I couldn't believe my ears. It was surreal. I didn't really feel any panic or anything, but I felt a calm, cold-blooded realization of what I needed to do.
My vacation was about to be cut short.
Ok, so you couldn't really call it a vacation, Sarah and I had come to the Koza Hospital as part of an exchange with Drs. Greg and Audrey who were now in Bere. We had now been in Northern Cameroun for just a day over two weeks but compared to Bere, it was a definite, much-needed break.
In those two weeks, I did 6 surgeries at Koza. Greg did 37 at Bere. I sat around all afternoon reading and watching movies while sipping cold drinks and eating homemade ice cream with a fan and a swampcooler as my constant companions while Greg and Audrey hardly saw the light of day and came home to Kerosene lamps and lukewarm tapwater.
This morning, I'd been woken out of my electric fan-cooled sleep by the nurse and ended up doing a crash c-section to save a distressed baby's life. Now, Greg's calm voice is speaking through my cell phone (yeah, even here in the African bush) telling me that one of our student missionaries (who we call Esther because there's just to many Sarah's) has severe abdominal pain and has vomited several times. Greg goes on to say that she has peritoneal signs and a positive Typhoid Fever test. She's been on IV fluids, antibiotics and morphine since yesterday. He doesn't know if she should be evacuated or what.
Fortunately, thanks to Gary Roberts' airplane, I have the luxury of saying, "I'll be right over, let me just quickly pack my bags and I'll see you in a few hours."
It's a Saturday morning and it's going to be a long day.
I quickly go over to the church right across from the house and find Yves, the administrator, to inform him of the situation. He is sitting on one of the front rows, so I drag him outside to break the news. He is understanding and wishes us bon voyage. After saying good-bye to Jacques and Calda, Sarah and I pack our bags and about 30 minutes after the phone call, Gary's wife, Wendy, is driving us out to the grass airstrip.
We take down the string "fence" Gary has guarded the plane with, detach the moorings, load up the barrels of fuel and our small backpacks, strap ourselves in and Gary fires up the single prop, we taxi (bump) across the grass and are soon banking sharply right en route to Garoua. An uneventful landing, flight plan and missed immigration agents (lucky for us since we didn't have visas) and we are heading to Moundou. Less than three hours from Koza and we land in Moundou where we have a little friendly discussion (heated argument) with customs ending in the usual way (laughs and hand pumping).
20 minutes, and a little flying lesson for James later we are circling Bere International watching Rich race down the airstrip on his motorcycle looking for goats, cows and soccer goal posts which could make our landing a little more bumpy.
"See that second path over the strip right before the little mound halfway down? That's where we'll try to put down in order to miss that little bump. We could circle around again, but this is faster..."
Gary says as my stomach gets left somewhere over to the right as be bank sharply left and downward towards the swath cut from the Chadian bush. Seconds later we are taxiing up to the quickly gathered crowd of mostly kids awaiting our arrival.
After the plane is unloaded, draped and secured and the watchmen posted, Anne kindly drives us over to the hospital in their Land Cruiser.
Greg is waiting for us dressed casually in jean shorts and a scrub top and large sandals. We go inside where the back room has been transformed into an intensive care of sorts with one patient, three doctors and three nurses, and multiple auxiliary staff (the other student missionaries) crowding around to help in any little way possible.
I slowly enter with my Sarah at my side. Esther (the other Sarah) gives us a weak, Morphine-influenced smile and says "hi". I ask her a few questions.
Apparently, her pain started yesterday morning early but she thought maybe it was just part of her monthly cramps. So she got on a motorcycle and took a little jaunt over to Kelo with a couple of the other volunteers. Curiously, the bumpy, bouncy ride did little to alleviate her pain. On her return, she had a typhoid test done which was sort of positive (they're sometimes hard to interpret and often have both false positives and false negatives). She was started on antibiotics and then IV fluids after she vomited. She had no urinary symptoms and bowel function was normal. She ate a little something at night. Her pain was equal on both sides of her pelvis. The pain increased with movement, tapping on the lower belly and "rebound tenderness".
Greg, Audrey, Sarah and I go to the next room to discuss what to do. She has evacuation insurance and with Gary's plane we could have her in N'Djamena maybe in time for the midnight, once-a-day flight to Paris. There is no hospital in Tchad I would prefer her to go to over ours (especially with Greg, a board-certified general surgeon there). We agree it could be typhoid fever, but that would usually have a longer course. While there are some atypical features I ask, "what if it is appendicitis"? In that case, she should be operated on ASAP, and an evacuation won't be fast enough to keep her from perforating with all the life-threatening complications. We continue to discuss, finally, I ask Greg, "If she was not a foreigner, would you operate on her." After a few moments, he says, "yes, I definitely would." So we are decided that if she chooses to stay in Bere, we'll open her up.
Now, Greg spends a long time explaining to Esther the options and she wisely calls her parents. With the time change, we at first only able to get through to her mom who wisely tells her that the decision is hers. Esther doesn't take long to say that here in Bere she is surrounded by friends and people she knows and the thought of flying to Europe (even accompanied by another of our volunteers who works in France and is leaving next week anyway) and being operated far away from anyone she knows, that thought scares her and she'd rather be operated on her in Chad.
So, the decision is made. Hans, Sonya and Christina go to prepare the OR and make sure everything is as clean and arranged as possible. Liz, Christina and Sarah prepare Esther for her operation.
Greg, Audrey and I wait just in the outer room of the operating block. Once the decision is made, I am anxious to get started. Greg calms me down. We'd already waited an hour or so for her to be able to talk to her father. At about 10pm we are finally ready to start.
I sit Esther up, wipe Betadine across her back, put on sterile gloves and inject a spinal anesthetic. We lay her down and Greg and I leave to respect her privacy while Audrey and the other girls prep the operating site and Audrey drapes her in sterile fashion. Greg and I scrub and when the all clear is given, enter the operating room. Contemporary Christian praise music is going in the background as Greg and I put on our gowns and gloves and Greg moves to the left side and asks for the scalpel.
We then pray officially once again (one of many continual prayers going up since our arrival) and we check to see if the anesthesia has taken effect. It isn't working completely, just giving her some warm tingling feelings in her legs, so Sarah gives her some Ketamine to go on top of her Diazepam and Greg slices from her pubis to just below her belly button.
As we enter the peritoneum, we get a small surge of liquidy pus from the pelvis. We know now, we've made the right decision. It just remains to be seen exactly what's the source. We irrigate and suction out the pus. As I retract, Greg examines the left tube and ovary, the uterus and then the right tube and ovary. Everything is completely normal. He moves over to the cecum and as his fingers work some inflamed tissue free, out pops a very angry appendix right about to burst. With a couple quick clamps, the vessels are clamped, cut and tied. The base of the appendix is then clamped and stick tied twice and sliced off. A lot more irrigation and suction and we close the fascia and skin. It's taken less than an hour, the anesthesia was completely uncomplicated and we take her home to the "ICU" 30 minutes praising God all the way!
If she had been evacuated, she would certainly have perforated either in Gary's plane or in the Air France plane. Amazingly enough, the best care available for her in the world at that moment in her life was found at the Bere Adventist Hospital.
(Story told with the permission of Sarah "Esther")
Monday, November 12, 2007
Wednesday, October 24, 2007
Airborne
The Land Cruiser crashes through the six foot high millet over a windy bumby trail towards the airstrip.
It's a cool Chadian morning just after 6:00 AM.
Rich has picked up Dr. Bond, Sarah and I from the hospital and brought us out here with our pilot, Gary Roberts. We finally burst on to the airstrip with just a tinge of pink lining the wisps of clouds barely clinging to the night before being swept away by the new day.
The plane looks tiny against the backdrop of grassy airstrip hacked from the African bush. Using well placed whacks with long switches a few kids guide some scattered goats across the strip halfway down.
A single prop, four-seater, our plane is about to go international.
Bond is a little nervous and plies Gary with all kinds of questions about flight hours, how many accidents, how much fuel the plane carries, is he going to check if there's water in the fuel, etc. As Gary takes off the tarps and I help him unattach the tie downs Bond is trying to visually inspect the plane from top to bottom. Dressed in his sport coat and sporting wild black hair streaked with gray and the beginnings of a bushy mustache, Bond looks like India's version of Albert Schweitzer.
Finally, luggage weighed and packed, we squeeze ourselves in the fuselage and strap ourselves in.
The engine fires up sending in a burst of "air conditioning" through the open windows. Last minute checks in place, the windows close and Gary turns the plane around away from the sunrise. Gary then reopens a window and yells to the night watchmen to run ahead and pull the stick "goal posts" out of the strip/soccer field so we can take off.
When all is clear, a pull of the throttle lurches us forward and we quickly pick up speed as we bump and bounce across the airstrip and in no time we are airborne as Bere drops out from below us and we take a sharp turn over the trees to buzz the hospital.
It's amazing to see how really small our 20,000 strong village really is. Just a bunch of mudhuts so well camoflouged by the mango trees and millet patches that you can't hardly see anything until the tin roofs of the church, school and finally hospital come into view.
Seeing that tiny clump of trees with a few tin roofs jutting up it's hard to believe that anyone would want to be treated there much less that people would come as far away as Lake Chad and Abeche on the border of Darfur to be operated on in our collection of ragged buildings.
Soon we are crossing a patchwork quilt of rice, millet, peanut and sweet potato fields. The artwork is more of the style of Barcelona's Gaudi with natural lines of trails, islands of trees and a symmetry more geographic than geometric.
We soon pick up the Logone river and follow it's course. Along the banks we see the tiny beehive-shaped, rounded tents of the Arab nomads with herds of cattle and a few horses scattered along the banks. Periodically the glassy surface is broken by the smooth gliding of a wooden log canoe and it's fishermen on their way or already casting their handwoven nets in the shallow, fish-rich waters.
We follow the Logone up and finally see the Tandjile snake it's way up and join it's fast flowing waters right before Koyom and the Pentocostal Hospital. We buzz it's airstrip and notice it's unusable.
Then we pick up altitude, leave the Logone behind and the African plane becomes a distant network of fields, forests and tiny villages.
Finally, we pick up Tchad's other major river, the Chari and follow that all the way to N'Djamena where the Logone and the Chari become one.
One doesn't even notice N'Djamena till one is right on top of it. It's just a large village lost amongst the trees. If it wasn't for the occasional 5-10 story building and the bridge across the Chari and the fact that I knew that's where the Logone joins in I wouldn't have been sure it was N'Djamena. I don't think there is any other capital village in the world like N'Djamena.
The airport is right across the river and has a single runway. There are two other planes pulled up at the airport. We land easily and taxi up the the MAF hangar. Probably the world's smallest international airport (a fact proven later on when we land in Garoua, Cameroun's international airport).
After a few days getting visa's and wasting time trying unsuccessfully to talk to the appropriate authorities to get Gary permission to fly on a permanent basis in Tchad we take off for Cameroun.
Cameroun is unremarkable for about 30 minutes until we hit the national park at Waza where we scare off some herds of antelope and giraffes. I finally feel like I'm really in Africa although some Elephants and Lions would be nice, too.
As we approach Garoua we hit some mountains and Gary flies us between two flat topped plateaus in a valley. The descent combined with an approaching storm and the mountains makes for a bumpy ride that threatens to loosen the tenous hold on my breakfast that I'd been maintaining since N'Djamena.
Sarah had already let up a sickening vomit smell from the back seat. Fortunately, Gary kindly provided us with vomit bags for the flight.
I think it's hypoglycemia as we haven't really eaten well the last few days. We couldn't find any place to stay in N'Djamena until someone finally opened us up a dorm room that hadn't been cleaned in months and didn't have a kitchen. So we were forced to eat off the streets which is slim pickins in N'Djamena (we had to content ourselves with boiled eggs, french rolls and fish soup).
After an uneventful landing and take off for formalities in Garoua, we head into the mountains. The beauty of the rugged cliffs rising from the rich green valleys sprinkeled with fields of corn and millet and wizard hat-like pointed roofed huts is impossible to describe.
Gary calls Maroua Airport to check in and the controller is shocked to hear we're going to Koza since no one has landed there in over 20 years but Gary assures her that the airstrip has been repaired.
One mountain plateau is so broad we dreamed aloud of building a hospital and airstrip on top of it...and it is not exaggerating.
Finally, we climb the last pass and look into Koza's valley. We approach the airstrip. I get the idea Gary is going to land because he goes so low but he's running out of airway. At the last minute he cranks the throttle and whips up over the tree tops before banking hard left and back around. Apparently, he was only looking for cows and holes that kids have dug to find mice to eat.
We circle around again and make a very bouncy jungle strip landing without any problem in time to greet the crowd of kids running up followed by a gang of bikers. By the time we have stopped and started to tie down our two guardians are there with sticks keeping the kids a safe 2-3 feet away. The crowd is so thick it is literally a sea of smiling, laughing and waving faces.
Gary's wife Wendy drives up in Greg and Audrey Shank's pick-up truck and Sarah and my 3 week adventure at the Koza Adventist Hospital (before returning to Bere) is about to begin...
It's a cool Chadian morning just after 6:00 AM.
Rich has picked up Dr. Bond, Sarah and I from the hospital and brought us out here with our pilot, Gary Roberts. We finally burst on to the airstrip with just a tinge of pink lining the wisps of clouds barely clinging to the night before being swept away by the new day.
The plane looks tiny against the backdrop of grassy airstrip hacked from the African bush. Using well placed whacks with long switches a few kids guide some scattered goats across the strip halfway down.
A single prop, four-seater, our plane is about to go international.
Bond is a little nervous and plies Gary with all kinds of questions about flight hours, how many accidents, how much fuel the plane carries, is he going to check if there's water in the fuel, etc. As Gary takes off the tarps and I help him unattach the tie downs Bond is trying to visually inspect the plane from top to bottom. Dressed in his sport coat and sporting wild black hair streaked with gray and the beginnings of a bushy mustache, Bond looks like India's version of Albert Schweitzer.
Finally, luggage weighed and packed, we squeeze ourselves in the fuselage and strap ourselves in.
The engine fires up sending in a burst of "air conditioning" through the open windows. Last minute checks in place, the windows close and Gary turns the plane around away from the sunrise. Gary then reopens a window and yells to the night watchmen to run ahead and pull the stick "goal posts" out of the strip/soccer field so we can take off.
When all is clear, a pull of the throttle lurches us forward and we quickly pick up speed as we bump and bounce across the airstrip and in no time we are airborne as Bere drops out from below us and we take a sharp turn over the trees to buzz the hospital.
It's amazing to see how really small our 20,000 strong village really is. Just a bunch of mudhuts so well camoflouged by the mango trees and millet patches that you can't hardly see anything until the tin roofs of the church, school and finally hospital come into view.
Seeing that tiny clump of trees with a few tin roofs jutting up it's hard to believe that anyone would want to be treated there much less that people would come as far away as Lake Chad and Abeche on the border of Darfur to be operated on in our collection of ragged buildings.
Soon we are crossing a patchwork quilt of rice, millet, peanut and sweet potato fields. The artwork is more of the style of Barcelona's Gaudi with natural lines of trails, islands of trees and a symmetry more geographic than geometric.
We soon pick up the Logone river and follow it's course. Along the banks we see the tiny beehive-shaped, rounded tents of the Arab nomads with herds of cattle and a few horses scattered along the banks. Periodically the glassy surface is broken by the smooth gliding of a wooden log canoe and it's fishermen on their way or already casting their handwoven nets in the shallow, fish-rich waters.
We follow the Logone up and finally see the Tandjile snake it's way up and join it's fast flowing waters right before Koyom and the Pentocostal Hospital. We buzz it's airstrip and notice it's unusable.
Then we pick up altitude, leave the Logone behind and the African plane becomes a distant network of fields, forests and tiny villages.
Finally, we pick up Tchad's other major river, the Chari and follow that all the way to N'Djamena where the Logone and the Chari become one.
One doesn't even notice N'Djamena till one is right on top of it. It's just a large village lost amongst the trees. If it wasn't for the occasional 5-10 story building and the bridge across the Chari and the fact that I knew that's where the Logone joins in I wouldn't have been sure it was N'Djamena. I don't think there is any other capital village in the world like N'Djamena.
The airport is right across the river and has a single runway. There are two other planes pulled up at the airport. We land easily and taxi up the the MAF hangar. Probably the world's smallest international airport (a fact proven later on when we land in Garoua, Cameroun's international airport).
After a few days getting visa's and wasting time trying unsuccessfully to talk to the appropriate authorities to get Gary permission to fly on a permanent basis in Tchad we take off for Cameroun.
Cameroun is unremarkable for about 30 minutes until we hit the national park at Waza where we scare off some herds of antelope and giraffes. I finally feel like I'm really in Africa although some Elephants and Lions would be nice, too.
As we approach Garoua we hit some mountains and Gary flies us between two flat topped plateaus in a valley. The descent combined with an approaching storm and the mountains makes for a bumpy ride that threatens to loosen the tenous hold on my breakfast that I'd been maintaining since N'Djamena.
Sarah had already let up a sickening vomit smell from the back seat. Fortunately, Gary kindly provided us with vomit bags for the flight.
I think it's hypoglycemia as we haven't really eaten well the last few days. We couldn't find any place to stay in N'Djamena until someone finally opened us up a dorm room that hadn't been cleaned in months and didn't have a kitchen. So we were forced to eat off the streets which is slim pickins in N'Djamena (we had to content ourselves with boiled eggs, french rolls and fish soup).
After an uneventful landing and take off for formalities in Garoua, we head into the mountains. The beauty of the rugged cliffs rising from the rich green valleys sprinkeled with fields of corn and millet and wizard hat-like pointed roofed huts is impossible to describe.
Gary calls Maroua Airport to check in and the controller is shocked to hear we're going to Koza since no one has landed there in over 20 years but Gary assures her that the airstrip has been repaired.
One mountain plateau is so broad we dreamed aloud of building a hospital and airstrip on top of it...and it is not exaggerating.
Finally, we climb the last pass and look into Koza's valley. We approach the airstrip. I get the idea Gary is going to land because he goes so low but he's running out of airway. At the last minute he cranks the throttle and whips up over the tree tops before banking hard left and back around. Apparently, he was only looking for cows and holes that kids have dug to find mice to eat.
We circle around again and make a very bouncy jungle strip landing without any problem in time to greet the crowd of kids running up followed by a gang of bikers. By the time we have stopped and started to tie down our two guardians are there with sticks keeping the kids a safe 2-3 feet away. The crowd is so thick it is literally a sea of smiling, laughing and waving faces.
Gary's wife Wendy drives up in Greg and Audrey Shank's pick-up truck and Sarah and my 3 week adventure at the Koza Adventist Hospital (before returning to Bere) is about to begin...
Saturday, September 22, 2007
Why bother?
Sometimes I wonder why I even bother. I stand in the semidarkness of the early evening with my hand over the heart of an 11 year old girl feeling the life ebb out of her. I've detached the ambu-bag from the tracheostomy tube in her neck and she's not breathing. Her pupils are fixed and dilated and I'm now getting to experience for the first time in a raw way the process of life leaving a broken body.
She came in four days ago. She was by the side of the road drawing water from the lake that has now all but flooded the road in between Bere and Kelo. A truck was trying to plow and rev it's way through the water logged mud and slid over towards the girl. She was knocked over and the truck turned on it's side crushing her legs beneath. The passengers frantically unloaded the barrels off the truck and were able to lift the truck up enough to pull her mangled body out from under it.
She arrived at the hospital conscious with her right leg twisted out at an impossible angle and her left leg wrapped in a bloody, mud-splotched t-shirt. She had no apparent head, chest or abdominal injuries, just her two legs.
I unwrap the shirt.
Her left lower leg is sliced open from just below the knee to just above the ankle as with a butcher knife. There is another 6 inch long cut on the side, a 2 inch long cut on the back of the calf and an inch long wound over her outside ankle.
The large lower leg bone is broken and the pieces sticking out at weird angles with much of the rest of the bone exposed.
Her right femur is also fractured, but not open.
We start an IV, give antibiotics and put her under anesthesia. We scrub out the wounds and rinse with liters and liters of antimicrobial fluids. I set the bones which have cracked in a V-shape making the reduction fairly stable. Liz holds the reduction at the foot and I suture the wounds closed.
I put casts around her ankle and knee with a broken broom stick on each side to act as an external fixator. The fracture is stabilized and we have room to clean and dress the wounds.
I then drill a pin through the bone on her other leg and we move her to her hospital bed where I attache a sand-filled shirt to the pin with a rope to act as traction for the femur fracture.
She is breathing well and is otherwise stable.
A few hours later I go to check on her and she is in respiratory distress. She has what is every anesthesiologist's worst nightmare: micrognathia. In other words, her lower jaw never developed well and is so tiny that her mouth won't really open, her tongue is too big for her throat and her airway is small.
She has too many secretions and now her neck has started to swell. She probably had head trauma as well. She is struggling to breath sucking desperately with her chest. I run and get the pulse oximeter and her oxygen is already going down. I yell for the family members to grab her bed and bring her to the OR (it has no wheels so has to be carried...with the traction it'll be impossible to move her quickly otherwise).
I run ahead to open up and go back to find they haven't really moved. I notice she has stopped breathing. I yell again and this time they come running. We somehow manage to get the bed out of the ward, across the courtyard and into the OR.
No breathing, no pulse.
I grab a scalpel and slice her throat. I poke aside the muscles with a clamp and expose her trachea. I cut into it with a scalpel and widen the hole with the clamp and grasp each side with clamps. I insert an endotracheal tube into the hole and attach an ambu bag while Anatole starts chest compressions.
Miraculously, she comes back to life. After a few minutes she is breathing on her own through the tube in her neck and after waiting a while to make sure she's stable we take her back to the ward.
She stays in a coma, however, and we realize she has brain swelling from the accident. For two days we keep the swelling down enough with medicines that she breathes on her own. Her pupils still react normally. On the third day, we have to start breathing for her. The family members take turns "bagging" her to force air into her lungs.
The fourth day, today, the pupils are fixed and dilated.
I'm amazed at how long it can take to try and save a life and how quickly one can remove those life saving devices. Surgery took two hours. The tracheostomy and resuscitation took another hour. Not to mention all the other time spent adjusting meds, explaining to family members, suctioning her tracheostomy tube, etc.
Now in 10 minutes her IV is out, the urinary catheter has been removed, the tracheostomie was pulled, the traction pin drilled out, and the cast cut off. Nothing remains but the sutures and the slightly twisted, un-stabilized legs.
As I sit to write this, I'm sobbing deep down with no tears. How much have I prayed for this girl over the last four days? How much of my own time, strength and energy have I put into her despite having Malaria myself? Why do I bother?
Why does God seem to never intervene? Why does it seem I'm on my own in this?
I need to make sense of it or I'll lose my faith.
Maybe it's not God's fault at all...maybe it's ours. Maybe if this girl had a clean well or running water she wouldn't have been forced to draw from the side of the road. Maybe if the road had been paved with appropriate bridges and drainage systems the truck wouldn't have slid into her. Maybe if the hospital had better lab facilities we could've intervened to prevent any of the number of things that could be unknown contributing factors to her death.
Maybe we in the West can't go out to buy the latest Energy drink or expensive gourmet coffee without using up the resources that could have gone to furnishing clean water sources in the Third World.
Maybe we can't buy bigger and fancier gas-guzzling SUVs without wasting the money that could've gone to provide simple improved infrastructure in developing nations.
Maybe we can't spend millions of dollars on boob jobs and face lifts and lipo suction without depriving bush hospitals of basic laboratory and x-ray equipment.
Maybe we can't live our comfortable lives and sit back and expect God to do the work that he has given us adequate resources, abilities, talents and time to do ourselves. Maybe God's saying, I haven't refused to save that girl's life...
You have.
She came in four days ago. She was by the side of the road drawing water from the lake that has now all but flooded the road in between Bere and Kelo. A truck was trying to plow and rev it's way through the water logged mud and slid over towards the girl. She was knocked over and the truck turned on it's side crushing her legs beneath. The passengers frantically unloaded the barrels off the truck and were able to lift the truck up enough to pull her mangled body out from under it.
She arrived at the hospital conscious with her right leg twisted out at an impossible angle and her left leg wrapped in a bloody, mud-splotched t-shirt. She had no apparent head, chest or abdominal injuries, just her two legs.
I unwrap the shirt.
Her left lower leg is sliced open from just below the knee to just above the ankle as with a butcher knife. There is another 6 inch long cut on the side, a 2 inch long cut on the back of the calf and an inch long wound over her outside ankle.
The large lower leg bone is broken and the pieces sticking out at weird angles with much of the rest of the bone exposed.
Her right femur is also fractured, but not open.
We start an IV, give antibiotics and put her under anesthesia. We scrub out the wounds and rinse with liters and liters of antimicrobial fluids. I set the bones which have cracked in a V-shape making the reduction fairly stable. Liz holds the reduction at the foot and I suture the wounds closed.
I put casts around her ankle and knee with a broken broom stick on each side to act as an external fixator. The fracture is stabilized and we have room to clean and dress the wounds.
I then drill a pin through the bone on her other leg and we move her to her hospital bed where I attache a sand-filled shirt to the pin with a rope to act as traction for the femur fracture.
She is breathing well and is otherwise stable.
A few hours later I go to check on her and she is in respiratory distress. She has what is every anesthesiologist's worst nightmare: micrognathia. In other words, her lower jaw never developed well and is so tiny that her mouth won't really open, her tongue is too big for her throat and her airway is small.
She has too many secretions and now her neck has started to swell. She probably had head trauma as well. She is struggling to breath sucking desperately with her chest. I run and get the pulse oximeter and her oxygen is already going down. I yell for the family members to grab her bed and bring her to the OR (it has no wheels so has to be carried...with the traction it'll be impossible to move her quickly otherwise).
I run ahead to open up and go back to find they haven't really moved. I notice she has stopped breathing. I yell again and this time they come running. We somehow manage to get the bed out of the ward, across the courtyard and into the OR.
No breathing, no pulse.
I grab a scalpel and slice her throat. I poke aside the muscles with a clamp and expose her trachea. I cut into it with a scalpel and widen the hole with the clamp and grasp each side with clamps. I insert an endotracheal tube into the hole and attach an ambu bag while Anatole starts chest compressions.
Miraculously, she comes back to life. After a few minutes she is breathing on her own through the tube in her neck and after waiting a while to make sure she's stable we take her back to the ward.
She stays in a coma, however, and we realize she has brain swelling from the accident. For two days we keep the swelling down enough with medicines that she breathes on her own. Her pupils still react normally. On the third day, we have to start breathing for her. The family members take turns "bagging" her to force air into her lungs.
The fourth day, today, the pupils are fixed and dilated.
I'm amazed at how long it can take to try and save a life and how quickly one can remove those life saving devices. Surgery took two hours. The tracheostomy and resuscitation took another hour. Not to mention all the other time spent adjusting meds, explaining to family members, suctioning her tracheostomy tube, etc.
Now in 10 minutes her IV is out, the urinary catheter has been removed, the tracheostomie was pulled, the traction pin drilled out, and the cast cut off. Nothing remains but the sutures and the slightly twisted, un-stabilized legs.
As I sit to write this, I'm sobbing deep down with no tears. How much have I prayed for this girl over the last four days? How much of my own time, strength and energy have I put into her despite having Malaria myself? Why do I bother?
Why does God seem to never intervene? Why does it seem I'm on my own in this?
I need to make sense of it or I'll lose my faith.
Maybe it's not God's fault at all...maybe it's ours. Maybe if this girl had a clean well or running water she wouldn't have been forced to draw from the side of the road. Maybe if the road had been paved with appropriate bridges and drainage systems the truck wouldn't have slid into her. Maybe if the hospital had better lab facilities we could've intervened to prevent any of the number of things that could be unknown contributing factors to her death.
Maybe we in the West can't go out to buy the latest Energy drink or expensive gourmet coffee without using up the resources that could have gone to furnishing clean water sources in the Third World.
Maybe we can't buy bigger and fancier gas-guzzling SUVs without wasting the money that could've gone to provide simple improved infrastructure in developing nations.
Maybe we can't spend millions of dollars on boob jobs and face lifts and lipo suction without depriving bush hospitals of basic laboratory and x-ray equipment.
Maybe we can't live our comfortable lives and sit back and expect God to do the work that he has given us adequate resources, abilities, talents and time to do ourselves. Maybe God's saying, I haven't refused to save that girl's life...
You have.
Wednesday, September 19, 2007
Dragonflies
I live in a world of incredible suffering and stunning beauty.
As the tall grass itches the backs of my calves I let myself down to the ground. I slip off my white and orange Crocs and use them as a mat. The soccer match is already underway.
The agility, grace and power of the players makes me forget their ages until halftime when the team sporting white t-shirts with their names handpainted on the back rushes by me and past the church yelling my name and shouting "lapia". It's then I remember they're just little kids.
They come back skipping, laughing and smiling, each with a half-eaten, half-ripe guava in hand ready for the second half.
There is not a single artificial sound to be heard. Just the gentle rustle of the breeze in the drying out remnants of the millet harvest, the distant shouts and babble of the kids joking in Nangjere and the buzz of a million dragonfly wings.
I let my focus drift off the obvious, sprawling lushness of the rainy season African bush and onto what hovers between earth and sky so startingly blue it almost hurts to the hundreds of seeming motionless hovering dragonflies. They are evenly spaced about a meter apart and at seemingly haphazard levels that nonetheless give a sense of order in some weird mathematical way.
The light has taken on that quality one only finds right before it sets low enough to turn color but after it's reached it's peak where it shines directly. The billowing white clouds make a perfect canvas to reflect the brilliance of the sun's perfect angle and to mute it just so it brings out everything in a sharpness of detail not noticed as absent until it rarely presents itself.
I feel transported to another time and another place. A time and a place where I wasn't watching babies die every day. A time and a place where it's almost unheard of for a woman to have lost a child tragically. A time and a place where I wasn't the only doctor for hundreds of thousands of the poor and suffering. A time and a place where I don't feel overwhelmed almost constantly. A time and a place that for me is a fading memory reawakened occasionally by miraculous, dragonfly filled moments.
As the kids resume their match, some older boys start a small circle of soccer "foreplay". Each one takes the ball and bounces it off a knee, or feet several times, maybe a head bump or two and then passes it to the next guy...hopefully without ever letting the ball touch the ground.
Four younger kids are alternately sprawling around, rolling back and forth and chasing a tiny, pink, half-deflated ball back and forth.
All the children on the field (and off) are barefoot except for one who looks like he's wearing army boots and socks three sizes to big. The score is one to one.
Behind me, I notice a newcomer on the scene. A boy about 12 or 13 years old. He's crippled. He has a single homemade wooden crutch. One leg is severely shortened causing his whole body to swerve and lean. Somehow, he still manages to join the boys in their game, kicking the ball around with both feet as he hops around on his crutch.
I call Tabegue, Samedi's nephew, over and tell him I want to talk to the handicapped kid.
His story is tragic, yet all to common here in Tchad.
In 2002, he was just running and then felt his leg "give way". According to him, it was "out of joint". He had many traditional bone setters try and put it in, but it never healed right and he's been crippled ever since.
I have him lie on the ground as all the kids not playing in the match gather quickly around to watch. His left knee is about 10 inches shorter than his right. His left lower leg is normal. His hip has a surprising range of motion, but there is a bony mass sticking up, out and back.
What probably happened is something that in the developed world would be operated on right away with a few pins and six weeks later he'd be back walking hardly knowing that if he'd been born in a different country, he'd be handicapped for life.
I tell him to come see me the next day at the hospital. I hope to be able to help him.
He still hasn't shown up...but the dragonflies hover on.
As the tall grass itches the backs of my calves I let myself down to the ground. I slip off my white and orange Crocs and use them as a mat. The soccer match is already underway.
The agility, grace and power of the players makes me forget their ages until halftime when the team sporting white t-shirts with their names handpainted on the back rushes by me and past the church yelling my name and shouting "lapia". It's then I remember they're just little kids.
They come back skipping, laughing and smiling, each with a half-eaten, half-ripe guava in hand ready for the second half.
There is not a single artificial sound to be heard. Just the gentle rustle of the breeze in the drying out remnants of the millet harvest, the distant shouts and babble of the kids joking in Nangjere and the buzz of a million dragonfly wings.
I let my focus drift off the obvious, sprawling lushness of the rainy season African bush and onto what hovers between earth and sky so startingly blue it almost hurts to the hundreds of seeming motionless hovering dragonflies. They are evenly spaced about a meter apart and at seemingly haphazard levels that nonetheless give a sense of order in some weird mathematical way.
The light has taken on that quality one only finds right before it sets low enough to turn color but after it's reached it's peak where it shines directly. The billowing white clouds make a perfect canvas to reflect the brilliance of the sun's perfect angle and to mute it just so it brings out everything in a sharpness of detail not noticed as absent until it rarely presents itself.
I feel transported to another time and another place. A time and a place where I wasn't watching babies die every day. A time and a place where it's almost unheard of for a woman to have lost a child tragically. A time and a place where I wasn't the only doctor for hundreds of thousands of the poor and suffering. A time and a place where I don't feel overwhelmed almost constantly. A time and a place that for me is a fading memory reawakened occasionally by miraculous, dragonfly filled moments.
As the kids resume their match, some older boys start a small circle of soccer "foreplay". Each one takes the ball and bounces it off a knee, or feet several times, maybe a head bump or two and then passes it to the next guy...hopefully without ever letting the ball touch the ground.
Four younger kids are alternately sprawling around, rolling back and forth and chasing a tiny, pink, half-deflated ball back and forth.
All the children on the field (and off) are barefoot except for one who looks like he's wearing army boots and socks three sizes to big. The score is one to one.
Behind me, I notice a newcomer on the scene. A boy about 12 or 13 years old. He's crippled. He has a single homemade wooden crutch. One leg is severely shortened causing his whole body to swerve and lean. Somehow, he still manages to join the boys in their game, kicking the ball around with both feet as he hops around on his crutch.
I call Tabegue, Samedi's nephew, over and tell him I want to talk to the handicapped kid.
His story is tragic, yet all to common here in Tchad.
In 2002, he was just running and then felt his leg "give way". According to him, it was "out of joint". He had many traditional bone setters try and put it in, but it never healed right and he's been crippled ever since.
I have him lie on the ground as all the kids not playing in the match gather quickly around to watch. His left knee is about 10 inches shorter than his right. His left lower leg is normal. His hip has a surprising range of motion, but there is a bony mass sticking up, out and back.
What probably happened is something that in the developed world would be operated on right away with a few pins and six weeks later he'd be back walking hardly knowing that if he'd been born in a different country, he'd be handicapped for life.
I tell him to come see me the next day at the hospital. I hope to be able to help him.
He still hasn't shown up...but the dragonflies hover on.
Sunday, September 2, 2007
Dabegue
It's pouring down rain soaking through my jeans and fogging up my glasses. Sarah and I have saddled up the horses, packed the medicines in the saddlebags and are on our way to Noel's.
The 6-8 foot tall millet and corn leans out haphazardly over the windy, mud puddle-filled road across the Western edge of town. I get slapped in the face and chest several times with the long, firm heads on the weaving stalks as the horse gallops back and forth in the slalom course of small ponds (complete with ducks and frogs) in the middle of the path.
Noel's house is the last one on the road that heads to Delbian and eventually Bao and Moundou. It's a conglomerate of partially finished mud brick buildings, some without roof, doors and windows, some with tin used for all of the above. He is waiting outside leaning his chair back against the wall.
Noel, former Russian and Libyan-trained terrorist turned hospital chaplain is dressed in a tan jump suit with a black and red striped beanie slouched lazily on his shaved head. He sports a scruffy goatee and partial beard already tinged with gray.
He manages to get on the third horse after a couple of attempts and we're off to Dabegue.
After a couple kilometers we enter the village which stretches for about 5km hugging the road without much depth. It's just a rough collection of mud hut concessions with interspersed fields of rice, millet, corn, peanuts and sweet potatos.
Halfway through the village we turn left at what's left of a burned out tree trunk that was struck by lightening years ago. We weave through a narrow passage with millet stalks swaying on both sides and come out in the open under a large mango tree with a mud brick wall on the left. Two rickety wooden chairs made low to the ground and leaned back for lounging are around a rickety metal "coffee table".
Our host hurries out to greet us with his wife. They both look familiar. I don't figure out how I know them till a little later after which I become amazed at God's working through our mistakes.
It doesn't take long for the kids to pour in from all directions and take their seat on a large mat with 4 galloping horses woven into the pattern in yellow and red. Noel pulls out two Bible picture rolls. At first the kids are shy with two strangers there. Noel tries to teach them a song in Nangere but no one gets into it until we make it a competition with Noel and the guys against me and the girls to see who can sing loudest.
Then, he calls up the kids to say what they can name from the picture story of last week. They are so proud to recognize Mary and Joseph and Jesus and the wise men, getting a round of applause and "bravos" let by Noel each time.
The toothy grins and laughter is contagious and I'm having a great time trying to pick up some Nangere here and there as Noel continues the story of Jesus.
After 15 minutes we sing another song and then I get to try and answer the adults' question from last week as to why horses and lions don't get along these days like they do in the picture of Adam in the Garden of Eden.
I talk in French and Noel translates into Nangere. They all understand about the serpent (Genesis 3) and then how it is really the devil who made war against God by rebelling against him (Revelation 12) and how it came about through his pride and ambition to be like God (Isaiah 14 and Ezekiel 28). It seems to make sense after all that rebellion from Adam and Eve leading up to the flood and Noah when God says that he'll make the animals afraid of humans that it's the result of rebellion why horses and lions just don't get along.
We finish after about 30 minutes and then Sarah and I start to consult kids. We've brought a battery powered device to check hemoglobin's and find 5 kids with hemoglobin's of 5 or less (normal is 14-16) due to malaria. We refer them to the hospital for blood transfusions. The rest we treat for Malaria and parasites. We see 80 kids in a little over an hour.
After a meal of boiled eggs, steamed corn and chicken and rice we pack up to go home.
Half an hour after arriving home, Deuhibe knocks on the door. Short with sharp facial features, Deuhibe is one of our newest and best nurses. Dressed in bright aqua scrubs and a long white coat I know he must have a case for me.
He starts to explain about several patients but I quickly realize I need to see the patients so I walk over to the hospital with him.
We head first to labor and delivery. The room is dark and there is a young woman, obviously pregnant stretched out on her left side on the exam table. It's her first pregnancy and she's been in our hospital in labor since 3:00am today. She has been fully dilated for hours and can't deliver.
I have her turn onto her back and grab the fetal doppler off the table. I squirt a glob of ultrasound jelly onto her belly between her belly button and her right pelvis and stretch out the doppler stick on its telephone like curly cue cord to place it on the jelly. I fire up the on button to a reassuring crackle as the move the device gently over the belly until I hear the reassuring boom-boom, boom-boom of a rapid fetal heart beat running at 140 per minute.
The baby's still alive.
I hurry to the OR and get the symphysiotomie kit, a suture, a scalpel, a razor blade, some gauze sponges, Bernadine, a syringe, some lidocaine, a foley catheter with bag, a pair of sterile gloves and a vacuum extractor.
While Deuhibe inserts the urinary catheter I shave the pubic area with the razor, prep it with betadine and inject 10cc of lidocaine into the skin and around and in the pubic cartilage of her pelvis.
I open the symphysiotomie kit, attach a large scalpel to the scalpel holder and make a small incision all the way down to the cartilage. I then stick my other hand inside to move the urinary catheter to the side effectively displacing the urethra. I slice through the cartilage which cuts remarkably easily until I'm most of the way through.
Then, Deuhibe and Odei pull the legs up out and down until we hear a pop and feel the pelvis come apart a few centimeters. She has a contraction, I attach the vacuum pump, I make an lateral episiotomy with the surgical scissors to open up the vaginal opening and with one push the baby is out.
His face wrinkles up and his arms and legs are nicely flexed but he doesn't cry or breath. I suck out the green, meconium thick fluid out of his mouth and nose, clamp the umbilical cord, cut between the clamps and take him over to the resuscitation table.
He has a good heart beat but still doesn't want to breath. I rough him up a little on his spine and feet while vigorously drying him off.
Still no cry.
I pump his chest a little and put a tiny mask on his face and give him a few breaths.
Finally he lets out a little whimper. I continue my shaking and rubbing and he finally starts to breath and wail.
I return to the mom, pull out the placenta, suture up the syphysiotomie wound in two layers (fascia and skin) and suture the episiotomie.
Deuhibe then takes me to see the next two cases.
The first is a four year old girl with fever and abdominal pain. They've started her on a quinine drip. I look at her, and I can't explain why, but I feel there's something else going on. She hasn't vomited but hasn't pooped in two days. She doesn't really want to eat but has taken some porridge. Her eyes look kind of glazed over (not unusual in severe malaria). The abdominal pain could be just malaria or constipation.
I feel her belly. It's soft but tender. She kind of whimpers when I touch her but it doesn't seem too bad.
For some reason, something bothers me, though. I decide to do a rectal exam. She seems tender on the right and not the left.
I'm afraid it might be appendicitis, but I'm nervous about operating. She'd come in the morning with anemia and had been transfused. Maybe it's just severe malaria. If it is, I could kill her by operating.
I decide to buy some time and order antibiotics and more IV fluids while I go look at the next patient.
This one is straight forward, a strangulated hernia. The hernia is massive, painful and won't go back inside. He's vomited once.
We take him straight to the OR.
After prep, scrub and drape under spinal anesthesia I make a large diagonal incision directly over the bulging hernia. I dissect the sack free from the spermatic cord and the contents pop back in to the abdomen. I take out the testicle, tie off the sack and stitch a piece of sterilized mosquito netting over the week spot between the transversalis fascia and the inguinal ligament.
He's 60 years old and doesn't need more than one testicle anyway and this way it's sure not to recur.
I close up the fascia and skin, take off my gloves and go back to see the four year old girl.
Something still bothers me and I make a tough decision. I tell the father that she'll die without an operation but she might die during the surgery. Does he want us to go through with it? He's in agreement so we wheel her off to the OR.
We give her Ketamine, prep the belly with Bernadine and drape it with sterile towels. I use the tubal ligation kit which has smaller re tractors for this tiny abdomen.
I pray as usual and then slice carefully through the thin skin, tiny fascia and muscles and gently enter the peritoneal cavity.
Purulent fluid and a dark intestine bulge out letting me know instantly it was a good decision to operate.
I enlarge the abdominal wound and out pops a blackened small intestine, so necrotic it's at the point of perforating but appears to have held itself intact so far.
I break away some adhesions and it's finally freed up. The black, dusky parts go almost all the way to the large intestine on the distal end and about a foot and a half proximally.
I open the laparotomie kit and pull out the bowel clamps. I clamp over healthy intestine and then a second one over the part to be removed. I then clamp off the vessels feeding the dead intestine and remove it all together.
I tie off the vessels in the mesentery and then examine the two ends of remaining intestine. the proximal end looks good but the distal end looks dead. I'm worried because there's only about 2-3 cms of intestine left until the colon. It'll be much more difficult if I have to open the colon to reattach the small intestine. I remove one centimeter more leaving just barely over a cm but now it looks fairly healthy.
I suture the tiny small bowel with tiny sutures and then do a second layer. I take off the clamps and there is no leaking or bleeding. I insert two drains.
Then she starts to vomit. And vomit. And vomit. Dark green with black coffee grounds. We insert an nasogastrique tube and get almost half a liter out of her stomach. I wash out the abdomen with a lot of fluids, close the fascia and skin, and place a bandage.
I prescribe antibiotics, IV fluids, tell the family not to give her anything to eat or drink and go home.
The next day, the woman and her baby, the man with the hernia and the little girl are all still alive. I give post-op advice to Samedi, our surgical nurse, and pack my bag and hop on a motorcycle to head to Moundou and the refugee camp at Gore...I wonder if the girl will be alive when I return...
The 6-8 foot tall millet and corn leans out haphazardly over the windy, mud puddle-filled road across the Western edge of town. I get slapped in the face and chest several times with the long, firm heads on the weaving stalks as the horse gallops back and forth in the slalom course of small ponds (complete with ducks and frogs) in the middle of the path.
Noel's house is the last one on the road that heads to Delbian and eventually Bao and Moundou. It's a conglomerate of partially finished mud brick buildings, some without roof, doors and windows, some with tin used for all of the above. He is waiting outside leaning his chair back against the wall.
Noel, former Russian and Libyan-trained terrorist turned hospital chaplain is dressed in a tan jump suit with a black and red striped beanie slouched lazily on his shaved head. He sports a scruffy goatee and partial beard already tinged with gray.
He manages to get on the third horse after a couple of attempts and we're off to Dabegue.
After a couple kilometers we enter the village which stretches for about 5km hugging the road without much depth. It's just a rough collection of mud hut concessions with interspersed fields of rice, millet, corn, peanuts and sweet potatos.
Halfway through the village we turn left at what's left of a burned out tree trunk that was struck by lightening years ago. We weave through a narrow passage with millet stalks swaying on both sides and come out in the open under a large mango tree with a mud brick wall on the left. Two rickety wooden chairs made low to the ground and leaned back for lounging are around a rickety metal "coffee table".
Our host hurries out to greet us with his wife. They both look familiar. I don't figure out how I know them till a little later after which I become amazed at God's working through our mistakes.
It doesn't take long for the kids to pour in from all directions and take their seat on a large mat with 4 galloping horses woven into the pattern in yellow and red. Noel pulls out two Bible picture rolls. At first the kids are shy with two strangers there. Noel tries to teach them a song in Nangere but no one gets into it until we make it a competition with Noel and the guys against me and the girls to see who can sing loudest.
Then, he calls up the kids to say what they can name from the picture story of last week. They are so proud to recognize Mary and Joseph and Jesus and the wise men, getting a round of applause and "bravos" let by Noel each time.
The toothy grins and laughter is contagious and I'm having a great time trying to pick up some Nangere here and there as Noel continues the story of Jesus.
After 15 minutes we sing another song and then I get to try and answer the adults' question from last week as to why horses and lions don't get along these days like they do in the picture of Adam in the Garden of Eden.
I talk in French and Noel translates into Nangere. They all understand about the serpent (Genesis 3) and then how it is really the devil who made war against God by rebelling against him (Revelation 12) and how it came about through his pride and ambition to be like God (Isaiah 14 and Ezekiel 28). It seems to make sense after all that rebellion from Adam and Eve leading up to the flood and Noah when God says that he'll make the animals afraid of humans that it's the result of rebellion why horses and lions just don't get along.
We finish after about 30 minutes and then Sarah and I start to consult kids. We've brought a battery powered device to check hemoglobin's and find 5 kids with hemoglobin's of 5 or less (normal is 14-16) due to malaria. We refer them to the hospital for blood transfusions. The rest we treat for Malaria and parasites. We see 80 kids in a little over an hour.
After a meal of boiled eggs, steamed corn and chicken and rice we pack up to go home.
Half an hour after arriving home, Deuhibe knocks on the door. Short with sharp facial features, Deuhibe is one of our newest and best nurses. Dressed in bright aqua scrubs and a long white coat I know he must have a case for me.
He starts to explain about several patients but I quickly realize I need to see the patients so I walk over to the hospital with him.
We head first to labor and delivery. The room is dark and there is a young woman, obviously pregnant stretched out on her left side on the exam table. It's her first pregnancy and she's been in our hospital in labor since 3:00am today. She has been fully dilated for hours and can't deliver.
I have her turn onto her back and grab the fetal doppler off the table. I squirt a glob of ultrasound jelly onto her belly between her belly button and her right pelvis and stretch out the doppler stick on its telephone like curly cue cord to place it on the jelly. I fire up the on button to a reassuring crackle as the move the device gently over the belly until I hear the reassuring boom-boom, boom-boom of a rapid fetal heart beat running at 140 per minute.
The baby's still alive.
I hurry to the OR and get the symphysiotomie kit, a suture, a scalpel, a razor blade, some gauze sponges, Bernadine, a syringe, some lidocaine, a foley catheter with bag, a pair of sterile gloves and a vacuum extractor.
While Deuhibe inserts the urinary catheter I shave the pubic area with the razor, prep it with betadine and inject 10cc of lidocaine into the skin and around and in the pubic cartilage of her pelvis.
I open the symphysiotomie kit, attach a large scalpel to the scalpel holder and make a small incision all the way down to the cartilage. I then stick my other hand inside to move the urinary catheter to the side effectively displacing the urethra. I slice through the cartilage which cuts remarkably easily until I'm most of the way through.
Then, Deuhibe and Odei pull the legs up out and down until we hear a pop and feel the pelvis come apart a few centimeters. She has a contraction, I attach the vacuum pump, I make an lateral episiotomy with the surgical scissors to open up the vaginal opening and with one push the baby is out.
His face wrinkles up and his arms and legs are nicely flexed but he doesn't cry or breath. I suck out the green, meconium thick fluid out of his mouth and nose, clamp the umbilical cord, cut between the clamps and take him over to the resuscitation table.
He has a good heart beat but still doesn't want to breath. I rough him up a little on his spine and feet while vigorously drying him off.
Still no cry.
I pump his chest a little and put a tiny mask on his face and give him a few breaths.
Finally he lets out a little whimper. I continue my shaking and rubbing and he finally starts to breath and wail.
I return to the mom, pull out the placenta, suture up the syphysiotomie wound in two layers (fascia and skin) and suture the episiotomie.
Deuhibe then takes me to see the next two cases.
The first is a four year old girl with fever and abdominal pain. They've started her on a quinine drip. I look at her, and I can't explain why, but I feel there's something else going on. She hasn't vomited but hasn't pooped in two days. She doesn't really want to eat but has taken some porridge. Her eyes look kind of glazed over (not unusual in severe malaria). The abdominal pain could be just malaria or constipation.
I feel her belly. It's soft but tender. She kind of whimpers when I touch her but it doesn't seem too bad.
For some reason, something bothers me, though. I decide to do a rectal exam. She seems tender on the right and not the left.
I'm afraid it might be appendicitis, but I'm nervous about operating. She'd come in the morning with anemia and had been transfused. Maybe it's just severe malaria. If it is, I could kill her by operating.
I decide to buy some time and order antibiotics and more IV fluids while I go look at the next patient.
This one is straight forward, a strangulated hernia. The hernia is massive, painful and won't go back inside. He's vomited once.
We take him straight to the OR.
After prep, scrub and drape under spinal anesthesia I make a large diagonal incision directly over the bulging hernia. I dissect the sack free from the spermatic cord and the contents pop back in to the abdomen. I take out the testicle, tie off the sack and stitch a piece of sterilized mosquito netting over the week spot between the transversalis fascia and the inguinal ligament.
He's 60 years old and doesn't need more than one testicle anyway and this way it's sure not to recur.
I close up the fascia and skin, take off my gloves and go back to see the four year old girl.
Something still bothers me and I make a tough decision. I tell the father that she'll die without an operation but she might die during the surgery. Does he want us to go through with it? He's in agreement so we wheel her off to the OR.
We give her Ketamine, prep the belly with Bernadine and drape it with sterile towels. I use the tubal ligation kit which has smaller re tractors for this tiny abdomen.
I pray as usual and then slice carefully through the thin skin, tiny fascia and muscles and gently enter the peritoneal cavity.
Purulent fluid and a dark intestine bulge out letting me know instantly it was a good decision to operate.
I enlarge the abdominal wound and out pops a blackened small intestine, so necrotic it's at the point of perforating but appears to have held itself intact so far.
I break away some adhesions and it's finally freed up. The black, dusky parts go almost all the way to the large intestine on the distal end and about a foot and a half proximally.
I open the laparotomie kit and pull out the bowel clamps. I clamp over healthy intestine and then a second one over the part to be removed. I then clamp off the vessels feeding the dead intestine and remove it all together.
I tie off the vessels in the mesentery and then examine the two ends of remaining intestine. the proximal end looks good but the distal end looks dead. I'm worried because there's only about 2-3 cms of intestine left until the colon. It'll be much more difficult if I have to open the colon to reattach the small intestine. I remove one centimeter more leaving just barely over a cm but now it looks fairly healthy.
I suture the tiny small bowel with tiny sutures and then do a second layer. I take off the clamps and there is no leaking or bleeding. I insert two drains.
Then she starts to vomit. And vomit. And vomit. Dark green with black coffee grounds. We insert an nasogastrique tube and get almost half a liter out of her stomach. I wash out the abdomen with a lot of fluids, close the fascia and skin, and place a bandage.
I prescribe antibiotics, IV fluids, tell the family not to give her anything to eat or drink and go home.
The next day, the woman and her baby, the man with the hernia and the little girl are all still alive. I give post-op advice to Samedi, our surgical nurse, and pack my bag and hop on a motorcycle to head to Moundou and the refugee camp at Gore...I wonder if the girl will be alive when I return...
Sunday, August 19, 2007
How to catch a wife, Chadian style
I follow the shadows in front of me. With just stars to light the way, I follow Samedi and Abre to Abre's house winding amongst the shadows in the shapes of pointed roofed huts, trees, tall millet stalks and brick fences.
We round a corner and the shadows dance on the walls of the compound in the flickering light of a kerosene lamp as the shadow of Abre's wife brings in some wooden stools for us to sit on. Then she returns for the formal greeting of curtsying at the waist and bending the knees to present her hand bent at a 45 degree angle down to be shaken by each visitor.
Abre presents his problem for Samedi and I to give advice on. Once the advice has been adequately discussed and accepted, Abre's wife brings out a small metal pot filled with pasta shells and a goat meat sauce. The repas is set on the rickety wooden "coffee table" and we lean forward and dig in with our large, flimsy spoons.
As we sit up, belly's full, I ask Abre what I think will be a simple question. It turns out to be a long, twisted story that I don't really understand until later.
"Abre, how did you meet your wife?"
Abre clears his throat and starts spinning his tale in his rich, deep baritone voice.
"I was back in the village. I'd come to Béré for high school. I went home on weekends. When classes were over I went home to work my field. I saw this girl from a long way off. She pleased me.
"A few days later, she came to draw water at our well. I had a mango in my hand. I offered it to her. She didn't want it. I insisted. I asked her why I would give her a bad mango? She took it.
"When she came back to draw water a few days later, I had a bunch of mangoes to give her. We started to talk.
"I told my father that was the girl I wanted to marry. She was from a village 6 km away but had come to go to the school in my village, Kalme, and was the servant of my neighbor.
"My dad said it wasn't wise to get a girl from that village, but it was up to me. He would pay the dowry, but then it was up to me. So he did.
"Half-way through the next school year, I decided it was time to find her. I heard she was in a certain village. I went there with my friends, but she had just left. I heard she was at the market, I went there with my friends, but she wasn't there. Finally, I heard she was back in Kalme. I went there to the house where she'd been a servant. She wasn''t there.
"I knew then she was back at her parents house. I called together three of my strongest friends. I told them that tonight was the night. They nodded and we left at 10pm to walk to the girl's village. When we got to the outskirts, I told my friends to wait. I left my bike a little farther on under a certain tree.
"I snuck into the village and stole into the girl's family compound. Stealthily, I made my way to her hut. I knocked on the door. No answer. I knocked again. Still nothing. I knocked again and whispered loudly 'it's me.' She opened the door and told me to leave. I refused. I told her to come out and go get my bike under such and such a tree. She said no so I grabbed her hand and made her come with me. She fought, but not loudly enough to wake her family.
"I brought her to my bike and then to my friends. We Took her by force home to my village that very night. We got in at 5am. That's how I got my wife."
I'm sitting there stunned. Not exactly the romantic love story I'd hoped for. Fortunately, before I could say anything stupid, Samedi pipes up with an explanation.
"That's our tradition. The woman should be stolen from her family by the man who's paid the dowry. He should get his strongest friends to go with him because the family will resist and if he's not strong enough to take his wife be force they'll beat him up. Then, a week later, the girl will get her girlfriend's together and they'll go to the boy for the marriage. But everyone will make fun of him and say he wasn't strong enough to fight for his woman. So, you need to strategize, come at night and bring some tough guys with you if you want to be respected."
The next night, I'm sitting around a similar table, only this time well lighted, with our Pastor Dieudonne Atchouma. I tell him what Abre had said last night.
"That's nothing," he said. "You should check out the tribe around Bongor. Their woman are tough. They all know how to use the bowstaff like the Chinese. From an early age, the girls practice out in the fields. When you want to get married, after you pay the dowry, you are sent off into the bush with the woman and you have to fight her. If you can't beat her, she'll beat you to a pulp and send you home with your tail between your legs and you'll have to find another woman. If you beat her however, and are able to disarm her and capture her and bring her home, then you've earned her and the village's respect and you can marry her.
"Those woman are fierce. Back in the days of the German colonists, they tried to conquer this people. They had guns and everything but they were beaten back by the women with their bowstaffs. They're hard-core."
James
We round a corner and the shadows dance on the walls of the compound in the flickering light of a kerosene lamp as the shadow of Abre's wife brings in some wooden stools for us to sit on. Then she returns for the formal greeting of curtsying at the waist and bending the knees to present her hand bent at a 45 degree angle down to be shaken by each visitor.
Abre presents his problem for Samedi and I to give advice on. Once the advice has been adequately discussed and accepted, Abre's wife brings out a small metal pot filled with pasta shells and a goat meat sauce. The repas is set on the rickety wooden "coffee table" and we lean forward and dig in with our large, flimsy spoons.
As we sit up, belly's full, I ask Abre what I think will be a simple question. It turns out to be a long, twisted story that I don't really understand until later.
"Abre, how did you meet your wife?"
Abre clears his throat and starts spinning his tale in his rich, deep baritone voice.
"I was back in the village. I'd come to Béré for high school. I went home on weekends. When classes were over I went home to work my field. I saw this girl from a long way off. She pleased me.
"A few days later, she came to draw water at our well. I had a mango in my hand. I offered it to her. She didn't want it. I insisted. I asked her why I would give her a bad mango? She took it.
"When she came back to draw water a few days later, I had a bunch of mangoes to give her. We started to talk.
"I told my father that was the girl I wanted to marry. She was from a village 6 km away but had come to go to the school in my village, Kalme, and was the servant of my neighbor.
"My dad said it wasn't wise to get a girl from that village, but it was up to me. He would pay the dowry, but then it was up to me. So he did.
"Half-way through the next school year, I decided it was time to find her. I heard she was in a certain village. I went there with my friends, but she had just left. I heard she was at the market, I went there with my friends, but she wasn't there. Finally, I heard she was back in Kalme. I went there to the house where she'd been a servant. She wasn''t there.
"I knew then she was back at her parents house. I called together three of my strongest friends. I told them that tonight was the night. They nodded and we left at 10pm to walk to the girl's village. When we got to the outskirts, I told my friends to wait. I left my bike a little farther on under a certain tree.
"I snuck into the village and stole into the girl's family compound. Stealthily, I made my way to her hut. I knocked on the door. No answer. I knocked again. Still nothing. I knocked again and whispered loudly 'it's me.' She opened the door and told me to leave. I refused. I told her to come out and go get my bike under such and such a tree. She said no so I grabbed her hand and made her come with me. She fought, but not loudly enough to wake her family.
"I brought her to my bike and then to my friends. We Took her by force home to my village that very night. We got in at 5am. That's how I got my wife."
I'm sitting there stunned. Not exactly the romantic love story I'd hoped for. Fortunately, before I could say anything stupid, Samedi pipes up with an explanation.
"That's our tradition. The woman should be stolen from her family by the man who's paid the dowry. He should get his strongest friends to go with him because the family will resist and if he's not strong enough to take his wife be force they'll beat him up. Then, a week later, the girl will get her girlfriend's together and they'll go to the boy for the marriage. But everyone will make fun of him and say he wasn't strong enough to fight for his woman. So, you need to strategize, come at night and bring some tough guys with you if you want to be respected."
The next night, I'm sitting around a similar table, only this time well lighted, with our Pastor Dieudonne Atchouma. I tell him what Abre had said last night.
"That's nothing," he said. "You should check out the tribe around Bongor. Their woman are tough. They all know how to use the bowstaff like the Chinese. From an early age, the girls practice out in the fields. When you want to get married, after you pay the dowry, you are sent off into the bush with the woman and you have to fight her. If you can't beat her, she'll beat you to a pulp and send you home with your tail between your legs and you'll have to find another woman. If you beat her however, and are able to disarm her and capture her and bring her home, then you've earned her and the village's respect and you can marry her.
"Those woman are fierce. Back in the days of the German colonists, they tried to conquer this people. They had guns and everything but they were beaten back by the women with their bowstaffs. They're hard-core."
James
Marie
I'm poised over the body, scalpel in hand. It's hard to believe that this will be the third major surgery on this poor woman in a month. I've been torn inside as to whether this is the right thing to do, but now as I stand ready to cut, I feel peace.
"Let's pray."
As Samedi prays in Nangjere I find images rapidly running through my mind:
Huge mass. Cut ureter. Tied femoral vessels. Sinking feeling realising what I've done. Meticulous suturing. 4 hour surgery. Feeling of failure. Swollen leg, but alive. Slow but sure recovery. Discharge. Return a week later with swollen belly. Ultrasound showing loculated fluid. Is it tumor or leaking urine. Abdominal surgery again. Belly full of yellow liquid. Every surface inflammed and stuck together. Jelly like substance on everything. Retention sutures. Two drains. Three weeks in the hospital with liters of fluid still coming out. Uncertainty. If it's the leaking ureter I should take out her kidney. If it's the tumor, why put her through another major operation. Today, there's pus coming out the drain. I can't wait longer.
I open my eyes and slice from the bottom of her last rib, across her side to in front of her pelvic bone. I use the electric cautery to slowy go through fat, fascia and the different muscle layers. I open the cavity over the kidney. I dissect out the fat. I slowly release the fine fibers attaching the kidney surface to the surronding tissues. I work my way deep in and around the top part taking off the adrenal gland. Then aroudn the bottom part and the back. Finally I find the huge renal artery and vein. I delicately strip off the fat till I can see it well. It's so deep. I'm trying to not shake in my nervousness. If I don't tie it off well, she could bleed out quick. I don't really have the right instruments. I finally get three clamps on the artery. I cut the artery and tie the part I'm leaving in two places and the part I'm taking out in one. The vein is huge and branches right under where I've cut the artery. I have to go deeper. Finally I clamp it and cut it. Then the ureter is clamped and cut. I pull out the kidney and then tie off the ureteral stump. Then I tie off the vein twice and release the clamp. Blood surges into the field. I clamp the stump quickly, put it under a little tension while Samedi suctions till I can see where it's bleeding and clamp that. I tie it off. I release it. No bleeding.
I close up and finally, Marie Guelia, goes home a week later completely healed. I know that what I have done I am incapable of having done. But that's the cool thing about working here, God puts me in situations where I know I can't do it, and then when I do, I can't help but give him the credit.
James
"Let's pray."
As Samedi prays in Nangjere I find images rapidly running through my mind:
Huge mass. Cut ureter. Tied femoral vessels. Sinking feeling realising what I've done. Meticulous suturing. 4 hour surgery. Feeling of failure. Swollen leg, but alive. Slow but sure recovery. Discharge. Return a week later with swollen belly. Ultrasound showing loculated fluid. Is it tumor or leaking urine. Abdominal surgery again. Belly full of yellow liquid. Every surface inflammed and stuck together. Jelly like substance on everything. Retention sutures. Two drains. Three weeks in the hospital with liters of fluid still coming out. Uncertainty. If it's the leaking ureter I should take out her kidney. If it's the tumor, why put her through another major operation. Today, there's pus coming out the drain. I can't wait longer.
I open my eyes and slice from the bottom of her last rib, across her side to in front of her pelvic bone. I use the electric cautery to slowy go through fat, fascia and the different muscle layers. I open the cavity over the kidney. I dissect out the fat. I slowly release the fine fibers attaching the kidney surface to the surronding tissues. I work my way deep in and around the top part taking off the adrenal gland. Then aroudn the bottom part and the back. Finally I find the huge renal artery and vein. I delicately strip off the fat till I can see it well. It's so deep. I'm trying to not shake in my nervousness. If I don't tie it off well, she could bleed out quick. I don't really have the right instruments. I finally get three clamps on the artery. I cut the artery and tie the part I'm leaving in two places and the part I'm taking out in one. The vein is huge and branches right under where I've cut the artery. I have to go deeper. Finally I clamp it and cut it. Then the ureter is clamped and cut. I pull out the kidney and then tie off the ureteral stump. Then I tie off the vein twice and release the clamp. Blood surges into the field. I clamp the stump quickly, put it under a little tension while Samedi suctions till I can see where it's bleeding and clamp that. I tie it off. I release it. No bleeding.
I close up and finally, Marie Guelia, goes home a week later completely healed. I know that what I have done I am incapable of having done. But that's the cool thing about working here, God puts me in situations where I know I can't do it, and then when I do, I can't help but give him the credit.
James
Subscribe to:
Posts (Atom)