It starts with a hum, then a buzz followed by an ever increasing noise that soon identifies itself as an unavoidable telephone ringtone that is a poor imitation of the William Tell Overture. Sarah walks over to the shelf, grabs the small silver object and passes it to me. I open it up and glance at the screen: an unknown number.
"Hallo?" I query.
"As salaam alek." A deep cheery voice greets me in Arabic.
"Wa alekum as salaam." I respond.
"It's me, Mahamat Shadara," the voice continues. "You operated on my leg, remember?"
"Yeah," I do remember him and have wondered how he was doing. "Kikef?" I ask back in Arabic.
"I'm bringing a brother from Central Africa with two broken feet." I'm assuming that he's using the colloquial expression meaning two broken legs.
"Ok, where are you?"
"We just left Moundou and are almost at Kelo. We're coming to Bere. He needs to be operated on today."
"Ok, ok," I try not to promise to operate today since I have no real idea what his problem is. "Bonne route!" I hang up.
Several hours later, as Sarah and I are finishing up some pasta salad along with an episode of "House, MD" the phone rings again.
"We've arrived at the hospital." It's Mahamat Shadara's voice again.
"D'accord, j'arrive." I finish my meal and my distraction and head over to the ER.
There is an old beat-up Toyota pickup in the middle of the courtyard between the ER and the OR. I assume the patient is in the back. A large Chadian walks over to me with just a slight limp using a cane. He holds out his massive hand and grasps mine in a firm grip as a huge smile lights up his face.
"Docteur, as salaam alekum."
"Wa alekum as salaam, yom katir..." The Arabic greetings continue on for several minutes before we walk over to see the patient.
A foul odor wafts up from the back of the truck where a weak looking man looks like he's barely hanging on. His head is propped way up on a pillow. Yellow shorts cover his waste and a dirty white sports jersey can't hide the thin arms and partially healed scratches. An old piece of foam probably carved from a used mattress is between his legs which are both twisted out at impossible angles. As I suspected, he probably has bilateral tibia fractures. Both are covered in layers of old matted cloth surrounding reeds and all covered in gentian violet. The flies buzzing and his burning hot skin confirm my suspicions that one if not both of the fractures is open and severely infected.
"How long since the accident?" I demand.
"Xamstachar, fifteen days," Mahamat confirms. "He came all the way from the Central African Republic. I brought him here because you helped me so much if anyone can help him it's you."
I'm not so sure, but I get the process rolling.
"Dinah," I call out to the pharmacist. "Call Abel, Simeon, Samedi, Abre and Youlou. We have an emergency surgery and I need there help immediately."
The family members along with our medical students grab the metal spring bed without legs that the man is lying on and lift him out of the bed of the truck. We bring him into the OR. Sarah and Salomon each find an IV and start pouring in antibiotics and IV fluids. I start cutting away the layers of old cloth and reeds around the fractures and uncover a hardened layer of what looks like dried roots, probably some traditional bone treatment. The right leg has some superficial wounds that look like scrapes or pressure sores from the binding. No bone is showing and it looks like the fracture is closed. Good news for him.
Meanwhile Samedi has arrived and is putting in a urinary catheter while Simeon is cutting away the wrappings on the left leg. Henri has come and done a hemoglobin which is 5.7 g/dl. He needs blood. Henri goes to get the stuff to cross match his blood and hopefully find donors among his family members since we have no blood bank. The left leg is completely open with bone fragments jutting out and dirty, peat moss like flesh around the wound edges. Pus and an awful odor pour out of the injury. There is also a green looking gash along the outside of his left knee. There's no way to save that leg and we need to amputate immediately.
Henri comes back. The patient has O negative blood, one of the rarest types and the one type that can't take anything but that one type of blood. None of the family is O negative. We'll have to operate without blood. Simeon brings a blood pressure cuff and a large elastic wrap. I start at the toes of his left leg and wrap tightly to try and squeeze as much blood out of the leg as possible and back into his circulation. Then Simeon pumps up the blood pressure cuff around his upper leg which acts as a tourniquet.
We wheel him into the OR where I quickly slice through the thigh muscles down to the bone. Pus gushes out. Right along the bone is more of that green, necrotic tissue. I saw through the bone and toss the leg into the trash can which gets knocked over. Youlou rapidly puts it back right while I try to chase down and cut out all the necrotic looking tissue. I also find the main artery, vein and nerve and clamp and tie them off. Once the debridement is done and we are down to healthy looking muscle, I ask Simeon to gently let down the tourniquet. Samedi and I spot the bleeders and clamp them off while Simeon reinflates the cuff to stop any oozing. I tie off the vessels, pack the wound deeply with diluted bleach soaked gauze and wrap the whole wound up tightly with an Ace wrap.
Simeon lets down the tourniquet and the dressing stays dry. I move to the right leg which I cast from toes to thigh after cleaning and dressing the wounds. I'll cut a window in the cast tomorrow so we can do dressing changes and if the wounds clear up then I may put in an intramedullary rod. Right now it's too much for him in his weakened condition. As we turn him to clean him off, I notice pressure sores over his sacrum which I also debride and dress. Finally we wheel him out to the wards.
I don't know how he stayed alive for 15 days in that condition, but people here are tough. I hope he makes it through the night.
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