Homemade guns

>
> "There's a guy in the ER with what looks like a bullet sticking out
> of his face." Franklin told me casually, as if commenting on the
> weather.
>
> "A bullet? Is he stable?" I reply.
>
> "Oh yeah, he's fully conscious, sitting up, talking. He walked in.
> Apparently he was hunting and the rifle backfired or something and
> the bullet went into his right cheek. He came from quite a
> distance. I think it even may have happened yesterday...my French
> isn't that good."
>
> "But it's not too emergent?"
>
> "No, I think it can wait."
>

Mad

>
> This has been one of my worst days yet. Believe me, I've had my
> share of them. But this definitely ranks (as in stinks) up there
> with the "best" of them.
>
> I could find plenty of excuses for my behavior. For example, we've
> done more surgeries the last 3 weeks than the last 2 months combined
> (including one 7 day stretch where we did 46 major operations). Or
> I could cite the fact that I've had amebic dysentery for the first
> time over the weekend making me feel nauseated, anorexic, fatigued
> and generally miserable for three days.
>
> But I'm tired of excuses, that's all I hear all day long and that's
> what started this day off so badly.
>
> "Enock left at six without giving sign-out, but he said he HAD to go
> to Kelo."
>
> "We don't know why the kid didn't get his blood transfusion, Enock
> left for Kelo and didn't tell us."
>
> "The father left four days ago. He said he'd be back with
> provisions and to donate his blood, but he hasn't come back. Can we
> go home now?"
>
> "Ma'am, your child has a hemoglobin of 3.3, he'll die if he doesn't
> get that blood, besides you've already paid for it anyway and the
> father has the same blood type."
>
> "But he's gone home. It's far away. We have no money."
>
> "Madame, do I need to remind you that you don't have to pay anything
> and we'll find one of our staff to give."
>
> "But my husband isn't here, he went home to...." I cut her off in
> midsentence. Michelle gives blood and soon the child is on his way
> back to health.
>
> "I don't know why this guy's still in the ER. I wasn't the one who
> hospitalized him 4 days ago."
>
> "Haven't you had a night shift and a couple of ER shifts since
> then? You just let him stay even though his wounds were sutured and
> they weren't severe enough for him to need to be hospitalized? What
> about his relative who was also beat up who didn't even need
> sutures? He's also occupied a bed for 4 days in the ER."
>
> As we inform the two nomads who had been beaten up because they
> tried to steal rice and then cut off a guys arm who tried to defend
> his rice, as we tell them they have to leave the hospital now they
> start muttering under their breath.
>
> "YOU didn't do anything for us! Four days in the hospital and
> nothing!"
>
> "What about the 4 wounds we sutured closed and the pills that you
> have been taking and still have?"
>
> "But we didn't get any IVs or shots or anything. Next time, we're
> going to the hospital in Lai!"
>
> "Doctor, the patient is writhing in pain!"
>
> "I have his carnet here for an ultrasound."
>
> "But he's really in bad shape!"
>
> I go outside, a barefoot man covered in dust is standing calmly to
> the side. We walk him over to the ER where I can examine him. I
> look in the carnet, nothing written except abdominal pain. The plan
> is to have him see the doctor and get an ultrasound.
>
> "Ok, let's find out more about his pain."
>
> I start to ask questions but none of the nurses know his dialect.
> They call in a translator who starts translating. It's pain-
> staking. I'm frustrated and walk out yelling over my shoulders.
>
> "Find out all you can about his pain and then come see me!"
>
> Somehow, before I can even get back to my office to do other
> ultrasounds, Sarah is there to present me with the same man's
> carnet. The nurse had managed to stop doing what I asked almost
> before I started and somehow managed to bypass me to get to Sarah
> before I could walk the short distance from the ER to my office.
>
> I storm back yelling at anyone and everyone in my path. I'm totally
> out of control.
>
> A small sampling of my day is sufficient. Needless to say, I'm
> pretty much yelling and shouting and flailing and insulting and
> making a fool of myself all day long.
>
> I get called back to the ER. A man with abdominal pain for 5 days.
> He hasn't pooped in five days either. No vomiting, he ate some
> porridge yesterday but didn't feel like it today. He's lying
> comfortably on the bed. Sounds like constipation to me. A real
> problem here. He has a fever so probably has associated malaria. I
> tell the nurse to prescribe quinine and treat his constipation. As
> I'm about to move on a small urging tells me to examine him more
> closely. I can't explain why. A still, small voice perhaps.
>
> I bend over him. His belly doesn't look too swollen. NOthing you
> wouldn't expect from constipation. If he had a bowel obstruction or
> appendicitis he would've been vomiting by now after 5 days. I push
> and tap. Somewhat tender but doesn't seem to have peritoneal
> signs. I'm still not satisfied. Something inside says that my
> initial impression is wrong. I get a glove and stick my finger up
> his butt. He's more tender on the right side than the left. Maybe
> he does have something.
>
> I decide to operate.
>
> Sarah calls me when the spinal has been done and Samedi and Abel
> have scrubbed and draped the patient.
>
> I enter the OR and notice a pool of yellow fluid on the right side
> of the patient next to the OR table on the floor.
>
> "What's that?"
>
> "Maybe his foley has come out."
>
> Samedi lifts up the sterile drape so we can look. I pull back
> instinctively as I see a huge puddle of liquid stool with floaters
> between his legs. It's been dripping down the drape to the ground.
>
> "Well, I guess it was constipation after all! Looks like the
> relaxation from the spinal was all he needed."
>
> I turn to walk out of the OR. Again, something deep within,
> something that has almost been repressed from my full day of self-
> righteous, angry behavior, that little something makes me turn
> around and speak to Samedi.
>
> "Well, since he's already anesthetized and prepped, we might as well
> have a quick look around inside his belly."
>
> "C'est bon." Samedi nods in agreement. I go outside and scrub.
>
> As I open the belly, nothing jumps out immediately. The intestines
> aren't swollen or inflamed. There's no rush of blood, pus or
> fluid. I start to poke around inside. I"m looking for the appendix
> on the right. I can't find it. Everything looks ok...boom...out
> gushes some thick pus. I open the incision for better exposure and
> peel away the inflamed bowel. With a scoop and a flick of my index
> finger, the ugly looking appendix pops into the surgical field. An
> obvious perforation is at it's tip.
>
> I remove the appendix, irrigate and aspirate the abdomen, place a
> drain and close up.
>
> I spend the rest of the afternoon and evening listening to the night
> shift team bombard me with questions about things the morning team
> didn't do or follow up on and seeing two patients that don't want to
> heal and keep having stool come out of places it shouldn't and
> wondering what I'm going to do as I pass hours in the prep room with
> Samedi, Sarah, Abel and Abre searching for IV access on two infants
> with anemia needing blood transfusions. I spend most of the time
> yelling and throwing things as I can't find the vein or can't thread
> the catheter. Finally, Samedi gets the last one in.
>
> "Halleluia!" I shout and try to go home.
>
> As I close up my office, Rosine is there looking at me sweetly as
> she innocently asks, "Can you help us find an IV? We've been
> searching all afternoon and the kid needs blood..."
>
> How could she have known what she did as I bite her head off with a
> snarl.
>
> "Don't bug me with that. That's not my specialty. I don't find IVs
> very well. That's nurses work. Go find someone else and what ever
> you do, don't call me!"
>
> I go home. As I walk through the door I pause and sobs begin to
> wrack my body. I am filled with anger that want's to explode out of
> me. I don't want it but it's there. I feel betrayed, overwhelmed
> and extremely ashamed of my behavior today.
>
> In spite of this, somehow God spoke to me and made me save a man's
> life instead of relying on my own skills which would've sent a
> perforated appendicitis home to die with a couple of laxatives.
>
> I think I'll ask for forgiveness tomorrow.
>
>

Premature

>
> I was forced to put in earplugs. I'd tried to think happy
> thoughts. I focused on the pleasant night sounds. In the end, I
> couldn't sleep. The pounding of the drums, not the simple happy
> rhythm of the children singing silly songs in the moon light, but a
> deep, dark, forbidding thumping accompanied by mournful howling,
> this sound I couldn't sleep to. It sent chills down to my entrails
> leaving me feeling ugly and used. The earplugs helped...too much.
> The next thing I know, Sarah is tugging me awake out of the deepness
> of a pleasant unconsciousness into the darkness and chill of an
> early Tchadian morning. It's 3:30AM and Samedi is at the door. I
> stumble over to the screen while pulling on an old pair of scrub
> pants.
>
> "Yeah?"
>
> "Docteur, there's a woman referred from the health center. She's
> seven months pregnant and bleeding. Her skirt is soaked in blood
> but her vital signs are stable for the moment."
>
> "Ok, start an IV, give her ampicilline, place a foley and prepare
> her for a c-section. Call Simeon and Abel. Oh, give her 10mg of
> Dexamethasone IM, first thing. Call me when she's ready."
>
> Earplugs back in, I'm soon back in la-la land. This time my slumber
> is not as profound. It's as if something in my conscious is trying
> to break through. I wonder why I'm still sleeping. Why haven't
> they got me? I get up and pull on a scrub shirt to go with the
> pants I'm still wearing. It's 5AM. I walk up to the hospital as
> the first light of dawn barely illumines my path through the mango
> trees and over the sand covered in horse dung. Even from a distance
> I can see the lights in the OR are on.
>
> I arrive and the woman is still in the delivery room. We bring her
> to the OR, turn on the generator and Samedi scrubs while I shave and
> prep the abdomen. After a spinal anesthetic, the woman is placed
> supine and I scrub as well. After a short prayer I take the large
> scalpel blade and cut into her abdomen cutting the fascia and
> tearing the muscle and peritoneum apart to get to the uterus. After
> deflecting the bladder away, I nick the uterus with the scalpel and
> push a curved clamp inside releasing a fountain of clear amniotic
> fluid. As suspected, she has a placenta previa where the placenta
> covers the exit and starts to bleed profusely when labor starts.
>
> I reach my hand inside the uterus and find a tiny little head way
> high above the placenta. Samedi pushes and the tiny, premature
> infant slips into the world. She grimaces and flexes her arms and
> legs. Her skin is underdeveloped and translucent revealing all her
> underlying blood vessels. Samedi clamps the cord, I cut it and we
> hand the little girl to Abel. We soon here a shrill little scream
> as the girl opens her lungs to that life giving oxygen. As I suture
> the uterus closed I have Abel turn off the fan in the OR and cover
> the baby up. We have no baby warmer and I'm afraid she'll get cold.
>
> I finish sewing up the skin and I take of my gown, clean up the
> blood and mess around the woman and go see the newborn.
>
> She's cold and has a slow heart beat. I pump her chest a few times
> and the heart beat comes back up. I put a tube in her nose and give
> her some glucose water. I have Abel go tell the family to boil some
> water. We'll heat her up that way. Meanwhile I pick up the tiny
> form that fits easily in my two hands and place her naked body
> against my stomach under my shirt. I'll use my own body heat to
> warm her. After a few minutes I feel a response. She starts to
> move more and make some weak cries. I pull out the feeding tube and
> suction out her mouth and nose as she's regurgitated some of the
> glucose water. I feel her stretch her tiny feet against my belly.
> Her hands are grasping. She's reflexively searching for her
> mother's milk. I curl her up in a ball and hold her close flipping
> her around like a burger on the grill to make sure she gets cooked
> on both sides.
>
> I go out to check on the hot water several times and the family says
> everytime that it's ready but it never is. Finally, I can't wait.
> The morning chill is too much. I take her home, held tight against
> me under my flimsy scrub shirt covered with a woman's wrap around
> skirt the family gave me. I knock on Tammy and Jamie's door. Tammy
> lets me in and when I explain quickly heats up water as Cory and
> Brichelle come to help. We put hot, but not scalding water in a
> plastic basin and put the girl in. She seems to like it and kicks
> and stretches. She's breathing well and has a strong heartbeat.
> Her limbs are quickly warmed up as we replenish the hot water
> supply. I gently hold her head up so her mouth and nose stay in the
> air to gulp down that important oxygen.
>

Perforation

>
> It must be bad. They only call me out of church for real
> emergencies. I gather my books and walk out on the dusty dirt floor
> to a bright late Tchadian morning. Noel and Pierre are waiting for
> me. I don't see a nurse anywhere. What's going on?
>
> "Abel's in-laws have just informed him that his fiancee will come to
> him tonight to become his wife. He has nothing to prepare a wedding
> with but wonders if we'll do a dedication for him in church."
>
> After much discussion it is decided that the women of the church
> will prepare a goat that I will provide and we'll do a wedding
> ceremony at his house tomorrow evening. He has no family here, so
> we will be his family.
>
> That afternoon, I'm too tired to go to the river. It's a good
> thing. Tchibtchang comes calling with the traditional "clap-clap"
> at my door.
>
> "There's a father who brought his son in for a blood transfusion for
> severe anemia and malaria. After we drew his blood to give to his
> child, he told us his hernia popped out in route on the motorcycle.
> We can't get it back in."
>
> I accompany him to the hospital and see Simeon and Abel already
> waiting.
>
> "Aren't you supposed to be preparing to receive your bride tonight?"
>
> Abel chuckles loudly with a huge, toothy grin. "No, tonight she
> comes to my house but I'm not supposed to be there until tomorrow
> night...so here I am!"
>
> A quick look reveals that this hernia is not going to be reduced
> without surgery.
>
> Just then Augustin One comes in. "There's a guy who's been gored in
> the butt by a bull."
>
> "Ok, bring him over." I take a look and fortunately the gore wound
> is to the side and back of the anus missing the intestines. It's
> pretty deep though so I order antibiotics and we prepare for the
> hernia.
>
> Simeon gives the spinal anesthetic while Abel scrubs. I prepare the
> surgical field with Betadine and then scrub. Abel puts my gown on
> and snaps my gloves into place. A few scalpel strokes later and we
> see a dark mass of intestines. I open the sack and there is already
> some dark, coagulated blood in the mesentery but the intestines
> still look viable. I push the squishy, slippery mass of bowel back
> into the abdomen and close the sack. He also has a hydrocele and
> since his left nut is good I take out the hydrocele, testicle and
> all. I sew a piece of mosquito net over the weak spot in the muscle
> and close the skin.
>
> The man with the anal wound is stoic. I give him local anesthesia
> and close the wound in four layers leaving the skin loosely
> approximated. I tell him to soak in salt baths four times a day and
> go home.
>
> Later that evening, Augustin One asks me to see a little girl who
> was treated here a month ago for malaria. She now has abdominal
> swelling. I approach the bed in pediatrics and see a thin little
> six year old with bright eyes who looks tired but not too acutely
> ill. Her belly seems slightly swollen but is soft and non-tender.
> She has diarrhea so I put her on Chloramphenicol and Metronidazole
> and go home.
>
> The next day, Sunday, I lazily do rounds around noon. Melodie asks
> me to see a girl on pediatrics she feels isn't doing well. Her
> glucose is a little low but she's awake. She just doesn't want to
> eat. It's the same girl I saw last night. She is alert but refuses
> to eat. The diarrhea has all but stopped but her belly seems more
> swollen. I examine her and the belly is soft and she doesn't flinch
> or anything when I touch her. I look in her face and something in
> her gaze tells me there's something serious going on. I feel a
> strong impression that I should operate on her. I feel bad because
> this means I'll probably miss Abel's wedding. I tell the father and
> he agrees. Koumabas calls in Simeon and Samedi.
>
> In the OR, Samedi has already scrubbed and the little girl is lying
> resignedly on the operating table. I feel a sudden panic. Why am I
> operating on her? Maybe she has abdominal TB. I run to my office
> and bring in the portable ultrasound. The images reveal a full
> bladder and a lot of stool but no intra-abdominal fluid. Well at
> least it's not abdominal TB. I'm still uncertain but feel committed
> now to the operation. I scrub and join Samedi at the surgical field.
>
> We all bow our heads and I pray in French "God, we're not sure
> what's going on with this girl. We just pray we are doing the right
> thing. Help this operation to be a success and this little girl to
> recover her health completely afterwards."
>
> I cut through the skin and fascia below the belly button. The
> peritoneum seems thickened and I'm not sure if the intestine is
> stuck. I enlarge the incision to above the belly button and make it
> into the abdominal cavity. A gush of liquid stool spurts out under
> pressure as we try to suck it up. I'm at first afraid I've
> punctured the bowel but as the stool spills everywhere over the
> surgical drapes I soon see that she must have had a perforated
> intestine. I can't believe she didn't have pain but am relieved we
> decided to operate. Samedi sucks out the stool as we irrigate and
> search for the damaged section. My finger digs into an inflammatory
> mass and a clump of green, peat moss looking stool slithers out.
> We've found the hole. I pull out the mass, clamp and cut it out.
> It's in the distal ileum. I then suture the two parts of good
> intestine back together, rinse out the belly with liters of fluid,
> put in two drains and close the fascia and partially close the skin.
>

Games Tchadians Play

The woman is in the OR for emergency surgery. Sarah comes to inform me that the family has only paid 15,000 francs ($30) of the 25,000 francs ($50) required. I tell Samedi and Abel to hold on. I'll see about that. I slip off my OR shoes and into my crocs, slide my mask down my face, push open the screen door and put my game face on.

As I approach the beacon of light coming out of the pharmacy window in an otherwise dark ad building I see a tall, lanky Tchadian in a dark tan matching pants and short-sleeved button down shirt. He slowly turns at the noise of my entrance and looks me up and down. His face is familiar. He's one of the former teachers at our elementary school. His name is Amos (pronounced Ah-moh). I can tell he's sizing me up. Let the games begin.

With a look of disdain on my face I march up to Amos. "What's the meaning of this? I hear you haven't paid for the surgery yet!"

Amos looks at me with a shocked and hurt look on his face. "What do you mean? I've just paid 10,000 francs."

I look at the pharmacist, Koumabas, who nods with his goofy half grin. He's enjoying the match.

I turn back to Amos in feigned disgust. "Do you realize that you should pay 25,000 francs. Do you think 10,000 is equal to 25,000? Aren't you a teacher? That's basic math!"

Amos responds coolly without blinking. "Oh it's ok. I'll just pay the rest tomorrow. Go ahead and do the surgery. You can trust me."

I laugh caustically. "Everyone says that but we've found that if they don't pay before the surgery they never pay after. Find a solution!" I pretend to turn away.

"But we're different. Maybe other people don't pay, but we will. You know us."

"Yes, I do. That's why you need to pay ahead of time. Look, we want to save your sister's life. We're ready to operate. We're only waiting on you!" I've played my trump card. Out of the corner of my eye I see Koumabas nod approvingly. He's enjoying this immensely.

"Ok ok." Amos pretends to concede defeat. "I have my bicycle outside. Can I just leave that as collateral to prove I'll pay later?"

"Let's see it." Amos quickly drags in a rusty, bent and twisted carcass of a bike with missing pedals and a torn up seat.

"Here it is." Amos smiles smugly, sure he's won.

Koumabas just shakes his head and chuckles. "Ca la! No way. That's worth 10,000 francs at best! That's not enough!" I've found a tag team partner in this traditional Tchadian sport.

I narrow my eyes, fixing them on Amos. "Don't you have a cell phone? You could leave that as collateral as well and then we can get going on saving your sister's life. We're only waiting on you, you know!"

Amos looks shocked. "I don't have a cell phone. I'm just a poor teacher." He looks like a puppy with his tail between his legs begging for bread at the table.

I turn away again. "Oh well, I guess we'll just have to wait. We're all ready and everything. Just waiting on you." I fold my arms across my chest and lean casually against the wall.

"Ok, ok." Amos starts to lose his composure. "David, come quickly!" Our night watchman comes in and extends his hand towards Amos holding a tiny cell phone in his outstretched palm.

"David, is that yours?" I ask. I don't want Amos to cop out by forcing our staff to cover for him. I won't lose that easily.

"No, no. It's mine." Amos doesn't even blink at the outright lie he just told me. But then again, I haven't exactly been telling the whole truth either.

"Thanks, Amos, you did the right thing." As I turn to leave I stop and look back. "By the way, I've already done my part. We've finished the operation and took out the twisted ovary with its tumor. She's doing fine and just waiting for you to come out of surgery. Too bad I had to play this game to get you to do your part."

Ah yeah, victory is always sweet in this Tchadian game of bluffing and bargaining. Poker's got nothing on it.

Poop

Silently the man slips stealthily through the shadows of a dark Chadian night. The Bere Adventist Hospital has become his temporary domain. His child is hospitalized for severe malaria and a blood transfusion is slowly dripping life back into his fever wracked body. The man has sinister motives. He really needs to go.

The hospital has had trouble for years with patients relieving themselves in piles on the ground in the tradition of the African bush. Despite the availability of latrines, the smell and foreignness of the cement structures is revolting to someone used to the pleasant peacefulness of natural surroundings and soft grass or sand. In the 90's a resourceful night watchman named Jairus made successful war on the perpetrators by taking the pile in a rubber gloved hand and moving from bed to bed wiping some of the stool on each bed until someone confessed or turned in the guilty party who then had to go out and bury the leftover turds.

The problem only got worse with the building of a fence around the hospital in 2004.

Now, this evening, maybe the tide will turn as our unknown man makes his way quietly past the operating theater to the outside water faucet. Taking a comfortable position squatting flexing and stretching his thigh muscles the man pulls down his pants and stretches out his hands to get a firm grip on the metal water pipe coming out of the cement slab he has chosen as his receptacle. Suffering from a common Chadian ailment, his knuckles turn white as he strains to force out the poop hardened in his dehydrated and constipated colon. A sigh of relief accompanies the success of his mission until a bright light suddenly blinds him and a harsh cry of "Ca c'est quoi?!!" brings to an end his devious deed.

Literally caught with his pants down the man hurriedly tries to cover his naked manhood as Jean-Jacques, our vigilant gatekeeper hauls him roughly to his feet. It's a little after midnight but our new administrator, Augustin, comes immediately from home.

Punishment is swift. The gendarmes are called. The man is forced to pick up his ca-ca and stuff it in his pocket before being escorted off to prison. He was last seen weeding the flower garden in front of the jail.

euthanasia

"The pain started suddenly at 4 o'clock this morning." The man stretched out before me on the gurney is in obvious distress. His abdomen is swollen and he's gasping for air. I look at his carnet. His name is Gaouna.

"How was he yesterday? Was he sick at all?" I ask through his brother who interprets from French to Ngambai and back again.

"Yeah, yesterday he was fine, but this morning, the pain started right here," he points to the epigastric region of the patient.

I examine the belly. It's firm but not tense. When I tap with my fingers it sounds hollow, full of air. Gaouna winces in pain with each touch: peritoneal signs. His breathing is shallow and his heart is rapid and his pulse weak. It sounds like a perforated ulcer. The ER had started an IV so I tell Abel to give Gaouna triple antibiotics, call in Samedi from home and go see the last of the ER patients while the OR staff preps for an immediate laparotomy.

The family doesn't have money to pay but they are well to do and leave their motorcycle at the hospital as collateral for future payment.

I finish in the ER and come back to the operating theater. I enter the room. Gaouna is lying on the OR table. Two IVs of Ringer's Lactate are raised high on IV poles running in fast into both arms. A foley catheter has about 300 cc of dark urine. His arms are stretched out on the arm boards and tied down as if he's about to be crucified. Gaouna's eyes are closed and his breathing is even shallower and more rapid. The beep of the pulse oximeter tells me instantly he's not getting enough oxygen. I glance at the numbers. He's at 60% saturation, way below the accepted norm. I'm afraid Gaouna is not going to make it. Maybe we're too late.

We have no oxygen, so I decide to intubate him. I grab a cardboard box off a top shelf. Inside is a mix of all our endotracheal tubes. I select one I think will work. I test the cuff with a 10cc syringe of air while Abel pulls out the laryngoscopes. In my hurry I forget to prepare suction or put in a stylet. I check the laryngoscope and the light works. Abel injects 2mL of ketamine and I insert the blade in the patients mouth. The light isn't working. I pull it out tap it a little, take the blade off and put it back on the laryngoscope handle. It works again. I put the instrument back in his mouth and lift up the tongue. I briefly see the vocal cords before a mass of saliva obscures my view. I call for suction and try to put in the breathing tube anyway. It bends down away from the vocal cords. I reach behind me and quickly leaf through a drawer in the anesthesia cart to find a stylet for the tube. I put it in and bend it into a distal hook to help me put the tube into the trachea. I try again and this time am successful. I put on a bag to the tube after blowing up the cuff and start to breathe for our dying patient. His saturation comes up to 85%. I give the bagging over to Samuel and go scrub. Samedi and Abel have already prepped and draped the abdomen. I'm sure that with release of the abdominal tension, Gaouna's breathing will improve.

I take the large scalpel and am quickly in the abdomen as a surge of dark red, slimy fluid surges out. We quickly suction out over 3 liters of fluid. The intestines look injected and angry but don't seem to be gangrenous. I start to explore and soon discover the real problem. As I cut up the abdominal wall to expose more of the contents a purplish, lumpy, alien-looking mass pops out of the right upper quadrant. Gaouna has end-stage liver cancer. Inside I'm furious. As I quickly try to close up the useless operation, many thoughts whirl through my head. How could the family deceive us? Of course, Gaouna's been sick for months if not years. Without CAT scans and other diagnostic equipment we base so much of our diagnosis on history and physical exam. This surgery could've been avoided. Now in all likelihood he'll die before making it out of surgery. How could God have let me make such a big mistake costing so much money for Gaouna's family and so much time and personnel resources for the hospital?

I've never closed up a surgery quicker. I take over from Samuel and take the bag off the breathing tube. Gaouna's sats go down to 57% but stabilize as he starts breathing on his own. I just want to get him out of here alive. I take out the ET tube and we transfer Gaouna to the gurney and wheel him out to the wards. I explain to the one family member who's there but it's not the same one who gave me false information.

An hour later, Pierre comes to inform me that Gaouna has "rendu l'ame" (given up his spirit). I'm not surprised. By this time, I've had more time to reflect. What if we wouldn't have operated? Gaouna may have lived several more days or even weeks. But he would've suffered. We have no real good pain medication. In hospital, we can give some pentazocine which is OK but not great. As far as pills, we only have Ibuprofen and Paracetamol (a medication like Tylenol). Instead of a slow, painful death, but operating on him we let him slip away in a Ketamine coma without any suffering. Sure, the operation didn't save his life, it just saved him from a torturous death. So maybe it was the right decision after all.

James