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...