...You might be a Tchadian

If when pregnant the only thing you really crave is dried fish.
If your idea of clean is a well swept dirt yard.
If when the temperature falls below 80 degrees you dust off your parka.
If you've ever traveled to the big city on top of a loaded dump truck.
If you've ever sold a chicken to pay your medical bill.
If you've ever ridden bareback on a cow.
If you refuse to take your horse into the river for fear he'll become a hippo.
If you've ever had to cut a fishing trip short because you got bit in the butt by a hippo.
If you've ever given birth in a rice field.
If you've ever been evacuated to the hospital on a motorcycle.
If you've ever tried to deliver a baby who came out hand first.
If your mama's ever slapped you for crying during birth pains.
If you've ever fixed a leaky pipe with an inner tube.
If you've ever fallen out of a mango tree while 8 months pregnant.
If your mom "potty trained" you by resting you on her legs to let you poop on the ground.
If your dad took multiple wives to have more workers for his rice field.
If you've ever done surgery without a high school diploma.
If you drink hot tea when it's 130 degrees out.
If you speak more than five obscure languages.
If you've never opened a car door before.
If you've ever thought a cement mixer was an airplane.
If you've ever opened a bottle of Coke with your teeth.
If it's ever taken you 2 days to travel 42 km.
If you've ever repaired a flat tire with needle and thread.
If you've ever packed a car rack higher than the car itself.
If you've ever carried more than your body weight balanced on your head.
If you've ever strapped a baby to your back.
If you fill up your gas tank using an old wine bottle filled at the side of the road.
If you grow gourds on the roof of your house.
If you've ever plowed a field by hand while talking on a cell phone.
If you've ever brought your child to church naked.
If you've ever ridden a motorcycle wearing a turban with an eyeshade over your mouth.
If you've ever paid tithe at church with a goat.
If no one stares when you dress your baby boy in hot pink.
If you think nothing of male soldiers walking down the street holding hands.
If you've never seen a guy and girl hold hands in public.
If you think nothing of seeing a woman's breasts but are scandalized by her naked knees.
If you've ever attended class under a mango tree.
If you've ever broken your arm falling off an ox cart.
If you know more than one person who's been gored by a bull.
If you've ever been thrown in prison for casting a spell on someone.
If you've ever sued someone for killing your pig.
If you've ever killed a rat by stepping on it.
If you've ever eaten a bat.
If you've ever fixed a radiator with chewing gum.
If when your child has a sore throat you cut his uvula.
If you feel like an honored guest when you're served soda pop.
If you've ever shared the highway with a herd of longhorns.
If you think all white people look alike.

Unexpected death

Yeah, I was tired, but I certainly didn't expect this one. I'm still trying to figure it out. But, with our deplorable working conditions and lack of staff and equipment, I'm afraid it's doomed to remain a mystery. I just hope we can do something to change conditions so it doesn't happen again.

It started yesterday. We have been even busier than usual, especially in surgery. We did our 50th surgery in January yesterday...and the day wasn't even finished yet and there's still a week to go in the month.

And to think, I thought yesterday would be relatively easy. I thought I'd only scheduled a couple of orchiectomies (taking out the testicle) and the excision of an abdominal wall mass. But when I finally got to the OR at around 11:30am I found that the first case was a hernia and we had one other one scheduled as well. I've been trying to schedule as many surgeries as possible for next week when a visiting surgeon, Dr. Dekraay, will give me a little break.

I was already tired having done 7 ultrasounds, consulted outpatients and had a meeting with our HIV patients under anti-retroviral therapy. Not to mention the fact that I was up till midnight the night before operating on a ruptured ectopic pregnancy.

I quickly did the hernia and two orchiectomies. In between, I followed up lab results and saw more outpatients. Then, things got a little out of control. This woman had a huge, lumpy abdominal mass that was mobile and apparently not fixed to the muscles or anything. There was kind of a peak to it with a little ulceration through the skin. I cut in and popped out 6 firm fibromas...then she started bleeding like crazy. She had high blood pressure and every little skin artery was shooting a geyser out spraying everything in sight. I compressed as best I could as I called for more hemostat clamps. The cavity was so big and deep I had to excise more skin and open it more to get to the depths and clamp off bleeders. By the time we were done the whole floor, bed, drapes and our scrubs were covered with the sticky red stuff.

Now it's 3pm, I should be going home but a nomad man has just brought in his wife. She was operated on (a c-section they say) at another hospital four months ago and now for two days she hasn't passed gas or stool and vomits all the time. Her belly is distended with absent bowel sounds. She has a bowel obstruction. I send her husband off to pay for the surgery. Meanwhile, the evening nursing team comes to tell me there's a young lad who fell out of a tree and has an open fracture.

Oh, yeah, there's also a patient we operated on 8 days ago for a hernia who's referred from the Bao health center for a strangulated hernia from an "operation badly practiced" at the "Bere BAPTIST Hospital". Interesting, I didn't know there was another hospital here in Bere! I go to examine him and find he has a pretty impressive scrotal hematoma but no hernia. The hernia wound is healing well. When we enter he starts writhing in exaggerated agony. Unfortunately, he'll have to wait.

I go see the boy. His elbow has somehow dislocated and come through the skin of the inside of his elbow without fracturing. The nerve is stretched tense over the exposed joint surface of the humerus. His circulation is intact. He also has a closed distal radio-ulnar fracture dislocation. I take him to surgery as first priority. What I don't do, I'll regret later...I don't do a full physical examination (which I know I would've if I hadn't been so overwhelmed already) nor do I check his vital signs.

In surgery I flush out the wound with 3 liters of irrigation fluid while our medical student, Jamie, and Israel pull the arm in opposite directions. It slowly starts to reduce. With a bend of the arm and a push with my thumb, the humerus enters back into its joint. The elbow bends normally. I rinse out the wound some more and close it up in two layers. I then reduce the wrist and place a cast from hand to above the elbow. The boy does fine with just a minimal dose of diazepam and Ketamine. Nothing concerning, although Israel does note later that he was perspiring profusely and his heart rate was elevated (not uncommon with pain and/or Ketamine).

Since we have no post-op recovery room nor enough nurses to staff one, we wheel the boy directly off to pediatrics. I will regret that as well.

We then bring in the nomad woman who ends up having a small bowel obstruction due to two strictures from adhesions caused by her previous surgery. Those two almost closed off scarred pieces of bowel along with a nick of the bowel on entering the abdomen require a resection and anastamosis. As I'm half way through the suturing of the intestine, Clarice enters. I am shocked by what she says.

"The boy is dead"

"Which one?"

"The one with the fracture you just operated on..."

I can't believe it. On further reflection, though, it was inevitable that something like this happen. In fact, it's a simple miracle that we haven't had more complications or deaths following surgery.

We have become a reference center for people from hundreds of miles around yet our facilities are pathetically inadequate. We have no cardiac monitor. Our pulse oximeter has been broken for over 6 months. Our large autoclave caught on fire months ago. Our two small autoclaves were fried last week. Now we are sending our instruments an hour away to Kélo to be sterilized. We only have one OR which is crammed packed with all our supplies since we have no supply room leaving it difficult to clean properly. We have to walk through the instrument sterilization room to get to the OR. We have one prep room also stocked from floor to ceiling with supplies. We have no real prep room (for bathing patients, etc.) which means a lot of filth gets tracked into the OR. We have no post-op recovery room (as mentioned above) which means patients get dumped on the wards along with all the other patients to wake up from anesthesia. Often, there is only one nurse for all the hospitalized patients who can't possibly give the attention needed to the post-op patients which means we depend on family members to alert us of problems. This time, it was too late.

What was the cause of death? Impossible to determine now...but the real cause is an overworked under-equipped staff and hospital. We need at least another physician and some more nurses. Then, we really need a new operating block with at least two operating rooms, a prep room, a post-op recovery room, a dressing room, an instrument/sterilization room, and a supply room. Of course God always helps us in our weaknesses, which is why we've been able to operate successfully on so many with almost never any complications. However, if we have the means to improve things and don't, I think God also will hold us accountable for that one day.

Unfortunately, one young boy will not have another chance in this life...

James

Nightmares

I wake up with a start. It's 3:26 AM. The nightmares are back. They always take a different form with the same theme. I'm running from some nameless terror. I have to hide. I am almost found a million times and then...I can tell I'm about to be discovered...and I wake up my heart pounding in my ear-plug filled ears.

The headaches continue. When I'm doing something I'm fine. Just a little nagging in the background. But when I try to relax, a constriction along the top of my neck, through the base of my skull and encircling it's grasping tentacles around to my throbbing eyes forces me to want to drink a ton of water and sleep.

My eyes are heavy and my throat is sore. I feel almost a desperation to sleep. But there's a lurking fear that when I lie down I won't be able to anyway so I watch a movie, read a book, wander around puttering till the inevitable stop of the generator forces me to hit the sack or attempt my meandering attempts at distraction.

Finally, I lie down. The mattress is soft yet firm. The pillow is perfect. The bed is long enough for my 6'5" frame to stretch out comfortably in any direction even when sharing it with a beautiful Dane. I start off with the illusion of falling to sleep immediately. Something I long and pray for. It doesn't come. Instead come the slow, persistent, building memories from the day's work, strategies, plans, ideas, anything to keep me from sleeping.

Above all, it's the thoughts of what I shoulda, coulda, woulda...and working at a small bush hospital in sub-saharan Africa as the only physician leaves plenty of fuel for that fire.

I should've cut an episiotomy sooner. The baby was already stressed. Sure it's heart beat was fine. But the 14 year old mom had been in labor on that small pelvis for too long. If I'd only got him out a few minutes earlier he might of made it. It was so close. Why did his heart have to beat so long? Why didn't he ever take a breath? Why did I even attempt that tendon release? It wasn't life threatening. He'd lived with it for years already. Sure it was painful and made it hard to walk, but I probably just made it worse. I'm way out of my league.

If I'd recognized that meningitis a day sooner instead of only treating his malaria, maybe that little girl would've lived. She made it a couple of days as it was. I'm sure we did everything: IV fluids, glucose, steroids, appropriate antibiotics...what did we miss?

I should've done a classical incision on that woman with the transverse lie and arm sticking out. If so she wouldn't have torn into both uterine arteries. Sure we managed to control the bleeding, but we almost lost her. What if I'd just done it right the first time?

Did I speak too harshly to the boy who we'd amputated and then had almost healed his wound when he left against medical advice? When he came back with a huge infection needing a higher up amputation I should've spoken gentler. Maybe he would've actually stayed...is he still alive?

How could I have thought it was an ectopic pregnancy? My ultrasound skills suck. An unnecessary operation on a woman with a normal intrauterine pregnancy...I could've saved myself the trouble and her a dangerous procedure.

Is the medical student having a good experience? Should I let him do more? Or less? Is he feeling too overwhelmed with the responsibility? Have I dumped on him or is it just a good experience?

Are Israel and Paul overworked? They are volunteer nurses after all...I want them to have a good time so they'll encourage others to come...am I assigning them too many night shifts? Do they get tired of my calling them to help with all the surgeries?

Will the work at the hospital ever slow down? We seem to just be getting busier and busier as our staff continues to dwindle and I remain the only doc. I can't even begin to count the surgeries I've done since coming back January 10...three to four a day with many minor procedures and the waiting room inside and outside under the mango tree packed. There are no beds available in the hospital. People are sleeping outside, their mosquito nets strung from branches of trees. The nurses can't even walk inside at night. Relatives are sleeping on every available floor space including under the beds.

Images flash through my semi-conscious brain: amniotic fluid squirting onto my face as I cut into the uterus to rescue an infant; my fingers push and pull around a tense hydrocele breaking apart the small fibers attaching it to the scrotum with the sound of tearing cardboard; a hernia bulges in and out with the patients breathing as I grab firm fascia and poke through with
a needle to close that moving masse inside where it belongs; with a small poke, pus bulges out and flows down the back of the throat like a stream of lava as I quickly suction back and forth on the Ketaminized HIV positive wife of the local chief; moans and babbling float across my brainwaves from a million Chadians waking up from a Ketamine nightmare; the baby's head
rolls around despite the firm grasp of Paul as I chase a splinter across his cornea trying to dig it out gently with an 18 gauge needle; gurgles and bad breath roll up to me in my stupor from an alcoholic desperately wishing he had a bowl of rice wine to assuage his pounding head from the beating he got last night while hammered; urine dribbles onto the ground from a foley bag
only partially closed...

Words in Arabic, Nangjere and French wind themselves around my thoughts as I relive my frustration at only being able to communicate on the level of a child...and my deep desire to learn Arabic and Nangjere clashes with feeling so overwhelmed that at any break I just want something to temporarily distract me...

Finally, I fall asleep, and the nightmare begins...until I jolt awake at 3:26 AM. My throat is sore, my lips are dry. I grope for a flashlight and take a drink of water in the bathroom. I turn off the light, roll onto my back, try to sink in...and a flashlight appears outside the window rapidly followed by a rap on the metal door. I unplug my ears, grab my headlamp, pull on some shorts and a t-shirt and go to see Clarice and David.

There is a woman in her 10th pregnancy under oxytocin to augment her labor who has been completely dilated for 3 hours without delivering. I change into scrubs, find my keys, head to the OR, snatch up the oft-used disposable hand-pump vacuum and head to Labor and Delivery.

I put on gloves and examine the woman. The head is high up but there seems to be room. I wet the vacuum and slide it in over the baby's crown. She has a strong contraction. I pump up the vacuum and slowly pull. The head descends and twists to the left as the eyes, nose and mouth pop out slowly over the perineum. I use the bulb suction to clear the airways, release the vacuum and pull the head down to free up the anterior shoulder quickly followed by the squirt of slimy child, arms and legs firmly contracting, already wanting to scream his anger at the world. We quickly dry her off and wrap her up against the cold. The placenta follows quickly. There are no tears and no bleeding. The uterus is firm as a rock. I go home hoping that for at least of few hours of nightmare free sleep...