The woman is in the OR for emergency surgery. Sarah comes to inform me that the family has only paid 15,000 francs ($30) of the 25,000 francs ($50) required. I tell Samedi and Abel to hold on. I'll see about that. I slip off my OR shoes and into my crocs, slide my mask down my face, push open the screen door and put my game face on.
As I approach the beacon of light coming out of the pharmacy window in an otherwise dark ad building I see a tall, lanky Tchadian in a dark tan matching pants and short-sleeved button down shirt. He slowly turns at the noise of my entrance and looks me up and down. His face is familiar. He's one of the former teachers at our elementary school. His name is Amos (pronounced Ah-moh). I can tell he's sizing me up. Let the games begin.
With a look of disdain on my face I march up to Amos. "What's the meaning of this? I hear you haven't paid for the surgery yet!"
Amos looks at me with a shocked and hurt look on his face. "What do you mean? I've just paid 10,000 francs."
I look at the pharmacist, Koumabas, who nods with his goofy half grin. He's enjoying the match.
I turn back to Amos in feigned disgust. "Do you realize that you should pay 25,000 francs. Do you think 10,000 is equal to 25,000? Aren't you a teacher? That's basic math!"
Amos responds coolly without blinking. "Oh it's ok. I'll just pay the rest tomorrow. Go ahead and do the surgery. You can trust me."
I laugh caustically. "Everyone says that but we've found that if they don't pay before the surgery they never pay after. Find a solution!" I pretend to turn away.
"But we're different. Maybe other people don't pay, but we will. You know us."
"Yes, I do. That's why you need to pay ahead of time. Look, we want to save your sister's life. We're ready to operate. We're only waiting on you!" I've played my trump card. Out of the corner of my eye I see Koumabas nod approvingly. He's enjoying this immensely.
"Ok ok." Amos pretends to concede defeat. "I have my bicycle outside. Can I just leave that as collateral to prove I'll pay later?"
"Let's see it." Amos quickly drags in a rusty, bent and twisted carcass of a bike with missing pedals and a torn up seat.
"Here it is." Amos smiles smugly, sure he's won.
Koumabas just shakes his head and chuckles. "Ca la! No way. That's worth 10,000 francs at best! That's not enough!" I've found a tag team partner in this traditional Tchadian sport.
I narrow my eyes, fixing them on Amos. "Don't you have a cell phone? You could leave that as collateral as well and then we can get going on saving your sister's life. We're only waiting on you, you know!"
Amos looks shocked. "I don't have a cell phone. I'm just a poor teacher." He looks like a puppy with his tail between his legs begging for bread at the table.
I turn away again. "Oh well, I guess we'll just have to wait. We're all ready and everything. Just waiting on you." I fold my arms across my chest and lean casually against the wall.
"Ok, ok." Amos starts to lose his composure. "David, come quickly!" Our night watchman comes in and extends his hand towards Amos holding a tiny cell phone in his outstretched palm.
"David, is that yours?" I ask. I don't want Amos to cop out by forcing our staff to cover for him. I won't lose that easily.
"No, no. It's mine." Amos doesn't even blink at the outright lie he just told me. But then again, I haven't exactly been telling the whole truth either.
"Thanks, Amos, you did the right thing." As I turn to leave I stop and look back. "By the way, I've already done my part. We've finished the operation and took out the twisted ovary with its tumor. She's doing fine and just waiting for you to come out of surgery. Too bad I had to play this game to get you to do your part."
Ah yeah, victory is always sweet in this Tchadian game of bluffing and bargaining. Poker's got nothing on it.
Monday, November 16, 2009
Thursday, November 5, 2009
Poop
Silently the man slips stealthily through the shadows of a dark Chadian night. The Bere Adventist Hospital has become his temporary domain. His child is hospitalized for severe malaria and a blood transfusion is slowly dripping life back into his fever wracked body. The man has sinister motives. He really needs to go.
The hospital has had trouble for years with patients relieving themselves in piles on the ground in the tradition of the African bush. Despite the availability of latrines, the smell and foreignness of the cement structures is revolting to someone used to the pleasant peacefulness of natural surroundings and soft grass or sand. In the 90's a resourceful night watchman named Jairus made successful war on the perpetrators by taking the pile in a rubber gloved hand and moving from bed to bed wiping some of the stool on each bed until someone confessed or turned in the guilty party who then had to go out and bury the leftover turds.
The problem only got worse with the building of a fence around the hospital in 2004.
Now, this evening, maybe the tide will turn as our unknown man makes his way quietly past the operating theater to the outside water faucet. Taking a comfortable position squatting flexing and stretching his thigh muscles the man pulls down his pants and stretches out his hands to get a firm grip on the metal water pipe coming out of the cement slab he has chosen as his receptacle. Suffering from a common Chadian ailment, his knuckles turn white as he strains to force out the poop hardened in his dehydrated and constipated colon. A sigh of relief accompanies the success of his mission until a bright light suddenly blinds him and a harsh cry of "Ca c'est quoi?!!" brings to an end his devious deed.
Literally caught with his pants down the man hurriedly tries to cover his naked manhood as Jean-Jacques, our vigilant gatekeeper hauls him roughly to his feet. It's a little after midnight but our new administrator, Augustin, comes immediately from home.
Punishment is swift. The gendarmes are called. The man is forced to pick up his ca-ca and stuff it in his pocket before being escorted off to prison. He was last seen weeding the flower garden in front of the jail.
The hospital has had trouble for years with patients relieving themselves in piles on the ground in the tradition of the African bush. Despite the availability of latrines, the smell and foreignness of the cement structures is revolting to someone used to the pleasant peacefulness of natural surroundings and soft grass or sand. In the 90's a resourceful night watchman named Jairus made successful war on the perpetrators by taking the pile in a rubber gloved hand and moving from bed to bed wiping some of the stool on each bed until someone confessed or turned in the guilty party who then had to go out and bury the leftover turds.
The problem only got worse with the building of a fence around the hospital in 2004.
Now, this evening, maybe the tide will turn as our unknown man makes his way quietly past the operating theater to the outside water faucet. Taking a comfortable position squatting flexing and stretching his thigh muscles the man pulls down his pants and stretches out his hands to get a firm grip on the metal water pipe coming out of the cement slab he has chosen as his receptacle. Suffering from a common Chadian ailment, his knuckles turn white as he strains to force out the poop hardened in his dehydrated and constipated colon. A sigh of relief accompanies the success of his mission until a bright light suddenly blinds him and a harsh cry of "Ca c'est quoi?!!" brings to an end his devious deed.
Literally caught with his pants down the man hurriedly tries to cover his naked manhood as Jean-Jacques, our vigilant gatekeeper hauls him roughly to his feet. It's a little after midnight but our new administrator, Augustin, comes immediately from home.
Punishment is swift. The gendarmes are called. The man is forced to pick up his ca-ca and stuff it in his pocket before being escorted off to prison. He was last seen weeding the flower garden in front of the jail.
Monday, November 2, 2009
euthanasia
"The pain started suddenly at 4 o'clock this morning." The man stretched out before me on the gurney is in obvious distress. His abdomen is swollen and he's gasping for air. I look at his carnet. His name is Gaouna.
"How was he yesterday? Was he sick at all?" I ask through his brother who interprets from French to Ngambai and back again.
"Yeah, yesterday he was fine, but this morning, the pain started right here," he points to the epigastric region of the patient.
I examine the belly. It's firm but not tense. When I tap with my fingers it sounds hollow, full of air. Gaouna winces in pain with each touch: peritoneal signs. His breathing is shallow and his heart is rapid and his pulse weak. It sounds like a perforated ulcer. The ER had started an IV so I tell Abel to give Gaouna triple antibiotics, call in Samedi from home and go see the last of the ER patients while the OR staff preps for an immediate laparotomy.
The family doesn't have money to pay but they are well to do and leave their motorcycle at the hospital as collateral for future payment.
I finish in the ER and come back to the operating theater. I enter the room. Gaouna is lying on the OR table. Two IVs of Ringer's Lactate are raised high on IV poles running in fast into both arms. A foley catheter has about 300 cc of dark urine. His arms are stretched out on the arm boards and tied down as if he's about to be crucified. Gaouna's eyes are closed and his breathing is even shallower and more rapid. The beep of the pulse oximeter tells me instantly he's not getting enough oxygen. I glance at the numbers. He's at 60% saturation, way below the accepted norm. I'm afraid Gaouna is not going to make it. Maybe we're too late.
We have no oxygen, so I decide to intubate him. I grab a cardboard box off a top shelf. Inside is a mix of all our endotracheal tubes. I select one I think will work. I test the cuff with a 10cc syringe of air while Abel pulls out the laryngoscopes. In my hurry I forget to prepare suction or put in a stylet. I check the laryngoscope and the light works. Abel injects 2mL of ketamine and I insert the blade in the patients mouth. The light isn't working. I pull it out tap it a little, take the blade off and put it back on the laryngoscope handle. It works again. I put the instrument back in his mouth and lift up the tongue. I briefly see the vocal cords before a mass of saliva obscures my view. I call for suction and try to put in the breathing tube anyway. It bends down away from the vocal cords. I reach behind me and quickly leaf through a drawer in the anesthesia cart to find a stylet for the tube. I put it in and bend it into a distal hook to help me put the tube into the trachea. I try again and this time am successful. I put on a bag to the tube after blowing up the cuff and start to breathe for our dying patient. His saturation comes up to 85%. I give the bagging over to Samuel and go scrub. Samedi and Abel have already prepped and draped the abdomen. I'm sure that with release of the abdominal tension, Gaouna's breathing will improve.
I take the large scalpel and am quickly in the abdomen as a surge of dark red, slimy fluid surges out. We quickly suction out over 3 liters of fluid. The intestines look injected and angry but don't seem to be gangrenous. I start to explore and soon discover the real problem. As I cut up the abdominal wall to expose more of the contents a purplish, lumpy, alien-looking mass pops out of the right upper quadrant. Gaouna has end-stage liver cancer. Inside I'm furious. As I quickly try to close up the useless operation, many thoughts whirl through my head. How could the family deceive us? Of course, Gaouna's been sick for months if not years. Without CAT scans and other diagnostic equipment we base so much of our diagnosis on history and physical exam. This surgery could've been avoided. Now in all likelihood he'll die before making it out of surgery. How could God have let me make such a big mistake costing so much money for Gaouna's family and so much time and personnel resources for the hospital?
I've never closed up a surgery quicker. I take over from Samuel and take the bag off the breathing tube. Gaouna's sats go down to 57% but stabilize as he starts breathing on his own. I just want to get him out of here alive. I take out the ET tube and we transfer Gaouna to the gurney and wheel him out to the wards. I explain to the one family member who's there but it's not the same one who gave me false information.
An hour later, Pierre comes to inform me that Gaouna has "rendu l'ame" (given up his spirit). I'm not surprised. By this time, I've had more time to reflect. What if we wouldn't have operated? Gaouna may have lived several more days or even weeks. But he would've suffered. We have no real good pain medication. In hospital, we can give some pentazocine which is OK but not great. As far as pills, we only have Ibuprofen and Paracetamol (a medication like Tylenol). Instead of a slow, painful death, but operating on him we let him slip away in a Ketamine coma without any suffering. Sure, the operation didn't save his life, it just saved him from a torturous death. So maybe it was the right decision after all.
James
"How was he yesterday? Was he sick at all?" I ask through his brother who interprets from French to Ngambai and back again.
"Yeah, yesterday he was fine, but this morning, the pain started right here," he points to the epigastric region of the patient.
I examine the belly. It's firm but not tense. When I tap with my fingers it sounds hollow, full of air. Gaouna winces in pain with each touch: peritoneal signs. His breathing is shallow and his heart is rapid and his pulse weak. It sounds like a perforated ulcer. The ER had started an IV so I tell Abel to give Gaouna triple antibiotics, call in Samedi from home and go see the last of the ER patients while the OR staff preps for an immediate laparotomy.
The family doesn't have money to pay but they are well to do and leave their motorcycle at the hospital as collateral for future payment.
I finish in the ER and come back to the operating theater. I enter the room. Gaouna is lying on the OR table. Two IVs of Ringer's Lactate are raised high on IV poles running in fast into both arms. A foley catheter has about 300 cc of dark urine. His arms are stretched out on the arm boards and tied down as if he's about to be crucified. Gaouna's eyes are closed and his breathing is even shallower and more rapid. The beep of the pulse oximeter tells me instantly he's not getting enough oxygen. I glance at the numbers. He's at 60% saturation, way below the accepted norm. I'm afraid Gaouna is not going to make it. Maybe we're too late.
We have no oxygen, so I decide to intubate him. I grab a cardboard box off a top shelf. Inside is a mix of all our endotracheal tubes. I select one I think will work. I test the cuff with a 10cc syringe of air while Abel pulls out the laryngoscopes. In my hurry I forget to prepare suction or put in a stylet. I check the laryngoscope and the light works. Abel injects 2mL of ketamine and I insert the blade in the patients mouth. The light isn't working. I pull it out tap it a little, take the blade off and put it back on the laryngoscope handle. It works again. I put the instrument back in his mouth and lift up the tongue. I briefly see the vocal cords before a mass of saliva obscures my view. I call for suction and try to put in the breathing tube anyway. It bends down away from the vocal cords. I reach behind me and quickly leaf through a drawer in the anesthesia cart to find a stylet for the tube. I put it in and bend it into a distal hook to help me put the tube into the trachea. I try again and this time am successful. I put on a bag to the tube after blowing up the cuff and start to breathe for our dying patient. His saturation comes up to 85%. I give the bagging over to Samuel and go scrub. Samedi and Abel have already prepped and draped the abdomen. I'm sure that with release of the abdominal tension, Gaouna's breathing will improve.
I take the large scalpel and am quickly in the abdomen as a surge of dark red, slimy fluid surges out. We quickly suction out over 3 liters of fluid. The intestines look injected and angry but don't seem to be gangrenous. I start to explore and soon discover the real problem. As I cut up the abdominal wall to expose more of the contents a purplish, lumpy, alien-looking mass pops out of the right upper quadrant. Gaouna has end-stage liver cancer. Inside I'm furious. As I quickly try to close up the useless operation, many thoughts whirl through my head. How could the family deceive us? Of course, Gaouna's been sick for months if not years. Without CAT scans and other diagnostic equipment we base so much of our diagnosis on history and physical exam. This surgery could've been avoided. Now in all likelihood he'll die before making it out of surgery. How could God have let me make such a big mistake costing so much money for Gaouna's family and so much time and personnel resources for the hospital?
I've never closed up a surgery quicker. I take over from Samuel and take the bag off the breathing tube. Gaouna's sats go down to 57% but stabilize as he starts breathing on his own. I just want to get him out of here alive. I take out the ET tube and we transfer Gaouna to the gurney and wheel him out to the wards. I explain to the one family member who's there but it's not the same one who gave me false information.
An hour later, Pierre comes to inform me that Gaouna has "rendu l'ame" (given up his spirit). I'm not surprised. By this time, I've had more time to reflect. What if we wouldn't have operated? Gaouna may have lived several more days or even weeks. But he would've suffered. We have no real good pain medication. In hospital, we can give some pentazocine which is OK but not great. As far as pills, we only have Ibuprofen and Paracetamol (a medication like Tylenol). Instead of a slow, painful death, but operating on him we let him slip away in a Ketamine coma without any suffering. Sure, the operation didn't save his life, it just saved him from a torturous death. So maybe it was the right decision after all.
James
Monday, October 5, 2009
Dancing
Suddenly, Samedi jumps to his feet. He has just finished translating my story of the Samaritan woman who meets Jesus by the well. We are in front of a packed house. Daniel, a school teacher, has just gotten up to sing in his tribal language, Kera. The rhythm is catchy and many heads are bobbing. The drums are pounding and Samedi can't hold back any longer. His overweight, yet strong, body has lost it's flexibility as he stomps to the small group surrounding Daniel and raises his fist pumping into the air. He circles around with the inner foot pounding out the beat as his body weaves back and forth. Bruno jumps up. The smallest of Pierre's boys, he has stayed to same size since he was 13 and despite being almost 18, he still has that pre-teen look. His energetic body bounces up alongside Samedi his knees bobbing up and down and both arms raised. Doulgue slides in smoothly stepping fluidly in and out of the dancing circle. The beat intensifies. Lam is whipping the drum as if it was a delinquent child while Allah lifts up his chin staring to the sky as his little hands flap in a furious blur all over the surface of the goat skin drum head. Koumakoy sets his drum down and hauls his lanky, athletic body across the aisle to join the fray, his shoulders bobbing up and down as his bent arms are held in closed fists against his chest.
It started with me telling stories of a woman caught in adultery and brought before Jesus and that same woman washing Jesus' feet with her tears at a dinner party. The young people around me seemed shocked at a God that would love that much. I finally went around and reluctantly got all of them to admit that God loved them just as much. Then the festivities began. Pierre's second oldest daughter and three friends got things off to a slow start as the younger girls were embarrassed to dance and the older girl was embarrassed to be dancing by herself. Amos then kicked things off in Nangjere with a furious rendition of "Kukusebur ne Jesu Christi" as Tabitha rounded it up with a raised, twirling fist and a high pitched "Ayyyee yi yi yi yiiiiiiiiiii." A flat song in English with the guitar and several Chadians singing in bad Nigerina English was soon forgotten as the same group kicked up their heels and clapped their hands to a up beat French song accompanied by a tight, but simple guitar stacatto.
Doulgue jumps up and looks directly at me. "It's not only Nangjere that can sing Nangere songs. James, come here." Grinning from ear to ear and throughly loving the first truly spontaneous church service I've ever been a part of I stand up and walk over to him, my brightly colored matching pants and shirt swishing as I walk. It's a song about Peter walking on water and we belt it out at the top of our lungs as Amos and a couple others join us. I'm not much of a dancer but I find my head, shoulders, and legs unable to resist the pull of the rhythm. We finish strong to many hearty amens. Degaulle's daughter stands up in the back, her baby hanging from her breast and lets out a high pitched wail. Antoinette echos from the back row of the choir, keeping herself hidden shyly behind the kids in front, but she can't hide her smile as Tabitha finishes off the response with a piercing cry that can only be appreciated by those who have lived in an African village.
We go into the early afternoon, much later than usual as group after group gets up to sing. We have sung in English, French, Nangjere, Ngambai, and Kera. No one has understood everything, but everyone has been moved.
That afternoon finds me on the new bridge staring down into the muddy, swirling water below. A crowd has gathered and I can't back down. I step up on the railing and launch myself out. My outstretched arms smack the water hard 30 feet below as the current quickly sweeps me under the bridge. I swim over to the support posts and find an eddy in the center. I rest briefly before striking out for the shore and clambering up the stony bank. Back on the bridge, someone shouts out "Lapia." I turn and see Marty smiling in the midst of the crowd along the rail.
Marty has survived a hippo attack and tuberculosis and looks in perfect health.
I rush over and grab his hand with both of mine shaking it vigorously as I greet him in Nangjere.
I call Jamie and Tammy over.
"Hey, this is the guy in the documentary that was bitten by the hippo!"
Carson and Michelle come over. Tim and Melody join us as well. All the foreigners want to shake his hand. I tell the crowd that Marty is famous in the United States, that's why all the white folk want to greet him. Everyone laughs as a local man translates my French into Nangjere. As everyone gets there picture taken with Marty I think how ironic this is. Usually it's the foreigners who are the center of attention that everyone wants to stare at or greet. Now, it's a poor fisherman who just happens to have been bitten my a hippo right before a film student came to make a documentary of our hospital. The film won some awards and was shown all over in the Adventist Church in the US and Denmark. Because of that film, many people gave money to support the hospital allowing it to become one of the best in the country.
I walk back over to Marty and the man who translated before.
"Tell Marty that while getting bit by a hippo was a tragedy, that God used that experience to help the hospital to become what it is today thanks to the film that he was in. Despite all he suffered, God turned it around to help many more people who are suffering."
As the man translates, Marty looks at me with a warm smile out of his small, bearded face. He nods and shakes my hand before walking off down the bridge.
James
It started with me telling stories of a woman caught in adultery and brought before Jesus and that same woman washing Jesus' feet with her tears at a dinner party. The young people around me seemed shocked at a God that would love that much. I finally went around and reluctantly got all of them to admit that God loved them just as much. Then the festivities began. Pierre's second oldest daughter and three friends got things off to a slow start as the younger girls were embarrassed to dance and the older girl was embarrassed to be dancing by herself. Amos then kicked things off in Nangjere with a furious rendition of "Kukusebur ne Jesu Christi" as Tabitha rounded it up with a raised, twirling fist and a high pitched "Ayyyee yi yi yi yiiiiiiiiiii." A flat song in English with the guitar and several Chadians singing in bad Nigerina English was soon forgotten as the same group kicked up their heels and clapped their hands to a up beat French song accompanied by a tight, but simple guitar stacatto.
Doulgue jumps up and looks directly at me. "It's not only Nangjere that can sing Nangere songs. James, come here." Grinning from ear to ear and throughly loving the first truly spontaneous church service I've ever been a part of I stand up and walk over to him, my brightly colored matching pants and shirt swishing as I walk. It's a song about Peter walking on water and we belt it out at the top of our lungs as Amos and a couple others join us. I'm not much of a dancer but I find my head, shoulders, and legs unable to resist the pull of the rhythm. We finish strong to many hearty amens. Degaulle's daughter stands up in the back, her baby hanging from her breast and lets out a high pitched wail. Antoinette echos from the back row of the choir, keeping herself hidden shyly behind the kids in front, but she can't hide her smile as Tabitha finishes off the response with a piercing cry that can only be appreciated by those who have lived in an African village.
We go into the early afternoon, much later than usual as group after group gets up to sing. We have sung in English, French, Nangjere, Ngambai, and Kera. No one has understood everything, but everyone has been moved.
That afternoon finds me on the new bridge staring down into the muddy, swirling water below. A crowd has gathered and I can't back down. I step up on the railing and launch myself out. My outstretched arms smack the water hard 30 feet below as the current quickly sweeps me under the bridge. I swim over to the support posts and find an eddy in the center. I rest briefly before striking out for the shore and clambering up the stony bank. Back on the bridge, someone shouts out "Lapia." I turn and see Marty smiling in the midst of the crowd along the rail.
Marty has survived a hippo attack and tuberculosis and looks in perfect health.
I rush over and grab his hand with both of mine shaking it vigorously as I greet him in Nangjere.
I call Jamie and Tammy over.
"Hey, this is the guy in the documentary that was bitten by the hippo!"
Carson and Michelle come over. Tim and Melody join us as well. All the foreigners want to shake his hand. I tell the crowd that Marty is famous in the United States, that's why all the white folk want to greet him. Everyone laughs as a local man translates my French into Nangjere. As everyone gets there picture taken with Marty I think how ironic this is. Usually it's the foreigners who are the center of attention that everyone wants to stare at or greet. Now, it's a poor fisherman who just happens to have been bitten my a hippo right before a film student came to make a documentary of our hospital. The film won some awards and was shown all over in the Adventist Church in the US and Denmark. Because of that film, many people gave money to support the hospital allowing it to become one of the best in the country.
I walk back over to Marty and the man who translated before.
"Tell Marty that while getting bit by a hippo was a tragedy, that God used that experience to help the hospital to become what it is today thanks to the film that he was in. Despite all he suffered, God turned it around to help many more people who are suffering."
As the man translates, Marty looks at me with a warm smile out of his small, bearded face. He nods and shakes my hand before walking off down the bridge.
James
Sunday, October 4, 2009
Moundou
I think my hand is stuck. I've been sticking it up the pipe trying to clear out 30 years of junk in the drain but I couldn't get it up far enough. Now, I'd managed to twist and angle my arm just right but now I can't get it out. I almost panic, but I twist turn and finally, scraping the skin off my knuckles on the rough cement, my dirty hand pops out.
Jamie and I are in Moundou putting the plumbing in the new surgery center. Everything has had to be redone.
We go to the local Quincaillerie or hardware store. Everything that you thought you could never find in Chad is stacked from floor to ceiling in a dusty, brick warehouse. We spend hours hunting down all we need. A large Arab in a simple white Jallibiya and a well trimmed gray beard walks in. He is the owner, Mahamat.
"As-salaam alekum. Wa alekum as-salaam. Inta afe? Afe, taybin? Al hamdullilah. Mashallah." And the greetings are over. He walks behind the counter. We continue shopping. After early afternoon prayers, Mahamat returns.
"You...eat..." he starts in broken French and then switches over to Arabic. "We want to you to eat with us. What do you think?" He almost seems sure we'll refuse. He is pleasantly surprised by my profuse response.
"Shukran, shukran, it would be an honor, thank you."
He calls outside to the others and ushers us into a tiny side room under the overhead office built high in the corner of the warehouse. We are seated and a huge platter is slung on the table before us. Piles of fluffy rice fill one huge bowl. A cast iron pot from Nigeria holds the steaming goat meat sauce while a shallow bowl to the side is bursting with a fresh tomato and onion salad. Surprisingly, we are given spoons to eat with as generous portions are heaped into our bowls. Jamie, the vegetarian, digs right in ripping the goat meat off the bones. Our host comes in last and there are no more chairs. We try to rise and give him ours, but he insists. A special bowl of cumin flavored yogurt sauce is placed in front of him along with a plastic bag filled with fluffy flat bread the size of large crepes.
Mahamat wishes us "bon appetit" and grabs a pancake. He bunches the whole thing into his hand leaving the ragged edges pointing out with which he mops up some yogurt sauce and shoves the whole mess into his hand. When we are all finally able to resist his efforts to get us to eat more he reaches outside the door and pulls a plastic bottle of wild honey off the shelf. He dumps some more rice in a bowl and covers it with honey. He tells me to dip in and try. When I say I like it and go for more he shakes his head and pulls the bowl over to him. Then he motions to one of his workers to pour me some of my own. I can't figure out if he just really wants to eat it all himself or doesn't want to have too much direct contact with an infidel.
Mahamat rises and thanks us again. "The French are always too busy. The Chinese sometimes take a snack or something, but this is the first time I've eaten a meal with a client here in my shop. Vraiment, merci beaucoup. Merci, merci, merci." He continues to thank us. He is quite pleased and so are we to be so honored.
We return to the job site.
I'm in the new operating room. I grab the jackhammer with the drill attachment. I lean into it and as it engages a puff of cement dust bursts out of the floor until it turns red when it hits the compacted earth beneath the slab. I slip out the drill bit, put in the small chisel bit and feel the vibrations up my arm and shoulder as the chirping and cracking of cement fills the room.
That night I find myself sitting on a hard stool under the stars in front of Antoine's house. The moon is 3/4 and provides enough light to eat the tiny, twisted potato like tubers covered with cabbage and peanut sauce. Antoine seems discouraged. The junior high that he runs has a drop in enrollment. I try to encourage him. We have brought some building materials that are still piled in the shipping container. Once we finish with the clinic, we can maybe help him with a couple of new buildings. Also, I hope to get a volunteer to help teach English to give his school an edge over the competition. I tell him that God has a plan and won't abandon something He has started.
The ladder is a little unsteady as I get to the top rung. There was no attic hole left in the new ceiling but one angle at the corner of the roof has been left open. I think I can squeeze through. I reach my hands up and grab the truss. I pull up as my feet kick out in mid air. I get to my waist and my tiny butt almost gets stuck but I slither through. I hop from truss to truss dragging the loops of plumbing pipe that I punch through the holes down to the sterilization room and consulting rooms below. The sweat makes the cobwebs stick easier as I try not to fall through the fragile ceiling below.
We pull up the van outside a brightly painted wooden shelter. Their are cartoon images of fish, chicken and millet painted garishly on the corners. Inside a crowd is loosely seated around a selection of differently sized rickety tables and wobbly benches. There is a tiny one open right in the middle. Someone, maybe a waiter, quickly wipes off the plastic mat covering the wood with his bare hand leaving a mixture of spilled beer and salad juice on the surface. Jamie and I sit down and nod hello to those sitting at other tables just a few inches from ours. Most seem to have liter bottles of Gala beer in various stages of consumption. The two men dressed in suits next to us are dipping their hands into a common bowl of lettuce and tomatoes covering some kind of meat.
"What's good to eat here?" I ask one of the men.
"Mutton ribs and salad's what we're having, c'est tres bon!"
"Merci."
We order two servings from the overweight Tchadian woman in charge of the kitchen carved out of one corner of the room. The sounds of popping oil and the smells of wood fire smoke waft out from the clatter of cast iron pots and cooking utensils.
A man approaches selling watches and cheap sunglasses. In the far corner, a man is stretching a piece of cloth between his hands to show a woman how strong it is. Several other woman are looking on eagerly as they sip their beers. A large man who looks more Nigerian than Tchadian comes up behind me and holds out a package of medication over my shoulder and in front of my face. There is a picture of a smiling black man on a yellow and red backdrop with "Super King" emblazoned boldly across the front. In small letters underneath I see the generic name for what is known in other circles as Viagra. I turn to look at the man who raises his eyebrows and winks.
"Super King?"
"Non, merci, I'm deja un Super King," I joke with him as I shake my head.
Disappointed he moves on to greener pastures.
Our meal has arrived. The cook holds out the traditional plastic basin with a plastic pitcher and brown soap for hand washing. I rip off pieces of tender, savory flesh off the sheep ribs, topping it off with lettuce, tomato and onion drenched in a vinaigrette. A small pile of grilled yellow chilies adds some spice to the mix. I was it all down with some Top pineapple soda and then help Jamie finish off the last of his meat.
Jamie and I are in Moundou putting the plumbing in the new surgery center. Everything has had to be redone.
We go to the local Quincaillerie or hardware store. Everything that you thought you could never find in Chad is stacked from floor to ceiling in a dusty, brick warehouse. We spend hours hunting down all we need. A large Arab in a simple white Jallibiya and a well trimmed gray beard walks in. He is the owner, Mahamat.
"As-salaam alekum. Wa alekum as-salaam. Inta afe? Afe, taybin? Al hamdullilah. Mashallah." And the greetings are over. He walks behind the counter. We continue shopping. After early afternoon prayers, Mahamat returns.
"You...eat..." he starts in broken French and then switches over to Arabic. "We want to you to eat with us. What do you think?" He almost seems sure we'll refuse. He is pleasantly surprised by my profuse response.
"Shukran, shukran, it would be an honor, thank you."
He calls outside to the others and ushers us into a tiny side room under the overhead office built high in the corner of the warehouse. We are seated and a huge platter is slung on the table before us. Piles of fluffy rice fill one huge bowl. A cast iron pot from Nigeria holds the steaming goat meat sauce while a shallow bowl to the side is bursting with a fresh tomato and onion salad. Surprisingly, we are given spoons to eat with as generous portions are heaped into our bowls. Jamie, the vegetarian, digs right in ripping the goat meat off the bones. Our host comes in last and there are no more chairs. We try to rise and give him ours, but he insists. A special bowl of cumin flavored yogurt sauce is placed in front of him along with a plastic bag filled with fluffy flat bread the size of large crepes.
Mahamat wishes us "bon appetit" and grabs a pancake. He bunches the whole thing into his hand leaving the ragged edges pointing out with which he mops up some yogurt sauce and shoves the whole mess into his hand. When we are all finally able to resist his efforts to get us to eat more he reaches outside the door and pulls a plastic bottle of wild honey off the shelf. He dumps some more rice in a bowl and covers it with honey. He tells me to dip in and try. When I say I like it and go for more he shakes his head and pulls the bowl over to him. Then he motions to one of his workers to pour me some of my own. I can't figure out if he just really wants to eat it all himself or doesn't want to have too much direct contact with an infidel.
Mahamat rises and thanks us again. "The French are always too busy. The Chinese sometimes take a snack or something, but this is the first time I've eaten a meal with a client here in my shop. Vraiment, merci beaucoup. Merci, merci, merci." He continues to thank us. He is quite pleased and so are we to be so honored.
We return to the job site.
I'm in the new operating room. I grab the jackhammer with the drill attachment. I lean into it and as it engages a puff of cement dust bursts out of the floor until it turns red when it hits the compacted earth beneath the slab. I slip out the drill bit, put in the small chisel bit and feel the vibrations up my arm and shoulder as the chirping and cracking of cement fills the room.
That night I find myself sitting on a hard stool under the stars in front of Antoine's house. The moon is 3/4 and provides enough light to eat the tiny, twisted potato like tubers covered with cabbage and peanut sauce. Antoine seems discouraged. The junior high that he runs has a drop in enrollment. I try to encourage him. We have brought some building materials that are still piled in the shipping container. Once we finish with the clinic, we can maybe help him with a couple of new buildings. Also, I hope to get a volunteer to help teach English to give his school an edge over the competition. I tell him that God has a plan and won't abandon something He has started.
The ladder is a little unsteady as I get to the top rung. There was no attic hole left in the new ceiling but one angle at the corner of the roof has been left open. I think I can squeeze through. I reach my hands up and grab the truss. I pull up as my feet kick out in mid air. I get to my waist and my tiny butt almost gets stuck but I slither through. I hop from truss to truss dragging the loops of plumbing pipe that I punch through the holes down to the sterilization room and consulting rooms below. The sweat makes the cobwebs stick easier as I try not to fall through the fragile ceiling below.
We pull up the van outside a brightly painted wooden shelter. Their are cartoon images of fish, chicken and millet painted garishly on the corners. Inside a crowd is loosely seated around a selection of differently sized rickety tables and wobbly benches. There is a tiny one open right in the middle. Someone, maybe a waiter, quickly wipes off the plastic mat covering the wood with his bare hand leaving a mixture of spilled beer and salad juice on the surface. Jamie and I sit down and nod hello to those sitting at other tables just a few inches from ours. Most seem to have liter bottles of Gala beer in various stages of consumption. The two men dressed in suits next to us are dipping their hands into a common bowl of lettuce and tomatoes covering some kind of meat.
"What's good to eat here?" I ask one of the men.
"Mutton ribs and salad's what we're having, c'est tres bon!"
"Merci."
We order two servings from the overweight Tchadian woman in charge of the kitchen carved out of one corner of the room. The sounds of popping oil and the smells of wood fire smoke waft out from the clatter of cast iron pots and cooking utensils.
A man approaches selling watches and cheap sunglasses. In the far corner, a man is stretching a piece of cloth between his hands to show a woman how strong it is. Several other woman are looking on eagerly as they sip their beers. A large man who looks more Nigerian than Tchadian comes up behind me and holds out a package of medication over my shoulder and in front of my face. There is a picture of a smiling black man on a yellow and red backdrop with "Super King" emblazoned boldly across the front. In small letters underneath I see the generic name for what is known in other circles as Viagra. I turn to look at the man who raises his eyebrows and winks.
"Super King?"
"Non, merci, I'm deja un Super King," I joke with him as I shake my head.
Disappointed he moves on to greener pastures.
Our meal has arrived. The cook holds out the traditional plastic basin with a plastic pitcher and brown soap for hand washing. I rip off pieces of tender, savory flesh off the sheep ribs, topping it off with lettuce, tomato and onion drenched in a vinaigrette. A small pile of grilled yellow chilies adds some spice to the mix. I was it all down with some Top pineapple soda and then help Jamie finish off the last of his meat.
Friday, August 14, 2009
Sign
It's 3;46 AM and I can't sleep. My eyes are bloodshot and heavy, my head pounds, but I can't sleep. Jet lag is at it again. As I huddle under the blankets to keep from freezing in the airconditioned hotel room in Richland, Washington it's hard to imagine that just a few sleepless days ago I was in the bush of the Sahel. A six hour bus ride from Bere to N'Djamena, a 5 hour overnight flight to Paris arriving at 6AM followed by 45 minutes to Amsterdam and a direct flight across Greenland and Canada to Seattle where I met Greg. We grab a rental car and head over the mountains covered with pines and firs into the central valley with it's rolling golden hills, small farming towns and fresh, cold cherries. Following a smaller river down we hit the Columbia River in the TriCities and we've arrived for the SIGN conference.
I get out of bed at about 4:30, strap on my running shoes and head out the door. The night is just beginning to turn a lighter shade of black but the well-lit streets need no natural light and guide me across the street, around the middle school with it's sprinklers caressing it's well manicured lawns, soccer and football fields, up a side street, off the road up a grassy slope and onto the riverside walking trail. The scent of sage, mountain misery, pine and fir wafts across the early morning breeze which would've surely chilled me if not for the vigorous sweat I've already worked up in my out of shape body. A grove of trees and dense shrubbery gives me only glimpses of the dark, alabaster surface of the river until I turn a corner and see an opening leading down a pebbly bank onto a small sandy beach. I stumble down and after some pushups squat on the sand to reflect.
Yesterday, I found myself surrounded by an international aura of languages swirling around me: Urdu, Hindi, Vietnamese, Slavic, Arabic, French, Spanish, and a wide variety of English from Nigeria, Cameroon, Tanzania, Kenya, India, Bangladesh, Mongolia, England and the wide variety of American accents. There is the slender Dr. Shah with his ample gray beard and thin, fierce face with a long pointed nose from Pakistan describing doing more than 1000 intramedullary nails for long bone fractures starting during the terrible earthquake in northern Pakistan and continuing on today in some of the most remote areas of the world. There is the dignified, dark skinned Dr. Faruque from Bangladesh speaking calmly out from under his mop of black hair and half smile. Dr. Shahab from Peshawar lectures us elegantly on bomb blast injuries, his portly figure fitting well in his classy suit framing a jolly face encompassed in a well trimmed white beard outlining his dark features. I find myself being guided through the machine shop where intramedullary rods, screws and instruments are made at a fraction of the competitors prices but with the same levels of quality control. I enter into a workshop where 20 artificial femurs and an equal number of tibias await our inexperienced hands.
I am led through the process by an orthopedist from Vietnam who explains how to attach the guiding frame to the rod and adjust it so the distal fixing screws will be able to be placed without intraoperative imagery. I am shown the technique of insertion with frequent side to side sweeps interspersed with gentle taps of the mallet. The whole process of guided drilling, finding the slot in the nail and inserting the screws is simple and elegant allowing most lower limb long bone fractures to be treated with the highest standard of care in the world without needing the normal high-tech equipment or even electricity! I go over the process many times in the next few days until I've mastered it. Of course, real bone covered with real flesh on a real person will be different but I'm confident I can do it...inshallah.
SIGN was started 10 years ago by Dr. Zirkle, an american orthopedist who has spent his life in developing countries with the idea of equality of fracture treatment around the world. By the end of 2008 SIGN had over 144 programs in 49 countries involving over 3000 surgeons who have performed over 36,000 operations. Now, Chad and the Bere Adventist Hospital will make it at least 50 countries. We have been given the instruments, our first set of 30 intramedullary nails, a cordless drill with sterile cover, training videos, wound suction treatment systems and the full support of the SIGN team...all on faith that we will raise the money to help cover the costs of this equipment.
Anyone interested in knowing more or donating to this program in the name of Bere Adventist Hospital can contact SIGN at www.sign-post.org.
James
I get out of bed at about 4:30, strap on my running shoes and head out the door. The night is just beginning to turn a lighter shade of black but the well-lit streets need no natural light and guide me across the street, around the middle school with it's sprinklers caressing it's well manicured lawns, soccer and football fields, up a side street, off the road up a grassy slope and onto the riverside walking trail. The scent of sage, mountain misery, pine and fir wafts across the early morning breeze which would've surely chilled me if not for the vigorous sweat I've already worked up in my out of shape body. A grove of trees and dense shrubbery gives me only glimpses of the dark, alabaster surface of the river until I turn a corner and see an opening leading down a pebbly bank onto a small sandy beach. I stumble down and after some pushups squat on the sand to reflect.
Yesterday, I found myself surrounded by an international aura of languages swirling around me: Urdu, Hindi, Vietnamese, Slavic, Arabic, French, Spanish, and a wide variety of English from Nigeria, Cameroon, Tanzania, Kenya, India, Bangladesh, Mongolia, England and the wide variety of American accents. There is the slender Dr. Shah with his ample gray beard and thin, fierce face with a long pointed nose from Pakistan describing doing more than 1000 intramedullary nails for long bone fractures starting during the terrible earthquake in northern Pakistan and continuing on today in some of the most remote areas of the world. There is the dignified, dark skinned Dr. Faruque from Bangladesh speaking calmly out from under his mop of black hair and half smile. Dr. Shahab from Peshawar lectures us elegantly on bomb blast injuries, his portly figure fitting well in his classy suit framing a jolly face encompassed in a well trimmed white beard outlining his dark features. I find myself being guided through the machine shop where intramedullary rods, screws and instruments are made at a fraction of the competitors prices but with the same levels of quality control. I enter into a workshop where 20 artificial femurs and an equal number of tibias await our inexperienced hands.
I am led through the process by an orthopedist from Vietnam who explains how to attach the guiding frame to the rod and adjust it so the distal fixing screws will be able to be placed without intraoperative imagery. I am shown the technique of insertion with frequent side to side sweeps interspersed with gentle taps of the mallet. The whole process of guided drilling, finding the slot in the nail and inserting the screws is simple and elegant allowing most lower limb long bone fractures to be treated with the highest standard of care in the world without needing the normal high-tech equipment or even electricity! I go over the process many times in the next few days until I've mastered it. Of course, real bone covered with real flesh on a real person will be different but I'm confident I can do it...inshallah.
SIGN was started 10 years ago by Dr. Zirkle, an american orthopedist who has spent his life in developing countries with the idea of equality of fracture treatment around the world. By the end of 2008 SIGN had over 144 programs in 49 countries involving over 3000 surgeons who have performed over 36,000 operations. Now, Chad and the Bere Adventist Hospital will make it at least 50 countries. We have been given the instruments, our first set of 30 intramedullary nails, a cordless drill with sterile cover, training videos, wound suction treatment systems and the full support of the SIGN team...all on faith that we will raise the money to help cover the costs of this equipment.
Anyone interested in knowing more or donating to this program in the name of Bere Adventist Hospital can contact SIGN at www.sign-post.org.
James
Sunday, August 9, 2009
Moonlight
I could never have imagined that things would turn out they did.
As I stare out into the moonlight filtering through the flamboyant tree branches casting shifting shadows with every breath of wind, as I hear the soft shuffle and breathing of our sweat-flecked horses outside the stable, as I draw my gaze back to the pile of pineapple carvings in front of the cutting board and bring the ice-cold pineapple to my mouth and slowly savor crunching into the juicy morsel, as I think back over the past few days I find it incredible to think of how this afternoon ended...I can only call it an unexpected grace, a surprising joy, a metaphysical moment when all things good come together out of the midst of all things wrong.
As I gallop through the forest, grasping Pepper's mane as fiercely as I hold to the reins; as I stand up in the stirrups and hug my body to the horse's powerful neck; as the leaves slap my face and a branch rips through the skin of my shoulder; as the full moon lights up the sandy trail like a river of silver stretching lazily out before me through the dark shadows of the trees; as my sweat soaked shirt clings to my back; as I am surrounded by the silence of an African evening in the bush I find myself carried way beyond the horrors, sorrows and sufferings of the last few days.
I can hardly remember the strong features of the handsome Arab man staring steadfastly upward with a look of incomprehensible peace as he is lugged up the ramp to the operating room in a vinyl stretcher with wooden handles held firmly in the grips of a dozen turbaned comrades his mangled body wrapped in a blood soaked turban in stark contrast to the serenity of his gaze. I almost forget the hours of working on his bilateral open fibula and tibia fractures uncovered on his right by a flap of skin running from his heel and achilles tendon up his calf and across the top of his foot revealing the anatomy of the muscles, tendons, ligaments and bones as I can only barely remember from Anatomy lab in medical school. The almost can't bring up the vague memory of him calmly complaining of neck pain since he can't move or feel the rest of his body is a silent grace to him allowing us to work on his tattered limbs without anesthesia after framing his chiseled face in a cervical collar. I thought I'd never survive the emotional roller coaster of the myriads of swishing robed, turbaned men and brightly wrapped head scarved women that filed incessantly in and out, many of the men leaving with tears unashamedly rolling down their cheeks as I had to console them to leave all in Allah's hands as only He can know the day of our death and we should trust Him. The memories flood in of fighting my way through crowds and over colorful mats and rugs to try and do his complicated dressings after spending what seemed like ages of emotional energy trying to get the swarming family and friends to respect visiting hours and hospital policies. When his paralysis didn't get better after three days I was almost relieved when the nurse came to get me yesterday morning to say "Ca ne va pas" and I arrived in time to see his unconscious, but still dignified face take it's last shallow breaths and feel his heart beat in his neck slow down and become weak. He was bound for a long road of suffering in this environment as a quadriplegic and it was certainly God's mercy that laid him to sleep.
As I stand on the bank of the river, looking down on the swirling eddies of the brown, engorged river; as I see the sun slowly set behind the great branching trees of the African plain; as I turn around and see the full moon rising through a circle made by two rounded trees and a small hill; as I watch the slow transformation of the day into moonlit night; as I feel the wet of the river slowly drying on my body; as I watch Stefan desperately trying to capture the moment on film; as Eddie slowly makes his way upstream against the current; as I pull on my jeans over my moist swimming suit and prepare for the ride home; as untangle Pepper from the bush I've tied him to I am amazed at how quickly depression and overwhelming burnout can be replaced by wonder and marvel and ecstasy.
Can it be that only this morning I found myself deep in a belly under the ribs carefully cauterizing a gallstone filled gallbladder from the liver of an elderly, lighter-skinned Muslim man? Is it possible that yesterday I was about to throw up and finally gave in and started taking malaria treatment only to go out immediately and take out an ovarian tumor stuck to all the intestines, omentum and uterus? Is it possible that only two days ago I didn't think I'd make it through the morning much less the weak because of fatique I refused to believe was another bout of Plasmodium falciparum destroying my blood cells? Is it possible that only three days ago the hospital was full to overflowing while we spent all of a Sunday afternoon filling it up with sick babies needing blood transfusions and malaria treatment? Is it possible that only four days ago I spent all Saturday in the OR with two motorcycle accidents needing emergent orthopedic intervention? Is it possible considering how things later turned out?
I come back from work almost collapsing. It's been another day of neverending hospital rounds, complicated surgeries, ER patients, ultrasounds all pleasantly muffled with the ringing of Quinine in my ears. I feel a little nauseated and drink some cold water. I sit down and finish reading "Flying Doctor of the Philippines". I just want to sleep, but decide I better go out and feed the horses to keep my wife happy. The next thing I know I'm in the saddle trotting past the mud huts of Bere, around the pond, through the forest and onto the river road mounted on Pepper while Stefan rides Bob and Eddie rides Libby. Out into the open Stefan and Eddie cluck their horses into a gallop. I can feel Pepper tensing beneath me and I give him the releasing cry and squeeze and he quickly closes the gap and passes the others through a mud puddle as Bob goes left and Libby goes right around it. We're in the open now and I slow down. We arrive quickly at the river ride down the ridges gauged out by the rain leading to the cattle crossing and then climb up the hill next to it. A quick assessment confirms the possibilities and Eddie and I strip down and race off the cliff arms and legs flailing wildly before crashing into the swift moving current below. It's not enough for Eddie, so we find ourselves pulling our reluctant bodies up the bank using exposed tree roots before climbing up the tree as high as possible with still a path clear of branches to the rushing waters below. I crouch on two diverging limbs my hands in front as I propel myself through the gap, past the other branches below and into the welcoming arms of the cool, refreshing liquid beneath. I'm glad there are no crocs and lions in this part of Africa.
As Eddie and I climb up the bank for the last time after multiple jumps from different levels, Stefan's face is glowing. It's hard to believe just last night he was talking about maybe wanting to leave. Now all he says is, "the only thing that could make this better would be a little ice cream."
Later as I walk through the cool of the moonlit evening from my house to his carrying the plate of chilled fruit I think to myself, "well, cold pineapple could arguably be as good or better..."
Then the clapping comes again...it's Salomon...
"There's an old man peeing blood since this morning..."
And I'm off to the hospital as the moonlight leads the way.
As I stare out into the moonlight filtering through the flamboyant tree branches casting shifting shadows with every breath of wind, as I hear the soft shuffle and breathing of our sweat-flecked horses outside the stable, as I draw my gaze back to the pile of pineapple carvings in front of the cutting board and bring the ice-cold pineapple to my mouth and slowly savor crunching into the juicy morsel, as I think back over the past few days I find it incredible to think of how this afternoon ended...I can only call it an unexpected grace, a surprising joy, a metaphysical moment when all things good come together out of the midst of all things wrong.
As I gallop through the forest, grasping Pepper's mane as fiercely as I hold to the reins; as I stand up in the stirrups and hug my body to the horse's powerful neck; as the leaves slap my face and a branch rips through the skin of my shoulder; as the full moon lights up the sandy trail like a river of silver stretching lazily out before me through the dark shadows of the trees; as my sweat soaked shirt clings to my back; as I am surrounded by the silence of an African evening in the bush I find myself carried way beyond the horrors, sorrows and sufferings of the last few days.
I can hardly remember the strong features of the handsome Arab man staring steadfastly upward with a look of incomprehensible peace as he is lugged up the ramp to the operating room in a vinyl stretcher with wooden handles held firmly in the grips of a dozen turbaned comrades his mangled body wrapped in a blood soaked turban in stark contrast to the serenity of his gaze. I almost forget the hours of working on his bilateral open fibula and tibia fractures uncovered on his right by a flap of skin running from his heel and achilles tendon up his calf and across the top of his foot revealing the anatomy of the muscles, tendons, ligaments and bones as I can only barely remember from Anatomy lab in medical school. The almost can't bring up the vague memory of him calmly complaining of neck pain since he can't move or feel the rest of his body is a silent grace to him allowing us to work on his tattered limbs without anesthesia after framing his chiseled face in a cervical collar. I thought I'd never survive the emotional roller coaster of the myriads of swishing robed, turbaned men and brightly wrapped head scarved women that filed incessantly in and out, many of the men leaving with tears unashamedly rolling down their cheeks as I had to console them to leave all in Allah's hands as only He can know the day of our death and we should trust Him. The memories flood in of fighting my way through crowds and over colorful mats and rugs to try and do his complicated dressings after spending what seemed like ages of emotional energy trying to get the swarming family and friends to respect visiting hours and hospital policies. When his paralysis didn't get better after three days I was almost relieved when the nurse came to get me yesterday morning to say "Ca ne va pas" and I arrived in time to see his unconscious, but still dignified face take it's last shallow breaths and feel his heart beat in his neck slow down and become weak. He was bound for a long road of suffering in this environment as a quadriplegic and it was certainly God's mercy that laid him to sleep.
As I stand on the bank of the river, looking down on the swirling eddies of the brown, engorged river; as I see the sun slowly set behind the great branching trees of the African plain; as I turn around and see the full moon rising through a circle made by two rounded trees and a small hill; as I watch the slow transformation of the day into moonlit night; as I feel the wet of the river slowly drying on my body; as I watch Stefan desperately trying to capture the moment on film; as Eddie slowly makes his way upstream against the current; as I pull on my jeans over my moist swimming suit and prepare for the ride home; as untangle Pepper from the bush I've tied him to I am amazed at how quickly depression and overwhelming burnout can be replaced by wonder and marvel and ecstasy.
Can it be that only this morning I found myself deep in a belly under the ribs carefully cauterizing a gallstone filled gallbladder from the liver of an elderly, lighter-skinned Muslim man? Is it possible that yesterday I was about to throw up and finally gave in and started taking malaria treatment only to go out immediately and take out an ovarian tumor stuck to all the intestines, omentum and uterus? Is it possible that only two days ago I didn't think I'd make it through the morning much less the weak because of fatique I refused to believe was another bout of Plasmodium falciparum destroying my blood cells? Is it possible that only three days ago the hospital was full to overflowing while we spent all of a Sunday afternoon filling it up with sick babies needing blood transfusions and malaria treatment? Is it possible that only four days ago I spent all Saturday in the OR with two motorcycle accidents needing emergent orthopedic intervention? Is it possible considering how things later turned out?
I come back from work almost collapsing. It's been another day of neverending hospital rounds, complicated surgeries, ER patients, ultrasounds all pleasantly muffled with the ringing of Quinine in my ears. I feel a little nauseated and drink some cold water. I sit down and finish reading "Flying Doctor of the Philippines". I just want to sleep, but decide I better go out and feed the horses to keep my wife happy. The next thing I know I'm in the saddle trotting past the mud huts of Bere, around the pond, through the forest and onto the river road mounted on Pepper while Stefan rides Bob and Eddie rides Libby. Out into the open Stefan and Eddie cluck their horses into a gallop. I can feel Pepper tensing beneath me and I give him the releasing cry and squeeze and he quickly closes the gap and passes the others through a mud puddle as Bob goes left and Libby goes right around it. We're in the open now and I slow down. We arrive quickly at the river ride down the ridges gauged out by the rain leading to the cattle crossing and then climb up the hill next to it. A quick assessment confirms the possibilities and Eddie and I strip down and race off the cliff arms and legs flailing wildly before crashing into the swift moving current below. It's not enough for Eddie, so we find ourselves pulling our reluctant bodies up the bank using exposed tree roots before climbing up the tree as high as possible with still a path clear of branches to the rushing waters below. I crouch on two diverging limbs my hands in front as I propel myself through the gap, past the other branches below and into the welcoming arms of the cool, refreshing liquid beneath. I'm glad there are no crocs and lions in this part of Africa.
As Eddie and I climb up the bank for the last time after multiple jumps from different levels, Stefan's face is glowing. It's hard to believe just last night he was talking about maybe wanting to leave. Now all he says is, "the only thing that could make this better would be a little ice cream."
Later as I walk through the cool of the moonlit evening from my house to his carrying the plate of chilled fruit I think to myself, "well, cold pineapple could arguably be as good or better..."
Then the clapping comes again...it's Salomon...
"There's an old man peeing blood since this morning..."
And I'm off to the hospital as the moonlight leads the way.
Sunday, July 26, 2009
INSHALLAH
I find myself in an SUV with a group of Muslims roaring across the desert towards Eastern Chad and the crisis in Darfur. We pass Bedouin caravans heading north. Women in brightly colored body wraps and head scarves with huge gold nose rings frantically beat donkeys to get them to move off the road as we come cruising past. Robed, turbaned and bearded, the men lumber by swaying on the backs of heavily loaded camels, bounce along on horseback or plod along on foot chasing the goats and sheep. Most are armed with bows and arrows or spears or staffs. Tucked away in the robes is the ever present dagger and many probably have rifles hidden in their saddle bags.
Dead animals in various states of decomposition and drying litter the shoulders of the highway. Poor rainfall this year has lead to famine and the loss of cattle, donkeys, horses and other vital livestock. Occasionally the smell of a rotting carcass sneaks it's way in through the windows of our passing vehicles.
The African plain starts to be interrupted by wadis, rolling hills and piles of boulders. In the distance, jagged peaks and granite outcroppings break up the horizon. We enter into the central Chadian Sahel where rain has been more abundant and the grasslands are bright green and crops of millet are starting to push their way out of the soil as local farmers dig up the ground with small spades on the end of long poles. Women coming back from the fields carry water and rations in woven net bags suspended from poles slung across one shoulder. No one carries things balanced on top of their heads like they do in Bere in the South.
We stop by the side of the road for a picnic. Tea and Arabic coffee is poured from thermoses as we wait in the shade of a thorny desert scrub tree. A platter of grilled goat chunks and French baguettes is shared among our two groups of five.
We continue on with regular stops for tea, milk and ritual prayer. One stop for prayer finds us in the midst of a cluster of mountains and date palms. The prayer rugs are rolled out and the absolution's begun in front of a man slicing up a sheep into large portions to be roasted on a piece of tin roofing suspended over a wood fire.
We spend the night in Mongo at the World Food Program compound and are up before five for morning prayers, milk, tea and Chadian beignets. We arrive late in the afternoon at Abeche, Chad's fourth largest city.
As we enter the mud brick compound and seat ourselves on enormous mats, I experience for the first time what an Arabic greeting really is. A rhythmic, staccato exchange of words proceeds for at least five minutes with at least 20 "mashallah's", 15 "Al hamdullilah's" and countless other words asking about health for everybody, strength, improvement, etc. I soon join in and find it very satisfying. Hands are shook during most of the greeting, eyes look down and occasionally the hand is released to bring one's own hand into touch the chest over the heart before reaching out again to take the other's hand in greeting. To end the salutation, one releases the hand and slowly sits down on the mat letting one's "mashallah's" and "al hamdullilah's" slowly fade out.
Adding to the milk and tea we now have local coffee seasoned with cardamom and added to the meat and bread is "boule" (millet or corn paste) and some of the best sauces I've had in Chad: ground meat with lots of cumin and okra.
I then take a shower in a walled in corner with a poop hole and a step up for showering from a bucket. Just outside, in the other corner, about 20 small girls are learning to recite the Koran in Arabic. Their sweet voices blend together in a cacophony of different rhythms as none of them is in sync with the other. It is beautiful and cute. It feels good to splash water on me and wash the red dust out of my hair and off my face and arms.
The men stretch out and sleep together on the mats in the men's courtyard where the women don't dare to enter. Whenever a female family member has arrived she starts her greeting and then kneels down just outside the low wall of the courtyard while the male family member goes outside to greet her and kneels down beside her for the prolonged ritual greeting.
The morning starts with sunrise at 4:30am and prayer. I read some passages of scripture, we drink milk and eat beignets and head out to see the local authorities.
First stop is the governor. Our host, Mahamat Saleh Abakar, explains that he's invited us out to look at the possibility of opening a medical center in his village of Gnelme. The Governor doesn't seem to keen since there's a health center in the neighboring town of Abougoudam. However, when Mahamat Saleh explains that it will be more than a health center, more like a hospital, the Governor reluctantly gives his ok. On walking out with his "Directeur du Cabinet", we receive a much warmer reception. The lighter skinned man with obvious Arabic features dressed in an ample robe and white turban beams a smile and says that he is from Gnelme and will do everything to help us get the paperwork pushed through for the land and anything else we need.
We miss the Prefet and Sultan who are out of town so we head out of Abeche towards the sous-prefecture of Abougoudam to see the local sous-prefet, the chief political figure of the group of villages including Gnelme.
He welcomes us into his old, colonial thick walled mansion that unfortunately hasn't been maintained since independence in 1960. We sit down on mats and drink tea and local coffee along with sodas and some goat meat. Directly in front of us is a room stacked to the ceiling with cement, all that's left of a project to build the sous-prefet a new house. Apparently, the rest of the supplies where stolen by bandits and the builder assassinated.
We follow the sous-prefet out to the village where he shows us a flat, barren stretch of ground he wants to give us. It doesn't feel right. We move onto where Mahamat Saleh and his brother have drilled a well for the village so they can have water. It's down in the wadi, too low for construction and likely to be washed away by flash floods. Next to the pump are three dried out cattle carcasses...the water came a little too late for them. About 10 boys mounted bareback on horses have come to water their flocks. I point to a fairly close plateau next to a small mountain and say that's more what I'm interested in. They say it's in another county and so they can't help.
We seem at an impasse when a local man almost hidden by his enormous turban rattles off something quickly in Arabic. We hop back in the SUVs and head a little out of the village towards another village where we find a small hill crowned with huge boulders that is unfarmed. In all directions stretches the African plain broken up by wadis and scrub brush and mountains in the distance ringing us in on all sides. It's perfect. They are happy and agree to give us 10 hectares (almost 25 acres). The location will also allow us to build using local stones.
That evening, I speak with Yacoub Abdoulaye, Mahamat Saleh's cousin.
"What's the hospital in Abeche like? For example, how's the surgery service?"
"Well, let's put it this way, if 10 people are operated on, 5 will live, 5 will die. Plus, often people die in the hallways of the hospital without even being seen by a doctor or nurse because they have nothing."
That goes along with what I'd heard last week in N'Djamena from a German mid-wife working at an Orphanage in Abeche.
"A few weeks ago, during a single week, three women died during c-sections while still on the table. Most of our orphans are orphans because of their mothers dying in childbirth. It's not AIDS or the refugee crisis or the war...it's almost complete lack of health care during deliveries."
If you have money, you can get health care, it just might be a little sketchy. An old Arab man with a skull cap, white robe and a wizened face with years of smile wrinkles shows me his lab slip and prescription. He has malaria and a negative Typhoid test. He was prescribed Typhoid fever treatment anyway along with 5 other meds including quinine for malaria. The total was the equivalent of $50, more than a month's wage for most. To top it off, they hadn't even filled the prescription right as he showed me his malaria medication which was actually Chloroquine instead of the prescribed Quinine.
That night, a funeral next door allows all the local Imam wannabes to practice their oral recitation of the Koran...with a microphone and speakers. All night long until 6am the next morning we are alternately soothed by those who have the talent and annoyed by those who seem to be screeching like dying mules trying to sing the otherwise beautiful Arabic of the Koran. I sleep well anyway.
On the way back, Mahamat Saleh tells us a story:
A man gets up one morning to go to the market. He fishes his money out from under the mattress and sticks it in his pocket.
"I'm going to the market to buy a donkey" he says to his wife.
"Inshallah" she responds.
Halfway out the door he looks back at her. "Inshallah? If God wills it? What has God got to do with it? I've got my money in my pocket and there are plenty of donkeys at the market. I'm going to buy one. Keep your 'Inshallah' to yourself"
With that he slams the door and marches off. Halfway to the market, he is waylaid by bandits who tie him up and take his money. They leave him under a tree all day and when it's dark they release him and take off into the bush. The man makes his way slowly back to his house where he finds the door locked. He knocks on the door.
"Who's there?" His wife asks from inside.
"It's me. Open the door...inshallah!"
As I finally pull up into Bere after two straight days of traveling back from Abeche I'm reminded of the story. I pray silently that God will continue to open the doors for us to have a hospital there in Eastern Chad...INSHALLAH!
Dead animals in various states of decomposition and drying litter the shoulders of the highway. Poor rainfall this year has lead to famine and the loss of cattle, donkeys, horses and other vital livestock. Occasionally the smell of a rotting carcass sneaks it's way in through the windows of our passing vehicles.
The African plain starts to be interrupted by wadis, rolling hills and piles of boulders. In the distance, jagged peaks and granite outcroppings break up the horizon. We enter into the central Chadian Sahel where rain has been more abundant and the grasslands are bright green and crops of millet are starting to push their way out of the soil as local farmers dig up the ground with small spades on the end of long poles. Women coming back from the fields carry water and rations in woven net bags suspended from poles slung across one shoulder. No one carries things balanced on top of their heads like they do in Bere in the South.
We stop by the side of the road for a picnic. Tea and Arabic coffee is poured from thermoses as we wait in the shade of a thorny desert scrub tree. A platter of grilled goat chunks and French baguettes is shared among our two groups of five.
We continue on with regular stops for tea, milk and ritual prayer. One stop for prayer finds us in the midst of a cluster of mountains and date palms. The prayer rugs are rolled out and the absolution's begun in front of a man slicing up a sheep into large portions to be roasted on a piece of tin roofing suspended over a wood fire.
We spend the night in Mongo at the World Food Program compound and are up before five for morning prayers, milk, tea and Chadian beignets. We arrive late in the afternoon at Abeche, Chad's fourth largest city.
As we enter the mud brick compound and seat ourselves on enormous mats, I experience for the first time what an Arabic greeting really is. A rhythmic, staccato exchange of words proceeds for at least five minutes with at least 20 "mashallah's", 15 "Al hamdullilah's" and countless other words asking about health for everybody, strength, improvement, etc. I soon join in and find it very satisfying. Hands are shook during most of the greeting, eyes look down and occasionally the hand is released to bring one's own hand into touch the chest over the heart before reaching out again to take the other's hand in greeting. To end the salutation, one releases the hand and slowly sits down on the mat letting one's "mashallah's" and "al hamdullilah's" slowly fade out.
Adding to the milk and tea we now have local coffee seasoned with cardamom and added to the meat and bread is "boule" (millet or corn paste) and some of the best sauces I've had in Chad: ground meat with lots of cumin and okra.
I then take a shower in a walled in corner with a poop hole and a step up for showering from a bucket. Just outside, in the other corner, about 20 small girls are learning to recite the Koran in Arabic. Their sweet voices blend together in a cacophony of different rhythms as none of them is in sync with the other. It is beautiful and cute. It feels good to splash water on me and wash the red dust out of my hair and off my face and arms.
The men stretch out and sleep together on the mats in the men's courtyard where the women don't dare to enter. Whenever a female family member has arrived she starts her greeting and then kneels down just outside the low wall of the courtyard while the male family member goes outside to greet her and kneels down beside her for the prolonged ritual greeting.
The morning starts with sunrise at 4:30am and prayer. I read some passages of scripture, we drink milk and eat beignets and head out to see the local authorities.
First stop is the governor. Our host, Mahamat Saleh Abakar, explains that he's invited us out to look at the possibility of opening a medical center in his village of Gnelme. The Governor doesn't seem to keen since there's a health center in the neighboring town of Abougoudam. However, when Mahamat Saleh explains that it will be more than a health center, more like a hospital, the Governor reluctantly gives his ok. On walking out with his "Directeur du Cabinet", we receive a much warmer reception. The lighter skinned man with obvious Arabic features dressed in an ample robe and white turban beams a smile and says that he is from Gnelme and will do everything to help us get the paperwork pushed through for the land and anything else we need.
We miss the Prefet and Sultan who are out of town so we head out of Abeche towards the sous-prefecture of Abougoudam to see the local sous-prefet, the chief political figure of the group of villages including Gnelme.
He welcomes us into his old, colonial thick walled mansion that unfortunately hasn't been maintained since independence in 1960. We sit down on mats and drink tea and local coffee along with sodas and some goat meat. Directly in front of us is a room stacked to the ceiling with cement, all that's left of a project to build the sous-prefet a new house. Apparently, the rest of the supplies where stolen by bandits and the builder assassinated.
We follow the sous-prefet out to the village where he shows us a flat, barren stretch of ground he wants to give us. It doesn't feel right. We move onto where Mahamat Saleh and his brother have drilled a well for the village so they can have water. It's down in the wadi, too low for construction and likely to be washed away by flash floods. Next to the pump are three dried out cattle carcasses...the water came a little too late for them. About 10 boys mounted bareback on horses have come to water their flocks. I point to a fairly close plateau next to a small mountain and say that's more what I'm interested in. They say it's in another county and so they can't help.
We seem at an impasse when a local man almost hidden by his enormous turban rattles off something quickly in Arabic. We hop back in the SUVs and head a little out of the village towards another village where we find a small hill crowned with huge boulders that is unfarmed. In all directions stretches the African plain broken up by wadis and scrub brush and mountains in the distance ringing us in on all sides. It's perfect. They are happy and agree to give us 10 hectares (almost 25 acres). The location will also allow us to build using local stones.
That evening, I speak with Yacoub Abdoulaye, Mahamat Saleh's cousin.
"What's the hospital in Abeche like? For example, how's the surgery service?"
"Well, let's put it this way, if 10 people are operated on, 5 will live, 5 will die. Plus, often people die in the hallways of the hospital without even being seen by a doctor or nurse because they have nothing."
That goes along with what I'd heard last week in N'Djamena from a German mid-wife working at an Orphanage in Abeche.
"A few weeks ago, during a single week, three women died during c-sections while still on the table. Most of our orphans are orphans because of their mothers dying in childbirth. It's not AIDS or the refugee crisis or the war...it's almost complete lack of health care during deliveries."
If you have money, you can get health care, it just might be a little sketchy. An old Arab man with a skull cap, white robe and a wizened face with years of smile wrinkles shows me his lab slip and prescription. He has malaria and a negative Typhoid test. He was prescribed Typhoid fever treatment anyway along with 5 other meds including quinine for malaria. The total was the equivalent of $50, more than a month's wage for most. To top it off, they hadn't even filled the prescription right as he showed me his malaria medication which was actually Chloroquine instead of the prescribed Quinine.
That night, a funeral next door allows all the local Imam wannabes to practice their oral recitation of the Koran...with a microphone and speakers. All night long until 6am the next morning we are alternately soothed by those who have the talent and annoyed by those who seem to be screeching like dying mules trying to sing the otherwise beautiful Arabic of the Koran. I sleep well anyway.
On the way back, Mahamat Saleh tells us a story:
A man gets up one morning to go to the market. He fishes his money out from under the mattress and sticks it in his pocket.
"I'm going to the market to buy a donkey" he says to his wife.
"Inshallah" she responds.
Halfway out the door he looks back at her. "Inshallah? If God wills it? What has God got to do with it? I've got my money in my pocket and there are plenty of donkeys at the market. I'm going to buy one. Keep your 'Inshallah' to yourself"
With that he slams the door and marches off. Halfway to the market, he is waylaid by bandits who tie him up and take his money. They leave him under a tree all day and when it's dark they release him and take off into the bush. The man makes his way slowly back to his house where he finds the door locked. He knocks on the door.
"Who's there?" His wife asks from inside.
"It's me. Open the door...inshallah!"
As I finally pull up into Bere after two straight days of traveling back from Abeche I'm reminded of the story. I pray silently that God will continue to open the doors for us to have a hospital there in Eastern Chad...INSHALLAH!
Tuesday, June 30, 2009
Snakebite
The sound of a load diesel motor and the sudden appearance of headlights outside the fence sucks me quickly out of a deep sleep into the darkness of a moonless Chadian night. The truck stops in front of the hospital. I have a feeling I might as well get up already.
Sure enough, within minutes, the all-too-familiar knock, knock, knock on the sheet metal door confirms my suspicions.
"Oui?" I mumble as I roll out of bed trying not to disturb Sarah.
"It's me." Sounds out from through the screen door and across the porch into the bedroom. It sounds like the night nurse, Augustin. I pull on some shorts, grab my glasses and fumble through the dark of the living room which is lit eerily by a blue bug lamp.
"They've just brought in a Fulani boy with a snake bite."
I arrive at the door and take the blue carnet from Augustin's outstretched arm.
"He's agitated and his leg is swollen."
"How long has it been."
"About two hours. They're camped out over by Lai and he went to get some water or something and was bit on the foot."
"How did they find a car at this hour?"
"They ran to Lai and found someone."
"Ok, give him a vial of anti-venom in 500cc of Ringer's. Let it run in over 30 minutes. There's not much else really to do. Either it'll work or it won't...oh, give him some Diazepam to calm him down."
"Ok." And Augustin disappears into the night.
I walk inside and pour some water into a canning jar which serves as my guide to make sure I drink at least 5 liters of water a day. As I stare out into the shadows of the yard my thoughts wander to the boy.
Should I go up to the hospital? Would it make a difference? Won't he just probably die anyway?
Then I start to think, of the two forces in this world, good and evil, which would want me to go up to the hospital and which would recommend I go back to sleep. It's a no brainer, so I put on scrubs, grab my keys and head up to the ER.
On the way I send up a quick prayer. "Whatever happens, make sure You get the glory. If I can pray with them, give me the chance so they'll recognize You as the One who heals."
I arrive in the ER and pull back the green and yellow curtain. Writhing on the bed in agony, looking like death warmed over is a slender, wiry nomad boy with dreads, traditional scarring on his face, leather fetish bags around his neck, string bracelets on his wrists and wild colored pants blood stained on the right leg. His right ankle is covered with blood-soaked gauze and the entire leg is swollen and already blistering.
He is moaning and non-responsive with gingival bleeding thrashing his legs and arms around from time to time.
A shaven headed man in a dark gray pant-suit and traditional tattoos and the obligatory leather pouches around the neck is remarkable amongst his people for the lack of dreads and the presence of a cell phone on a string around his neck and sticking out of his shirt pocket. He stands at the head of the bed. Squatting all around the ER are more men and several women with the crazy dreads and black, charcoal based lined tattoos on the face, arms and chest. Plastic shoes are standard. Another family member stands in a corner, the bottom of his left foot pushed against his inner right thigh as he balances on one foot like a flamingo.
Augustin arrives with the IV and we hold the boy's left arm still while the IV perfusion gets running.
"Give him an ampoule of Pentazocine sub-cue since obviously the Diazepam isn't enough."
As Augustin leaves to get the Pentazocine I motion to the Fulani men and speak to them in my broken Arabic.
"We pray to Allah. Allah give him health. Allah only. Ok?"
Heads nod vigorously in agreement as arms outstretch in the Muslim prayer position.
"Rabbina Allah! Give this boy health. Give this boy life. In the name of Isa al-Masih, Amin!"
As the simple prayer finishes our hands move to our faces to take in Allah's blessing as murmurs of "Shukran" and "Alhamdullilah" whisper around the sleeping, snake-bit boy. The bald man points to the sky and pronounces solemnly, "Allah only gives health and life. Allah only."
Augustin arrives and gives the Pentazocine.
I go to the OR and get a 60cc syringe. I draw up 20cc of Ringers and combine it with the 10cc of anti-venom and give it slow IV push over 10 minutes. Within minutes of starting the anti-venom, the gingival bleeding stops and the ankle bleeding slows down.
The boy is asleep now, thanks to the meds. In fact, he's gurgling. I show the Fulani man with the bald head how to do a jaw thrust to open his airway and the boy starts breathing easier. I keep reminding him to keep the airway open as he keeps getting distracted. Finally, he buckles down and gets it.
I tell Augustin to get some IV Chlorpheniramine ready in case he has an allergic reaction. He comes back to say that the pharmacy is out.
Just then, I notice some welts showing up on the boys arms and abdomen. I rush to the OR and come back with Adrenaline and Benadryl. We give him the shots. It seems to stop spreading. His heart is racing but he's still knocked out.
I go back to the OR into the stock room and find the Hydrocortisone we'd just finally found last week at the pharmacy in Lai. Augustin adds 100mg to the perfusion.
I stay by the boy's side often placing my hand on his chest to feel his heart beat and see if he has a fever. He's breathing is slow and shallow and without the constant pressure of his Fulani uncle's hands thrusting his lower jaw forward he would drown in his own saliva.
What I wouldn't give for an old foot powered suction pump!
The bleeding has all but stopped and the hives aren't spreading and, maybe it's my imagination, but they seem to be receding a little.
The Fulani faces around me seem to relax a little. They sense that he might live.
"Alhamdullilah!" I say and point skyward, "Allah only!"
I go home.
The next morning, the boy starts to wake up. We find he has malaria, after 3 more days of malaria treatment, he is eating, sitting up, moving around and the swelling in his leg has started to go down.
I bid them farewell after thanking God again one more time for saving his life.
James
Sure enough, within minutes, the all-too-familiar knock, knock, knock on the sheet metal door confirms my suspicions.
"Oui?" I mumble as I roll out of bed trying not to disturb Sarah.
"It's me." Sounds out from through the screen door and across the porch into the bedroom. It sounds like the night nurse, Augustin. I pull on some shorts, grab my glasses and fumble through the dark of the living room which is lit eerily by a blue bug lamp.
"They've just brought in a Fulani boy with a snake bite."
I arrive at the door and take the blue carnet from Augustin's outstretched arm.
"He's agitated and his leg is swollen."
"How long has it been."
"About two hours. They're camped out over by Lai and he went to get some water or something and was bit on the foot."
"How did they find a car at this hour?"
"They ran to Lai and found someone."
"Ok, give him a vial of anti-venom in 500cc of Ringer's. Let it run in over 30 minutes. There's not much else really to do. Either it'll work or it won't...oh, give him some Diazepam to calm him down."
"Ok." And Augustin disappears into the night.
I walk inside and pour some water into a canning jar which serves as my guide to make sure I drink at least 5 liters of water a day. As I stare out into the shadows of the yard my thoughts wander to the boy.
Should I go up to the hospital? Would it make a difference? Won't he just probably die anyway?
Then I start to think, of the two forces in this world, good and evil, which would want me to go up to the hospital and which would recommend I go back to sleep. It's a no brainer, so I put on scrubs, grab my keys and head up to the ER.
On the way I send up a quick prayer. "Whatever happens, make sure You get the glory. If I can pray with them, give me the chance so they'll recognize You as the One who heals."
I arrive in the ER and pull back the green and yellow curtain. Writhing on the bed in agony, looking like death warmed over is a slender, wiry nomad boy with dreads, traditional scarring on his face, leather fetish bags around his neck, string bracelets on his wrists and wild colored pants blood stained on the right leg. His right ankle is covered with blood-soaked gauze and the entire leg is swollen and already blistering.
He is moaning and non-responsive with gingival bleeding thrashing his legs and arms around from time to time.
A shaven headed man in a dark gray pant-suit and traditional tattoos and the obligatory leather pouches around the neck is remarkable amongst his people for the lack of dreads and the presence of a cell phone on a string around his neck and sticking out of his shirt pocket. He stands at the head of the bed. Squatting all around the ER are more men and several women with the crazy dreads and black, charcoal based lined tattoos on the face, arms and chest. Plastic shoes are standard. Another family member stands in a corner, the bottom of his left foot pushed against his inner right thigh as he balances on one foot like a flamingo.
Augustin arrives with the IV and we hold the boy's left arm still while the IV perfusion gets running.
"Give him an ampoule of Pentazocine sub-cue since obviously the Diazepam isn't enough."
As Augustin leaves to get the Pentazocine I motion to the Fulani men and speak to them in my broken Arabic.
"We pray to Allah. Allah give him health. Allah only. Ok?"
Heads nod vigorously in agreement as arms outstretch in the Muslim prayer position.
"Rabbina Allah! Give this boy health. Give this boy life. In the name of Isa al-Masih, Amin!"
As the simple prayer finishes our hands move to our faces to take in Allah's blessing as murmurs of "Shukran" and "Alhamdullilah" whisper around the sleeping, snake-bit boy. The bald man points to the sky and pronounces solemnly, "Allah only gives health and life. Allah only."
Augustin arrives and gives the Pentazocine.
I go to the OR and get a 60cc syringe. I draw up 20cc of Ringers and combine it with the 10cc of anti-venom and give it slow IV push over 10 minutes. Within minutes of starting the anti-venom, the gingival bleeding stops and the ankle bleeding slows down.
The boy is asleep now, thanks to the meds. In fact, he's gurgling. I show the Fulani man with the bald head how to do a jaw thrust to open his airway and the boy starts breathing easier. I keep reminding him to keep the airway open as he keeps getting distracted. Finally, he buckles down and gets it.
I tell Augustin to get some IV Chlorpheniramine ready in case he has an allergic reaction. He comes back to say that the pharmacy is out.
Just then, I notice some welts showing up on the boys arms and abdomen. I rush to the OR and come back with Adrenaline and Benadryl. We give him the shots. It seems to stop spreading. His heart is racing but he's still knocked out.
I go back to the OR into the stock room and find the Hydrocortisone we'd just finally found last week at the pharmacy in Lai. Augustin adds 100mg to the perfusion.
I stay by the boy's side often placing my hand on his chest to feel his heart beat and see if he has a fever. He's breathing is slow and shallow and without the constant pressure of his Fulani uncle's hands thrusting his lower jaw forward he would drown in his own saliva.
What I wouldn't give for an old foot powered suction pump!
The bleeding has all but stopped and the hives aren't spreading and, maybe it's my imagination, but they seem to be receding a little.
The Fulani faces around me seem to relax a little. They sense that he might live.
"Alhamdullilah!" I say and point skyward, "Allah only!"
I go home.
The next morning, the boy starts to wake up. We find he has malaria, after 3 more days of malaria treatment, he is eating, sitting up, moving around and the swelling in his leg has started to go down.
I bid them farewell after thanking God again one more time for saving his life.
James
Friday, June 26, 2009
Horses
It's a gray Saturday morning. 6:30 am and a cool breeze is blowing in a cloudy sky bringing out the deepness of the green starting to push up through the desert soil. The transformation of desert into lush grasslands has begun with the first rains. Stefan and I are going for a ride. Pepper and Bob are standing near the stables but Libby is nowhere to be found. I search the compound and finally find her standing under a tree staring blankly through the chain link fence across the soccer field into the horizon. I grab her halter. She resists briefly with her head pulled back before resigning herself to her fate.
I tie Bob up to the tree right outside the stables and grab the new, synthetic saddle someone just gave Sarah and cinch it up as tight as I can across Bob's ever increasing girth. He's getting so strong I'll use the bit today. I slide the beautifully worked leather and silver harness and bit into his mouth and squeeze it over his ears and attach it under his chin. I attach the saddle bags over Libby's rump and fill it with water bottles, and a French Bible and Nangere songbook. I place my left purpose into Bob's stirrup and swing up and into place.
We saunter up to the gate and out into the street. Most people are just waking up huddled around smoky leaf fires warming themselves up after a long "cold" night. Some are gathered around a pot of bouillie anticipating the temporary assuaging of the ever present hunger of the end of the dry season. We cross Bere and approach Bendele. Gary and Wendy's empty house stares at us from the left, it's gate locked with a padlock and it's windows barred. A heavy silence reigns.
A few meters up Noel's children wave and flash huge grins as they shout out the obligatory "lapia! James-uh! Stef-ahn!
Passing Noel's house takes us out of the village into the bush. The main road is packed with a steady procession of people on their way to market. Women in brightly colored wraps saunter along their arms swinging in rhyme keeping in balance on their heads the large basins filled with sweet potatoes, sugar, millet, rice, corn, bean leaves and other marketable items. An ox cart plods slowly by loaded with sacks of grain, a few young kids piled on top and one lazily sitting across the pulling bar with a stick in hand to swat the two long-horned cows into the right direction. More women pass, long piles of twisted sticks cut into six feet lengths, tied and bundled onto their heads. Old and young mix in a never ending procession heading for the biggest event of the week, the Bere market.
Further up, we enter a small village where some of the travelers have stopped under a mango tree gathering around a large pot of freshly prepared rice wine to fill their bellies for the exhausting trip to Bere on foot and to prepare themselves for the social scene and eventually a staggering stumble home, dead drunk. They wave wildly their faces lighting up with white, toothy grins as we pass and call out our greetings.
I've switched to Libbly now, as Stefan was having some troubles controlling her. We've been trotting for a while when an open stretch of road heading to Dabague opens up before us. I give a cluck and a kick with my heels and Libby is off on a fast gallop. She's our newest addition to the stables and like Pepper and Bob came to us at a good price thanks to her malnourishment. When Sarah walked her back from the Arab village where we bought her, she could barely do 5 kilometers at a slow walk. Now that she's put on some weight and become one of the friendliest horses around I want to see if she can run and if she's at all competitive.
I'm in front for a while before Bob catches up and barely passes us. Libby picks up speed a little but seems content to stay with Bob and not pass him. Alternately walking, trotting and galloping the 18 kilometers to Delbian pass quickly accompanied by a thousand "Lapias" and "As-salaam alekums".
We tie up Libby and Bob near some grass while a short man with a limp brings a bucket, fills it at the local water pump and gives the horses a much needed drink. We take off the saddle bags and saddles and hang them over mango tree branches out of the reach of curious little hands. I get to tell the story of David and Goliath to a group of kids where practically every other boy his carrying his own sling and sheep are grazing in the background. The story of a shepherd boy killing a giant with a stone and sling has never seemed more real.
I then am told by Noel that I'll be preaching so I pull out of my past the sermon I borrowed from the Pineapple Story guy about God loving impossibilities in using Gideon and 300 men to fight off an army of 135,000; Elijah taking on 400 prophets of Baal on a mountain and God burning up the wet wood, bull, stone and earth with fire from the sky; and Daniel's three friends being saved from a fiery furnace heated up seven times hotter.
In a surprising lack of African hospitality, Stefan and I are allowed to escape the usually obligatory millet paste and slime sauce meal and head back to Bere. Just outside of Dabegue, we come across three young boys bareback on tiny ponies herding cattle. As we trot past, one of them turns and starts running alongside heading towards the road. He wants to race! I cluck loudly and give a big kick to Libby's flanks and she almost shoots out from under me as she pushes to catch the pony. Within seconds we pull even and leave the surprisingly fast pony in the dust. Entering Dabegue we tear around puddles of water, under trees and around people scampering to get out of the way. I'd seen Stefan gunning Bob and was sure he'd catch us by now. I quickly over my shoulder and he's nowhere to be found. A commanding "whoa", a sharp pull on the reins and a lean back with all my force and Libby stops dead in her tracks.
Stefan finally catches up explaining that he lost his hat as Bob sprung forward to enter the race. We continue trotting and walking until we are about 5 kilometers from Bere.
"Let's race Bob and Libby. I want to really see what she can do. See that tree to the left just beyond that puddle? It'll be a walk up start. As soon as we enter the shadow of the tree, the race starts."
I feel my heart beat pick up as the tree approaches and we try to keep the horses even. It's a slow walk up. We're only a few feet away. The horses start to sense our excitement...and...we're there. Libby seems to have been expecting it as she rockets forward almost pulling my feet out of the stirrups. I'm holding on for dear life. We're ahead! I then see Bob cut around a little to the left where a side path goes around some bushes. He's picking up speed. At the same time I feel Libby fading, she's just not in shape and running out of energy. Bob leaves us way behind as we continue a slow gallop to the entrance to Bere and do a cool-down walk the rest of the way home.
As i finally pull myself out of the saddle, I can't believe how tired I am. I'm so wobbly I cna barely stay a foot. I'm covered with sweat and fine dust. The horses slurp up bucketfuls of water and then go for a roll as soon as their saddles are off. I take a quick shower and fall into a deep sleep before being awakened shortly by the nurse on duty.
"There's a woman with high blood pressure and seizures. She's seven months pregnant. The cervix is completely dilated."
I give some instructions and go back down to lay down, but then think better of it and get up, put on scrubs and head to the hospital.
The woman is thrashing around on the bed moaning and whining. The cervix is only at three centimeters. We start an oxytocin drip to give her better contractions and I go to see some other patients. The nurse runs to get me.
"She's having a crisis again!"
I enter the labor and delivery room. The husband is at the bed side and the woman is hysterical. It's not a seizure, though, and she quickly calms down when the husband leaves. I order some pain medication and then she has a grand mal seizure. We hurry her to the OR. Luckily Simeon is there and Samedi lives right next door. The woman is combative and agitated and difficult to get on the OR table. We tie her arms and legs down good, prep the abdomen, scrub and gown and drape.
We pray and Simeon gives one milliliter of Ketamine and I slice down to fascia, rip the fascia and muscles open, lift up a bladder flap, slice into the uterus, poke into the amniotic sac and squeeze out a full term baby boy who after a little rubbing and slapping starts to give a healthy cry. I suture up the uterus and skin and head home to finally rest.
James
I tie Bob up to the tree right outside the stables and grab the new, synthetic saddle someone just gave Sarah and cinch it up as tight as I can across Bob's ever increasing girth. He's getting so strong I'll use the bit today. I slide the beautifully worked leather and silver harness and bit into his mouth and squeeze it over his ears and attach it under his chin. I attach the saddle bags over Libby's rump and fill it with water bottles, and a French Bible and Nangere songbook. I place my left purpose into Bob's stirrup and swing up and into place.
We saunter up to the gate and out into the street. Most people are just waking up huddled around smoky leaf fires warming themselves up after a long "cold" night. Some are gathered around a pot of bouillie anticipating the temporary assuaging of the ever present hunger of the end of the dry season. We cross Bere and approach Bendele. Gary and Wendy's empty house stares at us from the left, it's gate locked with a padlock and it's windows barred. A heavy silence reigns.
A few meters up Noel's children wave and flash huge grins as they shout out the obligatory "lapia! James-uh! Stef-ahn!
Passing Noel's house takes us out of the village into the bush. The main road is packed with a steady procession of people on their way to market. Women in brightly colored wraps saunter along their arms swinging in rhyme keeping in balance on their heads the large basins filled with sweet potatoes, sugar, millet, rice, corn, bean leaves and other marketable items. An ox cart plods slowly by loaded with sacks of grain, a few young kids piled on top and one lazily sitting across the pulling bar with a stick in hand to swat the two long-horned cows into the right direction. More women pass, long piles of twisted sticks cut into six feet lengths, tied and bundled onto their heads. Old and young mix in a never ending procession heading for the biggest event of the week, the Bere market.
Further up, we enter a small village where some of the travelers have stopped under a mango tree gathering around a large pot of freshly prepared rice wine to fill their bellies for the exhausting trip to Bere on foot and to prepare themselves for the social scene and eventually a staggering stumble home, dead drunk. They wave wildly their faces lighting up with white, toothy grins as we pass and call out our greetings.
I've switched to Libbly now, as Stefan was having some troubles controlling her. We've been trotting for a while when an open stretch of road heading to Dabague opens up before us. I give a cluck and a kick with my heels and Libby is off on a fast gallop. She's our newest addition to the stables and like Pepper and Bob came to us at a good price thanks to her malnourishment. When Sarah walked her back from the Arab village where we bought her, she could barely do 5 kilometers at a slow walk. Now that she's put on some weight and become one of the friendliest horses around I want to see if she can run and if she's at all competitive.
I'm in front for a while before Bob catches up and barely passes us. Libby picks up speed a little but seems content to stay with Bob and not pass him. Alternately walking, trotting and galloping the 18 kilometers to Delbian pass quickly accompanied by a thousand "Lapias" and "As-salaam alekums".
We tie up Libby and Bob near some grass while a short man with a limp brings a bucket, fills it at the local water pump and gives the horses a much needed drink. We take off the saddle bags and saddles and hang them over mango tree branches out of the reach of curious little hands. I get to tell the story of David and Goliath to a group of kids where practically every other boy his carrying his own sling and sheep are grazing in the background. The story of a shepherd boy killing a giant with a stone and sling has never seemed more real.
I then am told by Noel that I'll be preaching so I pull out of my past the sermon I borrowed from the Pineapple Story guy about God loving impossibilities in using Gideon and 300 men to fight off an army of 135,000; Elijah taking on 400 prophets of Baal on a mountain and God burning up the wet wood, bull, stone and earth with fire from the sky; and Daniel's three friends being saved from a fiery furnace heated up seven times hotter.
In a surprising lack of African hospitality, Stefan and I are allowed to escape the usually obligatory millet paste and slime sauce meal and head back to Bere. Just outside of Dabegue, we come across three young boys bareback on tiny ponies herding cattle. As we trot past, one of them turns and starts running alongside heading towards the road. He wants to race! I cluck loudly and give a big kick to Libby's flanks and she almost shoots out from under me as she pushes to catch the pony. Within seconds we pull even and leave the surprisingly fast pony in the dust. Entering Dabegue we tear around puddles of water, under trees and around people scampering to get out of the way. I'd seen Stefan gunning Bob and was sure he'd catch us by now. I quickly over my shoulder and he's nowhere to be found. A commanding "whoa", a sharp pull on the reins and a lean back with all my force and Libby stops dead in her tracks.
Stefan finally catches up explaining that he lost his hat as Bob sprung forward to enter the race. We continue trotting and walking until we are about 5 kilometers from Bere.
"Let's race Bob and Libby. I want to really see what she can do. See that tree to the left just beyond that puddle? It'll be a walk up start. As soon as we enter the shadow of the tree, the race starts."
I feel my heart beat pick up as the tree approaches and we try to keep the horses even. It's a slow walk up. We're only a few feet away. The horses start to sense our excitement...and...we're there. Libby seems to have been expecting it as she rockets forward almost pulling my feet out of the stirrups. I'm holding on for dear life. We're ahead! I then see Bob cut around a little to the left where a side path goes around some bushes. He's picking up speed. At the same time I feel Libby fading, she's just not in shape and running out of energy. Bob leaves us way behind as we continue a slow gallop to the entrance to Bere and do a cool-down walk the rest of the way home.
As i finally pull myself out of the saddle, I can't believe how tired I am. I'm so wobbly I cna barely stay a foot. I'm covered with sweat and fine dust. The horses slurp up bucketfuls of water and then go for a roll as soon as their saddles are off. I take a quick shower and fall into a deep sleep before being awakened shortly by the nurse on duty.
"There's a woman with high blood pressure and seizures. She's seven months pregnant. The cervix is completely dilated."
I give some instructions and go back down to lay down, but then think better of it and get up, put on scrubs and head to the hospital.
The woman is thrashing around on the bed moaning and whining. The cervix is only at three centimeters. We start an oxytocin drip to give her better contractions and I go to see some other patients. The nurse runs to get me.
"She's having a crisis again!"
I enter the labor and delivery room. The husband is at the bed side and the woman is hysterical. It's not a seizure, though, and she quickly calms down when the husband leaves. I order some pain medication and then she has a grand mal seizure. We hurry her to the OR. Luckily Simeon is there and Samedi lives right next door. The woman is combative and agitated and difficult to get on the OR table. We tie her arms and legs down good, prep the abdomen, scrub and gown and drape.
We pray and Simeon gives one milliliter of Ketamine and I slice down to fascia, rip the fascia and muscles open, lift up a bladder flap, slice into the uterus, poke into the amniotic sac and squeeze out a full term baby boy who after a little rubbing and slapping starts to give a healthy cry. I suture up the uterus and skin and head home to finally rest.
James
Tuesday, June 23, 2009
Only God Knows
I've just started rounds on surgery. The young girl operated on for perforated bowel secondary to Typhoid Fever is doing much better. She still has a drain in and we're doing dressing changes on the open wound on her skin incision but she's eating, drinking, walking, pooping and peeing so we are otherwise happy. Suddenly, Carson comes in and in his slow drawl tells me they need me to help find an IV on a kid...it's kind of urgent.
I walk through the open screen door, across the porch covered with convalescing patients and family members lying on colorful mats, across the well-swept courtyard and over to the sidewalk where a small crowd has gathered around a mother with a brightly colored head wrap holding a limp child sitting on a wooden chair facing away from me and towards the white coated nurse bent closely over the child trying to start an IV. It's the new nurse, Tchiptchang. Standing to the side, muscles bulging out of his scrubs, Abel holds a bottle of 5% glucose attached to an IV line waiting for the chance to attach it to a venous access.
I'm quickly filled in as I stride up.
"Really low blood sugar. Sick for a week. Treated at home with market meds and who knows what else. Just came in. Unconscious. We can't get an IV."
The kid's eyes are rolled back in his head. His hands and face are pale. His body is like a rag doll. I listen and he has a faint heart beat. He's barely breathing.
"Let's get him to the OR!"
We rush off around the corner and into the brightly lit OR prep room. We place the child on a gurney and I start doing chest compressions. Abel and Tchiptchang are trying to find a scalp vein. Carson is holding the IV which we have placed subcutaneously on his abdomen which is swelling up. He remains unconscious. I suggest they try and external jugular vein on his neck. Augustin arrives and tries as well. No success. I try a femoral vein on both sides while Abel and Carson take turns doing CPR. I fail on both sides.
The nurses keep trying on the scalp and neck. No luck. I call for another hemoglobin as I can't believe the first one is really 10. He looks too pale. His heart is still beating, though barely. We keep on CPR. He's about 2 1/2 years old. His mom stands in the background, a helpless and hopeless expression on her face. She's probably thinking of all the other small boys she's seen buried in her life and thinking about probably burying hers today.
I'm thinking back to the 4 year old I was just doing similar, unsuccessful, resuscitation efforts on last week. I'm about ready to stop. The hemoglobin comes back 8. We keep on CPR. The nurses keep trying to find an IV. I finally try the right femoral vein again.
I stretch out the skin on his inner thigh. I feel for a pulse but find nothing. I poke blindly with a 22G IV catheter attached to a syringe I aspirate from. I get some dark blood back. I can't really thread the catheter. I take out the needle. No blood. I slowly pull it back until the blood starts to ooze out. I call for the IV tubing and attach the 5% glucose solution and hold the IV to let it run in fast. We tape it down but someone has to hold it just so in order for it to work. Within 30 seconds, the boy's eyes open. A few seconds later he's looking around and starting to move his limbs. He has a strong heart beat and is breathing!
We give him some oral sugar water and show the mom how to keep giving him that all day long.
We let the glucose run in. The nurses finally find a real IV and we start treatment for malaria. Why do some make it and some don't? Only God knows.
James
I walk through the open screen door, across the porch covered with convalescing patients and family members lying on colorful mats, across the well-swept courtyard and over to the sidewalk where a small crowd has gathered around a mother with a brightly colored head wrap holding a limp child sitting on a wooden chair facing away from me and towards the white coated nurse bent closely over the child trying to start an IV. It's the new nurse, Tchiptchang. Standing to the side, muscles bulging out of his scrubs, Abel holds a bottle of 5% glucose attached to an IV line waiting for the chance to attach it to a venous access.
I'm quickly filled in as I stride up.
"Really low blood sugar. Sick for a week. Treated at home with market meds and who knows what else. Just came in. Unconscious. We can't get an IV."
The kid's eyes are rolled back in his head. His hands and face are pale. His body is like a rag doll. I listen and he has a faint heart beat. He's barely breathing.
"Let's get him to the OR!"
We rush off around the corner and into the brightly lit OR prep room. We place the child on a gurney and I start doing chest compressions. Abel and Tchiptchang are trying to find a scalp vein. Carson is holding the IV which we have placed subcutaneously on his abdomen which is swelling up. He remains unconscious. I suggest they try and external jugular vein on his neck. Augustin arrives and tries as well. No success. I try a femoral vein on both sides while Abel and Carson take turns doing CPR. I fail on both sides.
The nurses keep trying on the scalp and neck. No luck. I call for another hemoglobin as I can't believe the first one is really 10. He looks too pale. His heart is still beating, though barely. We keep on CPR. He's about 2 1/2 years old. His mom stands in the background, a helpless and hopeless expression on her face. She's probably thinking of all the other small boys she's seen buried in her life and thinking about probably burying hers today.
I'm thinking back to the 4 year old I was just doing similar, unsuccessful, resuscitation efforts on last week. I'm about ready to stop. The hemoglobin comes back 8. We keep on CPR. The nurses keep trying to find an IV. I finally try the right femoral vein again.
I stretch out the skin on his inner thigh. I feel for a pulse but find nothing. I poke blindly with a 22G IV catheter attached to a syringe I aspirate from. I get some dark blood back. I can't really thread the catheter. I take out the needle. No blood. I slowly pull it back until the blood starts to ooze out. I call for the IV tubing and attach the 5% glucose solution and hold the IV to let it run in fast. We tape it down but someone has to hold it just so in order for it to work. Within 30 seconds, the boy's eyes open. A few seconds later he's looking around and starting to move his limbs. He has a strong heart beat and is breathing!
We give him some oral sugar water and show the mom how to keep giving him that all day long.
We let the glucose run in. The nurses finally find a real IV and we start treatment for malaria. Why do some make it and some don't? Only God knows.
James
Friday, June 12, 2009
Coffin
When I first saw the coffin it was half-finished. Lying amidst a pile of saw dust, it was a crude little thing, but somehow appropriate. Hard, twisted redwood had somehow been fashioned into a 3 foot long box with bottom, back and sides just waiting for the front and top to be able to enclose a little boy's body.
As I walk up to the container where Jeremy and Jonathan are making the coffin, I am struck by the cold beauty of the surroundings. A steel blue sky with gray angry clouds releases a slight drizzle of rain onto the African plain watering the wet sand and scrub bushes. A smattering of mango and Shea butter trees break up the monotony of the flat expanse. A group of tired grave diggers rest against the trunk of a tree to the right. Straight ahead is the beginnings of Gary's airplane hangar with the two old 20 foot containers making up the end of the hangar. Around the half-open doors of one container is gathered a crowd of mostly children with a smattering of adults all peering intently at the two white men making a coffin.
The purr of a small Honda generator is broken intermittently by the harsh roar of a power saw and the shocking pounding of large nails into hard wood. A cool breeze tries to soften the atmosphere which is heavy with grief. I squeeze through the crowd just in time to help Jeremy and Jonathan lift up the coffin, measure around and make the final trimmings. The wood is so hard that holes have to be drilled before nailing or the nails will bend. We place the small head piece on and Jeremy hammers the nails home. The only thing left is to place a small boy, recently alive and well, into the interior and hammer it shut until resurrection day.
The Adventist Youth Society has arrived in their sharp olive and tan uniforms. Jeremy, Jonathan and a couple of local men pick up the heavy burial box and lug it over to Gary and Wendy's humble abode. They place the casket gently on a simple wooden bed on the porch and wait for the final step.
Cherise, Gary and Wendy's two and a half year old daughter, runs in with a smile proudly showing off the cartoonish horse and car that Sarah has drawn on the back of her hands with a green marker.
It's almost time. Neighbors and friends are gathering outside. The rain continues to sprinkle the event as lighting flashes occasionally in the background. Gary looks at me. We walk silently over to the coffin and pick it up. It's rough and twisted wood bites into my hands with the weight of it's import crushing me more than it's physical gravitational force.
Followed by Wendy and Cherise we enter the house, pass through the living room and into the bedroom to the left where Caleb awaits, cold and silent. He is peacefully lying on the floor next to the two mosquito net covered mattresses where he slept with his sister. A small, baby blanket covers most of his lifeless form. Gary and I gently set the coffin down next to him. Gary lifts him up while Wendy arranges the blanket and smoothes it out over his face. Gary picks him up gently in his arms, tears streaming from his red and swollen eyes.
"Let me hold him one more time." Wendy's voice is deep and broken as she hugs her first born son for the last time on this earth.
"Cherise, do you want to kiss Caleb one more time?"; Gary asks softly.
"Yeah, daddy..."; She approaches wiping away a stray strand of pure, blond hair from her cherubic face. She leans forward, lips puckered, and places a tiny kiss on the top of Caleb's pale head.
Gary covers Caleb up again and lays him in the coffin. He fits too well. This shouldn't be happening. I sob quietly, letting the tears flow freely.
We take the even heavier coffin out to the porch where Jeremy expertly pounds the last nails home with a devastating sound of finality. It's definitely time now.
The uniformed young people wait outside. Gary and I place the coffin on the shoulders of six young Chadian girls who will bear the honors.
"Left, left, left-right-left..."; The solemn march begins as we all fall in behind while the young people sing a mournfully echoing marching song about following Jesus no matter the cost. The procession winds out the gate, around the fence, past the water tower and out towards the airstrip.
Gary's plane stares silently, it's windows covered with a tarp as if even it is too grief-stricken to observe the final steps of the young boy who loved so much to greet his daddy's return from mission flights or climb all over the cockpit dreaming of the day when he too would fly.
We march across the deep red laterite surface of the airstrip, cross a sandy path, pass through some low scrub brush and arrive at the six foot deep hole that will be Caleb's resting site until the end of the world. A pile of sandy clay with two hand made ropes strung across it lays to the side of the grave. The coffin is marched around the hole and deposited carefully on top of the ropes and dirt pile. A crowd has gathered. The wind blows. The rain falls. The universe mourns.
As I walk up to the container where Jeremy and Jonathan are making the coffin, I am struck by the cold beauty of the surroundings. A steel blue sky with gray angry clouds releases a slight drizzle of rain onto the African plain watering the wet sand and scrub bushes. A smattering of mango and Shea butter trees break up the monotony of the flat expanse. A group of tired grave diggers rest against the trunk of a tree to the right. Straight ahead is the beginnings of Gary's airplane hangar with the two old 20 foot containers making up the end of the hangar. Around the half-open doors of one container is gathered a crowd of mostly children with a smattering of adults all peering intently at the two white men making a coffin.
The purr of a small Honda generator is broken intermittently by the harsh roar of a power saw and the shocking pounding of large nails into hard wood. A cool breeze tries to soften the atmosphere which is heavy with grief. I squeeze through the crowd just in time to help Jeremy and Jonathan lift up the coffin, measure around and make the final trimmings. The wood is so hard that holes have to be drilled before nailing or the nails will bend. We place the small head piece on and Jeremy hammers the nails home. The only thing left is to place a small boy, recently alive and well, into the interior and hammer it shut until resurrection day.
The Adventist Youth Society has arrived in their sharp olive and tan uniforms. Jeremy, Jonathan and a couple of local men pick up the heavy burial box and lug it over to Gary and Wendy's humble abode. They place the casket gently on a simple wooden bed on the porch and wait for the final step.
Cherise, Gary and Wendy's two and a half year old daughter, runs in with a smile proudly showing off the cartoonish horse and car that Sarah has drawn on the back of her hands with a green marker.
It's almost time. Neighbors and friends are gathering outside. The rain continues to sprinkle the event as lighting flashes occasionally in the background. Gary looks at me. We walk silently over to the coffin and pick it up. It's rough and twisted wood bites into my hands with the weight of it's import crushing me more than it's physical gravitational force.
Followed by Wendy and Cherise we enter the house, pass through the living room and into the bedroom to the left where Caleb awaits, cold and silent. He is peacefully lying on the floor next to the two mosquito net covered mattresses where he slept with his sister. A small, baby blanket covers most of his lifeless form. Gary and I gently set the coffin down next to him. Gary lifts him up while Wendy arranges the blanket and smoothes it out over his face. Gary picks him up gently in his arms, tears streaming from his red and swollen eyes.
"Let me hold him one more time." Wendy's voice is deep and broken as she hugs her first born son for the last time on this earth.
"Cherise, do you want to kiss Caleb one more time?"; Gary asks softly.
"Yeah, daddy..."; She approaches wiping away a stray strand of pure, blond hair from her cherubic face. She leans forward, lips puckered, and places a tiny kiss on the top of Caleb's pale head.
Gary covers Caleb up again and lays him in the coffin. He fits too well. This shouldn't be happening. I sob quietly, letting the tears flow freely.
We take the even heavier coffin out to the porch where Jeremy expertly pounds the last nails home with a devastating sound of finality. It's definitely time now.
The uniformed young people wait outside. Gary and I place the coffin on the shoulders of six young Chadian girls who will bear the honors.
"Left, left, left-right-left..."; The solemn march begins as we all fall in behind while the young people sing a mournfully echoing marching song about following Jesus no matter the cost. The procession winds out the gate, around the fence, past the water tower and out towards the airstrip.
Gary's plane stares silently, it's windows covered with a tarp as if even it is too grief-stricken to observe the final steps of the young boy who loved so much to greet his daddy's return from mission flights or climb all over the cockpit dreaming of the day when he too would fly.
We march across the deep red laterite surface of the airstrip, cross a sandy path, pass through some low scrub brush and arrive at the six foot deep hole that will be Caleb's resting site until the end of the world. A pile of sandy clay with two hand made ropes strung across it lays to the side of the grave. The coffin is marched around the hole and deposited carefully on top of the ropes and dirt pile. A crowd has gathered. The wind blows. The rain falls. The universe mourns.
The service starts with a couple of French hymns that have never had much meaning for me until now.
"Jusqu'a la mort, c'est notre cri de guerre, le libre cri d'un peuple rachete, jusqu'a la mort nous te serons fideles..."; (Even unto death, it's our battle cry, the free cry of a redeemed people, even unto death we will be faithful...) Even song off tune the deep feeling of those singing it penetrates to the bottom of my heart. We are free, we are at war, their are casulties, but we don't mourn as those who have no hope...we will stay faithful...my heart wants to believe it.
"Et mon coeur n'a rien a craindre, puisque tu me conduiras. Je te suivrai sans me plaindre en m'appuyant sur ton bras." (And my heart has nothing to fear, because You are guiding me. I will follow You without complaint, leaning on your arm). A cold chill runs down my spine as I feel the presence of God. He is present. He weeps with us at this tragedy. We have nothing to fear.
After I give opening prayer, Andre exhorts us with a little eulogy reminding us that death is a sleep, that our hope is in the resurrection when Jesus comes again to reunite all of us who have abandoned our rebellion against him. Caleb's suffering is over, it's those of us left on earth who suffer, but Jesus is coming soon to wipe every tear from our eyes and destroy our last enemy, death.
Then, Gary talks about how much Caleb loved to talk about Jesus and his second coming and then he had us sing together Caleb's favorite song in English:
"When the trumpet of the Lord shall sound, and time shall be no more...when the roll is called up yonder I'll be there!";
Unfortunately, as the local gravediggers go to lay the coffin in the tomb they realize they've made the hole too small. As they rush to and fro quickly to dig the grave larger, the chorale saves the day with a some traditional, echo and repeat style African songs. Finally, the modifications are made and the coffin is slowly lowered into it's final resting place with the help of the rough ropes.
As the dirt starts to be shoveled on top of the coffin, Cherise seems to realize a little what's going on. Her heart-breaking cries and tears tear us all apart. Gary crouches down gently beside her.
"What is Caleb doing right now?";
"Sleeping, daddy."
"And when will he wake up."
"Oh yeah, when Jesus comes." Her face lights up a little and she wipes her eyes as Wendy picks her up and holds her close.
As the crowd starts spontaneously singing in Nangjere, the grave-diggers expertly create the funeral mound. A handmade hoe, a stick and the end of a shovel pound and stir the earth into place as two other men shovel the earth in and continually pick up what has fallen to the sides. Then with some final pounding with the flats of the shovels a perfectly oval mound arises as only those who've seen much death and assisted many funerals could make it.
We then turn to follow the Advent Youth as they lead us back singing the same marching songs. Arriving at the house, we follow local custom by seating Gary, Wendy and Cherise in lounge chairs along with the other participants in the memorial service while the mourners pass one by one to greet. The women curtsy and bow while solemnly shaking hands, often with two hands or the second hand touching the forearm of the right hand as they shake as a sign of respect. The men shuffle and nod somberly as they hold the hands for a long time and silently let you know they feel your loss (and they all have lost children so it means something). One crippled man on crutches hobbles in and hugs both parents while tears stream down his cheeks.
Finally, the kids file in for their respectful shaking of hands as the adults take a seat on mats spread out behind the choral which has been singing French hymns without ceasing. Annie and some of the local women serve Kool-Aid. People quietly converse. Occasional sobs burst forth. Laughter is sometimes heard. Gary and Wendy are periodically called away by phone calls from well-wishers around the world.
Dusk approaches. Noel rises and calls an end to the wake with a prayer. They graciously don't insist on their custom of singing, dancing and drumming all night long. Instead, everyone files solemnly out shaking our hands one last time. About this time, Rich and Anne, our friends from N'Djamena arrive.
The sun sets on a day that started out as any other day and quickly tumbled into an early morning ER call, a desperate last ditch effort and the laying to rest of a four year old boy in a crude, twisted coffin, resting peacefully in the African bush through the rest of this world's turmoil until the end of the world and the beginning of the next when God will wipe every tear from our eyes and our last enemy death will die as we all are reunited with those we have lost.
James
Wednesday, June 10, 2009
Tragedy
"Hurry to the ER! James! Run!" The familiar words come not in the usual African French but in the familiar English of our friends, Gary and Wendy Roberts as they whiz by the house on their motorcycle.
I'd just gotten up a little before 5:00am to write email when I heard the roar of the moto and the cries of the anguished parents.
I quickly pull on some scrubs and rush out the door where I run into Sarah who's just come to get me. She is just finishing up a night shift in the ER. It's about 6:00am.
The hospital is bathed with an early morning tranquility that would've been soothing on any other morning but this one.
I arrive at the ER and see Gary bent over his son, Caleb, giving him mouth to mouth as his pale, limp body wants to sink into the top of the desk he's lying on.
"He was still breathing as we were coming but he just stopped. He has no heart beat!"
I start giving chest compressions as I bark out orders to Sarah, Wendy, Koumabas, Hortance and Augustin who luckily happens to be there.
"Get some IV glucose and some IV tubing!"
"Someone look for an IV!"
"Call the lab for a hemoglobin and glucose check!"
"Get the pulse ox from the OR!"
As they rush off to find the material I look closer at Caleb. His body is flaccid, his face is pale and haggard, eyes closed, mouth half open, a mild gurgling coming out of his throat with each chest compression. He has no heart beat and his lungs sound filled with fluid. His belly is soft with an enlarged liver.
Gary takes over chest compressions as Hortance hands me the D5W attached to some IV tubing which I quickly insert under the skin of his stomach for a subcutaneous perfusion of glucose in case his blood sugar is low.
"Give him half an ampoule of IV furosemide IM.
Augustin is patiently searching for an IV on Caleb's small, white hands and arms. Sarah arrives with the pulse oximeter. We continue chest compressions. The O2 sat is 15%. I have Gary start rescue breathing again. The pulse ox stops working.
"Sarah, get some Adrenaline and Atropine from the OR!"
Still no IV.
"Koumabas, get me a blue IV catheter and a 5cc seringe!"
I keep doing compressions while Gary does two rescue breaths every 10 cardiac compressions.
Wendy has come back with an epi-pen and accidentally sticks her thumb with it instead of Caleb's leg.
Sarah gives Adrenaline and Atropine intramuscularly.
I listen and detect a faint, slow heart beat.
We continue CPR.
"Wendy, find me one of those small red, urine catheters in the OR so we can empty his bladder!"
Koumabas gives me the IV catheter with which I miraculously find his right femoral vein on the first try despite feeling no pulse and am able to thread the catheter in. I attach the IV glucose bottle and let it run in.
Meanwhile Mathieu has arrived and now has the results: hemoglobin a little low and blood sugar extremely low.
Wendy returns with the foley and Augustin drains Caleb's bladder. Calebs lungs are clearer. He still has a faint heartbeat.
"Sarah, inject the Adrenaline as rapidly as you can....now!" I quickly pump Caleb's heart has fast as I can with my external compressions to get the medicine to his heart.
"Sarah, take over chest compressions, I'm going to find some Magnesium in my office!"
The magnesium goes in the IV fluids and slowly trickles in.
Gary still does rescue breathing. Wendy offers to take over but Gary wants to keep going.
"Mathieu, can we do a Potassium?"
"Oui!"
I draw a milliliter of dark blood from Caleb's femoral vein and Mathieu hurries off to the lab.
CPR continues. We've been going for 40 minutes.
I listen to Caleb's chest. No heartbeat.
We continue CPR.
"Sarah, more atropine."
Gary speaks up after his 2 rescue breaths. "Should we stop?"
"Let's go just a little more."
Atropine is in. We continue CPR 5 more minutes.
I listen to Caleb's heart...
Nothing.
We stop.
Gary and Wendy collapse weeping into each others arms as sobs explode from within my chest. I grab Gary from the side my arm draped across his neck. Sarah is on the other side hugging Wendy.
Gary solemnly wraps up the still, little body.
"Do you want to use the van? We can drive you back home."
Gary turns to Wendy, "No, let's just put him between us on the motorcycle and go home."
"Anything we can do?"
"No, we just want some alone time. Then in the afternoon we'll have a service." The trudge out to the motorcycle, the quiet bundle in Gary's arms.
Tears streaming down my face I walk slowly back home thinking back to September 3, 2001 when I also found myself stopping CPR on someone I loved and sadly giving them up temporarily into God's hands. Just like then when I told my twin brother, "I know where you'll be...I just better make sure I'm there as well," I think the same thing about little Caleb and can't wait to see him again, maybe even by my brother David's side, when things are finally finished down here.
But, meanwhile, I'm back home sobbing like a baby. Sarah walks in and kneels down in front of me. We embrace and cry together. Outside, the wind is blowing, whipping up a storm. It starts to rain. God is crying too.
Message from: James Appel
I feel a cold sweat creeping along the surface of my skin. A sensation of nausea rises to my throat. I desperately try to focus my eyes somewhere that will calm the waves of motion sickness but as the Cessna 172 lurges and plunges in the turbulence 7500 feet above the surface of a desert in a wall of dust and clouds there seems to be no escape.
"I think I might need one of those barf bags Sarah just brought you." I stoically mention to Gary.
"Here, you better start flying again, that often helps...gives you a little sense of control when it's turbulent."
I grab the controls and try to remember to make small adjustments back and forth and side to side as my gaze shifts rapidly between the horizon and the various instruments on the panel as I try to maintain altitude, direction, vertical speed, and bearings as the thermals rising from the hot sand below buffet us up and down and side to side.
My nausea slowly disappears.
An hour later we as we approach Bere I give the controls back to Gary for the landing. The two men in the back from the Chadian government who have come to evaluate our work at the hospital break the silence with a heartfelt "Dieu merci" as the plane touches down smoothly and taxis in to the waiting hospital van.
I greet Levi warmly and we pack up and head to the hospital.
What was starting to turn green with the early April rains has changed to a dreary brown.
"I guess I must have taken the rain with me to the US," I joke with Levi. "A week after arriving in Florida they had a two week long rain storm that ended their drought. Don't worry, though, I brought it back with me!"
We both laugh, but half hope it's true as people are already starting to talk about famine this year (although they do every year no matter how much rain we get.)
I get our visitors settled in the guest house and change into scrubs to take a quick tour of the hospitalized patients.
The arab man with the broken tibia and jaw is elated to see me and immediately asks to have the PVC pipe external fixator removed. The wiring on his jaw was taken off a few days ago and seems to be well healed. The leg looks good too, we'll have to send him to Moundou for an x-ray since ours has been broken for years.
Mathieu, our friend who spent a month collecting a seriously infected fracture with the local traditional bone setters before coming to us just in time to save his leg waves to me from across the room. I greet him and take a brief look at the wound which has closed up somewhat but is still quite deep into the gap left where we'd removed the infected bone.
All the other patients are new.
That evening I am woken up by a fierce wind followed by a scattered rain. The next few days we have several intense thunderstorms. The drought is over. It's good to be back.
Friday, March 20, 2009
Hellp
I start rounds right across from labor and delivery. A long man operated on two days ago for hydrocele and hernia is sent home after being advised to quit drinking as his alcoholism became evident during his difficult Ketamine anesthesia. A pregnant woman who came in yesterday with a hemoglobin of 4.3 sits with a blood bag attached to her arm with the plasma still inside. She has got two 450ml bags of whole blood and needs more but no family members can be found. The baby with the ileostomy is sleeping comfortably beside her mother. The ostomy that herniated out last night is back in place and the midline incision appears to be healing well.
The little girl in the old maintenance closet turned into isolation ward is sitting up half naked eating some porridge. Six days of Chloramphenicol with a single dose of Ceftriaxone have done wonders to transform her meningitis coma into a hope of full recovery.
Moving past the nurses station and the chaplain's office I greet the Fulani nomad woman with a long, gunnysack sewn up wound across her chest into her armpit where her tumor filled breast and lymphnodes used to be. The deep cavity left by the removed lymphnodes has become infected and is being dressed with diluted bleach. She wants to go back to the bush where she can drink milk from her own cows. She just doesn't like the food available here in Bere. We finally convince her son to keep her here.
Two men operated on yesterday for large inguinal scrotal hernias grace the next two beds. I order there IVs out and for them to get up and ambulate.
Beside them is a woman who's life we barely saved three months ago. She had been in labor for 3 days and came in with a dead and decomposing baby stuck in her small pelvis. A symphysiotomy brought the baby out quickly but the gangrenous flesh had to be debrided several times and her vagina packed for weeks with diluted bleach soaked compresses and heavy doses of antibiotics. As a result, she developed an enormous vesico-vaginal fistula and a scarred down vaginal vault and cervix. Three days ago I attempted a vaginal repair with not much success. That evening I was awoken by a sense of God's presence and an idea to operated on her the next day which I did opening up her bladder from the abdominal side and inserting a ureteral catheter into her right ureter to drain the urine out the abdominal wall. Her left ureter appeared scarred down as the catheter wouldn't pass. I then closed up the defect from on top and left the a foley catheter in the urethra and the uretral catheter coming out her lower abdomen.
Today there is clear urine out of the right ureteral catheter and bloody urine out of the bladder drain meaning that maybe her left ureter is working after all. More importantly, she has no vaginal leakage.
An emaciated Arab lies across the way. I saw him at 4:30 this morning with almost no blood pressure and a raging fever. He responded to IV fluids and IV quinine. I suspect him of AIDS and add broad spectrum antibiotics. His HIV status is confirmed later and he dies in the early afternoon.
Meanwhile I move on to the middle aged woman who had a hysterectomy yesterday for fibromas. She is well. Next to her is a woman who has had her knees permanently bent since the age of 12 due to burn contractures until January when Dr. Bond released her right leg. I released her left leg in February and the wounds are healing well and she can almost straighten both legs now.
First bed on the left in the men's ward is a man with an abscess deep in his thigh to the side of his hip joint and back into his gluteus. The drain is still working and the swelling and pain have gone down. His neighbor is another hernia that is sent home. To the right is a man with gangrene of the scrotum debrided radically 6 days ago who got malaria and had a hemoglobin of 4.7 found yesterday who is still waiting for other family members to come since no one has the right blood type. His wound is much better and he is sitting up comfortably.
Missing from their mosquito net covered beds are the two miracle burn kids who are almost healed without skin grafts. In fact, little Bai has become Sarah's little adopted kid and walks around with her squirting patients with syringes full of water and sitting in her lap for morning worship. The older girl is healing well but is depressed and doesn't want to get up.
The young man who was stabbed clear through the front of his shin between his two leg bones into the back of his calf severing his large vein and puncturing his artery is doing better today. I thought he had an abscess so took him to the OR by myself only to find myself removing massive clumps of blood clot releasing a pent up surge of raging blood. Since it was coming from behind the tibia there was no way to compress it. I ran and pulled up a used suction tubing from a basin and quickly tied it around his leg above the knee to stop the bleeding before calling in help, opening up his calf, dissecting down to the vessels, suturing the hole in the artery and tying off both ends of the vein. He know complains of foot pain. I prescribe Ibuprofen and paracetamol.
His neighbor is the man who came back a month after refusing surgery for an open tibia fracture with his leg completely infected, swollen, edematous and spilling out pus from a non-union broken bone. We had to radically remove the front of the tibia and pierce his tibia with four Steinmann pins attached to some PVC pipe to act as an external fixator. The wound still smells but is much better and fortunately the pus around the pins is starting to dry up.
I tell Simeon and Abel to prepare the woman for the hysterectomy, do the spinal anesthesia and call me. Meanwhile I round on a pediatric ward filled with Malaria kids, most of whom are recovering and can be sent home.
I do the fastest hysterectomy of my life and go out to do a couple of ultrasounds while the OR crew prepares the 4 year old boy with bladder stones. As I approach my office a well-dressed woman greets me with her cute little daughter. She's about 4 years old with a spotless, frilly baby blue dress and newly braided hair and a sweet smile as she profers me her hand in a shy greeting.
"Do you recognize her? You delivered her by c-section in 2004 when you first came here."
I don't remember, but smile and nod as I go into my office with warmth in my heart.
I finish the first ultrasound and Sarah peeps in the door.
"You better see this patient in the ER."
"You mean now, is it urgent?"
"Yes, this woman is crashing!"
I rush out across the campus under the mango trees to the ER.
A woman lies in an army stretcher barely breathing, swollen eyes shut and gurgling through a weak respiratroy effort. She is obviously pregnant.
"Augustin, Job, Prudence! Grab her and bring her directly to the OR!"
We dump her directly onto the OR table and I prepare to intubate her as Abel quickly finds an IV. She starts to bleed as I search for her swollen vocal cords and finally slip the ET tube through with help from Simeon's cricoid pressure. I call for another IV and a glucometer and hemoglobin measurement. Her body is burning up so we have Ringer's Lactate running wide open on her right arm and IV quinine on her left. Simeon has put in an NG tube releasing some nasty gastric contents which spill onto the floor from the open urine bag attached to the end. She starts to gurgle blood from her nose and mouth in frothy spurts. Simeon suctions. Her glucose comes back way low and we trade Ringers' for Dextrose.
I go get the ultrasound from my office and confirm a normal fetal heartbeat, cephalic presentation and 33 weeks estimated gestational age. Her blood pressure is initially normal but suddenly sky rockets and stays high. We do a urine dipstick which is highly positive for protein suggesting the diagnosis of pre-eclampsia. With her enlarged liver and uncontroallable bleeding I also suspect HELLP syndrome. The only thing is to deliver the baby.
A quick, uneventful c-section brings a small but well-developed boy into the world with great tone and grimace. I pass him off to Hortance and sew up the uterus, fascia and skin. The woman is still doing poorly with heart rate over 150/minute and high blood pressure and low O2 saturations. Blood is everywhere as she continues to spray bloody foam all over. I don't hear a cry from the baby but Hortance has said he was breathing. I go over to look and find him pale, limp, with no respiratory effort and a slow heartbeat. I am furious and try desperately to do CPR and bring him back but it's too late.
We leave the woman in the OR on a gurney where we can monitor and suction her. We get two bags of whole blood running hoping the platelets will help the bleeding. We operate on the 4 year old pulling out two marble sized stones out of him and closing him up uneventfully. The woman is still breathing but sating in the low 80's. The watery blood continues to well up out of her nostrils and gurgle out her oral airway that has replaced her ET tube since we don't have a ventilator.
A quick inguinal hernia on a woman is done quickly and finally we decide to just wheel the woman out to the wards since the family is getting anxious and people don't understand when someone dies in the OR; they tend to think you killed them.
Gasps of fear flutter up from the crowd of relatives gathered outside surgery as we wheel the blood specked woman and gurney out to the wards. We drop her in a bed, tell the husband to wipe up the blood as it spouts out of the mouth and nose, write orders for IV fluids and IV quinine and leave her in God's hands.
The little girl in the old maintenance closet turned into isolation ward is sitting up half naked eating some porridge. Six days of Chloramphenicol with a single dose of Ceftriaxone have done wonders to transform her meningitis coma into a hope of full recovery.
Moving past the nurses station and the chaplain's office I greet the Fulani nomad woman with a long, gunnysack sewn up wound across her chest into her armpit where her tumor filled breast and lymphnodes used to be. The deep cavity left by the removed lymphnodes has become infected and is being dressed with diluted bleach. She wants to go back to the bush where she can drink milk from her own cows. She just doesn't like the food available here in Bere. We finally convince her son to keep her here.
Two men operated on yesterday for large inguinal scrotal hernias grace the next two beds. I order there IVs out and for them to get up and ambulate.
Beside them is a woman who's life we barely saved three months ago. She had been in labor for 3 days and came in with a dead and decomposing baby stuck in her small pelvis. A symphysiotomy brought the baby out quickly but the gangrenous flesh had to be debrided several times and her vagina packed for weeks with diluted bleach soaked compresses and heavy doses of antibiotics. As a result, she developed an enormous vesico-vaginal fistula and a scarred down vaginal vault and cervix. Three days ago I attempted a vaginal repair with not much success. That evening I was awoken by a sense of God's presence and an idea to operated on her the next day which I did opening up her bladder from the abdominal side and inserting a ureteral catheter into her right ureter to drain the urine out the abdominal wall. Her left ureter appeared scarred down as the catheter wouldn't pass. I then closed up the defect from on top and left the a foley catheter in the urethra and the uretral catheter coming out her lower abdomen.
Today there is clear urine out of the right ureteral catheter and bloody urine out of the bladder drain meaning that maybe her left ureter is working after all. More importantly, she has no vaginal leakage.
An emaciated Arab lies across the way. I saw him at 4:30 this morning with almost no blood pressure and a raging fever. He responded to IV fluids and IV quinine. I suspect him of AIDS and add broad spectrum antibiotics. His HIV status is confirmed later and he dies in the early afternoon.
Meanwhile I move on to the middle aged woman who had a hysterectomy yesterday for fibromas. She is well. Next to her is a woman who has had her knees permanently bent since the age of 12 due to burn contractures until January when Dr. Bond released her right leg. I released her left leg in February and the wounds are healing well and she can almost straighten both legs now.
First bed on the left in the men's ward is a man with an abscess deep in his thigh to the side of his hip joint and back into his gluteus. The drain is still working and the swelling and pain have gone down. His neighbor is another hernia that is sent home. To the right is a man with gangrene of the scrotum debrided radically 6 days ago who got malaria and had a hemoglobin of 4.7 found yesterday who is still waiting for other family members to come since no one has the right blood type. His wound is much better and he is sitting up comfortably.
Missing from their mosquito net covered beds are the two miracle burn kids who are almost healed without skin grafts. In fact, little Bai has become Sarah's little adopted kid and walks around with her squirting patients with syringes full of water and sitting in her lap for morning worship. The older girl is healing well but is depressed and doesn't want to get up.
The young man who was stabbed clear through the front of his shin between his two leg bones into the back of his calf severing his large vein and puncturing his artery is doing better today. I thought he had an abscess so took him to the OR by myself only to find myself removing massive clumps of blood clot releasing a pent up surge of raging blood. Since it was coming from behind the tibia there was no way to compress it. I ran and pulled up a used suction tubing from a basin and quickly tied it around his leg above the knee to stop the bleeding before calling in help, opening up his calf, dissecting down to the vessels, suturing the hole in the artery and tying off both ends of the vein. He know complains of foot pain. I prescribe Ibuprofen and paracetamol.
His neighbor is the man who came back a month after refusing surgery for an open tibia fracture with his leg completely infected, swollen, edematous and spilling out pus from a non-union broken bone. We had to radically remove the front of the tibia and pierce his tibia with four Steinmann pins attached to some PVC pipe to act as an external fixator. The wound still smells but is much better and fortunately the pus around the pins is starting to dry up.
I tell Simeon and Abel to prepare the woman for the hysterectomy, do the spinal anesthesia and call me. Meanwhile I round on a pediatric ward filled with Malaria kids, most of whom are recovering and can be sent home.
I do the fastest hysterectomy of my life and go out to do a couple of ultrasounds while the OR crew prepares the 4 year old boy with bladder stones. As I approach my office a well-dressed woman greets me with her cute little daughter. She's about 4 years old with a spotless, frilly baby blue dress and newly braided hair and a sweet smile as she profers me her hand in a shy greeting.
"Do you recognize her? You delivered her by c-section in 2004 when you first came here."
I don't remember, but smile and nod as I go into my office with warmth in my heart.
I finish the first ultrasound and Sarah peeps in the door.
"You better see this patient in the ER."
"You mean now, is it urgent?"
"Yes, this woman is crashing!"
I rush out across the campus under the mango trees to the ER.
A woman lies in an army stretcher barely breathing, swollen eyes shut and gurgling through a weak respiratroy effort. She is obviously pregnant.
"Augustin, Job, Prudence! Grab her and bring her directly to the OR!"
We dump her directly onto the OR table and I prepare to intubate her as Abel quickly finds an IV. She starts to bleed as I search for her swollen vocal cords and finally slip the ET tube through with help from Simeon's cricoid pressure. I call for another IV and a glucometer and hemoglobin measurement. Her body is burning up so we have Ringer's Lactate running wide open on her right arm and IV quinine on her left. Simeon has put in an NG tube releasing some nasty gastric contents which spill onto the floor from the open urine bag attached to the end. She starts to gurgle blood from her nose and mouth in frothy spurts. Simeon suctions. Her glucose comes back way low and we trade Ringers' for Dextrose.
I go get the ultrasound from my office and confirm a normal fetal heartbeat, cephalic presentation and 33 weeks estimated gestational age. Her blood pressure is initially normal but suddenly sky rockets and stays high. We do a urine dipstick which is highly positive for protein suggesting the diagnosis of pre-eclampsia. With her enlarged liver and uncontroallable bleeding I also suspect HELLP syndrome. The only thing is to deliver the baby.
A quick, uneventful c-section brings a small but well-developed boy into the world with great tone and grimace. I pass him off to Hortance and sew up the uterus, fascia and skin. The woman is still doing poorly with heart rate over 150/minute and high blood pressure and low O2 saturations. Blood is everywhere as she continues to spray bloody foam all over. I don't hear a cry from the baby but Hortance has said he was breathing. I go over to look and find him pale, limp, with no respiratory effort and a slow heartbeat. I am furious and try desperately to do CPR and bring him back but it's too late.
We leave the woman in the OR on a gurney where we can monitor and suction her. We get two bags of whole blood running hoping the platelets will help the bleeding. We operate on the 4 year old pulling out two marble sized stones out of him and closing him up uneventfully. The woman is still breathing but sating in the low 80's. The watery blood continues to well up out of her nostrils and gurgle out her oral airway that has replaced her ET tube since we don't have a ventilator.
A quick inguinal hernia on a woman is done quickly and finally we decide to just wheel the woman out to the wards since the family is getting anxious and people don't understand when someone dies in the OR; they tend to think you killed them.
Gasps of fear flutter up from the crowd of relatives gathered outside surgery as we wheel the blood specked woman and gurney out to the wards. We drop her in a bed, tell the husband to wipe up the blood as it spouts out of the mouth and nose, write orders for IV fluids and IV quinine and leave her in God's hands.
Sunday, March 15, 2009
The bell tolls
It's early Sunday morning and the drums are pounding. Deep, holding bass thumps with rhythic higher pitched hypnotizing beats wafting through the background. In a few minutes, a mournful call pierces the African pre-dawn calling the faithful to the first prayer of the day with a long, drawn out "Allahu akbar!" Finally, to complete the symphony, church bells start tolling across town as the dawn breaks. But the music is rudely interrupted by a harsh clanging on our sheet metal door that can only be pounded out by the bare knuckles of a nurse seeking a doctor.
"Yeah?!" I mumble.
"C'est moi, it's me, Augustin."
"I'm coming!"
I fumble for my shorts hanging over the foot of the bed and stumble out the door to the porch where I open the screen door and come face to face with our charge nurse bearing a flashlight and a small carnet which serves as our patients' portable medical records.
"I just received a young boy who has respiratory distress. His whole chest caves in and you can hear the noise of his breathing clear across campus."
As I hurriedly put on my scrubs and follow Augustin through the bushes, around Lazare's fire pit, under the mango trees, on top of the straw and horse poop, to the side of the container, and through the gate into the hospital compound I understand what he means as I can hear a high pitched rasping coming from the dimly lit emergency room door.
A young boy is slouched across his mother's lap as she balances on a stool holding him up under the arm pits as his lower chest literally caves in all the way to his spine while desperately trying to suck in oxygen as he lets out a stridorous breath. His eyes are bugging out and almost rolling back. I listen to his chest with my stethescope and hear practically nothing. I place it on his neck and hear loud stridor. I get him to open his mouth and where the back of his throat should be is a smooth, bulging mass.
I'm afraid I won't get him to the OR in time. I call Caroline to help me and pick up the child in my arms as I jog over to the OR, flip the padlock to the secret code, insert the key in the door and burst into the OR. Fortunately, this morning the batteries have held their charge through the night and we have light. However, I'm afraid the power will go out any minute so I send Augustin to wake up Steve to turn on the generator.
Meanwhile, I lay the child on the operating table and give him a shot of IM Ketamine while Caroline searches for an IV. Just then, power goes out but I hear the slowly increasing thump thump thump of the Lister engine starting up and in a few seconds I can turn on the overhead OR lights and we are back in business.
I dump the cardboard box of endotracheal tubes on the floor as I rifle through them searching for one small enough for my patient. I finally find a 6.0 uncuffed tube and grab the laryngoscope out of the bottom drawer of the anesthesia machine as I slip on gloves. Caroline now has the IV running and the boy is now under Ketamine anesthesia. I find a guide wire, put it in the ET tube, check the light on the laryngoscope, raise the bed and open the kid's mouth. There is no way I'm going to see the vocal cords, the entire back of the throat is swollen shut.
I toss the equipment aside, grab a 15 blade scalpel and a suture removal kit, slice vertically down the middle of the neck, find the space between the tracheal and cricoid cartilages and poke through into his wind pipe with a hemostat. I spread it open, suction out blood and shove in the ET tube. I then hook up a bag and give him some breaths. The chest rises and I see vapor in the tube. I check with a stethescope hear breath sounds only on the right. The tube's in too far. I pull it out slightly, confirm there's now bilateral breath sounds, suture the wound closed, suture the tube in place and continue bagging.
His oxygen saturation is now up to 92% from the initial 35% so I stop bagging and just let him breath through the tube. His sats hover around 84-88% which isn't great, but without a ventilator and labs to follow it's more dangerous to bag him then to let him breath on his own.
I then try to place a nasogastric tube so he can be fed past the obstruction in his throat. It won't pass the mass. I stick my finger in his mouth and try to shove the tube in through his nose while feeding it past the mass with my finger. Suddenly, pus gushes out his mouth. I've ruptured the peritonsillar abcess. I quickly suck out the foul smelling pus and am relieved that it was so easily taken care of.
We wheel him out to his room and give his family instructions.
Later that evening, I go to check on him and find his tube choked up with secretions. We have a suction with a trap that allows me to put one end down the ET tube and then by sucking on the other end pull out the gunk into a chamber between the two ends. Very high tech. He starts to breath easier. I tell Jason to check on him every hour and suction as needed.
The next morning, he is awake, but tired and breathing fairly easily through the tube. I have the family members sit him up, suction him one more time even though it's pretty clear and move on to the other hospitalized patients.
In less than 15 minutes, Annie comes running up to me.
"Stuff's coming out his trach, he's not breathing!"
I run back to his room, chase out the family members and see instantly his tube is clogged up with pus that's dripping out. As I grab the suction to clear his airway I see he's not breathing and his eyes are rolled back. He has no pulse. As I suction, Jacques starts chest compressions. When the airway is clear I attach the bag and start breathing for him.
We take him to the OR quickly. We attach our cardiac monitor. He finally gets a heartbeat back with a pulse but after a few minutes it slows down again until we do more chest compressions to bring it back. We try multiple doses of Atropine and Adrenaline. His oxygen saturation stays in the mid to upper 80's when we bag him. But he just doesn't want to come back. Finally, after 90 minutes we are forced to stop. We wrap him in a cloth and call in the family. The dad nods, he's been expecting it. He wraps the boy up in his arms, carries him out and the family mournfully walks out the gate.
The drum beats on. The call to prayer continues. The bell keeps on tolling.
"Yeah?!" I mumble.
"C'est moi, it's me, Augustin."
"I'm coming!"
I fumble for my shorts hanging over the foot of the bed and stumble out the door to the porch where I open the screen door and come face to face with our charge nurse bearing a flashlight and a small carnet which serves as our patients' portable medical records.
"I just received a young boy who has respiratory distress. His whole chest caves in and you can hear the noise of his breathing clear across campus."
As I hurriedly put on my scrubs and follow Augustin through the bushes, around Lazare's fire pit, under the mango trees, on top of the straw and horse poop, to the side of the container, and through the gate into the hospital compound I understand what he means as I can hear a high pitched rasping coming from the dimly lit emergency room door.
A young boy is slouched across his mother's lap as she balances on a stool holding him up under the arm pits as his lower chest literally caves in all the way to his spine while desperately trying to suck in oxygen as he lets out a stridorous breath. His eyes are bugging out and almost rolling back. I listen to his chest with my stethescope and hear practically nothing. I place it on his neck and hear loud stridor. I get him to open his mouth and where the back of his throat should be is a smooth, bulging mass.
I'm afraid I won't get him to the OR in time. I call Caroline to help me and pick up the child in my arms as I jog over to the OR, flip the padlock to the secret code, insert the key in the door and burst into the OR. Fortunately, this morning the batteries have held their charge through the night and we have light. However, I'm afraid the power will go out any minute so I send Augustin to wake up Steve to turn on the generator.
Meanwhile, I lay the child on the operating table and give him a shot of IM Ketamine while Caroline searches for an IV. Just then, power goes out but I hear the slowly increasing thump thump thump of the Lister engine starting up and in a few seconds I can turn on the overhead OR lights and we are back in business.
I dump the cardboard box of endotracheal tubes on the floor as I rifle through them searching for one small enough for my patient. I finally find a 6.0 uncuffed tube and grab the laryngoscope out of the bottom drawer of the anesthesia machine as I slip on gloves. Caroline now has the IV running and the boy is now under Ketamine anesthesia. I find a guide wire, put it in the ET tube, check the light on the laryngoscope, raise the bed and open the kid's mouth. There is no way I'm going to see the vocal cords, the entire back of the throat is swollen shut.
I toss the equipment aside, grab a 15 blade scalpel and a suture removal kit, slice vertically down the middle of the neck, find the space between the tracheal and cricoid cartilages and poke through into his wind pipe with a hemostat. I spread it open, suction out blood and shove in the ET tube. I then hook up a bag and give him some breaths. The chest rises and I see vapor in the tube. I check with a stethescope hear breath sounds only on the right. The tube's in too far. I pull it out slightly, confirm there's now bilateral breath sounds, suture the wound closed, suture the tube in place and continue bagging.
His oxygen saturation is now up to 92% from the initial 35% so I stop bagging and just let him breath through the tube. His sats hover around 84-88% which isn't great, but without a ventilator and labs to follow it's more dangerous to bag him then to let him breath on his own.
I then try to place a nasogastric tube so he can be fed past the obstruction in his throat. It won't pass the mass. I stick my finger in his mouth and try to shove the tube in through his nose while feeding it past the mass with my finger. Suddenly, pus gushes out his mouth. I've ruptured the peritonsillar abcess. I quickly suck out the foul smelling pus and am relieved that it was so easily taken care of.
We wheel him out to his room and give his family instructions.
Later that evening, I go to check on him and find his tube choked up with secretions. We have a suction with a trap that allows me to put one end down the ET tube and then by sucking on the other end pull out the gunk into a chamber between the two ends. Very high tech. He starts to breath easier. I tell Jason to check on him every hour and suction as needed.
The next morning, he is awake, but tired and breathing fairly easily through the tube. I have the family members sit him up, suction him one more time even though it's pretty clear and move on to the other hospitalized patients.
In less than 15 minutes, Annie comes running up to me.
"Stuff's coming out his trach, he's not breathing!"
I run back to his room, chase out the family members and see instantly his tube is clogged up with pus that's dripping out. As I grab the suction to clear his airway I see he's not breathing and his eyes are rolled back. He has no pulse. As I suction, Jacques starts chest compressions. When the airway is clear I attach the bag and start breathing for him.
We take him to the OR quickly. We attach our cardiac monitor. He finally gets a heartbeat back with a pulse but after a few minutes it slows down again until we do more chest compressions to bring it back. We try multiple doses of Atropine and Adrenaline. His oxygen saturation stays in the mid to upper 80's when we bag him. But he just doesn't want to come back. Finally, after 90 minutes we are forced to stop. We wrap him in a cloth and call in the family. The dad nods, he's been expecting it. He wraps the boy up in his arms, carries him out and the family mournfully walks out the gate.
The drum beats on. The call to prayer continues. The bell keeps on tolling.
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