until we hit the national park at Waza where we scare off some herds of antelope and giraffes. I finally feel like I'm really in Africa although some Elephants and Lions would be nice, too.
As we approach Garoua we hit some mountains and Gary flies us between two flat topped plateaus in a valley. The descent combined with an approaching storm and the mountains makes for a bumpy ride that threatens to loosen the tenous hold on my breakfast that I'd been maintaining since N'Djamena.
Sarah had already let up a sickening vomit smell from the back seat. Fortunately, Gary kindly provided us with vomit bags for the flight.
I think it's hypoglycemia as we haven't really eaten well the last few days. We couldn't find any place to stay in N'Djamena until someone finally opened us up a dorm room that hadn't been cleaned in months and didn't have a kitchen. So we were forced to eat off the streets which is slim pickins in N'Djamena (we had to content ourselves with boiled eggs, french rolls and fish soup).
After an uneventful landing and take off for formalities in Garoua, we head into the mountains. The beauty of the rugged cliffs rising from the rich green valleys sprinkeled with fields of corn and millet and wizard hat-like pointed roofed huts is impossible to describe.
Gary calls Maroua Airport to check in and the controller is shocked to hear we're going to Koza since no one has landed there in over 20 years but Gary assures her that the airstrip has been repaired.
One mountain plateau is so broad we dreamed aloud of building a hospital and airstrip on top of it...and it is not exaggerating.
Finally, we climb the last pass and look into Koza's valley. We approach the airstrip. I get the idea Gary is going to land because he goes so low but he's running out of airway. At the last minute he cranks the throttle and whips up over the tree tops before banking hard left and back around. Apparently, he was only looking for cows and holes that kids have dug to find mice to eat.
We circle around again and make a very bouncy jungle strip landing without any problem in time to greet the crowd of kids running up followed by a gang of bikers. By the time we have stopped and started to tie down our two guardians are there with sticks keeping the kids a safe 2-3 feet away. The crowd is so thick it is literally a sea of smiling, laughing and waving faces.
Gary's wife Wendy drives up in Greg and Audrey Shank's pick-up truck and Sarah and my 3 week adventure at the Koza Adventist Hospital (before returning to Bere) is about to begin...
Saturday, September 22, 2007
Why bother?
Sometimes I wonder why I even bother. I stand in the semidarkness of the early evening with my hand over the heart of an 11 year old girl feeling the life ebb out of her. I've detached the ambu-bag from the tracheostomy tube in her neck and she's not breathing. Her pupils are fixed and dilated and I'm now getting to experience for the first time in a raw way the process of life leaving a broken body.
She came in four days ago. She was by the side of the road drawing water from the lake that has now all but flooded the road in between Bere and Kelo. A truck was trying to plow and rev it's way through the water logged mud and slid over towards the girl. She was knocked over and the truck turned on it's side crushing her legs beneath. The passengers frantically unloaded the barrels off the truck and were able to lift the truck up enough to pull her mangled body out from under it.
She arrived at the hospital conscious with her right leg twisted out at an impossible angle and her left leg wrapped in a bloody, mud-splotched t-shirt. She had no apparent head, chest or abdominal injuries, just her two legs.
I unwrap the shirt.
Her left lower leg is sliced open from just below the knee to just above the ankle as with a butcher knife. There is another 6 inch long cut on the side, a 2 inch long cut on the back of the calf and an inch long wound over her outside ankle.
The large lower leg bone is broken and the pieces sticking out at weird angles with much of the rest of the bone exposed.
Her right femur is also fractured, but not open.
We start an IV, give antibiotics and put her under anesthesia. We scrub out the wounds and rinse with liters and liters of antimicrobial fluids. I set the bones which have cracked in a V-shape making the reduction fairly stable. Liz holds the reduction at the foot and I suture the wounds closed.
I put casts around her ankle and knee with a broken broom stick on each side to act as an external fixator. The fracture is stabilized and we have room to clean and dress the wounds.
I then drill a pin through the bone on her other leg and we move her to her hospital bed where I attache a sand-filled shirt to the pin with a rope to act as traction for the femur fracture.
She is breathing well and is otherwise stable.
A few hours later I go to check on her and she is in respiratory distress. She has what is every anesthesiologist's worst nightmare: micrognathia. In other words, her lower jaw never developed well and is so tiny that her mouth won't really open, her tongue is too big for her throat and her airway is small.
She has too many secretions and now her neck has started to swell. She probably had head trauma as well. She is struggling to breath sucking desperately with her chest. I run and get the pulse oximeter and her oxygen is already going down. I yell for the family members to grab her bed and bring her to the OR (it has no wheels so has to be carried...with the traction it'll be impossible to move her quickly otherwise).
I run ahead to open up and go back to find they haven't really moved. I notice she has stopped breathing. I yell again and this time they come running. We somehow manage to get the bed out of the ward, across the courtyard and into the OR.
No breathing, no pulse.
I grab a scalpel and slice her throat. I poke aside the muscles with a clamp and expose her trachea. I cut into it with a scalpel and widen the hole with the clamp and grasp each side with clamps. I insert an endotracheal tube into the hole and attach an ambu bag while Anatole starts chest compressions.
Miraculously, she comes back to life. After a few minutes she is breathing on her own through the tube in her neck and after waiting a while to make sure she's stable we take her back to the ward.
She stays in a coma, however, and we realize she has brain swelling from the accident. For two days we keep the swelling down enough with medicines that she breathes on her own. Her pupils still react normally. On the third day, we have to start breathing for her. The family members take turns "bagging" her to force air into her lungs.
The fourth day, today, the pupils are fixed and dilated.
I'm amazed at how long it can take to try and save a life and how quickly one can remove those life saving devices. Surgery took two hours. The tracheostomy and resuscitation took another hour. Not to mention all the other time spent adjusting meds, explaining to family members, suctioning her tracheostomy tube, etc.
Now in 10 minutes her IV is out, the urinary catheter has been removed, the tracheostomie was pulled, the traction pin drilled out, and the cast cut off. Nothing remains but the sutures and the slightly twisted, un-stabilized legs.
As I sit to write this, I'm sobbing deep down with no tears. How much have I prayed for this girl over the last four days? How much of my own time, strength and energy have I put into her despite having Malaria myself? Why do I bother?
Why does God seem to never intervene? Why does it seem I'm on my own in this?
I need to make sense of it or I'll lose my faith.
Maybe it's not God's fault at all...maybe it's ours. Maybe if this girl had a clean well or running water she wouldn't have been forced to draw from the side of the road. Maybe if the road had been paved with appropriate bridges and drainage systems the truck wouldn't have slid into her. Maybe if the hospital had better lab facilities we could've intervened to prevent any of the number of things that could be unknown contributing factors to her death.
Maybe we in the West can't go out to buy the latest Energy drink or expensive gourmet coffee without using up the resources that could have gone to furnishing clean water sources in the Third World.
Maybe we can't buy bigger and fancier gas-guzzling SUVs without wasting the money that could've gone to provide simple improved infrastructure in developing nations.
Maybe we can't spend millions of dollars on boob jobs and face lifts and lipo suction without depriving bush hospitals of basic laboratory and x-ray equipment.
Maybe we can't live our comfortable lives and sit back and expect God to do the work that he has given us adequate resources, abilities, talents and time to do ourselves. Maybe God's saying, I haven't refused to save that girl's life...
You have.
She came in four days ago. She was by the side of the road drawing water from the lake that has now all but flooded the road in between Bere and Kelo. A truck was trying to plow and rev it's way through the water logged mud and slid over towards the girl. She was knocked over and the truck turned on it's side crushing her legs beneath. The passengers frantically unloaded the barrels off the truck and were able to lift the truck up enough to pull her mangled body out from under it.
She arrived at the hospital conscious with her right leg twisted out at an impossible angle and her left leg wrapped in a bloody, mud-splotched t-shirt. She had no apparent head, chest or abdominal injuries, just her two legs.
I unwrap the shirt.
Her left lower leg is sliced open from just below the knee to just above the ankle as with a butcher knife. There is another 6 inch long cut on the side, a 2 inch long cut on the back of the calf and an inch long wound over her outside ankle.
The large lower leg bone is broken and the pieces sticking out at weird angles with much of the rest of the bone exposed.
Her right femur is also fractured, but not open.
We start an IV, give antibiotics and put her under anesthesia. We scrub out the wounds and rinse with liters and liters of antimicrobial fluids. I set the bones which have cracked in a V-shape making the reduction fairly stable. Liz holds the reduction at the foot and I suture the wounds closed.
I put casts around her ankle and knee with a broken broom stick on each side to act as an external fixator. The fracture is stabilized and we have room to clean and dress the wounds.
I then drill a pin through the bone on her other leg and we move her to her hospital bed where I attache a sand-filled shirt to the pin with a rope to act as traction for the femur fracture.
She is breathing well and is otherwise stable.
A few hours later I go to check on her and she is in respiratory distress. She has what is every anesthesiologist's worst nightmare: micrognathia. In other words, her lower jaw never developed well and is so tiny that her mouth won't really open, her tongue is too big for her throat and her airway is small.
She has too many secretions and now her neck has started to swell. She probably had head trauma as well. She is struggling to breath sucking desperately with her chest. I run and get the pulse oximeter and her oxygen is already going down. I yell for the family members to grab her bed and bring her to the OR (it has no wheels so has to be carried...with the traction it'll be impossible to move her quickly otherwise).
I run ahead to open up and go back to find they haven't really moved. I notice she has stopped breathing. I yell again and this time they come running. We somehow manage to get the bed out of the ward, across the courtyard and into the OR.
No breathing, no pulse.
I grab a scalpel and slice her throat. I poke aside the muscles with a clamp and expose her trachea. I cut into it with a scalpel and widen the hole with the clamp and grasp each side with clamps. I insert an endotracheal tube into the hole and attach an ambu bag while Anatole starts chest compressions.
Miraculously, she comes back to life. After a few minutes she is breathing on her own through the tube in her neck and after waiting a while to make sure she's stable we take her back to the ward.
She stays in a coma, however, and we realize she has brain swelling from the accident. For two days we keep the swelling down enough with medicines that she breathes on her own. Her pupils still react normally. On the third day, we have to start breathing for her. The family members take turns "bagging" her to force air into her lungs.
The fourth day, today, the pupils are fixed and dilated.
I'm amazed at how long it can take to try and save a life and how quickly one can remove those life saving devices. Surgery took two hours. The tracheostomy and resuscitation took another hour. Not to mention all the other time spent adjusting meds, explaining to family members, suctioning her tracheostomy tube, etc.
Now in 10 minutes her IV is out, the urinary catheter has been removed, the tracheostomie was pulled, the traction pin drilled out, and the cast cut off. Nothing remains but the sutures and the slightly twisted, un-stabilized legs.
As I sit to write this, I'm sobbing deep down with no tears. How much have I prayed for this girl over the last four days? How much of my own time, strength and energy have I put into her despite having Malaria myself? Why do I bother?
Why does God seem to never intervene? Why does it seem I'm on my own in this?
I need to make sense of it or I'll lose my faith.
Maybe it's not God's fault at all...maybe it's ours. Maybe if this girl had a clean well or running water she wouldn't have been forced to draw from the side of the road. Maybe if the road had been paved with appropriate bridges and drainage systems the truck wouldn't have slid into her. Maybe if the hospital had better lab facilities we could've intervened to prevent any of the number of things that could be unknown contributing factors to her death.
Maybe we in the West can't go out to buy the latest Energy drink or expensive gourmet coffee without using up the resources that could have gone to furnishing clean water sources in the Third World.
Maybe we can't buy bigger and fancier gas-guzzling SUVs without wasting the money that could've gone to provide simple improved infrastructure in developing nations.
Maybe we can't spend millions of dollars on boob jobs and face lifts and lipo suction without depriving bush hospitals of basic laboratory and x-ray equipment.
Maybe we can't live our comfortable lives and sit back and expect God to do the work that he has given us adequate resources, abilities, talents and time to do ourselves. Maybe God's saying, I haven't refused to save that girl's life...
You have.
Wednesday, September 19, 2007
Dragonflies
I live in a world of incredible suffering and stunning beauty.
As the tall grass itches the backs of my calves I let myself down to the ground. I slip off my white and orange Crocs and use them as a mat. The soccer match is already underway.
The agility, grace and power of the players makes me forget their ages until halftime when the team sporting white t-shirts with their names handpainted on the back rushes by me and past the church yelling my name and shouting "lapia". It's then I remember they're just little kids.
They come back skipping, laughing and smiling, each with a half-eaten, half-ripe guava in hand ready for the second half.
There is not a single artificial sound to be heard. Just the gentle rustle of the breeze in the drying out remnants of the millet harvest, the distant shouts and babble of the kids joking in Nangjere and the buzz of a million dragonfly wings.
I let my focus drift off the obvious, sprawling lushness of the rainy season African bush and onto what hovers between earth and sky so startingly blue it almost hurts to the hundreds of seeming motionless hovering dragonflies. They are evenly spaced about a meter apart and at seemingly haphazard levels that nonetheless give a sense of order in some weird mathematical way.
The light has taken on that quality one only finds right before it sets low enough to turn color but after it's reached it's peak where it shines directly. The billowing white clouds make a perfect canvas to reflect the brilliance of the sun's perfect angle and to mute it just so it brings out everything in a sharpness of detail not noticed as absent until it rarely presents itself.
I feel transported to another time and another place. A time and a place where I wasn't watching babies die every day. A time and a place where it's almost unheard of for a woman to have lost a child tragically. A time and a place where I wasn't the only doctor for hundreds of thousands of the poor and suffering. A time and a place where I don't feel overwhelmed almost constantly. A time and a place that for me is a fading memory reawakened occasionally by miraculous, dragonfly filled moments.
As the kids resume their match, some older boys start a small circle of soccer "foreplay". Each one takes the ball and bounces it off a knee, or feet several times, maybe a head bump or two and then passes it to the next guy...hopefully without ever letting the ball touch the ground.
Four younger kids are alternately sprawling around, rolling back and forth and chasing a tiny, pink, half-deflated ball back and forth.
All the children on the field (and off) are barefoot except for one who looks like he's wearing army boots and socks three sizes to big. The score is one to one.
Behind me, I notice a newcomer on the scene. A boy about 12 or 13 years old. He's crippled. He has a single homemade wooden crutch. One leg is severely shortened causing his whole body to swerve and lean. Somehow, he still manages to join the boys in their game, kicking the ball around with both feet as he hops around on his crutch.
I call Tabegue, Samedi's nephew, over and tell him I want to talk to the handicapped kid.
His story is tragic, yet all to common here in Tchad.
In 2002, he was just running and then felt his leg "give way". According to him, it was "out of joint". He had many traditional bone setters try and put it in, but it never healed right and he's been crippled ever since.
I have him lie on the ground as all the kids not playing in the match gather quickly around to watch. His left knee is about 10 inches shorter than his right. His left lower leg is normal. His hip has a surprising range of motion, but there is a bony mass sticking up, out and back.
What probably happened is something that in the developed world would be operated on right away with a few pins and six weeks later he'd be back walking hardly knowing that if he'd been born in a different country, he'd be handicapped for life.
I tell him to come see me the next day at the hospital. I hope to be able to help him.
He still hasn't shown up...but the dragonflies hover on.
As the tall grass itches the backs of my calves I let myself down to the ground. I slip off my white and orange Crocs and use them as a mat. The soccer match is already underway.
The agility, grace and power of the players makes me forget their ages until halftime when the team sporting white t-shirts with their names handpainted on the back rushes by me and past the church yelling my name and shouting "lapia". It's then I remember they're just little kids.
They come back skipping, laughing and smiling, each with a half-eaten, half-ripe guava in hand ready for the second half.
There is not a single artificial sound to be heard. Just the gentle rustle of the breeze in the drying out remnants of the millet harvest, the distant shouts and babble of the kids joking in Nangjere and the buzz of a million dragonfly wings.
I let my focus drift off the obvious, sprawling lushness of the rainy season African bush and onto what hovers between earth and sky so startingly blue it almost hurts to the hundreds of seeming motionless hovering dragonflies. They are evenly spaced about a meter apart and at seemingly haphazard levels that nonetheless give a sense of order in some weird mathematical way.
The light has taken on that quality one only finds right before it sets low enough to turn color but after it's reached it's peak where it shines directly. The billowing white clouds make a perfect canvas to reflect the brilliance of the sun's perfect angle and to mute it just so it brings out everything in a sharpness of detail not noticed as absent until it rarely presents itself.
I feel transported to another time and another place. A time and a place where I wasn't watching babies die every day. A time and a place where it's almost unheard of for a woman to have lost a child tragically. A time and a place where I wasn't the only doctor for hundreds of thousands of the poor and suffering. A time and a place where I don't feel overwhelmed almost constantly. A time and a place that for me is a fading memory reawakened occasionally by miraculous, dragonfly filled moments.
As the kids resume their match, some older boys start a small circle of soccer "foreplay". Each one takes the ball and bounces it off a knee, or feet several times, maybe a head bump or two and then passes it to the next guy...hopefully without ever letting the ball touch the ground.
Four younger kids are alternately sprawling around, rolling back and forth and chasing a tiny, pink, half-deflated ball back and forth.
All the children on the field (and off) are barefoot except for one who looks like he's wearing army boots and socks three sizes to big. The score is one to one.
Behind me, I notice a newcomer on the scene. A boy about 12 or 13 years old. He's crippled. He has a single homemade wooden crutch. One leg is severely shortened causing his whole body to swerve and lean. Somehow, he still manages to join the boys in their game, kicking the ball around with both feet as he hops around on his crutch.
I call Tabegue, Samedi's nephew, over and tell him I want to talk to the handicapped kid.
His story is tragic, yet all to common here in Tchad.
In 2002, he was just running and then felt his leg "give way". According to him, it was "out of joint". He had many traditional bone setters try and put it in, but it never healed right and he's been crippled ever since.
I have him lie on the ground as all the kids not playing in the match gather quickly around to watch. His left knee is about 10 inches shorter than his right. His left lower leg is normal. His hip has a surprising range of motion, but there is a bony mass sticking up, out and back.
What probably happened is something that in the developed world would be operated on right away with a few pins and six weeks later he'd be back walking hardly knowing that if he'd been born in a different country, he'd be handicapped for life.
I tell him to come see me the next day at the hospital. I hope to be able to help him.
He still hasn't shown up...but the dragonflies hover on.
Sunday, September 2, 2007
Dabegue
It's pouring down rain soaking through my jeans and fogging up my glasses. Sarah and I have saddled up the horses, packed the medicines in the saddlebags and are on our way to Noel's.
The 6-8 foot tall millet and corn leans out haphazardly over the windy, mud puddle-filled road across the Western edge of town. I get slapped in the face and chest several times with the long, firm heads on the weaving stalks as the horse gallops back and forth in the slalom course of small ponds (complete with ducks and frogs) in the middle of the path.
Noel's house is the last one on the road that heads to Delbian and eventually Bao and Moundou. It's a conglomerate of partially finished mud brick buildings, some without roof, doors and windows, some with tin used for all of the above. He is waiting outside leaning his chair back against the wall.
Noel, former Russian and Libyan-trained terrorist turned hospital chaplain is dressed in a tan jump suit with a black and red striped beanie slouched lazily on his shaved head. He sports a scruffy goatee and partial beard already tinged with gray.
He manages to get on the third horse after a couple of attempts and we're off to Dabegue.
After a couple kilometers we enter the village which stretches for about 5km hugging the road without much depth. It's just a rough collection of mud hut concessions with interspersed fields of rice, millet, corn, peanuts and sweet potatos.
Halfway through the village we turn left at what's left of a burned out tree trunk that was struck by lightening years ago. We weave through a narrow passage with millet stalks swaying on both sides and come out in the open under a large mango tree with a mud brick wall on the left. Two rickety wooden chairs made low to the ground and leaned back for lounging are around a rickety metal "coffee table".
Our host hurries out to greet us with his wife. They both look familiar. I don't figure out how I know them till a little later after which I become amazed at God's working through our mistakes.
It doesn't take long for the kids to pour in from all directions and take their seat on a large mat with 4 galloping horses woven into the pattern in yellow and red. Noel pulls out two Bible picture rolls. At first the kids are shy with two strangers there. Noel tries to teach them a song in Nangere but no one gets into it until we make it a competition with Noel and the guys against me and the girls to see who can sing loudest.
Then, he calls up the kids to say what they can name from the picture story of last week. They are so proud to recognize Mary and Joseph and Jesus and the wise men, getting a round of applause and "bravos" let by Noel each time.
The toothy grins and laughter is contagious and I'm having a great time trying to pick up some Nangere here and there as Noel continues the story of Jesus.
After 15 minutes we sing another song and then I get to try and answer the adults' question from last week as to why horses and lions don't get along these days like they do in the picture of Adam in the Garden of Eden.
I talk in French and Noel translates into Nangere. They all understand about the serpent (Genesis 3) and then how it is really the devil who made war against God by rebelling against him (Revelation 12) and how it came about through his pride and ambition to be like God (Isaiah 14 and Ezekiel 28). It seems to make sense after all that rebellion from Adam and Eve leading up to the flood and Noah when God says that he'll make the animals afraid of humans that it's the result of rebellion why horses and lions just don't get along.
We finish after about 30 minutes and then Sarah and I start to consult kids. We've brought a battery powered device to check hemoglobin's and find 5 kids with hemoglobin's of 5 or less (normal is 14-16) due to malaria. We refer them to the hospital for blood transfusions. The rest we treat for Malaria and parasites. We see 80 kids in a little over an hour.
After a meal of boiled eggs, steamed corn and chicken and rice we pack up to go home.
Half an hour after arriving home, Deuhibe knocks on the door. Short with sharp facial features, Deuhibe is one of our newest and best nurses. Dressed in bright aqua scrubs and a long white coat I know he must have a case for me.
He starts to explain about several patients but I quickly realize I need to see the patients so I walk over to the hospital with him.
We head first to labor and delivery. The room is dark and there is a young woman, obviously pregnant stretched out on her left side on the exam table. It's her first pregnancy and she's been in our hospital in labor since 3:00am today. She has been fully dilated for hours and can't deliver.
I have her turn onto her back and grab the fetal doppler off the table. I squirt a glob of ultrasound jelly onto her belly between her belly button and her right pelvis and stretch out the doppler stick on its telephone like curly cue cord to place it on the jelly. I fire up the on button to a reassuring crackle as the move the device gently over the belly until I hear the reassuring boom-boom, boom-boom of a rapid fetal heart beat running at 140 per minute.
The baby's still alive.
I hurry to the OR and get the symphysiotomie kit, a suture, a scalpel, a razor blade, some gauze sponges, Bernadine, a syringe, some lidocaine, a foley catheter with bag, a pair of sterile gloves and a vacuum extractor.
While Deuhibe inserts the urinary catheter I shave the pubic area with the razor, prep it with betadine and inject 10cc of lidocaine into the skin and around and in the pubic cartilage of her pelvis.
I open the symphysiotomie kit, attach a large scalpel to the scalpel holder and make a small incision all the way down to the cartilage. I then stick my other hand inside to move the urinary catheter to the side effectively displacing the urethra. I slice through the cartilage which cuts remarkably easily until I'm most of the way through.
Then, Deuhibe and Odei pull the legs up out and down until we hear a pop and feel the pelvis come apart a few centimeters. She has a contraction, I attach the vacuum pump, I make an lateral episiotomy with the surgical scissors to open up the vaginal opening and with one push the baby is out.
His face wrinkles up and his arms and legs are nicely flexed but he doesn't cry or breath. I suck out the green, meconium thick fluid out of his mouth and nose, clamp the umbilical cord, cut between the clamps and take him over to the resuscitation table.
He has a good heart beat but still doesn't want to breath. I rough him up a little on his spine and feet while vigorously drying him off.
Still no cry.
I pump his chest a little and put a tiny mask on his face and give him a few breaths.
Finally he lets out a little whimper. I continue my shaking and rubbing and he finally starts to breath and wail.
I return to the mom, pull out the placenta, suture up the syphysiotomie wound in two layers (fascia and skin) and suture the episiotomie.
Deuhibe then takes me to see the next two cases.
The first is a four year old girl with fever and abdominal pain. They've started her on a quinine drip. I look at her, and I can't explain why, but I feel there's something else going on. She hasn't vomited but hasn't pooped in two days. She doesn't really want to eat but has taken some porridge. Her eyes look kind of glazed over (not unusual in severe malaria). The abdominal pain could be just malaria or constipation.
I feel her belly. It's soft but tender. She kind of whimpers when I touch her but it doesn't seem too bad.
For some reason, something bothers me, though. I decide to do a rectal exam. She seems tender on the right and not the left.
I'm afraid it might be appendicitis, but I'm nervous about operating. She'd come in the morning with anemia and had been transfused. Maybe it's just severe malaria. If it is, I could kill her by operating.
I decide to buy some time and order antibiotics and more IV fluids while I go look at the next patient.
This one is straight forward, a strangulated hernia. The hernia is massive, painful and won't go back inside. He's vomited once.
We take him straight to the OR.
After prep, scrub and drape under spinal anesthesia I make a large diagonal incision directly over the bulging hernia. I dissect the sack free from the spermatic cord and the contents pop back in to the abdomen. I take out the testicle, tie off the sack and stitch a piece of sterilized mosquito netting over the week spot between the transversalis fascia and the inguinal ligament.
He's 60 years old and doesn't need more than one testicle anyway and this way it's sure not to recur.
I close up the fascia and skin, take off my gloves and go back to see the four year old girl.
Something still bothers me and I make a tough decision. I tell the father that she'll die without an operation but she might die during the surgery. Does he want us to go through with it? He's in agreement so we wheel her off to the OR.
We give her Ketamine, prep the belly with Bernadine and drape it with sterile towels. I use the tubal ligation kit which has smaller re tractors for this tiny abdomen.
I pray as usual and then slice carefully through the thin skin, tiny fascia and muscles and gently enter the peritoneal cavity.
Purulent fluid and a dark intestine bulge out letting me know instantly it was a good decision to operate.
I enlarge the abdominal wound and out pops a blackened small intestine, so necrotic it's at the point of perforating but appears to have held itself intact so far.
I break away some adhesions and it's finally freed up. The black, dusky parts go almost all the way to the large intestine on the distal end and about a foot and a half proximally.
I open the laparotomie kit and pull out the bowel clamps. I clamp over healthy intestine and then a second one over the part to be removed. I then clamp off the vessels feeding the dead intestine and remove it all together.
I tie off the vessels in the mesentery and then examine the two ends of remaining intestine. the proximal end looks good but the distal end looks dead. I'm worried because there's only about 2-3 cms of intestine left until the colon. It'll be much more difficult if I have to open the colon to reattach the small intestine. I remove one centimeter more leaving just barely over a cm but now it looks fairly healthy.
I suture the tiny small bowel with tiny sutures and then do a second layer. I take off the clamps and there is no leaking or bleeding. I insert two drains.
Then she starts to vomit. And vomit. And vomit. Dark green with black coffee grounds. We insert an nasogastrique tube and get almost half a liter out of her stomach. I wash out the abdomen with a lot of fluids, close the fascia and skin, and place a bandage.
I prescribe antibiotics, IV fluids, tell the family not to give her anything to eat or drink and go home.
The next day, the woman and her baby, the man with the hernia and the little girl are all still alive. I give post-op advice to Samedi, our surgical nurse, and pack my bag and hop on a motorcycle to head to Moundou and the refugee camp at Gore...I wonder if the girl will be alive when I return...
The 6-8 foot tall millet and corn leans out haphazardly over the windy, mud puddle-filled road across the Western edge of town. I get slapped in the face and chest several times with the long, firm heads on the weaving stalks as the horse gallops back and forth in the slalom course of small ponds (complete with ducks and frogs) in the middle of the path.
Noel's house is the last one on the road that heads to Delbian and eventually Bao and Moundou. It's a conglomerate of partially finished mud brick buildings, some without roof, doors and windows, some with tin used for all of the above. He is waiting outside leaning his chair back against the wall.
Noel, former Russian and Libyan-trained terrorist turned hospital chaplain is dressed in a tan jump suit with a black and red striped beanie slouched lazily on his shaved head. He sports a scruffy goatee and partial beard already tinged with gray.
He manages to get on the third horse after a couple of attempts and we're off to Dabegue.
After a couple kilometers we enter the village which stretches for about 5km hugging the road without much depth. It's just a rough collection of mud hut concessions with interspersed fields of rice, millet, corn, peanuts and sweet potatos.
Halfway through the village we turn left at what's left of a burned out tree trunk that was struck by lightening years ago. We weave through a narrow passage with millet stalks swaying on both sides and come out in the open under a large mango tree with a mud brick wall on the left. Two rickety wooden chairs made low to the ground and leaned back for lounging are around a rickety metal "coffee table".
Our host hurries out to greet us with his wife. They both look familiar. I don't figure out how I know them till a little later after which I become amazed at God's working through our mistakes.
It doesn't take long for the kids to pour in from all directions and take their seat on a large mat with 4 galloping horses woven into the pattern in yellow and red. Noel pulls out two Bible picture rolls. At first the kids are shy with two strangers there. Noel tries to teach them a song in Nangere but no one gets into it until we make it a competition with Noel and the guys against me and the girls to see who can sing loudest.
Then, he calls up the kids to say what they can name from the picture story of last week. They are so proud to recognize Mary and Joseph and Jesus and the wise men, getting a round of applause and "bravos" let by Noel each time.
The toothy grins and laughter is contagious and I'm having a great time trying to pick up some Nangere here and there as Noel continues the story of Jesus.
After 15 minutes we sing another song and then I get to try and answer the adults' question from last week as to why horses and lions don't get along these days like they do in the picture of Adam in the Garden of Eden.
I talk in French and Noel translates into Nangere. They all understand about the serpent (Genesis 3) and then how it is really the devil who made war against God by rebelling against him (Revelation 12) and how it came about through his pride and ambition to be like God (Isaiah 14 and Ezekiel 28). It seems to make sense after all that rebellion from Adam and Eve leading up to the flood and Noah when God says that he'll make the animals afraid of humans that it's the result of rebellion why horses and lions just don't get along.
We finish after about 30 minutes and then Sarah and I start to consult kids. We've brought a battery powered device to check hemoglobin's and find 5 kids with hemoglobin's of 5 or less (normal is 14-16) due to malaria. We refer them to the hospital for blood transfusions. The rest we treat for Malaria and parasites. We see 80 kids in a little over an hour.
After a meal of boiled eggs, steamed corn and chicken and rice we pack up to go home.
Half an hour after arriving home, Deuhibe knocks on the door. Short with sharp facial features, Deuhibe is one of our newest and best nurses. Dressed in bright aqua scrubs and a long white coat I know he must have a case for me.
He starts to explain about several patients but I quickly realize I need to see the patients so I walk over to the hospital with him.
We head first to labor and delivery. The room is dark and there is a young woman, obviously pregnant stretched out on her left side on the exam table. It's her first pregnancy and she's been in our hospital in labor since 3:00am today. She has been fully dilated for hours and can't deliver.
I have her turn onto her back and grab the fetal doppler off the table. I squirt a glob of ultrasound jelly onto her belly between her belly button and her right pelvis and stretch out the doppler stick on its telephone like curly cue cord to place it on the jelly. I fire up the on button to a reassuring crackle as the move the device gently over the belly until I hear the reassuring boom-boom, boom-boom of a rapid fetal heart beat running at 140 per minute.
The baby's still alive.
I hurry to the OR and get the symphysiotomie kit, a suture, a scalpel, a razor blade, some gauze sponges, Bernadine, a syringe, some lidocaine, a foley catheter with bag, a pair of sterile gloves and a vacuum extractor.
While Deuhibe inserts the urinary catheter I shave the pubic area with the razor, prep it with betadine and inject 10cc of lidocaine into the skin and around and in the pubic cartilage of her pelvis.
I open the symphysiotomie kit, attach a large scalpel to the scalpel holder and make a small incision all the way down to the cartilage. I then stick my other hand inside to move the urinary catheter to the side effectively displacing the urethra. I slice through the cartilage which cuts remarkably easily until I'm most of the way through.
Then, Deuhibe and Odei pull the legs up out and down until we hear a pop and feel the pelvis come apart a few centimeters. She has a contraction, I attach the vacuum pump, I make an lateral episiotomy with the surgical scissors to open up the vaginal opening and with one push the baby is out.
His face wrinkles up and his arms and legs are nicely flexed but he doesn't cry or breath. I suck out the green, meconium thick fluid out of his mouth and nose, clamp the umbilical cord, cut between the clamps and take him over to the resuscitation table.
He has a good heart beat but still doesn't want to breath. I rough him up a little on his spine and feet while vigorously drying him off.
Still no cry.
I pump his chest a little and put a tiny mask on his face and give him a few breaths.
Finally he lets out a little whimper. I continue my shaking and rubbing and he finally starts to breath and wail.
I return to the mom, pull out the placenta, suture up the syphysiotomie wound in two layers (fascia and skin) and suture the episiotomie.
Deuhibe then takes me to see the next two cases.
The first is a four year old girl with fever and abdominal pain. They've started her on a quinine drip. I look at her, and I can't explain why, but I feel there's something else going on. She hasn't vomited but hasn't pooped in two days. She doesn't really want to eat but has taken some porridge. Her eyes look kind of glazed over (not unusual in severe malaria). The abdominal pain could be just malaria or constipation.
I feel her belly. It's soft but tender. She kind of whimpers when I touch her but it doesn't seem too bad.
For some reason, something bothers me, though. I decide to do a rectal exam. She seems tender on the right and not the left.
I'm afraid it might be appendicitis, but I'm nervous about operating. She'd come in the morning with anemia and had been transfused. Maybe it's just severe malaria. If it is, I could kill her by operating.
I decide to buy some time and order antibiotics and more IV fluids while I go look at the next patient.
This one is straight forward, a strangulated hernia. The hernia is massive, painful and won't go back inside. He's vomited once.
We take him straight to the OR.
After prep, scrub and drape under spinal anesthesia I make a large diagonal incision directly over the bulging hernia. I dissect the sack free from the spermatic cord and the contents pop back in to the abdomen. I take out the testicle, tie off the sack and stitch a piece of sterilized mosquito netting over the week spot between the transversalis fascia and the inguinal ligament.
He's 60 years old and doesn't need more than one testicle anyway and this way it's sure not to recur.
I close up the fascia and skin, take off my gloves and go back to see the four year old girl.
Something still bothers me and I make a tough decision. I tell the father that she'll die without an operation but she might die during the surgery. Does he want us to go through with it? He's in agreement so we wheel her off to the OR.
We give her Ketamine, prep the belly with Bernadine and drape it with sterile towels. I use the tubal ligation kit which has smaller re tractors for this tiny abdomen.
I pray as usual and then slice carefully through the thin skin, tiny fascia and muscles and gently enter the peritoneal cavity.
Purulent fluid and a dark intestine bulge out letting me know instantly it was a good decision to operate.
I enlarge the abdominal wound and out pops a blackened small intestine, so necrotic it's at the point of perforating but appears to have held itself intact so far.
I break away some adhesions and it's finally freed up. The black, dusky parts go almost all the way to the large intestine on the distal end and about a foot and a half proximally.
I open the laparotomie kit and pull out the bowel clamps. I clamp over healthy intestine and then a second one over the part to be removed. I then clamp off the vessels feeding the dead intestine and remove it all together.
I tie off the vessels in the mesentery and then examine the two ends of remaining intestine. the proximal end looks good but the distal end looks dead. I'm worried because there's only about 2-3 cms of intestine left until the colon. It'll be much more difficult if I have to open the colon to reattach the small intestine. I remove one centimeter more leaving just barely over a cm but now it looks fairly healthy.
I suture the tiny small bowel with tiny sutures and then do a second layer. I take off the clamps and there is no leaking or bleeding. I insert two drains.
Then she starts to vomit. And vomit. And vomit. Dark green with black coffee grounds. We insert an nasogastrique tube and get almost half a liter out of her stomach. I wash out the abdomen with a lot of fluids, close the fascia and skin, and place a bandage.
I prescribe antibiotics, IV fluids, tell the family not to give her anything to eat or drink and go home.
The next day, the woman and her baby, the man with the hernia and the little girl are all still alive. I give post-op advice to Samedi, our surgical nurse, and pack my bag and hop on a motorcycle to head to Moundou and the refugee camp at Gore...I wonder if the girl will be alive when I return...
Sunday, August 19, 2007
How to catch a wife, Chadian style
I follow the shadows in front of me. With just stars to light the way, I follow Samedi and Abre to Abre's house winding amongst the shadows in the shapes of pointed roofed huts, trees, tall millet stalks and brick fences.
We round a corner and the shadows dance on the walls of the compound in the flickering light of a kerosene lamp as the shadow of Abre's wife brings in some wooden stools for us to sit on. Then she returns for the formal greeting of curtsying at the waist and bending the knees to present her hand bent at a 45 degree angle down to be shaken by each visitor.
Abre presents his problem for Samedi and I to give advice on. Once the advice has been adequately discussed and accepted, Abre's wife brings out a small metal pot filled with pasta shells and a goat meat sauce. The repas is set on the rickety wooden "coffee table" and we lean forward and dig in with our large, flimsy spoons.
As we sit up, belly's full, I ask Abre what I think will be a simple question. It turns out to be a long, twisted story that I don't really understand until later.
"Abre, how did you meet your wife?"
Abre clears his throat and starts spinning his tale in his rich, deep baritone voice.
"I was back in the village. I'd come to Béré for high school. I went home on weekends. When classes were over I went home to work my field. I saw this girl from a long way off. She pleased me.
"A few days later, she came to draw water at our well. I had a mango in my hand. I offered it to her. She didn't want it. I insisted. I asked her why I would give her a bad mango? She took it.
"When she came back to draw water a few days later, I had a bunch of mangoes to give her. We started to talk.
"I told my father that was the girl I wanted to marry. She was from a village 6 km away but had come to go to the school in my village, Kalme, and was the servant of my neighbor.
"My dad said it wasn't wise to get a girl from that village, but it was up to me. He would pay the dowry, but then it was up to me. So he did.
"Half-way through the next school year, I decided it was time to find her. I heard she was in a certain village. I went there with my friends, but she had just left. I heard she was at the market, I went there with my friends, but she wasn't there. Finally, I heard she was back in Kalme. I went there to the house where she'd been a servant. She wasn''t there.
"I knew then she was back at her parents house. I called together three of my strongest friends. I told them that tonight was the night. They nodded and we left at 10pm to walk to the girl's village. When we got to the outskirts, I told my friends to wait. I left my bike a little farther on under a certain tree.
"I snuck into the village and stole into the girl's family compound. Stealthily, I made my way to her hut. I knocked on the door. No answer. I knocked again. Still nothing. I knocked again and whispered loudly 'it's me.' She opened the door and told me to leave. I refused. I told her to come out and go get my bike under such and such a tree. She said no so I grabbed her hand and made her come with me. She fought, but not loudly enough to wake her family.
"I brought her to my bike and then to my friends. We Took her by force home to my village that very night. We got in at 5am. That's how I got my wife."
I'm sitting there stunned. Not exactly the romantic love story I'd hoped for. Fortunately, before I could say anything stupid, Samedi pipes up with an explanation.
"That's our tradition. The woman should be stolen from her family by the man who's paid the dowry. He should get his strongest friends to go with him because the family will resist and if he's not strong enough to take his wife be force they'll beat him up. Then, a week later, the girl will get her girlfriend's together and they'll go to the boy for the marriage. But everyone will make fun of him and say he wasn't strong enough to fight for his woman. So, you need to strategize, come at night and bring some tough guys with you if you want to be respected."
The next night, I'm sitting around a similar table, only this time well lighted, with our Pastor Dieudonne Atchouma. I tell him what Abre had said last night.
"That's nothing," he said. "You should check out the tribe around Bongor. Their woman are tough. They all know how to use the bowstaff like the Chinese. From an early age, the girls practice out in the fields. When you want to get married, after you pay the dowry, you are sent off into the bush with the woman and you have to fight her. If you can't beat her, she'll beat you to a pulp and send you home with your tail between your legs and you'll have to find another woman. If you beat her however, and are able to disarm her and capture her and bring her home, then you've earned her and the village's respect and you can marry her.
"Those woman are fierce. Back in the days of the German colonists, they tried to conquer this people. They had guns and everything but they were beaten back by the women with their bowstaffs. They're hard-core."
James
We round a corner and the shadows dance on the walls of the compound in the flickering light of a kerosene lamp as the shadow of Abre's wife brings in some wooden stools for us to sit on. Then she returns for the formal greeting of curtsying at the waist and bending the knees to present her hand bent at a 45 degree angle down to be shaken by each visitor.
Abre presents his problem for Samedi and I to give advice on. Once the advice has been adequately discussed and accepted, Abre's wife brings out a small metal pot filled with pasta shells and a goat meat sauce. The repas is set on the rickety wooden "coffee table" and we lean forward and dig in with our large, flimsy spoons.
As we sit up, belly's full, I ask Abre what I think will be a simple question. It turns out to be a long, twisted story that I don't really understand until later.
"Abre, how did you meet your wife?"
Abre clears his throat and starts spinning his tale in his rich, deep baritone voice.
"I was back in the village. I'd come to Béré for high school. I went home on weekends. When classes were over I went home to work my field. I saw this girl from a long way off. She pleased me.
"A few days later, she came to draw water at our well. I had a mango in my hand. I offered it to her. She didn't want it. I insisted. I asked her why I would give her a bad mango? She took it.
"When she came back to draw water a few days later, I had a bunch of mangoes to give her. We started to talk.
"I told my father that was the girl I wanted to marry. She was from a village 6 km away but had come to go to the school in my village, Kalme, and was the servant of my neighbor.
"My dad said it wasn't wise to get a girl from that village, but it was up to me. He would pay the dowry, but then it was up to me. So he did.
"Half-way through the next school year, I decided it was time to find her. I heard she was in a certain village. I went there with my friends, but she had just left. I heard she was at the market, I went there with my friends, but she wasn't there. Finally, I heard she was back in Kalme. I went there to the house where she'd been a servant. She wasn''t there.
"I knew then she was back at her parents house. I called together three of my strongest friends. I told them that tonight was the night. They nodded and we left at 10pm to walk to the girl's village. When we got to the outskirts, I told my friends to wait. I left my bike a little farther on under a certain tree.
"I snuck into the village and stole into the girl's family compound. Stealthily, I made my way to her hut. I knocked on the door. No answer. I knocked again. Still nothing. I knocked again and whispered loudly 'it's me.' She opened the door and told me to leave. I refused. I told her to come out and go get my bike under such and such a tree. She said no so I grabbed her hand and made her come with me. She fought, but not loudly enough to wake her family.
"I brought her to my bike and then to my friends. We Took her by force home to my village that very night. We got in at 5am. That's how I got my wife."
I'm sitting there stunned. Not exactly the romantic love story I'd hoped for. Fortunately, before I could say anything stupid, Samedi pipes up with an explanation.
"That's our tradition. The woman should be stolen from her family by the man who's paid the dowry. He should get his strongest friends to go with him because the family will resist and if he's not strong enough to take his wife be force they'll beat him up. Then, a week later, the girl will get her girlfriend's together and they'll go to the boy for the marriage. But everyone will make fun of him and say he wasn't strong enough to fight for his woman. So, you need to strategize, come at night and bring some tough guys with you if you want to be respected."
The next night, I'm sitting around a similar table, only this time well lighted, with our Pastor Dieudonne Atchouma. I tell him what Abre had said last night.
"That's nothing," he said. "You should check out the tribe around Bongor. Their woman are tough. They all know how to use the bowstaff like the Chinese. From an early age, the girls practice out in the fields. When you want to get married, after you pay the dowry, you are sent off into the bush with the woman and you have to fight her. If you can't beat her, she'll beat you to a pulp and send you home with your tail between your legs and you'll have to find another woman. If you beat her however, and are able to disarm her and capture her and bring her home, then you've earned her and the village's respect and you can marry her.
"Those woman are fierce. Back in the days of the German colonists, they tried to conquer this people. They had guns and everything but they were beaten back by the women with their bowstaffs. They're hard-core."
James
Marie
I'm poised over the body, scalpel in hand. It's hard to believe that this will be the third major surgery on this poor woman in a month. I've been torn inside as to whether this is the right thing to do, but now as I stand ready to cut, I feel peace.
"Let's pray."
As Samedi prays in Nangjere I find images rapidly running through my mind:
Huge mass. Cut ureter. Tied femoral vessels. Sinking feeling realising what I've done. Meticulous suturing. 4 hour surgery. Feeling of failure. Swollen leg, but alive. Slow but sure recovery. Discharge. Return a week later with swollen belly. Ultrasound showing loculated fluid. Is it tumor or leaking urine. Abdominal surgery again. Belly full of yellow liquid. Every surface inflammed and stuck together. Jelly like substance on everything. Retention sutures. Two drains. Three weeks in the hospital with liters of fluid still coming out. Uncertainty. If it's the leaking ureter I should take out her kidney. If it's the tumor, why put her through another major operation. Today, there's pus coming out the drain. I can't wait longer.
I open my eyes and slice from the bottom of her last rib, across her side to in front of her pelvic bone. I use the electric cautery to slowy go through fat, fascia and the different muscle layers. I open the cavity over the kidney. I dissect out the fat. I slowly release the fine fibers attaching the kidney surface to the surronding tissues. I work my way deep in and around the top part taking off the adrenal gland. Then aroudn the bottom part and the back. Finally I find the huge renal artery and vein. I delicately strip off the fat till I can see it well. It's so deep. I'm trying to not shake in my nervousness. If I don't tie it off well, she could bleed out quick. I don't really have the right instruments. I finally get three clamps on the artery. I cut the artery and tie the part I'm leaving in two places and the part I'm taking out in one. The vein is huge and branches right under where I've cut the artery. I have to go deeper. Finally I clamp it and cut it. Then the ureter is clamped and cut. I pull out the kidney and then tie off the ureteral stump. Then I tie off the vein twice and release the clamp. Blood surges into the field. I clamp the stump quickly, put it under a little tension while Samedi suctions till I can see where it's bleeding and clamp that. I tie it off. I release it. No bleeding.
I close up and finally, Marie Guelia, goes home a week later completely healed. I know that what I have done I am incapable of having done. But that's the cool thing about working here, God puts me in situations where I know I can't do it, and then when I do, I can't help but give him the credit.
James
"Let's pray."
As Samedi prays in Nangjere I find images rapidly running through my mind:
Huge mass. Cut ureter. Tied femoral vessels. Sinking feeling realising what I've done. Meticulous suturing. 4 hour surgery. Feeling of failure. Swollen leg, but alive. Slow but sure recovery. Discharge. Return a week later with swollen belly. Ultrasound showing loculated fluid. Is it tumor or leaking urine. Abdominal surgery again. Belly full of yellow liquid. Every surface inflammed and stuck together. Jelly like substance on everything. Retention sutures. Two drains. Three weeks in the hospital with liters of fluid still coming out. Uncertainty. If it's the leaking ureter I should take out her kidney. If it's the tumor, why put her through another major operation. Today, there's pus coming out the drain. I can't wait longer.
I open my eyes and slice from the bottom of her last rib, across her side to in front of her pelvic bone. I use the electric cautery to slowy go through fat, fascia and the different muscle layers. I open the cavity over the kidney. I dissect out the fat. I slowly release the fine fibers attaching the kidney surface to the surronding tissues. I work my way deep in and around the top part taking off the adrenal gland. Then aroudn the bottom part and the back. Finally I find the huge renal artery and vein. I delicately strip off the fat till I can see it well. It's so deep. I'm trying to not shake in my nervousness. If I don't tie it off well, she could bleed out quick. I don't really have the right instruments. I finally get three clamps on the artery. I cut the artery and tie the part I'm leaving in two places and the part I'm taking out in one. The vein is huge and branches right under where I've cut the artery. I have to go deeper. Finally I clamp it and cut it. Then the ureter is clamped and cut. I pull out the kidney and then tie off the ureteral stump. Then I tie off the vein twice and release the clamp. Blood surges into the field. I clamp the stump quickly, put it under a little tension while Samedi suctions till I can see where it's bleeding and clamp that. I tie it off. I release it. No bleeding.
I close up and finally, Marie Guelia, goes home a week later completely healed. I know that what I have done I am incapable of having done. But that's the cool thing about working here, God puts me in situations where I know I can't do it, and then when I do, I can't help but give him the credit.
James
Tuesday, August 14, 2007
Baby Hernia
Friday. The end of a long week. I'm set to travel Sunday to N'Djamena to pick up some volunteers. The day is almost over. It's been pretty quiet...
"Docteur, you should see this case." Jacob pokes his head in my office at around noon.
A talk, lean father with his young wife wrapped in a bright blue, and yellow patterned body wrap walks in carrying a chubby little three month old. He's sleeping quietly. The mom sits on the exam table and unwraps the baby exposing the obvious problem.
His left groin and scrotum is swollen to 10 times the normal size.
I palpate it and with gentle pressure the "mass" slithers back into the belly causing the child to wake up and cry. My finger is in a hole in the inguinal canal. When I release, the cries cause the baby's intestines to pouch right back out.
If I wait, the intestines could get trapped outside, and since I'm leaving Sunday, I should operate today even though I'm tired.
Samedi, Abel and Simeon all try tirelessly to find an IV without success. Finally, we are forced to use intramuscular Ketamine for the anesthesia.
The tiny is strapped onto a "papoose board" so he can't move and Betadine applied generously to his abdomen, groin, scrotum, penis and upper legs.
I open the hernia pack, scrub, pull on sterile gown and gloves and pick up the scalpel.
It seems so big compared to the little body now draped in sterile towels.
I carefully, gently slice a two centimenter incision over the still bulging hernia.
The sac is so thin I can see the intestines inside. It reaches all the way down to the testicule. It is a delicate thing to dissect off the spermatic cord from the thin sac and it tears in a couple places but finally is free.
I push in the intestines and clamp off the sac. I tie it closed and cut off the rest of the sac. This is where I briefly think of doing something I regret not doing later. Everything I've just read says that tying off the sac in infants is almost always enough with just a 1% chance of recurrence. So, I decide not to close the hernia defect but just close the fascia over the spermatic cord. I attach the testicle to the scrotum with a button on the outside and close up the skin.
He did well under anesthesia and I go home.
The next day is Saturday so I don't do rounds until the afternoon.
I come up to see the nurse and he says that I need to see the baby I operated on yesterday, his scrotum is swollen up.
I have a sinking feeling in my stomach as I walk down the dimly lit corrider to the bare bones hospital ward packed with visitors.
The baby looks sick. He is somewhat lethargic and has a rapid heartbeat and is a little pale. His scrotum is swollen and edematous. It's not readily obvious if it's the hernia come back or a hematoma. I ask the father and he says the swelling started on the inferior part of the scrotum and worked it's way up.
Sounds like a hematoma, but I'm not sure. I feel a sense of helplessness. If it's the hernia he'll die without an operation, but he's so sick he won't survive another operation. And I'm leaving tomorrow morning early.
I make a tough decision to not operate. I suspect he has malaria as well, so I treat his malaria and hope it's just a hematoma that will resolve itself. I don't feel good about my decision, but go home with a heavy heart. I'm sure I'll never see him again.
The next day is an early day. I get on the motorcycle and as I pull away from the hospital I can't help but wondering if the baby's not already dead.
I get back to Béré after midnight Wednesday after getting stuck in the mud just right before the barge crossing...just a few kilometers from Béré.
By the time I eat and hit the sack it's 1:30am. I sleep till almost 10:00 the next morning before going up to the hospital.
To my surprise, the baby is still alive and looking a lot better. He is alert and bright eyed, but his belly is very swollen and he's still pale. He now has an IV that has given him some much needed IV fluids. I order a hemoglobin...it's barely over 6, about a third of normal. We give him a blood transfusion.
The testicle is still swollen and it's obvious now that it's the hernia that's come back. I take him to surgery as the blood transfusion runs in.
Odei assists me as I incise larger and perpindicular to the old incision. A mass of swollen, dark red intestines pop into the field. I try to push them back in but without muscle relaxation and an already swollen abdomen, it's all but impossible.
It seems like most of the intestine is still viable. I push and push but can't get it all inside. It starts to get darker. The blood supply is being cut off before my very eyes. I'm feeling desperate and am sweating and swearing under my breath.
Finally, part of the intestine tears partway through. Thankfully, the inner part doesn't tear but now I have to take out part of the intestine. I open the appropriate instrument pack, put bowel clamps over where the intestine looks nice and pink. Then I clamp off the blood vessels supplying the dying part and cut it out.
Now, I'm stuck trying to suture the tiniest of small intestines in a field only about 3cm big. I make a ton of tiny interrupted stitches through the inner lining and then run a second layer through the tougher muscle layer. I release the bowel clamps. Air and stool inflates the newly sewn intestine without leakage.
Now, I'm able to push the rest of the intestine inside. I take out the testicle and cut and tie the cord pushing the stump inside. Then I close the fascia and all the the rest in three layers.
The I close my cross shaped incision. The kid's still alive though his belly is tense and he's not breathing that well.
I put him on IV fluids and antibiotics and tell his parents to not let him breastfeed or take anything to drink.
He's still alive the next few days but his belly is still very swollen.
Three days later, I come in and his belly is flat and soft, he's been farting and pooping and looks wide-eyed and has normal vital signs. The wound is healing well and he starts breast-feeding.
We'll send him home tomorrow.
"Docteur, you should see this case." Jacob pokes his head in my office at around noon.
A talk, lean father with his young wife wrapped in a bright blue, and yellow patterned body wrap walks in carrying a chubby little three month old. He's sleeping quietly. The mom sits on the exam table and unwraps the baby exposing the obvious problem.
His left groin and scrotum is swollen to 10 times the normal size.
I palpate it and with gentle pressure the "mass" slithers back into the belly causing the child to wake up and cry. My finger is in a hole in the inguinal canal. When I release, the cries cause the baby's intestines to pouch right back out.
If I wait, the intestines could get trapped outside, and since I'm leaving Sunday, I should operate today even though I'm tired.
Samedi, Abel and Simeon all try tirelessly to find an IV without success. Finally, we are forced to use intramuscular Ketamine for the anesthesia.
The tiny is strapped onto a "papoose board" so he can't move and Betadine applied generously to his abdomen, groin, scrotum, penis and upper legs.
I open the hernia pack, scrub, pull on sterile gown and gloves and pick up the scalpel.
It seems so big compared to the little body now draped in sterile towels.
I carefully, gently slice a two centimenter incision over the still bulging hernia.
The sac is so thin I can see the intestines inside. It reaches all the way down to the testicule. It is a delicate thing to dissect off the spermatic cord from the thin sac and it tears in a couple places but finally is free.
I push in the intestines and clamp off the sac. I tie it closed and cut off the rest of the sac. This is where I briefly think of doing something I regret not doing later. Everything I've just read says that tying off the sac in infants is almost always enough with just a 1% chance of recurrence. So, I decide not to close the hernia defect but just close the fascia over the spermatic cord. I attach the testicle to the scrotum with a button on the outside and close up the skin.
He did well under anesthesia and I go home.
The next day is Saturday so I don't do rounds until the afternoon.
I come up to see the nurse and he says that I need to see the baby I operated on yesterday, his scrotum is swollen up.
I have a sinking feeling in my stomach as I walk down the dimly lit corrider to the bare bones hospital ward packed with visitors.
The baby looks sick. He is somewhat lethargic and has a rapid heartbeat and is a little pale. His scrotum is swollen and edematous. It's not readily obvious if it's the hernia come back or a hematoma. I ask the father and he says the swelling started on the inferior part of the scrotum and worked it's way up.
Sounds like a hematoma, but I'm not sure. I feel a sense of helplessness. If it's the hernia he'll die without an operation, but he's so sick he won't survive another operation. And I'm leaving tomorrow morning early.
I make a tough decision to not operate. I suspect he has malaria as well, so I treat his malaria and hope it's just a hematoma that will resolve itself. I don't feel good about my decision, but go home with a heavy heart. I'm sure I'll never see him again.
The next day is an early day. I get on the motorcycle and as I pull away from the hospital I can't help but wondering if the baby's not already dead.
I get back to Béré after midnight Wednesday after getting stuck in the mud just right before the barge crossing...just a few kilometers from Béré.
By the time I eat and hit the sack it's 1:30am. I sleep till almost 10:00 the next morning before going up to the hospital.
To my surprise, the baby is still alive and looking a lot better. He is alert and bright eyed, but his belly is very swollen and he's still pale. He now has an IV that has given him some much needed IV fluids. I order a hemoglobin...it's barely over 6, about a third of normal. We give him a blood transfusion.
The testicle is still swollen and it's obvious now that it's the hernia that's come back. I take him to surgery as the blood transfusion runs in.
Odei assists me as I incise larger and perpindicular to the old incision. A mass of swollen, dark red intestines pop into the field. I try to push them back in but without muscle relaxation and an already swollen abdomen, it's all but impossible.
It seems like most of the intestine is still viable. I push and push but can't get it all inside. It starts to get darker. The blood supply is being cut off before my very eyes. I'm feeling desperate and am sweating and swearing under my breath.
Finally, part of the intestine tears partway through. Thankfully, the inner part doesn't tear but now I have to take out part of the intestine. I open the appropriate instrument pack, put bowel clamps over where the intestine looks nice and pink. Then I clamp off the blood vessels supplying the dying part and cut it out.
Now, I'm stuck trying to suture the tiniest of small intestines in a field only about 3cm big. I make a ton of tiny interrupted stitches through the inner lining and then run a second layer through the tougher muscle layer. I release the bowel clamps. Air and stool inflates the newly sewn intestine without leakage.
Now, I'm able to push the rest of the intestine inside. I take out the testicle and cut and tie the cord pushing the stump inside. Then I close the fascia and all the the rest in three layers.
The I close my cross shaped incision. The kid's still alive though his belly is tense and he's not breathing that well.
I put him on IV fluids and antibiotics and tell his parents to not let him breastfeed or take anything to drink.
He's still alive the next few days but his belly is still very swollen.
Three days later, I come in and his belly is flat and soft, he's been farting and pooping and looks wide-eyed and has normal vital signs. The wound is healing well and he starts breast-feeding.
We'll send him home tomorrow.
Monday, August 6, 2007
Chantal
I only get to know, really know, two classes of patients: ones hospitalized with chronic wounds or osteomyelitis and AIDS patients. There are really no other chronic diseases here...people don't live long enough (life expectancy = 49 years for men and 47 years for women).
For example, our little friend, Clement, has been back with us for a couple months now. He came to us three years ago with osteomyelitis of the tibia (bone infection in the lower leg) and has now had four surgeries to try and get his bone to heal so he can walk again. Two Romanian orthopedists were the last to operate on him in May and he's slowly but surely healing...we hope.
In the next bed over is his twin brother except that his is the right leg and he has been with us now for only two months. Both of them love it when we come on rounds. Their faces light up and they each try to outdo each other in slapping my hand hardest in giving me "five". Sarah also entertains them with the occasional balloon, animals drawn on their hands with markers or empty syringes she's taught them to use as water guns.
Two days ago, after giving me "five", Clement held out a handful of fresh, unroasted peanuts insisting that I take them. Even though I know he doesn't get enough to eat, how could I refuse his generosity coming from such a pure heart?
The other patients I really get to know are our AIDS patients. I consult them for free to encourage them to come to the hospital whenever they're sick without waiting too long at home hoping it'll "just get better." We also only make them pay half price for lab tests and medications.
Once they are in full blown AIDS, we are able to treat them for free, thanks to generous donors, with anti-retrovirals (triple therapy) and all other medications for opportunistic infections.
Plus, each week, they come to get a week's supply of ARVs and we have a meeting to discuss problems and teach them how to care for their health and how to recognize sickness and how to avoid transmission.
I get to know them very well. The down side, of course, is that I have to watch many of them die.
Koumabeng Chantal is an exceptional case. When I first arrived in Béré, she was already considered a "Cas Social" that was treated free by the hospital. She was eight years old, an orphan taken care of by a mentally slow, yet very loving grandma. I thought for several years that she was a "Cas Social" due to her being an orphan. It's so rare for a child given HIV by her mother during pregnancy or delivery to live past five years that I was sure she couldn't be HIV positive.
I was wrong.
Since before I came, HIV was kept a secret from patients and staff, there was no record of an HIV test done on Chantal. She was in good health overall. I treated her for several bouts of simple Malaria and some ear infections over the years. The only thing that gave me a clue that she might be immunocompromised were the umbilicated nodules on her face and arms, like tiny, fat donuts (molluscum contagiosum). But I'd found them on other children here who tested negative so I didn't think much of it.
When I came back from furlough this year, Chantal came to see me and I noticed she was getting quite thin. She had another ear infection and malaria again. This time, I decided to test her for HIV.
She came pack positive. I was shocked. She was now 11 years old. How had she lived so long?
I started her on ARVs which she tolerated well and was faithful in taking (at least, she came back each week to get her next week's supply).
Two months ago, she came in with a severe headache. She was in such pain that she cried and moaned all night long keeping all the other patients awake. I was afraid of some opportunistic infection like Toxoplasmosis but she did have severe malaria so I decided to treat her for that first before thinking of something else.
After three days, she went home pain free to finish her malaria treatment at home.
A month later, she repeated the same thing. She was suffering horribly. This time she needed five days of IV Quinine before the malaria and headache cleared.
Now, she's in my office again. As always she is gentle and subdued with big trusting eyes. As I gaze into that unblinking stare I see the quiet suffering. She only whimpers as I lay her on the exam table. Her only complaint is headache and vomiting.
Her malaria smear comes back very positive at 0,20% (I'm dead sick with 0,05%). We hospitalize her again and try a new, once a day anti-malarial called artemether. A single shot in the thigh once a day without all the side effects of Quinine.
Every day, I go to see her. She lies there quietly, her form thin, but not emaciated and that same look in her eyes. One eye is slightly crosseyed. Her grandma says she refuses to eat and has vomited several times. I decide to put her back on IV quinine. Her vital signs are stable and with some Tylenol and Ibuprofen, she doesn't have hardly any pain.
That night, the nurse goes to place her evening perfusion. She calmly looks up at him and tells him it's not necessary, she's going to die. He reassures her, although, she's not afraid and seems completely at peace. He starts the drip and moves on as she falls into a deep sleep.
At 2 am, she quietly stops breathing. She's gone.
For example, our little friend, Clement, has been back with us for a couple months now. He came to us three years ago with osteomyelitis of the tibia (bone infection in the lower leg) and has now had four surgeries to try and get his bone to heal so he can walk again. Two Romanian orthopedists were the last to operate on him in May and he's slowly but surely healing...we hope.
In the next bed over is his twin brother except that his is the right leg and he has been with us now for only two months. Both of them love it when we come on rounds. Their faces light up and they each try to outdo each other in slapping my hand hardest in giving me "five". Sarah also entertains them with the occasional balloon, animals drawn on their hands with markers or empty syringes she's taught them to use as water guns.
Two days ago, after giving me "five", Clement held out a handful of fresh, unroasted peanuts insisting that I take them. Even though I know he doesn't get enough to eat, how could I refuse his generosity coming from such a pure heart?
The other patients I really get to know are our AIDS patients. I consult them for free to encourage them to come to the hospital whenever they're sick without waiting too long at home hoping it'll "just get better." We also only make them pay half price for lab tests and medications.
Once they are in full blown AIDS, we are able to treat them for free, thanks to generous donors, with anti-retrovirals (triple therapy) and all other medications for opportunistic infections.
Plus, each week, they come to get a week's supply of ARVs and we have a meeting to discuss problems and teach them how to care for their health and how to recognize sickness and how to avoid transmission.
I get to know them very well. The down side, of course, is that I have to watch many of them die.
Koumabeng Chantal is an exceptional case. When I first arrived in Béré, she was already considered a "Cas Social" that was treated free by the hospital. She was eight years old, an orphan taken care of by a mentally slow, yet very loving grandma. I thought for several years that she was a "Cas Social" due to her being an orphan. It's so rare for a child given HIV by her mother during pregnancy or delivery to live past five years that I was sure she couldn't be HIV positive.
I was wrong.
Since before I came, HIV was kept a secret from patients and staff, there was no record of an HIV test done on Chantal. She was in good health overall. I treated her for several bouts of simple Malaria and some ear infections over the years. The only thing that gave me a clue that she might be immunocompromised were the umbilicated nodules on her face and arms, like tiny, fat donuts (molluscum contagiosum). But I'd found them on other children here who tested negative so I didn't think much of it.
When I came back from furlough this year, Chantal came to see me and I noticed she was getting quite thin. She had another ear infection and malaria again. This time, I decided to test her for HIV.
She came pack positive. I was shocked. She was now 11 years old. How had she lived so long?
I started her on ARVs which she tolerated well and was faithful in taking (at least, she came back each week to get her next week's supply).
Two months ago, she came in with a severe headache. She was in such pain that she cried and moaned all night long keeping all the other patients awake. I was afraid of some opportunistic infection like Toxoplasmosis but she did have severe malaria so I decided to treat her for that first before thinking of something else.
After three days, she went home pain free to finish her malaria treatment at home.
A month later, she repeated the same thing. She was suffering horribly. This time she needed five days of IV Quinine before the malaria and headache cleared.
Now, she's in my office again. As always she is gentle and subdued with big trusting eyes. As I gaze into that unblinking stare I see the quiet suffering. She only whimpers as I lay her on the exam table. Her only complaint is headache and vomiting.
Her malaria smear comes back very positive at 0,20% (I'm dead sick with 0,05%). We hospitalize her again and try a new, once a day anti-malarial called artemether. A single shot in the thigh once a day without all the side effects of Quinine.
Every day, I go to see her. She lies there quietly, her form thin, but not emaciated and that same look in her eyes. One eye is slightly crosseyed. Her grandma says she refuses to eat and has vomited several times. I decide to put her back on IV quinine. Her vital signs are stable and with some Tylenol and Ibuprofen, she doesn't have hardly any pain.
That night, the nurse goes to place her evening perfusion. She calmly looks up at him and tells him it's not necessary, she's going to die. He reassures her, although, she's not afraid and seems completely at peace. He starts the drip and moves on as she falls into a deep sleep.
At 2 am, she quietly stops breathing. She's gone.
Sunday, July 22, 2007
Waste?
I shouldn't have tried to do three surgeries at once. Of course, it's always easy to look back and see what we should've or shouldn't have done.
It all started off so routine.
I enter surgery, the old arab man is sitting upright on the table ready for his spinal anesthesia. He has two bulges sticking out of each side of his lower abdomen. He bends as far as his arthritic back will let him. Miracoulously, the needle goes straight in despite his twisted, calcified spine and I inject the marcaine plus adrenaline.
We lay him down quickly and tilt the head of the table down. Odei has already scrubbed and is putting his sterile gloves on. I scrub and join him. After draping him with the sterile towels we pause and pray as usual.
I start on the right side. It's a hernia all right but not the traditional one. Half his intestines have come through his abdominal wall through the hole where the spermatic cord comes out, but instead of going down the canal into the scrotum it has wormed it's way under the skin of the belly.
It's fairly easy to dissect out since it's not attached to the cord. I bury the sac inside with a purse string suture and close the weak area with mesh so there's no tension. I repeat the same thing on the left side. A little over an hour has passed and the patient is doing well.
I then go for operation number three. I make a small midline incision over the distended bladder and enter the bladder easily. Urine gushes out. I suction rapidly and ask them to unclamp the foley catheter. Nothing comes out below but urine continues to pour out from above. When I've finally sucked up all the urine I ask Abel if it was difficult to get the foley in. He says, yes, he had to force it.
Great. I look in the bladder. I see the bulging prostate but there's no catheter. I stick my finger into the middle of the prostate and start scooping it out in a circular motion starting at the left around to the back and then to the right. It comes out cleanly and easily.
I then ask Simeon to reinsert the large bore three way foley. It won't enter the bladder. I feel down in the mush of blood clots that used to house the prostate and I can't feel the urethral opening for anything.
Abel's created a false track that the foley prefers to the real one.
We try and try as the blood continues to well out of the bladder. Nothing.
We try passing a urethral dilator. Nothing.
I try passing one from above but still can't find the urethral opening. I'm not sure how much time passes, but it seems like forever. Finally, I'm able to find the urethra with a dilator and it comes out the penis. I then have Simeon attach a large suture which I pull back into the bladder and detach from the dilator. Simeon then threads the suture through the opening in the foley and inserts it while I pull from above. Finally, the catheter enters the bladder.
By this time, the spinal has worn off and we have to give him Ketamine. He starts to react by contracting all his muscles making it impossible to continue the operation. Finally, with Diazepam and Chlorpromazine, he relaxes.
I close up the bladder in two layers, the balloon on the foley is blown up and pulled into the prostatic fossa, and irrigation of the bladder is started.
I close the fascia and skin and take off the gown.
I look at the monitor: blood pressure is normal, pulse is a little elevated but not much considering the effect of Ketamine and surgery, oxygen saturation is normal, he is breathing easily on his own. Nothing concerning, nothing to prepare me for half an hour later when...
"James, come quick, the patient's not breathing."
I run over to the surgical ward where I find a crowd of arabs around a cold body with no pulse or respitory effort. I am about to give my condolances and walk away but something pushes me in the opposite direction.
"Bring the gurney" I shout as I start chest compressions.
The nurses arrive shortly, but not after my vigorous CPR hasn't let to a few cracks of breaking ribs.
I continue the compressions as we race to the OR.
In the OR, Abel takes over compressions as I whip out the intubation kit and place an endotracheal tube. Deuhibe does CPR while Abel attaches the cardiac monitor.
Flatline, Oxygen sat 28%, no pulse.
We continue. Electrical activity starts to come and go on the monitor.
We try adrenaline and atropine.
There seems to be electrical activity (QRS complexes) but the rate is slow. Still no pulse. Abel and Deuhibe haven't done much CPR but with my encouragement they are really pumping vigorously as I bag to breath for the patient (we have no ventilator).
Suddenly, there is good electrical activity. I ask them to stop the chest compressions, sure enough, there's a booming carotid pulse. His O2 sat is up to 90%. We keep bagging. I add some IV glucose. Abel makes sure the bladder irrigation isn't blocked.
Still no neurologic response.
I notice his blood pressure is hanging on the very low end of normal. As Sarah takes over bagging I start to leaf through an anesthesia book. Look, a chapter on the elderly. Interesting, their adrenal function is diminished (duh). I look up onto the anesthesia cart and my eyes light on the hydrocortisone that I secretly wondered why the Romanian orthopedists had brought and left for us (duh).
I quickly give our Arab man 100mg and, shockingly, 5 minutes later his blood pressure is up to normal.
We had brought him to the OR as he was on his Persian rug with his prayer shawl, little skull cap and two sets of Muslim prayer beads. Oh, and his covering, a piece of cloth with a picture of Jesus on it surrounded by the words "Je suis le chemin, la verite et la vie" (I am the Way, the Truth and the Life).
The family wants to know what's going on. We've been inside with the patient for three hours now. I invite the brother in and tell him that his bro has been resurrected by the power of Isa Al-Masih he is the way the truth and the LIFE.
"Al hamdullilah" the brother states with a smile as he is escorted out.
30 minutes later he has started to breath on his own. I pull out his breathing tube and leave him on the oxygen extractor for several minutes. I slowly turn the oxygen down. He continues to breath spontaneously. I turn the oxygen off. I watch him for 15 minutes and he breathes fine with a normal O2 sat. He's still not awake though. Since we don't have oxygen tanks, an ICU or ventilators, we are forced to finally just take the risk and send him back to the ward.
I call in all the family members. Over 20 robed arab men and veiled arab women crowd around. I explain how to keep his airway open and to how to watch his breathing and how to notify the nurse. Then I explain that they've all witnessed a miracle. He was dead, but now he's alive thanks to Isa Al-Masih.
I ask Odei to pray in Arabic. Wisely he turns to them with outstretched palms open towards heaven and says, "Al Fatiha".
Over 20 pairs of hands come up and heads are raised as each one individually repeats his prayer of thanks to Allah. At the end, there are smiles all around with mumbled "Al hamdulillahs" and "Mashallahs" and "Barakas".
At 3 am, I am called to see him. He is barely breathing. We repeat the same thing until 7am next morning. He is back alive but this time, from the rib fractures he has a tension pneumothorax. As I slice open the side of his chest and poke a hemostat into his lung a long hiss of pressurized air comes out. He also has anemia which we transfuse. We keep him in a corner of the OR to breath for him while I take out a 10cm ovarian cyst trapped in the broad ligament all the time trying to avoid the rolls of fat pouring into the operating field.
Then, I do a hernia and take out a small lipoma.
Our Arab is still alive but not breathing on his own. His face, neck and chest are swollen from subcutaneous air from the pneumothorax.
We turn the breathing over to the family members.
He makes it until 2am the next morning, when he dies.
I'm so exhausted that I can't really do my work right the next two days basically neglecting the other hospitalized patients. Was it a waste? Did I poorly use the resource of myself? I may never know...and I don't know what I'll do next time...only God knows...
Pray for us.
It all started off so routine.
I enter surgery, the old arab man is sitting upright on the table ready for his spinal anesthesia. He has two bulges sticking out of each side of his lower abdomen. He bends as far as his arthritic back will let him. Miracoulously, the needle goes straight in despite his twisted, calcified spine and I inject the marcaine plus adrenaline.
We lay him down quickly and tilt the head of the table down. Odei has already scrubbed and is putting his sterile gloves on. I scrub and join him. After draping him with the sterile towels we pause and pray as usual.
I start on the right side. It's a hernia all right but not the traditional one. Half his intestines have come through his abdominal wall through the hole where the spermatic cord comes out, but instead of going down the canal into the scrotum it has wormed it's way under the skin of the belly.
It's fairly easy to dissect out since it's not attached to the cord. I bury the sac inside with a purse string suture and close the weak area with mesh so there's no tension. I repeat the same thing on the left side. A little over an hour has passed and the patient is doing well.
I then go for operation number three. I make a small midline incision over the distended bladder and enter the bladder easily. Urine gushes out. I suction rapidly and ask them to unclamp the foley catheter. Nothing comes out below but urine continues to pour out from above. When I've finally sucked up all the urine I ask Abel if it was difficult to get the foley in. He says, yes, he had to force it.
Great. I look in the bladder. I see the bulging prostate but there's no catheter. I stick my finger into the middle of the prostate and start scooping it out in a circular motion starting at the left around to the back and then to the right. It comes out cleanly and easily.
I then ask Simeon to reinsert the large bore three way foley. It won't enter the bladder. I feel down in the mush of blood clots that used to house the prostate and I can't feel the urethral opening for anything.
Abel's created a false track that the foley prefers to the real one.
We try and try as the blood continues to well out of the bladder. Nothing.
We try passing a urethral dilator. Nothing.
I try passing one from above but still can't find the urethral opening. I'm not sure how much time passes, but it seems like forever. Finally, I'm able to find the urethra with a dilator and it comes out the penis. I then have Simeon attach a large suture which I pull back into the bladder and detach from the dilator. Simeon then threads the suture through the opening in the foley and inserts it while I pull from above. Finally, the catheter enters the bladder.
By this time, the spinal has worn off and we have to give him Ketamine. He starts to react by contracting all his muscles making it impossible to continue the operation. Finally, with Diazepam and Chlorpromazine, he relaxes.
I close up the bladder in two layers, the balloon on the foley is blown up and pulled into the prostatic fossa, and irrigation of the bladder is started.
I close the fascia and skin and take off the gown.
I look at the monitor: blood pressure is normal, pulse is a little elevated but not much considering the effect of Ketamine and surgery, oxygen saturation is normal, he is breathing easily on his own. Nothing concerning, nothing to prepare me for half an hour later when...
"James, come quick, the patient's not breathing."
I run over to the surgical ward where I find a crowd of arabs around a cold body with no pulse or respitory effort. I am about to give my condolances and walk away but something pushes me in the opposite direction.
"Bring the gurney" I shout as I start chest compressions.
The nurses arrive shortly, but not after my vigorous CPR hasn't let to a few cracks of breaking ribs.
I continue the compressions as we race to the OR.
In the OR, Abel takes over compressions as I whip out the intubation kit and place an endotracheal tube. Deuhibe does CPR while Abel attaches the cardiac monitor.
Flatline, Oxygen sat 28%, no pulse.
We continue. Electrical activity starts to come and go on the monitor.
We try adrenaline and atropine.
There seems to be electrical activity (QRS complexes) but the rate is slow. Still no pulse. Abel and Deuhibe haven't done much CPR but with my encouragement they are really pumping vigorously as I bag to breath for the patient (we have no ventilator).
Suddenly, there is good electrical activity. I ask them to stop the chest compressions, sure enough, there's a booming carotid pulse. His O2 sat is up to 90%. We keep bagging. I add some IV glucose. Abel makes sure the bladder irrigation isn't blocked.
Still no neurologic response.
I notice his blood pressure is hanging on the very low end of normal. As Sarah takes over bagging I start to leaf through an anesthesia book. Look, a chapter on the elderly. Interesting, their adrenal function is diminished (duh). I look up onto the anesthesia cart and my eyes light on the hydrocortisone that I secretly wondered why the Romanian orthopedists had brought and left for us (duh).
I quickly give our Arab man 100mg and, shockingly, 5 minutes later his blood pressure is up to normal.
We had brought him to the OR as he was on his Persian rug with his prayer shawl, little skull cap and two sets of Muslim prayer beads. Oh, and his covering, a piece of cloth with a picture of Jesus on it surrounded by the words "Je suis le chemin, la verite et la vie" (I am the Way, the Truth and the Life).
The family wants to know what's going on. We've been inside with the patient for three hours now. I invite the brother in and tell him that his bro has been resurrected by the power of Isa Al-Masih he is the way the truth and the LIFE.
"Al hamdullilah" the brother states with a smile as he is escorted out.
30 minutes later he has started to breath on his own. I pull out his breathing tube and leave him on the oxygen extractor for several minutes. I slowly turn the oxygen down. He continues to breath spontaneously. I turn the oxygen off. I watch him for 15 minutes and he breathes fine with a normal O2 sat. He's still not awake though. Since we don't have oxygen tanks, an ICU or ventilators, we are forced to finally just take the risk and send him back to the ward.
I call in all the family members. Over 20 robed arab men and veiled arab women crowd around. I explain how to keep his airway open and to how to watch his breathing and how to notify the nurse. Then I explain that they've all witnessed a miracle. He was dead, but now he's alive thanks to Isa Al-Masih.
I ask Odei to pray in Arabic. Wisely he turns to them with outstretched palms open towards heaven and says, "Al Fatiha".
Over 20 pairs of hands come up and heads are raised as each one individually repeats his prayer of thanks to Allah. At the end, there are smiles all around with mumbled "Al hamdulillahs" and "Mashallahs" and "Barakas".
At 3 am, I am called to see him. He is barely breathing. We repeat the same thing until 7am next morning. He is back alive but this time, from the rib fractures he has a tension pneumothorax. As I slice open the side of his chest and poke a hemostat into his lung a long hiss of pressurized air comes out. He also has anemia which we transfuse. We keep him in a corner of the OR to breath for him while I take out a 10cm ovarian cyst trapped in the broad ligament all the time trying to avoid the rolls of fat pouring into the operating field.
Then, I do a hernia and take out a small lipoma.
Our Arab is still alive but not breathing on his own. His face, neck and chest are swollen from subcutaneous air from the pneumothorax.
We turn the breathing over to the family members.
He makes it until 2am the next morning, when he dies.
I'm so exhausted that I can't really do my work right the next two days basically neglecting the other hospitalized patients. Was it a waste? Did I poorly use the resource of myself? I may never know...and I don't know what I'll do next time...only God knows...
Pray for us.
Report 2006
Mes amis,
Just to give you an idea of what finances are like at the Bere Hospital and also send out the report for 2006 from our newly opened Chaplain's office (since June 2006).
Here goes:
Revenues
Hospitalizations $3238.15
Labor & Delivery $227.00
Surgery $8670.40
Lab $6877.45
Radiologie/Ultrasound $556.00
Clinic Visits $5469.25
Pharmacy $46,617.78
Other $311.90
TOTAL $70,565.95
Misc.
Cash on hand $2605.81
Patient loans $2527.66
Staff loans $1270.58
TOTAL $6404.05
Expenses
Salaries $18,827.93
Social Security $1409.81
Medical expenses-Staff $1098.89
Bonuses-Staff $1633.40
Pharmacy $29,644.76
Diesel & other $25,527.47
TOTAL $78,142.26
DEFICIT $7576.31
Note: In reality, the deficit is bigger because some of the Pharmacy revenue is from the sale of medications left over from the PASS project (which finished in 2005) and from donated meds and supplies from a variety of sources. The patient loans are for when patients don't have cash on hand we take a bicycle or a push cart or a large cooking pot or something else as collateral until they can find the money by selling a sack of millet, a goat, etc. The diesel expenses are for running the generator for surgeries and for 1.5-2 hours at night. The generator consumes 5L/hour and costs $1.25-$1.50 per liter. Expenses do not include infrastructure and equipment upgrades and education and training which has been financed through Adventist Health International.
Chaplain's report June-December 2006
Special prayer with patients 441
Exorcisms 3
Spiritual healing 90
Conversion to Christianity 46
Bible studies 17
Baptisms 12
Seminars 1
Funeral services 2
Visits to local authorities 4
Baptismal candidates 9
Meaningful Muslim contacts 11
Muslims accepting Isa as savior 3
Cell groups organized 1
Churches planted 0
Contact avec AIDS patients 6
Difficulties encountered: prevelance of Tuberculosis and HIV/AIDS, lack of time and staff for followup after patient discharge, behavior of certain staff members, lack of literature (Bibles)
Hope this gives a different perspective on the work here in Tchad at the Bere Adventist Hospital.
Just to give you an idea of what finances are like at the Bere Hospital and also send out the report for 2006 from our newly opened Chaplain's office (since June 2006).
Here goes:
Revenues
Hospitalizations $3238.15
Labor & Delivery $227.00
Surgery $8670.40
Lab $6877.45
Radiologie/Ultrasound $556.00
Clinic Visits $5469.25
Pharmacy $46,617.78
Other $311.90
TOTAL $70,565.95
Misc.
Cash on hand $2605.81
Patient loans $2527.66
Staff loans $1270.58
TOTAL $6404.05
Expenses
Salaries $18,827.93
Social Security $1409.81
Medical expenses-Staff $1098.89
Bonuses-Staff $1633.40
Pharmacy $29,644.76
Diesel & other $25,527.47
TOTAL $78,142.26
DEFICIT $7576.31
Note: In reality, the deficit is bigger because some of the Pharmacy revenue is from the sale of medications left over from the PASS project (which finished in 2005) and from donated meds and supplies from a variety of sources. The patient loans are for when patients don't have cash on hand we take a bicycle or a push cart or a large cooking pot or something else as collateral until they can find the money by selling a sack of millet, a goat, etc. The diesel expenses are for running the generator for surgeries and for 1.5-2 hours at night. The generator consumes 5L/hour and costs $1.25-$1.50 per liter. Expenses do not include infrastructure and equipment upgrades and education and training which has been financed through Adventist Health International.
Chaplain's report June-December 2006
Special prayer with patients 441
Exorcisms 3
Spiritual healing 90
Conversion to Christianity 46
Bible studies 17
Baptisms 12
Seminars 1
Funeral services 2
Visits to local authorities 4
Baptismal candidates 9
Meaningful Muslim contacts 11
Muslims accepting Isa as savior 3
Cell groups organized 1
Churches planted 0
Contact avec AIDS patients 6
Difficulties encountered: prevelance of Tuberculosis and HIV/AIDS, lack of time and staff for followup after patient discharge, behavior of certain staff members, lack of literature (Bibles)
Hope this gives a different perspective on the work here in Tchad at the Bere Adventist Hospital.
Sunday, July 8, 2007
Mistakes
I'm in way over my head and it's all I can do to not panic. I'm not a surgeon after all and the mistakes I've just made prove it. Now, can I save this lady's leg and kidney?
I had opened the belly of a woman with a large lower abdominal mass. A huge smooth lumpy, solid but not hard mass fills her entire pelvis. I identify the right ovary and tube with what appears to be a fibroma sticking out behind and a huge fibroma filling the rest of the belly.
I start to remove the uterus but it's difficult because there's no room to manouver to get down the side to the base. I do most of the right side and then move over to the left. That's where I start to make mistakes because I misdiagnosed the problem.
It's already taken an hour and a half with no muscle relaxation and trying to keep all the intestines out of the already cramped pelvis. I'm moving down the uterus staying close to it like I've been trained to avoid the ureters when I cut through...the ureter.
Mistake number two...the first one I won't discover till later.
I realize I'll have to repair it later so I tag it and keep moving. Finally, I get low enough where it's time to separate the bladder from the cervix.
It's stuck. As I try to free it, I enter the bladder which is weird because their doesn't seem to be really any uterus behind it.
Mistake number three.
I decide to open up the uterus and take out the myomas to free up some space and try to identify things better. I open it up and find thick, jelly like contents.
It's a huge mucinous ovarian cyst that has attached to the uterus and ovaries making it seem like fibromas.
I shell it out and suddenly, the normal sized, half taken out uterus appears in the right pelvis. I then look back at what I thought were the enlarged uterine vessels and realize I've probably cut the femoral vessels.
I ask Simeon to feel the left leg. He's says it's a lot colder than the right.
I'm getting desperate. In my ignorance I've probably cost this lady her leg and kidney. We're already two hours into the surgery, the leg is without blood for 30 minutes already and I still have to take out the uterus and the rest of the ovary before clearing up room to try and do something about the artery and vein and ureter and bladder.
I'm fighting off panic. I want to rush. I have to make myself turn on autopilot.
Do I have what it takes?
I've been praying almost continuously that God won't make my stupidity or ignorance or whatever you call it be the cause of such a catastrophe.
Somehow, while the panic rests under the surface, I feel somehow that I'm not alone in this. That I have a mentor, an attending physician with me but who says, I'm not going to take over, I've given you what you need and I'll walk you through it.
I suture up the bladder in two layers.
I search for the femoral vein first. I find both ends of a large severed vein in the right place (now the anatomy is clear) and clamp them with vascular clamps before cutting off the sutures and trimming the ends. I find the proximal end of the artery but can't really find the distal end.
I take some very fine suture and painstakingly put in the sutures starting from the back side and working around to the front. Odei and Taiana, my assistants are fighting a neverending battle to help me against the intestines and the oozing blood and fluids and the vein itself that doesn't want to stay close enough to suture.
In the meantime, Simeon has done a hemoglobin and it's 6 so he's ordered a blood transfusion.
I release the clamps and a huge clot bursts out followed by dark blood rapidly filling the operating field. We suction and mop up desperately as I reattach the clamp. I suture a bit more where the leaking was and try again.
The same thing. I'm trying hard not to get desperate and just quit.
Finally, we release the clamps again and there's no bleeding.
I start the search for the distal part of the artery. I just can't seem to find it. What I thought was the artery turns out to be the vein as I release the clamp I thought was holding the artery to try and attach it better. I know it's the vein because dark blood immediately begins to gush out again.
We repeat the same process until it's definitely stopped. I hunt and hunt for the artery. It has to be here.
Finally, I find and clamp it and start the slow process of suturing with fine suture.
We are four hours into the sugery, two hours without blood to the leg.
I release the clamps on the artery. There is no bleeding, but no real pulsation either. It's probably clotted up. I don't know what else to do so I head to the ureter.
I always wondered what we were going to do with all those ureteral stints that someone put in the container of supplies we got two years ago, but I'm glad for them now. I open one up, slide it into both ends of the severed ureter making sure it goes all the way into the bladder, and suture up the ureter around it.
Finally, we close up the abdomen and I check her leg.
Is it my imagination, or does she have a faint pulse in her foot? The leg is still cool. Only time will tell.
We put her on some Heparin and Diclofenac, the only blood thinners we have and pray for the best.
I don't know how to explain it, but as I walk out, instead of feeling stressed and annoyed, I almost feel refreshed, at least spiritually, even though my body is tired, it has been a time when I knew God was with me. He didn't say, well, you caused the problem so you're on your own.
Rather, he encouraged me, kept me from giving up and led me through.
(Today, two days later, her leg is a little swollen, but not bad and she has a good pulse and can move her leg normally. Her urine is clear, her intestinal function has returned and she's starting to take liquids...Al hamdullilah)
I had opened the belly of a woman with a large lower abdominal mass. A huge smooth lumpy, solid but not hard mass fills her entire pelvis. I identify the right ovary and tube with what appears to be a fibroma sticking out behind and a huge fibroma filling the rest of the belly.
I start to remove the uterus but it's difficult because there's no room to manouver to get down the side to the base. I do most of the right side and then move over to the left. That's where I start to make mistakes because I misdiagnosed the problem.
It's already taken an hour and a half with no muscle relaxation and trying to keep all the intestines out of the already cramped pelvis. I'm moving down the uterus staying close to it like I've been trained to avoid the ureters when I cut through...the ureter.
Mistake number two...the first one I won't discover till later.
I realize I'll have to repair it later so I tag it and keep moving. Finally, I get low enough where it's time to separate the bladder from the cervix.
It's stuck. As I try to free it, I enter the bladder which is weird because their doesn't seem to be really any uterus behind it.
Mistake number three.
I decide to open up the uterus and take out the myomas to free up some space and try to identify things better. I open it up and find thick, jelly like contents.
It's a huge mucinous ovarian cyst that has attached to the uterus and ovaries making it seem like fibromas.
I shell it out and suddenly, the normal sized, half taken out uterus appears in the right pelvis. I then look back at what I thought were the enlarged uterine vessels and realize I've probably cut the femoral vessels.
I ask Simeon to feel the left leg. He's says it's a lot colder than the right.
I'm getting desperate. In my ignorance I've probably cost this lady her leg and kidney. We're already two hours into the surgery, the leg is without blood for 30 minutes already and I still have to take out the uterus and the rest of the ovary before clearing up room to try and do something about the artery and vein and ureter and bladder.
I'm fighting off panic. I want to rush. I have to make myself turn on autopilot.
Do I have what it takes?
I've been praying almost continuously that God won't make my stupidity or ignorance or whatever you call it be the cause of such a catastrophe.
Somehow, while the panic rests under the surface, I feel somehow that I'm not alone in this. That I have a mentor, an attending physician with me but who says, I'm not going to take over, I've given you what you need and I'll walk you through it.
I suture up the bladder in two layers.
I search for the femoral vein first. I find both ends of a large severed vein in the right place (now the anatomy is clear) and clamp them with vascular clamps before cutting off the sutures and trimming the ends. I find the proximal end of the artery but can't really find the distal end.
I take some very fine suture and painstakingly put in the sutures starting from the back side and working around to the front. Odei and Taiana, my assistants are fighting a neverending battle to help me against the intestines and the oozing blood and fluids and the vein itself that doesn't want to stay close enough to suture.
In the meantime, Simeon has done a hemoglobin and it's 6 so he's ordered a blood transfusion.
I release the clamps and a huge clot bursts out followed by dark blood rapidly filling the operating field. We suction and mop up desperately as I reattach the clamp. I suture a bit more where the leaking was and try again.
The same thing. I'm trying hard not to get desperate and just quit.
Finally, we release the clamps again and there's no bleeding.
I start the search for the distal part of the artery. I just can't seem to find it. What I thought was the artery turns out to be the vein as I release the clamp I thought was holding the artery to try and attach it better. I know it's the vein because dark blood immediately begins to gush out again.
We repeat the same process until it's definitely stopped. I hunt and hunt for the artery. It has to be here.
Finally, I find and clamp it and start the slow process of suturing with fine suture.
We are four hours into the sugery, two hours without blood to the leg.
I release the clamps on the artery. There is no bleeding, but no real pulsation either. It's probably clotted up. I don't know what else to do so I head to the ureter.
I always wondered what we were going to do with all those ureteral stints that someone put in the container of supplies we got two years ago, but I'm glad for them now. I open one up, slide it into both ends of the severed ureter making sure it goes all the way into the bladder, and suture up the ureter around it.
Finally, we close up the abdomen and I check her leg.
Is it my imagination, or does she have a faint pulse in her foot? The leg is still cool. Only time will tell.
We put her on some Heparin and Diclofenac, the only blood thinners we have and pray for the best.
I don't know how to explain it, but as I walk out, instead of feeling stressed and annoyed, I almost feel refreshed, at least spiritually, even though my body is tired, it has been a time when I knew God was with me. He didn't say, well, you caused the problem so you're on your own.
Rather, he encouraged me, kept me from giving up and led me through.
(Today, two days later, her leg is a little swollen, but not bad and she has a good pulse and can move her leg normally. Her urine is clear, her intestinal function has returned and she's starting to take liquids...Al hamdullilah)
Death Encore
I'm not even sure what time it is as I stumble like a drunk man trying to walk the line over to the hospital. It has to be after midnight and there is no moon leaving us in cave like blackness. Only my dim head lamp briefly lights up the grass on either side of the path like the headlamps of a car going in slow motion.
David thanks me for coming and I mumble something in reply. I just can't clear the cobwebs and I didn't even take a Benadryl or anything. Maybe it was the four hour surgery earlier on top of three previous one's that day capped off by learning that the patient died three hours later. While it wasn't a surprise since he'd had intestinal volvulus for over a week, it still is draining.
I exam the child. He's panting, his eyes are wide with that starting to get vacant stare. His belly is swollen and tender. He hasn't had any bowl function since the morning. He needs an operation.
I manage to scribble out some orders and then weave my way over to where the night watchman has slung out a thin, lumpy cotton mattress on the cement in front of the clinic. I tell the nurses to call the OR team and wake me when the patient is ready.
I collapse. My whole body wants to sink through the mattress and through the cement even. As I drift off, I beg God to somehow give me the strength to do this operation.
Simeon is shaking me awake. "We're ready."
I wearily get up and enter the surgical suite.
A few moments later, as I stare at the 18 month old boy lying naked on the blue plastic covering the OR table I have a hard time imagining that I'm actually going to shortly be taking a very sharp scalpel and slicing open his belly.
But I do and pus comes out in clumps mixed with slippery, inflammatory fluid. We suction and suction all the corners of the abdomen until we've gopped most of it up. We rinse out and then I start looking for the source.
I find nothing. Absolutely nothing.
I stuff the intestines back inside and suture up the midline incision. As I take off the drape, I glance at the urinary catheter and see pus coming out instead of urine.
Of course, a severe kidney infection. We've already given antibiotics so I write to continue him on them.
He has been stable throughout the surgery and we move him out to the ward.
The next morning he is doing a little better but still breathing fast and not really waking up. His urine has cleared up though and his heart rate has decreased.
Half way through the day the nurses call me. I rush over to his bedside but find that he is actually a little improved over the morning.
It seems like he'll make it.
That night, the nurse calls me to see a kid she's hospitalizing. I go over to the Pediatric ward and notice an empty bed.
The little boy died a few hours ago.
I can't wait for the day when "He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away." (Revelation 21:4)
David thanks me for coming and I mumble something in reply. I just can't clear the cobwebs and I didn't even take a Benadryl or anything. Maybe it was the four hour surgery earlier on top of three previous one's that day capped off by learning that the patient died three hours later. While it wasn't a surprise since he'd had intestinal volvulus for over a week, it still is draining.
I exam the child. He's panting, his eyes are wide with that starting to get vacant stare. His belly is swollen and tender. He hasn't had any bowl function since the morning. He needs an operation.
I manage to scribble out some orders and then weave my way over to where the night watchman has slung out a thin, lumpy cotton mattress on the cement in front of the clinic. I tell the nurses to call the OR team and wake me when the patient is ready.
I collapse. My whole body wants to sink through the mattress and through the cement even. As I drift off, I beg God to somehow give me the strength to do this operation.
Simeon is shaking me awake. "We're ready."
I wearily get up and enter the surgical suite.
A few moments later, as I stare at the 18 month old boy lying naked on the blue plastic covering the OR table I have a hard time imagining that I'm actually going to shortly be taking a very sharp scalpel and slicing open his belly.
But I do and pus comes out in clumps mixed with slippery, inflammatory fluid. We suction and suction all the corners of the abdomen until we've gopped most of it up. We rinse out and then I start looking for the source.
I find nothing. Absolutely nothing.
I stuff the intestines back inside and suture up the midline incision. As I take off the drape, I glance at the urinary catheter and see pus coming out instead of urine.
Of course, a severe kidney infection. We've already given antibiotics so I write to continue him on them.
He has been stable throughout the surgery and we move him out to the ward.
The next morning he is doing a little better but still breathing fast and not really waking up. His urine has cleared up though and his heart rate has decreased.
Half way through the day the nurses call me. I rush over to his bedside but find that he is actually a little improved over the morning.
It seems like he'll make it.
That night, the nurse calls me to see a kid she's hospitalizing. I go over to the Pediatric ward and notice an empty bed.
The little boy died a few hours ago.
I can't wait for the day when "He will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away." (Revelation 21:4)
Wednesday, June 27, 2007
A Sad Tale
They could've been twins, but the outcomes couldn't have been different. Sarah had come to get me just after I'd fallen asleep Friday night.
"I think I have a case for a symphysiotomie for you." She said.
I dragged myself out of bed trying desperately to sweep the cobwebs from my mind. I was so adrenaline depleted after the long day in the OR that I could barely summon enough reserve to pull on my scrubs, slip on my Crocs and stumble through the moonlit night towards the hospital.
That morning I had taken out two huge prostates from a couple of old Arabs before being called back to the clinic to see a man with a strangulated hernia. We took him immediately to the OR where I sliced open his groin to reveal a hernia sack the size of a medium size Ziplock filled with stale, bloody inflammatory fluid and a portion of small intestine hanging onto life by it's teeth. As I cut open the internal inguinal ring I watched carefully to see if the dusky intestine would pink up. I watched as slowly, but surely, the tiny capillaries on the glistening intestinal surface started to pump back to life. While the intestine didn't return completely to normal color it was encouraging enough that I shoved it back in his belly, sutured closed the hernia in three layers and closed the skin.
I then took out small ovarian cysts on a young woman and cut out a weird, cystic mass on a three year old boy right below his belly button on the midline.
Tuesday through Thursday had also been brutal with two hysterectomies, a double sided recurrent hernia after a 10 year old repair, three c-sections with one of them being a ruptured uterus requiring a hysterectomie with some much shredded abdominal wall on the rupture side that I despaired of stopping the bleeding for a long time. Another one of the c-sections had an allergic reaction to the lidocaine spinal anesthetic causing her lungs to clamp down and her blood pressure to plummet. Only after intubating her, giving her steriods and adrenaline and bronchodilators and a ton of IV fluids were we able to get her back and do the c-section pulling out a 5kg screaming monster of a newborn. I also took out another prostate the size of a baseball (each of the three lobes would've qualified as an enlarged prostate itself).
So, I clumsily find my way to the labor and delivery suite. The girl is in her mid-teens and tiny. Her legs are midget sized. She has to be under 5 feet tall. I learn it's her second pregnancy. Two years ago she had labored at home for days before going to another hospital where they somehow managed to extract the dead fetus. This time, she's been in labor for three days. I feel the belly. It's tender and she has lost her normal uterine contour. A ruptured uterus.
David, the night watchman, calls in Simeon and Abel and we start to prepare for surgery. As I attempt to insert the urinary catheter I find it won't pass more than an inch. I check and the head of the baby isn't blocking it at all. As I push up the head of the fetus, a gush or urine comes out. Apparently, she had a fistula from her previous long delivery and her urethra is completely scarred down with the urine leaking out her vagina uncontrollably. We are forced to abandon the urinary catheter.
I place a spinal anesthetic, prep and drape her abdomen, Abel prays and I cut down quickly in a midline incision. Dark blood gushes out as I enter the abdominal cavity. Abel aspirates it up with the suction catheter while I pull out the large dead baby and look at the dark edges of the uterine rupture which look like an exit wound from a shotgun blast. Fortunately, it's anterior, almost exactly where we would've made our uterine incision for a normal c-section so I trim off the dead muscle and suture up the tear. She should recover fine but will have to come back in a couple of months to have her fistula repaired. In the mean time, she will leak out urine uncontrollably having already tragically and needlessly lost two newborns.
I go back to sleep a little after midnight.
At three, I am woken from an even deeper sleep by my lovely red-headed wife. However, she brings bad news. Another girl has arrived in labor since this morning. I manage to again drag myself out of bed and accompany Sarah back to the hospital. She says this girl is from the same village over 40 km away and is practically the same size.
As I enter labor and delivery I'd swear this girl was the other girl's twin. However, for this teenager, it is her first pregnancy, the fetal heart beat is still there and her uterus appears intact. However, her pelvis is small and the head is completely deformed from trying to be squeezed out a too small opening.
I grab the symphysiotomie tray, inject local anesthetic over her pubic bone, insert a urinary catheter, move the catheter to the side with my left hand inside and cut through the skin down to cartilage with my right hand. I then cut through the fibers from top to bottom until I'm mostly through the pubis (which connects the pelvis together in front). I then have Sarah and David, the night watchman, pull her legs out and down effectively opening her pelvis 2-3 cm. I attach a hand pump vacuum that we've used for over a year now but is still trucking along (it's a single use item in the US) and the head descends and a fat, screaming baby comes out less than 5 minutes later.
I suture up a couple of small vaginal lacerations and the symphysiotomie wound, help mop up the blood and fluids spilled all over the floor and table and head home.
Two teenagers, practically twins, but different outcomes based on a simple thing like coming to the hospital before it's too late. Same situation but one has two dead babies, urinary incontinence from a difficult to repair fistula, a huge abdominal scar, a recently sutured large tear in her uterus and a long recovery ahead of her with dismal prospects for more children and if she does become pregnant will die if she doesn't have a scheduled c-section before boing into labor. Her twin has a healthy newborn, a small pubic scar and can deliver vaginally safely for however many children she and her husband decide to have.
God also gives us choices. Each choice has it's consequences. God wants us to see that his recommendations are actually in our best interests but if we persist in our rebellion we'll see the consequences like these two girls, one of whom decided that maybe we were right when we suggested it was in her best interests to deliver at the hospital and the other who thought she'd do it her way like everyone has always done it and now has unfortunately seen the results of her poor decisions.
May God protect us all from our own foolish "wisdom".
James
"I think I have a case for a symphysiotomie for you." She said.
I dragged myself out of bed trying desperately to sweep the cobwebs from my mind. I was so adrenaline depleted after the long day in the OR that I could barely summon enough reserve to pull on my scrubs, slip on my Crocs and stumble through the moonlit night towards the hospital.
That morning I had taken out two huge prostates from a couple of old Arabs before being called back to the clinic to see a man with a strangulated hernia. We took him immediately to the OR where I sliced open his groin to reveal a hernia sack the size of a medium size Ziplock filled with stale, bloody inflammatory fluid and a portion of small intestine hanging onto life by it's teeth. As I cut open the internal inguinal ring I watched carefully to see if the dusky intestine would pink up. I watched as slowly, but surely, the tiny capillaries on the glistening intestinal surface started to pump back to life. While the intestine didn't return completely to normal color it was encouraging enough that I shoved it back in his belly, sutured closed the hernia in three layers and closed the skin.
I then took out small ovarian cysts on a young woman and cut out a weird, cystic mass on a three year old boy right below his belly button on the midline.
Tuesday through Thursday had also been brutal with two hysterectomies, a double sided recurrent hernia after a 10 year old repair, three c-sections with one of them being a ruptured uterus requiring a hysterectomie with some much shredded abdominal wall on the rupture side that I despaired of stopping the bleeding for a long time. Another one of the c-sections had an allergic reaction to the lidocaine spinal anesthetic causing her lungs to clamp down and her blood pressure to plummet. Only after intubating her, giving her steriods and adrenaline and bronchodilators and a ton of IV fluids were we able to get her back and do the c-section pulling out a 5kg screaming monster of a newborn. I also took out another prostate the size of a baseball (each of the three lobes would've qualified as an enlarged prostate itself).
So, I clumsily find my way to the labor and delivery suite. The girl is in her mid-teens and tiny. Her legs are midget sized. She has to be under 5 feet tall. I learn it's her second pregnancy. Two years ago she had labored at home for days before going to another hospital where they somehow managed to extract the dead fetus. This time, she's been in labor for three days. I feel the belly. It's tender and she has lost her normal uterine contour. A ruptured uterus.
David, the night watchman, calls in Simeon and Abel and we start to prepare for surgery. As I attempt to insert the urinary catheter I find it won't pass more than an inch. I check and the head of the baby isn't blocking it at all. As I push up the head of the fetus, a gush or urine comes out. Apparently, she had a fistula from her previous long delivery and her urethra is completely scarred down with the urine leaking out her vagina uncontrollably. We are forced to abandon the urinary catheter.
I place a spinal anesthetic, prep and drape her abdomen, Abel prays and I cut down quickly in a midline incision. Dark blood gushes out as I enter the abdominal cavity. Abel aspirates it up with the suction catheter while I pull out the large dead baby and look at the dark edges of the uterine rupture which look like an exit wound from a shotgun blast. Fortunately, it's anterior, almost exactly where we would've made our uterine incision for a normal c-section so I trim off the dead muscle and suture up the tear. She should recover fine but will have to come back in a couple of months to have her fistula repaired. In the mean time, she will leak out urine uncontrollably having already tragically and needlessly lost two newborns.
I go back to sleep a little after midnight.
At three, I am woken from an even deeper sleep by my lovely red-headed wife. However, she brings bad news. Another girl has arrived in labor since this morning. I manage to again drag myself out of bed and accompany Sarah back to the hospital. She says this girl is from the same village over 40 km away and is practically the same size.
As I enter labor and delivery I'd swear this girl was the other girl's twin. However, for this teenager, it is her first pregnancy, the fetal heart beat is still there and her uterus appears intact. However, her pelvis is small and the head is completely deformed from trying to be squeezed out a too small opening.
I grab the symphysiotomie tray, inject local anesthetic over her pubic bone, insert a urinary catheter, move the catheter to the side with my left hand inside and cut through the skin down to cartilage with my right hand. I then cut through the fibers from top to bottom until I'm mostly through the pubis (which connects the pelvis together in front). I then have Sarah and David, the night watchman, pull her legs out and down effectively opening her pelvis 2-3 cm. I attach a hand pump vacuum that we've used for over a year now but is still trucking along (it's a single use item in the US) and the head descends and a fat, screaming baby comes out less than 5 minutes later.
I suture up a couple of small vaginal lacerations and the symphysiotomie wound, help mop up the blood and fluids spilled all over the floor and table and head home.
Two teenagers, practically twins, but different outcomes based on a simple thing like coming to the hospital before it's too late. Same situation but one has two dead babies, urinary incontinence from a difficult to repair fistula, a huge abdominal scar, a recently sutured large tear in her uterus and a long recovery ahead of her with dismal prospects for more children and if she does become pregnant will die if she doesn't have a scheduled c-section before boing into labor. Her twin has a healthy newborn, a small pubic scar and can deliver vaginally safely for however many children she and her husband decide to have.
God also gives us choices. Each choice has it's consequences. God wants us to see that his recommendations are actually in our best interests but if we persist in our rebellion we'll see the consequences like these two girls, one of whom decided that maybe we were right when we suggested it was in her best interests to deliver at the hospital and the other who thought she'd do it her way like everyone has always done it and now has unfortunately seen the results of her poor decisions.
May God protect us all from our own foolish "wisdom".
James
Moto
It feels good to be on the road again. I never thought that a trip to N'Djamena would be something to look forward to, especially without my own car. However, after practically never leaving the hospital in the month I've been back in Tchad, it's good to be going anywhere.
Besides, it's a relatively cool morning, the desert is starting to be transformed into the green, African Sahel and I'm on the back of a moto with the wind blasting my face bringing tears to my eyes. The humid, fragrant smell of freshly rained on earth and grass rushes into my brain bringing back memories of calmer times.
Sarah and I are accompanying our Swiss volunteer, Esther, to the airport and then hope to bring back enough medicines and supplies to make it through the rainy season when the road to Bere gets really bad. Esther was the first to be off, followed by Sarah. They are no where in sight.
The overcast sky starts to lift as a few rays of sun pierce the clouds. The red clay road already has a few mudholes that the moto taxi man zigzags through like a professional slalom skier. It seems that my driver is a little more aggressive than most but I notice that we seem to be accelerating even more than usual. We skirt the potholes and dodge the goats, chickens, bikes, kids and women carrying goods to market on their heads. Our speed steadily increases.
I'm trying not to worry or think about what will happen to my helmetless head if we slip in the slimy clay or hit a hole or something worse. We go faster and faster. I notice the taxi man fiddling with a cable coming out of the handlebar. It hits me: the accelerator is stuck. He wiggles, pushes, twists and turns the cable as our velocity steadily increases. I now truly feel like I'm in the Olympic downhill as we caroum at ever increasing angles in our now deadly slalom course.
At about the same moment as I ask myself why he doesn't just turn the engine off I see him reach for the ignition. My gase follows his hand to where the key should be, but isn't. Apparently, the bouncing of the dirt road has shook the key out of the ignition and it is flapping in the breeze attached to the handlebar by a cell phone SIM card and a small wire.
We aren't slowing down.
All my hopes rest on the coordination of this stranger as the key places keep away from his desperately grasping fingers. Finally, he has it. Now, as he continues his slalom moves with one hand, he plays target practice with his other trying to fit the key into the jiggling, wiggling, shaking ignition.
The key enters, and is quickly turned to off. The moto slowly decreases it's velocity as we cruise around the mudholes and finally come to rest, like Noah's ark after the flood, on the side of the road.
My taxi man apparently is also a "mechanic". He pulls off a makeshift, crudely welded tool, uses his hand as a hammer and hits the tool against the cover of where the accelerator cable enters the engine until it slowly unscrews. He fiddles with the cable that had some gunk in it keeping it from releasing. When he's satisfied it's back to "normal" we get back on and continue on our way.
Now, I'm starting to feel the uncomfortableness of wearing a heavy backpack that is forced up onto my shoulder blades by Esther's hard suitcase that has been strapped vertically on the back of the moto with some strips of old innertube.
About 8 km from Kelo, 35 km from Bere, the back wheel starts to make some serious grinding noises. We stop again. The bearing is shot. So, we get back on and start to move forward at about 10km/hour. It feels and sounds as if the wheel could fall off at any time.
3 km from Kelo, we run out of gas. Coincidentally it seems, at the same time I notice that all the clouds have disappeared, the sun has moved higher in the sky, the humidity has increased and I'm starting to seriously sweat.
Even before we start to push the moto the last three kilometers to Kelo.
Despite the weight of the moto and the grinding of the back wheel, we still manage to pass a lot of people on foot. My hands grip the top of the suitcase and my thighs start to burn. As the women whisper and giggle to see a tall, skinny white dude passing them pushing a moto (they are easily entertained), I start to wonder if my out of shape body will make it the three kilometers.
Miraculously, 45 minutes (it seemed like hours) later we arrive on the outskirts of Kelo.
My guy calls another moto taxi over and he says he'll take my across town for 500 FCFA. I laugh and tell him I didn't just arrive here yesterday. I'd already agreed to pay 3000 francs to go to the bus station (such as it is) and if my moto can't make it then it's up to my taxi man to arrange other transport. The crowd that has gathered (as it usually does around unusual and interesting things like a white person) laughs in approval and the two taxi men smile begrudgingly and work it out amongst themselves.
Finally, I arrive at Kelo, 43 painful kilometers later, and just the beginning of my journey to the grand capital of Tchad.
Besides, it's a relatively cool morning, the desert is starting to be transformed into the green, African Sahel and I'm on the back of a moto with the wind blasting my face bringing tears to my eyes. The humid, fragrant smell of freshly rained on earth and grass rushes into my brain bringing back memories of calmer times.
Sarah and I are accompanying our Swiss volunteer, Esther, to the airport and then hope to bring back enough medicines and supplies to make it through the rainy season when the road to Bere gets really bad. Esther was the first to be off, followed by Sarah. They are no where in sight.
The overcast sky starts to lift as a few rays of sun pierce the clouds. The red clay road already has a few mudholes that the moto taxi man zigzags through like a professional slalom skier. It seems that my driver is a little more aggressive than most but I notice that we seem to be accelerating even more than usual. We skirt the potholes and dodge the goats, chickens, bikes, kids and women carrying goods to market on their heads. Our speed steadily increases.
I'm trying not to worry or think about what will happen to my helmetless head if we slip in the slimy clay or hit a hole or something worse. We go faster and faster. I notice the taxi man fiddling with a cable coming out of the handlebar. It hits me: the accelerator is stuck. He wiggles, pushes, twists and turns the cable as our velocity steadily increases. I now truly feel like I'm in the Olympic downhill as we caroum at ever increasing angles in our now deadly slalom course.
At about the same moment as I ask myself why he doesn't just turn the engine off I see him reach for the ignition. My gase follows his hand to where the key should be, but isn't. Apparently, the bouncing of the dirt road has shook the key out of the ignition and it is flapping in the breeze attached to the handlebar by a cell phone SIM card and a small wire.
We aren't slowing down.
All my hopes rest on the coordination of this stranger as the key places keep away from his desperately grasping fingers. Finally, he has it. Now, as he continues his slalom moves with one hand, he plays target practice with his other trying to fit the key into the jiggling, wiggling, shaking ignition.
The key enters, and is quickly turned to off. The moto slowly decreases it's velocity as we cruise around the mudholes and finally come to rest, like Noah's ark after the flood, on the side of the road.
My taxi man apparently is also a "mechanic". He pulls off a makeshift, crudely welded tool, uses his hand as a hammer and hits the tool against the cover of where the accelerator cable enters the engine until it slowly unscrews. He fiddles with the cable that had some gunk in it keeping it from releasing. When he's satisfied it's back to "normal" we get back on and continue on our way.
Now, I'm starting to feel the uncomfortableness of wearing a heavy backpack that is forced up onto my shoulder blades by Esther's hard suitcase that has been strapped vertically on the back of the moto with some strips of old innertube.
About 8 km from Kelo, 35 km from Bere, the back wheel starts to make some serious grinding noises. We stop again. The bearing is shot. So, we get back on and start to move forward at about 10km/hour. It feels and sounds as if the wheel could fall off at any time.
3 km from Kelo, we run out of gas. Coincidentally it seems, at the same time I notice that all the clouds have disappeared, the sun has moved higher in the sky, the humidity has increased and I'm starting to seriously sweat.
Even before we start to push the moto the last three kilometers to Kelo.
Despite the weight of the moto and the grinding of the back wheel, we still manage to pass a lot of people on foot. My hands grip the top of the suitcase and my thighs start to burn. As the women whisper and giggle to see a tall, skinny white dude passing them pushing a moto (they are easily entertained), I start to wonder if my out of shape body will make it the three kilometers.
Miraculously, 45 minutes (it seemed like hours) later we arrive on the outskirts of Kelo.
My guy calls another moto taxi over and he says he'll take my across town for 500 FCFA. I laugh and tell him I didn't just arrive here yesterday. I'd already agreed to pay 3000 francs to go to the bus station (such as it is) and if my moto can't make it then it's up to my taxi man to arrange other transport. The crowd that has gathered (as it usually does around unusual and interesting things like a white person) laughs in approval and the two taxi men smile begrudgingly and work it out amongst themselves.
Finally, I arrive at Kelo, 43 painful kilometers later, and just the beginning of my journey to the grand capital of Tchad.
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