Adventist Mission

I'm sitting in the dark. The generator has just wound to a halt. A kerosene lamp gives it's warm but not far-reaching light to an otherwise shadow filled room. Sarah has gone to N'Djamena to take our Danish medical student, Trine, to the airport for her return to Denmark. It's just me and the guys. I'm sitting at the table in front of the lamp. The cat is playing with my foot as if it was a dead rat. Israel is lying on the couch on the right and Paul is sitting on the couch to the left.

As with most conversations between guys the topic swiftly turns to...missions. What would you talk about? Gosh! Israel is a nurse from Puerto Rico recently graduated from Southern Adventist University. He is fluent in English and Spanish and already speaks French quite well after only two months. He has taken night shifts where he is the only nurse in the hospital and post-call still comes into help in surgery. He's what you might call a missionary stud.

Not to be left behind is Paul. A Nigerian trained at the Ile-Ife Adventist Hospital he has had the highest level of nursing training, speaks fluent English, Hausa and Yoruba and has also learned enough French to be very dangerous. Despite not being Adventist and having most of his classmates tell him not to come to some God-forsaken place like Tchad, he has dedicated a year of his life to help his Chadian brothers.

Both have fearlessly followed Sarah's lead and learned to ride horses the hard way...both having fallen off at full gallop, not much the worse for wear.

So, I’m talking about the good and bad of Adventist missions. I mention that one of the positive things is the fact that my school loans are being repaid in exchange for six years of service allowing me to head out immediately after residency. However, the weakness is that our church only does that for doctors and dentists, not for nurses, PTs, Physician's Assistants, midwifes, etc. Israel states that if he could have his loans from nursing school paid off he'd gladly spend at least four years in the mission field. How hard could that be? Does the General Conference have to do it or couldn't we just ask the local churches to remember they are part of a worldwide movement, the body of Christ, each one interdependent on each other, those who have been entrusted with resources using them to help those who have not?

When an Adventist wants to be a missionary the Church tells him we have a budget here and there and in that small place where no one has been in a long time. Where do you want to go? Instead of asking the person, where do you feel God is calling you? We say where do we have a budget for a missionary. Instead of asking, where do we need someone? We ask if you have any other financial obligations. Instead of feeling called to life work among a certain people un-reached by the news about God and who he is, we jump around from place with a budget to another place with a budget every six years never bothering to learn to communicate with the locals in their own language, "because I'm just going to leave anyway, why waste the effort?"

If someone does decide to accept a "call" to where there is a missionary budget there is no contact with any local churches for the spiritual support and encouragement that is so desperately needed when one is so far removed from everything familiar and comforting. That responsibility is left to some people at a high level of administration who may have never seen you and may not even really know your name, where you are, what the conditions are like, and for sure haven't ever visited "sur le terrain" (on site). This robs both the missionary and the members of the local church who then never have contact with the outside world leaving their world small and inward focused on their own needs easily forgetting those "far away."

Paul brings up the problem in Ile-Ife. He literally begs me if there is anything that can be done to bring in specialist physicians, especially surgeons. They desperately need a general surgeon or an orthopedist or a traumatologist as they see so many motor vehicle accidents with mass casualties needing surgical intervention. They also need a neurosurgeon for the same reason, lots of head trauma. If only someone could come and teach their physicians and help them take care of the overwhelming load. Since when does the Third World not really need our help anyway?

Somehow I think we have that idea...they have their own doctors, their own nurses, their own etc...let them suffer on their own. But since when are we called to ignore suffering? Most of their doctors are in the cities making the "big bucks" too. Who's willing to go out to the small villages and towns? So even in Nigeria, where things are a lot more developed than Tchad, Paul is pleading, "Come help us!"

What is the ratio of patients to doctors in the US? Is it better than 140,000 to one? Here in Béré, our hospital serves a population of 142,000 in our district plus the thousands who come to us from the outside districts. I’m the only physician. Does that seem normal to you? How can anyone say we don't need another doctor here at the Béré Adventist Hospital? But I can guarantee you the General Conference of SDAs will never allocate another physician budget here...in fact, they are cutting back the number of missionary budgets because people aren't giving to the missionary fund anymore. And why should they? Does anyone in the church even know the names of the missionaries that are out there much less where they are? Only a andful of close friends and family.

So, what can be done? Mass changes. We need to create either a mission focused church again (the reason for the church structure to begin with was to better organize outreach/mission activities...not maintain existing structures and institutions)...but that's not likely. The church is too weighed down with top-heavy administrative loads to change. So, I propose a separate, yet affiliated mission organization whose only task is to coordinate and arrange support--financial and spiritual.

For example, start with medical missions. As a physician, I could work two months out of the year in the US and make around $16-20,000 depending on where and how much I worked. Working for a locums company specializing in placement of physicians in temporary positions I would have travel, car and lodging taken care of for those two months. Air travel to and from Tchad would be $2000 (x2 for me and Sarah) = $4000. Say we live pretty frugally but want to travel some the third month to visit relatives and sponsoring churches so we spend $3000 for those three months. That leaves us with $7-11,000 (depending on original sum). Emergency evacuation through South Africa can be purchased for $2000/person/year leaving us with $3000. Local health insurance bought through the Central African Union (I don't know the actual price but I'll guess) $1000/person/year leaving us with $1000. We can easily live off the local salary of $500/month that we are receiving currently from the Union so that would be $4500/year (for 9 months in Tchad). Therefore, Sarah only needs to work as a nurse enough to make $3500. An easy task with traveling nurse in the US or if we took our month vacation in Denmark (at least a vacation for me...she'd take the two months in the US as vacation) she could work in Denmark or Norway and easily make $8-9,000. Essentially, we could be self supporting by working 2-3 months abroad and spending 9 months at home in Tchad. Any excess expenses we could ask our sponsoring churches to help us cover keeping them involved financially as well as morally and spiritually (they could also help out
with hospital needs, etc.)

This would free up medical personnel from all fields (nurses, PTs, Pas, RNPs, Midwives, OTs, lab techs, etc.) to become missionaries where they would feel called and where their was a need without depending on someone "higher up" to create a budget there. The main thing many of them, especially the young ones like Israel would need would be loan repayment. If that could be raised by the local churches and then paid off each year based on years served according to a contract established between the churches and the missionary, that would free up many promising missionaries to go where they feel called.

Does it seem normal that a whole country like Tchad has only two Adventist missionaries, my wife and I? We should have a whole team here to meet the overwhelming needs and to support and encourage each other. There are so many amazing things that I'm getting to experience professionally and spiritually that others should have the chance to share but our current system blocks that on anything more than a one year volunteer scale. How much more could we be experiencing if we were a team and not just a burned out overworked doctor-nurse team trying desperately to salvage what lives we can from the teeming masses of under-treated people so desperate to find healing that they'll come from miles and miles around to our pathetic hospital just because it's so much better than they can find where they are.

Am I just venting or does somebody out there hear me?!

James Appel
Medical Director
Béré Adventist Hospital
BP 52 Kélo
Tchad
00-235-645-5188

Gwame

I strip down to my underwear, half-walk, half run down the sandy slope and plunge into the coolness of the river. The hot season is upon us and nothing is cool here except the river. The harmatan winds blow hot dust and wind off the Sarah leaving the Sun a well defined, somewhat darkened orb in a murky sky.

Sarah, Israel and I have brought our two volunteer resident physicians, Aimee and Jennifer out here on horseback. Everyone is hot, dusty and sweaty but I'm the only one to take the plunge. I feel invigoratedand take long crawl strokes upstream. However, due to the force of the current and my long unused swimming muscles my progress is slow and my fatigue comes onfast. Every once in a while I lift the head up for along look ahead…you never know if their might be hippos! I pull out of the water and dry off with my shirt and pull on my pants. Sarah and Israel have disappeared with mine and Sarah's horses. The girls inform me that the horses ran off and they went to chase them. They soon come back. I grab the single rope attached to the nose bridle, place my left foot in the stirrup and swing up. My butt is already sore from being to long out of the saddle. We start off in a slow trot. The girls are behind Sarah and Israel and are bouncingup and down like jackhammers. That's gotta hurt!

They can't really gallop so I spur my horse, Bob, onahead. The wind whips through my hair as I fly overthe dusty trails passed the burned fields awaiting thenext rainy season to be transformed. There is one field that is surrounded by a two foot high thorn fence and dirt retaining wall where someone is desperately and pathetically trying to grow something (looks like weeds, maybe it's their local smoke). A pack of women with huge metal basins covered with brightly colored cloth perched on their heads block my path. I pull in the rein (singular) tightly and Bob slows down as they also realize that a horse is upon them and quickly move to the sides. I wave and shout"Lapia" and continue on.

I turn around and gallop into the Harmatan winds until I rejoin the others and we slowly walk back. At thef irst house on the outskirts of the village Sarah stops to ask if they have any chickens for our going away party for our volunteers tomorrow. They have none. Just then I see Gwame run up. A cute 4-5 year old hehas old shorts, a torn shirt and a huge grin as he stops near my horse with arm outstretched to give me"five". After I slap his hand his tongue pokes out in concentration and he rears back his palm to smack mine with all his little might.

Hard to believe that less than a year ago he was acripple with nothing but a lifetime of suffering ahead of him.

In August, thanks to my old (yes, old) friend Troy Dickson and his wife he was sent to Kenya to the Cure Hospital for a life-changing operation. He had what is called "wind swept knees" meaning that both knees were displaced laterally as if a strong wind was blowing them to the side making it almost impossiblefor him to walk. In fact, when Troy and I first saw him he was also malnourished and covered with scabies from head to toe. Being an indentical twin made it even sadder as by looking at his brother we could see what he should be.

Now, radiating joy and health he begs me to lift him up for a horse ride as I have the habit of doing whenever I pass. I reach down and grab him under the armpit and swing up his little body onto the horse. His straightened legs easily fall on either side of the horses shoulder and off we go. We take off in a trot with the other kids following screaming at the top of their lungs and a permanent grin on Gwame's face threatening to split his ears in two. When wecome back and chase the other kids all the way into the courtyard of the house he giggles and chuckles with a contagious hilarity that makes us all feel like nothing could touch us in this moment. We are as free as free can be. Free to rejoice in a miracle, in a transformed life, in the moment.

James

Panic

I wake up in a panic...did I ever really sleep? I'm not sure. Yet, I'm not really awake either. I'm in that gray zone between...the netherworld. I reel the desperation rising within me. Images of the day'ssurgeries well up as well as a nebulous, all-pervadingfear that gnaws deep down...a fear put into wordsearlier in the day by Dr. Warren.

"James, I don't know how you're going to be able to handle it when I'm gone. It's just too much."

A retired surgeon, Warren arrived at the end of January to much anticipation on my part. I was surethat I would have a break and be able to catch up onso much other stuff I'd let slip by in January. I had reached the breaking point with our 71 surgeries in the first month of 2007, but now, with the arrival of a real surgeon, I was sure that things were on the upswing. Maybe I'd have time for a little exercise. Shoot some hoops, go to the river for a swim, ride the horses, jog a little, you know, some leisurely activities having nothing to do with the hospital.

I even hoped that while I was at work I'd have a chance to relax, really follow the inpatients well, have some in depth outpatient visits. You know, be areal, thorough doctor for once, not just someone scrambling around to try and do the minimum possible to save as many of the masses that came from all overthe country to the one hospital still functioning and still affordable.
I was wrong...dead wrong.

Warren arrived on Sunday. On Monday, he did two hernias, a hysterectomie, and a nephrectomie. I saw 50 inpatients and 28 outpatients, and did 6 ultrasounds. Then, we all got called in at midnight for a perforated duodenal ulcer that needed to be intubated and resuscitated in a difficult anesthesiacase. While Warren operated I was bagging him and telling Paul what drugs to give to keep the man alive.We managed to save his live for a few days before he succumbed. Who knows exactly what since we have noelectrolyte or chemistry panels in our lab and nointensive care.

Then, things started to get really bad.

First, the big autoclave has been out for monthswaiting for parts. Then, within the week prior to Warren's arrival, both small autoclaves got fried. Then, the generator went out leaving us without wateror power. We had a small generator given us by the Shanks in Koza, Cameroun that at least allowed us alittle light, suction and a monitor in the OR. However, Warren, at the age of 74, was forced to workwithout air conditioning in the ever-increasing Chadian hot season.

And work he did. In three weeks, counting today, he's done 55 surgeries, many of them complicated like the man with a redundant small bowel cyst and many hysterectomies and some osteomyelitis. Of course, there's always the tons of hernias and hydroceles aswell as a c-section with 8 liters of ascites and anovarian cyst the size of a soccer ball.

The lab then ran out of power. We hooked everything up in reverse (since the small generator is 110V and the hospital is wired for 220V) so the lab battery could charge and than they could run things off the inverter. I thought we had it all set up but they managed to fry a microscope bulb and the hematocrit machine leaving us without the ability to even check the hemoglobin. Now, we rely entirely on the color of the conjunctiva to decide if a person needs to be transfused. Modern day medicine at it's best.

We adapted. We borrowed a 220V generator from the District to pump water every few days and continued to operate with the small 110V one. I continued to see about twice as many outpatients as normal as well as the increased number of inpatients due to the increase in frequentation and the increase in surgical cases. We borrowed a stand up autoclave (a glorified pressurecooker) that takes 6 hours to sterilize with either apetrol or propane stove stuck underneath trying toheat it up...we have no adequate heating source.

Not to mention that our accountant is not working as we're giving him time off to try and find money to payoff the $1200 he stole from the hospital. Not to mention the fact that Andre's been in N'Djamena formost of the month trying to get medicines from the central pharmacy as we run out of even basic thingslike Bactrim and Flagyl. We haven't had a new urine collection bag in months. We've been re-washing oldones and using feeding tube bags. So, all the administrative decisions have been falling back on meas well.

And, all the nurses are working themselves to the bone at the same time. What would we do without our two student missionary nurses, Paul and Israel? What about our half deaf new nurse, Abel, who's not above getting down and dirty to assist on surgeries, cleanup the blood and guts, wash the instruments, and staytill sundown almost every day except Saturday? Whatabout the two new government nurses just assigned?

God always gives us just enough to get by.

But, now, today, with the bloody c-section for uterinerupture leading to a hysterectomy with four blood transfusions and difficulty controlling the bleeding rolling around in my head after a "relaxed" Sunday spending over six hours in the OR (we had a case ofosteomyelitis of the tibia as well as an incarcerated hernia that came in during the c-section), now, when I don't eat from a few hash browns for breakfast until some cold pasta late in the evening, now, as the panic sets in as Warren's departure approaches...How will I handle it? And more importantly, what will happen to the hospital and health care in the region when Sarah and I go on vacation March 11...and both Paul and Israel leave?

And more importantly, how will my body handle this stress if I can't even sleep but spend my nights tossing and turning or begging God with racking sobs to intervene? It's been too much for too long and it's just getting heavier...Is God not listening or is someone else out there who He's calling to come help not listening? All I know is that I'm not going to last much longer with out some kind of intervention.

Is there anybody out there?

James

mangos and urinary retention

Her face was so swollen it was all but unrecognizable. Her right eye was completely shut. Blood caked in streaks and dotted lines ran from her lower lip, down her chin around a large gash under her chin across her neck and spattered her shirt with dark maroon patches like a painted mustang. Out of her left ear and nose dribbled an oily, blood tinged liquid. Patches of bloody cotton stuffed haphazardly into her left ear attempted to control to flow.

She was awake, alert and not afraid despite her small size for her 8 years.

Her father had brought her all the way from Kelo on a motorcycle after she fell from a mango tree that afternoon.

It was Sunday night after a long, busy day at the hospital.

She opened her mouth to reveal a cut inside along the gums leading to a visible mandible fracture. Most of the teeth on the right had been knocked out except one molar on the top, a split molar on the bottom and 4 of her front teeth.

All caused by an addiction to mangos...what can I say, I'm guilty myself.

As I have them prepare for immediate surgery, Lona and Rahama, the nurses on duty, ask me to see an old man who can't pee. Lona tried to pass a foley catheter but was unable to get it into the bladder.

I walk into labor & delivery where they've placed him and see a sobering sight.

A wizened, almost blind man in his 70's is squatting on one of the delivery beds with a wrap half covering his manhood. His chest is bare, sunken and twisted. His scrawny arms still reveal what was once a wiry, tough man.

Blood is smeared all over the table, the wrap, and the man's groin, several clots drip blood from his urethra.

His bladder is swollen halfway to his belly button. I stick a gloved finger up his rectum and confirm a grossly enlarged prostate. He begs to be taken home so he can die. I explain that we will operate on him first thing in the morning, that he won't die. He refuses. We leave the sons to reason with him while Israel, Paul, Sarah and I take the small girl to the OR.

Sarah gives her general anesthesia and I first attempt to wire her jaw. I take a steel suture pass it around the base of her only two molars on the right (the side of the fractures). I twist them together leaving a tail that I then twist together with the molar's twin to bring the jaw together in a functional position. I repeat the process with the front teeth. It's sketchy but is sort of working.

I then open up our internal, maxillo-facial fixation tray and enlarge the wound between her lower lip and chin to expose the fracture. I drill four small holes through a small compression plate, measure the depth of the holes, select the appropriate sized screws and carefully screw them in with a hand screwdriver. Just like I learned in carpentry class (and in the Ventura County Medical Center OR)!

We wash out the wounds well and then I close a couple and Israel closes the rest. She also has a probable basilar skull fracture causing the cerebrospinal fluid to come out her nose and ears. I put her on a strong antibiotic for a week. A few days later the swelling is almost gone and her pain is controlled with ibuprofen and tylenol. After a week of IV antibiotics the leaking has stopped and she goes home.

Meanwhile, I come out of the OR to find that the man with the enlarged prostate is at the gate and would've been home already if the night watchman hadn't blocked his leaving.

As I walk up under the starry Chadian sky a huge part of me wants to just yell at him for being so stupid and let him go home to die. He refuses to wait for the morning saying he'll die before then.

The air is cool and I am tired. It's 11pm already. But, an unfortunately rare thought enters my
head...what if it was my dad? My grandpa? Me? What would I want done?

I offer to operate right now. After much discussion and suspicious glances thrown my way by the old man, his sons convince him.

We carry him to the OR, prep him and give him a spinal anesthetic. I scrub my already well scrubbed hands. I'm almost in a dream, a moment frozen in time as my hands go through the automatic ritual of nails, fingers, hands, wrists to the elbows that has been drilled in me. It's a comforting and important ritual.

I open the OR door with my back, dripping elbows out and hands up. I grab a towel, dry my hands slowly and methodically and drop the towel on the floor. I grab the gown, shake it out and slide my hands through. I'm in another world. I put on my sterile gloves and then Israel and I place the sterile towels around the lower abdomen of the man and then lay on the drape.

After prayer, I take the scalpel and slice horizontally through the skin right above the syphysis pubis...the same as for a c-section. I cut down to the fascia and just through to the muscle on either side of the mid-line. I take the scissors, spread them under the fascia to detach the muscles and cut to the edges of the skin incision both ways. I grab the fascia with clamps, lift up and with my fingers and scissors take the muscles off first superiorly and then inferiorly. I split the muscles with a clamp, insert my fingers and pull the muscles apart. Israel inserts retractors and I open the bladder with the scalpel in a vertical incision. Israel uses the suction tubing to sop up the fountain of urine that pours out. I extend the incision with the scissors.

Israel sucks out all the urine and then pulls the wound open with the retractors. I find the posterior part of the prostate and make a nick with the scalpel. Then we pull out all clamps and retractors and I stick my finger into the bladder, find the small incision and push into the mucosa around the prostate and then sweep around the prostate, shelling it out. Blood pours into the bladder as I lift out the trophy.

Paul inserts a small urethral dilater from below, I attach a heavy suture to the dilator, and Paul pulls it out the urethra. He then ties the suture to a large foley catheter which is then guided into the bladder around the false track. Paul inserts 30ml of water and yanks the foley down into the hole that used to have the prostate.

Israel and I close the bladder, fascia and skin while Paul attaches the irrigation tubing to the three way foley catheter as bloody fluids start coming out into the urine bag.

The next day, our man, who I find out lives in our same neighborhood, is pleasantly surprised to find himself still alive. He's even more surprised to find out a week later that he is going home in very good condition with normal urine function...the only draw back is that he has to suffer through a large indwelling catheter for another week. He smiles, grabs my hand with both his and repeats over and over "Lapia, merci beja, lapia, lapia, lapia..."

( P.S. for other similar email stories look to bereadventisthospital.blogspot.com )

James