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
Wednesday, June 27, 2007
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.
Sunday, June 10, 2007
Sight to the Blind
The wizened little arab grandpa has already been in the hospital for awhile. He arrived at the end of my vacation and was operated on for a hydrocele then rehospitalized for a urinary infection with urinary retention. He has come back now after being sent home with urinary retention again. I found he had an enlarged prostate and scheduled him for surgery tomorrow.
I approach his bed in the semidarkness of an overcast day. There are no lights without the generator. At his side is another old arab with a gap toothed smile revealing teeth pointing in all four directions of the compass and then some. Another elderly, robed muslim hangs out quietly in the corner next to a middle aged woman ("middle-aged" through a tough life rather then by length of years) wearing a brightly colored green dress with poofy sleeves and a shawl draped lazily over her head covering the small leather fetish pouches dangling haphazardly from a thick leather cord around her neck. She is breast feeding the child cradled absentmindedly in her right arm.
"Al salaam alekum" I start the long greeting process.
When we have finished they tell me that suddenly, last night, he became totally blind and has been vomiting since yesterday despite his intravenous malaria treatment. I examine him and he is completely blind.
I can think of no medical explanation for it but plenty of spiritual ones.
"Ibliss or one of his angels has blinded him." I explain that only through praying to Allah, the one true God can he be healed.
They all nod expectantly and gather around with hands outstretched, palms up expecting the baraka of Allah. I pray in the same way with my arms and hands in the appropriate position.
As I finish they all smile and demonstrate a faith I can only marvel in. They have complete confidence now that Allah's will will be done.
None of us are surprised the next morning to come and find his vision completely restored. They all just smile, hold their hands out while looking up and saying "Praise be to Allah."
I approach his bed in the semidarkness of an overcast day. There are no lights without the generator. At his side is another old arab with a gap toothed smile revealing teeth pointing in all four directions of the compass and then some. Another elderly, robed muslim hangs out quietly in the corner next to a middle aged woman ("middle-aged" through a tough life rather then by length of years) wearing a brightly colored green dress with poofy sleeves and a shawl draped lazily over her head covering the small leather fetish pouches dangling haphazardly from a thick leather cord around her neck. She is breast feeding the child cradled absentmindedly in her right arm.
"Al salaam alekum" I start the long greeting process.
When we have finished they tell me that suddenly, last night, he became totally blind and has been vomiting since yesterday despite his intravenous malaria treatment. I examine him and he is completely blind.
I can think of no medical explanation for it but plenty of spiritual ones.
"Ibliss or one of his angels has blinded him." I explain that only through praying to Allah, the one true God can he be healed.
They all nod expectantly and gather around with hands outstretched, palms up expecting the baraka of Allah. I pray in the same way with my arms and hands in the appropriate position.
As I finish they all smile and demonstrate a faith I can only marvel in. They have complete confidence now that Allah's will will be done.
None of us are surprised the next morning to come and find his vision completely restored. They all just smile, hold their hands out while looking up and saying "Praise be to Allah."
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