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 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.

Ostomy

"Doctor, you need to see this baby." Samedi calls me to the ER. "She's only 7 days old, but she's never had a bowel movement."

I pull back the curtain and see the frightened mother holding her newborn baby in her arms. The infant's belly is markedly distended, but still somewhat soft. I listen and hear good bowel sounds. The mother says she breastfeeds well and goes on to prove it by feeding the baby right in front of me. I examine the perineum and the anus is present.

"Samedi, get me a glove and some lubricant."

He comes back in a few minutes, I slip the glove on my right hand, apply some goo and gently press my pinky into the tiny anus slowly dilating it until my finger can go all the way in. It's a blind rectal pouch as I suspected.

I inform the parents that their little girl will need surgery immediately and they agree.

Without x-ray, I'm forced to guess exactly the extent of the malformation of the colon. I'm hoping it's just the sigmoid (the last part of the large intestine). Sarah and Simeon tag team the anesthesia calculating the tiny doses of Atropine and Ketamine for it's small, 2.4 kg frame. We strap her into the "papoose" so she can't move, prep her distended abdomen with betadine, scrub and drape and before cutting, pray.

I decide to gamble that I can make a colostomy from the descending colon so I cut a small circle out of her skin to the left of her bellybutton, cut through the fascia and muscles and enter the peritoneal cavity. Small intestines burst out under pressure and I can't get them back in. I move to the center and make a midline incision releasing the pile of intestines to the outside air. I then bring back those that have gone out the side hole and explore inside. The colon hasn't formed (atresia) all the way from beginning to end. The whole thing looks like a long appendix running from cecum to rectum.

Everything is so tiny. I take a part of the ileum about 10 cm from where it joins the cecum and clamp the bowel with non-crushing clamps. I divide the intestine and slowly identify the miniscule vessels in the mesentary and clamp/cut/tie them. I then open up the distal end and suction out all the meconium resting there and suture it closed in two layers. I then pull out the proximal part through the side window, sew the wall to the strong fascia, evert the gooey mucosa and suture that to the skin. I then suck out all the stool from 9 months in mommy and 7 days in the real world and close up the midline incision after irrigating profusely.

I write post-op antibiotic and immediate breastfeeding orders and go home.

Except for a fever the next day found to be malaria and treated with blind rectal pouch quinine suppositories, she has a routine post-op course and is just waiting to have her sutures removed in a few days.

Lubambashi

The plane has stopped. I thought we were going directly to Lubambashi but we suddenly find ourselves on the ground at another airport. Apparently it was planned since I see people getting up and climbing down the stairs that open up from the tail of the old 727 airplane. I was actually extremely cold during the flight so I decide to take a breath of Congolese air outside. A sharply dressed young Congolese man is standing at the foot of the stairs just under the middle engine. We strike up an easy conversation until he notices something dripping on his suit.

I think it is fuel at first, but on closer inspection, it turns out to be simply water. The man is very friendly and I explain that we are with Adventist Medical Aviation and are doing some research on maybe doing some medical work in Democratic Republic of Congo and in Congo Brazzaville.

At this point our attention is caught by a large mobile staircase being pushed past us to the right engine of the plane a few feet away. Some men scramble up to the engine and start taking off the bottom enclosure. As jet fuel starts to cascade out, the ground crew rushes around collecting plastic buckets to catch it in as a small lake starts to form and flow off the runway.

A man in a suit rambles up lugging an ancient, twisted metal tool chest that folds out from the middle into several trays carrying some large, simple tools. He selects a large screwdriver and climbs up the ladder to the now-exposed engine as a couple of blue-overall wearing maintenance guys scrape out the fuel left in the bottom of the casing.

The mechanic tinkers around and eventually manages to pull of what appears to be the fuel filter. He takes off the filter and examines the cover which appears to be missing a gasket. He shows it around to a few other people amidst the shaking of heads and then puts it right back on. He tightens it up well as the blue guys mop up the remaining jet fuel with rags. Meanwhile, more ground crew have sloshed the tarmac underneath the engine with buckets of sudsy water.

The engine cover goes back on and we are escorted back up the stairway into the plane. Miraculously, we take off and land again at Lobambashi without further incident.

A thin, lighter skinned man with a huge smile, blue ringed brown eyes and a warm handshake greets us at immigration along with a short, stocky dark man who speaks some decent English. We breeze through passport control and are taken to the Adventist Surgery and Gynecology Clinic in a Toyota Hilux Surf SUV. The Hilux Surfs are everywhere but unfortunately no boards or waves are to be seen anywhere.

Most of the vehicles in town have the steering wheel on the right side of the car even though they drive on the right since most of them are imported from British East Africa.



We arrive at the clinic and are told there is an emergency. They are just waiting for the surgeon, Dr. Delgado to arrive.

When I inform them I'd like to assist, they drag me up some steep winding stairs to the attic which serves as pharmacy and stock room. I'm given a pair of elastic waist band scrubs and slippers too small for my feet and I quickly change and enter the OR.

It is small and long with tile running from floor to ceiling. Xrays showing obvious bowel obstruction are illuminated on a viewer straight ahead over the operating table. On the table, covered in a hospital gown is a young, 14 year old girl with a nasogastric tube coming out of her nose attached to a bottle of 5% dextrose for gastric lavage.

At the foot of the table is a metal table covered with a dark green cloth covered with shiny instruments and presided over by the surgical assistant robed from head to foot in the same dark green. His white surgical gloves rapidly arrange the instruments guided by his barely visible eyes behind a blue mask and protective goggles.

At the head of the bed is a jolly, pudgy man in ill-fitting scrubs whose large smile can't be contained by that silly piece of paper trying to pose as a surgical mask. In answer to my inquiries he shows me his anesthesia setup.

The archaic monitor is black and green with erratic QRS complexes running together on the EKG lead making their form, rate and rhythm almost impossible to interpret. But that is child's play next to trying to read the systolic and diastolic blood pressure and heart rate which for some reason are projected as mirror images of themselves.

The anesthesia machine consists of a metal table with bars on the back. An oxygen extractor behind the machine runs a jerry-rigged tubing apparatus up to a canister attached to the bar. The inhaled anesthetic is put in the canister and regulated with a twisting knob that the anesthetist proudly says he made himself. He shows me the scoring marks on the knob that let him roughly know the concentration given.

Laid out in an orderly fashion on the table are 4 endo-tracheal tubes, a laryngoscope and three unmarked syringes containing, according to him, Valium/Atropine, Thiopental and Succinalcholine.

Just then, Dr. Delgado bursts into the room. An Argentinean of Peruvian descent, Delgado has been in DRC for over 20 years. He started at the Songa Adventist Hospital before moving to Lobambashi and opening this surgery and gynecology center. He is known all over the region as the best surgeon around, is personal friends with the governor, has performed over 12,000 major operations there and has trained countless young, Congolese physicians and medical students in the art of surgery.




But I was to learn all that later. For the moment, Delgado was focused on the task at hand.

"What's her story?" He asks the resident who called him in.

"She was sick since Friday, went into another clinic on Saturday, was given malaria treatment and sent off for a bunch of lab tests and x-rays. After three days, she was getting worse and the family brought her here. When we examined her, she had an acute abdomen with signs of obstruction. As soon as we told the family she needed an operation, they wanted to evacuate her to South Africa until we assured them you would come yourself and do the operation."

"Ok, well she obviously needs surgery, it's too bad they waited. I'll go scrub."

Soon the operation is under way. On entering the abdominal cavity, we find pus everywhere with the small intestines stuck together. It takes awhile to clean things up and separate out the intestines to find just what we suspected, a perforated appendicitis.



After the appendectomy, massive irrigation and placement of a drain, Delgado leaves the closure to the residents and he starts telling me about his latest project: a new surgery hospital on the outskirts of town.

The girl is extubated and wheeled off to post-op recovery in stable condition.

The next morning, Delgado is flying to South Africa himself so we meet him at 7:30 in the suburbs of Lobambashi. He has been given 100 hectares by the government where he's built himself a beautiful house and is almost finished with his new surgery hospital. A local Muslim business man from Lebanon has financed the project to the tune of over $1,000,000. The equipment and initial medications are a combination of donations from the AMALF (Adventist Medical Association of the French Language) and purchases from a Swiss company that refurbishes medical equipment.

There will be two full functional Ors, a minor procedure room, a post-op recovery room, an ICU, private rooms, and an outpatient center. Everything is beautifully tiled and the solid, hard wooden doors have been imported from South Africa. It will probably be the best surgery center in between Nairobi and Johannesburg.

Also, on the 100 hectares, Delgado is helping build a Conference Office for the local SDA mission and an Adventist Church.

That evening, I check up on our young patient and she is lying comfortably with no fever and only slight tachycardia. Her abdomen is still slightly swollen, but soft and I already hear a few bowel sounds. I talk with the father who is eternally grateful and tells me that his son has just returned from a visit to Orlando, Florida where my parents live and his daughter wants to go there for nursing school.

As he gives me a ride back to the Union offices where I'm staying, I offer to put him in contact with the SDA nursing school at Florida Hospital and he likes the idea and takes my email address. He insists we come eat at his restaurant the next day but unfortunately, we already have plans.

The last day before heading back to Kinchasa, I make my final rounds and find the girl in even better condition having already passed gas letting us know that bowel function is returning. I pray with the family one more time leaving her in God's hands.

Kinchasa-ball

Kinchasa has a sort of sport found maybe no where else in the world. I don't know if anyone has actually named it, but it seems the rules are well known. I'll call it Kinchasa-ball and it's played out every day on the wharfs of the city where the ferry crosses to Brazzaville.

There is a walkway from the street to the pier that is enclosed by steel bars that serves as the playing field. The game starts as the ferry prepares for crossing. Somewhere out on the street, the visiting team starts it's preparations as the trucks arrive bearing all kinds of cheap, processed goods for the markets of Brazzaville. Hordes of "runners" gather. Yellow and blue vests are handed out. The players have the option of wearing them over their shoulders and backs, tying them around their necks, or wrapping them around their heads as turbans. Most wear pants cut off just below the knees, ragged t-shirts and flip-flops. The players come in all sizes and shapes, but all are wiry tough and most are quite buff.

Meanwhile, the home team gathers at the elbow where the walkway curves around through a gate, runs parallel to the river for 50 feet before making its final turn down the gangway to the rusted out ferry boat teeming with spectators. The home team consists of a couple of player-coaches and five or six large, uniformed port authorities. The one who appears to be the head coach is of average height, has a scowling face and wears Arabic robes. His piercing eyes glare out from behind small spectacles perched on his flat nose. The "assistant" coach is a huge man with a beer-belly and a large, pocked marked face with a smug grin permanently hovering ready to pounce.

Gary, Jeremy and I have stumbled upon first row seats just behind the home team where the passengers wait to cross over the Congo River into Brazzaville on speed boats.



The first member of the visiting team pads around the corner, his slippers flip-flopping across the cement in cadence to his labored breathing as he struggles under an enormous load of yellow soap bars balanced on his sweaty scalp. The home team is just warming up so they let the first one pass.

The second is not so lucky.

A smaller man, with a 8 foot wide plastic wrapped burden of cracker rolls perched on his head, jogs down the gauntlet towards the corner where the uniformed home team waits. Each of the port authorities carries a doubled up rope in his hand which he occasionally fondles with the other hand in eager anticipation of feeling it zing down on another human beings flesh.

As the man approaches, the head coach steps out and grasps the side of the opposing teams load. There is a brief struggle as the unfortunate man desperately tries to keep his precarious balance. Finally, he is forced to drop down his load next to the leering home team members. He argues briefly and half-heartedly as if it's the thing to do even though he knows it's hopeless. Meanwhile, the same scene is repeated over and over. Most get through the gauntlet, but randomly, someone will be pulled down using their top heavy loads as leverage against them.

The game continues as those who have been pulled aside run back to the street and come back shortly with something in their hands to pass on to the home team in the form of a "secret" handshake. However, they don't seem to take too many pains to make it secret and don't seem to be ashamed at all of the blatant bribery and corruption.

In fact, after a giant, hulk of a uniformed man on the home team pulls down a tiny man half his size carrying double his wait he lifts his massive head into a victorious grin as he air boxes like Rocky his fists pumping the air in jubilant victory.

The worst is still to come. The visiting team has recruited some new players. A line of 5 blind people walk slowly up each left hand placed on the shoulder of the man in front with a guide showing the way. In their right hands, they carry some small bundles of merchandise for which they will be paid a few cents allowing them to honestly earn a living playing Kinchasa-ball.

There is no mercy. The coach himself steps out with an evil grin and pushes them back. They stumble trying to keep their balance, sightless eyes rolling around in their lolling heads. Kinchasa-ball is not for the faint of heart.

Next is a man in a wheelchair. It is a tricycle that allows him to pedal the front wheel with his hands. The chair has been loaded with goods and he is perched on top pedaling furiously. Surely, he'll make it through the gauntlet! But no! Our brutish giant lumbers a few steps forward and places his beefy hand on the cripples chest as he sneers out his order to stop! He too must pay to get through.

After about half an hour of intense competition, the game winds down, the gates are shut and the ferry pulls out slowly from the dock. The home team gives each other satisfied smiles as they finger their fat pockets as the visiting team, slowly climbs back up the gangway, sweat dripping from their soaked shirts and glistening on their ripped, but tired bodies.