Sign

It's 3;46 AM and I can't sleep. My eyes are bloodshot and heavy, my head pounds, but I can't sleep. Jet lag is at it again. As I huddle under the blankets to keep from freezing in the airconditioned hotel room in Richland, Washington it's hard to imagine that just a few sleepless days ago I was in the bush of the Sahel. A six hour bus ride from Bere to N'Djamena, a 5 hour overnight flight to Paris arriving at 6AM followed by 45 minutes to Amsterdam and a direct flight across Greenland and Canada to Seattle where I met Greg. We grab a rental car and head over the mountains covered with pines and firs into the central valley with it's rolling golden hills, small farming towns and fresh, cold cherries. Following a smaller river down we hit the Columbia River in the TriCities and we've arrived for the SIGN conference.

I get out of bed at about 4:30, strap on my running shoes and head out the door. The night is just beginning to turn a lighter shade of black but the well-lit streets need no natural light and guide me across the street, around the middle school with it's sprinklers caressing it's well manicured lawns, soccer and football fields, up a side street, off the road up a grassy slope and onto the riverside walking trail. The scent of sage, mountain misery, pine and fir wafts across the early morning breeze which would've surely chilled me if not for the vigorous sweat I've already worked up in my out of shape body. A grove of trees and dense shrubbery gives me only glimpses of the dark, alabaster surface of the river until I turn a corner and see an opening leading down a pebbly bank onto a small sandy beach. I stumble down and after some pushups squat on the sand to reflect.

Yesterday, I found myself surrounded by an international aura of languages swirling around me: Urdu, Hindi, Vietnamese, Slavic, Arabic, French, Spanish, and a wide variety of English from Nigeria, Cameroon, Tanzania, Kenya, India, Bangladesh, Mongolia, England and the wide variety of American accents. There is the slender Dr. Shah with his ample gray beard and thin, fierce face with a long pointed nose from Pakistan describing doing more than 1000 intramedullary nails for long bone fractures starting during the terrible earthquake in northern Pakistan and continuing on today in some of the most remote areas of the world. There is the dignified, dark skinned Dr. Faruque from Bangladesh speaking calmly out from under his mop of black hair and half smile. Dr. Shahab from Peshawar lectures us elegantly on bomb blast injuries, his portly figure fitting well in his classy suit framing a jolly face encompassed in a well trimmed white beard outlining his dark features. I find myself being guided through the machine shop where intramedullary rods, screws and instruments are made at a fraction of the competitors prices but with the same levels of quality control. I enter into a workshop where 20 artificial femurs and an equal number of tibias await our inexperienced hands.

I am led through the process by an orthopedist from Vietnam who explains how to attach the guiding frame to the rod and adjust it so the distal fixing screws will be able to be placed without intraoperative imagery. I am shown the technique of insertion with frequent side to side sweeps interspersed with gentle taps of the mallet. The whole process of guided drilling, finding the slot in the nail and inserting the screws is simple and elegant allowing most lower limb long bone fractures to be treated with the highest standard of care in the world without needing the normal high-tech equipment or even electricity! I go over the process many times in the next few days until I've mastered it. Of course, real bone covered with real flesh on a real person will be different but I'm confident I can do it...inshallah.

SIGN was started 10 years ago by Dr. Zirkle, an american orthopedist who has spent his life in developing countries with the idea of equality of fracture treatment around the world. By the end of 2008 SIGN had over 144 programs in 49 countries involving over 3000 surgeons who have performed over 36,000 operations. Now, Chad and the Bere Adventist Hospital will make it at least 50 countries. We have been given the instruments, our first set of 30 intramedullary nails, a cordless drill with sterile cover, training videos, wound suction treatment systems and the full support of the SIGN team...all on faith that we will raise the money to help cover the costs of this equipment.

Anyone interested in knowing more or donating to this program in the name of Bere Adventist Hospital can contact SIGN at www.sign-post.org.

James

Moonlight

I could never have imagined that things would turn out they did.

As I stare out into the moonlight filtering through the flamboyant tree branches casting shifting shadows with every breath of wind, as I hear the soft shuffle and breathing of our sweat-flecked horses outside the stable, as I draw my gaze back to the pile of pineapple carvings in front of the cutting board and bring the ice-cold pineapple to my mouth and slowly savor crunching into the juicy morsel, as I think back over the past few days I find it incredible to think of how this afternoon ended...I can only call it an unexpected grace, a surprising joy, a metaphysical moment when all things good come together out of the midst of all things wrong.

As I gallop through the forest, grasping Pepper's mane as fiercely as I hold to the reins; as I stand up in the stirrups and hug my body to the horse's powerful neck; as the leaves slap my face and a branch rips through the skin of my shoulder; as the full moon lights up the sandy trail like a river of silver stretching lazily out before me through the dark shadows of the trees; as my sweat soaked shirt clings to my back; as I am surrounded by the silence of an African evening in the bush I find myself carried way beyond the horrors, sorrows and sufferings of the last few days.



I can hardly remember the strong features of the handsome Arab man staring steadfastly upward with a look of incomprehensible peace as he is lugged up the ramp to the operating room in a vinyl stretcher with wooden handles held firmly in the grips of a dozen turbaned comrades his mangled body wrapped in a blood soaked turban in stark contrast to the serenity of his gaze. I almost forget the hours of working on his bilateral open fibula and tibia fractures uncovered on his right by a flap of skin running from his heel and achilles tendon up his calf and across the top of his foot revealing the anatomy of the muscles, tendons, ligaments and bones as I can only barely remember from Anatomy lab in medical school. The almost can't bring up the vague memory of him calmly complaining of neck pain since he can't move or feel the rest of his body is a silent grace to him allowing us to work on his tattered limbs without anesthesia after framing his chiseled face in a cervical collar. I thought I'd never survive the emotional roller coaster of the myriads of swishing robed, turbaned men and brightly wrapped head scarved women that filed incessantly in and out, many of the men leaving with tears unashamedly rolling down their cheeks as I had to console them to leave all in Allah's hands as only He can know the day of our death and we should trust Him. The memories flood in of fighting my way through crowds and over colorful mats and rugs to try and do his complicated dressings after spending what seemed like ages of emotional energy trying to get the swarming family and friends to respect visiting hours and hospital policies. When his paralysis didn't get better after three days I was almost relieved when the nurse came to get me yesterday morning to say "Ca ne va pas" and I arrived in time to see his unconscious, but still dignified face take it's last shallow breaths and feel his heart beat in his neck slow down and become weak. He was bound for a long road of suffering in this environment as a quadriplegic and it was certainly God's mercy that laid him to sleep.

As I stand on the bank of the river, looking down on the swirling eddies of the brown, engorged river; as I see the sun slowly set behind the great branching trees of the African plain; as I turn around and see the full moon rising through a circle made by two rounded trees and a small hill; as I watch the slow transformation of the day into moonlit night; as I feel the wet of the river slowly drying on my body; as I watch Stefan desperately trying to capture the moment on film; as Eddie slowly makes his way upstream against the current; as I pull on my jeans over my moist swimming suit and prepare for the ride home; as untangle Pepper from the bush I've tied him to I am amazed at how quickly depression and overwhelming burnout can be replaced by wonder and marvel and ecstasy.



Can it be that only this morning I found myself deep in a belly under the ribs carefully cauterizing a gallstone filled gallbladder from the liver of an elderly, lighter-skinned Muslim man? Is it possible that yesterday I was about to throw up and finally gave in and started taking malaria treatment only to go out immediately and take out an ovarian tumor stuck to all the intestines, omentum and uterus? Is it possible that only two days ago I didn't think I'd make it through the morning much less the weak because of fatique I refused to believe was another bout of Plasmodium falciparum destroying my blood cells? Is it possible that only three days ago the hospital was full to overflowing while we spent all of a Sunday afternoon filling it up with sick babies needing blood transfusions and malaria treatment? Is it possible that only four days ago I spent all Saturday in the OR with two motorcycle accidents needing emergent orthopedic intervention? Is it possible considering how things later turned out?

I come back from work almost collapsing. It's been another day of neverending hospital rounds, complicated surgeries, ER patients, ultrasounds all pleasantly muffled with the ringing of Quinine in my ears. I feel a little nauseated and drink some cold water. I sit down and finish reading "Flying Doctor of the Philippines". I just want to sleep, but decide I better go out and feed the horses to keep my wife happy. The next thing I know I'm in the saddle trotting past the mud huts of Bere, around the pond, through the forest and onto the river road mounted on Pepper while Stefan rides Bob and Eddie rides Libby. Out into the open Stefan and Eddie cluck their horses into a gallop. I can feel Pepper tensing beneath me and I give him the releasing cry and squeeze and he quickly closes the gap and passes the others through a mud puddle as Bob goes left and Libby goes right around it. We're in the open now and I slow down. We arrive quickly at the river ride down the ridges gauged out by the rain leading to the cattle crossing and then climb up the hill next to it. A quick assessment confirms the possibilities and Eddie and I strip down and race off the cliff arms and legs flailing wildly before crashing into the swift moving current below. It's not enough for Eddie, so we find ourselves pulling our reluctant bodies up the bank using exposed tree roots before climbing up the tree as high as possible with still a path clear of branches to the rushing waters below. I crouch on two diverging limbs my hands in front as I propel myself through the gap, past the other branches below and into the welcoming arms of the cool, refreshing liquid beneath. I'm glad there are no crocs and lions in this part of Africa.


As Eddie and I climb up the bank for the last time after multiple jumps from different levels, Stefan's face is glowing. It's hard to believe just last night he was talking about maybe wanting to leave. Now all he says is, "the only thing that could make this better would be a little ice cream."

Later as I walk through the cool of the moonlit evening from my house to his carrying the plate of chilled fruit I think to myself, "well, cold pineapple could arguably be as good or better..."

Then the clapping comes again...it's Salomon...

"There's an old man peeing blood since this morning..."

And I'm off to the hospital as the moonlight leads the way.

INSHALLAH

I find myself in an SUV with a group of Muslims roaring across the desert towards Eastern Chad and the crisis in Darfur. We pass Bedouin caravans heading north. Women in brightly colored body wraps and head scarves with huge gold nose rings frantically beat donkeys to get them to move off the road as we come cruising past. Robed, turbaned and bearded, the men lumber by swaying on the backs of heavily loaded camels, bounce along on horseback or plod along on foot chasing the goats and sheep. Most are armed with bows and arrows or spears or staffs. Tucked away in the robes is the ever present dagger and many probably have rifles hidden in their saddle bags.



Dead animals in various states of decomposition and drying litter the shoulders of the highway. Poor rainfall this year has lead to famine and the loss of cattle, donkeys, horses and other vital livestock. Occasionally the smell of a rotting carcass sneaks it's way in through the windows of our passing vehicles.

The African plain starts to be interrupted by wadis, rolling hills and piles of boulders. In the distance, jagged peaks and granite outcroppings break up the horizon. We enter into the central Chadian Sahel where rain has been more abundant and the grasslands are bright green and crops of millet are starting to push their way out of the soil as local farmers dig up the ground with small spades on the end of long poles. Women coming back from the fields carry water and rations in woven net bags suspended from poles slung across one shoulder. No one carries things balanced on top of their heads like they do in Bere in the South.



We stop by the side of the road for a picnic. Tea and Arabic coffee is poured from thermoses as we wait in the shade of a thorny desert scrub tree. A platter of grilled goat chunks and French baguettes is shared among our two groups of five.



We continue on with regular stops for tea, milk and ritual prayer. One stop for prayer finds us in the midst of a cluster of mountains and date palms. The prayer rugs are rolled out and the absolution's begun in front of a man slicing up a sheep into large portions to be roasted on a piece of tin roofing suspended over a wood fire.

We spend the night in Mongo at the World Food Program compound and are up before five for morning prayers, milk, tea and Chadian beignets. We arrive late in the afternoon at Abeche, Chad's fourth largest city.



As we enter the mud brick compound and seat ourselves on enormous mats, I experience for the first time what an Arabic greeting really is. A rhythmic, staccato exchange of words proceeds for at least five minutes with at least 20 "mashallah's", 15 "Al hamdullilah's" and countless other words asking about health for everybody, strength, improvement, etc. I soon join in and find it very satisfying. Hands are shook during most of the greeting, eyes look down and occasionally the hand is released to bring one's own hand into touch the chest over the heart before reaching out again to take the other's hand in greeting. To end the salutation, one releases the hand and slowly sits down on the mat letting one's "mashallah's" and "al hamdullilah's" slowly fade out.

Adding to the milk and tea we now have local coffee seasoned with cardamom and added to the meat and bread is "boule" (millet or corn paste) and some of the best sauces I've had in Chad: ground meat with lots of cumin and okra.

I then take a shower in a walled in corner with a poop hole and a step up for showering from a bucket. Just outside, in the other corner, about 20 small girls are learning to recite the Koran in Arabic. Their sweet voices blend together in a cacophony of different rhythms as none of them is in sync with the other. It is beautiful and cute. It feels good to splash water on me and wash the red dust out of my hair and off my face and arms.

The men stretch out and sleep together on the mats in the men's courtyard where the women don't dare to enter. Whenever a female family member has arrived she starts her greeting and then kneels down just outside the low wall of the courtyard while the male family member goes outside to greet her and kneels down beside her for the prolonged ritual greeting.

The morning starts with sunrise at 4:30am and prayer. I read some passages of scripture, we drink milk and eat beignets and head out to see the local authorities.

First stop is the governor. Our host, Mahamat Saleh Abakar, explains that he's invited us out to look at the possibility of opening a medical center in his village of Gnelme. The Governor doesn't seem to keen since there's a health center in the neighboring town of Abougoudam. However, when Mahamat Saleh explains that it will be more than a health center, more like a hospital, the Governor reluctantly gives his ok. On walking out with his "Directeur du Cabinet", we receive a much warmer reception. The lighter skinned man with obvious Arabic features dressed in an ample robe and white turban beams a smile and says that he is from Gnelme and will do everything to help us get the paperwork pushed through for the land and anything else we need.

We miss the Prefet and Sultan who are out of town so we head out of Abeche towards the sous-prefecture of Abougoudam to see the local sous-prefet, the chief political figure of the group of villages including Gnelme.

He welcomes us into his old, colonial thick walled mansion that unfortunately hasn't been maintained since independence in 1960. We sit down on mats and drink tea and local coffee along with sodas and some goat meat. Directly in front of us is a room stacked to the ceiling with cement, all that's left of a project to build the sous-prefet a new house. Apparently, the rest of the supplies where stolen by bandits and the builder assassinated.



We follow the sous-prefet out to the village where he shows us a flat, barren stretch of ground he wants to give us. It doesn't feel right. We move onto where Mahamat Saleh and his brother have drilled a well for the village so they can have water. It's down in the wadi, too low for construction and likely to be washed away by flash floods. Next to the pump are three dried out cattle carcasses...the water came a little too late for them. About 10 boys mounted bareback on horses have come to water their flocks. I point to a fairly close plateau next to a small mountain and say that's more what I'm interested in. They say it's in another county and so they can't help.

We seem at an impasse when a local man almost hidden by his enormous turban rattles off something quickly in Arabic. We hop back in the SUVs and head a little out of the village towards another village where we find a small hill crowned with huge boulders that is unfarmed. In all directions stretches the African plain broken up by wadis and scrub brush and mountains in the distance ringing us in on all sides. It's perfect. They are happy and agree to give us 10 hectares (almost 25 acres). The location will also allow us to build using local stones.

That evening, I speak with Yacoub Abdoulaye, Mahamat Saleh's cousin.

"What's the hospital in Abeche like? For example, how's the surgery service?"

"Well, let's put it this way, if 10 people are operated on, 5 will live, 5 will die. Plus, often people die in the hallways of the hospital without even being seen by a doctor or nurse because they have nothing."

That goes along with what I'd heard last week in N'Djamena from a German mid-wife working at an Orphanage in Abeche.

"A few weeks ago, during a single week, three women died during c-sections while still on the table. Most of our orphans are orphans because of their mothers dying in childbirth. It's not AIDS or the refugee crisis or the war...it's almost complete lack of health care during deliveries."

If you have money, you can get health care, it just might be a little sketchy. An old Arab man with a skull cap, white robe and a wizened face with years of smile wrinkles shows me his lab slip and prescription. He has malaria and a negative Typhoid test. He was prescribed Typhoid fever treatment anyway along with 5 other meds including quinine for malaria. The total was the equivalent of $50, more than a month's wage for most. To top it off, they hadn't even filled the prescription right as he showed me his malaria medication which was actually Chloroquine instead of the prescribed Quinine.

That night, a funeral next door allows all the local Imam wannabes to practice their oral recitation of the Koran...with a microphone and speakers. All night long until 6am the next morning we are alternately soothed by those who have the talent and annoyed by those who seem to be screeching like dying mules trying to sing the otherwise beautiful Arabic of the Koran. I sleep well anyway.

On the way back, Mahamat Saleh tells us a story:

A man gets up one morning to go to the market. He fishes his money out from under the mattress and sticks it in his pocket.

"I'm going to the market to buy a donkey" he says to his wife.

"Inshallah" she responds.

Halfway out the door he looks back at her. "Inshallah? If God wills it? What has God got to do with it? I've got my money in my pocket and there are plenty of donkeys at the market. I'm going to buy one. Keep your 'Inshallah' to yourself"

With that he slams the door and marches off. Halfway to the market, he is waylaid by bandits who tie him up and take his money. They leave him under a tree all day and when it's dark they release him and take off into the bush. The man makes his way slowly back to his house where he finds the door locked. He knocks on the door.

"Who's there?" His wife asks from inside.

"It's me. Open the door...inshallah!"

As I finally pull up into Bere after two straight days of traveling back from Abeche I'm reminded of the story. I pray silently that God will continue to open the doors for us to have a hospital there in Eastern Chad...INSHALLAH!

Snakebite

The sound of a load diesel motor and the sudden appearance of headlights outside the fence sucks me quickly out of a deep sleep into the darkness of a moonless Chadian night. The truck stops in front of the hospital. I have a feeling I might as well get up already.

Sure enough, within minutes, the all-too-familiar knock, knock, knock on the sheet metal door confirms my suspicions.

"Oui?" I mumble as I roll out of bed trying not to disturb Sarah.

"It's me." Sounds out from through the screen door and across the porch into the bedroom. It sounds like the night nurse, Augustin. I pull on some shorts, grab my glasses and fumble through the dark of the living room which is lit eerily by a blue bug lamp.

"They've just brought in a Fulani boy with a snake bite."

I arrive at the door and take the blue carnet from Augustin's outstretched arm.

"He's agitated and his leg is swollen."

"How long has it been."

"About two hours. They're camped out over by Lai and he went to get some water or something and was bit on the foot."

"How did they find a car at this hour?"

"They ran to Lai and found someone."

"Ok, give him a vial of anti-venom in 500cc of Ringer's. Let it run in over 30 minutes. There's not much else really to do. Either it'll work or it won't...oh, give him some Diazepam to calm him down."

"Ok." And Augustin disappears into the night.

I walk inside and pour some water into a canning jar which serves as my guide to make sure I drink at least 5 liters of water a day. As I stare out into the shadows of the yard my thoughts wander to the boy.

Should I go up to the hospital? Would it make a difference? Won't he just probably die anyway?

Then I start to think, of the two forces in this world, good and evil, which would want me to go up to the hospital and which would recommend I go back to sleep. It's a no brainer, so I put on scrubs, grab my keys and head up to the ER.

On the way I send up a quick prayer. "Whatever happens, make sure You get the glory. If I can pray with them, give me the chance so they'll recognize You as the One who heals."

I arrive in the ER and pull back the green and yellow curtain. Writhing on the bed in agony, looking like death warmed over is a slender, wiry nomad boy with dreads, traditional scarring on his face, leather fetish bags around his neck, string bracelets on his wrists and wild colored pants blood stained on the right leg. His right ankle is covered with blood-soaked gauze and the entire leg is swollen and already blistering.

He is moaning and non-responsive with gingival bleeding thrashing his legs and arms around from time to time.

A shaven headed man in a dark gray pant-suit and traditional tattoos and the obligatory leather pouches around the neck is remarkable amongst his people for the lack of dreads and the presence of a cell phone on a string around his neck and sticking out of his shirt pocket. He stands at the head of the bed. Squatting all around the ER are more men and several women with the crazy dreads and black, charcoal based lined tattoos on the face, arms and chest. Plastic shoes are standard. Another family member stands in a corner, the bottom of his left foot pushed against his inner right thigh as he balances on one foot like a flamingo.

Augustin arrives with the IV and we hold the boy's left arm still while the IV perfusion gets running.

"Give him an ampoule of Pentazocine sub-cue since obviously the Diazepam isn't enough."

As Augustin leaves to get the Pentazocine I motion to the Fulani men and speak to them in my broken Arabic.

"We pray to Allah. Allah give him health. Allah only. Ok?"

Heads nod vigorously in agreement as arms outstretch in the Muslim prayer position.

"Rabbina Allah! Give this boy health. Give this boy life. In the name of Isa al-Masih, Amin!"

As the simple prayer finishes our hands move to our faces to take in Allah's blessing as murmurs of "Shukran" and "Alhamdullilah" whisper around the sleeping, snake-bit boy. The bald man points to the sky and pronounces solemnly, "Allah only gives health and life. Allah only."

Augustin arrives and gives the Pentazocine.

I go to the OR and get a 60cc syringe. I draw up 20cc of Ringers and combine it with the 10cc of anti-venom and give it slow IV push over 10 minutes. Within minutes of starting the anti-venom, the gingival bleeding stops and the ankle bleeding slows down.

The boy is asleep now, thanks to the meds. In fact, he's gurgling. I show the Fulani man with the bald head how to do a jaw thrust to open his airway and the boy starts breathing easier. I keep reminding him to keep the airway open as he keeps getting distracted. Finally, he buckles down and gets it.

I tell Augustin to get some IV Chlorpheniramine ready in case he has an allergic reaction. He comes back to say that the pharmacy is out.

Just then, I notice some welts showing up on the boys arms and abdomen. I rush to the OR and come back with Adrenaline and Benadryl. We give him the shots. It seems to stop spreading. His heart is racing but he's still knocked out.

I go back to the OR into the stock room and find the Hydrocortisone we'd just finally found last week at the pharmacy in Lai. Augustin adds 100mg to the perfusion.

I stay by the boy's side often placing my hand on his chest to feel his heart beat and see if he has a fever. He's breathing is slow and shallow and without the constant pressure of his Fulani uncle's hands thrusting his lower jaw forward he would drown in his own saliva.

What I wouldn't give for an old foot powered suction pump!

The bleeding has all but stopped and the hives aren't spreading and, maybe it's my imagination, but they seem to be receding a little.

The Fulani faces around me seem to relax a little. They sense that he might live.

"Alhamdullilah!" I say and point skyward, "Allah only!"

I go home.

The next morning, the boy starts to wake up. We find he has malaria, after 3 more days of malaria treatment, he is eating, sitting up, moving around and the swelling in his leg has started to go down.

I bid them farewell after thanking God again one more time for saving his life.

James

Horses

It's a gray Saturday morning. 6:30 am and a cool breeze is blowing in a cloudy sky bringing out the deepness of the green starting to push up through the desert soil. The transformation of desert into lush grasslands has begun with the first rains. Stefan and I are going for a ride. Pepper and Bob are standing near the stables but Libby is nowhere to be found. I search the compound and finally find her standing under a tree staring blankly through the chain link fence across the soccer field into the horizon. I grab her halter. She resists briefly with her head pulled back before resigning herself to her fate.

I tie Bob up to the tree right outside the stables and grab the new, synthetic saddle someone just gave Sarah and cinch it up as tight as I can across Bob's ever increasing girth. He's getting so strong I'll use the bit today. I slide the beautifully worked leather and silver harness and bit into his mouth and squeeze it over his ears and attach it under his chin. I attach the saddle bags over Libby's rump and fill it with water bottles, and a French Bible and Nangere songbook. I place my left purpose into Bob's stirrup and swing up and into place.

We saunter up to the gate and out into the street. Most people are just waking up huddled around smoky leaf fires warming themselves up after a long "cold" night. Some are gathered around a pot of bouillie anticipating the temporary assuaging of the ever present hunger of the end of the dry season. We cross Bere and approach Bendele. Gary and Wendy's empty house stares at us from the left, it's gate locked with a padlock and it's windows barred. A heavy silence reigns.

A few meters up Noel's children wave and flash huge grins as they shout out the obligatory "lapia! James-uh! Stef-ahn!

Passing Noel's house takes us out of the village into the bush. The main road is packed with a steady procession of people on their way to market. Women in brightly colored wraps saunter along their arms swinging in rhyme keeping in balance on their heads the large basins filled with sweet potatoes, sugar, millet, rice, corn, bean leaves and other marketable items. An ox cart plods slowly by loaded with sacks of grain, a few young kids piled on top and one lazily sitting across the pulling bar with a stick in hand to swat the two long-horned cows into the right direction. More women pass, long piles of twisted sticks cut into six feet lengths, tied and bundled onto their heads. Old and young mix in a never ending procession heading for the biggest event of the week, the Bere market.

Further up, we enter a small village where some of the travelers have stopped under a mango tree gathering around a large pot of freshly prepared rice wine to fill their bellies for the exhausting trip to Bere on foot and to prepare themselves for the social scene and eventually a staggering stumble home, dead drunk. They wave wildly their faces lighting up with white, toothy grins as we pass and call out our greetings.

I've switched to Libbly now, as Stefan was having some troubles controlling her. We've been trotting for a while when an open stretch of road heading to Dabague opens up before us. I give a cluck and a kick with my heels and Libby is off on a fast gallop. She's our newest addition to the stables and like Pepper and Bob came to us at a good price thanks to her malnourishment. When Sarah walked her back from the Arab village where we bought her, she could barely do 5 kilometers at a slow walk. Now that she's put on some weight and become one of the friendliest horses around I want to see if she can run and if she's at all competitive.

I'm in front for a while before Bob catches up and barely passes us. Libby picks up speed a little but seems content to stay with Bob and not pass him. Alternately walking, trotting and galloping the 18 kilometers to Delbian pass quickly accompanied by a thousand "Lapias" and "As-salaam alekums".

We tie up Libby and Bob near some grass while a short man with a limp brings a bucket, fills it at the local water pump and gives the horses a much needed drink. We take off the saddle bags and saddles and hang them over mango tree branches out of the reach of curious little hands. I get to tell the story of David and Goliath to a group of kids where practically every other boy his carrying his own sling and sheep are grazing in the background. The story of a shepherd boy killing a giant with a stone and sling has never seemed more real.

I then am told by Noel that I'll be preaching so I pull out of my past the sermon I borrowed from the Pineapple Story guy about God loving impossibilities in using Gideon and 300 men to fight off an army of 135,000; Elijah taking on 400 prophets of Baal on a mountain and God burning up the wet wood, bull, stone and earth with fire from the sky; and Daniel's three friends being saved from a fiery furnace heated up seven times hotter.

In a surprising lack of African hospitality, Stefan and I are allowed to escape the usually obligatory millet paste and slime sauce meal and head back to Bere. Just outside of Dabegue, we come across three young boys bareback on tiny ponies herding cattle. As we trot past, one of them turns and starts running alongside heading towards the road. He wants to race! I cluck loudly and give a big kick to Libby's flanks and she almost shoots out from under me as she pushes to catch the pony. Within seconds we pull even and leave the surprisingly fast pony in the dust. Entering Dabegue we tear around puddles of water, under trees and around people scampering to get out of the way. I'd seen Stefan gunning Bob and was sure he'd catch us by now. I quickly over my shoulder and he's nowhere to be found. A commanding "whoa", a sharp pull on the reins and a lean back with all my force and Libby stops dead in her tracks.

Stefan finally catches up explaining that he lost his hat as Bob sprung forward to enter the race. We continue trotting and walking until we are about 5 kilometers from Bere.

"Let's race Bob and Libby. I want to really see what she can do. See that tree to the left just beyond that puddle? It'll be a walk up start. As soon as we enter the shadow of the tree, the race starts."

I feel my heart beat pick up as the tree approaches and we try to keep the horses even. It's a slow walk up. We're only a few feet away. The horses start to sense our excitement...and...we're there. Libby seems to have been expecting it as she rockets forward almost pulling my feet out of the stirrups. I'm holding on for dear life. We're ahead! I then see Bob cut around a little to the left where a side path goes around some bushes. He's picking up speed. At the same time I feel Libby fading, she's just not in shape and running out of energy. Bob leaves us way behind as we continue a slow gallop to the entrance to Bere and do a cool-down walk the rest of the way home.

As i finally pull myself out of the saddle, I can't believe how tired I am. I'm so wobbly I cna barely stay a foot. I'm covered with sweat and fine dust. The horses slurp up bucketfuls of water and then go for a roll as soon as their saddles are off. I take a quick shower and fall into a deep sleep before being awakened shortly by the nurse on duty.

"There's a woman with high blood pressure and seizures. She's seven months pregnant. The cervix is completely dilated."

I give some instructions and go back down to lay down, but then think better of it and get up, put on scrubs and head to the hospital.

The woman is thrashing around on the bed moaning and whining. The cervix is only at three centimeters. We start an oxytocin drip to give her better contractions and I go to see some other patients. The nurse runs to get me.

"She's having a crisis again!"

I enter the labor and delivery room. The husband is at the bed side and the woman is hysterical. It's not a seizure, though, and she quickly calms down when the husband leaves. I order some pain medication and then she has a grand mal seizure. We hurry her to the OR. Luckily Simeon is there and Samedi lives right next door. The woman is combative and agitated and difficult to get on the OR table. We tie her arms and legs down good, prep the abdomen, scrub and gown and drape.

We pray and Simeon gives one milliliter of Ketamine and I slice down to fascia, rip the fascia and muscles open, lift up a bladder flap, slice into the uterus, poke into the amniotic sac and squeeze out a full term baby boy who after a little rubbing and slapping starts to give a healthy cry. I suture up the uterus and skin and head home to finally rest.

James

Only God Knows

I've just started rounds on surgery. The young girl operated on for perforated bowel secondary to Typhoid Fever is doing much better. She still has a drain in and we're doing dressing changes on the open wound on her skin incision but she's eating, drinking, walking, pooping and peeing so we are otherwise happy. Suddenly, Carson comes in and in his slow drawl tells me they need me to help find an IV on a kid...it's kind of urgent.

I walk through the open screen door, across the porch covered with convalescing patients and family members lying on colorful mats, across the well-swept courtyard and over to the sidewalk where a small crowd has gathered around a mother with a brightly colored head wrap holding a limp child sitting on a wooden chair facing away from me and towards the white coated nurse bent closely over the child trying to start an IV. It's the new nurse, Tchiptchang. Standing to the side, muscles bulging out of his scrubs, Abel holds a bottle of 5% glucose attached to an IV line waiting for the chance to attach it to a venous access.

I'm quickly filled in as I stride up.

"Really low blood sugar. Sick for a week. Treated at home with market meds and who knows what else. Just came in. Unconscious. We can't get an IV."

The kid's eyes are rolled back in his head. His hands and face are pale. His body is like a rag doll. I listen and he has a faint heart beat. He's barely breathing.

"Let's get him to the OR!"

We rush off around the corner and into the brightly lit OR prep room. We place the child on a gurney and I start doing chest compressions. Abel and Tchiptchang are trying to find a scalp vein. Carson is holding the IV which we have placed subcutaneously on his abdomen which is swelling up. He remains unconscious. I suggest they try and external jugular vein on his neck. Augustin arrives and tries as well. No success. I try a femoral vein on both sides while Abel and Carson take turns doing CPR. I fail on both sides.

The nurses keep trying on the scalp and neck. No luck. I call for another hemoglobin as I can't believe the first one is really 10. He looks too pale. His heart is still beating, though barely. We keep on CPR. He's about 2 1/2 years old. His mom stands in the background, a helpless and hopeless expression on her face. She's probably thinking of all the other small boys she's seen buried in her life and thinking about probably burying hers today.

I'm thinking back to the 4 year old I was just doing similar, unsuccessful, resuscitation efforts on last week. I'm about ready to stop. The hemoglobin comes back 8. We keep on CPR. The nurses keep trying to find an IV. I finally try the right femoral vein again.

I stretch out the skin on his inner thigh. I feel for a pulse but find nothing. I poke blindly with a 22G IV catheter attached to a syringe I aspirate from. I get some dark blood back. I can't really thread the catheter. I take out the needle. No blood. I slowly pull it back until the blood starts to ooze out. I call for the IV tubing and attach the 5% glucose solution and hold the IV to let it run in fast. We tape it down but someone has to hold it just so in order for it to work. Within 30 seconds, the boy's eyes open. A few seconds later he's looking around and starting to move his limbs. He has a strong heart beat and is breathing!

We give him some oral sugar water and show the mom how to keep giving him that all day long.

We let the glucose run in. The nurses finally find a real IV and we start treatment for malaria. Why do some make it and some don't? Only God knows.

James

Coffin

When I first saw the coffin it was half-finished. Lying amidst a pile of saw dust, it was a crude little thing, but somehow appropriate. Hard, twisted redwood had somehow been fashioned into a 3 foot long box with bottom, back and sides just waiting for the front and top to be able to enclose a little boy's body.

As I walk up to the container where Jeremy and Jonathan are making the coffin, I am struck by the cold beauty of the surroundings. A steel blue sky with gray angry clouds releases a slight drizzle of rain onto the African plain watering the wet sand and scrub bushes. A smattering of mango and Shea butter trees break up the monotony of the flat expanse. A group of tired grave diggers rest against the trunk of a tree to the right. Straight ahead is the beginnings of Gary's airplane hangar with the two old 20 foot containers making up the end of the hangar. Around the half-open doors of one container is gathered a crowd of mostly children with a smattering of adults all peering intently at the two white men making a coffin.

The purr of a small Honda generator is broken intermittently by the harsh roar of a power saw and the shocking pounding of large nails into hard wood. A cool breeze tries to soften the atmosphere which is heavy with grief. I squeeze through the crowd just in time to help Jeremy and Jonathan lift up the coffin, measure around and make the final trimmings. The wood is so hard that holes have to be drilled before nailing or the nails will bend. We place the small head piece on and Jeremy hammers the nails home. The only thing left is to place a small boy, recently alive and well, into the interior and hammer it shut until resurrection day.

The Adventist Youth Society has arrived in their sharp olive and tan uniforms. Jeremy, Jonathan and a couple of local men pick up the heavy burial box and lug it over to Gary and Wendy's humble abode. They place the casket gently on a simple wooden bed on the porch and wait for the final step.

Cherise, Gary and Wendy's two and a half year old daughter, runs in with a smile proudly showing off the cartoonish horse and car that Sarah has drawn on the back of her hands with a green marker.

It's almost time. Neighbors and friends are gathering outside. The rain continues to sprinkle the event as lighting flashes occasionally in the background. Gary looks at me. We walk silently over to the coffin and pick it up. It's rough and twisted wood bites into my hands with the weight of it's import crushing me more than it's physical gravitational force.

Followed by Wendy and Cherise we enter the house, pass through the living room and into the bedroom to the left where Caleb awaits, cold and silent. He is peacefully lying on the floor next to the two mosquito net covered mattresses where he slept with his sister. A small, baby blanket covers most of his lifeless form. Gary and I gently set the coffin down next to him. Gary lifts him up while Wendy arranges the blanket and smoothes it out over his face. Gary picks him up gently in his arms, tears streaming from his red and swollen eyes.

"Let me hold him one more time." Wendy's voice is deep and broken as she hugs her first born son for the last time on this earth.

"Cherise, do you want to kiss Caleb one more time?"; Gary asks softly.

"Yeah, daddy..."; She approaches wiping away a stray strand of pure, blond hair from her cherubic face. She leans forward, lips puckered, and places a tiny kiss on the top of Caleb's pale head.

Gary covers Caleb up again and lays him in the coffin. He fits too well. This shouldn't be happening. I sob quietly, letting the tears flow freely.

We take the even heavier coffin out to the porch where Jeremy expertly pounds the last nails home with a devastating sound of finality. It's definitely time now.

The uniformed young people wait outside. Gary and I place the coffin on the shoulders of six young Chadian girls who will bear the honors.

"Left, left, left-right-left..."; The solemn march begins as we all fall in behind while the young people sing a mournfully echoing marching song about following Jesus no matter the cost. The procession winds out the gate, around the fence, past the water tower and out towards the airstrip.

Gary's plane stares silently, it's windows covered with a tarp as if even it is too grief-stricken to observe the final steps of the young boy who loved so much to greet his daddy's return from mission flights or climb all over the cockpit dreaming of the day when he too would fly.

We march across the deep red laterite surface of the airstrip, cross a sandy path, pass through some low scrub brush and arrive at the six foot deep hole that will be Caleb's resting site until the end of the world. A pile of sandy clay with two hand made ropes strung across it lays to the side of the grave. The coffin is marched around the hole and deposited carefully on top of the ropes and dirt pile. A crowd has gathered. The wind blows. The rain falls. The universe mourns.

The service starts with a couple of French hymns that have never had much meaning for me until now.

"Jusqu'a la mort, c'est notre cri de guerre, le libre cri d'un peuple rachete, jusqu'a la mort nous te serons fideles..."; (Even unto death, it's our battle cry, the free cry of a redeemed people, even unto death we will be faithful...) Even song off tune the deep feeling of those singing it penetrates to the bottom of my heart. We are free, we are at war, their are casulties, but we don't mourn as those who have no hope...we will stay faithful...my heart wants to believe it.

"Et mon coeur n'a rien a craindre, puisque tu me conduiras. Je te suivrai sans me plaindre en m'appuyant sur ton bras." (And my heart has nothing to fear, because You are guiding me. I will follow You without complaint, leaning on your arm). A cold chill runs down my spine as I feel the presence of God. He is present. He weeps with us at this tragedy. We have nothing to fear.

After I give opening prayer, Andre exhorts us with a little eulogy reminding us that death is a sleep, that our hope is in the resurrection when Jesus comes again to reunite all of us who have abandoned our rebellion against him. Caleb's suffering is over, it's those of us left on earth who suffer, but Jesus is coming soon to wipe every tear from our eyes and destroy our last enemy, death.

Then, Gary talks about how much Caleb loved to talk about Jesus and his second coming and then he had us sing together Caleb's favorite song in English:

"When the trumpet of the Lord shall sound, and time shall be no more...when the roll is called up yonder I'll be there!";

Unfortunately, as the local gravediggers go to lay the coffin in the tomb they realize they've made the hole too small. As they rush to and fro quickly to dig the grave larger, the chorale saves the day with a some traditional, echo and repeat style African songs. Finally, the modifications are made and the coffin is slowly lowered into it's final resting place with the help of the rough ropes.

As the dirt starts to be shoveled on top of the coffin, Cherise seems to realize a little what's going on. Her heart-breaking cries and tears tear us all apart. Gary crouches down gently beside her.

"What is Caleb doing right now?";

"Sleeping, daddy."

"And when will he wake up."

"Oh yeah, when Jesus comes." Her face lights up a little and she wipes her eyes as Wendy picks her up and holds her close.

As the crowd starts spontaneously singing in Nangjere, the grave-diggers expertly create the funeral mound. A handmade hoe, a stick and the end of a shovel pound and stir the earth into place as two other men shovel the earth in and continually pick up what has fallen to the sides. Then with some final pounding with the flats of the shovels a perfectly oval mound arises as only those who've seen much death and assisted many funerals could make it.

We then turn to follow the Advent Youth as they lead us back singing the same marching songs. Arriving at the house, we follow local custom by seating Gary, Wendy and Cherise in lounge chairs along with the other participants in the memorial service while the mourners pass one by one to greet. The women curtsy and bow while solemnly shaking hands, often with two hands or the second hand touching the forearm of the right hand as they shake as a sign of respect. The men shuffle and nod somberly as they hold the hands for a long time and silently let you know they feel your loss (and they all have lost children so it means something). One crippled man on crutches hobbles in and hugs both parents while tears stream down his cheeks.

Finally, the kids file in for their respectful shaking of hands as the adults take a seat on mats spread out behind the choral which has been singing French hymns without ceasing. Annie and some of the local women serve Kool-Aid. People quietly converse. Occasional sobs burst forth. Laughter is sometimes heard. Gary and Wendy are periodically called away by phone calls from well-wishers around the world.

Dusk approaches. Noel rises and calls an end to the wake with a prayer. They graciously don't insist on their custom of singing, dancing and drumming all night long. Instead, everyone files solemnly out shaking our hands one last time. About this time, Rich and Anne, our friends from N'Djamena arrive.

The sun sets on a day that started out as any other day and quickly tumbled into an early morning ER call, a desperate last ditch effort and the laying to rest of a four year old boy in a crude, twisted coffin, resting peacefully in the African bush through the rest of this world's turmoil until the end of the world and the beginning of the next when God will wipe every tear from our eyes and our last enemy death will die as we all are reunited with those we have lost.

James