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.
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