...You might be a Tchadian

If when pregnant the only thing you really crave is dried fish.
If your idea of clean is a well swept dirt yard.
If when the temperature falls below 80 degrees you dust off your parka.
If you've ever traveled to the big city on top of a loaded dump truck.
If you've ever sold a chicken to pay your medical bill.
If you've ever ridden bareback on a cow.
If you refuse to take your horse into the river for fear he'll become a hippo.
If you've ever had to cut a fishing trip short because you got bit in the butt by a hippo.
If you've ever given birth in a rice field.
If you've ever been evacuated to the hospital on a motorcycle.
If you've ever tried to deliver a baby who came out hand first.
If your mama's ever slapped you for crying during birth pains.
If you've ever fixed a leaky pipe with an inner tube.
If you've ever fallen out of a mango tree while 8 months pregnant.
If your mom "potty trained" you by resting you on her legs to let you poop on the ground.
If your dad took multiple wives to have more workers for his rice field.
If you've ever done surgery without a high school diploma.
If you drink hot tea when it's 130 degrees out.
If you speak more than five obscure languages.
If you've never opened a car door before.
If you've ever thought a cement mixer was an airplane.
If you've ever opened a bottle of Coke with your teeth.
If it's ever taken you 2 days to travel 42 km.
If you've ever repaired a flat tire with needle and thread.
If you've ever packed a car rack higher than the car itself.
If you've ever carried more than your body weight balanced on your head.
If you've ever strapped a baby to your back.
If you fill up your gas tank using an old wine bottle filled at the side of the road.
If you grow gourds on the roof of your house.
If you've ever plowed a field by hand while talking on a cell phone.
If you've ever brought your child to church naked.
If you've ever ridden a motorcycle wearing a turban with an eyeshade over your mouth.
If you've ever paid tithe at church with a goat.
If no one stares when you dress your baby boy in hot pink.
If you think nothing of male soldiers walking down the street holding hands.
If you've never seen a guy and girl hold hands in public.
If you think nothing of seeing a woman's breasts but are scandalized by her naked knees.
If you've ever attended class under a mango tree.
If you've ever broken your arm falling off an ox cart.
If you know more than one person who's been gored by a bull.
If you've ever been thrown in prison for casting a spell on someone.
If you've ever sued someone for killing your pig.
If you've ever killed a rat by stepping on it.
If you've ever eaten a bat.
If you've ever fixed a radiator with chewing gum.
If when your child has a sore throat you cut his uvula.
If you feel like an honored guest when you're served soda pop.
If you've ever shared the highway with a herd of longhorns.
If you think all white people look alike.

Unexpected death

Yeah, I was tired, but I certainly didn't expect this one. I'm still trying to figure it out. But, with our deplorable working conditions and lack of staff and equipment, I'm afraid it's doomed to remain a mystery. I just hope we can do something to change conditions so it doesn't happen again.

It started yesterday. We have been even busier than usual, especially in surgery. We did our 50th surgery in January yesterday...and the day wasn't even finished yet and there's still a week to go in the month.

And to think, I thought yesterday would be relatively easy. I thought I'd only scheduled a couple of orchiectomies (taking out the testicle) and the excision of an abdominal wall mass. But when I finally got to the OR at around 11:30am I found that the first case was a hernia and we had one other one scheduled as well. I've been trying to schedule as many surgeries as possible for next week when a visiting surgeon, Dr. Dekraay, will give me a little break.

I was already tired having done 7 ultrasounds, consulted outpatients and had a meeting with our HIV patients under anti-retroviral therapy. Not to mention the fact that I was up till midnight the night before operating on a ruptured ectopic pregnancy.

I quickly did the hernia and two orchiectomies. In between, I followed up lab results and saw more outpatients. Then, things got a little out of control. This woman had a huge, lumpy abdominal mass that was mobile and apparently not fixed to the muscles or anything. There was kind of a peak to it with a little ulceration through the skin. I cut in and popped out 6 firm fibromas...then she started bleeding like crazy. She had high blood pressure and every little skin artery was shooting a geyser out spraying everything in sight. I compressed as best I could as I called for more hemostat clamps. The cavity was so big and deep I had to excise more skin and open it more to get to the depths and clamp off bleeders. By the time we were done the whole floor, bed, drapes and our scrubs were covered with the sticky red stuff.

Now it's 3pm, I should be going home but a nomad man has just brought in his wife. She was operated on (a c-section they say) at another hospital four months ago and now for two days she hasn't passed gas or stool and vomits all the time. Her belly is distended with absent bowel sounds. She has a bowel obstruction. I send her husband off to pay for the surgery. Meanwhile, the evening nursing team comes to tell me there's a young lad who fell out of a tree and has an open fracture.

Oh, yeah, there's also a patient we operated on 8 days ago for a hernia who's referred from the Bao health center for a strangulated hernia from an "operation badly practiced" at the "Bere BAPTIST Hospital". Interesting, I didn't know there was another hospital here in Bere! I go to examine him and find he has a pretty impressive scrotal hematoma but no hernia. The hernia wound is healing well. When we enter he starts writhing in exaggerated agony. Unfortunately, he'll have to wait.

I go see the boy. His elbow has somehow dislocated and come through the skin of the inside of his elbow without fracturing. The nerve is stretched tense over the exposed joint surface of the humerus. His circulation is intact. He also has a closed distal radio-ulnar fracture dislocation. I take him to surgery as first priority. What I don't do, I'll regret later...I don't do a full physical examination (which I know I would've if I hadn't been so overwhelmed already) nor do I check his vital signs.

In surgery I flush out the wound with 3 liters of irrigation fluid while our medical student, Jamie, and Israel pull the arm in opposite directions. It slowly starts to reduce. With a bend of the arm and a push with my thumb, the humerus enters back into its joint. The elbow bends normally. I rinse out the wound some more and close it up in two layers. I then reduce the wrist and place a cast from hand to above the elbow. The boy does fine with just a minimal dose of diazepam and Ketamine. Nothing concerning, although Israel does note later that he was perspiring profusely and his heart rate was elevated (not uncommon with pain and/or Ketamine).

Since we have no post-op recovery room nor enough nurses to staff one, we wheel the boy directly off to pediatrics. I will regret that as well.

We then bring in the nomad woman who ends up having a small bowel obstruction due to two strictures from adhesions caused by her previous surgery. Those two almost closed off scarred pieces of bowel along with a nick of the bowel on entering the abdomen require a resection and anastamosis. As I'm half way through the suturing of the intestine, Clarice enters. I am shocked by what she says.

"The boy is dead"

"Which one?"

"The one with the fracture you just operated on..."

I can't believe it. On further reflection, though, it was inevitable that something like this happen. In fact, it's a simple miracle that we haven't had more complications or deaths following surgery.

We have become a reference center for people from hundreds of miles around yet our facilities are pathetically inadequate. We have no cardiac monitor. Our pulse oximeter has been broken for over 6 months. Our large autoclave caught on fire months ago. Our two small autoclaves were fried last week. Now we are sending our instruments an hour away to Kélo to be sterilized. We only have one OR which is crammed packed with all our supplies since we have no supply room leaving it difficult to clean properly. We have to walk through the instrument sterilization room to get to the OR. We have one prep room also stocked from floor to ceiling with supplies. We have no real prep room (for bathing patients, etc.) which means a lot of filth gets tracked into the OR. We have no post-op recovery room (as mentioned above) which means patients get dumped on the wards along with all the other patients to wake up from anesthesia. Often, there is only one nurse for all the hospitalized patients who can't possibly give the attention needed to the post-op patients which means we depend on family members to alert us of problems. This time, it was too late.

What was the cause of death? Impossible to determine now...but the real cause is an overworked under-equipped staff and hospital. We need at least another physician and some more nurses. Then, we really need a new operating block with at least two operating rooms, a prep room, a post-op recovery room, a dressing room, an instrument/sterilization room, and a supply room. Of course God always helps us in our weaknesses, which is why we've been able to operate successfully on so many with almost never any complications. However, if we have the means to improve things and don't, I think God also will hold us accountable for that one day.

Unfortunately, one young boy will not have another chance in this life...

James

Nightmares

I wake up with a start. It's 3:26 AM. The nightmares are back. They always take a different form with the same theme. I'm running from some nameless terror. I have to hide. I am almost found a million times and then...I can tell I'm about to be discovered...and I wake up my heart pounding in my ear-plug filled ears.

The headaches continue. When I'm doing something I'm fine. Just a little nagging in the background. But when I try to relax, a constriction along the top of my neck, through the base of my skull and encircling it's grasping tentacles around to my throbbing eyes forces me to want to drink a ton of water and sleep.

My eyes are heavy and my throat is sore. I feel almost a desperation to sleep. But there's a lurking fear that when I lie down I won't be able to anyway so I watch a movie, read a book, wander around puttering till the inevitable stop of the generator forces me to hit the sack or attempt my meandering attempts at distraction.

Finally, I lie down. The mattress is soft yet firm. The pillow is perfect. The bed is long enough for my 6'5" frame to stretch out comfortably in any direction even when sharing it with a beautiful Dane. I start off with the illusion of falling to sleep immediately. Something I long and pray for. It doesn't come. Instead come the slow, persistent, building memories from the day's work, strategies, plans, ideas, anything to keep me from sleeping.

Above all, it's the thoughts of what I shoulda, coulda, woulda...and working at a small bush hospital in sub-saharan Africa as the only physician leaves plenty of fuel for that fire.

I should've cut an episiotomy sooner. The baby was already stressed. Sure it's heart beat was fine. But the 14 year old mom had been in labor on that small pelvis for too long. If I'd only got him out a few minutes earlier he might of made it. It was so close. Why did his heart have to beat so long? Why didn't he ever take a breath? Why did I even attempt that tendon release? It wasn't life threatening. He'd lived with it for years already. Sure it was painful and made it hard to walk, but I probably just made it worse. I'm way out of my league.

If I'd recognized that meningitis a day sooner instead of only treating his malaria, maybe that little girl would've lived. She made it a couple of days as it was. I'm sure we did everything: IV fluids, glucose, steroids, appropriate antibiotics...what did we miss?

I should've done a classical incision on that woman with the transverse lie and arm sticking out. If so she wouldn't have torn into both uterine arteries. Sure we managed to control the bleeding, but we almost lost her. What if I'd just done it right the first time?

Did I speak too harshly to the boy who we'd amputated and then had almost healed his wound when he left against medical advice? When he came back with a huge infection needing a higher up amputation I should've spoken gentler. Maybe he would've actually stayed...is he still alive?

How could I have thought it was an ectopic pregnancy? My ultrasound skills suck. An unnecessary operation on a woman with a normal intrauterine pregnancy...I could've saved myself the trouble and her a dangerous procedure.

Is the medical student having a good experience? Should I let him do more? Or less? Is he feeling too overwhelmed with the responsibility? Have I dumped on him or is it just a good experience?

Are Israel and Paul overworked? They are volunteer nurses after all...I want them to have a good time so they'll encourage others to come...am I assigning them too many night shifts? Do they get tired of my calling them to help with all the surgeries?

Will the work at the hospital ever slow down? We seem to just be getting busier and busier as our staff continues to dwindle and I remain the only doc. I can't even begin to count the surgeries I've done since coming back January 10...three to four a day with many minor procedures and the waiting room inside and outside under the mango tree packed. There are no beds available in the hospital. People are sleeping outside, their mosquito nets strung from branches of trees. The nurses can't even walk inside at night. Relatives are sleeping on every available floor space including under the beds.

Images flash through my semi-conscious brain: amniotic fluid squirting onto my face as I cut into the uterus to rescue an infant; my fingers push and pull around a tense hydrocele breaking apart the small fibers attaching it to the scrotum with the sound of tearing cardboard; a hernia bulges in and out with the patients breathing as I grab firm fascia and poke through with
a needle to close that moving masse inside where it belongs; with a small poke, pus bulges out and flows down the back of the throat like a stream of lava as I quickly suction back and forth on the Ketaminized HIV positive wife of the local chief; moans and babbling float across my brainwaves from a million Chadians waking up from a Ketamine nightmare; the baby's head
rolls around despite the firm grasp of Paul as I chase a splinter across his cornea trying to dig it out gently with an 18 gauge needle; gurgles and bad breath roll up to me in my stupor from an alcoholic desperately wishing he had a bowl of rice wine to assuage his pounding head from the beating he got last night while hammered; urine dribbles onto the ground from a foley bag
only partially closed...

Words in Arabic, Nangjere and French wind themselves around my thoughts as I relive my frustration at only being able to communicate on the level of a child...and my deep desire to learn Arabic and Nangjere clashes with feeling so overwhelmed that at any break I just want something to temporarily distract me...

Finally, I fall asleep, and the nightmare begins...until I jolt awake at 3:26 AM. My throat is sore, my lips are dry. I grope for a flashlight and take a drink of water in the bathroom. I turn off the light, roll onto my back, try to sink in...and a flashlight appears outside the window rapidly followed by a rap on the metal door. I unplug my ears, grab my headlamp, pull on some shorts and a t-shirt and go to see Clarice and David.

There is a woman in her 10th pregnancy under oxytocin to augment her labor who has been completely dilated for 3 hours without delivering. I change into scrubs, find my keys, head to the OR, snatch up the oft-used disposable hand-pump vacuum and head to Labor and Delivery.

I put on gloves and examine the woman. The head is high up but there seems to be room. I wet the vacuum and slide it in over the baby's crown. She has a strong contraction. I pump up the vacuum and slowly pull. The head descends and twists to the left as the eyes, nose and mouth pop out slowly over the perineum. I use the bulb suction to clear the airways, release the vacuum and pull the head down to free up the anterior shoulder quickly followed by the squirt of slimy child, arms and legs firmly contracting, already wanting to scream his anger at the world. We quickly dry her off and wrap her up against the cold. The placenta follows quickly. There are no tears and no bleeding. The uterus is firm as a rock. I go home hoping that for at least of few hours of nightmare free sleep...

Pus Surprise

I can feel my heart start to beat a little faster in anticipation. My mouth starts to water and I hope I don't drool. The suspense is killing me! Every time I see someone with some kind of rag draped over a body part or waddling in like a sore cowboy after a long ride wearing nothing but a wrap draped around the waist, I can't help but wonder, what gross thing am I going to get to cut open or take out next?

Friday, it's an eight-year-old boy from Kélo. The father brings him in his arms. The right leg is draped in an army green rag that was probably a shirt at one point. The air gets a little thicker and I'm glad for my cold that dampens the odors. I quickly pull out the strip of paper to cover the exam table. The rag is hanging wet and limp. As soon as the boy is put down I regret having brought him into my office as the paper is starting to soak up whatever foul liquid is oozing from whatever it is under that "bandage." I hurriedly pick him back up myself and take him outside to the gurney where I gingerly lift up the cloth to reveal...

Saturday night, it's a quiet shake from my wife. Sarah's on night duty and I am feeling drugged from fatigue. The last two weeks we've been doing 2-3 surgeries a day and it's taking it out of me. She's saying something about a teenager who has no lung sounds on one side. I seriously can't wake up. I'm trying but it's like I took a sleeping pill. I mumble something about sticking a needle in over the rib and seeing if there's liquid or air making the lung collapse. I tell her if there's air to come get me, if liquid than I'll see him in the morning. I wake up early Sunday morning wondering what I'll find as I walk over to the hospital in the coolness and stillness of an early African morning...

Monday, two guys waddle into my office wearing only skirts. They've both come from far away. I can hardly contain my excitement as I ask them to lie down on the exam table and fumble with the knot attaching the cloth skirt to their waist. As I slowly un-wrap it to look I find just what I was expecting...

Tuesday, I operate on a woman who'd come in the Thursday before. She had a cloth wrapped around her mid-abdomen. She'd been sick for a month with pus draining from a small hole (fistula) in her belly button. As I am poised with my scalpel after the pre-op prayer, I wonder what I'll find inside. I quickly slice down from her belly button to her pelvis. To my surprise, I find...

Wednesday, Sarah comes running up to me with an amazed grin on her face. "James, you have to see this guy's arm. It's three times the usual size." I walk into the clinic and see an elderly man with whitening hair and beard on his rugged face lying moaning on a stretcher on the floor. His left arm is wrapped in a rag that at one time ages ago was probably white. From finger tips to mid upper arm I can see nothing. The upper arm to the shoulder is swollen to three times the size of the other arm. As I grab some gloves and bend over to unwrap it and take a look I have a feeling I might find... sure enough, as I snap off the gloves and order him to surgery...

One of the glorious benefits of working in a bush hospital is the phenomenon of pus surprise. No matter how often I see it. No matter how often I suspect it. No matter how often I have to really search for it... I always find it. Seek and ye shall find is my motto for tropical pus explorers. It is usually deeper than you think... but it's always there. But why this rush when I suspect it or the anticipation when I suspect it's there hidden under some rag? Maybe I'm weird, but few things bring instant gratification like liberating some imprisoned pus.

The boy's leg is a fungating, purulent mass surrounding his entire lower leg with the exception of his foot which is swollen and edematous. I take him to surgery, wrap a blood pressure cuff around his upper thigh and slice down to his tibia. I then cut up his tibia taking off his patellar tendon from the bone. That opens up his knee joint where I cut through the ligaments and menisci exposing his patellar space. There is barely a drop of blood anywhere thanks to the tourniquet. I divide and tie his vessels and cut through his sciatic nerve. I then slice down leaving some muscle for the flap. Israel lifts off the leg under the drape while I attach the patellar tendon to the posterior cruciate ligament. I then suture the flap closed and put a dressing and ace wrap on. While I didn't get to directly liberate pus, I did get to cut it off.
Three days later he's already up on crutches moving around on his own. Sarah has been giving him books to read and crayons to draw and he is quite smart and a talented artist. He talks almost nonstop without fear. The only time he expressed any reserve was after I took the dressing off and was going to replace the bandage. In a tiny, timid voice he begged "please, not too tight, it hurts."

As I enter the OR, Sarah has already prepared the young man for his chest tube. I infiltrate around the ribs between his nipple and his armpit. I slice down to muscle and then poke up and over the rib with a curved clamp. I feel the pop. I see the stream of liquid pus squirt up. Most severely, I am almost floored by the pungent force of the odor that escapes with the pus geyser. I smell plenty of body fluids and odors in my work but this one I can barely take. It's not that I feel nauseated, I just feel like I really don't want to breathe that one more second. I try to hold my breath as I grab the large bore chest tube with the clamp and push it in over the rib and into the pleural space. I then attach the drainage chamber and suture the tube in place. The damage has been done, though, and I think I have never attached and wrapped a chest tube in place faster in my life before bursting out for a breath of fresh air. The block isn't the same for days, despite our best efforts at deodorizing.

Tuesday, I operate on the two skirt-wearing gentlemen. Out of the first, I take a newborn-baby-sized hydrocele with his testicule and cord ensemble. It's the only way for a man to really experience the joys of childbirth as we push the hydrocele out of the incision into the air I almost expect to hear a baby's cry. The joy is about the same for either. The second, I cut into his scrotum, expecting the same pleasurable result only to realize it's actually an extremely large hernia. Changing strategy mid-operation, I open up his inguinal canal but with the size of the defect and sac I'm obligated to take out his testicule and cord as well. Well, it's almost as good as pus!

Unfortunately, as I follow the fistula down from the woman's umbilicus I find it leads to the bladder which is filled with friable tumor which I scrape out as much as I can. I know that this is a very advanced cancer that I can do nothing about so I'm forced to close up and give the family the bad news. Sometimes the surprise is a bad surprise...especially when there's something besides pus. If you find pus, you can usually do something about it. If you find cancer...
I lift off the rags from the man's arm. The whole arm is three times the usual size. The skin on the back of his hand is like the bladder from a basketball that is half-filled with water. It pokes in and bounces out as if there's nothing but liquid inside. His skin is peeling off in many places and in others is like wet cornmeal that crumbles off when rubbed. He has blisters in spots and holes leaking pus in a few spots. We inject Diazepam and Ketamine to put him under and I incise down the back of his wrist. Yellow and red liquid seeps out. I extend the incision towards his shoulder with scissors. The skin is thin and like rubber with nothing attached underneath all the way to the elbow. There is just a little yellow jello like substance that melts away with pressure like a jellyfish caught on the beach on a hot summer day. I find what used to be muscle or fat but is now just a fibrous mass the consistency of sponge cake which dissolves into pus when my fingers dig into it searching for the limits of the infection. I pull up mats of this spongy pus leaving anatomy I haven't seen since cadaver lab in Gross Anatomy my first year of med school. All the superficial veins are intact and thrombosed. A fine net of superficial nerves remains draped over the veins. All the tendons and aponeuroses are exposed on the back of the hand leaving skin covering the fingers like an inverted weight lifter's glove. When I finish debriding the wound it extends from the base of the fingers to above the elbow and half way around the circumference of the arm on both sides. The other side of the arm, while swollen, doesn't appear to be necrotic or pus-filled.

We wrap up the arm in diluted bleach soaked lap sponges and wrap it tightly with an ACE wrap before letting off the blood pressure cuff tourniquet. There is some brisk bleeding near the elbow that I compress while sending Siméon to get a sand bag. A family member soon comes with a piece of cloth filled with a few kilos of sand that I place over the bleeding part to compress it and we take him out to his bed.

I'll never forget the pleasant sensation of feeling my fingers dig into that mass of necrotic fat and muscle squeezing out the pus along the length of the man's arm. To get all that nastiness out is a source of great satisfaction. I pray that with dressing changes and powerful antibiotics we'll be able to save his arm by liberating his pus surprise!

James

Darkness II

One minute I'm eating my Danish tuna pasta salad garnished with circles of fresh green pepper and the next I can't even see my hand in front of my face. Then, silence abruptly descends as the motor driving the generator is shut off. With the increasing silence, the sounds of mourning increases as well. The wails and shrieks and moans that have become all too common and yet still cut deep into my psyche with their piercing hopelessness come from directly behind our house.

It must be our neighbors. It must be the family of Allawaye, the father of "Naked Boy" and "One Armed Boy", our little neighbors with self-explanatory names (although "Naked Boy" has recently transformed himself into "T-shirt and Sometimes Pants Boy"). Allawaye's third wife's little one-year-old was recently hospitalized for meningitis and treated with a full course of IV Chloramphenicol. At discharge, the fontanel was normal, there was no fever, and the child was breastfeeding and otherwise acting cured. Three days later, the child came back seizing and with a tense fontanel. The H. flu bacteria infecting his little cerebral spinal fluid was resistant. We had no other good alternative but did what we could.

Last night, David came to talk to me.

"Allawaye's wife came to the gate with the child insisting on going home. I told them to wait until morning."

This morning, I enter the peds ward and see Allawaye with two of his wives including the mother of the child with meningitis. The mother looks down the whole time and has a scowl on her face. The baby is breastfeeding... an improvement from two days ago when I was forced to put in a feeding tube. The fontanel has become less tense. I start to explain to Allawaye that while the baby is still sick and could die, there are some positive signs. Just then the other wife pipes up with a low, vicious voice and an evil glare. The nurse translates her Nangjere. She insists on going home. The child isn't better. Our treatments haven't worked. It's time to consult the witchdoctor.

I make her leave and continue to explain to Allawaye why I think the child should stay in the hospital. He seems to understand and agrees to finish treatment. The mother of the child continues to act like we're trying to torture her child by asking him to stay.

I offer to pray for the child and they accept. I'm desperate for God to prove that it's not some witchcraft that is making the child sick (although, I guess one could say all sickness originates with our enemy, the devil). I ask that God continue to heal the child. We've done our best but with the limit in our arsenal of antibiotics we need a miracle.

Now, in the crying, wailing, and yelling coming from next door I'm afraid God has once again not intervened.

Siméon told me this evening another related tall tale.

On Friday, a boy from lie presents with a leg wound "treated" for 18 days at the Kélo Hospital. All I see is a fungating mass encompassing his entire lower leg between the knee and ankle. The foot is swollen and the eight-year-old is in obvious pain. We take him immediately to surgery.
His leg is doubled up in contractures from weeks of not moving so I prop up the leg with rolled up towels after giving him his spinal anesthetic. He is naturally afraid, but curious at the same time. I feel his eyes on my every movement. I put on my sterile gloves and attach sterile towels around the legs, leaving just the knee exposed. I'm about ready to start, but then Israel asks if I'm going to let the boy watch. I look over and see him still staring at me in wonder tinged with anxiety.

I ask for a sterile drape as well so that the surgical site can be hidden from the boy's view. Israel pumps up the blood pressure cuff around his thigh to 260 and then I pray before starting. I imagine in my head the two flaps I want to create and then slice down to bone across the anterior tibia. I retract up the skin flap with forceps and slice up the bone cutting off the patellar tendon from its attachment. I then enter the knee joint and cut across the menisci and the ligaments. There is no blood thanks to the tourniquet. The only things holding the leg on now are the popliteal blood vessels, the sciatic nerve and the posterior muscles. I dissect a little around the vessels and clamp and tie them off before cutting them loose along with the nerve. I then slice inferiorly to leave a muscle flap and have Israel pull off the leg from under the drape. He tosses it in the trash as I sew up the two flaps and wrap an Ace bandage around the wound.

As I'm about to leave the OR after the boy has been taken out and we've cleaned up, I pause over the trash can. It's in the middle of the floor filled with plastic IV bottles, tubing, tape, gauze, plastic drapes and an upside down, normal looking foot sticking straight out like someone has been dumped in there upside down. I'm reminded of Samedi's tale during the time of Dr. Kip when they did a ton of amputations and dumped the body parts in a pit behind the hospital. One day, after a rain, a woman came running into the compound screaming that someone had drowned in the now water-filled pit. All she saw was a foot sticking out and was sure there had to be a body attached somewhere in the water. I get the same feeling now as I stare down at the bottom of the boy's foot so recently attached to a living body.

Now, for the tale: apparently, Siméon had to listen to this boy talk and talk all day long the following day. He wouldn't keep quiet and told Siméon how his leg got infected. His dad sent his mom away shortly after he was born and married another woman. According to the boy, the woman is a sorceress who transforms herself into a cat. A few months ago, she had it out for the boy so she became a cat and bit his leg which subsequently got "poisoned" and that's why it didn't heal and had to be cut off. It was natural since it had been cursed by his witch stepmom.

The problem is, these stories are not uncommon. Most people's idea of cause of disease here is that it's witchcraft and someone has "poisoned" them or cast a spell on them or performed some sorcery against them. Therefore, usually some sort of "traditional" treatment has been tried before they are brought to the hospital in the throes of death. Then, the hospital is blamed when the patient dies.

As I sit in the darkness listening to my neighbors trying to appease the spirit of the departed child, dead from meningitis, I feel frustrated and hopeless. How can one fight against not only the forces of physical disease in a resource poor setting, but against the forces of ignorance and the forces of darkness? It seems sometimes that they want the person to die to prove that they were right that it was some witchcraft and that our medicines are useless. I've seen people go out of their way to discourage a patient and tell them they're going to die and after I've spent so much time trying to get them to be encouraging and hopeful, when the person finally does die, largely in part to the psychological attacks of their family, they go out of their way to say "I told you so. I knew they would die, but you kept insisting they had a chance. See, I was right and you were wrong." Nothing that I've experienced here comes close to that for discouraging.

After lighting a kerosene lamp to bring a little light to the darkness of my room, I pull out my Bible. Finally, I find what I'm looking for, but in a surprising place: right after the most famous verse in the Bible, John 3:16. "This is the verdict: Light has come into the world, but men loved darkness instead of light because their deeds were evil." John 3:19.

Yes, I can understand a little God's dilemma. He can't "mess with free will" (as he says in the movie "Bruce Almighty"). In other words, Satan has an advantage: he can use fear, force, superstition, manipulation, coercion, brutality, etc. God can't. And because I've aligned myself on God's side, I can't use those things either. As much as I'd like to take some parents by the neck and shake them until they realize they need to bring their kids to the hospital when they first become sick rather then when they're on death's door, I can't. I have to try to persuade them. But, I've found it amazingly true that men (and women) really do love the darkness rather than the light... and it's so frustrating realizing there's nothing one can do about it except continue to fight, even if it seems like a losing battle, to continue to fight, because who knows, maybe one or two will see the light and come out of the darkness...

James

Darkness

One minute I'm eating my Danish tuna pasta salad garnished with circles of fresh green pepper and the next I can't even see my hand in front of my face. Then, silence abruptly descends as the motor driving the generator is shut off. With the increasing silence, the sounds of mourning increases as well. The wails and shrieks and moans that have become all to common and yet still cut deep into my psyche with its piercing hopelessness come from directly behind our house.

It must be our neighbors. It must be the family of Allawaye, the father of "Naked Boy" and "One Armed Boy", our little neighbors with self-explanatory names (although "Naked Boy" has recently transformed himself into "T-shirt and Sometimes Pants Boy"). Allawaye's third wife's little one year old was recently hospitalized for meningitis and treated with a full course of IV Chloramphenicol. At discharge, the fontanel was normal, there was no fever and the child was breastfeeding and otherwise acting cured. Three days later, the child comes back seizing and with a tense fontanel. The H. flu bacteria infecting his little cerebral spinal fluid was resistant. We had no good other alternative but did what we could.

Last night, David comes to talk to me.

"Allawaye's wife came to the gate with the child insisting on going home. I told them to wait until morning."

This morning, I enter the peds ward and see Allawaye with two of his wives including the mother of the child with meningitis. The mother looks down the whole time and has a scowl on her face. The baby is breastfeeding...an improvement from two days ago when I was forced to put in a feeding tube. The fontanel has become less tense. I start to explain to Allawaye that while the baby is still sick and could die, there are some positive signs. Just then the other wife pipes up with a low, vicious voice and an evil glare. The nurse translates her Nangjere. She insists on going home. The child isn't better. Our treatments haven't worked. It's time to consult the witchdoctor.

I make her leave and continue to explain to Allawaye why I think the child should stay in the hospital. He seems to understand and agrees to finish treatment. The mother of the child continues to act like we're trying to torture her child by asking him to stay. I offer to pray for the child and they accept. I'm desperate for God to prove that it's not some witchcraft that is making the child sick (although, I guess one could say all sickness originates with our enemy, the devil). I ask that he continue to heal the child. We've done our best but with the limit in our arsenal of antibiotics we need a miracle.

Now, in the crying, wailing and yelling coming from next door I'm afraid God has once again not intervened.

Siméon told me this evening another, related tall tale.

Friday, a boy from lie presents with a leg wound "treated" for 18 days at the Kélo Hospital. All I see is a fungating mass encompassing his entire lower leg between the knee and ankle. The foot is swollen and the eight year old is in obvious pain. We take him immediately to surgery.

His leg is doubled up in contractures from weeks of not moving so I prop up the leg with rolled up towels after giving him his spinal anesthetic. He is naturally afraid and curious at the same time. I feel his eyes on my every movement. I put on my sterile gloves and attach sterile towels around the legs leaving just the knee exposed. I'm about ready to start, but then Israel asks if I’m going to let the boy watch. I look over and see him still staring at me in wonder tinged with anxiety.

I ask for a sterile drape as well so that the surgical site can be hidden from the boy's view. Israel pumps up the blood pressure cuff around his thigh to 260 and then I pray before starting. I imagine in my head the two flaps I want to create and then slice down to bone across the anterior tibia. I retract up the skin flap with forceps and slice up the bone cutting off the patellar tendon from its attachment. I then enter the knee joint and cut across the menisci and the ligaments. There is no blood thanks to the tourniquet. The only things holding the leg on now are the popliteal blood vessels, the sciatic nerve and the posterior muscles. I dissect a little around the vessels and clamp and tie them off before cutting them loose along with the nerve. I then slice inferiorly to leave a muscle flap and have Israel pull off the leg from under the drape. He tosses it in the trash as I sew up the two flaps and wrap an Ace bandage around the wound.

As I'm about to leave the OR after the boy has been taken out and we've cleaned up, I pause over the trash can. It's in the middle of the floor filled with plastic IV bottles, tubing, tape, gauze, plastic drapes and an upside down, normal looking foot sticking straight out like someone has
been dumped in their upside down. I'm reminded of Samedi's tale during the time of Dr. Kip when they did a ton of amputations and dumped the body parts in a pit behind the hospital. One day, after a rain, a woman came running into the compound screaming that someone had derowned in the now water-filled pit. All she saw was a foot sticking out and was sure there had to be a body attached somewhere in the water. I get the same feeling now as I stare down at the bottom of the boy's foot so recently attached to a living body.

Now, for the tale: apparently, Siméon had to listen to this boy talk and talk all day long the following day. He wouldn't keep quiet and told Siméon how his leg got infected. His dad sent his mom away shortly after he was born and married another woman. According to the boy, the
woman is a sorceress who transforms herself into a cat. A few months ago, she had it out for the boy so she became a cat and bit his leg which subsequently got "poisoned" and that's why it didn't heal and had to be cut off. It was natural since it had been cursed by his witch stepmom. The problem is, these stories are not uncommon. Most people's idea of cause of disease here is that it's witchcraft and someone has "poisoned" them or cast a spell on them or performed some sorcery against them. Therefore, usually some sort of "traditional" treatment has been tried before they are brought to the hospital in the throes of death. Then, the hospital is blamed when the patient dies.


As I sit in the darkness listening to my neighbors trying to appease the spirit of the departed child, dead from meningitis, I feel frustrated and hopeless. How can one fight against not only the forces of physical disease in a resource poor setting, but against the forces of ignorance and the forces of darkness? It seems sometimes that they want the person to die to prove that they were right that it was some witchcraft and that our medicines are useless. I've seen people go out of their way to discourage a patient and tell them they're going to die and after I've spent so much time trying to get them to be encouraging and hopeful, when the person finally does die, largely in part to the psychological attacks of their family, they go out of their way to say "I told you so. I knew they would die, but you kept insisting they had a chance. See, I was right and you were wrong." Nothing that I've experienced here comes close to that for discouraging.

After lighting a kerosene lamp to bring a little light to the darkness of my room I pull out my Bible. Finally, I find what I'm looking for, but in a surprising place: right after the most famous verse in the Bible, John 3:16. "This is the verdict: Light has come into the world, but men loved darkness instead of light because their deeds were evil." John 3:19.


Yes, I can understand a little God's dilemma. He can't "mess with free will" (as he says in the movie "Bruce Almighty"). In other words, Satan has an advantage: he can use fear, force, superstition, manipulation, coercion, brutality, etc. God can't. And because I've aligned myself on God's side, I can't use those things either. As much as I'd like to take some parents by the neck and shake them until they realize they need to bring their kids to the hospital when they first become sick rather then when they're on death's door, I can't. I have to try and persuade them. But, I've found it amazingly true: men (and women) really do love the darkness rather than the light...and it's so frustrating realizing there's nothing one can do about it except continue to fight, even if it seems like a losing battle, to continue to fight, because who knows, maybe one or two will see the light and come out of the darkness...

James

Der

I'm walking back from the hospital. I've just finished late Sunday morning rounds and plan on doing some emails or computer work. I see André standing by the gate. I waltz up and ask him what's going on. He's dressed in a light blue and white full jogging suit like he's about to head out
to warm up for some match.

"We're going to Der to visit Daniel. We haven't seen him in awhile and we heard he was deathly sick. Pierre, David and I are going as soon as David gets here."

Daniel is one of the teachers at our school. I instantly am impressed I should go. The words of my late brother, David, come to mind: "do what's important, not what's urgent." I decide this is important.

I put on my swimming suit and a t-shirt and grab the keys for the truck.

Pierre, André, Doumpa and David pile in and we head across Béré till we find a narrow, sandy track out of town heading more or less west. We go until we hit water.

"It only gets worse," remarks David, "We'll be up to our knees at least. Everything is flooded this year." There's no room to turn around but I try anyway and immediately get stuck in the thick mud of the adjacent rice field. The guys easily push me out but I decide I'll just have to back out when we get back. Little did I know how hard that would prove to be. We tumble out and I lock up.

The day is beautiful. The sky is blue like a Pacific atoll on a calm day. Billowy white clouds add character making the sky seem infinite, yet so close. The sun brings out the warm greens of the vast fields of tall, orderly rice waving in the gentle breeze in neat, but not perfect rows. The
water is warm under my feet and the sandy bottom almost makes me believe I could be near the ocean and that I should hear the crash of waves at any time.

Small fish and tad poles swim in schools around our legs and through the rice fields. Tiny, delicate dragonflies with fluorescent green heads and fluorescent blue tails flit across the surface of the water covered trail as larger, uglier dragonflies ply the air between the heads of rice. Dark, bug-like animals scoot with coordinated flaps of their legs across the sandy bottom...dragonfly larvae according to David.

Sparrow-sized, pudgy, bright red or yellow "millet eaters" chirp and dart from patches of scrub bushes on slightly elevated "islands" in between the flooded fields. The sand gives way to a black silt. The clay makes turns our march into a slick situation. I almost fall several times. We head out into the rice fields where at least walking on the grasses makes it less likely we'll slip.

The water gets deeper. I'm wading up to my thighs. The path/river takes a bend around an "island" and I finally see the village poking their thatch roofed heads above the tall heads of millet and between the mango trees. Smoke rises from several cooking fires. I reach a dry path and put my shoes back on.

David, Doumpa and I wait up for Andre and Pierre and then we march through the village till we find Daniel's house at the other side. It has been blown down in the last rain. When it rains it pours! We finally catch up with him at this mother-in-law's.

Apparently, he became dizzy and weak while out working in the fields. Then he couldn't move his legs and arms because they just cramped up. He thought he was going to die. All his family and friends came by but refused to pray for him because he's been going to the Adventist Church. "Pronounce the name of the Evangelical Church of Chad or we won't pray for you," they said. So he did. He was very confused though, wondering why Christians wouldn't pray for other
Christians just because they were from a different denomination. I wondered the same thing out loud to him.

After all, at the Adventist Hospital we pray for all our patients whether Adventist, Evangelical, Muslim, Animist, Atheist, Pagan, whatever. His two daughters are sick now, too. So we convince him to come back with us. I put the four year old on my shoulders and wade back through the water until it gets shallower and shallower and arrives back at the truck. We've gone two
kilometers each way through the flooding.

After waiting again for Andre and Pierre we start backing up. There is no problem until we almost get to the dry sand when suddenly the engine revs and the car slows down as the
right front sinks.

I get out to look and see that apparently the hard sand is only about a foot thick under which is a liquid soup of muddy sand. We work for an hour or so without even the slightest movement of the truck. I call Rich Hoyt again to see if he can pull me out. I can't get a hold of him. I try Sarah, nothing. Andre finally calls Enock, the guy who's building our staff housing who agrees to go search for Rich. David heads off on foot since it's getting dark and he needs to start the generator at the hospital and start his shift as night watchman. We are about to head off on foot
ourselves when we see and hear a motorcycle followed by a Land Cruiser. They've come!

Rich comes to check things out on foot and then returns to the Land Cruiser to turn it around and back up to pull us out. He ignores the rule he'd taught me last time he pulled me out and backs into a field to turn around. Now he's stuck too!

Enock heads off to the Evangelical Church of Chad of Béré #7 to round up manpower. We wait around getting eaten alive by mosquitoes the size of small vultures. It's night and the beauty of the day has fast faded. I’m starting to get frustrated. Then, I remember that I felt impressed to come, that this was important and that I have a choice as to my reaction to a situation. Instead of getting mad, Rich and I go apart and talk. Apparently, he's had a horrible weekend and this just tops it off. But, he's amazingly upbeat. I am able to unburden some of my hard times from the past week and I realize that this bad situation has given us both a chance to debrief that we
wouldn't of had otherwise. We pray together and then the crowd arrives.

With the arms, legs and backs of 21 people, the Land Cruiser is fairly easily pushed back onto the road. Rich doesn't want to risk getting closer to us to pull us out so he goes to where the road is solid. Then, with a lot more effort but no less enthusiasm, the 21 lift the back of the truck out of the holes onto more solid ground and then push the truck out of it's front tire pits as I gun the engine for all it's worth in low four-wheel drive reverse! I get about 100 feet when the left side of the truck sinks again into the mush. This time the 21 man force just pushes the truck to the right out of the hole and I wind the engine out until I’m on solid ground! What a great feeling! (although, I don't think I want to drive again for awhile...at least until the rainy season is over!)

James