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
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