Planes, Trains, and Automobiles

It's surprisingly cold for a Chadian morning. I'm glad for the fleece that Olen has lent me. I swing my backpack filled with Christmas gifts onto my back, grab my computer bag and head out to where Jonathan has left us his motorcycle.




Olen tries to start the bike unsuccessfully. The ignition is hanging down to the side by it's wires and despite all our efforts it won't start. Even Frederic can't get it going. Finally, the engine sputters to life only to die within a few seconds. In the ensuing silence we hear the sounds of the "scalded dog" rumbling up the road from Bendele. Gary is borrowing the Toyota minivan to go to Moundou so he gives us a ride to the market.

I sit on a wooden bench as the bush bus taxi roars up from Lai, swinging from side to side. There is a mad rush for the door as there are only five places and about twenty of us waiting.

"Hey, we have tickets since yesterday!" I shout out in French to the man holding the list.

"Ca c'est vrai," he replies and makes everyone come back out. He reads of the list and my name is first on the list followed closely by Philip's. I squeeze down the aisle to a seat that has been rigged to fold down into the corridor with a tiny seat back that folds up. It's worn and the padding has all but disappeared. If I shift my weight around I can almost get my butt off the metal poles making up the skeleton of the chair. It's going to be a long trip.

A large woman pushes down the aisle making me stand up and lift the seat to let her in behind me. She is yelling in Nangjere that she can't sit there, it's broken. Many people yell back until she grudgingly accepts her fate and plops in behind me. A toothless man bangs on the window. Tobacco breath pours into the bus as he tells me to give him money to put my bags on top. I start yelling back and move out the crowded bus to the outside where I lift my bag up to the roof rack myself as the crazy man yells to his colleague not to tie it on and the chauffeur yells at me to get back in and let him handle it.

As we get bouncing down the dirt road to Kelo, I have a pleasant conversation with Philip about his film project on Samedi and his plans for the future. In Bongor we stop for a 15 minutes. I cross the road, avoiding the weaving motos. I buy two yogurts in small plastic bottles. As we get moving again, the fat woman behind me asks me in Nangjere if she can have it when I'm done. I give it to her. When Philip finishes his yogurt, the beautiful, thin girl sitting next to me asks for it almost causing a small war between her and the fat woman who wanted both.

In N'Djamena, I jump off and head for the latrine. My bladder is about to explode. The hole in the ground is no longer a hole. It is completely filled with human waste and urine is lying in puddles around the edge and flowing out under the tin roof nailed haphazardly on as a door. I empty my bladder and get out of there as fast as possible. Philip and I sit in a bench in the shade drinking cold Hibiscus tea as we wait for Fatchou.

Dr. Fatchou walks up with a big smile on his dark, wrinkled face and begins talking a thousand miles an hour about all his projects as he hustles us into to his beat up Camry. We drive around Chad's capital as he shows us his old office at the National Leper Program and his new one down by the river. FInally, he drops us off at Farcha at David and Sarah the Swede's house/cheese factory.

Sarah greets us and invites us in to some cold meat and french fries left over from their lunch which we devour. On TV that night I see that a huge snowstorm has closed or limited flights to many European airports including Paris, Copenhagen and Frankfurt. Not good news for my plans for tomorrow. I sleep well despite the incessant barking of the dogs and the dive bombing of mosquitos in my ears. The next morning one of David's workers takes me around on a moto. I'm supposed to meet the DIrector of the Organization of Health Services in Chad. He shows up an hour and fifteen minutes late to our meeting. Good thing I was 30 minutes late so I didn't have to wait long. After hearing a 30 minute diatribe on national politics I turn in the papers for the Moundou Surgery Center, remind him of his promise to go on a mission to see our problematic Distric Medical Officer and ask a question about our project in Eastern Chad.

I hand in the photocopies of mine, Gary and Jonathan's passports to Aime so he can help us get authorization to fly to the Chad side of Darfur where the Sultan has invited us to reopen some medical work there. Now I have barely enough time to catch my plane. I tear off my Arabic Djallabiya, put on pants and a t-shirt, grab my back pack and computer bag again and Sarah drops us off at the airport.

In the line out Chad's one international gate I spot a short Phillipino girl I recognize! Caitlin was a volunteer at the Koza Hospital who I met just a few weeks ago. We chat and I find out she's heading to England before going to Bangladesh. In Addis Abeba I part ways with Philip who's headed to Washington, D.C. and Caitlin. I wander the airport and watch a movie to make the 5 hour layover pass quicker. My flight to Rome leaves at 20 minutes after midnight. I spend the 4 hours talking about Africa and NGO's and what kind of hope is there with a Swedish girl working for Unicef and an Indian businessman from Zanzibar.

In Rome I realize I not only don't have a ticket for the rest of my trip but I don't even know what airline I'm on. Sarah's brother Kim bought the tickets and the next leg is either at 9:35 to Zurich or at 12:15 to somewhere in Germany. I try SwissAir first but they have no reservations for me. I then try Lufthansa but they can't find me on flights either to Frankfurt or Zurich. Finally, they find me on a flight to Munich at noon. The agent with the cute Italian accent comes to help me check in at the automatic check in modules. Suddenly, as if having a brilliant idea, she turns to me and asks me if I'd like to go to Munich now. There's a flight leaving at 6:10 and if I hurry I can make it.




I run, barely catch the flight and find myself descending into Germany at a little after 8am as the sun is just barely sneaking over the snow capped peaks illuminating the snow dusted fields and rooftops of Munich. Inside the airport, I find a flight to Copenhagen that leaves at 10:45am. My flight is scheduled for 2:30pm. I head to the gate. The woman at the counter is not too optimistic.

"We usually can't modify this type of ticket," the woman says in English with just the slightest German accent. "But I'll see what I can do."

Munich has free hot chocolote, hot milk or hot coffee and not having eaten breakfast I down about 10 cups of hot chocolate mixed with hot milk. And I wait. The woman calls me up to the counter.

"I've put you on standby, but just leave the ticket here."

I go back down to sit. Soon the flight is delayed, not due to snow like I'd expect since 30% of flights into Copenhagen have been canceled, but rather due to "technical problems." The woman motions me back up to the counter.

"I've given you a seat, but just leave the boarding pass here, I need to..." Her voice wanders off. She seems distracted. I thank her and go sit back down.

The plane keeps getting delayed. Finally, at 11:50 we're ready for boarding. I go up to the counter.

"Here's your ticket, but there are kids sitting around you and I'd like to get them all together. Just wait a minute." I sit back down again. I wonder if I'll actually get on the flight after all.

Finally, the woman motions for me to come back up. "I hope you don't mind, I had to put you in Business class."

Oh yes, I mind terribly. Give me my ticket! I think as I calmly reach out for the boarding pass and settle in comfortably for a well hydrated and well nourished flight to the land of the Vikings. Instead of being delayed like many European holiday travelers or even having my flight canceled, instead I arrive 4 hours earlier than scheduled!




My friend Henrik is there to pick me up and takes me to his apartment near the train station. I get a bite to eat finally for the first time that day. A cheese a red pepper sandwich with Thousand Island dressing has never tasted so good! Henrik, Pernille and I take the closest train to the main station where I buy a ticket for my 4 1/2 hour train ride to Aalborg.

I descend the elevators to Quay 7 and enter into the chaos of the holiday travel season complicated by record low temperatures and snow fall. The train pulls up 20 minutes late and a surge of humanity rushes the door creating a standstill that lasts almost half and hour as we push and struggle to get on the train bursting at the seams with Danes (and others) trying to get home for Christmas. If it had been 40 degrees Celsius warmer I'd have thought I was in a crowded Indian or African train station rather than a European one. I finally managed to wedge into the doorway, make it up the stairs and stand with my back pressed into the wall of the entryway. Suddenly, everyone starts rushing out, not in a panic but rather quickly. I hear a Dane speaking English and ask him what's going on.



"There's smoke, a fire maybe, it's ok, we have to get off." Just then Henrik and Pernille come back up and explain that now we have to evacuate the quay as well. The train station is now more crowded than ever and rush hour is about to start. Another announcement tells those of us without reserved seats to not get on a train but they'll send a bus. We go and change my ticket for one that leaves tomorrow at 6:50am and go back to the apartment. Pernille later finds out that her sister took 10 hours to travel to Vejle, a trip that normally takes 2 1/2 hours! Instead of spending my evening in stop and go traffic all night to northern Jutland I spend it wandering the beautiful, snow covered, Christmas decorated streets of Denmark's capital culminating in a magical promenade through Tivoli which has been transformed into a winter wonderland.




A good night's sleep behind me I step out into the dark streets of Copenhagen where a gently falling snow welcomes me. My face is almost frozen off by the time I walk to the train station and get on the train to Aalborg in normal, organized fashion. I don't have a seat, but there are three fold-down seats in front of the bathroom. One of them is occupied by a Ghanian girl who immigrated to Denmark 7 years ago and is now studying Optometry. We have a stimulating conversation about the positive and negative aspects of life in Africa versus the West. After 2 hours she gets off and I find a regular seat where I stretch out my legs, watch a couple movies and enjoy the snow covered farming scenes rushing by outside the window.

Kim, Sarah's brother, meets me at the train station in Aalborg.

"James, this is Eva, a film student. We have to film something. It shouldn't take more than an hour and then I have some shopping to do. Then we'll go surprise Sarah." I jump into the car, glad to get out of the cold. Kim takes us to the edge of the fjord next to a cargo ship unloading grain into a 12 story silo. We take a tiny elevator to the top of the silo and enter a long room with pipes and rumbling machinery bringing the grain up and dumping it in the huge storage tanks. At the other end is a small door leading out to a spiral exit stairway and a fabulous view of North Jutland's largest city and industrial center. The fjord is iced over, but the ice is starting to crack leaving the surface like a kaleidoscope of ice chunks with tiny lines of dark green ocean in between.




Kim goes up and down while Eva films and then they switch places. My role is to try and stay warm as I wrap the scarf Henrik lent me tighter and tighter around my frostbitten, running nose as my glasses fog up. Finally, Kim goes to get his shopping done while I'm supposed to help Eva. This consists of my tired, hungry body going up and down 12 stories of snow covered stairs outside a concrete silo in below freezing weather (not counting the wind chill factor) not once, not twice but 2 1/2 times!




Finally, we head off the 40 minute car drive to Ostervra. We pull up outside Sarah's mom's apartment. The door is open. I don't knock. I'm in the entry way. The door to the living room is closed. I open it. I still don't see anyone. I go around the corner to the kitchen and there, stretched out on the couch, covered with a blanket facing me is a curly, red headed Dane. Her eyes widen. Her hands fly to her mouth.

"No way, are you serious? Is it really you?" She gasps in surprise, then in Danish tells her mom to come from the kitchen and see what's here.

And thus ends an incredible journey, and begins a very merry Christmas season indeed.

Cold

I sit in the cold of a Cameroonian morning here in the mountains of Koza. The sunlight is beginning to stream through the dust covered windows, seeming to sift slowly to the floor with the ever present dust in the start of the dry season.

I wait. The lab guy should be coming any time. My body is weary and my back aches. Will I have to give blood or not? The result of the hematocrit will tell me. My mind wanders. Did yesterday really happen? It's kind of all blurred together. In my head, I'm back in the OR yesterday...

We're getting started late. I'm a little frustrated as I try to occupy my time straightening up the counter that serves as the anesthetist's work station. I'm alone with the patient stretched out on the bed barely covered with a skimpy hospital gown. This is going to be a long, tough surgery and it's already approaching noon. The system here is archaic. The patient's family must pay for the surgery, then go to the pharmacy and get all the supplies needed for the surgery since the OR has almost nothing there. Then they have to go to the lab to get tested and give blood. All this could've and should've been done yesterday or at least early this morning. Finally, the nurse himself had to go get the supplies because no one oriented the family members where to go and what to do.

Finally, I stand with scalpel poised in hand, flanked by two congolese doctors, Roger and Solomon. I start the incision in the old, midline c-section scar. I decide to repair the vesico-vaginal fistula first. Urine has been leaking from a hole in her bladder through her vagina for over a year since she was operated on in Maiduguri, Nigeria. Sometimes, after a difficult delivery or as a result of a surgery on the uterus, the bladder can be damaged creating what's called a fistula, or a hole so that the woman has no control over her urination, but leaks pee constantly.

I open the bladder and spot the fistula. I cut out the mucosa and free up the tissues and then close the deep vaginal layer, the bladder wall muscle and finally the mucosa of the bladder in three separate layers. I suture up the bladder and extend the abdominal incision all the way to her chest. My back is already starting to hurt as the ancient operating table will only raise itself so high, not nearly enough for a scrawny, six-foot-five man. I have to lean way in as I dissect the colon off the enlarged, non-functioning left kidney. It must have been chronically infected as well since there is a lot of inflammation that makes dissecting and identifying the ureter and the large blood vessels difficult.

After hours, I've finally mostly freed it up, but the blood vessels remains in a mass of inflammatory tissue. I've just damaged the kidney and it starts to bleed dark blood. A lot. I hold pressure and tell the staff to get the blood transfusion running. Ganava calmly tells me there's been a mistake, the family never actually gave blood, that was for the next patient. I'm incredulous. I would've never operated on such a big case without having blood available. I send Elissa running to the lab to check this patient's blood type and see if there's any blood from other surgeries left in the fridge.

After what seems like an eternity, Elissa comes back with the blood typing reagents and a bag of O + blood. Sure enough the woman is O + as well so we get one bag running. I release the compression on the kidney and dark blood wells up again. I send up a quick prayer and go for broke. I sweep my fingers behind the kidney and tear it loose from the adhesions holding it in until just a stalk remains attaching it to the circulatory system of the body. In that stalk is the vein and artery. I put a clamp across the whole mess and then a second one almost on the kidney and cut the kidney off and lift it out. The bleeding has stopped. I then leisurely double tie the blood vessels under the clamp, pull out all the gauze holding the intestines at bay, making sure to get them all and close up.




I do a hernia next and then we all eat for the first time since breakfast as Caitlin and Elissa have brought back some beans, rice, eggplant and dinner rolls from the house. They also have a case of Fanta and Coke. Since there's not bottle opener I try something I saw someone do once. I place the cap over a metal edge and hit the top of the bottle several times until I break off the glass. I gingerly drink from the now sharp edged bottle the renewing sugary mix.

The final case is a young 30 year-old-woman with advanced cervical cancer. I feel it's worth a shot at least in opening her up to see if the cancer is resectable. Since we don't have CAT scans or other ways to see the extent of the spread, an exploratory surgery is the only way. Unfortunately, I soon realize that the cancer has surrounded the ureters and blood vessels and started to erode into the bladder and rectum. By this time, she is oozing dark blood from many small wounds in the uterus that are two friable to suture. I hold pressure for a long time, but in some surgicel and a drain and close up. Fortunately, she has three bags of blood: two B+ corresponding with her blood type and one O+ that is also compatible. We get the first bag in quickly and get the second one running as we take her out to the hospital ward.

I go to see the first woman we operated on and she really needs more blood but there's none available except the one bag of O+ for the woman with the cancer. I make a tough decision. Both need the blood, but the woman with the cancer has an incurable disease. I go in to see the family. I explain that her cancer is inoperable and she has a few months to live at best. After some translation from French into Mafa they understand and express their thanks that we at least tried. I offer to pray for them and the nurse prays in Mafa. They all warmly shake my hand. I then explain that we are going to take the last bag of blood and give it to someone else. At first they resist, but finally agree after much time spent explaining.

I give the bag to the nurse and head home, weary, walking gingerly because of my back pain and ready for some Ibuprofen and a hard cold floor to stretch my back out on.

After a wonderful, but too short night's sleep I hear a knock on the door. The nurse needs my on the surgery ward. It's the woman with the cervical cancer. Her blood pressure is 90/50. That doesn't worry me to much. She is awake and alert, but her heartbeat is fast. Her conjunctiva are a little pale. The drain has put out over 200cc of blood overnight but her abdomen is soft. I prescribe IV fluids and tell them to call the lab guy for a hematocrit. I told him to come give me the results directly at home. If she needs blood, my B- blood will be the first bag she gets.




So I wait, in the cold, bare feet and short-sleeved to know my fate early this Saturday morning in the mountains of the Extreme North of Cameroon...

AMA

In many ways, being in Cameroon is like a vacation. I came down from N'Djamena with Dr. Roger and Dr. Solomon, our two congolese doctors who'd just joined us in Chad but were chased off by the psychopathic behavior of our local District Medical Officer who threatened to throw them in jail the first day they arrived if he saw them in the hospital. It's been 6 weeks of running around trying to meet all the requirements he's listed despite the fact that the local Regional Medical Officer (his boss) and the governor gave the docs the ok to start practicing. Finally, since the Koza Hospital in Northern Cameroon has been without a doc for 3 months, I brought them here where we have been welcomed with open arms by all the local authorities, the hospital staff and the local church who all keep thanking God for answering their prayers and providing them with doctors so they don't have to refer c-sections an hour away over bumpy mountain roads to the nearest public hospital which is sketchy at best if they don't die en route.

So, I've felt an oppressive load fall off my shoulders, a load I wasn't even completely aware of until I was in an atmosphere where people were happy to have me and do everything to help rather than menace and threaten and coerce and intimidate. All in all, it's been embarrassing because in 7 years in Chad it's the first time I've ever had a real problem with a Chadian, and to have it happen when I finally find some young doctors willing to come and help me, it's discouraging as well. But, then again, Koza has it's own difficulties as well.

I walk into the surgery ward the first day in Koza. A young boy had fallen out of a tree 3 days ago and cut open his upper lip. I take off the bandage and see that the nurses have done an excellent job of suturing what seems to have been quite a complex laceration. I notice that besides his swollen face, the boy is favoring his right arm which is wrapped in some rags with sticks tied together in a splint around the entire forearm.

"Does he also have a broken arm?" I ask the nurse who rushes over to look.

"I don't know what that is, some traditional bone setter must have snuck in here last night. It wasn't there yesterday."

The boys' father, a short, man standing straight with a white skull cap and a dirty blue robe smiles pleasantly and confirms the nurses questionings.

I unwrap the arm to take a look. The arm slightly swollen and tender over the distal radius. It seems to be reduced well. A simple fracture.

"We can put a short arm cast on it for three weeks and it should heal fine." I get ready to move on, but the father says something harshly in Mafa, his mother tongue. I don't understand a word and look questioningly at the nurse who looks sheepish.

"He says, no plaster. He's had it once on his arm all the way to the shoulder, but he didn't bring the kid here for the broken bone, just the cut lip. The bone setter says that in two weeks he'll take off the sticks look at it and proclaim it healed so he prefers that. No plaster."

"Did the cast work for him when he broke his arm years ago?" The nurse translates for the father who smiles and nods while moving his arm briskly in all directions and flexing to show he has no problems as he spouts off some shotgun sentences in Mafa.

"He says he has no pain and can work all day in the fields for years...but no plaster for his son."

I spend about another 15 minutes trying to reason with the man who just keeps smiling and refusing the nice doctor who just doesn't have a clue about broken bones and how fast they can heal in the hands of the right witch doctor. I move on.

That evening I go to the ER to see a pregnant woman with high blood pressure. She says she is 8 months pregnant and has swelling in her legs. In fact, her legs are extremely edematous and she is hugely pregnant. I examine her belly and while she doesn't have pain or bleeding, i feel the fetal presenting parts so well I'm afraid of a ruptured uterus. She says she has been having contractions for 3 days. I bring out the ultrasound and find that there is no ruptured uterus, but rather two healthy twins at term. With the added complication of twins, the fact that they are at term and her pre-eclampsia, I decide the best thing is to do a c-section, take out the twins with as little risk as possible and treat the pre-eclampsia as well by removing the pregnancy.

I calmly call over the woman's mother and explain. She is categorically against it. She says they have to wait for the father and the husband. The husband is in Nigeria and the father is in the village 10 km away. I nurse asks her is she has a phone number. Yes, but her phone's battery is dead. I borrow a phone and try to call the husband. No answer. The nurse calls the father. No answer. I recommend the mother go get the father so we can operate tonight. 10km on a moto taxi is not far. She refuses. Says it's dangerous at night. I have them sign a paper saying they refused treatment and go home to sleep.

The next morning I see the woman and her mom. She says she went to the village but didn't bring back the father. Soon the husband shows up. He seems educated and understands my reasons for wanting to do a c-section but says without the father's ok, he can't agree to it. The mother told the nurse last night she doesn't understand why we want to operate. Her daughter is walking, eating, talking and doesn't seem sick. When asked why they came to the hospital then, she had no good answer.

Finally, later in the morning, they take the girl home. I find out later that they must have thought I was an idiot since I tried to show them the edemas and blood pressure to show that the girl was really sick. Apparently, one nurse told me that night at the house, the Mafa know that if you have edemas, it's because you're going to have twins. So I was trying to tell them the edemas were caused by a sickness when they knew perfectly well it was just the twin pregnancy that caused that and that obviously I didn't know a thing and couldn't be trusted.

That same night, I see a 13 year old girl with classic symptoms and signs of acute appendicitis. I sit the father down on a bench in the ER in front of the nurse who translates as the girl writhes in pain on the bed behind me. The father listens attentively and then tells me that she has worms, maybe tenia, and that she needs some good bark or roots. I explain again. He says, ok, just give her some pills tonight and we'll see how she does tomorrow. I'd already started an IV and I pointed out that she was still in obvious pain. He countered with the fact that it was probably because she was sneaking off with some boy getting pregnant or something. Another wasted half and hour later and I go home as the father insists that the nurse take out the IV and let them take her home where she can get some appropriate witchdoctor cure for what ails her.

At least one story has a happy ending as the next morning the other family members bring the girl back saying she was crying all night long and they want her to be operated on which we do without complications and send her off to a hopefully speedy recovery as we hope and pray the young pregnant girl somehow either delivers ok at home or comes back before the twins are dead or she's in a coma or seizing.

But at least they all like me here...so far...