Police

It's strange, because if I'd been in the US and the same thing happened, I'd be scared spitless. It happened like this...

I'm in N'Djamena to pick up Sarah from the airport. My friend and fellow AHI board member, Chief Justice Aimé, has lent me his Toyota 4-Runner. I take Sarah and her Danish sidekick, Nathaneal, to the central market. I park right in front of the Grand Mosque, just ahead of where the taxis pick up and let off passengers. I roll down the windows and sit back to watch the passersby.



A few kids come up with their metal bowls asking for alms for the mosque. I chat a little with them in my broken Arabic. One sticks his hand in and is fascinated by seeing the locks go up and down with just the push of a button. Finally, I can't get rid of them, even with the usual "Allah eftah" (God will provide) which should be followed by an "Amin" but instead these kids just say "Ma fi" (no way). Finally, I grab a bowl and toss it to the side and put on a fierce expression. They get the hint.

A young, beak-nosed Arab greets me from behind on the left. I turn my head and greet him back. As I turn back I see Sarah coming up to the window. She's just finished changing money and is about to head out to buy vegetables.

"Who was that guy and what was he doing by the window?"

"Nothing, he was just saying 'Hi'."

"Oh, he just looked suspicious."

"Don't worry about it. See you in a bit."

She heads out again with the green army duffel bag accompanied by Nathaneal.

A brand-new dark green pick up approaches from the left. "Police" is written in bold letters across the door. There are machine gun toting gendarmes in the back and a camo-wearing man with a maroon beret sticks his head out the passenger window, spots me, turns back and says something in Arabic. I hear the word "Nasara" (foreigner or "whitey") and the truck pulls in just in front of me and parks.

"Oh, boy," I think. "Here we go again."

Sure enough, the beret man and a couple of Kalishnikov bearers hop out and approach the right side of the 4-Runner. I'm a bit surprised, however, by their next move.

A young, gap-toothed teenager with his old school Russian automatic weapon opens the passenger door and gets in beside me, his gun slung loosely by his left side.

"Let's go to the police station!" barks the beret-wearing man, obviously in charge. "You're illegally parked."

I guess if I had recently arrived in Tchad I might be soiling my britches at this point, but for some reason I'm not afraid, just exasperated. I try not to sound angry and frustrated as I reply that I didn't know I was illegally parked since there is no sign and I've seen others park there often before.

The chief doesn't budge. I try a new tactic.

"I can't go because my wife is in the market and how will she know where I've gone and how will I find her?" I can see he's not convinced. "Now that you've done your job of informing me that one can't park here, I'll just move the car. Tell me where I can park and thanks for the warning, I won't park here again."

"You can park there on the other side."

I start up the car and back up and cross the one-way traffic to the other side right in front of the mosque, which seems to me a more likely spot to have a "no parking" sign, but I keep this thought to myself.

My passenger is still with me grinning stupidly at me from time to time.

The head honcho follows us over.

"Well, now that you've told us about Madame," he begins the negociations. "We'll let you off easy this time with just a 6000 francs fine."

I then pull out what I think is my ace. I reach into the glove compartment and pull out an invitation signed by the president of the republic to the year end meeting of the Supreme Court.

"This isn't even my car," I suggest. "Do you really want to haul off one of the supreme court justice's cars? One who's intimate with the Head of State himself?"

"Well, you're the one driving it now!" he retorts, "So it's you who gets to pay the fine."

What is it those Frenchies say? Touché?

At this point, a young man approaches me from the left with a bag of something.

"Are you Dr. James from Bere?"

"Yes." I reply, grateful for the distraction as time is an important element of the bargaining process.

"I've been looking all over for you. I'm the son of the man with the broken femur you operated on last week. I tried to find you earlier at the Mission guest house but I was told you weren't there. Then, my dad told me you were at the National Security Counsel office but I barely missed you there too."

"Yeah, I was there registering our new volunteer for the hospital. He just came back from Denmark with my wife. I called your dad back and told him to have you meet me here."

"So what's up with the gendarmes?"

I explain the situation to him and he starts up with explaining how I'm new to town and don't know the rules and that I'm the big doctor from Bere who just operated on his dad who is also a gendarme and one of there compatriots, etc.

The chief officer seems to be convinced...a little.

"Well, since you didn't really know and since you're here helping us out, we'll only make you pay 3000 francs."

My new friend has now gone over to the other side to talk more intimately with the police. He starts off in French but the officer quickly switches to Arabic saying he doesn't want me to hear their negociations. Unfortunately for him, I now understand a little Arabic and reply in Arabic that I understand him fine, thank you very much for asking.

He looks at me surprised and starts to laugh good-naturedly.

"Well, you obviously have money since you're driving a car so just share some with us for our tea."

"I have no money," I respond in Arabic. "If I did, why would I come from Bere on motorcycles and the common market car?"

The young, ugly, armed gendarme next to me now has a huge gap-toothed grin. He shakes his finger at me in wonder "You...you...you..." and gets out. They all walk off shaking there heads and laughing. Right before getting into their truck they turn one last time and offer a friendly wave goodbye.

As I thank my new friend and offer to carry his sack of homemade pasta to his convalescing dad, Sarah returns with Nathaneal.

It's then I realize that my cell phone has been stolen. In talking more with Sarah, it seems the guy she saw was on the right side of the car and was just pulling his head out of the window. Apparently, his partner greeted me from behind on the left so I'd turn my head long enough for the other guy to reach in the open window and take the cell phone from the central console. A slick manoeuvre.

Just when I thought Tchad was gettting boring!

Roadtrip

"I dont' know, I really want to pick you up in the airport, but it'd be hard now. It's pouring down rain, the roads are already bad, the car doesn't start, I'd have to go by motorcycle and public transport. I'd like to see you as soon as possible, but I'm exhausted, plus the extra expense...couldn't you just take a taxi from the airport and then come back on public transport?"

Sarah is supposed to arrive tomorrow in N'Djamena, but with the rainy season and all, I try to excuse myself. Deep down, I feel I should go to meet her though, but she doesn't have to know that!

I haven't decided for sure one way or another, but I get a text message from her later that evening telling me she understands and I should feel free to not come to pick her up, I'll just owe her a ton of back rubs later!

I call Ndilbe, our nursing student who has just finished his 3 month internship and is ready to go back to N'Djamena.

"We leave tomorrow at 5am. Can you arrange some motos for us?"

At 3am, Augustin knocks on my door.

"There's a kid in respiratory distress, can you come see him."

Sure. I haven't been able to sleep anyway thinking about surprising my wife at the airport.

The kid is grunting, wheezing, retracting and has nasal flaring. Severe asthma. I open my office and find a few vials of expired Xopenex that we put in the nebulizer. I tell Augustin to give him some Dexamethazone IM while I hook up the machine.

The kid suddenly comes alive and it's all the mom and I can do to hold him and the mask in close enough proximity for some of the medication to get in his lungs. Despite his best efforts, something must be getting in those tiny lungs as he starts to breath easier. I tell Augustin to start a Quinine drip for malaria, add some Ampicillin in case it's pneumonia that provoked the attack and return home.

I'm too wired now for sure to go back to sleep for a few minutes so I make some egg gravy and toast and finish packing my small backpack, a skirt and t-shirt for Sarah and an army duffle bag to bring back fresh vegetables from the N'Djamena market.

The predawn glow appears. It's cool and humid and a little haze rests across the African plain. Two old Nigerian motorcycles with dim headlights waxing and waning with the speed of the engine and spewing out white, burned-oil-smelling exhaust, limp up to the front gate.

Ndilbe wraps himself up in a turban and we strap on our bags to the back of the motos with old bicycle innertubes.

We're off, with the cool air whipping gritty humidity into our faces.

The road is one long series of mudpuddles with improvised footpaths around most of them extending sometimes into the rice fields. Often we have to just plow through green, muddy water up to midway on the tires. We cross the new bridge and down the other side where the gravel buttress has mostly fallen away with the rains leaving a small middle section carved up with a few metal beams tied together with steel cable barely holding things together. We're through the barrier at the bottom and pass through Tchoua on our way to the hippopotamus lake.

The elevated road through the lake with a central drainage pipe is pock marked with a million ruts carved out by heavy trucks and a billion ridges carved out by the draining rainwater. It's confounded by being made of clay, slickened by the rains making it a bumby slip and slide experience wondering when we'll just slide down into that wide open hippo mouth.

The last stretch before Kelo is completely submerged and we plow our way through and wind our way through the early morning mud streets lined with tiny mud brick shops just yawning a good morning to another day of fasting in this month of Ramadan. A few lonely robed figures stroll through the red tinged early morning fog as we finally hit the pavement and pull up to the "bus station" on the side of the road opposite the air compressor and rickety wooden tables lined with various shapes and sizes of glass bottles filled with an assorted variety and mixture of fuels.



After paying the moto taxi-men and for our bus tickets, a young, turbaned man approaches and greets us. He is chewing on the typical Ramadan teeth cleaning stick. It's the son of the builder constructing our new junior high in Bere. He's on his way to Cameroon to study. I buy some bananas and then confirm his fasting by offering him one which he politely refuses.

We get on the bus and have two of the back four seats. Ndilbe takes one window and I take the other. Next to Ndilbe is another flowing robed, turbaned Muslim spitting occasionally out the window to keep from violating one of the Five Pillars by inadvertantly swallowing his saliva. A fully covered and veiled Muslim woman with dark gloves and stockings makes her way down the aile towards the back. A young Arab in front of me seems concerned that this obviously pious woman may be forced to sit by an obviously foreign and thus necessarily infidel white man. He shouts in Arabic to Ndilbe and the other man to move over which they do.



"Da bas adil" he responds nodding his approval as the deeply perfumed, modest example of virtue makes her way to the seat as far away from me as possible in the same row on a tiny bus. I'm relieved too.

The rest of the four hours passes quickly with a "Tale of Two Cities" and an occasional nap to keep me busy. We arrive without incident in the midst of a vusy market in N'Djamena.

I had planned to catch a taxi straight to the mission guest house, but decide to go with Ndilbe instead and try and arrange to see his nursing school and pay the school fees for the next year.

We walk down the crowded, noisy market street and turn the corner. We try and catch a taxi, but as we're putting our bags in the back, three people have got in the back seat and two in the front. There's only one space left. We start arguing as we have to travel together since I don't know how to get to Ndilbe's place. The woman in the back who'd stolen my spot doesn't budge and just smirks in reply. Finally, a young Muslim girl is kind enough to get out of the front seat leaving me crammed next to a very large woman occupying the other "half" of a tiny Peugot taxi passenger seat.

The trip is short and we take another road with a drainage ditch in the middle filled with small, bare-footed boys searching for something in the muck.

We open the gate to the house and enter the courtyard where we thankfully dump our bags under a shade tree and I thankfully relieve a very overworked bladder in the corner latrine.

The woman of the house, the wife of one of Chad's chief justices, generously lets me use her car which takes us on a bumby ride through the suburbs of N'Djamena to a Goudi looking three story structure where two secretaries sit doing their nails and gossiping in front of empty adminstration offices. Strike out!

I then get a call from Babana Benzaki who has arrived from Nigeria. A former Muslim, originally from Tchad, who converted to Christianity while studying in Nigeria and who is in his last year of public health at Babcock University, Benzaki has come to get the financial support voted on by the last AHI committee. We have many very interesting conversations about health, life and God. In the meantime, Kaitama shows up to get the letter I brought from his brother and Dieudonne shows up from work so we can discuss how I'm going to take off the lipoma from his neck tomorrow and how maybe in return he can let me borrow his car to pick up Sarah from the airport.

It also happens to coincide with the birthday of the four year old son of the Chief Justice who's mom had prepared a birthday feast even though she had invited no one. With nothing but a couple of boiled eggs and some bananas in my stomach since 4:30am I am more than happy to be part of the celebration! We finish off with a deep red Jus d'Osei (Hibiscus flower tea) and some strong, cold homemade Ginger drink.

I finally head to the guest house in the judge's Toyota Four-runner for a few hours rest before the 9pm arrival of my Danish wife.

I stand patiently outside the barred entrance to the baggage claim as various "important" people are let through while others are kept out. Finally, they seem to be letting down their guard and I slip through with the next batch let in.

I wait in front of the door leading to the immigration booths. I had glanced in quickly to see if I saw Sarah's red head without her seeing me and I succeeded. Finally, after an eternity, she appears at the door and looks at me with a shocked look and then starts laughing and saying "no, no, no, I can't believe it." Unfortunately for me, it's not a pleasant surprise at seeing me that has brought on this reaction but shock at seeing my recently smoothly shaven scalp that makes her incredulous. She is very cute with her long red hair pulled up in back with a few ringlets of curls escaping to the sides to run down her cheeks and forehead. I give her a warm hug and breath in the fresh smell of her hair as I kiss her head. It's good to have her back and definitely worth it all!

Shocking

I stand at the foot of her bed. Kristin and Augustin are the nurses on duty and the three nursing students, Ndilbe, Honoré and Innocent are gathered around, white coats spotless, notebooks and charts in hand.

The patient has just come out of surgery two days ago for a walled off, perforated appendicitis. At first glance, she seems to be doing fine. She's staring at me with understanding eyes and breathing rapidly but easily. Then, I notice beads of sweat all over her chest, face and arms. I pull off my stethescope from around my neck and press it against her thorax. The heart beat is rapid and irregular. She's mid thirties and shouldn't have heart disease. What is it?

I look at the chart. Her vital signs there are listed as normal. Then I notice that she's been still kept NPO (nothing to eat or drink) but hasn't got IV fluids in 24 hours. I quickly have the nurse put up some Ringer's lactate IV solution. I think maybe she's dehydrated and has some electrolyte imbalances. We can now at least check his potassium thanks to the Danes and I go ahead and give him a little expired Magnesium that I've been hording in my little stash in the pharmacy.

Then, I remember the heart monitor/defibrillators that our two young volunteers for the summer brought over. I go to the OR stock room and find one that still has a charged battery despite never being charged since arrival in Tchad three months ago.

I hook it up to the patient. The screen is so small and the heart beat so fast it's hard to tell for sure, but it looks like atrial fibrillation or atrial flutter.


She's gotten a couple liters of fluid and the magnesium and now the potassium comes back normal. She seems stable enough so I leave the monitor hooked up but turn it off to save battery and move on to the next patient. Maybe she'll come out of it on her own.

It's 9:30am.

After finishing rounds and seeing the first batch of ER patients I perform a hernia operation with mosquito net mesh and repair to my office for some ultrasounds.

Augustin knocks on the door.

"Ca ne va pas," he says "Bed 10 is in respiratory distress."

I hurry over to the ward, worried that she's already dead (which is what "ca ne va pas" usually means coming out of a nurse's mouth). Fortunately, not only is she still alive, but she's consious and not really in respiratory distress. However, as I turn on the monitor, I see that her heart beat is still 150-160 and irregular. I feel I should do something but it's been a long time since I've had to deal with cardiac patients and I'm not exactly in the best equipped place to deal with it.

I hurry back my office to look up my little "cheat sheet" on electrical cardioversion. It tells me I should sedate the patient first if possible, put the defibrillator on "sync" and start with 100J. Ok, I feel a little better, it's starting to come back.

I hook up the defibrillator pads, give her some Valium IV, turn on "sync" and see the little dots appear over the QRS complexes on the EKG, turn the knob to 100J and hit charge. I hear the whirring of the charge and then it's ready. But now, I don't know how to make it decharge. I look all over and see nothing. Great.

I turn everything off, take off the pads and return to the OR where I find the paddles with their large, curly-cue phone cable like cords. I hook it into the defibrillator, check out the little buttons and place one over her sternum and the other on her left side under her armpit.

"Everyone back," I announce. "Don't touch the bed or anything!"

She's still staring up at me wondering what the heck I'm doing (as do I). I see that everything is well sync'ed. I hit the charge button and then the two "shock" buttons. Just like in the movies or on TV she bounces a little off the bed, her head thrown back, and then flops back down. The EKG makes a big wave, a brief flat-line and then a normal rhythm of 110 beats per minute starts to play across the little green screen.

I almost can't believe it. I know it's supposed to work according to all I've read and been told in my ACLS courses, but come to think of it, even in the US I don't think I've ever been present for a synchronized cardioversion.

My heart is full with thanks to God for bringing everything together to make it possible for us to save this woman's life first with the operation and then with what I had considered mostly useless defibrillator monitors.

Shocking!

Insomnia

I've had a nice relaxing day. I slept in, thanks to a sleeping pill, did an
appendectomy, came home and watched The Gospel of John on DVD, played the
guitar, cooked some beans and rice, fed the horses, went to evening prayer
and read "Le Comte de Monte Cristo" until 10pm when my eyes were so heavy I
knew I'd fall asleep immediately.

Boy, was I wrong.

At first, the earplugs seem to drown out all noise and the bed is so
comfortable. It's not even too hot. I feel myself sinking into the bed and
a deep sleep. But then, slowly, the ear plugs un plug a little and the
sounds of children's squeals and shouts breaks through. The drum beats waft
over the full-moon lit night. I start to feel a little cold. I pull on the
sheets. Then my muscles feel a little stiff. I stretch them out. I start
to toss and turn. Then I feel hot and take the sheets off. My thoughts
start to pour in on themselves.

Maybe I should've taken out that inflamed Cecum instead of just draining the
peri-appendiceal abscess. I'll probably have to operate tomorrow and it'll
be complicated and who knows what will happen.

Is that a knock on the door? I pull out my earplugs. Nothing. Then a
faint, "tap, tap, tap" of knuckles on sheet metal. I pull off the eye shade
and the other ear plug. I fumble for some shorts and stumble out to the
door, the way lit by the incandescent blue of the bug lamp. It's Samedi.

"The young man with the snake bite. His dad wants to take him home. I told
him I can't release him without the doctor's orders. I tried to explain to
him to wait until the morning, but he says that everyone in the neighborhood
is saying that his son is dead, so he wants to take him home."

"What kind of excuse is that?" I think to myself then reply to Samedi,
"have him sign the form that he's leaving against medical advice. We're not
a prison, we can't force anyone to stay. The dad doesn't even care that his
son is better and if he was going to die he would've done it the first day
or two?"

"I've tried to reason with him," Samedi replies. "Even Pierre and the lab
guy tried to talk to him. He's totally beyond reason."

"Ok, bon travail!"

I try to return and hope that now I'll be able to sleep.

At first, I think it'll work. But then the thoughts start to come in,
unwanted worries crowd my head. The kid's voices keep penetrating the
silence of the ear plugs. Medical and surgical cases keep parading through
my subconscious along with preoccupations that I should have done things
differently or maybe I should've done this and not done that. Then, I start
thinking about the projects I want to do, all the preventative measures that
could be taken. What are we going to do about malaria? Will DDT spraying
ever happen? What about the TB and AIDS patients? Will I ever get time to
train the village health care workers like I want to? What about the
Moundou project? How are the volunteers going to work out? Am I giving
them enough direction? Am I being too controlling?

As I fitfully fall into a light slumber, the tossing and turning continues
as I continually wake up, my heart beating fast having dreamt once again
that I'm having to flee something...that I need to escape something that is
chasing me and almost finds me except miraculously, they somehow overlook my
obvious hiding place. It's a recurrent nightmare.

Thoughts in French wander in about the Count of Monte Christo and what I've
just read. Is that a knock on the door? I pull out the right earplug.

"Oui?" I ask. I look out the small bedroom window onto the porch. The
moon illuminates the door. There's no one there.

I'm cold again. Now I'm hot. Oh, it's so comfortable on my back as I
stretch my legs out. Now it's uncomfortable. Maybe on my side. I
should've taken a sleeping pill.

I pull out my earplugs. The dancing and singing and playing has stopped.
The crickets and frogs are blasting a cacophony around the house. Somewhere
a rooster crows. His friends answer from all over the neighborhood. A tint
of red lights up the windows. Dawn is on it's way. I get up, turn on the
computer and write this email...

Fixin da bone

Considering I'd only done it once before in my life, it's hard to believe that this is the third time this month I'm slicing open a thigh. This one should be the hardest one to date.

Abel helps me stretch a sticky, yellow plastic covering over the thigh where we'll cut to try and get to the unhealed femur. As I poise with the scalpel over the now yellow window of thigh in the surgical field the first two cases flash through my mind.

The first was a large man hit by a motorcycle two years ago. His twin brother came to our hospital for some other reason and then asked me if I could do anything for his brother whose leg had healed badly leaving him crippled hobbling around with the aid of a crutch thanks to his now shortened right leg. Surprisingly, the traditional method of bone setting hadn't worked leaving him only with a circomferential scar where they had attached a cord too tightly.

Maybe it was the twin angle, but I told him to have his brother see me when I'd be in N'Djamena next. Sure enough he showed up with several sets of xrays showing his femur shortened by 4 cm and angled at about 25 degrees. It was well healed though. When he came to Bere I was able to break the two fragments apart and then put him in traction to pull it out to length. He's been here for a month now.

The second was an 8 year old girl referred by the first patient. In fact, she was his niece or something, also with a right femur fracture 3 months old due to a motorcycle hitting her. Basically the same procedure and she's been here for a couple weeks now. She also ended up with malaria needing a blood transfusion. She is stoic and looks me directly in the eyes every time I do rounds lifting out her hand solemnly for the obligatory greeting and exchange of "Ca va's". I look forward to seeing her every day.

As I slice through the yellow plastic, the black skin and the light yellow fat turning quickly red with blood, I think again that this one won't be as easy...

Again another call came to me while I was in N'Djamena last week saying he also had heard that we'd operated successfully on two of his relatives with right femur fractures and he hoped we could do the same for him who had the same problem. Yep, the right femur broken by a motorcycle hitting him while he was riding a bicycle.

As I held up the xrays in the faint rays of light filtering through the slats of the ER windows I could tell instantly that this was complicated. The two fragments of the femur were separated by about 4-5 cms with a separate fragment also to the side and no evidence of any type of callous or new bone formation anywhere. It was a year already after the accident. His fracture had also been an open fracture with a draining would for 3 months before it closed. As I looked again at the thigh I saw the healed scars from where the bone shard had pierced the skin. As I picked up his leg I found he had an extra joint mid-thigh. I could move his lower leg in all for directions without his hip moving at all. Not good!

I cut through the fascia and the red muscle wells up into the wound as Abel retracts. As I continue down through the muscle, I see the fibers twitch and retract. I hit some nice arteries and scramble to clamp them off. I call for a suture and tie off the bleeders. I can feel the proximal fragment of bone with a muscle spilling over it down into a cavity where the other bone has to be somewhere. I keep digging until I find the distal part of the femur. There is about 2 inches of muscle and a ton of scar tissue all around. I try to free it up with various instruments: scalpel, scissors, periosteal elevators and various others. I get into part of the scar tissue that has walled off some yellow inflammatory liquid like a cyst. It is clear though and happily doesn't look infected. The distal part just doesn't want to free itself.

I'm kind of a little nervous as I know somewhere around the back or medial side of that deep bone are the big arteries and veins that supply the leg. I don't want to have to resort to a Celox miracle again.

I have the scar tissue freed up superiorly, medially and laterally, but behind the bone I just can't seem to get to it. Finally, I find some dangerous looking pincher-like instrument and manage to grasp the fragment and pull it up enough to cut off the scar tissue keeping it from moving.

I then grab some Rongeurs and start ripping and tearing and biting and cracking off pieces of calloused bone over the two unhealed ends. Finally, I'm down to pretty fresh, raw, bleeding bone. Klevin and Gabrielle have been taking turns putting some traction on the foot and now I really have them tug with all they've got. The bones are still overlapped by a centimeter. I wedge in a chisel and with my prying and the boys' pulling the distal part finally slips over the proximal and meshes together with all the sharp edges left after my gnawing at them.

As Klevin and Gabrielle maintain tension on the leg I suture closed the fascias and the skin and place a sterile dressing.

I then take out a sterile, threaded pin about 20cm long and put one end into a very not sterile cordless drill. I make a small incision on the skin over the tibia and pull the trigger. The pin barely moves, the battery is weak. It makes it a few millimeters into the bone before conking out completely. I ask for the other battery. It is even deader since the charger hasn't been plugged in. I try an old rusty hand drill. Doesn't move at all. Finally, I send Gabrielle to my house to get another cordless drill. After a long five minutes he's back and I drill through the bone, nick the skin on the other side and let the pin work it's way halfway through before detaching the drill. I then attach a U-shaped wire onto it so we can attach a bag of sand to work as traction to keep the leg out to length.

After transferring him from the OR to his bed and attaching the sand bag, I do the final manoeuver, I put two empty Ceftriaxone vials over the sharp edges of the pin, make sure the legs are the same length and go home.