Morning

It's early morning and I can't sleep again. This time, though, it's because I'm excited. For the first time in several weeks I'll actually be doing something. My ankle wound that just won't heal has kept me from doing just the bare minimum. I go up to the hospital, quickly see the hospitalized patients, do all the scheduled surgeries and then retire home to elevate my swollen foot. My day revolves around how fast I can get home to make the swelling go down and do a dressing change and take antibiotics. I even got so scared for a few days that I had Sarah start an IV on me and give me IV antibiotics.

This morning, though, my ankle seems to have turned the corner and I'm up, happy to be doing something I want to do. I'm going flying with Gary to N'Djamena. I'd needed to go to N'Djamena for a while, but with my foot, the idea of a long, bumpy ride in the back of a Toyota mini-bus just wasn't that appealing. With Gary's return after a 6 month absence, getting to N'Djamena has turned into a two hour pleasant flight over the African plain.

It's still dark, but since I can't sleep anyway, I get up and fix "breakfast" which consists of frying up some day old rice and beans with little bit of curry. Not a typical American breakfast but sometimes you have to eat for strength and not for sport (as some of my friends used to tell me in the early days when I was first in Tchad).

With the roosters having started their crowing since about 3am, the dogs barking and the drums and dancing having just stopped, the morning is quiet and peaceful with just the lulling, rhythmic sound of crickets breaking the early dawn's silence. I step outside into the desert cold. I quickly go back in and put on a sweatshirt. I pull my small North Face backpack over the sweatshirt and slip on my Crocs.

The ankle is a little stiff, but it feels good to be out on the deep, sandy road towards Bere's laterite airstrip. It's a 2 km walk and I have the village mostly to myself.

An early morning fog rests over the tops of the thatched roof, brownish red clay huts combined with the pungent smoke of wood and dried grass fires. The only ones awake are a few women pounding millet in homemade wooden mortars with 6 feet long wooden pestles. The dooomp, dooomp of the pounding of grain into the base for the typical Chadian breakfast porridge echos across the stillness. A few children are also up trying to chase away the night's chill around hastly gathered grass and stick fires. Their dark faces hidden amidst the white smoke wafting from the incompletely dried weed fires break into toothy grins as they see the "Nasara" walking steadily and gingerly away from the hospital. It's not every day that something this new and exciting happens!

They are mostly dressed in ragged shorts, holey pants and torn t-shirts. It's no wonder they're cold as the dry season has descended upon us leaving us with the extremes of up to 40 degrees Fahrenheit difference between day and night temperatures. The luscious greenness of the rainy season has rapidly evaporated into the brown, dead grass powdery dusty dryness of the majority of the year here in the heart of Africa.

I approach some of them, who eye me warily with looks of mixed curiosity and fear. I extend my hand, palm up. Several of the bigger, braver ones approach to shake hands. I shake my head and show them how to "give me five."

"Tak kebeng (slap my hand)" I encourage them in Nangjere. When they finally get up the courage to try, everyone wants to get in on the action and they all start giggling and laughing. What a privilege to really smack hard the hand of a grown-up, much less a foreigner!

I finally get to the airstrip where the early morning sunrise colors the mostly white plane with a tinge of pink. Gary is testing the oil and fuel and filling up the wing tanks with his bright red cans of Cameroonian gasoline. A few kids have gathered around as usual, but not the usual crowd since it's still so early. After Gary eats a "late" breakfast, we slide into the tiny Cessna loaded up with empty fuel and propane containers and after a short taxi we are soaring up and over where the 10,000 inhabitants of a Chadian county seat disappear quickly into the groves of mango trees with just occasional glimpses of thatched or rarely, tin roofed, houses give us a clue that there's actually a village hidden in this vast plane. We bank over the hospital to get a good aerial view and it also suddenly seems so small and insignificant when seen from on high.



We're on our way to N'Djamena...

Thanksgiving

It all started with a little lying. I had too, otherwise I would've spoiled the surprise.

Monday, I went to Moundou to check up on the remodeling project for our new utpatient surgery center in Chad's second largest city. The route is simple: follow the bumpy, dirt road to Kelo and turn left onto the paved road until you hit Moundou. In Kelo, as we turned left, I saw the post office. I decided to stop. I found 14 packages waiting for our student missionaries. I paid for them all, loaded to car and continued to Moundou.

The project is going well, I talked over a few details with the builder and then he joined us for the ride back to Bere so he could look over our existing operating room to better understand what we were shooting for. It was when we were back on the road to Bere that I had the wonderful idea for my surprise. Little did I know how much deception I would have to employ in order for it to succeed.

The first thing was to swear our driver, Levi, to secrecy. We then had to quickly unload the packages into my house without the student missionaries seeing them. Since Thursday was Thanksgiving but American holidays tend to get neglected or rolled into one, I decided to turn it into an early Christmas surprise. I wasn't going to tell them I'd picked up their packages sent from home, not until Thanksgiving morning.

I didn't count on our volunteers' desperation to have those goodies.

The very next day, Stephan came to me to explain how he'd arranged everything with our Administrator, Andre, to have the day off so he could take a motorcycle taxi to Kelo to see if they had any packages. They were all expecting some that would have things to make Thanksgiving dinner with.

I put on my severest, coldest boss face.

"Stephan, did you come here to work, or to get packages. You should've told me yesterday. I passed right by the post-office and could've easily checked to see if there was anything for you guys. We're really busy right now, besides, how are you going to get a bunch of packages back on a motorcycle. It's just not a good idea. I'll probably be making another trip early next week, I can pick them up then."

Stephan's face falls, but he has no choice but to accept.

"Well, ok, but Kristin was going to go with me, maybe she can just go. She's not scheduled till this evening so she wouldn't miss work."

Thinking quickly, I'm amazed at how easily I continue the deception. "Stephan, do you really think it's a good idea for a girl to go by herself to Kelo? It's just not very smart. It'll be even harder for her to carry all those packages back. Plus, this is Chad, it could be dangerous." I'm lying through my teeth, but somehow keep a straight, concerned face.

Stephan turns sadly away to go back to his accounting office. I smile inwardly at my success. It is short lived as lies tend to pile on top of each other; once you start it's hard to stop.

I have to repeat a bunch more to Kristin later on as she is unwilling to accept Stephan's explanation and feels that if she talks to me personally, maybe this mean boss will change his mind. I hold firm and convince her it's just not a good idea. Besides, there's other things already planned and we won't really have a real Thanksgiving anyway, we might as well just wait and have our Thanksgiving next week sometime. She's crestfallen but also has to accept.

Tuesday night, I find myself chatting with Kristin and Ansley and, unfortunately, they've come up with a solution that I can't lie my way out of. I'm forced to spill the beans. They are excited but agree with me to keep it a secret from the others. Ansley joins to lying as she announces to the others on Wednesday that due to her 6 episodes of explosive diarrhea the night before she's just not up to a trip to Kelo and Emily shouldn't go by herself.

Early Thursday morning, I pull the 14 packages and numerous letters out of my closet and carry them over to the SM's common room in the middle house. I leave a note that says "ho, ho, ho, merry thanksgiving, merry thanksgiving." And it turns out to be just that...after a long day at work.

Work starts out with rounds on a completely full hospital with no beds to spare. Then, I have a tubal ligation, a D&C/tubal ligation combo, a rectal polyp to remove on an 8 year old Arab boy, a bilateral inguinal hernia repair with mosquito net, another emergency D&C for an incomplete spontaneous abortion and finally finish at 4:30pm just in time to go to Gilbert's going away party that Jason has organized.

I slip into the courtyard where many of the staff and Gilbert's friends are already seated on a variety of chairs and stools and mats. I slip off my Crocs and settle onto a mat. My ankle is aching a little and somewhat swollen after a long day upright in the OR, but it's not too bad. I exhange pleasantries with Job and Koumakoy and nod at Simeon and Abel who I've spent all day with in surgery. Gilbert slides onto the mat next to me and we have some decent small talk as Jason serves us the best "bouille" I've had in Chad. Zachee, our cook, is the best and Jason contracted him for the feast. The "bouille" is a rice porridge with milk, sugar, cinnamon and peanut paste. I grab the crude metal bowl from Jason and slurp it up without a spoon.

The second course is either roasted goat or chicken in a tomato sauce with boiled sweet potatoes, all served over mushy rice. It's quite tasty, but I'm trying to save room for Thanksgiving dinner later.

At 6pm, we all head to my house to prepare the feast. We have invited Gary and Wendy and their volunteers (Steve, Jeremy and Annie) as well our our 6 student missionaries, Maria (our Danish volunteer) and Sarah and I. Jacob's mom has sent 5 packages stuffed with everything needed. The menu is impressive: Fri-Chik, garlic mashed potatoes and gravy, cranberry sauce and relish, anti-pasta salad, stuffing, spiced apple cider, candied yams, and a pumpkin pie spice squash dessert with real whipped cream! Gary and Wendy add some real (not powder) mashed potatoes, more gravy, a cranberry-like hibiscus flower sauce, and some stuffing made from scratch. Jeremy and Annie bring a fresh garden salad of tomatoes, lettuce, cucumbers and sprouts; fresh squeezed lemonade; and boiled beets.

Jacob's mom has also sent Thanksgiving-themed plates, napkins and decorations and with the half-cut into pumpkin-like squash in the center of the table we're only missing NFL football to make it feel like a real American holiday.



Right before eating, Sarah comes over to tell me that she's already hospitalized 5 kids with malaria, 3 of them with severe anemia needing blood transfusions. Luckily, Samedi is on with her until 9pm so they're managing, but the hospital has been filled back up despite being cleared out by me in the morning. She refuses my offer to eat with us, saying she'd rather I just brought her something later.

We all sit around the table and go around with each person saying one thing they're thankful for for each of the 5 kernels of corn placed before them. We pray and then we chow down.

Just as I'm finishing my overloaded plate (the first one done of course) Hortance, the midwife, comes knocking to tell me about a woman, 8 months pregnant with vaginal bleeding referred from the health center 2 days ago but just now arriving. She is severly anemic with a hemoglobin of 4.8 g/dl and has a placenta previa where the placenta wants to come out before the baby. I think I find a fetal heart beat so we quickly resuscitate her with two large bore IV's and a lot of IV fluids, give her anti-biotics, and take her to the OR. Fortunately, her blood type is AB + making her a universal recipient (i.e. she can take blood from anyone) so we have both her brother and father give blood while we prep her for surgery.

We start the first bag of blood running as we pull out a dead baby with skin already peeling off meaning he's been gone for a few days. Fortunately, there's not much bleeding and we quickly close her up as the second bag runs in. Her heartbeat is almost normal now and her blood pressure has come up. We wheel her into the wards almost running over some Arab women who've spread their sleeping mats right across the entrance and then are forced to leave her on the gurney for the night since there are no available beds.

I come home at about 10pm and we play Settler of Catan and Citadels until almost 2 in the morning when I fall into a deep, contented sleep.

Happy Thanksgiving!

Mistake

Have you ever been glad you made a mistake? I was sure the elderly man had a gallbladder problem. I mean, I'm no ultrasound expert, but there was obviously something inside that gall bladder that shouldn't have been there. Besides, he was complaining of pain right over that spot that was worse when he ate. And his bilirubin was elevated, another sign that could point to gall bladder problem.

I was hesitant to operate, though, because he was a friend. In fact, he is the chief of our neighborhood here in Bere. Totho Timothée. His brother has AIDS and is a motorcycle taximan who takes us often back and forth to Kélo when our car isn't running or the rainy season makes the roads all but impassible for anything except a moto.

But, I finally decided it was the right thing to do. I was sure he needed an operation for his gallbladder. I was wrong.

I stand to his right side. Franklin has given him a "high spinal" anesthetic so I can make a somewhat relaxed incision right below his right ribs. We pray and I start cutting with Abel and Jacques assisting. I've decided to splurge today, since it's a gall bladder, and have set up the electrocautery. Soon the smell of barbecuing human flesh fills the room as I burn through the abdominal muscles before entering the peritoneal cavity.

We also are using the air conditioner since it's about 110 degrees fahrenheit outside. Jacques, however, having just recently arrived from Togo where it's relatively cooler, is having a hard time as the sweat runs in rivulets down his face. I usually don't notice until afterwards when I pull off my gown and find my scrubs are soaked with my own sweat.

I have Abel retract the liver gently and I get a good look at the gallbladder. It looks normal. I pinch it between my fingers. It feels normal. I'm starting to feel sheepish. Especially since on entering the abdomen I found a lot of ascites fluid and now I see that he has advanced liver cirrhosis. Of course the bilirubin was elevated! I'm starting to realize I was wrong to operate on him and it could've maybe even endangered his life. Better close and get out of here before I do more harm.

Then I notice something out of the corner of my eye that gives me pause.

"Jacques, pull the stomach back a little again. Yeah, just like that."

I see a small black spot on the first part of the small intestine coming right out of the stomach. Before my brain can even formulate it's idea of what it is, the spot confirms itself by opening up right before my eyes and etting out a stream of clear, gooey liquid.

A duodenal ulcer just perforated before my very eyes! Abel quickly aspirates up the stomach acid with the suction tip and I call for some suture.

I place some interrupted sutures along the edge of the ulcer and leave them untied till I have a whole row ready to close the wound. I then pull some of the omentum back from the stomach edge and lay it across the perforation. I tie the sutures across the omentum patching up the hole. I irrigate and suction and then close up the muscle, fascia and skin of the abdominal wall.

I've just witnessed a miracle to save our friend, Timothée's life. If I hadn't mistakenly misread the ultrasound I wouldn't have operated. If I hadn't mistakenly thought it was the gallbladder I wouldn't have made the perfect incision to allow me to see and close the ulcer. If I'd have waited half and hour more it would have perforated letting stomach acid all in the stomach to burn and irritate the intestines and cause all kinds of complications. If it had happened a day or two before I did the operation, he'd probably be dead...especially with having already liver cirrhosis.

Sometimes it's ok to make a mistake!

Too late

I squat on the ground outside the operating room. A thin Muslim man squats in front of me, his green Arabic robe pulled tightly across his knees as he hugs them with his arms. He is staring at the blue basin between us. The insides of the basin is covered with a blood-soaked, brightly-patterned yellow wrap around skirt. I lift up the cloth with a gloved hand covered with dried blood. Underneath is a dead infant with a huge head (hydrocephalos). His blank eyes stare up at us as his neck bends back at an impossible angle. Underneath is the placenta still attached to the child by the umbilical cord. All is cold, lifeless and bloody.

I do my best to explain to him in Arabic what happened.

"The child, dead, when arrived, dead already. The head, big, not come out. The house of the child broken, the child come out here (point to my stomach). Blood come out, a lot, here also. The woman there, she not have much blood when she arrive not have. Si there is not much blood, she found death."

"Both of them, the two of them, both dead?" The man asks in disbelief.

"Yes, both dead, all dead," I repeat a million images of the last two hours flashing through my head...

"Doctor, doctor!"

I slowly stumble out of a deep sleep and a pleasant dream. "Yeah, what is it?"

"It's me, Augustin, I have a case to present to you."

"Ok, I'm coming." I pull on a pair of scrub bottoms and feel my way through the dark to the door and out onto the porch. Augustin is standing outside the screen door with a headlamp and a "carnet" or portable medical record.

"There's a woman, referred, in labor for two days..." Augustin stumbles through presenting the woman. He is one of our laziest nurses and often does as little as possible. I'm a little irritated.

"Whoa, whoa! Start over, give me that!" I take the labor and delivery sheet. I glance quickly over it and it's incomplete. I see the vital signs, heart rate 60 bpm, blood pressure 100/70, temperature 37 degrees Celsius. I'll regret later not noticing how generically normal they were.

"What? What's going on?" A voice comes from the room next to us where Jacques, our newly arrived doc fresh from medical school in Mali, has been sleeping.

"I'm talking to Dr. James," replies Augustin. Jacques quickly appears outside just as I'm telling Augustin to go get more information and come back to see me with the chart completely filled out.

As Augustin and Jacques walk off together I almost yell after him to check a hemoglobin. I catch myself, thinking I'll be over to see her shortly anyway. The second thing I later regret not doing.

I go back to my room and decide to lie down, after all it's been a long week filled with tons of surgeries and the training seminar I've been doing for the village health care workers on HIV and tuberculosis. I'll just close my eyes for a few minutes until Augustin and Jacques get back. The third thing I later regret.

"Docteur? Docteur?" The soft voice of Jacques floats across my subconscious. I go to the door. I glance up at the clock. It reads 4:25 am. I didn't look at the clock when Augustin first came, but I did hear the fridge running which it's programmed to do 4 times a day for an hour at a time: at 6am, noon, 6pm and midnight. It's been 3-4 hours since I saw Augustin and Jacques walking off together. A strange sense of foreboding falls over me.

"I've examined the woman and I think she has a ruptureed uterus."

"Go call Abel and Dr. Franklin and I'll be right there."

I pull on a scrub top, grab my keys and I'm out the door. I stop by the other house real quick to make sure Franklin's awake and then make my way across the compound to the labor and delivery room just past the OR.

As I walk in the room and glance at the patient, my heart skips a beat. A tiny Arabic woman lies stretched out on the table with one knee bent in the air. Blood has pooled between her legs. An IV with Glucose and I quickly assume Oxytocin is dripping into her left arm. Her thin abdomen is grossly distorted with several large, not normal pregnancy looking lumps. But what arrests my attention is when I look at her face.

Her head is flopped to one side and her eyes are rolled back in her head. She is pale and her only breaths are occasional sighs. She is on death's door and I see it instantly. I quickly feel for her heartbeat which is present but slow. I flip down her eyelids with my finger and my blood freezes. Her conjonctiva is white. She has practically bled to death in our hospital.

"Augustin, quick call the lab, we need blood! Abre, run and get me some Ringers!" Franklin arrives and quickly starts looking for a better IV. Then she stops breathing and I start chest compressions. Franklin has found an IV in her neck and we get fluids running. Abel has arrived and we take turns with chest compressions.

"Franklin, what about the monitor from the OR?" He runs quickly and arrives. We get no blood pressure and a weak O2 sat.

Finally, after what seems like hours the lab guy arrives.

"Abre, what blood type are you?"

"O positive."

"Mathieu, just check to see if she's positive or negative and if she's positive Abre will give."

She is B positive and Jacques and Abre run off to donate a bag of blood each. Augustin is B positive and refuses to give.

Abel and I keep up the chest compressions while Franklin guards her airway.

We get the first bag which is only a third full of Abre's blood. We hang it up.

"Abel, you and Abre get the stretcher and lets take her to the OR."

We flop her bloodied body onto the stretcher and Abel and Augustin carry her quickly to the OR while I continue chest compressions and Franklin carries the blood and IVs.

We get her all set up on the OR table with blood splashed everywhere. Still no heartbeat so we continue our ressucitation hoping that if we can keep her oxygen circulating until we replace her blood loss maybe we can save her.

We try some Atropine to start her heart. We try shocking her. Nothing. We have no Adrenaline. Then I remember we have some spinal kits. I open up two kits so we can use the adrenaline inside. Nothing works so we continue CPR.

Finally, a third bag of blood is running and I decide to take out the baby. We slosh Betadine on the belly, I quickly open up a C-section kit and put on a gown and sterile gloves. One slash and I'm in the belly. I cut the baby's face but he's dead already. His head is 5 times normal size with hydrocephalus. That's why he couldn't come out. Her uterus is in tatters. I pull out the baby and placenta. Place some clamps across what's left of the uterus and cut it out. I tie off the clamps, dump some Celox in the pelvis and hold pressure for 5 minutes. The whole thing takes about 15 minutes. All the donated blood is in, we've been working on her for almost 2 hours and she still is flatlined. I tell the guys to stop CPR, I sew up the belly and I go out to tell the husband.

As I'm kneeling in front of the Muslim husband, having just told him his wife and the unborn child between us are dead, I'm not sure how he'll react. A brief image flashes through my mind of the violence of two weeks ago with Arabs stabbing and killing Africans and vice versa and the chaos in the hospital trying to save as many as possible. But there is no revenge taken on me today. Instead, a gentle chanting in classic Arabic rises from the depths of his sorrowed heart.

"Illallah le Allah wa rassulloh Mahamat." The Muslim creed repeated over and over seems to soothe the sorrow. "Al hamdullilah" (Allah be praised) breaks in occasionally. A fellow Muslim from Lai comes and kneels down beside him reciting some Koranic verses in a low voice.

"Find me some brothers of Islam here. All the believers here in the hospital." The other Muslim goes off and soon a small group of robed and turbaned men surround us.

I ask him if he'd like to see his wife. He nods and we go into the OR where Abel and Jacques have been cleaning and covering the body. A portly Arab with a beige robe and white turban accompanies us. The woman is lying on the stretcher covered with a black, Muslim woman's cloth with intricate Arabic designs in gold woven into the fabric. The husband uncovers the wife's face and asks for water.

I get some water from the faucet and bring it to him in a small basin.

"Put a little over my hands," he asks me in Arabic.

I pour water over his right hand and he uses it to gently wash and wipe down his dead wife's face closing the eyes. The other Arab also moves his hand down the face to close the eyes and then they cover her back up. As we take her out to the morgue I hear some low sobs coming back from the OR.

15 minutes later, the brothers from the Mosque have arrived and I carefully explain in broken Arabic again what has happened.

"Xalas, inshallah, mashallah, al hamdullilah" come out in intervals from all resent. The accept and comfort and then take the body off to be appropriately buried as soon as possible in the Muslim fashion.

I go home.