Roadside

I've blown a head gasket, literally and now I'm sitting on a bench by the side of the road. My scrub shirt sticks to my back; it's soaked. The front is covered with grease. I've been on the road since 4am. I'm 30 km from my destination, N'Djamena, and I'm not going anywhere soon. The car has been overheating for the last 100 km. Every 20 km or so, I add 1-2 liters of water to the radiator. I pull over in this nice village under the shade of some trees and pour in my water. Now it won't start, and it's making a real funny noise I've never heard before. The "Scalded Dog" is known for funny noises, but this is definitely new, wrong and we're not going anywhere.




To my left is a water pump. I've been searching those out all day to fill up my two water bottles and one jug for the constant replenishing of the radiator. Just a couple stops back I found one and freed it from tyranny.

I'd pulled up in the shade. Thatch roof tops poking through the bush let me know there was a village there and therefore probably water. A young man passes as I gingerly and slowly remove the radiator cap to let the steam out slowly.

"Is there any water here?"

"Sure just 10 meters farther on."

I finish filling the radiator, close the seat back over the engine, hop in, start her up and drive to the well. Someone has put a bolt across so the handle won't move up and down, thus impeding access to water someone in Europe or the West paid good money to provide these people with. I'm suddenly on a short term mission with easily obtainable objectives. The young man is unperturbed and just takes my water bottles to his house where he probably has stocked up a supply. Meanwhile, I go get my socket set.

The bolt doesn't stand a chance against two 12 mm sockets and it is soon in may hands. I wait until the young man comes back and with a leer on my face I show him the bolt right before launching it across the road into a dense thicket.

"NO ONE SHOULD LOCK UP WATER!" With my mission accomplished, I get back in the van and drive off into the sunset.

Back in the present I watch a little kid bouncing up and down on the handle trying to get the water to come out. He's only about 3 or 4 years old but already has his chores. Another kid about his age is trying to catch the unsteady stream in an old 5 liter oil jug as the excess runs off into a stagnant pool in front of a small store. The water is green with algae and littered with plastic bags and tin cans. The store has a veranda made of a straw mat balancing precariously on some gnarled tree branches stuck in the ground. There are three old fired clay water jars covered with metal plates with an upside down plastic cup on top and a plastic teapot at the base of the jar.

One man, covered from head to toe in sand has just descended from the dump truck across the street which is filled with...you guessed it, sand. He walks up and greets the group of robed and turbaned men on the mat.

"As salaam aleikum!"

"Wa aleikum as salaam!"

He goes and shakes each man's hand in turn before sitting before one of the jars and washing his arms to the elbows, his feet to mid calf and his face, ears and mouth. He's preparing for mid day prayers, but he's a little late.

When I first realized I was stuck I felt kind of awkward. I kind of mill around before sitting on the small bench in front of some mats. I greet an old man in Arabic and ask him about the food in the clear plastic garbage pails on the rickety, homemade table.

"There's donuts here." He points to the middle pail.

"What's this?" I motion towards the bucket to my left that has some whitish meatball looking things swimming around in a red sauce. "Is it meat? Fish?" My Arabic is limited.

"Fish, yes fish." His face brightens up, communication has happened.

I decide to pass for now and I go get a small watermelon from the van.

"Do you have a knife?" I ask the old man, knowing the answer as no respectable Arab would be seen anywhere without one.

The man graciously smiles and pulls up his robe, unsheathing a homemade dagger about a foot long. Looks kind of like a toy and feels light in my hand, but it's razor sharp and cuts through the watermelon like butter.

I haven't eaten all day and hardly drunk anything since I contaminated my water bottles with radiator fluid. I devour one quarter of it, but start to feel awkward. I've been here long enough that some good things have rubbed off on me. No respectable African, much less a Muslim would think of eating alone in front of people. I slice up the other half into manageable portions, arrange it on a tray a little girl has brought out and offer it to the old man and those resting with him on the mat.

"Faddal," I say in Arabic motioning him to partake. As I sit on the bench the munching and slurping behind me is reward enough for the tiny sacrifice of my coveted watermelon.




As I finish my piece at my leisure, I realize why the others are hurrying as the call to prayer rings out from the mosque across the street and men get up from all over where they've been resting in the hot afternoon son and make there way across for the 2nd of the 5th daily ritual prayers. The roadside is suddenly empty and quiet with only the occasional "Allahu akbar" ringing out over the microphone from the Imam. Then, after a few minutes, the roadside is a bustling, noisy thoroughfare again.

Soon, an old French army Land Cruiser with it's all important yellow license plate pulls up. Out jump two Chadians I've never seen before. We greet each other and they get to work. A mass of rope is pulled out and quickly untangled and doubled then quadrupled and lashed from a hook on the front of my van to the rear bumper of the land cruiser.

"You, go forward. Me, I drive." The man says in poor French with a heavy Arabic accent. I oblige, having not really wanted the daunting task of driving a car being towed by a rope on roads barely wide enough for two vehicles and crowded with broken down trucks, cows, goats, pigs, pedestrians and bicycles and motorcycles weaving in and out amongst the whole mess. Not to mention the potholes.

And so, without even a look back or a fond farewell, I say goodbye to my roadside friends.

Timing

Bad timing. Just when I really needed it, the van refuses to start. So much for the "scalded dog." I really need to go to N'Djamena to get the two new doctors from Congo their work permits. The local Police Commissioner has volunteered to help (for a small per diem of $80/day) and we can't refuse. His brother is second in command at the Police Headquarters in the capital that hands these things out. If he goes with us, we get the visas easily. If we refuse his help, he calls up his brother to slow the whole process down or even refuse.

I send them on ahead. I'm sure the van can be easily fixed. It was running perfectly when I parked it last Friday. Besides, Jamie's back and knows this car backwards and forwards.

All Monday passes and Jamie and I can't figure out why it won't run. We check everything we can think of. There's good compression, spark, fuel getting to the carburetor, etc but it doesn't want to start.

"I have a feeling I wasn't supposed to travel today, Jamie." I say with a touch of frustration. "Maybe one day we'll realize why. It must not be the right time."

I go home and go to sleep early. I must have fallen deeply asleep because when I finally hear the banging on the door I am totally disoriented in the dark room, barely lit by a pale blue bug lamp.

"Yeah, hallo." I shout groggily out the window in the general direction of the screened in porch's door. "C'est qui?"

"Hey, it's me, Cory." I recognize Jamie's son's voice. "Brichelle, is really sick in a lot of pain in her stomach and she's been vomiting. We tried to bring her to you first but no one answered our knock. She's at the hospital, can you come quickly.




I sense the urgency in Cory's voice and as I slip on the slightly used scrubs hanging over the end of the bed I wonder how I could've missed the knock. I must be getting out of my light sleeper mode. For seven years I've been woken up at all hours of the day and night for emergencies here in Chad and never not heard the call. At least until recently. This is the second time now in the last few weeks that I've slept through someone banging on my door.

I walk into the ER and Tchibtchang points me to the cubicle where Brichelle, Jamie's young teenage daughter lies in obvious discomfort. The signs and symptoms are classic for acute appendicitis. Even in my groggy state of trying to wake up, I recognize that. But the words come out kind of heavy. I must not have been very convincing because Tammy laughs loudly and hollowly, desperately hoping she misheard.

"Are you kidding? Appendicitis!?" I definitely would've woken up to that voice. "James, what does that mean...?"

"Well, I'm serious. She has acute appendicitis and the only treatment is an operation."

I can see Tammy is taking this hard, but Brichelle is calm and seems to just be glad that something is going to be done immediately for her severe pain. I call in Samedi, Simeon and Abel as we take Brichelle to the OR. Tammy accompanies us inside and makes sure that things are kept modest. Samedi arrives first and sits to start an IV on her right arm. I take the left and am happy to see she has great veins. I don't want to mess this one up. But I do, twice missing fat veins right in front of my face. Meanwhile, Samedi has the other IV up and running so I motion him over and he quickly finds the second IV and starts to give the antibiotics. Abel and Simeon are there but now there's the problem of the urinary catheter. Tammy has promised Brichelle privacy but there are only male nurses and doctors. We send Cory to the other side of town to get Wendy.

Meanwhile, we've prepped the OR, prepared the instruments and Samedi has scrubbed. Brichelle is on the OR table and we've given her Diazepam to relax her. We can't wait for the catheter. Then I remember, Lucie's on duty. She's not one of our best nurses, but I'm pretty sure she can put in a foley catheter. Besides, I'll be there to supervise. Lucie comes immediately and gets the urinary catheter in quickly, just as Wendy arrives.

I scrub and Samedi helps me on with gown and gloves. We drape the abdomen. It feels weird to have white skin under the drape. As I make my small incision in her right lower quadrant, I notice how even though the surface looks so different, just millimeters in under the slight pressure of a sharp scalpel and the blood, fat, muscle, and other tissues is exactly the same on black and white. I've made my incision a little high so I have to dig down to find where small and large bowel join until finally an inflamed appendix pops into view. I quickly clamp and tie the vessels and the stump after amputating that weird little intestinal appendage. I sew up the fascia, subcutaneous tissues and skin and apply some dermabond over the subcuticular suture.

The next morning, I go to see her at the hospital before getting on the public bus for N'Djamena. If not for the bad timing of having the car not start I wouldn't have been there to operate on Brichelle. That evening she goes home and rapidly recovers.

A week later, Jamie and Gary having exhausted their vast reserve of mechanical knowledge without success, the van still isn't running. It's a big mystery. Saturday morning I get a call from the vice-president of Chad's constitutional advisors. I met him a couple weeks ago. He is Muslim and a true believer. We talked about God for over an hour as he invited us to come to his village near the Sudanese border and look into helping his people in the area of health care. He tells me he's talked to the sultan who is excited to meet us. Can I come sometime this week?

So, I need a way to get to N'Djamena quickly as our meeting is tomorrow at noon. Jamie calls Maccabé, a local mechanic from Kelo who's helped him before. We go over the engine from top to bottom again. He's found a few things he thinks are wrong and assures me the car will start. We get it all put back together, and no change. Just as I'm about to throw in the towel, Maccabé reaches for the distributor.

"Have they checked this out?" Before I can reply that "Yes, of course we have..." Maccabé has reached under with a wrench and loosened it up. He puts the key in the ignition and starts up the car. With a little twist of the distributor, the engine roars to life. It looks like the timing of the spark plug firing was a little off. A few more adjustments and the vehicle is ready to go for my early departure tomorrow.

Imagine that, it was all about timing...=

CATS

I'm lying on the floor. It's my back again. After a long day as a tall person in world made for short people the only relief I get is stretching out on the cold cement floor. Our newest little companion, Garfield, is lying on my chest purring contentedly. He's finally stopped whining and meowing now that he feels he's the center of my attention.




I'm waiting for them to call me from the hospital. A young man previously operated on in April 2006 is back with a swollen tender belly...all the signs of intestinal obstruction. I fill out the OR sheet and send the family to the Pharmacy. They say they need to wait for the boy's father. So I finish the rest of my work and come home. Koumabas, the pharmacist, comes in the late afternoon to say the father has come but he's not sure he wants the operation. I walk over there and call the father into my office. He says his son has been operated on already two times, he's not sure about this time. Besides, he says it's too expensive. I look at what has been calculated for the surgery, anesthesia, hospitalization and post-op care: $145. It seems a bit steep to me too. I have Koumabas recalculate. We have two different payment scales. If the patient is in our health district they pay half of what the others pay. It seems, they didn't know he was from Bere. We recalculate: $110. He seems more agreeable and says he'll sell some bags of peanuts in the market tomorrow and pay us if we can wait.

I explain to him that it's urgent, his son needs an operation yesterday. He says he has a motorcycle, but his "brother" took it to the market. I tell Koumabas that when he comes back he should fill out the forms, call the OR team and when the patient is ready have them come and get me.

So, I'm lying with a kitten on my lap on a cool cement floor waiting. A knock comes on the door.

"Oui?"

"Hey, it's Cory, we're having worship at our house later on."

"When?"

"What time is it?"

"6:30."

"Ok, in half an hour or so?"

"Sure."

I get up and straighten up the house and do the dishes. 7:00pm comes and still no call from the hospital. I go over to Cory's. After half an hour or so of beating on a drum, mostly in rhythm with Philip's guitar playing, I figure I better go find out what's going on. As I go outside, I see our original cat, Erling, waiting for me. He follows me to the gate but is impatient and jumps up the wall and through the chain link while I fiddle with the padlock. He rolls around in the grass begging for some attention. I pet him for a few seconds, but have more important things to do. I find Koumabas.

"Salut, ca va? What's up with the OR case?"

"Abel and Enock came, but Simeon is out 20km away in his rice field so they went home to wait for Simeon. I tried to call Samedi, his phone is shut off."

I go to see the young man.

"Have you pooped? Farted?"

"No."

"Ok, come with me."

He slowly gets up and shuffles behind me, his nasogastric tube hanging limply from his right nostril without any collection bag attached, just a little green, bilious fluid resting in the curve of the tube.

I open the OR and place him on a gurney. The generator is already on so I flip on the A/C in the OR so it can cool down from the day's heat and grab an IV catheter, some IV tubing, a bottle of normal saline and a bottle of Metronidazole.

I turn on the dental light adapted as a minor procedure light in the prep room, attach a tourniquet and am pleased to see many nice fat veins pop up on our young patient's arm. I see a monstrous one in the depression on the opposite side of his elbow and figure I'll go for that since there's no way I can miss it. I blow it. I undo the tourniquet, have the youth hold pressure with cotton and find another catheter. I put the tourniquet back on and this time nail a much smaller vein.

As I'm preparing to put in the urine catheter, Samedi shows up followed shortly thereafter by Enock and Abel. Just as I'm getting ready to do the spinal, Simeon arrives and I begin to breath easier now that we have a full OR team. Samedi and Abel scrub and prepare the instruments. I scrub and we drape the patient after Enoch has slathered him in Betadine. After prayer, I decide to start in his lower abdomen. I follow the old scar from his pelvis to his belly button. Swollen small bowel wants to burst out. Many sections are stuck to the abdominal wall and everything is swollen and oozes easily. We are mopping up inflammatory fluid and blood which obscures the surgical field as I try to dissect the small bowel off the abdominal wall so I can open the rest of the belly.



Finally, I'm able to start running the bowel and I find a section that had been cut off by adhesions from the previous surgery and there's a small necrotic section. I try and free up the adhesion but it's impossible. I clamp it off and take out the bad section. I then call for a sterile basin and open up the end of the bowel that is distended. Liquid stool and gas almost explodes out. Samedi and I find the most proximal part possible and with our fingers gently squeeze the stool and gas towards where the bowel is open until we've cleared out almost three liters of watery stool. I clamp the bowel again, Enock takes the basin off the field, we irrigate and place the intestines back in the abdomen. I get a fresh lap sponge under the cut section of intestine and slowly suture it back together in two layers.

We irrigate again with several liters of fluid, place two drains and close the fascia leaving the skin open. I'm exhausted and slip to the OR floor resting against the wall as the others clean up. I then help them transfer the patient to the gurney, turn off the A/C, water pump and OR lights before switching off the generator, and head home.

Erling is waiting for me and I give him the love he deserves before heading home, the cat scampering ahead and then waiting for me until we get to the house. He slips in and then meows as I go inside to get him some peanut clusters. Erling is afraid of Garfield and our other cat Chir, so he stays on the porch crunching happily on his dried peanut paste. I take a shower and then stretch out on the floor again to ease my aching back.

Garfield comes gingerly over, meowing plaintively. I grab him around the chest and place him on my stomach. He curls up contentedly and starts purring as his eyes open and close as only happy cats do.