Cripple

My life as a cripple began insignificantly enough.

As far as I can tell, it started with digging that latrine last Sunday morning. I must have accidently hit the inside of my right ankle with the pickax. Whatever the cause, by Sunday night it was swollen and painful. By Monday morning, I could barely walk and it was red and angry. I tried to go to work, hobbled around on lightning rounds before I couldn't take the pain.

At the same time, I was hit with the worst attack of Malaria since the first time I got it in 2004. By the time I hobbled home my muscles were twitching so badly and my teeth chattering so hard you'd of thought I was in the midst of a Danish blizzard instead of 110 degree sub-saharan Africa.

I slammed down 8 anti-malarial combo pills straight in from China and huddled under the blankets desperately trying to fight off the cold.

Did I mention my ankle was killing me?

After a day or two, the malaria was better, but as of last night, I hadn't walked in a week.

I'd been hoping there wouldn't be any surgical emergencies as you can imagine. Despite two symphysiotomies performed resting my bum leg on a stool on wheels in order to bring in two floppy, but eventually revivable newborns, things had been relatively calm.

Until last night...

After a leisurely Saturday lounging around with my foot elevated to control the edema listening to David Asherick talk about living in the End of Time, I found myself strangely drawn to the window around 5pm that evening. I picked up my crutches (hand made in Chad and borrowed from a bed-ridden patient) and limped over to the screen door facing the fence between us and the Emergency Room.

It was hard to see because of the two screens and the distance between me and the action, but I saw a group of people gathering hurredly. A couple of push carts moved back and forth. Two people were carrying a stretcher.

I was not surprised to see one of the Intern nurses, Aimée, coming up the path a few minutes later.

"There's a situation," she blurted out, gasping for breath. "There's been a fight at the market. They've brought in a bunch of victims. One woman's dead. A man has a huge knife wound to his neck. This other woman is all beat up around the head and unconscious. There's a baby that's been wounded..."

"Ok, ok, I'll be right there."

I pull on some scrubs as quickly as a cripple can and somehow cram my swollen foot into my crocs and hobble over. Crutches over moist, sandy soil is not easy.

I pull aside the curtain to the ER and see groups of people huddled around bloody clothes with arms and legs sticking out everywhere. Some are on beds, some on the ground. Sarah looks up.

"I think this one is the most critical. She's pregnant too. We can't get the baby's heart beat. She has a huge wound on her head."

In the midst of a bloody pile I see a slender, young Arab girl with a bulging middle sticking out of a brightly colored dress made even more bright by her life's fluid spilled all over it. Her face is irrecognizably swollen, contorted and bloodied. One eye is completely swollen shut and her long, tight braids are matted with the dark, drying human liquid.

Jason tells me one pupil doesn't react well. I don't bother to confirm.

Samedi and Abel have arrived. Simeon is there shortly. Ansley, Kristin, Emily and Jacob are also there.

I start shouting out orders.

"Get IV's started on everyone.

"I want one liter of Ringers running full speed.

"Give them all 2 grams of Ampicilline.

"Where's Stephan? Stephan, get a carton of those 1 L Ringers that just came yesterday.

"Is there a pharmacist? Where's Pierre?"

Andre has arrived and speaks up.

"I'll call him and get him right in," he says already punching in numbers on his cell phone.

"That guy there is probably the second sickest," Sarah shouts across the room as she attaches IV tubing to the arm of the first woman.

A young man is staring at me calmly. His once white pants are now tie dyed in his own color of red wine. A bundle of gauze has been taped under his right jaw on his neck.

I pull it off and see a 10cm laceration cut neatly from right under his chin to under his ear. It's about 5 cm deep and oozing a lot of blood until I push the compresses back in the gaping wound. It doesn't appear he got his jugular or carotid though. And he's breathing fine.

"Nathaneal, come and push on this as hard as you can...right there in the center of the wound. Don't let go."

IVs are running and nurses are frantically mixing up and administering Ampicillin.

"Jacob, you and Jason...et Abel aussi...go get the gurney from surgery...ABEL...LE BRANCARD...AU BLOC!" I yell at Abel since he's almost deaf, but one of our hardest workers and head nurse in surgery.

"Jacob, never mind, Jason and Abel can get the gurney, here take my keys and bring me the ultrasound from my office."

I briefly look at the other two women who are beat up and bruised but otherwise look ok. One is pregnant and I quickly do an ultrasound confirming the fetus is doing well.

Justine walks in with the baby who's mom had been killed, strapped to her back.

"She's not injured at all luckily, we just thought so at first because she was covered with blood."

"C'est bon!" I quip and head off to the OR.

In the OR, the lights aren't on so I hobble into the battery room/solar panel master control room and flip on the switch giving us solar power to light up the OR.

People scrambling around. IVs going up and flowing in. Needles, seringes, gauze, scalpels, instruments, suture, gloves, scissors, razors, shaved braids, and blood, blood everywhere.

After Abel finishes taking off a life's worth of braided African hair in a few minutes time, Samedi gets going suturing up the huge upside down V shaped gash in her scalp. She starts to moan, she had been unconscious we thought.

"Simeon, get her some Ketamine and Diazepam and put her under."

Meanwhile, there's a baby with anemia that no one has been able to find an IV on all day. They'd brought him to me at the house and I had tried putting a needle into the bone marrow of his tibia, but I didn't have the right needle and the others just kept bending. It was about this time that I was called for the mass casualty. Now, the baby i before me again.

"Jacob, give the baby a milliliter of Ketamine IM and strap him into the Papoose."

As Samedi starts suturing up the head wound, I slice into the baby's ankle and dissect down to the saphenous vein. I find it and slide in an IV catheter. We hook up the blood, see it's running in and I suture the wound closed around the IV.

They've now brought in the young man with the neck wound.

"Kristin, you and Ansley take this baby off to peds. Simeon, you and Jackson (Jason) move the man onto this gurney."

"If it wasn't for Allah, I'd be dead." The young man stares at me earnestly, speaking in Chadian Arabic.

"Alhamdullilah!" I reply and he nods and closes his eyes as he starts softly repeating Koranic verses.

I stay seated on my stool as Simeon puts him under anesthesia with the usual meds.

A couple sutures to bring the muscles together after washing it out well and a few loose skin stitches and I'm done.

"ABEL...PANSEMENT!" I point to the gauze bucket and to the man's neck. Abel and I have our own sign language between us. He nods and dives right in.

Meanwhile Emily has brought the ultrasound in to the OR and I do a quick ultrasound on the woman that Samedi has just finished stitching up her scalp. Her fetus is also doing well and at 32 weeks should survive even if the mom dies if we can do a C-section quick enough.

I grab my crutches and swing outside. Sarah is coming from the OR.

"They've just brought in another guy...a Nangjere man. The sous-prefet's truck is out looking for other victims. This one doesn't look too bad."

He's got some cuts on his hand and a stab wound to the shoulder blade that isn't deep. I leave it for Samedi and hobble home with the volunteers.

After a game of Settlers of Catan our second game is quickly interrupted with the arrival of more victims.

This time there're people scattered all over. Camouflaged gendarmes armed with AK47s and Kalishnikovs are unloading people from the truck. I just head straight to the OR and tell them to bring the worst one's in.

Samedi is just finishing up with the man I'd left him.

"James, I just heard the story of how it all started. It started with this guy..."

Apparently, the man was out in his field and saw some cows eating his rice. He challenged the herdsman, an Arab nomad. The nomad started to pull out his bow and arrow so the Nangjere man rushed him and grappled with him. The Arab pulled out his knife and the Nangjere grabbed the blade with his hand (hence the cuts). He quickly let go and the Arab stabbed him in the back. The man fainted and the Arab fled. The women watching assumed the Nangjere man was dead and ran to the market screaming bloody murder. When their relatives heard that their "brother" was dead, they attacked a group of Arab women just leaving the market. Hence our first wave of casualties. Now both sides were on the prowl and apparently a group of Nangjere had headed to the Arab village going from door to door dragging women and children out
and the Arab men were organizing their reprisals. There weren't enough gendarmes to control it so they were just picking up bodies and wounded.

Samedi finished and wheeled the man outside. At some point later on, he wisely dissappeared.

Now, they bring in a wiry Arab with the face of Kobe Bryant who has a huge slash across his right lower chest. It's about 25 cm long and all the way down to the ribs God gave him to protect his liver and lung. The other Arab is a wizened middle aged man with cuts all over. His main complaint is they've taken out his left eye but closer examination reveals a 10cm slash across his cheek and a left eye swollen shut. Small laceration cover his body and arms. An open dislocation of a finger I quickly "pop" back in. He also has a stab wound to his leg which has broken his tibia.

I put the tibia back in place, wash out the wound well, slosh some Betadine of a gauze and place it over the wound.

"Jacob, hold that tight. Jackson, keep pulling on his leg and hold it in this position. ABEL...PLATRE...PPPPLLLLLAAAATTTRRREEE!" He doesn't understand so I point him to the wound which he holds pressure to.

"Jacob, go get all the stuff for a cast. Just like we did last Saturday night: webroll, tubing, plaster, a basin of water, scissors"

"Simeon, Diazepam and Ketamine for this guy too." I point to the man with the chest wound.

"Ashadu Allah illaha ilalallah, wa ashadu ana Muhammador rasullallah." He starts to repeat over and over his Muslim creed until he drifts off. But he doesn't go quietly. He starts to have a reaction to the Ketamine and tenses all up not wanting to breath.

"Sarah, get me some Chlorpromazine." She can't find it.

"Someone get me some from the Pharmacy."

"There is none." replies Samedi. "I needed some last night and we're all out."

Just then Sarah comes out of the inside OR, "I found one ampoule."

The man finally calms down and I do a running subcutaneous suture to bring the muscles and fascia back together and then some loose interrupteds to bring the skin partly together, still allowing it to drain since it's contaminated.

"ABEL...PANSEMENT!" and I turn back to put the cast on the other Arab's leg while Samedi finishes suturing up all the lacerations.

Meanwhile, Kristin and Ansely and Augustin (who's just joined us) are working on another man just brought into the room on a stretcher.

"His intestine is sticking out his side and he's got a ton of cuts."

"Start an IV with Ringers. Simeon, Ampicilline 2g, Gentamycin 4 ampoules, Flagyl 2 bottles! Augustin, urinary catheter. Abel, nasogastric tube!"

I turn back to the fracture and Jacob has already wrapped it well. I wet the plaster and quickly wind it around the leg while Jason holds it in position.

"Hold it there until it's dry."

I turn to the guy on the floor. They've got all the antibiotics and tubes in and an IV is running well.

"Simeon, start the generator. Let's move him into the operating room."

A few minutes later I hop in on one foot having just scrubbed my hands and arms. I dry off and Abel puts on my gowns and gloves. The room is lit just by the two overhead OR lights focused on the betadined abdomen. Jacob slips me my stool and I position myself on the right side of the patient. We drape him and then Augustin prays.

I open him up from his sternum to his belly button and dark blood surges out. I suck it up and start exploring. There's no major gusher anywhere. In fact, I don't see any injury. The liver is fine. There is no stool in the abdomen. The stomach and intestines are undamaged. I pull out the omentum which is what had come out his side and cut off the contaminated part, tying off the vessels. As I can now examine the spleen as well I'm surprised to see no damage to that either. Where's the blood coming from?

Finally, I get Abel to give me a good look at the wound and I see air and blood spurting into the abdomen with each breath. Of course, it's coming from his lung through the punctured diaphragm.

That would also explain his poor oxygen saturation. Duh!

I suture up the diaphragmatic tear. Suck out as much blood as possible. Re-examine the spleen since I can't believe the knife left a 3cm laceration in the diaphragm right over the spleen without touching it, but the spleen is clean. I leave in a drain and close up.

Then I poke in a chest tube, hear the welcome rush of released air and a smattering of blood, hook him up to the water-seal/suction apparatus, suture up the large gash on his arm, the three small gashes on his back, and finally come to the left buttock.

Jacob and Abel hold him as we roll him on his right side. The wound is 15cm long and 10cm deep and bloody. I use a huge needle to bring the deep muscles together and then sew the fascia shut. I leave the skin loosely approximated and Abel and Simeon dress all the wounds.

It's a half hour after midnight when I get home. The truck drives up again an hour later but since no one comes to get me I fall back asleep. At six o-clock, my haggard, yet still beautiful wife shakes me awake.

"Well, they brought in a bunch more Arab women but they all only have minor injuries so I didn't wake you. They also brought in three more bodies. "Do you want to continue antibiotics or anything else on that guy you operated on?"

Oh yeah, post-op orders would be nice. Sarah smilingly holds out an OR order sheet that I quickly fill out.

She comes back at 8am showing me her lab slip.

"Yeah, not only was that the craziest night shift I've ever done, but I had malaria the whole time!"

An hour later, I limp over to the hospital on my crutches to see the patients. Everyone is doing well. All the women are awake, and while in pain and swollen all over are able to sit up and take some water. The neck and chest wound men are also awake and praising Allah. The man with the punctured lung is also stable but not too awake yet.

Just then, a huge group of robed and turbaned Arabs flows in accompanied by a bunch of soldiers with machine guns. They go through and out the back gate to the morgue. I continue to the ER to see the other patients who'd arrived after I'd gone back to bed.

I've just started and Djibrine, the nurse in charge of supervising our district's health centers comes in.

"The governor and the sous-prefet want to see all the wounded."

I find them in the wards packed in with Arabs and gendarmes. I send most of them out with the full support of the sous-prefet except for a couple of guards for the governor and the rest of his team. I show them around as they take town everyone's name and injuries and put them either on the Nangjere or Arab list.

I finally make it home at noon and my ankle has ballooned.

I think I might always be a cripple.