Miracles start with small things and are often small themselves and go
unrecognized unless we have eyes to see and ears to hear.
I almost forgot to bring my pillow. Sarah held it out to me at the last
minute as I rushed out the door, hopped in the back of the van and took a
nap all the way to Kelo where we dropped off Andre and his adopted daughter.
They got on public transport for Lere while Levi and I went to the TEAM
mission station there in Kelo to find some Arabic new testaments. The rep
for the Gideons wasn't there but promised to meet me at noon at the Kelo
hospital.
I foolishly thought I'd be done in Moundou before then.
We arrive in Moundou and go directly to the construction site. Frederic,
the boss, isn't there. I call him and while waiting check out the progress.
The bricked up windows have been reopened letting in a ton of light. The
back two rooms have been converted into one large room with three huge
windows and a double door from the outside and a small door into the
hallway. This will be the operating room. The slab for the veranda has
been re poured, the trusses have been repaired, the roof replaced and the new
ceiling mostly done.
I go back outside and see Anatole, our head lab tech. Two days ago I received a message that his son had meningitis here in Moundou.
"Anatole, bonjour, ca va? I tried to call you but I couldn't get through."
"Yeah, my phone was stolen at the hospital."
"I wanted to contact you to have you bring your son back to Bere, how did you find me here?"
"I just happened to see the van drive by and followed it here."
Anatole then goes on to explain how his son was treated (or mal-treated) first at the health center with once a day IM Quinine and Penicilline and then referred to the only hospital here in Moundou, Chad's second largest city. No lab tests were done to confirm or deny meningitis or cerebral malaria but treatment was started. The antibiotic wasn't available and had to be purchased on the black market for 5 times the going price. Nurses came by once a day only for injections and once, the nurse came to give a shot with an empty seringe and didn't notice until Anatole pointed out he'd just injected air into his son's thigh! In a week at the hospital, he saw a doctor once. He finally decided last night to just take him home where at
least he himself could make sure the meds were given when they were supposed to!
Antoine, our church contact in Moundou shows up and we go to see the "Chef de Quartier" to find out about purchasing 1 or 2 of the empty lots next to our project. We bounce over the dirt streets of this industrial capital of Chad and turn down a small side street before pulling up in front of a brick wall.
Attached to the wall is a small lean two with low ceiling made of brick and tin roofing. I stoop through the narrow door into a dark room filled with old men. The dim light comes through cracks in the bricks and ceiling and through the door illuminating several low wood slat chairs and a rickety hand made coffee table with various documents spread across the top. The chief is a wizened man in his late 60's or 70's with short white curly hair, a traditional long pocketed shirt and trousers and a leg wrapped in an elastic bandage.
We are motioned to some of the low chairs, only a few inches off the ground. I find myself basically squatting with the slats digging into my bony butt. Antoine starts speaking in Ngambai. I catch a few words like "doctor" "hospital" "magistrate" etc. and after much dialogue Antoine gives me the resume that he knows the original owner of one lot and he'll ask who he sold it to so we can see if we can buy it and that the owner of the second property is an old magistrate who is too old and tired to build and has told the Chief to contact him if he finds a worthy buyer. He is very content that we're building a health institution in his neighborhood and will do all he can to help.
"It seems your sick," I speak to the chief in French, pointing to his leg. "Mind if I take a look?"
He motions for a young man outside who comes in and between the two of us we lift up and unwrap his leg revealing a bunch of crumbled up dry leaves wrapped around a single swollen ankle and foot in the traditional manner. The other leg isn't swollen at all so I suspect early elephantiasis and prescribe him medicines for filarial worms and tell him to elevate his leg at night.
Just then, the pudgy old man to his right starts hacking up a lung. He's been coughing for a while so I prescribe him two antibiotics and an inhaler to open up his airways.
They are very happy and the chief steps outside with us to wish us well and tell Antoine to check back tomorrow about the properties.
After a few other errands, we stop at one of this metropolis's two gas stations. A couple of Arabs are lounging on chairs between the three antique pumps in the sandy courtyard. They slowly rise up as we place our three gas cans open in front of them and unlock the gas tank. We place our airplane fuel filter in the opening as they "warm up" the pump. It slowly whirs into action and after a few minutes they start pumping. The gas spews out in spurts and little bursts of air spraying the gasoline into our tank. After 18 L (4 1/2 gallons) it stops running.
"Sorry, that's the last of it. We should have some more tomorrow!"
We drive off to the second and last gas station. As we pull up the two guys sitting out front just look at us when we ask if they have gas and shake their fingers "no".
We pick up Anatole and his son and lay him in the back, conviently there is a slightly used pillow waiting for him to rest his head on.
We arrive in Kelo without incident. The Post is closed. We go to the hospital. It's 2pm and Mathias, my contact for the Arab Bibles has gone home. We get his number from the nurse on night duty and he tells us to meet him at the Pili-Pili Hotel.
After picking him up and going back to the hospital to get the Bibles we return him directly to his house in the "suburbs". As we head back towards the main robe a tall, athletic man comes running after us in a green Arab robe barely covering his basketball shorts. He waves his hands and yells after us.
"You have a ton of packages at the Post Office. You need to pick them up tomorrow."
"We're heading back to Bere now and it's not easy to come. Can't you open up the office and let us take them with us now?"
"Ok. Ca va."
He hops in and we pick up 25 packages, most for the student missionaries but one from the AMALF in France containing 150 vials of Ceftriaxone, the exact medicine we need (and just ran out of) in order to treat Anatole's son's partially and poorly treated meningitis.
As I pray with Anatole later, after arriving in Bere I am convinced that God will heal his son since he went to some much effort in so many small ways to bring us in contact and get us the exact medicines we need. Seemingly insignificant details when seen alone, but miracles none the less.
Wednesday, December 17, 2008
Thursday, December 11, 2008
Blue baby
Dr. Jacques knocks on the door.
"I just assited an uncomplicated vaginal delivery, but the baby is having espiratory distress. The nares are flaring, the intercostal muscles are retracting and he's just having a hard time. I tried aspirating to see if he had any mucus but it seems his nose is blocked...it's like there's just no connection to the throat."
In my mind I'm thinking, "yeah, right, he must just not know how to stick a tube down a baby's nose..." but my better judgement says I should just go and look.
I enter the dimly lit corridor and push open the labor and delivery room door into a brightly lit, but small chamber. A quick glance takes in a young woman lying comfortably on the bed, not much blood around, and breathing and glancing around normally. She's fine.
I turn to the baby reanimation table and see a chubby, bluish gray baby with a disproportionately tiny head (normal newborns heads are huge compared to their bodies) lying staring up and grunting but not really breathing.
I grab him around the chest, flip him over on my hand and slap him hard on his back. He starts to cry vigourously. I think that must be it. They just are afraid of these supposedly fragile little beings and don't stimulate them enough.
I flip him back over on his back on the green, brightly patterned cloth underneath him and reach for the aspirator. A tiny tube goes into a small canister with a slightly larger tube coming out the same top. I slip the bigger end in my mouth ready to suck and slide the smaller tube into the baby's nose. It only goes in 1-2cm and is stuck. I wiggle it around and then try the other nostril. Still no passage. I stick my finger into the newborn's mouth straight back into his throat. He starts to gag as I feel around and confirm, there's no opening between his nostrils and his airway.
Now, here's the problem. Instinctively, a newborn is an obligatory nose breather. This allows him to nurse and breath at the same time, two very important things God makes sure they now how to do instinctively because there's just no spare time to have to learn it in. He only breaths through his mouth if he cries.
We can't just make him cry all the time, he just won't do it. He cries a little and starts to pink up and then goes back to sucking in impotently on his blocked up nostrils.
What to do? I think quickly and go to the OR to find some probes and see if there isn't some passage back there after all that's just blocked up.
The probes go nowhere. I've brought the hemorroidectomy kit as that's the only one I know of with probes.
I call the father in and explain the situation.
"He can't breath through his mouth because it's against his instinct and he can't live without breathing and we can try to poke a hole through but he could bleed a lot and die or we could damage some important things, but the bottom line is he won't live if we do nothing. What do you think?"
"Do what you have to, it's in God's hands."
I grab a Kelly clamp and probe downward in the right nostril to where the palatte seems thinnest between the nose and mouth. I poke through. I then do the same on the other side. However, he still can't breath because the mucosa of the mouth just falls back in place. We need something to keep it open. I grab the aspirator and cut off a piece of the bigger tubing. I reach the clamp through into the mouth, grasp the tube and pull it out through the nose. The first time it pops all the way out. I then attach another clamp onto the mouth and and pull it through again, this time the clamp prevents it from coming all the way out. I repeat it for the other
nostril.
I suck up some blood out of the nose and mouth and down the tubes using what's left of the newborn aspirator. He's still struggling but I can hear and feel air coming out the two tubes.
I then insert a feeding tube in the mouth and the mother starts squeezing out breastmild which we feed the baby through the tube with a syringe.
He's already pinking up, only his hands and feet stay blueish gray.
Yep, he's in God's hands all right.
"I just assited an uncomplicated vaginal delivery, but the baby is having espiratory distress. The nares are flaring, the intercostal muscles are retracting and he's just having a hard time. I tried aspirating to see if he had any mucus but it seems his nose is blocked...it's like there's just no connection to the throat."
In my mind I'm thinking, "yeah, right, he must just not know how to stick a tube down a baby's nose..." but my better judgement says I should just go and look.
I enter the dimly lit corridor and push open the labor and delivery room door into a brightly lit, but small chamber. A quick glance takes in a young woman lying comfortably on the bed, not much blood around, and breathing and glancing around normally. She's fine.
I turn to the baby reanimation table and see a chubby, bluish gray baby with a disproportionately tiny head (normal newborns heads are huge compared to their bodies) lying staring up and grunting but not really breathing.
I grab him around the chest, flip him over on my hand and slap him hard on his back. He starts to cry vigourously. I think that must be it. They just are afraid of these supposedly fragile little beings and don't stimulate them enough.
I flip him back over on his back on the green, brightly patterned cloth underneath him and reach for the aspirator. A tiny tube goes into a small canister with a slightly larger tube coming out the same top. I slip the bigger end in my mouth ready to suck and slide the smaller tube into the baby's nose. It only goes in 1-2cm and is stuck. I wiggle it around and then try the other nostril. Still no passage. I stick my finger into the newborn's mouth straight back into his throat. He starts to gag as I feel around and confirm, there's no opening between his nostrils and his airway.
Now, here's the problem. Instinctively, a newborn is an obligatory nose breather. This allows him to nurse and breath at the same time, two very important things God makes sure they now how to do instinctively because there's just no spare time to have to learn it in. He only breaths through his mouth if he cries.
We can't just make him cry all the time, he just won't do it. He cries a little and starts to pink up and then goes back to sucking in impotently on his blocked up nostrils.
What to do? I think quickly and go to the OR to find some probes and see if there isn't some passage back there after all that's just blocked up.
The probes go nowhere. I've brought the hemorroidectomy kit as that's the only one I know of with probes.
I call the father in and explain the situation.
"He can't breath through his mouth because it's against his instinct and he can't live without breathing and we can try to poke a hole through but he could bleed a lot and die or we could damage some important things, but the bottom line is he won't live if we do nothing. What do you think?"
"Do what you have to, it's in God's hands."
I grab a Kelly clamp and probe downward in the right nostril to where the palatte seems thinnest between the nose and mouth. I poke through. I then do the same on the other side. However, he still can't breath because the mucosa of the mouth just falls back in place. We need something to keep it open. I grab the aspirator and cut off a piece of the bigger tubing. I reach the clamp through into the mouth, grasp the tube and pull it out through the nose. The first time it pops all the way out. I then attach another clamp onto the mouth and and pull it through again, this time the clamp prevents it from coming all the way out. I repeat it for the other
nostril.
I suck up some blood out of the nose and mouth and down the tubes using what's left of the newborn aspirator. He's still struggling but I can hear and feel air coming out the two tubes.
I then insert a feeding tube in the mouth and the mother starts squeezing out breastmild which we feed the baby through the tube with a syringe.
He's already pinking up, only his hands and feet stay blueish gray.
Yep, he's in God's hands all right.
Ma Joie
At the last minute, I decide to go. I hardly got any sleep last night and woke up at 3am before falling back asleep until the alarm sounds at 4:30am.
"Sarah, I think I'm not going to N'Djamena. What am I really going to do there anyway? I'll just stay."
Sarah get's up and get's ready. I still don't hear Levi, the driver, so at 5 till 5am I get up and drive the car over to the hospital. I flip on the lights in the men's ward.
"Hey, you two, get up. We're leaving at five, remember? You're supposed to be ready!"
Our two friends, Mahamat and Lamglé, slowly raise up wiping their eyes. Their "garde-malades" start pulling down the mosquito nets and taking off the sheets carefully from under their right legs, twin-casted from groin to ankle.
I'd just performed the second surgery on each of them for non-union and mal-union femur fractures. They are relatives and both were in motorcycle accidents. I tried doing an open reduction and traction for each of them first but it didn't work. I just operated again a week ago and put in plates and screws with a cast. Now, I wanted to take them to N'Djamena for an xray since ours hasn't been working for years. Besides, they lived there and this way they can convalesce at home.
I'm now awake, and since Levi still isn't here I quickly pack, grab some cold Zachée pizza from the fridge and a week old bottle of vanilla protein drink for the road and we're off.
The headlights actually make driving on the rain scourged roads easier as the shadows light up where the holes are. Dawn breaks and a cool desert morning rushes in the open windows.
I startle a brightly colored bird with several shades of brilliant blue and a super-long tail. Unfortunately, it isn't fast enough and gets taken out in mid flight by the left side of the minibuses grill going out with a quick crunch.
A short time later, after missing countless sheep, goats, horses, cattle and camels I come across an Arab donkey caravan on a one way bridge and as I've almost come to a complete stop one of those dumb asses turns into the car with a piece of wood strapped to it's side and a crinkle of glass tells me my left headlight is no more.
Moving on, two little baby goats, one black and one white with black spots streak suddenly across the highway with just enough space in them for simultaneously sickening crunches under each front wheel. A quick glance in the rearview mirror shows the white one motionless but the black one struggling with it's head and front legs while it's back legs lie stuck to the asphalt.
Rounding the corner into N'Djamena over the bridge we strain to catch a glimpse of the hippos in the river but to no avail.
We drop off Mahamat and Lamglé at the National Reference Hospital in the midst of a chaotic ER filled with bodys in various stages of casting, wrapping, dressing and IV'ing.
Sarah and I bounce around N'Djamena in the minibus over near the airport towards the National Tuberculosis Program buildings. We enter our order for TB meds and are told to go wait in the pharmacy.
A small, lean, lighter skinned Chadian with a six-o'clock shadow beard and a bright smile waves us into his office and orders a young boy to bring "Chai" while he fills our order.
His French isn't that great and when we speak a few words of Arabic he lights up and speaks clearly and slowly so we can understand, peppering his talk with the occasional French or English word.
Apparently, he did all his studies here in Arabic, which is possible, but unusual, even getting his "bac" in Arabic (the French equivalent of a high school diploma). He then studied three years of nursing and three years of pharmacy in Syria.
He mentions that Christians and Muslims are very similar. We nod in agreement. He talks about not drinking alcohol and eating pork. I mention how we don't smoke as well.
I say the most important thing in life is to make it to paradise and he agrees with multiple "inshallahs" (God willing).
We start talking about the holy books and that there is the Tawrat (Torah), the Injil (the Gospel) and the Koran. They all are God's way of communicating with Man.
I mention that the true religion is the religion of Ibrahim (Abraham) he nods.
He asks if we are married. We nod and Sarah points out that Adoum (Adam) had only Hawa (Eve) and not Maryam, Khadidja, etc. as well. He laughs and says that in Islam it is permitted to have 4 wives, but only under special circumstances.
I agree saying that yes in countries hit hard by war, like Chad where women outnumber men, I can understand that, but it's an exception and I laughingly say that there is enough trouble with one woman, why add more? He stretches out his hand to be slapped and grasped in the Chadian way of sharing a joke and laughs along with me.
He agrees, which is why he also only has one wife, besides, life is difficult and who can afford more than one wife anyway?
He then asks if we have any children. We say not yet, and he replies that Allah will give us some, inshallah.
He then calls the boy back and tells him to pour us some more tea as we continue some small talk.
Sarah mentions that we have several Korans at home.
He asks if they're in English or what language.
We say Arabic, English and French. He nods approvingly.
We finish our tea, he helps us haul out the TB meds to our van and we shake hands promising to see each other another day, inshallah.
I somehow have no doubt that I will see him again, whether on earth or not, certainly in paradise.
Sarah and I are off. We run some other errands before being called back to pick up Mahamat and Lamglé. We wander through several dirt road detours through the "suburbs" of N'Djamena (mud brick houses slightly more spread apart than in the "Grande ville") until we come to a mud plastered three roomed house with a ramshackle covered dirt "porch" which Mahamat claims as his. He apologizes saying a huge wind knocked half his wall down last May.
After helping them out onto crutches and onto a mat in the shade we are invited to sit with them. A metal bowl of water is placed before us. I try to ignore the floating things as I bring it slowly to my parched lips. A young boy is sent off for some Cokes and Grapefruit "Top". We then have some rice "boule" with some green leaf and dried fish sauce. I must be starving because as I dig into the sticky rice paste and dip it into the spicy sauce, I actually can't eat it fast enough. It just seems to hit the spot.
We then head off back to the "big city" and stop at Ma Joie's house. Ma Joie is the 8 year old girl, also a relative of Mahamat and Lamglé who also had a right femur fracture that also wasn't healed properly that we also opened and reduced and put in traction. The only difference is that she healed after two months and has been home for over a month already.
We enter a low, dank mud entrance down an open alley past some couches in various stages of fabrication until we turn into an open courtyard. There our shy, cute little friend limps towards us on one crutch. Apparently, she doesn't need it but her grandfather insisted she use it in front of us in case we expected it. We greet all 14 members of the extended family and Ma Joie makes my day by lighting up with a crooked tooth grin when I lay out my hand palm up so she can give me "five". She slaps it hard and soon all the other kids are lining up! Right before we leave, she runs off and brings us each a black plastic bag with some brightly colored African cloth as a present.
She is not only Ma Joie but Notre Joie (our joy)...
"Sarah, I think I'm not going to N'Djamena. What am I really going to do there anyway? I'll just stay."
Sarah get's up and get's ready. I still don't hear Levi, the driver, so at 5 till 5am I get up and drive the car over to the hospital. I flip on the lights in the men's ward.
"Hey, you two, get up. We're leaving at five, remember? You're supposed to be ready!"
Our two friends, Mahamat and Lamglé, slowly raise up wiping their eyes. Their "garde-malades" start pulling down the mosquito nets and taking off the sheets carefully from under their right legs, twin-casted from groin to ankle.
I'd just performed the second surgery on each of them for non-union and mal-union femur fractures. They are relatives and both were in motorcycle accidents. I tried doing an open reduction and traction for each of them first but it didn't work. I just operated again a week ago and put in plates and screws with a cast. Now, I wanted to take them to N'Djamena for an xray since ours hasn't been working for years. Besides, they lived there and this way they can convalesce at home.
I'm now awake, and since Levi still isn't here I quickly pack, grab some cold Zachée pizza from the fridge and a week old bottle of vanilla protein drink for the road and we're off.
The headlights actually make driving on the rain scourged roads easier as the shadows light up where the holes are. Dawn breaks and a cool desert morning rushes in the open windows.
I startle a brightly colored bird with several shades of brilliant blue and a super-long tail. Unfortunately, it isn't fast enough and gets taken out in mid flight by the left side of the minibuses grill going out with a quick crunch.
A short time later, after missing countless sheep, goats, horses, cattle and camels I come across an Arab donkey caravan on a one way bridge and as I've almost come to a complete stop one of those dumb asses turns into the car with a piece of wood strapped to it's side and a crinkle of glass tells me my left headlight is no more.
Moving on, two little baby goats, one black and one white with black spots streak suddenly across the highway with just enough space in them for simultaneously sickening crunches under each front wheel. A quick glance in the rearview mirror shows the white one motionless but the black one struggling with it's head and front legs while it's back legs lie stuck to the asphalt.
Rounding the corner into N'Djamena over the bridge we strain to catch a glimpse of the hippos in the river but to no avail.
We drop off Mahamat and Lamglé at the National Reference Hospital in the midst of a chaotic ER filled with bodys in various stages of casting, wrapping, dressing and IV'ing.
Sarah and I bounce around N'Djamena in the minibus over near the airport towards the National Tuberculosis Program buildings. We enter our order for TB meds and are told to go wait in the pharmacy.
A small, lean, lighter skinned Chadian with a six-o'clock shadow beard and a bright smile waves us into his office and orders a young boy to bring "Chai" while he fills our order.
His French isn't that great and when we speak a few words of Arabic he lights up and speaks clearly and slowly so we can understand, peppering his talk with the occasional French or English word.
Apparently, he did all his studies here in Arabic, which is possible, but unusual, even getting his "bac" in Arabic (the French equivalent of a high school diploma). He then studied three years of nursing and three years of pharmacy in Syria.
He mentions that Christians and Muslims are very similar. We nod in agreement. He talks about not drinking alcohol and eating pork. I mention how we don't smoke as well.
I say the most important thing in life is to make it to paradise and he agrees with multiple "inshallahs" (God willing).
We start talking about the holy books and that there is the Tawrat (Torah), the Injil (the Gospel) and the Koran. They all are God's way of communicating with Man.
I mention that the true religion is the religion of Ibrahim (Abraham) he nods.
He asks if we are married. We nod and Sarah points out that Adoum (Adam) had only Hawa (Eve) and not Maryam, Khadidja, etc. as well. He laughs and says that in Islam it is permitted to have 4 wives, but only under special circumstances.
I agree saying that yes in countries hit hard by war, like Chad where women outnumber men, I can understand that, but it's an exception and I laughingly say that there is enough trouble with one woman, why add more? He stretches out his hand to be slapped and grasped in the Chadian way of sharing a joke and laughs along with me.
He agrees, which is why he also only has one wife, besides, life is difficult and who can afford more than one wife anyway?
He then asks if we have any children. We say not yet, and he replies that Allah will give us some, inshallah.
He then calls the boy back and tells him to pour us some more tea as we continue some small talk.
Sarah mentions that we have several Korans at home.
He asks if they're in English or what language.
We say Arabic, English and French. He nods approvingly.
We finish our tea, he helps us haul out the TB meds to our van and we shake hands promising to see each other another day, inshallah.
I somehow have no doubt that I will see him again, whether on earth or not, certainly in paradise.
Sarah and I are off. We run some other errands before being called back to pick up Mahamat and Lamglé. We wander through several dirt road detours through the "suburbs" of N'Djamena (mud brick houses slightly more spread apart than in the "Grande ville") until we come to a mud plastered three roomed house with a ramshackle covered dirt "porch" which Mahamat claims as his. He apologizes saying a huge wind knocked half his wall down last May.
After helping them out onto crutches and onto a mat in the shade we are invited to sit with them. A metal bowl of water is placed before us. I try to ignore the floating things as I bring it slowly to my parched lips. A young boy is sent off for some Cokes and Grapefruit "Top". We then have some rice "boule" with some green leaf and dried fish sauce. I must be starving because as I dig into the sticky rice paste and dip it into the spicy sauce, I actually can't eat it fast enough. It just seems to hit the spot.
We then head off back to the "big city" and stop at Ma Joie's house. Ma Joie is the 8 year old girl, also a relative of Mahamat and Lamglé who also had a right femur fracture that also wasn't healed properly that we also opened and reduced and put in traction. The only difference is that she healed after two months and has been home for over a month already.
We enter a low, dank mud entrance down an open alley past some couches in various stages of fabrication until we turn into an open courtyard. There our shy, cute little friend limps towards us on one crutch. Apparently, she doesn't need it but her grandfather insisted she use it in front of us in case we expected it. We greet all 14 members of the extended family and Ma Joie makes my day by lighting up with a crooked tooth grin when I lay out my hand palm up so she can give me "five". She slaps it hard and soon all the other kids are lining up! Right before we leave, she runs off and brings us each a black plastic bag with some brightly colored African cloth as a present.
She is not only Ma Joie but Notre Joie (our joy)...
Friday, November 28, 2008
Morning
It's early morning and I can't sleep again. This time, though, it's because I'm excited. For the first time in several weeks I'll actually be doing something. My ankle wound that just won't heal has kept me from doing just the bare minimum. I go up to the hospital, quickly see the hospitalized patients, do all the scheduled surgeries and then retire home to elevate my swollen foot. My day revolves around how fast I can get home to make the swelling go down and do a dressing change and take antibiotics. I even got so scared for a few days that I had Sarah start an IV on me and give me IV antibiotics.
This morning, though, my ankle seems to have turned the corner and I'm up, happy to be doing something I want to do. I'm going flying with Gary to N'Djamena. I'd needed to go to N'Djamena for a while, but with my foot, the idea of a long, bumpy ride in the back of a Toyota mini-bus just wasn't that appealing. With Gary's return after a 6 month absence, getting to N'Djamena has turned into a two hour pleasant flight over the African plain.
It's still dark, but since I can't sleep anyway, I get up and fix "breakfast" which consists of frying up some day old rice and beans with little bit of curry. Not a typical American breakfast but sometimes you have to eat for strength and not for sport (as some of my friends used to tell me in the early days when I was first in Tchad).
With the roosters having started their crowing since about 3am, the dogs barking and the drums and dancing having just stopped, the morning is quiet and peaceful with just the lulling, rhythmic sound of crickets breaking the early dawn's silence. I step outside into the desert cold. I quickly go back in and put on a sweatshirt. I pull my small North Face backpack over the sweatshirt and slip on my Crocs.
The ankle is a little stiff, but it feels good to be out on the deep, sandy road towards Bere's laterite airstrip. It's a 2 km walk and I have the village mostly to myself.
An early morning fog rests over the tops of the thatched roof, brownish red clay huts combined with the pungent smoke of wood and dried grass fires. The only ones awake are a few women pounding millet in homemade wooden mortars with 6 feet long wooden pestles. The dooomp, dooomp of the pounding of grain into the base for the typical Chadian breakfast porridge echos across the stillness. A few children are also up trying to chase away the night's chill around hastly gathered grass and stick fires. Their dark faces hidden amidst the white smoke wafting from the incompletely dried weed fires break into toothy grins as they see the "Nasara" walking steadily and gingerly away from the hospital. It's not every day that something this new and exciting happens!
They are mostly dressed in ragged shorts, holey pants and torn t-shirts. It's no wonder they're cold as the dry season has descended upon us leaving us with the extremes of up to 40 degrees Fahrenheit difference between day and night temperatures. The luscious greenness of the rainy season has rapidly evaporated into the brown, dead grass powdery dusty dryness of the majority of the year here in the heart of Africa.
I approach some of them, who eye me warily with looks of mixed curiosity and fear. I extend my hand, palm up. Several of the bigger, braver ones approach to shake hands. I shake my head and show them how to "give me five."
"Tak kebeng (slap my hand)" I encourage them in Nangjere. When they finally get up the courage to try, everyone wants to get in on the action and they all start giggling and laughing. What a privilege to really smack hard the hand of a grown-up, much less a foreigner!
I finally get to the airstrip where the early morning sunrise colors the mostly white plane with a tinge of pink. Gary is testing the oil and fuel and filling up the wing tanks with his bright red cans of Cameroonian gasoline. A few kids have gathered around as usual, but not the usual crowd since it's still so early. After Gary eats a "late" breakfast, we slide into the tiny Cessna loaded up with empty fuel and propane containers and after a short taxi we are soaring up and over where the 10,000 inhabitants of a Chadian county seat disappear quickly into the groves of mango trees with just occasional glimpses of thatched or rarely, tin roofed, houses give us a clue that there's actually a village hidden in this vast plane. We bank over the hospital to get a good aerial view and it also suddenly seems so small and insignificant when seen from on high.
We're on our way to N'Djamena...
This morning, though, my ankle seems to have turned the corner and I'm up, happy to be doing something I want to do. I'm going flying with Gary to N'Djamena. I'd needed to go to N'Djamena for a while, but with my foot, the idea of a long, bumpy ride in the back of a Toyota mini-bus just wasn't that appealing. With Gary's return after a 6 month absence, getting to N'Djamena has turned into a two hour pleasant flight over the African plain.
It's still dark, but since I can't sleep anyway, I get up and fix "breakfast" which consists of frying up some day old rice and beans with little bit of curry. Not a typical American breakfast but sometimes you have to eat for strength and not for sport (as some of my friends used to tell me in the early days when I was first in Tchad).
With the roosters having started their crowing since about 3am, the dogs barking and the drums and dancing having just stopped, the morning is quiet and peaceful with just the lulling, rhythmic sound of crickets breaking the early dawn's silence. I step outside into the desert cold. I quickly go back in and put on a sweatshirt. I pull my small North Face backpack over the sweatshirt and slip on my Crocs.
The ankle is a little stiff, but it feels good to be out on the deep, sandy road towards Bere's laterite airstrip. It's a 2 km walk and I have the village mostly to myself.
An early morning fog rests over the tops of the thatched roof, brownish red clay huts combined with the pungent smoke of wood and dried grass fires. The only ones awake are a few women pounding millet in homemade wooden mortars with 6 feet long wooden pestles. The dooomp, dooomp of the pounding of grain into the base for the typical Chadian breakfast porridge echos across the stillness. A few children are also up trying to chase away the night's chill around hastly gathered grass and stick fires. Their dark faces hidden amidst the white smoke wafting from the incompletely dried weed fires break into toothy grins as they see the "Nasara" walking steadily and gingerly away from the hospital. It's not every day that something this new and exciting happens!
They are mostly dressed in ragged shorts, holey pants and torn t-shirts. It's no wonder they're cold as the dry season has descended upon us leaving us with the extremes of up to 40 degrees Fahrenheit difference between day and night temperatures. The luscious greenness of the rainy season has rapidly evaporated into the brown, dead grass powdery dusty dryness of the majority of the year here in the heart of Africa.
I approach some of them, who eye me warily with looks of mixed curiosity and fear. I extend my hand, palm up. Several of the bigger, braver ones approach to shake hands. I shake my head and show them how to "give me five."
"Tak kebeng (slap my hand)" I encourage them in Nangjere. When they finally get up the courage to try, everyone wants to get in on the action and they all start giggling and laughing. What a privilege to really smack hard the hand of a grown-up, much less a foreigner!
I finally get to the airstrip where the early morning sunrise colors the mostly white plane with a tinge of pink. Gary is testing the oil and fuel and filling up the wing tanks with his bright red cans of Cameroonian gasoline. A few kids have gathered around as usual, but not the usual crowd since it's still so early. After Gary eats a "late" breakfast, we slide into the tiny Cessna loaded up with empty fuel and propane containers and after a short taxi we are soaring up and over where the 10,000 inhabitants of a Chadian county seat disappear quickly into the groves of mango trees with just occasional glimpses of thatched or rarely, tin roofed, houses give us a clue that there's actually a village hidden in this vast plane. We bank over the hospital to get a good aerial view and it also suddenly seems so small and insignificant when seen from on high.
We're on our way to N'Djamena...
Thanksgiving
It all started with a little lying. I had too, otherwise I would've spoiled the surprise.
Monday, I went to Moundou to check up on the remodeling project for our new utpatient surgery center in Chad's second largest city. The route is simple: follow the bumpy, dirt road to Kelo and turn left onto the paved road until you hit Moundou. In Kelo, as we turned left, I saw the post office. I decided to stop. I found 14 packages waiting for our student missionaries. I paid for them all, loaded to car and continued to Moundou.
The project is going well, I talked over a few details with the builder and then he joined us for the ride back to Bere so he could look over our existing operating room to better understand what we were shooting for. It was when we were back on the road to Bere that I had the wonderful idea for my surprise. Little did I know how much deception I would have to employ in order for it to succeed.
The first thing was to swear our driver, Levi, to secrecy. We then had to quickly unload the packages into my house without the student missionaries seeing them. Since Thursday was Thanksgiving but American holidays tend to get neglected or rolled into one, I decided to turn it into an early Christmas surprise. I wasn't going to tell them I'd picked up their packages sent from home, not until Thanksgiving morning.
I didn't count on our volunteers' desperation to have those goodies.
The very next day, Stephan came to me to explain how he'd arranged everything with our Administrator, Andre, to have the day off so he could take a motorcycle taxi to Kelo to see if they had any packages. They were all expecting some that would have things to make Thanksgiving dinner with.
I put on my severest, coldest boss face.
"Stephan, did you come here to work, or to get packages. You should've told me yesterday. I passed right by the post-office and could've easily checked to see if there was anything for you guys. We're really busy right now, besides, how are you going to get a bunch of packages back on a motorcycle. It's just not a good idea. I'll probably be making another trip early next week, I can pick them up then."
Stephan's face falls, but he has no choice but to accept.
"Well, ok, but Kristin was going to go with me, maybe she can just go. She's not scheduled till this evening so she wouldn't miss work."
Thinking quickly, I'm amazed at how easily I continue the deception. "Stephan, do you really think it's a good idea for a girl to go by herself to Kelo? It's just not very smart. It'll be even harder for her to carry all those packages back. Plus, this is Chad, it could be dangerous." I'm lying through my teeth, but somehow keep a straight, concerned face.
Stephan turns sadly away to go back to his accounting office. I smile inwardly at my success. It is short lived as lies tend to pile on top of each other; once you start it's hard to stop.
I have to repeat a bunch more to Kristin later on as she is unwilling to accept Stephan's explanation and feels that if she talks to me personally, maybe this mean boss will change his mind. I hold firm and convince her it's just not a good idea. Besides, there's other things already planned and we won't really have a real Thanksgiving anyway, we might as well just wait and have our Thanksgiving next week sometime. She's crestfallen but also has to accept.
Tuesday night, I find myself chatting with Kristin and Ansley and, unfortunately, they've come up with a solution that I can't lie my way out of. I'm forced to spill the beans. They are excited but agree with me to keep it a secret from the others. Ansley joins to lying as she announces to the others on Wednesday that due to her 6 episodes of explosive diarrhea the night before she's just not up to a trip to Kelo and Emily shouldn't go by herself.
Early Thursday morning, I pull the 14 packages and numerous letters out of my closet and carry them over to the SM's common room in the middle house. I leave a note that says "ho, ho, ho, merry thanksgiving, merry thanksgiving." And it turns out to be just that...after a long day at work.
Work starts out with rounds on a completely full hospital with no beds to spare. Then, I have a tubal ligation, a D&C/tubal ligation combo, a rectal polyp to remove on an 8 year old Arab boy, a bilateral inguinal hernia repair with mosquito net, another emergency D&C for an incomplete spontaneous abortion and finally finish at 4:30pm just in time to go to Gilbert's going away party that Jason has organized.
I slip into the courtyard where many of the staff and Gilbert's friends are already seated on a variety of chairs and stools and mats. I slip off my Crocs and settle onto a mat. My ankle is aching a little and somewhat swollen after a long day upright in the OR, but it's not too bad. I exhange pleasantries with Job and Koumakoy and nod at Simeon and Abel who I've spent all day with in surgery. Gilbert slides onto the mat next to me and we have some decent small talk as Jason serves us the best "bouille" I've had in Chad. Zachee, our cook, is the best and Jason contracted him for the feast. The "bouille" is a rice porridge with milk, sugar, cinnamon and peanut paste. I grab the crude metal bowl from Jason and slurp it up without a spoon.
The second course is either roasted goat or chicken in a tomato sauce with boiled sweet potatoes, all served over mushy rice. It's quite tasty, but I'm trying to save room for Thanksgiving dinner later.
At 6pm, we all head to my house to prepare the feast. We have invited Gary and Wendy and their volunteers (Steve, Jeremy and Annie) as well our our 6 student missionaries, Maria (our Danish volunteer) and Sarah and I. Jacob's mom has sent 5 packages stuffed with everything needed. The menu is impressive: Fri-Chik, garlic mashed potatoes and gravy, cranberry sauce and relish, anti-pasta salad, stuffing, spiced apple cider, candied yams, and a pumpkin pie spice squash dessert with real whipped cream! Gary and Wendy add some real (not powder) mashed potatoes, more gravy, a cranberry-like hibiscus flower sauce, and some stuffing made from scratch. Jeremy and Annie bring a fresh garden salad of tomatoes, lettuce, cucumbers and sprouts; fresh squeezed lemonade; and boiled beets.
Jacob's mom has also sent Thanksgiving-themed plates, napkins and decorations and with the half-cut into pumpkin-like squash in the center of the table we're only missing NFL football to make it feel like a real American holiday.
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Right before eating, Sarah comes over to tell me that she's already hospitalized 5 kids with malaria, 3 of them with severe anemia needing blood transfusions. Luckily, Samedi is on with her until 9pm so they're managing, but the hospital has been filled back up despite being cleared out by me in the morning. She refuses my offer to eat with us, saying she'd rather I just brought her something later.
We all sit around the table and go around with each person saying one thing they're thankful for for each of the 5 kernels of corn placed before them. We pray and then we chow down.
Just as I'm finishing my overloaded plate (the first one done of course) Hortance, the midwife, comes knocking to tell me about a woman, 8 months pregnant with vaginal bleeding referred from the health center 2 days ago but just now arriving. She is severly anemic with a hemoglobin of 4.8 g/dl and has a placenta previa where the placenta wants to come out before the baby. I think I find a fetal heart beat so we quickly resuscitate her with two large bore IV's and a lot of IV fluids, give her anti-biotics, and take her to the OR. Fortunately, her blood type is AB + making her a universal recipient (i.e. she can take blood from anyone) so we have both her brother and father give blood while we prep her for surgery.
We start the first bag of blood running as we pull out a dead baby with skin already peeling off meaning he's been gone for a few days. Fortunately, there's not much bleeding and we quickly close her up as the second bag runs in. Her heartbeat is almost normal now and her blood pressure has come up. We wheel her into the wards almost running over some Arab women who've spread their sleeping mats right across the entrance and then are forced to leave her on the gurney for the night since there are no available beds.
I come home at about 10pm and we play Settler of Catan and Citadels until almost 2 in the morning when I fall into a deep, contented sleep.
Happy Thanksgiving!
Monday, I went to Moundou to check up on the remodeling project for our new utpatient surgery center in Chad's second largest city. The route is simple: follow the bumpy, dirt road to Kelo and turn left onto the paved road until you hit Moundou. In Kelo, as we turned left, I saw the post office. I decided to stop. I found 14 packages waiting for our student missionaries. I paid for them all, loaded to car and continued to Moundou.
The project is going well, I talked over a few details with the builder and then he joined us for the ride back to Bere so he could look over our existing operating room to better understand what we were shooting for. It was when we were back on the road to Bere that I had the wonderful idea for my surprise. Little did I know how much deception I would have to employ in order for it to succeed.
The first thing was to swear our driver, Levi, to secrecy. We then had to quickly unload the packages into my house without the student missionaries seeing them. Since Thursday was Thanksgiving but American holidays tend to get neglected or rolled into one, I decided to turn it into an early Christmas surprise. I wasn't going to tell them I'd picked up their packages sent from home, not until Thanksgiving morning.
I didn't count on our volunteers' desperation to have those goodies.
The very next day, Stephan came to me to explain how he'd arranged everything with our Administrator, Andre, to have the day off so he could take a motorcycle taxi to Kelo to see if they had any packages. They were all expecting some that would have things to make Thanksgiving dinner with.
I put on my severest, coldest boss face.
"Stephan, did you come here to work, or to get packages. You should've told me yesterday. I passed right by the post-office and could've easily checked to see if there was anything for you guys. We're really busy right now, besides, how are you going to get a bunch of packages back on a motorcycle. It's just not a good idea. I'll probably be making another trip early next week, I can pick them up then."
Stephan's face falls, but he has no choice but to accept.
"Well, ok, but Kristin was going to go with me, maybe she can just go. She's not scheduled till this evening so she wouldn't miss work."
Thinking quickly, I'm amazed at how easily I continue the deception. "Stephan, do you really think it's a good idea for a girl to go by herself to Kelo? It's just not very smart. It'll be even harder for her to carry all those packages back. Plus, this is Chad, it could be dangerous." I'm lying through my teeth, but somehow keep a straight, concerned face.
Stephan turns sadly away to go back to his accounting office. I smile inwardly at my success. It is short lived as lies tend to pile on top of each other; once you start it's hard to stop.
I have to repeat a bunch more to Kristin later on as she is unwilling to accept Stephan's explanation and feels that if she talks to me personally, maybe this mean boss will change his mind. I hold firm and convince her it's just not a good idea. Besides, there's other things already planned and we won't really have a real Thanksgiving anyway, we might as well just wait and have our Thanksgiving next week sometime. She's crestfallen but also has to accept.
Tuesday night, I find myself chatting with Kristin and Ansley and, unfortunately, they've come up with a solution that I can't lie my way out of. I'm forced to spill the beans. They are excited but agree with me to keep it a secret from the others. Ansley joins to lying as she announces to the others on Wednesday that due to her 6 episodes of explosive diarrhea the night before she's just not up to a trip to Kelo and Emily shouldn't go by herself.
Early Thursday morning, I pull the 14 packages and numerous letters out of my closet and carry them over to the SM's common room in the middle house. I leave a note that says "ho, ho, ho, merry thanksgiving, merry thanksgiving." And it turns out to be just that...after a long day at work.
Work starts out with rounds on a completely full hospital with no beds to spare. Then, I have a tubal ligation, a D&C/tubal ligation combo, a rectal polyp to remove on an 8 year old Arab boy, a bilateral inguinal hernia repair with mosquito net, another emergency D&C for an incomplete spontaneous abortion and finally finish at 4:30pm just in time to go to Gilbert's going away party that Jason has organized.
I slip into the courtyard where many of the staff and Gilbert's friends are already seated on a variety of chairs and stools and mats. I slip off my Crocs and settle onto a mat. My ankle is aching a little and somewhat swollen after a long day upright in the OR, but it's not too bad. I exhange pleasantries with Job and Koumakoy and nod at Simeon and Abel who I've spent all day with in surgery. Gilbert slides onto the mat next to me and we have some decent small talk as Jason serves us the best "bouille" I've had in Chad. Zachee, our cook, is the best and Jason contracted him for the feast. The "bouille" is a rice porridge with milk, sugar, cinnamon and peanut paste. I grab the crude metal bowl from Jason and slurp it up without a spoon.
The second course is either roasted goat or chicken in a tomato sauce with boiled sweet potatoes, all served over mushy rice. It's quite tasty, but I'm trying to save room for Thanksgiving dinner later.
At 6pm, we all head to my house to prepare the feast. We have invited Gary and Wendy and their volunteers (Steve, Jeremy and Annie) as well our our 6 student missionaries, Maria (our Danish volunteer) and Sarah and I. Jacob's mom has sent 5 packages stuffed with everything needed. The menu is impressive: Fri-Chik, garlic mashed potatoes and gravy, cranberry sauce and relish, anti-pasta salad, stuffing, spiced apple cider, candied yams, and a pumpkin pie spice squash dessert with real whipped cream! Gary and Wendy add some real (not powder) mashed potatoes, more gravy, a cranberry-like hibiscus flower sauce, and some stuffing made from scratch. Jeremy and Annie bring a fresh garden salad of tomatoes, lettuce, cucumbers and sprouts; fresh squeezed lemonade; and boiled beets.
Jacob's mom has also sent Thanksgiving-themed plates, napkins and decorations and with the half-cut into pumpkin-like squash in the center of the table we're only missing NFL football to make it feel like a real American holiday.
.jpg)
Right before eating, Sarah comes over to tell me that she's already hospitalized 5 kids with malaria, 3 of them with severe anemia needing blood transfusions. Luckily, Samedi is on with her until 9pm so they're managing, but the hospital has been filled back up despite being cleared out by me in the morning. She refuses my offer to eat with us, saying she'd rather I just brought her something later.
We all sit around the table and go around with each person saying one thing they're thankful for for each of the 5 kernels of corn placed before them. We pray and then we chow down.
Just as I'm finishing my overloaded plate (the first one done of course) Hortance, the midwife, comes knocking to tell me about a woman, 8 months pregnant with vaginal bleeding referred from the health center 2 days ago but just now arriving. She is severly anemic with a hemoglobin of 4.8 g/dl and has a placenta previa where the placenta wants to come out before the baby. I think I find a fetal heart beat so we quickly resuscitate her with two large bore IV's and a lot of IV fluids, give her anti-biotics, and take her to the OR. Fortunately, her blood type is AB + making her a universal recipient (i.e. she can take blood from anyone) so we have both her brother and father give blood while we prep her for surgery.
We start the first bag of blood running as we pull out a dead baby with skin already peeling off meaning he's been gone for a few days. Fortunately, there's not much bleeding and we quickly close her up as the second bag runs in. Her heartbeat is almost normal now and her blood pressure has come up. We wheel her into the wards almost running over some Arab women who've spread their sleeping mats right across the entrance and then are forced to leave her on the gurney for the night since there are no available beds.
I come home at about 10pm and we play Settler of Catan and Citadels until almost 2 in the morning when I fall into a deep, contented sleep.
Happy Thanksgiving!
Sunday, November 2, 2008
Mistake
Have you ever been glad you made a mistake? I was sure the elderly man had a gallbladder problem. I mean, I'm no ultrasound expert, but there was obviously something inside that gall bladder that shouldn't have been there. Besides, he was complaining of pain right over that spot that was worse when he ate. And his bilirubin was elevated, another sign that could point to gall bladder problem.
I was hesitant to operate, though, because he was a friend. In fact, he is the chief of our neighborhood here in Bere. Totho Timothée. His brother has AIDS and is a motorcycle taximan who takes us often back and forth to Kélo when our car isn't running or the rainy season makes the roads all but impassible for anything except a moto.
But, I finally decided it was the right thing to do. I was sure he needed an operation for his gallbladder. I was wrong.
I stand to his right side. Franklin has given him a "high spinal" anesthetic so I can make a somewhat relaxed incision right below his right ribs. We pray and I start cutting with Abel and Jacques assisting. I've decided to splurge today, since it's a gall bladder, and have set up the electrocautery. Soon the smell of barbecuing human flesh fills the room as I burn through the abdominal muscles before entering the peritoneal cavity.
We also are using the air conditioner since it's about 110 degrees fahrenheit outside. Jacques, however, having just recently arrived from Togo where it's relatively cooler, is having a hard time as the sweat runs in rivulets down his face. I usually don't notice until afterwards when I pull off my gown and find my scrubs are soaked with my own sweat.
I have Abel retract the liver gently and I get a good look at the gallbladder. It looks normal. I pinch it between my fingers. It feels normal. I'm starting to feel sheepish. Especially since on entering the abdomen I found a lot of ascites fluid and now I see that he has advanced liver cirrhosis. Of course the bilirubin was elevated! I'm starting to realize I was wrong to operate on him and it could've maybe even endangered his life. Better close and get out of here before I do more harm.
Then I notice something out of the corner of my eye that gives me pause.
"Jacques, pull the stomach back a little again. Yeah, just like that."
I see a small black spot on the first part of the small intestine coming right out of the stomach. Before my brain can even formulate it's idea of what it is, the spot confirms itself by opening up right before my eyes and etting out a stream of clear, gooey liquid.
A duodenal ulcer just perforated before my very eyes! Abel quickly aspirates up the stomach acid with the suction tip and I call for some suture.
I place some interrupted sutures along the edge of the ulcer and leave them untied till I have a whole row ready to close the wound. I then pull some of the omentum back from the stomach edge and lay it across the perforation. I tie the sutures across the omentum patching up the hole. I irrigate and suction and then close up the muscle, fascia and skin of the abdominal wall.
I've just witnessed a miracle to save our friend, Timothée's life. If I hadn't mistakenly misread the ultrasound I wouldn't have operated. If I hadn't mistakenly thought it was the gallbladder I wouldn't have made the perfect incision to allow me to see and close the ulcer. If I'd have waited half and hour more it would have perforated letting stomach acid all in the stomach to burn and irritate the intestines and cause all kinds of complications. If it had happened a day or two before I did the operation, he'd probably be dead...especially with having already liver cirrhosis.
Sometimes it's ok to make a mistake!
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I was hesitant to operate, though, because he was a friend. In fact, he is the chief of our neighborhood here in Bere. Totho Timothée. His brother has AIDS and is a motorcycle taximan who takes us often back and forth to Kélo when our car isn't running or the rainy season makes the roads all but impassible for anything except a moto.
But, I finally decided it was the right thing to do. I was sure he needed an operation for his gallbladder. I was wrong.
I stand to his right side. Franklin has given him a "high spinal" anesthetic so I can make a somewhat relaxed incision right below his right ribs. We pray and I start cutting with Abel and Jacques assisting. I've decided to splurge today, since it's a gall bladder, and have set up the electrocautery. Soon the smell of barbecuing human flesh fills the room as I burn through the abdominal muscles before entering the peritoneal cavity.
We also are using the air conditioner since it's about 110 degrees fahrenheit outside. Jacques, however, having just recently arrived from Togo where it's relatively cooler, is having a hard time as the sweat runs in rivulets down his face. I usually don't notice until afterwards when I pull off my gown and find my scrubs are soaked with my own sweat.
I have Abel retract the liver gently and I get a good look at the gallbladder. It looks normal. I pinch it between my fingers. It feels normal. I'm starting to feel sheepish. Especially since on entering the abdomen I found a lot of ascites fluid and now I see that he has advanced liver cirrhosis. Of course the bilirubin was elevated! I'm starting to realize I was wrong to operate on him and it could've maybe even endangered his life. Better close and get out of here before I do more harm.
Then I notice something out of the corner of my eye that gives me pause.
"Jacques, pull the stomach back a little again. Yeah, just like that."
I see a small black spot on the first part of the small intestine coming right out of the stomach. Before my brain can even formulate it's idea of what it is, the spot confirms itself by opening up right before my eyes and etting out a stream of clear, gooey liquid.
A duodenal ulcer just perforated before my very eyes! Abel quickly aspirates up the stomach acid with the suction tip and I call for some suture.
I place some interrupted sutures along the edge of the ulcer and leave them untied till I have a whole row ready to close the wound. I then pull some of the omentum back from the stomach edge and lay it across the perforation. I tie the sutures across the omentum patching up the hole. I irrigate and suction and then close up the muscle, fascia and skin of the abdominal wall.
I've just witnessed a miracle to save our friend, Timothée's life. If I hadn't mistakenly misread the ultrasound I wouldn't have operated. If I hadn't mistakenly thought it was the gallbladder I wouldn't have made the perfect incision to allow me to see and close the ulcer. If I'd have waited half and hour more it would have perforated letting stomach acid all in the stomach to burn and irritate the intestines and cause all kinds of complications. If it had happened a day or two before I did the operation, he'd probably be dead...especially with having already liver cirrhosis.
Sometimes it's ok to make a mistake!
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Saturday, November 1, 2008
Too late
I squat on the ground outside the operating room. A thin Muslim man squats in front of me, his green Arabic robe pulled tightly across his knees as he hugs them with his arms. He is staring at the blue basin between us. The insides of the basin is covered with a blood-soaked, brightly-patterned yellow wrap around skirt. I lift up the cloth with a gloved hand covered with dried blood. Underneath is a dead infant with a huge head (hydrocephalos). His blank eyes stare up at us as his neck bends back at an impossible angle. Underneath is the placenta still attached to the child by the umbilical cord. All is cold, lifeless and bloody.
I do my best to explain to him in Arabic what happened.
"The child, dead, when arrived, dead already. The head, big, not come out. The house of the child broken, the child come out here (point to my stomach). Blood come out, a lot, here also. The woman there, she not have much blood when she arrive not have. Si there is not much blood, she found death."
"Both of them, the two of them, both dead?" The man asks in disbelief.
"Yes, both dead, all dead," I repeat a million images of the last two hours flashing through my head...
"Doctor, doctor!"
I slowly stumble out of a deep sleep and a pleasant dream. "Yeah, what is it?"
"It's me, Augustin, I have a case to present to you."
"Ok, I'm coming." I pull on a pair of scrub bottoms and feel my way through the dark to the door and out onto the porch. Augustin is standing outside the screen door with a headlamp and a "carnet" or portable medical record.
"There's a woman, referred, in labor for two days..." Augustin stumbles through presenting the woman. He is one of our laziest nurses and often does as little as possible. I'm a little irritated.
"Whoa, whoa! Start over, give me that!" I take the labor and delivery sheet. I glance quickly over it and it's incomplete. I see the vital signs, heart rate 60 bpm, blood pressure 100/70, temperature 37 degrees Celsius. I'll regret later not noticing how generically normal they were.
"What? What's going on?" A voice comes from the room next to us where Jacques, our newly arrived doc fresh from medical school in Mali, has been sleeping.
"I'm talking to Dr. James," replies Augustin. Jacques quickly appears outside just as I'm telling Augustin to go get more information and come back to see me with the chart completely filled out.
As Augustin and Jacques walk off together I almost yell after him to check a hemoglobin. I catch myself, thinking I'll be over to see her shortly anyway. The second thing I later regret not doing.
I go back to my room and decide to lie down, after all it's been a long week filled with tons of surgeries and the training seminar I've been doing for the village health care workers on HIV and tuberculosis. I'll just close my eyes for a few minutes until Augustin and Jacques get back. The third thing I later regret.
"Docteur? Docteur?" The soft voice of Jacques floats across my subconscious. I go to the door. I glance up at the clock. It reads 4:25 am. I didn't look at the clock when Augustin first came, but I did hear the fridge running which it's programmed to do 4 times a day for an hour at a time: at 6am, noon, 6pm and midnight. It's been 3-4 hours since I saw Augustin and Jacques walking off together. A strange sense of foreboding falls over me.
"I've examined the woman and I think she has a ruptureed uterus."
"Go call Abel and Dr. Franklin and I'll be right there."
I pull on a scrub top, grab my keys and I'm out the door. I stop by the other house real quick to make sure Franklin's awake and then make my way across the compound to the labor and delivery room just past the OR.
As I walk in the room and glance at the patient, my heart skips a beat. A tiny Arabic woman lies stretched out on the table with one knee bent in the air. Blood has pooled between her legs. An IV with Glucose and I quickly assume Oxytocin is dripping into her left arm. Her thin abdomen is grossly distorted with several large, not normal pregnancy looking lumps. But what arrests my attention is when I look at her face.
Her head is flopped to one side and her eyes are rolled back in her head. She is pale and her only breaths are occasional sighs. She is on death's door and I see it instantly. I quickly feel for her heartbeat which is present but slow. I flip down her eyelids with my finger and my blood freezes. Her conjonctiva is white. She has practically bled to death in our hospital.
"Augustin, quick call the lab, we need blood! Abre, run and get me some Ringers!" Franklin arrives and quickly starts looking for a better IV. Then she stops breathing and I start chest compressions. Franklin has found an IV in her neck and we get fluids running. Abel has arrived and we take turns with chest compressions.
"Franklin, what about the monitor from the OR?" He runs quickly and arrives. We get no blood pressure and a weak O2 sat.
Finally, after what seems like hours the lab guy arrives.
"Abre, what blood type are you?"
"O positive."
"Mathieu, just check to see if she's positive or negative and if she's positive Abre will give."
She is B positive and Jacques and Abre run off to donate a bag of blood each. Augustin is B positive and refuses to give.
Abel and I keep up the chest compressions while Franklin guards her airway.
We get the first bag which is only a third full of Abre's blood. We hang it up.
"Abel, you and Abre get the stretcher and lets take her to the OR."
We flop her bloodied body onto the stretcher and Abel and Augustin carry her quickly to the OR while I continue chest compressions and Franklin carries the blood and IVs.
We get her all set up on the OR table with blood splashed everywhere. Still no heartbeat so we continue our ressucitation hoping that if we can keep her oxygen circulating until we replace her blood loss maybe we can save her.
We try some Atropine to start her heart. We try shocking her. Nothing. We have no Adrenaline. Then I remember we have some spinal kits. I open up two kits so we can use the adrenaline inside. Nothing works so we continue CPR.
Finally, a third bag of blood is running and I decide to take out the baby. We slosh Betadine on the belly, I quickly open up a C-section kit and put on a gown and sterile gloves. One slash and I'm in the belly. I cut the baby's face but he's dead already. His head is 5 times normal size with hydrocephalus. That's why he couldn't come out. Her uterus is in tatters. I pull out the baby and placenta. Place some clamps across what's left of the uterus and cut it out. I tie off the clamps, dump some Celox in the pelvis and hold pressure for 5 minutes. The whole thing takes about 15 minutes. All the donated blood is in, we've been working on her for almost 2 hours and she still is flatlined. I tell the guys to stop CPR, I sew up the belly and I go out to tell the husband.
As I'm kneeling in front of the Muslim husband, having just told him his wife and the unborn child between us are dead, I'm not sure how he'll react. A brief image flashes through my mind of the violence of two weeks ago with Arabs stabbing and killing Africans and vice versa and the chaos in the hospital trying to save as many as possible. But there is no revenge taken on me today. Instead, a gentle chanting in classic Arabic rises from the depths of his sorrowed heart.
"Illallah le Allah wa rassulloh Mahamat." The Muslim creed repeated over and over seems to soothe the sorrow. "Al hamdullilah" (Allah be praised) breaks in occasionally. A fellow Muslim from Lai comes and kneels down beside him reciting some Koranic verses in a low voice.
"Find me some brothers of Islam here. All the believers here in the hospital." The other Muslim goes off and soon a small group of robed and turbaned men surround us.
I ask him if he'd like to see his wife. He nods and we go into the OR where Abel and Jacques have been cleaning and covering the body. A portly Arab with a beige robe and white turban accompanies us. The woman is lying on the stretcher covered with a black, Muslim woman's cloth with intricate Arabic designs in gold woven into the fabric. The husband uncovers the wife's face and asks for water.
I get some water from the faucet and bring it to him in a small basin.
"Put a little over my hands," he asks me in Arabic.
I pour water over his right hand and he uses it to gently wash and wipe down his dead wife's face closing the eyes. The other Arab also moves his hand down the face to close the eyes and then they cover her back up. As we take her out to the morgue I hear some low sobs coming back from the OR.
15 minutes later, the brothers from the Mosque have arrived and I carefully explain in broken Arabic again what has happened.
"Xalas, inshallah, mashallah, al hamdullilah" come out in intervals from all resent. The accept and comfort and then take the body off to be appropriately buried as soon as possible in the Muslim fashion.
I go home.
I do my best to explain to him in Arabic what happened.
"The child, dead, when arrived, dead already. The head, big, not come out. The house of the child broken, the child come out here (point to my stomach). Blood come out, a lot, here also. The woman there, she not have much blood when she arrive not have. Si there is not much blood, she found death."
"Both of them, the two of them, both dead?" The man asks in disbelief.
"Yes, both dead, all dead," I repeat a million images of the last two hours flashing through my head...
"Doctor, doctor!"
I slowly stumble out of a deep sleep and a pleasant dream. "Yeah, what is it?"
"It's me, Augustin, I have a case to present to you."
"Ok, I'm coming." I pull on a pair of scrub bottoms and feel my way through the dark to the door and out onto the porch. Augustin is standing outside the screen door with a headlamp and a "carnet" or portable medical record.
"There's a woman, referred, in labor for two days..." Augustin stumbles through presenting the woman. He is one of our laziest nurses and often does as little as possible. I'm a little irritated.
"Whoa, whoa! Start over, give me that!" I take the labor and delivery sheet. I glance quickly over it and it's incomplete. I see the vital signs, heart rate 60 bpm, blood pressure 100/70, temperature 37 degrees Celsius. I'll regret later not noticing how generically normal they were.
"What? What's going on?" A voice comes from the room next to us where Jacques, our newly arrived doc fresh from medical school in Mali, has been sleeping.
"I'm talking to Dr. James," replies Augustin. Jacques quickly appears outside just as I'm telling Augustin to go get more information and come back to see me with the chart completely filled out.
As Augustin and Jacques walk off together I almost yell after him to check a hemoglobin. I catch myself, thinking I'll be over to see her shortly anyway. The second thing I later regret not doing.
I go back to my room and decide to lie down, after all it's been a long week filled with tons of surgeries and the training seminar I've been doing for the village health care workers on HIV and tuberculosis. I'll just close my eyes for a few minutes until Augustin and Jacques get back. The third thing I later regret.
"Docteur? Docteur?" The soft voice of Jacques floats across my subconscious. I go to the door. I glance up at the clock. It reads 4:25 am. I didn't look at the clock when Augustin first came, but I did hear the fridge running which it's programmed to do 4 times a day for an hour at a time: at 6am, noon, 6pm and midnight. It's been 3-4 hours since I saw Augustin and Jacques walking off together. A strange sense of foreboding falls over me.
"I've examined the woman and I think she has a ruptureed uterus."
"Go call Abel and Dr. Franklin and I'll be right there."
I pull on a scrub top, grab my keys and I'm out the door. I stop by the other house real quick to make sure Franklin's awake and then make my way across the compound to the labor and delivery room just past the OR.
As I walk in the room and glance at the patient, my heart skips a beat. A tiny Arabic woman lies stretched out on the table with one knee bent in the air. Blood has pooled between her legs. An IV with Glucose and I quickly assume Oxytocin is dripping into her left arm. Her thin abdomen is grossly distorted with several large, not normal pregnancy looking lumps. But what arrests my attention is when I look at her face.
Her head is flopped to one side and her eyes are rolled back in her head. She is pale and her only breaths are occasional sighs. She is on death's door and I see it instantly. I quickly feel for her heartbeat which is present but slow. I flip down her eyelids with my finger and my blood freezes. Her conjonctiva is white. She has practically bled to death in our hospital.
"Augustin, quick call the lab, we need blood! Abre, run and get me some Ringers!" Franklin arrives and quickly starts looking for a better IV. Then she stops breathing and I start chest compressions. Franklin has found an IV in her neck and we get fluids running. Abel has arrived and we take turns with chest compressions.
"Franklin, what about the monitor from the OR?" He runs quickly and arrives. We get no blood pressure and a weak O2 sat.
Finally, after what seems like hours the lab guy arrives.
"Abre, what blood type are you?"
"O positive."
"Mathieu, just check to see if she's positive or negative and if she's positive Abre will give."
She is B positive and Jacques and Abre run off to donate a bag of blood each. Augustin is B positive and refuses to give.
Abel and I keep up the chest compressions while Franklin guards her airway.
We get the first bag which is only a third full of Abre's blood. We hang it up.
"Abel, you and Abre get the stretcher and lets take her to the OR."
We flop her bloodied body onto the stretcher and Abel and Augustin carry her quickly to the OR while I continue chest compressions and Franklin carries the blood and IVs.
We get her all set up on the OR table with blood splashed everywhere. Still no heartbeat so we continue our ressucitation hoping that if we can keep her oxygen circulating until we replace her blood loss maybe we can save her.
We try some Atropine to start her heart. We try shocking her. Nothing. We have no Adrenaline. Then I remember we have some spinal kits. I open up two kits so we can use the adrenaline inside. Nothing works so we continue CPR.
Finally, a third bag of blood is running and I decide to take out the baby. We slosh Betadine on the belly, I quickly open up a C-section kit and put on a gown and sterile gloves. One slash and I'm in the belly. I cut the baby's face but he's dead already. His head is 5 times normal size with hydrocephalus. That's why he couldn't come out. Her uterus is in tatters. I pull out the baby and placenta. Place some clamps across what's left of the uterus and cut it out. I tie off the clamps, dump some Celox in the pelvis and hold pressure for 5 minutes. The whole thing takes about 15 minutes. All the donated blood is in, we've been working on her for almost 2 hours and she still is flatlined. I tell the guys to stop CPR, I sew up the belly and I go out to tell the husband.
As I'm kneeling in front of the Muslim husband, having just told him his wife and the unborn child between us are dead, I'm not sure how he'll react. A brief image flashes through my mind of the violence of two weeks ago with Arabs stabbing and killing Africans and vice versa and the chaos in the hospital trying to save as many as possible. But there is no revenge taken on me today. Instead, a gentle chanting in classic Arabic rises from the depths of his sorrowed heart.
"Illallah le Allah wa rassulloh Mahamat." The Muslim creed repeated over and over seems to soothe the sorrow. "Al hamdullilah" (Allah be praised) breaks in occasionally. A fellow Muslim from Lai comes and kneels down beside him reciting some Koranic verses in a low voice.
"Find me some brothers of Islam here. All the believers here in the hospital." The other Muslim goes off and soon a small group of robed and turbaned men surround us.
I ask him if he'd like to see his wife. He nods and we go into the OR where Abel and Jacques have been cleaning and covering the body. A portly Arab with a beige robe and white turban accompanies us. The woman is lying on the stretcher covered with a black, Muslim woman's cloth with intricate Arabic designs in gold woven into the fabric. The husband uncovers the wife's face and asks for water.
I get some water from the faucet and bring it to him in a small basin.
"Put a little over my hands," he asks me in Arabic.
I pour water over his right hand and he uses it to gently wash and wipe down his dead wife's face closing the eyes. The other Arab also moves his hand down the face to close the eyes and then they cover her back up. As we take her out to the morgue I hear some low sobs coming back from the OR.
15 minutes later, the brothers from the Mosque have arrived and I carefully explain in broken Arabic again what has happened.
"Xalas, inshallah, mashallah, al hamdullilah" come out in intervals from all resent. The accept and comfort and then take the body off to be appropriately buried as soon as possible in the Muslim fashion.
I go home.
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