MUD

I set up a cell saver and autotransfuseur kit that I found in the back stockroom covered in rat poop. Fortunately, the heavy plastic sealing it's sterility was intact. Simeon searches for a second IV. We give her a spinal anesthetic. The scalpel quickly reveals dark, uncoagulated blood that we suction into the cell saver to give back to the girl later. I scoop out mounds and handfuls of placenta and blood clots finally isolating her right adnexa which I remove between stick ties. I leave in a drain and we start the autotransfusion as well as a bag of O+ blood from the little fridge that serves as our blood bank.




It's now a little after 6 AM. By 6:30AM Ndilbe, one of our nursing students, and I are on the road in the old Hiace mini-bus affectionately known as "scalded dog." I'd just brought it back through a round about road through the bush that was really bumpy but had no water. The main road is still covered with water where the hippos hang out and so people and motorcycles are ferried along the road in dugout canoes. Needless to say, "Scalded Dog" doesn't want to go there. Last night, someone told me of a shorter route that is passable as well. I try to find it. Right after the bridge I turn left at the flag pole and wind through the village until coming to a Y in the road. I'd come from the left last week so I assume the right one is the short cut.

This road is not only shorter, but it's flat, packed sand and we're able to make good time until I come to a 30 foot section of mud. I make a bad decision. I go right and am soon stuck and spinning deeper and deeper in despite four wheel drive. The right front wheel is deep in some watery, slippery clay mud lifting the back left tire up onto some other slippery mud taking the weight off it so neither of the two that are spinning are getting any traction. Ndilbe and I get down and get dirty. We shove sticks underneath, try and scoop out mud. try going forward and try going back. We're in the deep bush and don't see anyone around.

We try our futile efforts for 10 more minutes until we spot an old man coming out of the bush on the road and heading away from us. We call him back and he waddles slowly over. Meanwhile, a middle age, stocky man comes up from nowhere headed to his field with his throwing knife hanging casually over his shoulder. He dives right in and starts hacking away the earth that has stopped up under the axle. He is soon covered with the gray, slimy mess. Before we know it we are surrounded by 10 stout farmers who all just get busy. We push, we lift, we dig, we stuff things under the tires. Finally, we lift the entire care up and stuff branches under the right front tire. Then I put it in 4-wheel low. The same thing starts, just spinning. Then I turn the wheel a little left and with a big push from everyone behind it starts to get traction and then inches slowly out of the mud and onto solid sand.




I think them profusely and hand them two 2000 franc notes to split amongst themselves. They wave good bye and we're on our way.

Just think, if I the woman hadn't of showed up just right before I was going to leave, she probably would've died and as a bonus, our leaving late allowed us to get stuck just in time for the farmers to be on the road heading to their fields! I drive on through the tall grasses and narrow tire ruts in the sand with a silly smirk on my face as I reach into the plastic pail and pull out a square of watermelon.

ALONE

I sit on the stool in the prep room. My whole body slumps. I stare at the concrete floor. The odor of sweat, blood and chlorine wafts gently towards me. I'm vaguely aware of Simeon and Abel moving past, taking a patient out; moving another in. I don't know if I can get off the stool. I just did a hernia and I don't remember much. My mind was elsewhere. I think I did it well. I hope so, it's one of our employees.

That morning started off alright. I woke up early, took the horses out to graze. I played a few songs on my much neglected guitar. I ate leftover garbanzos and rice. I guess things fell apart when I went to do rounds...

I walk into the courtyard and see two heavily turbaned men walking out with one of our patients' sons. I have a hunch. I call them over and ask them to return to whichever patient they were visiting. See we have a policy that only two family members can stay with each patient except during visiting hours from 3pm to 6pm. We've tried everything to enforce it but it's been a seven year battle. Our most recent strategy is to charge the extra family or friends a $2 overnight fee or fine. It's worked pretty well. Not on these guys though. The argument starts up almost immediately in Arabic.

"You are five with the patient, you are only allowed two."

"Yeah, we just came to visit we're on our way out."

"Do you know when visiting hours are?"

"We just came this morning. We're leaving."

"Now you have to pay a fine because visiting hours aren't until the afternoon."

"We have no money, we're just going now."

"How did you get in?"

"The gatekeeper let us in."

"Did you tell him you were visitors?"

"The other one maybe, not me."

"Yes, they told me they were sick and wanted to get consulted," adds the gatekeeper who's standing right there.

"I don't know, pardon, excuse us...we're going."

"Ok, I forgive you, now go pay the fine."

And on and on in never-ending circles goes the conversation.

Finally, I'm called to see a sick kid in the ER. I tell the gatekeeper not to let anyone in or out until we solve this problem. If they pay the fine, they can go. Five minutes later I come out of the ER in time to see about 20 people flowing in the open gate and the two men claiming to have no money hopping on their new motorcycle and taking off. In my head I can hear them mocking me the whole way home.

It seems silly, but somehow it's symbolic to me. I've been going round and round with this for seven years of staff members telling me it's good to have order in the hospital and respect the rules but no one enforcing except me occasionally creating unnecessary conflicts that drain my spirits. Yet I somehow feel compelled to keep trying. Today, as I do the hernia, though, I can think of nothing but despair and darkness as I think of the hopelessness of anything changing in this twisted world.

So, I sit on the stool. I don't know if I can get off it. Simeon comes up.

"We're ready for the next case."

Somehow, I lift my heavy limbs off the chair and shuffle in. The woman has a large tumor at the end of a pendulous breast reaching to her belly button. I'm not in the mood for careful dissection and a long, drawn out procedure. I stretch the breast out straight off the chest, attach two allis clamps at either end and N'Dilbe stretches the clamps out. I slash through, taking off the breast and mass in 4 or 5 strokes of the scalpel as large arteries squirt out blood everywhere including a major one that smacks me in the forehead and spatters my OR glasses. N'Dilbe holds compresses on the wound as I reach for clamps and clamp off all the blood vessels as the drape gets soaked with blood. It's over in a few seconds. Then I tie them all off and suture it closed. I'm in automatic mode.

My ankle is killing me. I got a rope burn on the opposite side of the ankle where I had the almost year long tropical ulcer that wouldn't heal. I fear it's twin has shown up. My ankle has been swelling up off and on over the last two weeks with red, painful skin all around. When I'm on my feet to long, especially in the OR, I can hardly walk for the pain. I limp home, throw a pillow on the concrete floor and lie there with my leg elevated on the couch. I stare at the ceiling as sweat makes my back stick to the cement.

I forget what drags me back up to see some of the patients. Somehow 2pm arrives and Samedi reminds me I've called a committee meeting. Great, just what I need. I somehow get through it without letting my anger and frustration show too much. I go back to a house empty except for two cats. I lie down all evening but can't get comfortable as my thin frame rests on the hard concrete. My neck hurts. I take some pain killers, brush my teeth and crawl into bed.

Outside the window, on the street by the fence a group of kids is yelling, screaming and laughing harshly and forced. Most parents let their kids run around wild like little goat kids. There's a bright moon and the under 10 party is happening a few meters away. I slip on some cut off scrubs, put my sore ankle into a worn out Croc, grab a stick and a head lamp and head to the gate. I slip out and dark little shapes are milling around me. I start swinging the stick indiscriminately and feel several resounding "thwacks" followed by small yelps as the crowd runs off quickly.

After yelling a little at all the teenagers and adults just sitting around watching, doing nothing I stumble back into the darkness of my house lit only by a bug lamp. I can't feel anything. Deep down I have a sense that at this moment I'm not the model missionary, but after seven years of seeing and participating in extreme suffering and poverty and ignorance I really could care less. I try to pray and read something uplifting but I still feel empty.

I'll probably feel better tomorrow...

Twice

I somehow feel like I'm missing something but I don't know what. The old man's belly sure gave me reason to think I needed to operate. He had a hernia and talked about it coming out and hurting a lot before he finally stuffed it back in. I thought maybe he had some necrotic bowel or something. His belly was certainly swollen and tender and he'd had no stool for 6 days and no gas for one day.

But now I've opened up a small hole in his abdomen big enough to both get a good look and fit my hand inside to explore with tactile sensation. There's no fluid, no pus, no stool no blood. All the intestines look pink, healthy and clean. The appendix is normal. I run the small bowel which is slightly distended distally but peters off to normal proximally with no twisted areas, no masses, no holes, nothing. The large bowel is quite distended but soft with no lesions or masses that I can see or feel. Maybe it's just constipation after all. It won't be the first time I've operated on severe constipation. But something just doesn't feel right. Against my nagging feelings I close up and then proceed to fix his hernia.

At the end, I clear out his rectum and give him several liters of enema which washes out some hard stool but not much. I hope that will stimulate things. He had a fever so maybe it's just an ileus from malaria.

Everyday for three days I keep hoping I'm right, but he still has no stool or gas and vomits frequently. I can't get the idea out of my head that I've missed an obstructing colon cancer. I hadn't thought of it at the time, until afterwards. I'm wishy washy and don't want to take an old man back to surgery so soon. He looks so frail. I go home. Maybe tomorrow he'll have regained bowel function. My hopes don't comfort me much.

At midnight, Faka, one of the nurses is at the door.



"His belly is really tense, he's vomiting," he says. "I think you should come see him."

"No, just call the OR team," I reply. "We have to take him back to surgery.

I reopen the lower abdominal wound and swollen small bowel spills out. I enlarge the midline incision all the way up to his chest and really explore as Samedi holds the eviscerated bowel covered with lap sponges to keep it from falling off. Abel retracts the lower abdominal muscles away so can get a good look. Still nothing is obvious, but this time I'm a little more thorough and since I'm looking for cancer now, I find it. His sigmoid colon has a small hard mass right in the center of it that is obstructing the flow of stool and gas.

I clamp off the bowel, clamp and tie off the blood vessels and remove the mass. I painstakingly sew the two sections of colon together with two layers of sutures and release the bowel clamps. No leakage. I realize I'll have a hard time closing the abdomen with the swollen small intestine and it would speed recovery of function if I emptied them. It seems like a good idea at the time.

I tie a purse string around where I want to make the hole and get the suction catheter ready. I incise the bowel wall but the suction gets plugged up with a hard chunk and stool starts to spill out everywhere contaminating everything. I quickly try to block the flow with my fingers and get Samedi to hold it while I clear off the suction. It keeps getting blocked so I call for a basin. We don't have any sterile ones, but then we are no longer in a sterile field anyway. I grab the basin and just let the stool pour into it instead of the abdomen. Samedi and I milk the still down from both sides of the hole until the intestines are relatively empty and we have a couple of liters of stool in the basin. I hand it off, wash off my gloves in bleach water and then suture up the hole in the intestine with the previously placed purse string followed by another layer over it. We copiously irrigate the intestines and the entire abdomen with sterile saline until everything looks really clean and we've diluted the pollution.

I insert two drains in the deepest portions of the abdomen to drain off any excess contamination and close up. We then dilate his anus and evacuate much more green liquid badness into the plastic basin until his belly is actually flat and matches the rest of his lean body. I place him on antibiotics and IV fluids and with a final prayer go home 4 hours later.

Arriving home, the adrenaline starts to wear off and I notice my ankle is swollen, red and hot around the rope burn I got 3 days ago. I take some antibiotics myself, soak and elevate it but can't go in to work the next day. Today I hobble out a little and go to see my old man. He's lying in bed asleep. He looks kind of bad but when I shake him awake, his eyes alertly open and he shakes my hand in a firm grip.



"Can I have some tea?" He asks.

His family laughs and says that since yesterday that's all he's wanted. He's a big tea drinker at home, apparently.

"Ok, you can have tea," I reply through the interpretation of the nurse from French into Ngambai. "But only if you sit up."

Despite no pain meds except Tylenol and Ibuprofen on a huge abdominal incision, he lifts himself up with only a little help and looks at me defiantly as I ask the family to bring him porridge and tea.

I examine the wound which is clean. The drains have only clear fluid in them and he has had regular bowel movements 3 times since surgery. As the family hands him the porridge he slurps it up hungrily before spitting out the chunks of rice he doesn't like.




I think he's going to be ok.

Ecodome Chad

I stand in the darkness of the hut and tears stream down my sunburned, dirt caked cheeks. My body has reached it's limits and now my spirit has too. I've been living and working in an African village in Eastern Chad for a week now. My bed has been the packed earth of the village chief's courtyard. My food has been left over rice sweetened with a little sugar and peanut oil interspersed with a few cucumbers and the occasional boiled goat organs. My shirt has been the same one I've worn every day out on the construction site and it's ripeness cannot be described, only experienced.

I came out packed like a sardine with 5 other large Americans and a Chadian chauffeur named Issa Mahamat (Jesus Mohammed) over 900km of mostly bad subsaharan roads on a trip that lasted over 14 hours. That night I call Mahamat Saleh Abakar, our host and patron, to inform him of our safe arrival at his house in Abeche. He is his usual jovial self. I have no indication of the tragic news that will awaken me next morning before 6am. Arlo leans into my mosquito net and with a quavering voice gives me the bad news.

"James, Mahamat Saleh is dead."




"What?" I'm still groggy and wonder if I'm in dream land until the sobs and wails coming from around the courtyard jolt me awake. "Are you serious?"

"Yeah, we just got a call from N'Djamena. He went to open the mosque at 4am and then, after praying went back to bed. He never woke up. They found him cold."

I get up and move out onto the sand of the courtyard towards the short brick wall separating it from the walkway to other parts of the compound. Issa Mahamat comes up to me with tears in his eyes.

"Mahamat Saleh mot," he bemoans in Arabic as he shakes his head in disbelief.

I'm assured later by the family that this won't undermine the project but that the whole family is behind us in the creation of this health center. We pick up the "Chef de Terre" (Land Chief) of the area who accompanies us out to the village where we are introduced to the chief and his second in command. We set up camp and go out to the job site where Arlo has already dug the foundations for the Ecodome we will hopefully build in the next week.



Monday I am occupied with visiting local authorities back in Abeche while the team gets working. Arlo has identified three locals, Naim, Aimé and Richard who we will soon realize are indispensable for the success of this project. They are not only amazingly hard workers but are of impeccable character. Naim especially always has a smile on his face as he motivates the local workers to move ever faster and stronger. Then as we rest in the unbearable midday heat he prepares our simple fare along with the obligatory tea. Later he helps translate, count out and distribute pills and make it possible for me to see hundreds of patients at night after our evening work session. He is tireless, humble and dedicated to his faith. None of all these responsabilities can make him miss even one of his five daily prayers. He studied Arabic in the university and can read and write it fluently as well us understand completely the Qur'an. Like any true student of the Qur'an he was led to study the other ancient scriptures as well and is familiar with the Injil and the teachings of Jesus. While at the university, he organized a dramatic troupe to do street theater to promote social awareness, health principles and to point out corruption at the hospital and elsewhere. He is one of those men in whom one instantly recognizes veiled greatness.



Aimé and Richard are quieter and more subdued yet no less hard working and dedicated in all areas of life.

Wednesday I am on the wall filling a superadobe bag and I suddenly feel as if have no strength. I'd had diarrhea once that morning but no other symptoms. Now my whole body is aching and my skin is on fire. I am drained. I manage to finish the row and then wobble down the hill to the cattle watering hole where I jump in after stripping off down to my underwear. I find temporary relief in the coolness of the shallow muddy pond. I go back to the compound and am flat out on my back for the next two days. I start treatment with antibiotics and Flagyl for amebas. I've used up all my malaria medication in treating sick kids in the village. I send someone Thursday into Abeche to buy me some and after one treatment that evening am feeling better the next day.

I have seen such suffering. No clean water, hardly any food, sick kids with pus filled eyes everywhere. Malaria, diarrhea, skin wounds, blind adults from cataracts. My simple supply of pills is soon gone and the needs are overwhelming. I get more in Abeche on Friday and that night see 50 of the 130 signed up to see me. I have no where to consult but on a mat, often with a flashlight to guide me and Naim and the village chief at my side as assistants. Saturday afternoon, I try to see the almost 100 that remain. As it gets dark I go to get my headlamp and it's gone. I flip out. Exhaustion has taken it's toll. I pack up what little meds remain and close shop. Many have come from miles away to see me. My missing head lamp just gives me an excuse to escape from the overwhelming needs that have pushed my body to it's limits.




That morning, we'd decided to hike to and climb a nearby mountain. We almost died of heat exhaustion. One of our group, Brian, had to turn back early. On the way back on a simple path through the millet fields we hear a voice thundering from under a nearby tree.

"Don't come over here unless you want to get naked and wait till the moon comes out." I glance over and see a hairy, naked body leaning with one arm casually against the trunk. Fortunately, the intervening millet stalks blur the details. In our own delirious state, none of us thinks it abnormal as we are just trying to survive ourselves. We wave goodbye and continue back to the village. It's only after downing a few liters of water and some porridge that I start to panic. We sort of realized that it wasn't good so we'd sent out Issa Mahamat and Naim along with Brian's son, Bradon in the truck to try and find him.

The locals are chastising us for our carelessness. The truck comes back with out Brian. Naim and Issa are covered from head to foot in sand. The car got stuck in the sand and had to be dug out. We head out again. I hope I can find that tree again and that Brian hasn't moved. We finally find the small path and sure enough there's Brian still under the tree. He was smart enough to recognize his limits and stayed out of the sun and heat thus saving his life.



So, Saturday night, I'm exhausted from working all week, having amebas and malaria, almost dying of heat stroke, not eating enough and seeing too much suffering. So, I find myself standing in the dark crying, bemoaning my weakness yet feeling at the end of my resources. These people have lived like this their whole lives and I am done after a week. And now I've turned away dozens of suffering people because I just can't go on.

"Father God, forgive me my weakness, only you can make me strong."