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

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.