Primitive?

I should have followed my instinct. Yesterday, Friday, was my first day back at work in Bere. Apparently, during my absence, the nurses have restarted their morning report. I walked in at the end of it. The nurse presenting was one of our sketchier government nurses named Desiré. He had just talked about a man who had constipation for four days. He was just on observation in the ER because he wasn't that sick. Deep down, I thought, I better go look at this patient now with Desiré. But then I thought, well, the nurses have been doing well during my absence, and I'm sure they can recognize and treat constipation. If they want me to see a patient, they usually tell me. So I went about my day and didn't see the patient.

This morning, Samedi comes to see me before 6 AM.

"The patient with constipation wasn't doing well, so the night nurse called me at 2 AM to see him. He was bloated and vomiting so I put in an NG tube but nothing came out."

"Let's go see him."

The middle aged man is sweating and in obvious discomfort, but able to converse normally. His abdomen is swollen and filled with air. He jumps when I tap it with my finger and shake the bed. There is no stool in his rectum but he is quite tender. He obviously needs an operation.

As the abdominal wall splits open under my knife a dark purple mass pops into view. I enlarge the incision and slide out an edematous, necrotic sigmoid colon that has twisted around itself effectively committing suicide. I clamp across where the colon is still healthy on both sides and remove the necrotic bowel. I free up the upper part of the descending colon so it is more mobile and suture it painstakingly to what's left of the rectum. After three hours, a lot of sutures and irrigation, I close the fascia and leave the skin open. As I pull off the surgical drape I discover his bowels are already moving as he's deposited quite the pile between his legs.

After a brief lunch and rest, Sarah and I saddle up the horses who haven't been out in three months. They are eager, yet controllable. I enjoy the thrill of power beneath me as we race to the river.

There's no relief like soaking in cool water on a hot sub-saharan day. Because of the massive rains yesterday, it is also quite humid and my shirt and pants are soaked with sweat after the five kilometer ride. I unsaddle Libby and lead her into the water where she kicks up a whirlpool playfully with her front hoof before wandering back and forth in the cool stream.

Some of the neighborhood kids have finally arrived, brought two by two on Cory's motorcycle taxi. I put them all through the same initiation. If they want to swim out in the middle they have to survive being attacked by me as I throw, spin, toss and tackle them for several minutes to their screams and cries of joy!

As Sarah and I relax a while later, up to our necks in the swift moving water, we spot an Arab crossing the river on his pregnant horse, following his herd of cows back to his village.

"Lalé!" Sarah shouts. No reply.

"As salaam aleikum!" I attempt but no response. This is quite unusual as most people will respond to a salutation.

"Kikef?" I try again. Finally, the man looks at us and seeing us looking at him wonderingly, he sheepishly reaches up to his ears and removes his tiny earpieces from his MP3 player and greets us back!

By now Sarah and I are laughing at the shear ridiculousness of the contrast between primitive and modern. The man laughs back and greets us many times.

Returning to the hospital on horseback we go cross country relishing in the green grass everywhere in between the broad leaved bushes and freshly plowed fields. We get slightly lost but are reoriented when we see the cell phone tower which is right behind the hospital.

That night, Sarah and I walk through a completely dark village, trying to avoid the mud puddles in the path until we get to a hut that has a single fluorescent bulb out front. We turn into a narrow alley and duck under a hangar made with straw mats. There are mud brick benches arranged between the twisted sticks holding up the roof and in the front is a mat in front of a small television. We have come to see the World Cup. Denmark is playing Cameroon and everyone is surprised to see a woman, much less one fanatically cheering and whistling every time Denmark scores a goal. The rest of the room is silent as we lift our arms and shout as Denmark comes back from 1 to 0 to win the game 2 to 1.

Chad, as usual, a country of contrasts, stuck in the past yet in some ways, just as modern as anywhere else in the world.

BACK

The flight has been uneventful. We spent the night in Paris and now are descending towards N'Djamena. Only a few scattered lights in the darkness of the desert remind us that we are coming into a capital city of a million inhabitants. The warm blast of air that hits me as I step out of the plane and walk down the steps to the tarmac remind me that I have left Scandinavia behind. Despite the fact that we could get there faster by walking as there is only one terminal about 100 feet away we are forced to ride in a bus. As we stand in line in one of the two passport control points I spot David who points us out to the man with him who comes and takes our passports directly to the booth where he stamps them himself. The one conveyor belt in baggage claim is broken so the bags are dumped on the floor as everyone scrambles to reclaim his and mount it on a rickety cart, most of which have broken, missing or twisted wheels.
Our bags are near the end and meanwhile David introduces us to his cousin. She works in Customs and I remember her from last year when she told the other customs agents to stop bothering us as we were in the medical work. She is happy that I remember her. With David's friend leading the way we breeze through all the controls and are soon in David's Land Cruiser heading to his cheese factory.

Suddenly, I hear a screech and the crunch of metal on metal. The UN mini-bus in front of us stops and puts on it's hazards. In the intersection is a mangled motorcycle and a body laid out straight on the pavement showing no movement at all. A small crowd quickly gathers and tries to shake the limp form. He was killed instantly and the car fled the scene. As we move past, turning right at that intersection people stare in our windows shaking their fists and yelling "what are you looking at?"

Down some dirt roads and a metal gate opens to David's horn. He jumps out and starts the generator as we haul in our heavy bags. Two mattresses await us on the living room floor as the fan tries desperately to remind us we are not in an oven. We open the double door to the courtyard where two dogs wag their tails furiously as they cautiously wonder if we'll beat them or pet them.

"How's N'Djamena?" I ask David.

"Things are changing. They no longer allow those small plastic bags in the markets. You get heavily fined and they're strict. If someone offers you something in a plastic bag, everyone will refuse as they don't want to be seen with it either. So the women have been taking the empty cement bags, cleaning them out well and making small bags to put vegetables, sugar and other things in it for their customers."

"That's amazing, is it happening all over the country?"

"Yes, they're strict everywhere."

"That's great!"

"Yeah, and every Saturday from 7 to 10 am no one is allowed to open their business and everyone is supposed to be out sweeping and cleaning things up. In fact, the President of the country was out the first Saturday with his ministers to lead the way. The President was well dressed in a jogging suit and got right to work. The ministers were all in suits thinking it was something symbolic for the TV. But the President kept sweeping for like an hour or an hour and a half. It was hilarious. FIrst the ministers took off their jackets as they wiped the sweat off and tried to keep up. Then ties were being untied and sleeves rolled up. It was NOT what they expected at all."

I fall asleep to the buzz of mosquitoes. It's good to be back.

Hysterectomy

>
> I decide to do the surgery outside. It's just to hot inside so I
> borrow our neighbors old table and set it up just outside my front
> porch.
>
> "Should we start an IV?" Sarah asks.
>
> "Nah, just give her an shot of Ketamine, she'll be fine. We'll just
> hold her down well if she starts to move a little...and you can
> always give her another shot."
>
> I hold the patients hand while Sarah gives the Ketamine in the
> muscles of her leg. She squirms and moans but otherwise tolerates
> the shot well. As she starts to drift off to sleep, I inject her
> with an antibiotic.
>
> Jamie and his family and the new doctors, Liz and Tony, help Sarah
> carry the patient and deposit her on the table.
>
> I shave and prep the abdomen, open the box of instruments and put on
> sterile gloves.
>
> "Ok, Allah you hold the left arm, Cory you hold the right. Carson
> if you and Michelle can make sure the legs don't move and are spread
> out well, I think we can get started."
>
> I put the scalpel blade on the handle, grab a compress and start
> cutting through just above her belly button down to her pelvis. I
> get a little off center and at first am a little confused as to
> where I am anatomically. Maybe it's the early evening shadows that
> are playing tricks.
>
> "Does anyone have a head lamp or something?"
>
> "Yeah, here's a brand new headlamp," Liz replies.
>
> Jamie also goes and gets his high powered work flashlight which
> helps a lot. I enter the abdominal cavity.
>
> The uterus is strange. Instead of being short, rounded and compact
> it stretches up through the abdomen and has two long horns. It's
> also very thin. The ovaries are attached at the ends of the horns
> and deep in the belly. I need to do a complete removal of the organs.
>
> "Liz, could you and Tony assist me?"
>
> "Sure, no problem." They both put on disposable gloves and reach in
> to help pull aside intestines and abdominal wall so I can get a
> double clamp on both ovarian stumps. I then clamp the blood vessels
> dangling off the sides of the uterus and place two clamps vagina
> just past the cervix. I cut out the uterus and ovaries together and
> place fixating sutures through the stumps, around and behind the
> clamps and tie everything off.
>
> I close the first layer of abdominal wall.
>
> "Could I get some irrigation, please?"
>
> "Here's a bottle with well water in it, is that ok?" Liz asks.
>
> "Sure, whatever." I reply.
>
> I then close the other layers and the skin with washings with tap
> water in between.
>
> Sarah then brings the plastic funnel and we attach it to our dog,
> Caramel's collar and carry her back into the porch for recovery.
>

Moonlight safari

>
> "Only in Chad," Gary muses as I swing into the pack of the pickup
> and pull my beanie low over my ears. "No where else could we be
> going out into a game park at night in an open truck with no top or
> windows without a guide and be the only humans around. Only in
> Chad. God bless this rebel country!"
>

Complications

>
> "I've got another patient for you, this time it's really serious."
> Lorraine's voice on the other end of the line sounded panicky. "The
> daughter of one of our pastor's has been hit by a car and her leg's
> broken and there's blood everywhere!"
>
> "Ok, well send her to the hospital." I reply.
>
> "Right. We're at the cellphone tower. They've taken her to a
> traditional bone setter, but I've convinced them they need to come
> to the hospital. We'll be right over."
>
> "Alright. Just tell the nurse or the gatekeeper to come get me when
> you arrive. I'm at home."
>
> So much for a leisurely Saturday. I'd spent the morning telling the
> story of Joseph to a group of teenagers and using it as an example
> of responsible sexuality and speaking to a group of adult Christians
> later about the positive sides of Islam. Then a brisk ride to the
> river to try and cool off. I always forget how just when you think
> it's gotten really hot and unbearable it can just get worse.
>
> I send a text message to Samedi, Simeon and Abel and slowly put my
> scrubs on. As I look out my front porch, I see a truck pull up to
> the hospital. The patient must have arrived. I saunter over and
> see a crowd behind a Toyota Forerunner. Inside is a large, moaning
> woman with tightly coiled braided hair, new clothes and a blood
> soaked wrap around her twisted, swollen left leg.
>
> With many hands making light work she is quickly transferred to a
> gurney and wheeled into the OR. She has an obvious femur fracture
> with a tiny wound telling me the bone had poked out at one point.
> She has a similar wound over her tibia just below her knee but her
> lower leg seems stable. There is also an open fracture of her big
> toe which has been reduced. Her left thigh is twice the size of her
> right one and she's obviously lost a lot of blood already. Her
> heart rate is 150-160 but her blood pressure is holding. We start
> two large bore IVs to try and replace her lost blood volume as
> someone calls the lab tech on duty to test the family and friends
> for possible blood donors. Her heart rate quickly drops to 110-120
> with a couple liters of IV fluid.
>
> After Simeon injects the antibiotics, I give her some Diazepam and
> Ketamine to dull the pain and allow me to place a tourniquet around
> her upper thigh to slow down the blood loss. We quickly wheel her
> into the inner OR, give her a spinal anesthetic and prep and drape
> the leg. WIth the blood supply cut off to the leg by the tourniquet
> I know I only have a limited amount of time to get this operation
> done. I figure it shouldn't be as hard as the many other fractures
> I've operated on recently because this one is fresh. All the
> other's have been old ones with poorly healed bones needing to be
> cut apart, wound contractures, scar tissue, infections and many
> other complications. I should know better than to think something
> will be easy.
>
> After praying, I slice open her thigh over the puncture wound.
> Swollen muscle pops out under pressure. I cut down do the fracture
> and find nothing but shards of crushed bone for about 10-15 cm in
> the middle of her femur. A pre-op x-ray would've been nice, if we
> had a working x-ray machine. Now I have to go by feel as I probe
> the wound with my double gloved finger. I decide to go through the
> knee to insert the rod since she has had so much blood loss and this
> allows me to keep the tourniquet on. As I expose the entry site,
> dark blood spurts out of the knee joint confirming my suspicion that
> she also has a fracture of her upper tibia plateau into her
> articulation.
>
> Using the SIGN technique I just learned in August, I bore into the
> bone and insert the first reamer to clear out the bone marrow in
> preparation for the metal rod I'll use to fix the fracture. Going
> through the distal part of the femur is no problem. But since the
> proximal part is shattered I have a difficult time finding the
> hole. I try and explore with my finger through the other incision
> to guide the reamer but finally realize that bone fragments have
> gotten jambed up the marrow cavity blocking the entry of the reamer
> (and later the nail I want to insert). I have to put it in from
> above. I expose the hip, swab it with Betadine and cut down to the
> bone. The patient is quite large and muscular and the hole is
> deep. I pray desperately as I've already wasted a lot of time and I
> don't have much left on the tourniquet before I have to let her
> start bleeding again. Fortunately, there are two bags of blood up
> and running now.
>
> I insert the awl and find the marrow cavity. "Al hamdullilah" I
> shout as I start the progressive hand reaming. I finally hit the
> largest size that will easily pass and call for the right sized
> rod. I carefully attach the external guide apparatus and twist and
> hammer the rod into the bone. With Youlou pulling on the leg from
> below and Samedi twisting and positioning over the fracture site we
> are able to get the rod into the distal section and stabilize the
> injury. I position the guide pin, incise the skin, place the drill
> guide, drill the first cortex of bone, insert the hand hole enlarger
> and twist in but don't feel it enter the hole of the rod like it
> should. It means I'm a little off. I use the curved hole finder to
> reposition the apparatus and then am able to locate the whole again
> with the next drill guide so I can drill the second cortex. I
> measure the length from cortex to cortex through the drill holes and
> place the first fixation screw. The second one is easier and the
> two proximal ones even easier.
>

Zakouma

>
> It's a cool night in the Sahel. Baboons are howling across the
> wadi. I pull on my beanie and climb in the back of the modified
> Land Cruiser. Cutting off the cab, welding chairs in the bed and
> painting it forest green have made the old rebel attack pickup
> almost unrecognizable. I stand behind the front seat holding onto
> the bar across my chest. Gary fires up the engine and Wendy hands
> me the spotlight plugged into the cigarette lighter. Sarah is
> seated to my right and Cherise lays across Wendy's lap staring into
> the moonlit sky. Except for a group of Tunisian engineers who
> arrived earlier in the evening, we are the only visitors to the
> Zakouma National Park near Am Timan. Exhausted by their 15 hour
> trip, the Tunisians hole up in the restaurant, leaving us alone to
> explore the African night.
>
> In a few minutes we have left the small campground behind and turn
> on the road towards the airstrip. To our right, a pool of water
> houses a couple of crocodiles as an image from earlier in the day
> flashes across my mind of a large jaw and head bursting out of the
> calm waters clutching a mammoth catfish temporarily in its teeth
> before twisting and swallowing the huge mouthful and disappearing
> again into the green depths.
>
> We are looking for eyes. Skimming the spotlight across the surface
> of the grasslands and acacia trees from right to left we seek out
> the night prowlers and resting herds through the reflection of their
> eyes. Groups of reddish green pairs reveal striped antelopes with
> twisted horns as triangular faces stare us down. Smaller
> reflections lead to tiny nimble footed gazelles that skip and hop
> and jump about, frightened by their own shadows. Narrow set eyes
> close to the ground on closer inspection lead to long, slender genet
> cats with their striped bushy tails hunting mice and other critters
> in the short grass around the watering holes as the slither and
> slink close to the ground. Large, bouncing eyes high in trees let
> us know of the presence of Galapagos tree climbers that are to swift
> to follow, appearing and disappearing only to reappear several
> meters away up the branches.
>
> In the vast, green pastures around the water holes that dot the
> wadi, herds of gazelles, deer and antelope rest, graze and cast a
> nonchalant look at the passing human intruders. One herd is guarded
> by a pair of greenish, blue eyes, wide set apart encirceled by horns
> flowing over the sides of the head like a wig over powerful
> shoulders and the stocky body of a water buffalo. Several hundred
> meters further on a group of those evil, green eyes is staring at us
> from the edge of the pond. Without a working four wheel drive, we
> are loathe to pursue, but instead, these fearless creatures make
> their move towards us as they huddle together and move confidently
> and deliberately towards the truck in an oblique manoeuvre meant to
> impress but not threaten.
>
> Huge black and white storks stand awkwardly in the marshes. Great
> herons balance on slender legs before taking off in lumbering
> flight. Small headed, spotted birds that fly like butterflies
> startle up from the road and sides of the road at the approach of
> the headlights. Some seem paralyzed till the last minute when they
> make a desperate flutter to escape right in front of the charging
> grill. Gary actually stops once and manages to get his hands around
> one that I've stunned with the spotlight before it flaps out of his
> palms. Small, big eyed birds reflect the spotlight light wildcats
> temporarily confusing me until the eyes start to take flight. An
> owl stares us down with it's unblinking eyes sitting on a branch
> directly overhead before taking off, its silent wings beating
> noiselessly through the dry and dusty night.
>
> Gary punches the gas and the Land Cruiser lurges forward towards
> some antelopes grazing near the road and a dark, compact, lumbering
> creature holding close to the ground. He enters the road and turns
> to follow directly in our headlights revealing short, powerful legs
> and dense, black fur. A long, thick neck leads to a flattened head
> with a mouse grasped firmly in it's teeth. If there was still any
> doubt, its characteristed back and forth lumbering gait gives it
> away as a badger.
>
> Harder to see than the genets, we get glimpses here and there in the
> distance across the grass of a larger, slinkier striped cat: a
> civit cat. A raccoon like tail disappears into the bush. A panther
> like back end slinks around a corner. We never get a full few, but
> enough to appreciate the grace of this medium sized feline.
>
> We see quite a few giraffes from a distance, but none up close. One
> small herd has a couple of babies only recognizable that far away by
> the reflections of the eyes being so much closer to the ground than
> the adults.
>
> We near the end of our night safari. We pass the mud, thatched
> roofed huts of the village of Zakouma and pull onto the airstrip
> where Gary zig zags across at high speed. We see one hyena lazily
> reclining on the edge of the strip. Coming back out from the hangar
> we see another Galapagos' eyes bouncing quickly away in the
> treetops. Coming back out onto the airstrip I see a group of eyes
> far away. We pursue and find two groups of four hyenas each, all
> lying down in two piles. As we pull within 20 feet, they lumber up
> staring at us with their evil eyes and panting jaws open revealing
> dangerous teeth over their skulking, spotted bodies. The move off
> into the bush, cackling in their high pitched witches' laughs.
>
> At the end of the airstrip we take the road heading back to the
> camp. Out of the corner of my eye I see a big shape pull to its
> feet. I swing the spotlight and just catch a giraffe who has just
> pulled to it's feet 10 meters away. Another giant turns its long
> neck around to stare at us from it's long face before starting to
> walk gracefully away like a couple of long-legged models strutting
> their stuff. They move up to a blob on the ground with a chimney
> pointing to the sky. Rocking forward to get it's hind legs up and
> then backward like a camel the slumbering giraffe gracefully and
> rapidly regains its footing. Picking up speed, the three now gallop
> off in seemingly slow motion their front legs moving like huge
> scissors as their back legs move in tandem to catch up. They
> effortlessly cover huge amounts of ground in each stride. After
> putting a little distance between them and us they move back into
> their most graceful of walks like a couple of movie stars exiting
> the premier in their fur coats.
>
> Several hundred meters later I briefly catch a glimpse of a large,
> black animal staring straight at me. I'm sure it's a baby
> elephant! Gary backs up and tells me to turn off the spotlight as
> it may charge. When we're just across from where I see it, Gary
> plugs in the spotlight...and we see a huge waterbuffalo staring us
> down. Impressive, but not what I hoped to see!
>
> Almost back to camp, we see what looks at first like a dog running
> on the road ahead of us. We approach and when we are within a few
> feet it turns sharply into the bush revealing a Serval cat with it's
> tiny head, spotted body and long, lithe legs and tail. It springs
> away as only a cat can and disappears into the night. Just 100 feet
> from the turnoff into the camp I spot three pairs of eyes to the
> left. One pair lifts up revealing a blood stained snout. I shout
> at Gary and he screeches to a halt and backs up. We turn off the
> road and head straight for a recently killed buck. It's lifeless
> eyes stare back at us from the ground. It's fat stomach spills out
> matted grass where it has been left under the tree where it was
> killed. The two hyenas that dragged it away lift their snouts out
> of the carcass revealing red stained fur all the way down their
> chests. The back leg is missing leaving a mound of tattered flesh
> up to the open abdomen pooled with blood. The neck shows no injury,
> but matted fur suggests maybe a lion killed it before being chased
> off by the hyenas. They are reluctant to leave their meal, but
> slink around in the periphery of our headlights waiting for us to
> leave which we soon do.
>
> The next morning, we drive out to the site and see four hyenas
> fighting over all that's left, a piece of torn leather. Their
> bellies are engorged so they can barely walk. No bones, organs or
> even blood remains....only that tattered hide. One hyena tries to
> make off with it. Another runs up and grabs it in a macabre game of
> tug of war as they run of cackling and chortling into the early dawn
> of a new day in Chad.
>
>

Preterm

>
> I feel her kick for the first time. I've felt other fetuses kick
> before on other pregnant women's bellies, but this time is special.
> The child is mine. A thrill goes through me and a silly grin wraps
> around my face. It's Friday evening, Sarah has malaria and I've
> just started her treatment. Leaving Sarah, who wants to rest, I go
> spend some time with Franklin and boast about my strong, athletic
> little daughter. After a little singing and worship, I return home.
>
> After checking the IV drip with a flashlight and being satisfied
> it's running well, I crawl into bed and fall fast asleep.
>
> A gentle shaking startles me from a profound slumber. My heart
> sinks at Sarah's words.
>
> "I'm all wet down there, what could it be?"
>
> I try to reason that maybe it's urine but my heart tells me
> different. Her bag of water has broke. The pregnancy is only 21
> weeks, too early too survive if she delivers now.
>
> I pull on some shorts, grab a flashlight and head up to the
> hospital. I bring back the portable ultrasound. I place the jelly
> on her belly and confirm my deepest suspicions: our little daughter
> has almost no amniotic fluid around her. However, her heart is
> still beating normally and she is still kicking if not screaming. I
> take the ultrasound back, but halfway there realize I've left my
> keys at home. After making the return trip I pick up my obstetrical
> textbook and try to find the pertinent passages.
>
> It's not encouraging. Most women with preterm rupture of membranes
> and fluid leaking deliver within less than 2 weeks and the outcomes
> are not good. I take the book home and discuss the bad news with
> Sarah. We pray and both toss and turn all night long. Drums pound
> in the distance as someone is mourning a lost loved one. Sarah has
> just a little more leaking through the night and by morning it seems
> to have stopped.
>
> Saturday morning. I give Sarah some yoghurt, hang up some more IV
> fluids and head out to church at 8:30. The doors are shut. It's a
> cool desert morning, but the sun is starting to heat things up. I
> sit in the shade along the rough brick wall in the dust. I'm
> reading a little when I sense a presence beside me. I look up. A
> tall, poorly dressed man stands proudly to my right clutching a
> tattered Bible. As he greets me I recognize him as the husband of
> one of our patients who explained to me yesterday that he's a
> traditional healer from up north.
>
> We start talking. I soon discover he is a man of God if not a
> prophet. He can barely speak French, but his words have a power
> that can only come from above. I confide in him and ask him to pray
> for Sarah. My spirits are uplifted.
>
> After the teaching in the first part of the service, I head home to
> check up on Sarah. She's vomiting and not feeling good. I stay
> with her. I look back at the passages in my obstetrical book and
> see a section saying that if there is at least one pocket more than
> 2 cm deep, than the outcomes are surprisingly better. I go back,
> get the ultrasound and to my joy find a 3 cm pocket and another 2 cm
> pocket. The heart still beats well. Maybe there is hope that Sarah
> won't lose the pregnancy.
>
> We both start to plan. If she hasn't delivered in two weeks we'll
> change our plane tickets and head to Denmark to arrive when the baby
> is 24 weeks and has a chance of living with modern intensive care
> nursing.
>
> We rest all afternoon as I try to control Sarah's nausea and treat
> her malaria.
>
> She starts to have contractions that night. Some bloody discharge
> discourages us again. I sleep only fitfully. When I wake up, Sarah
> informs me the contractions stopped halfway through the night. I
> repeat and ultrasound and our girl is doing fine, if anything it
> seems like there is more fluid inside. Hope rises...then falls as
> the contractions start again after breakfast. Sarah is in agony.
> She is moaning and tossing in pain. She vomits frequently. I try
> anything and everything to control the pain and vomiting. Nothing
> works.
>
> I am at her side almost constantly. She grasps my arms in vice
> grips every time the contractions hit. They are getting closer and
> closer together. She had more bleeding. I'm afraid, but repeat the
> ultrasound. The baby's heart is still beating well. But then a
> contraction hits and I see the heart beat start to slow. I'm losing
> it. It seems almost to disappear, then miraculously, as the
> contraction ceases, the heart slowly picks back up. She's
> suffering. Her heart can't take much more. The cervix is opening.
> It's just a matter of time.
>
> I prepare some towels and basins. I have a bottle of water handy.
> We start to talk of what to do with the body. Where will we bury it
> and what will we use as a coffin. Our conversation is interrupted
> every couple of minutes by severe pain and writhing as I sit
> helplessly by watching my wife suffer, knowing the outcome of her
> suffering will be an extreme loss. There's nothing I can do but be
> with her.
>
> The cervix is dilating. I can feel the bottom of our daughter. She
> is coming out butt first. A few more contractions and Sarah says
> "It's coming!" I reach inside and touch the tiny leg and foot. I
> grasp and gently pull as my daughter enters a world she'll never
> know. Her heart is still beating under my fingers. She fits in the
> palm of my hand. Every part of her is perfect. There are no
> malformations. She has Sarah's nose and my long skinny legs and
> arms. Her mouth is open as she tries to get air into her
> undeveloped lungs which will never be able to extract the oxygen she
> so desperately needs. Her little ears will never hear. Her closed
> eyes will never open. Her heart starts to slow down. But as I
> touch her tiny hand, she curves her fingers in an attempt to grasp
> my gigantic finger. She does this several times. She is getting
> colder. It's all over.
>
> I burst into uncontrollable sobbing. I hold her and watch her and
> examine her every little perfect human part over and over. We take
> pictures. Sarah lays her on her stomach. While she can curl up
> into the tiniest ball, when she's stretched out she's way longer
> than I could've imagined. We wash her, tie off the umbilical cord
> and cut off the placenta. I place her in an old mayonnaise jar and
> seal the lid tightly. I dig a hole under the small tree with the
> red flowers just outside our door. The dry soil is rock hard. I
> use the hose to wet and loosen the dirt. I get down about two feet
> and bury our girl in the soft mud. Sarah shovels in the first few
> piles and I finish. I read from I Thessalonians 4 about the
> resurrection and place a huge, porous stone over the top of the
> little grave as a marker.
>
> It is finished.
>

Homemade guns

>
> "There's a guy in the ER with what looks like a bullet sticking out
> of his face." Franklin told me casually, as if commenting on the
> weather.
>
> "A bullet? Is he stable?" I reply.
>
> "Oh yeah, he's fully conscious, sitting up, talking. He walked in.
> Apparently he was hunting and the rifle backfired or something and
> the bullet went into his right cheek. He came from quite a
> distance. I think it even may have happened yesterday...my French
> isn't that good."
>
> "But it's not too emergent?"
>
> "No, I think it can wait."
>

Mad

>
> This has been one of my worst days yet. Believe me, I've had my
> share of them. But this definitely ranks (as in stinks) up there
> with the "best" of them.
>
> I could find plenty of excuses for my behavior. For example, we've
> done more surgeries the last 3 weeks than the last 2 months combined
> (including one 7 day stretch where we did 46 major operations). Or
> I could cite the fact that I've had amebic dysentery for the first
> time over the weekend making me feel nauseated, anorexic, fatigued
> and generally miserable for three days.
>
> But I'm tired of excuses, that's all I hear all day long and that's
> what started this day off so badly.
>
> "Enock left at six without giving sign-out, but he said he HAD to go
> to Kelo."
>
> "We don't know why the kid didn't get his blood transfusion, Enock
> left for Kelo and didn't tell us."
>
> "The father left four days ago. He said he'd be back with
> provisions and to donate his blood, but he hasn't come back. Can we
> go home now?"
>
> "Ma'am, your child has a hemoglobin of 3.3, he'll die if he doesn't
> get that blood, besides you've already paid for it anyway and the
> father has the same blood type."
>
> "But he's gone home. It's far away. We have no money."
>
> "Madame, do I need to remind you that you don't have to pay anything
> and we'll find one of our staff to give."
>
> "But my husband isn't here, he went home to...." I cut her off in
> midsentence. Michelle gives blood and soon the child is on his way
> back to health.
>
> "I don't know why this guy's still in the ER. I wasn't the one who
> hospitalized him 4 days ago."
>
> "Haven't you had a night shift and a couple of ER shifts since
> then? You just let him stay even though his wounds were sutured and
> they weren't severe enough for him to need to be hospitalized? What
> about his relative who was also beat up who didn't even need
> sutures? He's also occupied a bed for 4 days in the ER."
>
> As we inform the two nomads who had been beaten up because they
> tried to steal rice and then cut off a guys arm who tried to defend
> his rice, as we tell them they have to leave the hospital now they
> start muttering under their breath.
>
> "YOU didn't do anything for us! Four days in the hospital and
> nothing!"
>
> "What about the 4 wounds we sutured closed and the pills that you
> have been taking and still have?"
>
> "But we didn't get any IVs or shots or anything. Next time, we're
> going to the hospital in Lai!"
>
> "Doctor, the patient is writhing in pain!"
>
> "I have his carnet here for an ultrasound."
>
> "But he's really in bad shape!"
>
> I go outside, a barefoot man covered in dust is standing calmly to
> the side. We walk him over to the ER where I can examine him. I
> look in the carnet, nothing written except abdominal pain. The plan
> is to have him see the doctor and get an ultrasound.
>
> "Ok, let's find out more about his pain."
>
> I start to ask questions but none of the nurses know his dialect.
> They call in a translator who starts translating. It's pain-
> staking. I'm frustrated and walk out yelling over my shoulders.
>
> "Find out all you can about his pain and then come see me!"
>
> Somehow, before I can even get back to my office to do other
> ultrasounds, Sarah is there to present me with the same man's
> carnet. The nurse had managed to stop doing what I asked almost
> before I started and somehow managed to bypass me to get to Sarah
> before I could walk the short distance from the ER to my office.
>
> I storm back yelling at anyone and everyone in my path. I'm totally
> out of control.
>
> A small sampling of my day is sufficient. Needless to say, I'm
> pretty much yelling and shouting and flailing and insulting and
> making a fool of myself all day long.
>
> I get called back to the ER. A man with abdominal pain for 5 days.
> He hasn't pooped in five days either. No vomiting, he ate some
> porridge yesterday but didn't feel like it today. He's lying
> comfortably on the bed. Sounds like constipation to me. A real
> problem here. He has a fever so probably has associated malaria. I
> tell the nurse to prescribe quinine and treat his constipation. As
> I'm about to move on a small urging tells me to examine him more
> closely. I can't explain why. A still, small voice perhaps.
>
> I bend over him. His belly doesn't look too swollen. NOthing you
> wouldn't expect from constipation. If he had a bowel obstruction or
> appendicitis he would've been vomiting by now after 5 days. I push
> and tap. Somewhat tender but doesn't seem to have peritoneal
> signs. I'm still not satisfied. Something inside says that my
> initial impression is wrong. I get a glove and stick my finger up
> his butt. He's more tender on the right side than the left. Maybe
> he does have something.
>
> I decide to operate.
>
> Sarah calls me when the spinal has been done and Samedi and Abel
> have scrubbed and draped the patient.
>
> I enter the OR and notice a pool of yellow fluid on the right side
> of the patient next to the OR table on the floor.
>
> "What's that?"
>
> "Maybe his foley has come out."
>
> Samedi lifts up the sterile drape so we can look. I pull back
> instinctively as I see a huge puddle of liquid stool with floaters
> between his legs. It's been dripping down the drape to the ground.
>
> "Well, I guess it was constipation after all! Looks like the
> relaxation from the spinal was all he needed."
>
> I turn to walk out of the OR. Again, something deep within,
> something that has almost been repressed from my full day of self-
> righteous, angry behavior, that little something makes me turn
> around and speak to Samedi.
>
> "Well, since he's already anesthetized and prepped, we might as well
> have a quick look around inside his belly."
>
> "C'est bon." Samedi nods in agreement. I go outside and scrub.
>
> As I open the belly, nothing jumps out immediately. The intestines
> aren't swollen or inflamed. There's no rush of blood, pus or
> fluid. I start to poke around inside. I"m looking for the appendix
> on the right. I can't find it. Everything looks ok...boom...out
> gushes some thick pus. I open the incision for better exposure and
> peel away the inflamed bowel. With a scoop and a flick of my index
> finger, the ugly looking appendix pops into the surgical field. An
> obvious perforation is at it's tip.
>
> I remove the appendix, irrigate and aspirate the abdomen, place a
> drain and close up.
>
> I spend the rest of the afternoon and evening listening to the night
> shift team bombard me with questions about things the morning team
> didn't do or follow up on and seeing two patients that don't want to
> heal and keep having stool come out of places it shouldn't and
> wondering what I'm going to do as I pass hours in the prep room with
> Samedi, Sarah, Abel and Abre searching for IV access on two infants
> with anemia needing blood transfusions. I spend most of the time
> yelling and throwing things as I can't find the vein or can't thread
> the catheter. Finally, Samedi gets the last one in.
>
> "Halleluia!" I shout and try to go home.
>
> As I close up my office, Rosine is there looking at me sweetly as
> she innocently asks, "Can you help us find an IV? We've been
> searching all afternoon and the kid needs blood..."
>
> How could she have known what she did as I bite her head off with a
> snarl.
>
> "Don't bug me with that. That's not my specialty. I don't find IVs
> very well. That's nurses work. Go find someone else and what ever
> you do, don't call me!"
>
> I go home. As I walk through the door I pause and sobs begin to
> wrack my body. I am filled with anger that want's to explode out of
> me. I don't want it but it's there. I feel betrayed, overwhelmed
> and extremely ashamed of my behavior today.
>
> In spite of this, somehow God spoke to me and made me save a man's
> life instead of relying on my own skills which would've sent a
> perforated appendicitis home to die with a couple of laxatives.
>
> I think I'll ask for forgiveness tomorrow.
>
>

Premature

>
> I was forced to put in earplugs. I'd tried to think happy
> thoughts. I focused on the pleasant night sounds. In the end, I
> couldn't sleep. The pounding of the drums, not the simple happy
> rhythm of the children singing silly songs in the moon light, but a
> deep, dark, forbidding thumping accompanied by mournful howling,
> this sound I couldn't sleep to. It sent chills down to my entrails
> leaving me feeling ugly and used. The earplugs helped...too much.
> The next thing I know, Sarah is tugging me awake out of the deepness
> of a pleasant unconsciousness into the darkness and chill of an
> early Tchadian morning. It's 3:30AM and Samedi is at the door. I
> stumble over to the screen while pulling on an old pair of scrub
> pants.
>
> "Yeah?"
>
> "Docteur, there's a woman referred from the health center. She's
> seven months pregnant and bleeding. Her skirt is soaked in blood
> but her vital signs are stable for the moment."
>
> "Ok, start an IV, give her ampicilline, place a foley and prepare
> her for a c-section. Call Simeon and Abel. Oh, give her 10mg of
> Dexamethasone IM, first thing. Call me when she's ready."
>
> Earplugs back in, I'm soon back in la-la land. This time my slumber
> is not as profound. It's as if something in my conscious is trying
> to break through. I wonder why I'm still sleeping. Why haven't
> they got me? I get up and pull on a scrub shirt to go with the
> pants I'm still wearing. It's 5AM. I walk up to the hospital as
> the first light of dawn barely illumines my path through the mango
> trees and over the sand covered in horse dung. Even from a distance
> I can see the lights in the OR are on.
>
> I arrive and the woman is still in the delivery room. We bring her
> to the OR, turn on the generator and Samedi scrubs while I shave and
> prep the abdomen. After a spinal anesthetic, the woman is placed
> supine and I scrub as well. After a short prayer I take the large
> scalpel blade and cut into her abdomen cutting the fascia and
> tearing the muscle and peritoneum apart to get to the uterus. After
> deflecting the bladder away, I nick the uterus with the scalpel and
> push a curved clamp inside releasing a fountain of clear amniotic
> fluid. As suspected, she has a placenta previa where the placenta
> covers the exit and starts to bleed profusely when labor starts.
>
> I reach my hand inside the uterus and find a tiny little head way
> high above the placenta. Samedi pushes and the tiny, premature
> infant slips into the world. She grimaces and flexes her arms and
> legs. Her skin is underdeveloped and translucent revealing all her
> underlying blood vessels. Samedi clamps the cord, I cut it and we
> hand the little girl to Abel. We soon here a shrill little scream
> as the girl opens her lungs to that life giving oxygen. As I suture
> the uterus closed I have Abel turn off the fan in the OR and cover
> the baby up. We have no baby warmer and I'm afraid she'll get cold.
>
> I finish sewing up the skin and I take of my gown, clean up the
> blood and mess around the woman and go see the newborn.
>
> She's cold and has a slow heart beat. I pump her chest a few times
> and the heart beat comes back up. I put a tube in her nose and give
> her some glucose water. I have Abel go tell the family to boil some
> water. We'll heat her up that way. Meanwhile I pick up the tiny
> form that fits easily in my two hands and place her naked body
> against my stomach under my shirt. I'll use my own body heat to
> warm her. After a few minutes I feel a response. She starts to
> move more and make some weak cries. I pull out the feeding tube and
> suction out her mouth and nose as she's regurgitated some of the
> glucose water. I feel her stretch her tiny feet against my belly.
> Her hands are grasping. She's reflexively searching for her
> mother's milk. I curl her up in a ball and hold her close flipping
> her around like a burger on the grill to make sure she gets cooked
> on both sides.
>
> I go out to check on the hot water several times and the family says
> everytime that it's ready but it never is. Finally, I can't wait.
> The morning chill is too much. I take her home, held tight against
> me under my flimsy scrub shirt covered with a woman's wrap around
> skirt the family gave me. I knock on Tammy and Jamie's door. Tammy
> lets me in and when I explain quickly heats up water as Cory and
> Brichelle come to help. We put hot, but not scalding water in a
> plastic basin and put the girl in. She seems to like it and kicks
> and stretches. She's breathing well and has a strong heartbeat.
> Her limbs are quickly warmed up as we replenish the hot water
> supply. I gently hold her head up so her mouth and nose stay in the
> air to gulp down that important oxygen.
>

Perforation

>
> It must be bad. They only call me out of church for real
> emergencies. I gather my books and walk out on the dusty dirt floor
> to a bright late Tchadian morning. Noel and Pierre are waiting for
> me. I don't see a nurse anywhere. What's going on?
>
> "Abel's in-laws have just informed him that his fiancee will come to
> him tonight to become his wife. He has nothing to prepare a wedding
> with but wonders if we'll do a dedication for him in church."
>
> After much discussion it is decided that the women of the church
> will prepare a goat that I will provide and we'll do a wedding
> ceremony at his house tomorrow evening. He has no family here, so
> we will be his family.
>
> That afternoon, I'm too tired to go to the river. It's a good
> thing. Tchibtchang comes calling with the traditional "clap-clap"
> at my door.
>
> "There's a father who brought his son in for a blood transfusion for
> severe anemia and malaria. After we drew his blood to give to his
> child, he told us his hernia popped out in route on the motorcycle.
> We can't get it back in."
>
> I accompany him to the hospital and see Simeon and Abel already
> waiting.
>
> "Aren't you supposed to be preparing to receive your bride tonight?"
>
> Abel chuckles loudly with a huge, toothy grin. "No, tonight she
> comes to my house but I'm not supposed to be there until tomorrow
> night...so here I am!"
>
> A quick look reveals that this hernia is not going to be reduced
> without surgery.
>
> Just then Augustin One comes in. "There's a guy who's been gored in
> the butt by a bull."
>
> "Ok, bring him over." I take a look and fortunately the gore wound
> is to the side and back of the anus missing the intestines. It's
> pretty deep though so I order antibiotics and we prepare for the
> hernia.
>
> Simeon gives the spinal anesthetic while Abel scrubs. I prepare the
> surgical field with Betadine and then scrub. Abel puts my gown on
> and snaps my gloves into place. A few scalpel strokes later and we
> see a dark mass of intestines. I open the sack and there is already
> some dark, coagulated blood in the mesentery but the intestines
> still look viable. I push the squishy, slippery mass of bowel back
> into the abdomen and close the sack. He also has a hydrocele and
> since his left nut is good I take out the hydrocele, testicle and
> all. I sew a piece of mosquito net over the weak spot in the muscle
> and close the skin.
>
> The man with the anal wound is stoic. I give him local anesthesia
> and close the wound in four layers leaving the skin loosely
> approximated. I tell him to soak in salt baths four times a day and
> go home.
>
> Later that evening, Augustin One asks me to see a little girl who
> was treated here a month ago for malaria. She now has abdominal
> swelling. I approach the bed in pediatrics and see a thin little
> six year old with bright eyes who looks tired but not too acutely
> ill. Her belly seems slightly swollen but is soft and non-tender.
> She has diarrhea so I put her on Chloramphenicol and Metronidazole
> and go home.
>
> The next day, Sunday, I lazily do rounds around noon. Melodie asks
> me to see a girl on pediatrics she feels isn't doing well. Her
> glucose is a little low but she's awake. She just doesn't want to
> eat. It's the same girl I saw last night. She is alert but refuses
> to eat. The diarrhea has all but stopped but her belly seems more
> swollen. I examine her and the belly is soft and she doesn't flinch
> or anything when I touch her. I look in her face and something in
> her gaze tells me there's something serious going on. I feel a
> strong impression that I should operate on her. I feel bad because
> this means I'll probably miss Abel's wedding. I tell the father and
> he agrees. Koumabas calls in Simeon and Samedi.
>
> In the OR, Samedi has already scrubbed and the little girl is lying
> resignedly on the operating table. I feel a sudden panic. Why am I
> operating on her? Maybe she has abdominal TB. I run to my office
> and bring in the portable ultrasound. The images reveal a full
> bladder and a lot of stool but no intra-abdominal fluid. Well at
> least it's not abdominal TB. I'm still uncertain but feel committed
> now to the operation. I scrub and join Samedi at the surgical field.
>
> We all bow our heads and I pray in French "God, we're not sure
> what's going on with this girl. We just pray we are doing the right
> thing. Help this operation to be a success and this little girl to
> recover her health completely afterwards."
>
> I cut through the skin and fascia below the belly button. The
> peritoneum seems thickened and I'm not sure if the intestine is
> stuck. I enlarge the incision to above the belly button and make it
> into the abdominal cavity. A gush of liquid stool spurts out under
> pressure as we try to suck it up. I'm at first afraid I've
> punctured the bowel but as the stool spills everywhere over the
> surgical drapes I soon see that she must have had a perforated
> intestine. I can't believe she didn't have pain but am relieved we
> decided to operate. Samedi sucks out the stool as we irrigate and
> search for the damaged section. My finger digs into an inflammatory
> mass and a clump of green, peat moss looking stool slithers out.
> We've found the hole. I pull out the mass, clamp and cut it out.
> It's in the distal ileum. I then suture the two parts of good
> intestine back together, rinse out the belly with liters of fluid,
> put in two drains and close the fascia and partially close the skin.
>