Fracture

The man is lying on the twisted gurney in obvious pain. His relatives and friends stand around panting, trying to catch their breath. They've just hauled him in off the back of the pick-up where he had bounced up and down and all around on the pothole-filled dirt road from Lai.

I bend over his left leg and gently lift the blood soaked rags.

A Betadine browned compress with a bright red bloody center is all that stands between me and the fracture. I gingerly lift it up to see the bright white shard of bond sticking up from a black spider-webbed mass of sutures ineffectively attempting to hold the wound together.

It's been three days since he fell of the gravel truck.

A piece of cardboard is bent around the back and sides of the legs and tied on with string in a lame effort to stabilize the broken tibia.

"We have to operate, clean out the wound and try to get the fracture stabilized."

The family understands and willing forks over the $60 necessary for the surgery, medications, hospital stay, etc.

After knocking him out with a heavy dose of "Special K" (Ketamine) and Valium I have my sister Chelsey grab his foot and pull.

"Lean into it, let your body weight do the work, not your arms," I tell her.

Simeon is at the head of the gurney. We are in the OR prep room with a pulse oximeter attached to monitor our anesthetized patient. Simeon has also given the antibiotics.

Meanwhile, i prepare a 5 liter basin of diluted bleach solution and open up a tray of sterile instruments. The procedure is not sterile as the sand and gravel inside the wound testify, but I guess sterile-to-start-with instruments isn't a bad idea.

I cut all the old sutures and bend the foot down and back so the bone fragment sticks out more allowing me to put my finger behind the bone and with the help of a bulb syringe start to wash out the debris.

After five liters, the wound is fairly clean. I cut off any dead looking tissue and then try and reduce the fracture. A huge posterior piece of the bone is not there, probably removed in Lai, meaning the bone is trying to balance itself on the half centimenter anterior segment. It doesn't work very well but with Simeon now pulling and Chelsey putting medial pressure on the lower segment and lateral pressure on the upper segment it stays pretty well.

Then I have to try and close a gaping 10 cm wound. I use heavy suture with special mattress type sutures and little by little it mostly closes but under a lot of tension. Who knows if it'll hold up, but it's the best I can do.

Then, I pull out an external hard plastic shell for lower leg fractures I picked up last year at my old haunt in Ventura County, California and strap it around the leg to stabilize the fracture.

Amazingly, three days later, the wound is still holding together with no signs of infection and the fracture is more or less still in a good orientation to heal. Maybe a miracle will happen again...

HIV premie

I tried to tell her. I warned her so many times. I told her of the potential consequences. But she just wanted to do what felt right in the moment. She just wanted to have a baby.

She's only a child still herself; 19 years old but looks 13 or 14. She has AIDS, has already been treated for tuberculosis for 8 months and is on antiretroviral therapy. She's unmarried.

Now, she sits in my office cradling affectionately a tiny premature baby boy. All the books on HIV management tell me that if possible, the baby should not be breast fed, but formula fed to avoid the risk of HIV infection through the milk. However, this tiny, malnourished life needs all the help it can get. Despite her obvious thrill at being a mom and holding a baby in her arms, she has no clue what sacrifice taking care of this baby will mean so that it grows up healthy and HIV-free. She has been underfeeding him, feeding him "when he's hungry."

"So he tells you when he's hungry?" I gently chide trying to use humor to get her to realize it's her responsability to feed him regularly whether he "wants" it or not.

It does seem she is doing some things right: washing and boiling the bottle, using only clean water to mix the formula. I decide to continue the formula but I decide to hospitalize her to try and get her help with the idea of regular feedings and what's the appropriate amount. Of course, nurses who are trained to suture, treat emergencies, deliver babies and give shots and start IVs, like our locals, haven't been exposed to the other side of nursing, the educational, daily needs assessment, et cetera kind.

As I look into the gaunt, yet strangely peaceful and trusting face of this four pound premie, I fear his days are numbered

Farcha

As I step out of the plane the heat hits me smack in the face. The hazy, orange low lit airstrip of the Hassan Djamous International airport rises to meet me as I descend the portable stairs onto the tarmac. A brief passport and visa check later and I'm waiting for my bags which never arrive. Odei, Hans and Levi are there to meet us. The team from Florida is with us as well as my sister, Chelsey and, of course, Sarah. Everyone else's bags has arrived so we load up the truck and Rick, Hans and I climb in the back on top of the luggage for a dimly lit ride through downtown N'Djamena to the mission guest house at TEAM.

After some spaghetti and watermelon, I take a cold shower to try and cool down a little. By not drying off and letting the fan evaporate the water on my skin I am able to at least lie down and sleep fitfully. By 6:00am I can no longer sleep and the sheets are soaked with my sweat.

True to his promise, Odei is there to meet me at 8:30 to take me to his church in Farcha. The pounding rhythm of a homemade drumset fashioned out of various tin cans and scraps of metal welded together and covered with goat skins guides the three different choirs in their diverse African chants that course through the blood bringing one into an awareness of the divine.

Afterwards, Odei and I hop on his motorcycle and swerve through the dips and humps of the unpaved city streets towards the district hospital. One of his friends has been hospitalized that week. We first pull over to a shack made of woven reeds where a 12 year old boy is selling water in a bag. We rip open the edges and guzzle half a liter each down our parched throats.

To turn into the hospital we must carefully navigate a ditch filled with putrid water and covered in slime. A variety of bottles and cans struggle desperately to stay above the surface as the gook relentlessly tugs them under. We turn past a rickety, iron framed chain link gate hanging off a couple of badly attached hinges and into the small courtyard of the District Hospital of Farcha.

Peeling yellow paint, twisted hand rails and crumbly cement steps lead us past a few customers lounging on torn mats under the shade of a few gnarled bushes almost resembling trees.

The well-tiled hallway branches immediately off left and right while straight ahead is a tiny courtyard filled with plastic bags, IV tubing and littered with paper that has all tumbled off a pile of trash from an overstuffed metal barrel that has been cut in half. A few Chadians wearing white coats means that there are a few nurses present. Odei greets several of them and we are oriented down the dimly lit hall to the left. We peer into a dark room filled with a few beds, less mattresses and lots of visitors wearing brightly colored robes and head scarves surrounding a few patients hooked up to IVs suspended from windows, a couple of rickety IV poles and even the ceiling.

Odei's friend is outside we're told so we head to the back where some stray dogs scrounge through the piles of refuse around the smoky outdoor kitchen.
We finally find our man under a tree with a few buddies. After some extended greetings and joking around we discover that his malaria is being sort of treated but his chronic cough hasn't even been suspected of being tuberculosis. We give some suggestions, shoot the breeze some more and finally get up to leave.

The next day, after an early morning departure from N'Djamena, I find myself back in Bere which I suddenly appreciate so much more after the shock of the Farcha Hospital in the capital. And we're off...