It's hard to get out of my warm bed. The nights have been actually cool here lately and getting out on the cool cement floor is all the more difficult. I finally make a break for the bathroom and am thankful for one of the few luxuries we have here...hot showers. I dress in scrubs and head to the kitchen on the other side of the duplex for breakfast. Nathan gives me a chunk of eggs well cooked on account of their sketchy appearance on being cracked open. I also fry up some of Salomon's now stale bread dipped in eggs and cinnamon to form a sort of French Toast. The final element is the big bowl of local Arab milk turned into yogurt overnight mixed with fresh limes, bananas and sugar. The breakfast of champions and definitely not a "petit déjeuner"!
I walk over in the early morning haze to our temporary waiting room under the mango tree. Behind me is the skeleton of our clinic with it's roof and ceiling completely removed and all furniture and equipment moved to the main hospital ward. Pierre reads from Psalms, we pray, Samedi gives his report from "Garde" duty and we pray again. It's 8am and the day is about to begin.
I enter my temporary office, the midwife's office, and am bombarded by a foul smell that has been growing. We put out poison for the mice a few nights ago and everyone tells me they've all died in my office. I tell Ferdinand to pull of the two boards covering a pile of wires in the corner as that appears to be their nest. I grab my army shoulder bag that serves as my doctor bag and then am accosted by Koumabas for supplies from the main pharmacy. After giving him the syringes, needles and meds he needs I check in on Ferdinand who has discovered one dried, splayed out mouse high up in the wires and a fresh kill down below along with tons of plastic, papers and a former nurses surgical cap that the mice have used for their nest.
I head out to the wards. I see Anatole's child first whose mom prefers to be hospitalized on the porch instead of inside. They are all spread out on a variety of mats and Arabic rugs. The kid has malaria and still has a very rapid heartbeat but otherwise appears to be doing somewhat better despite vomiting a couple times. I go inside.
The unlighted wards are perpetually dim and filled with shadows. I visit Pediatrics first. One adolescent with cerebral malaria and possibly syphilis is ready to go home. A nomadic Fulabi child with malaria is also ready to be discharged. The little 6 year old with meningitis and resultant right sided paralysis has woken out of his coma today and started to eat a little soup. The young boy with the osteomyelitis of his femur from a long standing thigh abscess gets his Ketamine and dressing change with a diluted blend of Clorox. Little Angeline who has been with us for over 4 months with osteomyelitis of her tibia necessitating removal of part of the bone has finally closed her wound. I have the mom buy a roll of fiberglass casting so I can replace her windowed leg cast that has been supported for months with two sticks.
I move on to the adults. The first patient is a sad case of teenage pregnancy. She labored for 4 days at home before going to the health center where they let her labor one day more before referring her to the hospital. Instead of coming to the hospital she continued to labor 4 more days at home until she delivered a dead baby while shredding her cervix and bladder. When she finally came to the hospital 2 weeks after being referred she had a raging infection with dead tissue hanging out and a 10 cm tear in her bladder. Her infection has now been treated and we've tried two repairs on her bladder with restoration of almost completely normal anatomy. Unfortunately, there is still a little leak (vesicovaginal fistula) meaning she has no control over urination. Our other local doctor has been trained in repair of these types of fistulas and if he's ever around we'll see if he can help her.
The second patient is an adult with malaria ready to go home. Next up is a woman with a huge jaw abscess from neglected dental caries. She's doing better after 3 extractions and antibiotics. I move onto an elderly gentleman with a huge inoperable bladder tumor who we are providing palliative care to. Another woman with Malaria and some strange shoulder pain is fine except for the hypersensitive painful, unswollen shoulder that just won't get better no matter what treatment we try. Following is a man admitted last night with ascites and lower extremity edema. Questioning reveals a heavy drinking past so I assume it's cirrhosis and plan a paracentesis later to draw off a bunch of the fluid in his belly.
I head back to the office, stop to change a dressing on a man who'd passed under my knife for a finger amputation a couple weeks ago. Then I see Angeline and her mom who've paid for the new cast. I pull out the newly donated cast saw, hook up to the lab's small generator and tear through the old fiberglass. Jennie and Nathan then help me rub off the thickened old skin over her leg and wash her down. The leg kind of flops for lack of a completely formed new tibia. I then wrap her leg in cotton and apply the fiberglass cast from thigh to foot. She only cries a few times and then with sniffles gives me our traditional 5 or ten high fives.
Back to my now clean smelling, mice-free office for clinic. It's 10am. Five of my nine patients are HIV positive. Two of the girls are relatives of one of my patients who just died on Monday. All three have AIDS. The one who died was one who had the resources to buy anti-retrovirals and took it for 3 months without any improvement...in fact she steadily got worse. One of the girls I see today, Honorine, on the other hand, started ARVs at the same time and has been healthy since gaining over 14 lbs. It's good to see all of them as they are the patients I see often enough to actually have formed relationships with them. Honorine just finished her last ARV pill and doesn't have money to buy more. She is an orphan and has some property in Kélo left her by her mom. It will be sold the 20th...too late to buy the ARVs as even a day or two of missed treatment can allow the HIV to become resistant. I lend her the money and she takes off immediately for Kélo. It is her life.
I finish clinic at about 1:30pm and head to do the paracentesis on the man with the ascites. I stick a large needle and catheter in the left lower quadrant of his belly and the anticipated straw colored fluid flows out. I send some to the lab and let 4 liters drain off. As the fluid goes down I examine his belly and am surprised to find his liver quite enlarged rather than the shrunken one that one usually finds in cirrhosis. Also, the consistency of his abdominal wall is thickened and doughy. Instantly, another possible diagnosis enters my head...abdominal tuberculosis. If this is the case it is good for him as we can treat that while the end stage of cirrhosis has no cure and is universally fatal in less than a year. I put him on a two week trial of anti-tuberculosis meds just as Dimanche, the Garde, comes up to tell me there are two patients just arrived referred from the hospital in Kélo. Apparently their generator is broken.
I go to see the first at about 2:30pm. A young man who shows the wear and tear of a hard life is lying temporarily on one of the delivery beds. His hair is wild and sticking straight up like Buckwheat's. He has a deep old scar on his left forearm and various smaller scars scattered across his torso. According to the story he was gored by a bull yesterday evening at 5pm. His intestines popped out and he went to the hospital where they covered the intestines with betadine soaked gauze and gave him antibiotics and pain meds. He was then told to come to Béré. I look at his belly. It is soft with good bowel sounds. He has bowel function intact (he farts). I take off the dressing and see a 10cm portion of irritated small bowl already starting to adhere to the skin. I give him Valium and try to reduce it at bedside. He doesn't tolerate. We rush him to the OR where I inject Ketamine, prep and scrub and push the intestines back in. Clear, serosanguinous fluid comes out of the belly. By the angle of the wound it appears that he was gored almost parallel with the abdominal wall and it is unlikely that the intestines have been punctured. I leave a drain inside, close the fascia and leave the skin open with our famous diluted Clorox dressings. Interestingly, I didn't need the generator...
I go to see the next patient. It is 4pm. She is a young girl at 7 months of her first pregnancy. She has been bleeding for a day and has abdominal pain. I check for the fetal heartbeat; it is absent. There is minimal amount of bleeding and she is stable. I order IV fluids and plan surgery for 6:30pm when our generator comes on. I go home. I haven't eaten yet since breakfast.
I eat heartily of Salomon's excellent vegetable sauce over rice and relax of an hour and a half by watching "Step Into Liquid", a great surfing movie, on the computer.
At 6:30pm on the dot the generator comes on and I rush over where Samedi has already brought the patient to the OR and is getting her set up. We put in a urinary catheter, I give her a spinal anesthetic, we prep the abdomen, scrub, drape and then pause for prayer before cutting through the lower abdominal skin straight down to fascia. In less than 5 minutes the baby is out...premature and unfortunately dead. We find she has had a placental abruption where the placenta separates from the uterus before the baby is born. We close quickly and by 7:30pm I am back home and ready for seconds on Salomon's sauce.
After supper, at 8pm the lights go off. I gather with Nathan, Jennie, and Becky out on the porch under another fantastic, pitch black, star filled Tchadian sky. We pray and I feel a peace pour over me that cannot be described. Strangely enough, I am completely content. I go to sleep almost immediately afterwards...
James
Saturday, December 11, 2004
Friday, November 26, 2004
Chills
I close my office door. I feel cold and tired. My muscles and joints ache. I put my Old Navy sweatshirt on over my scrubs. I lie down on the exam table. It's not even my office. I'm in the Prenatal care office temporarily as the main building gets renovated. I'm sure it's just exhaustion. I don't really feel sick. It feels so good to lie down. Since Sarah left three days ago my life has been crazy again.
I drove her to the N'Djamena airport in our pickup. We walked across the courtyard and into the waiting area past huddled groups of Tchadians, many wearing the traditional robes and round hats or turbans. Sarah packs lightly so I had her backpack on and she had just a tiny carry on bag. Acting like we knew what we were doing we walked past the guards through the cage like entrance to the check in room. I held her hand. We loaded her bag onto the belt and I hugged her good bye. Apparently, people were watching in wonder to see someone actually show affection because when I let her go where only ticketed passengers can go a woman came up and told me to go with her. She said we could go up to the observatory to watch the plane come in. The woman checked her passport and then we walked up the steps to a huge glass window with open slats letting the cool N'Djaména night air blow in. We stood there laughing and talking watching a plane come in (not many come into N'Djaména). Finally, I knew I had to say goodbye. I felt weird, surreal. It hadn't sunk in that she was leaving and that I wouldn't see her again until a week before we got married. I had the strange sensation of wondering if I even knew this beautiful girl with wild red hair beside me and would I feel even weirder after a month apart. Then I walked down the stairs, past the passport checkpoints, out the guarded cage-like entrance and into the eerily dimly lit yellow N'Djaména night. Across the pavement, into the car, zombie like thinking how normal this all seemed and yet within a few hours one could be in Europe in a different universe.
Rahama knocks on the door and opens it. "Docteur, pardonnez-moi, mais il y a d'un urgence." And three sweaty, out-of-breath men come in carrying an elderly woman who's moaning but not responsive. Probably malaria. I examine her and order some tests and treatments and send her to the ward. I really start to feel chills. I head to the lab and have Matthieu poke my finger for a Goutte Epaisse (malaria smear). Then I go back and lie down, slipping quickly into that nebulous zone not awake, not asleep, not thinking, not dreaming just there kind of aware but not aware.
I arrive back at SIL, the Bible translator's compound in N'Djaména, and shoot the breeze with Nathan until well after midnight. At 6:30am I'm awake again with the truck ready to go. We'd spent all day yesterday getting it fixed after running around, buying and replacing several parts. Now I go pick up Joy and Michelle from Pasteur Job's house. They've come visiting from the Adventist Hospital in Koze, North Cameroun. They are student missionary nurses. All we had to do is go to the Camerounian embassy to renew their Camerounian visas. Simple right? Wait, I'm forgetting we're in French Africa. We're told that even though they have 45 day valid Tchadian visas they need to go buy Visa de Court Sejour (3 months) before the ambassador can give them new Camerounian visas. A technicality but we run back and forth all over N'Djamena several times before it's resolved. I'm driving as we've left the chauffeur in Béré due to lack of space in the car.
Finally, at 10:45 we leave N'Djaména. We race through the pothole filled roads to Guelengdeng dodging them mostly but feeling the severe jolt when we come on one suddenly. No flat tires this time, though, not like the trip to N'Djaména. Suddenly, in Guelengdeng the truck stalls when I brake and put in the clutch. The same problem we'd supposedly fixed in N'Djaména. Now, leaving Guelengdeng we also start to lose power. I'm not sure we'll make it to Bongor but I find that by pumping the gas pedal I'm able to keep a little power and the pickup limps in. We stop right where we normally eat chicken, drink pineapple milkshakes and buy soap. As soon as I open the hood, a group crowds around quickly hoping to benefit from "Nasara." Everyone's a mechanic, several are drunk and I don't trust any. All I need is to change to fuel filter I think. We have an extra with us. I ask for a number 12 wrench. They give me one that is worn and when I say it doesn't work they try to show me that I'm just stupid Nasara who needs their expert help by grabbing it and almost stripping the nut before I can wrestle it away from them. I spot a public transport van just ahead and go ask for a real wrench which I get and soon have the filter off. Then someone comes with a tire chain welded to a pipe which grips the filter allowing me to unscrew the head. Then, I hear my name (although they've all been calling me "Docteur" from the beginning, I guess I've been there enough times now), Docteur James and I recognize the mechanic/chauffeur from the health district of Béré. Just happens to have stopped there on his way to N'Djaména so he makes a few adjustments to the idle and we are on our way. Not before pipe/bike chain man demands to be paid. I give him 500 francs. He refuses saying he'll take nothing rather than that small amount. I say fine. I'm going. The passengers with us, the chaplain's daughter, adds 500 making it a 1000 francs ($2). He still refuses. They say I should give him more. I tell him I just spent time with the second best mechanic in N'Djaména who charges 4000 francs/hour and since he wants more than 1000 francs for 15 minutes he must think he's a better mechanic. He continues to refuse. I get in the car. His friend takes the 1000 francs. I say it's not for you. My tchadian passengers say that's the way it works in Africa. The "mechanic" tries to make me feel guilty by coming up to wish me "bon voyage" even though I'm robbing him because he's a good person (according to him). I say, "Ça va" and start up the car. Finally, he realizes he isn't going to get more so his attitude changes, he takes the 1000 francs, smiles, shakes my hand and wishes me a real "bon voyage" now. Having visited with 6 different mechanics here in Tchad in the span of 2 weeks with 2 different cars has kind of made me a "local" as far as knowing what's appropriate payment for services.
We arrive in Béré at 6pm.
I'm really starting to feel the chills. I have goose bumps all over and my hair is standing on end. My teeth are chattering and my legs shivering. I go to the house and climb in my zero degree down sleeping bag still chattering. The muscle aches are severe now and my head is pounding. I drift into a troubled snooze.
At 8:30pm I'm sitting on the porch ready for our evening prayer time with the missionaries. As a good missionary I've only waited 11 months to start having regular prayer with the other missionaries! I finish my opening prayer and am interrupted by Anatole. A case of intestinal obstruction. After struggling to place a nasogastric tube I go to place the urinary catheter in the patient before surgery. It gets blocked. Bloody tip. Try again. Finally, after 4 different types of catheters and no success we decide to just start the surgery. It's about 10pm. I scrub, Samedi preps with Betadine, and we gown and drape. After a prayer by Anatole, I grab the scalpel and slice quickly from sternum to pubis. Going through skin and subcutaneous fat I hit the fascia and slice through. The pressure inside the belly bulges out as I dissect carefully into the peritoneal cavity and then with my fingers protecting cut rapidly through the rest of the fascia till his belly is laid open from top to bottom. Black, foul-smelling small intestine pours out along with thick, dark red fluid. The Sigmoid colon is hugely dilated with the necrotic small intestine wrapped around it's base. I try to reduce the colon through the trap unsuccessfully. I poke a hole in the bowel wall letting out the gas and some nasty fluid then pull tight the purse string suture to close the hole and reduce the sigmoid freeing it. It is inflamed but still viable. The small intestine is dead just up to about 6-8 cm from the Cecum and halfway back to the duodenum. I clamp the bowel, poke/clamp/cut/tie across the blood supply to the dead part and heave it off onto the floor. Then I suture the two cut ends of good intestine back together in two layers. Then it's irrigation with cold fluids (I know they‚re supposed to be warm but how in the middle of the night in an emergency with no reliable source of power?) and suck out all the nastiness. I leave in two drains and stuff the colon and intestines back into their rightful place. I then close him up. By the end I can barely stand. I feel drained. It's 1am. Walking back I feel chills and have to warm up under the shower for half an hour before being able to sleep.
Matthieu comes to tell me my Malaria smear is positive for Falciparum (the worst kind). I take 5 Mefloquines and go back to the warmth of my sleeping bag.
Yesterday was no better. I come in to a hospital filled to the gills, mostly with nomadic arabs. I clear the place out by sending many home (as they should've been days ago). Then there's a girl with a post partum infection. She'd been to the Health Center on the 10th after 5 days of labor and was referred to the hospital. She shows up here two weeks later after delivering a dead baby at home with pus dripping out from down below. I take her to surgery, give her a spinal anesthetic and then try to clean up the damage. There is dead tissue in side that is easily pulled out. I then notice what looks like the inside of her bladder and I can‚t identify the cervix. It turns out her bladder has about an 8cm tear in it into the anterior vagina and her cervix was so shredded I can't even really find the opening into the uterus. I finally find it but it's at a weird angle, impossible to do a D&C. I have the mom by a urinary catheter and a suture and I proceed to repair her bladder injury. It seems to be working so far. Pray is all I can say.
That evening we celebrated Thanksgiving with mashed potatoes and gravy and Fri-chik Nathan got in a package from his mom. I just wasn't that hungry. I went to sleep early.
After worship today, I'd told the staff we would like them to celebrate Thanksgiving with us today even though it's a day late. After taking my Mefloquine and sleeping a few hours the chills and fever have worn off so I weakly join them in the courtyard under the trees where we have three coffee tables full of boiled chicken and rice. This is the first meal as a hospital staff together. I explain the rules and we all say what we're thankful for and then "Papa" Sam (Samedi) prays and we dig in and enjoy an hour of pleasant conversation. Everyone totally loved it. We finish and I head back to bed to sleep off my malaria and hope for no more terrible bouts of severe chills.
This evening I'm lying on the couch listening to Avalon's "We Are the Reason" and "Adonai" and I get chills for a different reason and I start to cry (I don't know if it's just the Mefloquine making me emotionally labile or not--I don't care). It's tears of joy though and overwhelming thanks to "my Adonai" who has brought me here to Béré.
Malaria's giving me a headache and a few chills now--gotta go.
James
I drove her to the N'Djamena airport in our pickup. We walked across the courtyard and into the waiting area past huddled groups of Tchadians, many wearing the traditional robes and round hats or turbans. Sarah packs lightly so I had her backpack on and she had just a tiny carry on bag. Acting like we knew what we were doing we walked past the guards through the cage like entrance to the check in room. I held her hand. We loaded her bag onto the belt and I hugged her good bye. Apparently, people were watching in wonder to see someone actually show affection because when I let her go where only ticketed passengers can go a woman came up and told me to go with her. She said we could go up to the observatory to watch the plane come in. The woman checked her passport and then we walked up the steps to a huge glass window with open slats letting the cool N'Djaména night air blow in. We stood there laughing and talking watching a plane come in (not many come into N'Djaména). Finally, I knew I had to say goodbye. I felt weird, surreal. It hadn't sunk in that she was leaving and that I wouldn't see her again until a week before we got married. I had the strange sensation of wondering if I even knew this beautiful girl with wild red hair beside me and would I feel even weirder after a month apart. Then I walked down the stairs, past the passport checkpoints, out the guarded cage-like entrance and into the eerily dimly lit yellow N'Djaména night. Across the pavement, into the car, zombie like thinking how normal this all seemed and yet within a few hours one could be in Europe in a different universe.
Rahama knocks on the door and opens it. "Docteur, pardonnez-moi, mais il y a d'un urgence." And three sweaty, out-of-breath men come in carrying an elderly woman who's moaning but not responsive. Probably malaria. I examine her and order some tests and treatments and send her to the ward. I really start to feel chills. I head to the lab and have Matthieu poke my finger for a Goutte Epaisse (malaria smear). Then I go back and lie down, slipping quickly into that nebulous zone not awake, not asleep, not thinking, not dreaming just there kind of aware but not aware.
I arrive back at SIL, the Bible translator's compound in N'Djaména, and shoot the breeze with Nathan until well after midnight. At 6:30am I'm awake again with the truck ready to go. We'd spent all day yesterday getting it fixed after running around, buying and replacing several parts. Now I go pick up Joy and Michelle from Pasteur Job's house. They've come visiting from the Adventist Hospital in Koze, North Cameroun. They are student missionary nurses. All we had to do is go to the Camerounian embassy to renew their Camerounian visas. Simple right? Wait, I'm forgetting we're in French Africa. We're told that even though they have 45 day valid Tchadian visas they need to go buy Visa de Court Sejour (3 months) before the ambassador can give them new Camerounian visas. A technicality but we run back and forth all over N'Djamena several times before it's resolved. I'm driving as we've left the chauffeur in Béré due to lack of space in the car.
Finally, at 10:45 we leave N'Djaména. We race through the pothole filled roads to Guelengdeng dodging them mostly but feeling the severe jolt when we come on one suddenly. No flat tires this time, though, not like the trip to N'Djaména. Suddenly, in Guelengdeng the truck stalls when I brake and put in the clutch. The same problem we'd supposedly fixed in N'Djaména. Now, leaving Guelengdeng we also start to lose power. I'm not sure we'll make it to Bongor but I find that by pumping the gas pedal I'm able to keep a little power and the pickup limps in. We stop right where we normally eat chicken, drink pineapple milkshakes and buy soap. As soon as I open the hood, a group crowds around quickly hoping to benefit from "Nasara." Everyone's a mechanic, several are drunk and I don't trust any. All I need is to change to fuel filter I think. We have an extra with us. I ask for a number 12 wrench. They give me one that is worn and when I say it doesn't work they try to show me that I'm just stupid Nasara who needs their expert help by grabbing it and almost stripping the nut before I can wrestle it away from them. I spot a public transport van just ahead and go ask for a real wrench which I get and soon have the filter off. Then someone comes with a tire chain welded to a pipe which grips the filter allowing me to unscrew the head. Then, I hear my name (although they've all been calling me "Docteur" from the beginning, I guess I've been there enough times now), Docteur James and I recognize the mechanic/chauffeur from the health district of Béré. Just happens to have stopped there on his way to N'Djaména so he makes a few adjustments to the idle and we are on our way. Not before pipe/bike chain man demands to be paid. I give him 500 francs. He refuses saying he'll take nothing rather than that small amount. I say fine. I'm going. The passengers with us, the chaplain's daughter, adds 500 making it a 1000 francs ($2). He still refuses. They say I should give him more. I tell him I just spent time with the second best mechanic in N'Djaména who charges 4000 francs/hour and since he wants more than 1000 francs for 15 minutes he must think he's a better mechanic. He continues to refuse. I get in the car. His friend takes the 1000 francs. I say it's not for you. My tchadian passengers say that's the way it works in Africa. The "mechanic" tries to make me feel guilty by coming up to wish me "bon voyage" even though I'm robbing him because he's a good person (according to him). I say, "Ça va" and start up the car. Finally, he realizes he isn't going to get more so his attitude changes, he takes the 1000 francs, smiles, shakes my hand and wishes me a real "bon voyage" now. Having visited with 6 different mechanics here in Tchad in the span of 2 weeks with 2 different cars has kind of made me a "local" as far as knowing what's appropriate payment for services.
We arrive in Béré at 6pm.
I'm really starting to feel the chills. I have goose bumps all over and my hair is standing on end. My teeth are chattering and my legs shivering. I go to the house and climb in my zero degree down sleeping bag still chattering. The muscle aches are severe now and my head is pounding. I drift into a troubled snooze.
At 8:30pm I'm sitting on the porch ready for our evening prayer time with the missionaries. As a good missionary I've only waited 11 months to start having regular prayer with the other missionaries! I finish my opening prayer and am interrupted by Anatole. A case of intestinal obstruction. After struggling to place a nasogastric tube I go to place the urinary catheter in the patient before surgery. It gets blocked. Bloody tip. Try again. Finally, after 4 different types of catheters and no success we decide to just start the surgery. It's about 10pm. I scrub, Samedi preps with Betadine, and we gown and drape. After a prayer by Anatole, I grab the scalpel and slice quickly from sternum to pubis. Going through skin and subcutaneous fat I hit the fascia and slice through. The pressure inside the belly bulges out as I dissect carefully into the peritoneal cavity and then with my fingers protecting cut rapidly through the rest of the fascia till his belly is laid open from top to bottom. Black, foul-smelling small intestine pours out along with thick, dark red fluid. The Sigmoid colon is hugely dilated with the necrotic small intestine wrapped around it's base. I try to reduce the colon through the trap unsuccessfully. I poke a hole in the bowel wall letting out the gas and some nasty fluid then pull tight the purse string suture to close the hole and reduce the sigmoid freeing it. It is inflamed but still viable. The small intestine is dead just up to about 6-8 cm from the Cecum and halfway back to the duodenum. I clamp the bowel, poke/clamp/cut/tie across the blood supply to the dead part and heave it off onto the floor. Then I suture the two cut ends of good intestine back together in two layers. Then it's irrigation with cold fluids (I know they‚re supposed to be warm but how in the middle of the night in an emergency with no reliable source of power?) and suck out all the nastiness. I leave in two drains and stuff the colon and intestines back into their rightful place. I then close him up. By the end I can barely stand. I feel drained. It's 1am. Walking back I feel chills and have to warm up under the shower for half an hour before being able to sleep.
Matthieu comes to tell me my Malaria smear is positive for Falciparum (the worst kind). I take 5 Mefloquines and go back to the warmth of my sleeping bag.
Yesterday was no better. I come in to a hospital filled to the gills, mostly with nomadic arabs. I clear the place out by sending many home (as they should've been days ago). Then there's a girl with a post partum infection. She'd been to the Health Center on the 10th after 5 days of labor and was referred to the hospital. She shows up here two weeks later after delivering a dead baby at home with pus dripping out from down below. I take her to surgery, give her a spinal anesthetic and then try to clean up the damage. There is dead tissue in side that is easily pulled out. I then notice what looks like the inside of her bladder and I can‚t identify the cervix. It turns out her bladder has about an 8cm tear in it into the anterior vagina and her cervix was so shredded I can't even really find the opening into the uterus. I finally find it but it's at a weird angle, impossible to do a D&C. I have the mom by a urinary catheter and a suture and I proceed to repair her bladder injury. It seems to be working so far. Pray is all I can say.
That evening we celebrated Thanksgiving with mashed potatoes and gravy and Fri-chik Nathan got in a package from his mom. I just wasn't that hungry. I went to sleep early.
After worship today, I'd told the staff we would like them to celebrate Thanksgiving with us today even though it's a day late. After taking my Mefloquine and sleeping a few hours the chills and fever have worn off so I weakly join them in the courtyard under the trees where we have three coffee tables full of boiled chicken and rice. This is the first meal as a hospital staff together. I explain the rules and we all say what we're thankful for and then "Papa" Sam (Samedi) prays and we dig in and enjoy an hour of pleasant conversation. Everyone totally loved it. We finish and I head back to bed to sleep off my malaria and hope for no more terrible bouts of severe chills.
This evening I'm lying on the couch listening to Avalon's "We Are the Reason" and "Adonai" and I get chills for a different reason and I start to cry (I don't know if it's just the Mefloquine making me emotionally labile or not--I don't care). It's tears of joy though and overwhelming thanks to "my Adonai" who has brought me here to Béré.
Malaria's giving me a headache and a few chills now--gotta go.
James
Tuesday, October 19, 2004
Footsteps right behind you
I walked swiftly down the path. Through the sunlight flickering off the rustling leaves of the guava trees I could see the kids slinking up. I felt the adrenaline surge. This was my time. The kids always stole our guavas. I knew how to stop them. All I had to do was catch one and beat him up like any good Nangjere man would do and the theft would stop. Unfortunately, for some reason beating up on small children has been something I‚ve never been able to do. Now, if it was the pigs that came scrounging for worms every morning. I could beat them up without a qualm. The only problem is they're too fast. You'd never think it to see them, but they're fast.
The kid in the tree saw me. Two things happened simultaneously: one, I kicked off my flip flops and began to lope towards the tree while, two, the boy almost fell out of the tree in his hurry to get down. His watchman took off and quickly veered left. I was hot on the tail of the second, the one who'd actually been in the tree.
A few days before I thought I'd found a solution. We watched from our screen window as a 12 or 13 year old took off one shoe, leaving the other shoe and both socks on, and climbed up the tree while his watchman stood casually by. Nathan went out the side door and ran up. Amazingly, for the first time ever, they didn't run. Everyone runs when Nasara comes anywhere close to where they are stealing guavas. They must've been new and didn't know the rules. So Nathan casually grabs his shoe. I follow close behind. I ask the boy how many guavas he's stolen. He looks confused. I explain that taking things that don't belong to you is called stealing. He nods and seems to understand. I notice two green guavas in his hand. I say, we'll keep your shoe here, you come back tomorrow to pay for the guavas and we'll give the shoe back.
He hangs around all afternoon with a small crowd of boys eager to see how the drama will unfold.
Nathan and I are on my side later that afternoon and see another boy up a tree. We pounce easily and take his hat. He follows us to the porch where we are soon surrounded by boys of all ages and a ritual dance of bargaining begins. He claims its not stealing. He claims it is only one guava and since when we caught him he dropped it to the ground he didn't really take it. I ask how much guavas go for. The boys say 10 francs (about 2 pennies). Finally, we bargain down to 5 francs and he pays for the two guavas of the other boy, they get their hat and shoe back respectively, and I explain how we don't like stealing so if they want our guavas all they have to do is ask for them.
This boy I'm chasing obviously hasn't been informed of that. He just knows someone is chasing him and he needs to get away. He's in too much of a hurry. I pace myself. I keep up with him easily with a measured stride. He cuts down a pit where mud bricks have been harvested and falls getting up in almost the same motion as I circle the rim. He ascends the other side with me know hotly on his heels. We enter an opening in a mud brick wall and circle around a hut into a courtyard. Â I can smell his fear. I know he's mine. He realizes he's in a dead end. He finds a narrow break behind a pile of reed mats. I cut him off. He stops behind the mats. Only the mats protects him from what he is sure is a severe beating. He begs for forgiveness then makes a break for it. I'm only a few feet behind. The pigs are his ruin.
You see, everywhere a small patch of water gathers, there the pigs will gather as well wallowing deep in with silly grins plastered on their snouts. When our outside faucet leaked last spring the melodious sounds of contentedly snorting pigs never ceased to freshen the airwaves as they kept it boggy. The pig's snuggling down keeps the wallow wet and slick even when all around has dried out.
Our friend met his wallow. With a look of surprise and terror he went down fast and hard skidding along the slime for a good 5 feet on his belly. I was on him in a second. I grabbed his wrist and pulled him up out of the bog. Come with me. He couldn't do anything but comply because of his fear even though I barely had his wrist with one hand. I had no idea what I was going to do with him but it had been good sport by the powers. He finally realized my weak grip and broke free only to trip and fall within 10 feet. By then the crowd has gathered and I explained again that while we don't like stealing we don't mind if they eat our guavas if they ask. I release him.
Between chasing them from our guava trees, playing basketball on our leaning tower of hoop and playing guitar and drums on the porch, we have gained quite a following among the local kids who never cease to tirelessly yell out "jay-mmm-suh, jay-mmm-suh, lalé, lapia, lalé" as they wave joyously anytime we pass or hang out. They are dirty, naked, barefoot, ragged, cheery, playful, mischievous, tireless, incorrigible and about the cutest to be found anywhere.
Since that day, one tiny little 6 year old boy never fails to come up every day and with a big grin ask in broken French, "Je mange les guyabes??" We of course say, "Oui, eat all you want"
James
The kid in the tree saw me. Two things happened simultaneously: one, I kicked off my flip flops and began to lope towards the tree while, two, the boy almost fell out of the tree in his hurry to get down. His watchman took off and quickly veered left. I was hot on the tail of the second, the one who'd actually been in the tree.
A few days before I thought I'd found a solution. We watched from our screen window as a 12 or 13 year old took off one shoe, leaving the other shoe and both socks on, and climbed up the tree while his watchman stood casually by. Nathan went out the side door and ran up. Amazingly, for the first time ever, they didn't run. Everyone runs when Nasara comes anywhere close to where they are stealing guavas. They must've been new and didn't know the rules. So Nathan casually grabs his shoe. I follow close behind. I ask the boy how many guavas he's stolen. He looks confused. I explain that taking things that don't belong to you is called stealing. He nods and seems to understand. I notice two green guavas in his hand. I say, we'll keep your shoe here, you come back tomorrow to pay for the guavas and we'll give the shoe back.
He hangs around all afternoon with a small crowd of boys eager to see how the drama will unfold.
Nathan and I are on my side later that afternoon and see another boy up a tree. We pounce easily and take his hat. He follows us to the porch where we are soon surrounded by boys of all ages and a ritual dance of bargaining begins. He claims its not stealing. He claims it is only one guava and since when we caught him he dropped it to the ground he didn't really take it. I ask how much guavas go for. The boys say 10 francs (about 2 pennies). Finally, we bargain down to 5 francs and he pays for the two guavas of the other boy, they get their hat and shoe back respectively, and I explain how we don't like stealing so if they want our guavas all they have to do is ask for them.
This boy I'm chasing obviously hasn't been informed of that. He just knows someone is chasing him and he needs to get away. He's in too much of a hurry. I pace myself. I keep up with him easily with a measured stride. He cuts down a pit where mud bricks have been harvested and falls getting up in almost the same motion as I circle the rim. He ascends the other side with me know hotly on his heels. We enter an opening in a mud brick wall and circle around a hut into a courtyard. Â I can smell his fear. I know he's mine. He realizes he's in a dead end. He finds a narrow break behind a pile of reed mats. I cut him off. He stops behind the mats. Only the mats protects him from what he is sure is a severe beating. He begs for forgiveness then makes a break for it. I'm only a few feet behind. The pigs are his ruin.
You see, everywhere a small patch of water gathers, there the pigs will gather as well wallowing deep in with silly grins plastered on their snouts. When our outside faucet leaked last spring the melodious sounds of contentedly snorting pigs never ceased to freshen the airwaves as they kept it boggy. The pig's snuggling down keeps the wallow wet and slick even when all around has dried out.
Our friend met his wallow. With a look of surprise and terror he went down fast and hard skidding along the slime for a good 5 feet on his belly. I was on him in a second. I grabbed his wrist and pulled him up out of the bog. Come with me. He couldn't do anything but comply because of his fear even though I barely had his wrist with one hand. I had no idea what I was going to do with him but it had been good sport by the powers. He finally realized my weak grip and broke free only to trip and fall within 10 feet. By then the crowd has gathered and I explained again that while we don't like stealing we don't mind if they eat our guavas if they ask. I release him.
Between chasing them from our guava trees, playing basketball on our leaning tower of hoop and playing guitar and drums on the porch, we have gained quite a following among the local kids who never cease to tirelessly yell out "jay-mmm-suh, jay-mmm-suh, lalé, lapia, lalé" as they wave joyously anytime we pass or hang out. They are dirty, naked, barefoot, ragged, cheery, playful, mischievous, tireless, incorrigible and about the cutest to be found anywhere.
Since that day, one tiny little 6 year old boy never fails to come up every day and with a big grin ask in broken French, "Je mange les guyabes??" We of course say, "Oui, eat all you want"
James
Calloused Hearts or Just Feet?
The sunset that evening sank into the dusty earth as if in a trance. Just a yellow orb leaving only a tiny trail of pink...it was like a sticky yellow ball flung onto a wall of light blue and slowly sliding into the night with no dying breath or comment. How jipped I felt!
In the early hours before dawn of that same day, Sarah, another nurse, and I had lost a small baby boy to death. His small body was already too weak to live when the parents had finally brought him to the hospital as a last resort. His small round belly had the markings of local healing. That is, he had scars on either side of his stomach where the parents had tried to bleed the evil out. It hadn't helped.
His bone thin extremities barely moved, and his eyes stared up at me in an empty gaze. I lead his parents down the dark hospital hallway, holding his infusion of quinine and glucose high as if it would light my step. I remember thinking I should put him in a bed where the least amount of kids had died. Maybe that would help. It hadn't.
Some people have made light of death of small children at Béré Hospital. It makes continuing with life easier if they laugh about it- saying the parents have eight other kids to worry about. They'll just have another kid to make up for that one. Some have even gone so far as to say that the villagers don't feel much human pain or loss. How unfair that is!
It you could only see the way a worried grandmother looked over her small granddaughter. I watched the shriveled brown fingers of the grandmother's hand gently caress the baby's forehead. Then the grandmother hunched forward as if in extreme pain. I thought she was going to let out a wail for a second, but she just put her head in her hands silently. And people have suggested they don't feel pain?
It is true that most of the dark eyed women here are forced into marriage at an absurd early age. Even before their breasts are fully developed, they are soon sagging after only five years. They are uneducated about sanitation and mud-hut keeping, and trained to cower beneath their old decrepit husbands who already have four other wives.
However, I believe their hearts are calloused (if I should apply such a term) out of necessity of survival...like their mud-soiled feet, yet their motherhood (or fatherhood) seems to bring about a softening of that guarded heart. I guess I can explain it as the kind of life that keeps their feet tough and their brown faces smiling.
Today, for example, I observed an old man squish his face like a contorted raisin with whiskers, (he had extreme pain from his toe amputation,) then in the next second, he stuck out his hand grinning from ear to ear to greet me. Amazing!
I think maybe they have naturally discovered this Buddha thought that "the secret of health for both mind and body is not to mourn for the past, not to worry about the future, or not to anticipate troubles, but to live in the present moment wisely and earnestly." Or perhaps Buddha arrived at such a conclusion from watching civilizations similar to Béré?
With their loads piled high on their heads, (the women anyway), and life shooting out of every sandy crevice throughout the village, the people keep laughing. No time is spent on burial...for life is alive and kicking around the corner. It is not their heartlessness or lack of pain that keeps them going each day. It is wisdom!
Becky Jarnes
In the early hours before dawn of that same day, Sarah, another nurse, and I had lost a small baby boy to death. His small body was already too weak to live when the parents had finally brought him to the hospital as a last resort. His small round belly had the markings of local healing. That is, he had scars on either side of his stomach where the parents had tried to bleed the evil out. It hadn't helped.
His bone thin extremities barely moved, and his eyes stared up at me in an empty gaze. I lead his parents down the dark hospital hallway, holding his infusion of quinine and glucose high as if it would light my step. I remember thinking I should put him in a bed where the least amount of kids had died. Maybe that would help. It hadn't.
Some people have made light of death of small children at Béré Hospital. It makes continuing with life easier if they laugh about it- saying the parents have eight other kids to worry about. They'll just have another kid to make up for that one. Some have even gone so far as to say that the villagers don't feel much human pain or loss. How unfair that is!
It you could only see the way a worried grandmother looked over her small granddaughter. I watched the shriveled brown fingers of the grandmother's hand gently caress the baby's forehead. Then the grandmother hunched forward as if in extreme pain. I thought she was going to let out a wail for a second, but she just put her head in her hands silently. And people have suggested they don't feel pain?
It is true that most of the dark eyed women here are forced into marriage at an absurd early age. Even before their breasts are fully developed, they are soon sagging after only five years. They are uneducated about sanitation and mud-hut keeping, and trained to cower beneath their old decrepit husbands who already have four other wives.
However, I believe their hearts are calloused (if I should apply such a term) out of necessity of survival...like their mud-soiled feet, yet their motherhood (or fatherhood) seems to bring about a softening of that guarded heart. I guess I can explain it as the kind of life that keeps their feet tough and their brown faces smiling.
Today, for example, I observed an old man squish his face like a contorted raisin with whiskers, (he had extreme pain from his toe amputation,) then in the next second, he stuck out his hand grinning from ear to ear to greet me. Amazing!
I think maybe they have naturally discovered this Buddha thought that "the secret of health for both mind and body is not to mourn for the past, not to worry about the future, or not to anticipate troubles, but to live in the present moment wisely and earnestly." Or perhaps Buddha arrived at such a conclusion from watching civilizations similar to Béré?
With their loads piled high on their heads, (the women anyway), and life shooting out of every sandy crevice throughout the village, the people keep laughing. No time is spent on burial...for life is alive and kicking around the corner. It is not their heartlessness or lack of pain that keeps them going each day. It is wisdom!
Becky Jarnes
Saturday, October 9, 2004
Moonlight and Guavas
The Tchadian sky stretches out expanding beyond what seems possible to give the effect of being in some circus mirror show where everything is distorted to become larger than life. It's a brilliant light clear blue sky except for one huge bank of stacked puffy white clouds on the horizon. We are escaping Bere and the hospital. Becky, our second redhead nurse leads the way down the small path away from the back of the compound. Nathan, our 6'7" student missionary, strides casually beside her. Wendi, the third redhead in the group walks behind me with Jennie, the second newly arrived volunteer nurse. Sarah, the first and final redhead, brings up the rear. The sun beats down fiercely as we enter the rice fields where the path disappears under water for long stretches at a time. The water is hot to our bare feet alternating between a fresh sandy and a sticky mud bottom. We occasionally pass locals on their way to or from who knows where carrying flip flops and wading purposefully through the water much as we are. Friendly "lapia's" are exchanged and repeated as befits local custom. Occasionally, a "lapia aye" or "lalay" will be thrown in for variety. Of course, Sarah has to always show off by actually carrying on brief conversations in Nangjere not just giving generic greetings. I found it's not really necessary as "lapia" repeated often back and forth seems to keep everyone content.
At the river finally we are surrounded as usual by half naked children with fishing spears or poles who are more than happy to leave what their doing to watch "nasara" swim. What could be more entertaining than watching weird looking strange white foreigners jumping, swimming, mud wrestling and tossing mud at them? Getting them to hum the tune of "Indiana Jones" is also a big hit.
Coming back the moon is reflecting perfectly off the still waters of the rice paddies as the sky is still pinked from the recently setting sun.
A few days later a baby comes in with a severe infection in her groin and legs and lower abdomen. Antibiotics help but then large black dead skin patches remain with yellow pus filled edges. They need to be debrided (taken off). I do. That afternoon Sarah comes to me to say she's unconscious. I come and find her recently dead. I desperately refuse to believe. She's pale. The bandages are red with blood. She's bled out and no one noticed. I do CPR furiously unable to let go and accept that I should have checked back on her several times before going home. I would've noticed. No one else did or seemed to be concerned about her at all. A waste. We have no post operative recovery room or any real post operative care. I see death all the time but this one gets to me. I should've checked more carefully to make sure all bleeding was stopped. Sarah is also devastated when I see her later. She feels it's her fault. I hug her and let her know it's not. I feel sick to my stomach.
Dimanche's sister comes in the next morning with abdominal pain. I first hear from the nurse that it's probably a urinary infection. I go to see her and I at first think it's appendicitis. She gives a good story and has peritoneal signs consistent with appendicitis. I decide I should do a pelvic exam first. Then I think it's probably an infection of the uterus or tubes. The pain has switched sides to the left. Then, her story changes too. I wish I had an ultrasound or other tests. I check a blood count which is normal. I put her on antibiotics and continue my work. I don't feel quite comfortable with the diagnosis. After work, the gang wants to go to the river. Right before leaving I decide to check on the patient again. She's worse. I look some stuff up in books and ask some more questions. I wish I had an ultrasound again. After reading I remember I should have checked to see if she was pregnant even if she hasn't missed a period. Matthieu comes in from home to do the test but says it probably won't work because it's not a morning urine sample. We do it anyway. The faintest of lines appears telling us it's positive. I feel relief. God has helped us come to the probable diagnosis even with our lack of equipment--ectopic pregnancy (out of the uterus). I know I need to operate but I'm always more nervous when it's a friend or a relative someone I work with everyday in this case. What if I'm wrong and I operate for nothing and something goes wrong? I'd operated a woman a few months ago who I'd thought had an ectopic pregancy and it turned out to be a simple pelvic infection treatable with antibiotics. Was I making the same mistake? I open up her belly in a low pelvic (Pfannensteil) incision and dark blood comes out of the abdomen. Sure enough there's a swollen mass in the left Eustachian tube. It was about to rupture. Despite some delays due to lack of equipment and my not having anyone to consult eventually with the help of books God led me to do the right thing in time to save her. What if I'd just gone to the river like I really wanted to? It's so hard to find that balance between doing what's right and needs to be done and not getting so overwhelmed and sucked in that you lose yourself and who you are in the incredible, never ending needs of a place like Béré.
Today, I'm finishing up lunch and look out the window at our guava trees. I see three kids staring up. There must be another kid up them again stealing our guavas. If they'd just ask I'd give it to them but kids here have no sense of right and wrong or respect for what belongs to others (like privacy for example). It's not their fault. They have no boundaries. They are outside naked and barefoot with other kids with no regular meals, often dependent on what they find in order to be able to eat. Then at night they can be out until 2-3 in the morning dancing and singing and pounding on drums without any set bedtime. I'm talking about 3 and 4 and 5 year olds as well as the pre-teens and teens. So they get the idea they shouldn't be doing something but not because it's wrong; because they might get beat if they're caught.
So I sneak out the front door to the edge of the house. The three kids are absorbed in whatever's happening in the branches above them. I start running. About 15 feet away they see me and start to run. I arrive at the tree and look up. Sure enough, a kid is caught there. She's about 8-9 years old dressed in a rag wrapped around her waist with bare feet and chest. I look at her with an expressionless face. Then I feel a shock course through me as she lets out a blood curdling yell that doesn't stop as her eyes go wild with fear and she's starts swaying on the branch while holding on tightly above her. I tell her to come down in a flat voice. I feel cut to the quick by her unreasonable fear. She starts to come down howls filling the air.
Other kids start gathering and laughing hysterically at her cries and fear and that she'll probably get the beating of her life now from the terrible "nasara." A couple adults who appear to be relatives approach. She comes down and when I reach to help her down she goes ballistic hanging onto the tree for all she's worth while her screams make my blood go cold. I pull her off the tree and let her down to the ground. She collapses and tries to wriggle away. I grab her wrist gently but firmly. She has wrapped herself around the legs of one of her relatives. Â I pull her free and if possible her cries intensify. I have a sick pit in my stomach half-loving and half-loathing the fear I cause in her. I explain to her relatives that this is our property and that taking stuff from someone else's property is called stealing. They agree. The surrounding kids continue to chortle gleefully at the young girl's distress.
The relatives start to yell viciously at the poor girl. I interrupt to continue trying to explain reasonably why she shouldn't be in our tree. I ask what they will do about it. The young man says they'll discipline her. I let her go as the giggles from the kids continue. The young man picks up a switch as she takes off. I turn away hoping that they won't beat her if I'm not there--that they would only do it because they think I want it and that when I leave they'll all just laugh but somehow I just think the whole situation was sick. If the kids would just ask for the guavas I'd give them to them. But their parents have never taught them how to behave so they have no clue. They learn from their fellow children and that is the basis for the society and social structure and attitudes that leads them later in life to prefer to let their kid die than pay $5 for a complete treatment.
I return home subdued--life is hard here in so many ways.
James
At the river finally we are surrounded as usual by half naked children with fishing spears or poles who are more than happy to leave what their doing to watch "nasara" swim. What could be more entertaining than watching weird looking strange white foreigners jumping, swimming, mud wrestling and tossing mud at them? Getting them to hum the tune of "Indiana Jones" is also a big hit.
Coming back the moon is reflecting perfectly off the still waters of the rice paddies as the sky is still pinked from the recently setting sun.
A few days later a baby comes in with a severe infection in her groin and legs and lower abdomen. Antibiotics help but then large black dead skin patches remain with yellow pus filled edges. They need to be debrided (taken off). I do. That afternoon Sarah comes to me to say she's unconscious. I come and find her recently dead. I desperately refuse to believe. She's pale. The bandages are red with blood. She's bled out and no one noticed. I do CPR furiously unable to let go and accept that I should have checked back on her several times before going home. I would've noticed. No one else did or seemed to be concerned about her at all. A waste. We have no post operative recovery room or any real post operative care. I see death all the time but this one gets to me. I should've checked more carefully to make sure all bleeding was stopped. Sarah is also devastated when I see her later. She feels it's her fault. I hug her and let her know it's not. I feel sick to my stomach.
Dimanche's sister comes in the next morning with abdominal pain. I first hear from the nurse that it's probably a urinary infection. I go to see her and I at first think it's appendicitis. She gives a good story and has peritoneal signs consistent with appendicitis. I decide I should do a pelvic exam first. Then I think it's probably an infection of the uterus or tubes. The pain has switched sides to the left. Then, her story changes too. I wish I had an ultrasound or other tests. I check a blood count which is normal. I put her on antibiotics and continue my work. I don't feel quite comfortable with the diagnosis. After work, the gang wants to go to the river. Right before leaving I decide to check on the patient again. She's worse. I look some stuff up in books and ask some more questions. I wish I had an ultrasound again. After reading I remember I should have checked to see if she was pregnant even if she hasn't missed a period. Matthieu comes in from home to do the test but says it probably won't work because it's not a morning urine sample. We do it anyway. The faintest of lines appears telling us it's positive. I feel relief. God has helped us come to the probable diagnosis even with our lack of equipment--ectopic pregnancy (out of the uterus). I know I need to operate but I'm always more nervous when it's a friend or a relative someone I work with everyday in this case. What if I'm wrong and I operate for nothing and something goes wrong? I'd operated a woman a few months ago who I'd thought had an ectopic pregancy and it turned out to be a simple pelvic infection treatable with antibiotics. Was I making the same mistake? I open up her belly in a low pelvic (Pfannensteil) incision and dark blood comes out of the abdomen. Sure enough there's a swollen mass in the left Eustachian tube. It was about to rupture. Despite some delays due to lack of equipment and my not having anyone to consult eventually with the help of books God led me to do the right thing in time to save her. What if I'd just gone to the river like I really wanted to? It's so hard to find that balance between doing what's right and needs to be done and not getting so overwhelmed and sucked in that you lose yourself and who you are in the incredible, never ending needs of a place like Béré.
Today, I'm finishing up lunch and look out the window at our guava trees. I see three kids staring up. There must be another kid up them again stealing our guavas. If they'd just ask I'd give it to them but kids here have no sense of right and wrong or respect for what belongs to others (like privacy for example). It's not their fault. They have no boundaries. They are outside naked and barefoot with other kids with no regular meals, often dependent on what they find in order to be able to eat. Then at night they can be out until 2-3 in the morning dancing and singing and pounding on drums without any set bedtime. I'm talking about 3 and 4 and 5 year olds as well as the pre-teens and teens. So they get the idea they shouldn't be doing something but not because it's wrong; because they might get beat if they're caught.
So I sneak out the front door to the edge of the house. The three kids are absorbed in whatever's happening in the branches above them. I start running. About 15 feet away they see me and start to run. I arrive at the tree and look up. Sure enough, a kid is caught there. She's about 8-9 years old dressed in a rag wrapped around her waist with bare feet and chest. I look at her with an expressionless face. Then I feel a shock course through me as she lets out a blood curdling yell that doesn't stop as her eyes go wild with fear and she's starts swaying on the branch while holding on tightly above her. I tell her to come down in a flat voice. I feel cut to the quick by her unreasonable fear. She starts to come down howls filling the air.
Other kids start gathering and laughing hysterically at her cries and fear and that she'll probably get the beating of her life now from the terrible "nasara." A couple adults who appear to be relatives approach. She comes down and when I reach to help her down she goes ballistic hanging onto the tree for all she's worth while her screams make my blood go cold. I pull her off the tree and let her down to the ground. She collapses and tries to wriggle away. I grab her wrist gently but firmly. She has wrapped herself around the legs of one of her relatives. Â I pull her free and if possible her cries intensify. I have a sick pit in my stomach half-loving and half-loathing the fear I cause in her. I explain to her relatives that this is our property and that taking stuff from someone else's property is called stealing. They agree. The surrounding kids continue to chortle gleefully at the young girl's distress.
The relatives start to yell viciously at the poor girl. I interrupt to continue trying to explain reasonably why she shouldn't be in our tree. I ask what they will do about it. The young man says they'll discipline her. I let her go as the giggles from the kids continue. The young man picks up a switch as she takes off. I turn away hoping that they won't beat her if I'm not there--that they would only do it because they think I want it and that when I leave they'll all just laugh but somehow I just think the whole situation was sick. If the kids would just ask for the guavas I'd give them to them. But their parents have never taught them how to behave so they have no clue. They learn from their fellow children and that is the basis for the society and social structure and attitudes that leads them later in life to prefer to let their kid die than pay $5 for a complete treatment.
I return home subdued--life is hard here in so many ways.
James
Friday, October 1, 2004
Nose Peanuts
Warning: no bloody, gory or otherwise crazy-nuts stories available at this time.
So I'm hauling sand what was left after construction of the wall. I decided to landscape a little around the house which is really ridiculous because now there's this one tiny patch of niceness replete with cactus, volcanic rock and a brick piece border on one corner of a tin roof house with peeling paint, cracked windows and moth eaten rafters harboring bats and rats. So anyway, the boys start gathering as they usually do anytime "Nasara" starts doing anything. Soon they have insisted on grabbing the shovels and hauling the sand in the wheel barrows as well--but you already know the story--this is really a tale about a boy--Fambe (think Thumper and Bambi crossed and you have an idea of the pronunciation). He starts dancing on the sand pile. He's only three, runs around naked most of the time and dances as if he was born to it. He's Lona's second youngest son. He loves to stare at "Nasara" with a blank look on his face. He won't smile, talk or do anything accept come up to you in church and want to sit on your lap until he rips your Arab robes. Then he'll run off to sweep up peanut shells off the floor. Occasionally, you'll be walking to work in the early morning fog and you'll see someone sitting in the dirt waving with a huge grin saying "lalé, lalé" but other than that it's all just serious, expressionless staring. I'm not sure if Fambe still likes me now after I circumcised him and he then got infected because, well he runs around naked and rolls in the dirt at every opportunity. Not to mention that he was quite proud of his new look and would show off to anyone. Oh, and there was the time I was tossing the football and accidently pegged him right on the head causing him to tumble off the porch railing he was perched on 4 feet to the ground. I got there quickly to find him screaming like a hyena with blood pouring off a tiny slit in his scalp. Lona just laughed and shook his head when I told him. As mentioned, Fambe has natural rhythm and likes to take one of my small drums, lay it between his legs as he sprawls on the ground and pound it--sometimes in rhythm with what we are playing.
Fambe's brother Henri on the other hand just stands around looking at you with the cheesiest grin all the time. I've never seen a kid so happy and with a bigger smile. Even when he was deadly sick with Malaria his smile never diminished--his eyes just looked a little droopy.
A boy with a huge Burkitt's Lymphoma on his right cheek (bigger than two huge grapefruits) who I've searched to world over to find treatment for comes into see me when I say I've found it. I first saw him walking down the street to market months ago and stopped the car to yell at him to come see me which he always has done everytime I've called for him. Now when I have the meds finally I set up an appointment to start chemo and he never shows up. I see him by the basketball court we've rigged up in a field the other day and he says he's coming tomorrow then never shows up. I don't get it--maybe he's afraid of getting his hopes up or what--I often can't figure out how people think here.
So, finally--nose peanuts. Never say never. You can teach an old dog new tricks. I never cease to be amazed. Sarah calls me to come see a baby with a peanut stuck up it's nose. I hurry over and see the baby comfortably in mom's arms. I walk down the hall to my office and gather my arsenal: Otoscope, nasal speculum, forceps, clamps, spray anesthetic. I'm armed to the teeth. I walk back balancing all my goodies in both hands. I turn the corner and see a strange man bending over the child. One of the other patients' fathers. I don't get it until I hear loud sucking noises. I'm frozen. He then lifts his lips off the baby's nostrils and there is the slimy peanut sitting right there. He nimbly picks it off and tosses it aside. I'm flabbergasted feeling a little foolish with my "modern" medecine. I tell Sarah to give them their money back and return home laughing and shaking my head. It's brilliant!
James
So I'm hauling sand what was left after construction of the wall. I decided to landscape a little around the house which is really ridiculous because now there's this one tiny patch of niceness replete with cactus, volcanic rock and a brick piece border on one corner of a tin roof house with peeling paint, cracked windows and moth eaten rafters harboring bats and rats. So anyway, the boys start gathering as they usually do anytime "Nasara" starts doing anything. Soon they have insisted on grabbing the shovels and hauling the sand in the wheel barrows as well--but you already know the story--this is really a tale about a boy--Fambe (think Thumper and Bambi crossed and you have an idea of the pronunciation). He starts dancing on the sand pile. He's only three, runs around naked most of the time and dances as if he was born to it. He's Lona's second youngest son. He loves to stare at "Nasara" with a blank look on his face. He won't smile, talk or do anything accept come up to you in church and want to sit on your lap until he rips your Arab robes. Then he'll run off to sweep up peanut shells off the floor. Occasionally, you'll be walking to work in the early morning fog and you'll see someone sitting in the dirt waving with a huge grin saying "lalé, lalé" but other than that it's all just serious, expressionless staring. I'm not sure if Fambe still likes me now after I circumcised him and he then got infected because, well he runs around naked and rolls in the dirt at every opportunity. Not to mention that he was quite proud of his new look and would show off to anyone. Oh, and there was the time I was tossing the football and accidently pegged him right on the head causing him to tumble off the porch railing he was perched on 4 feet to the ground. I got there quickly to find him screaming like a hyena with blood pouring off a tiny slit in his scalp. Lona just laughed and shook his head when I told him. As mentioned, Fambe has natural rhythm and likes to take one of my small drums, lay it between his legs as he sprawls on the ground and pound it--sometimes in rhythm with what we are playing.
Fambe's brother Henri on the other hand just stands around looking at you with the cheesiest grin all the time. I've never seen a kid so happy and with a bigger smile. Even when he was deadly sick with Malaria his smile never diminished--his eyes just looked a little droopy.
A boy with a huge Burkitt's Lymphoma on his right cheek (bigger than two huge grapefruits) who I've searched to world over to find treatment for comes into see me when I say I've found it. I first saw him walking down the street to market months ago and stopped the car to yell at him to come see me which he always has done everytime I've called for him. Now when I have the meds finally I set up an appointment to start chemo and he never shows up. I see him by the basketball court we've rigged up in a field the other day and he says he's coming tomorrow then never shows up. I don't get it--maybe he's afraid of getting his hopes up or what--I often can't figure out how people think here.
So, finally--nose peanuts. Never say never. You can teach an old dog new tricks. I never cease to be amazed. Sarah calls me to come see a baby with a peanut stuck up it's nose. I hurry over and see the baby comfortably in mom's arms. I walk down the hall to my office and gather my arsenal: Otoscope, nasal speculum, forceps, clamps, spray anesthetic. I'm armed to the teeth. I walk back balancing all my goodies in both hands. I turn the corner and see a strange man bending over the child. One of the other patients' fathers. I don't get it until I hear loud sucking noises. I'm frozen. He then lifts his lips off the baby's nostrils and there is the slimy peanut sitting right there. He nimbly picks it off and tosses it aside. I'm flabbergasted feeling a little foolish with my "modern" medecine. I tell Sarah to give them their money back and return home laughing and shaking my head. It's brilliant!
James
Monday, May 17, 2004
AIDS in Bere
As most people realize, AIDS is a huge problem in Africa. At first I didn't think it was that big a problem here but as it turns out that's just because people don't want to know, don't get tested, and if they are seropositive everyone hushes it up because to them its a death sentence and the health care workers feel like there's nothing to do either.
I felt the same way at first because all I saw were advanced cases who ended up dying.
Now I've started to identify and work with a group who I've tested because of various risk factors or exam findings (or often when they come with a kid at the end stage then I identify the parent as HIV +) This group is healthy and I've discovered that there are things we can do.
1. We can educate to prevent transmission (fidelity, if there are several wives and some are negatif...condoms, etc)
2. We can treat pregnant mothers to prevent transmission to the newborn (if we have the medicines which we hope to soon...transmission can also be reduced by elective c-section) We are trying to start a program to test pregnant women for HIV (very rarely done here)
3. We can see them at regularly scheduled monthly visits for routine physical exams and lab tests to identify and treat infections early
4. We can identify and treat Tuberculosis or give primary prevention with Isoniazid
5. We can provide emotional and psychological support...especially if they end up abandoned by their families (as unfortunately happens only too often)
And, if we can identify a group that is trustworthy and comes to regularly scheduled visits and is reliable we could hopefully start some of them on Anti-retroviral therapy (anti-HIV meds) if we could find some donors or if the government comes around to decreasing the cost.
We have somehow found a little hope on this dark continent that is at the point of an epidemic. Pray for us and if you can in anyway give us other suggestions or help in any way...
I felt the same way at first because all I saw were advanced cases who ended up dying.
Now I've started to identify and work with a group who I've tested because of various risk factors or exam findings (or often when they come with a kid at the end stage then I identify the parent as HIV +) This group is healthy and I've discovered that there are things we can do.
1. We can educate to prevent transmission (fidelity, if there are several wives and some are negatif...condoms, etc)
2. We can treat pregnant mothers to prevent transmission to the newborn (if we have the medicines which we hope to soon...transmission can also be reduced by elective c-section) We are trying to start a program to test pregnant women for HIV (very rarely done here)
3. We can see them at regularly scheduled monthly visits for routine physical exams and lab tests to identify and treat infections early
4. We can identify and treat Tuberculosis or give primary prevention with Isoniazid
5. We can provide emotional and psychological support...especially if they end up abandoned by their families (as unfortunately happens only too often)
And, if we can identify a group that is trustworthy and comes to regularly scheduled visits and is reliable we could hopefully start some of them on Anti-retroviral therapy (anti-HIV meds) if we could find some donors or if the government comes around to decreasing the cost.
We have somehow found a little hope on this dark continent that is at the point of an epidemic. Pray for us and if you can in anyway give us other suggestions or help in any way...
What I wish...
Tout le monde,
Well, here's to disappointment. If you expect this to be inspiring or moving, please just delete and move on. All I can think of now is what I wish was different about the situation I'm in. Basically this is going to be one big "poor me" session. Here's my wish list:
1. One night to not have to sleep in my own sweat (or someone else's), to be cool enough to cover up and snuggle down in my own comfortable bed. While I'm at it how about sleeping inside instead of out on the porch because it's even hotter inside.
2. One day without having to eat rice, beans or lentils. One day where all I eat is fresh stuff (fruit, salad, yogurt, a sandwich,...)
3. One afternoon at the beach. One surf session even if there are no waves. I just want to paddle out and sit on my board and feel that anticipation that no matter how flat it is a great wave with my name on it is about to roll in. If it could be cold where I had to where my wetsuit and my fingers were so cold afterwards I couldn't hardly get out of the wetsuit or zip up my pants...that'd be sweet...
4. One meal without flies...
5. Grass...one day without staring at, walking on, and breathing dust.
6. Air conditioning
7. Flushing toilets all the time
8. Electricity just one full day when I could plug in my computer when I needed to use it or turn on the fan or listen to music besides 6:30pm to 10pm.
9. Water I could drink from the tap. One shower when I could just throw my head back and drink up some cold fresh water straight, unfiltered, un-partially-refrigerated-with-old-cabbage-smell-on-the-bottle
10. One day of speaking only English with everyone I met...no French, no Arabic and definitely no Nangjere.
11. One day when I could actually have at my disposal all I needed to make the diagnosis.
12. One ICU stay for one patient so one patient who should live...could.
13. One consult with a specialist, any specialist I wanted.
14. One day when I could give the patients all they needed without worrying about whether they'd paid for it or not.
15. One day when I could trust that what I'd ordered would actually be done by the nurses as I ordered it.
16. One of mom's home cooked meals.
17. A game of hoops...with a few weeks ahead of time to get back in shape for it.
18. One day without seeing armed soldiers.
19. One day without being stared at.
20. One hour of privacy without kids standing outside my windows staring in.
21. One trip to town in anonymity without hearing one single "NASARAH"...
22. A vehicle I could take anywhere I wanted, anytime I wanted.
23. One church service with music that moved me.
24. One email session without bugs on the screen.
25. One less trip to N'Djaména for administrative business.
26. One hospital administrator so I didn't have to be it.
27. One guy friend I could just hang out with, shoot hoops with, laugh with, etc...Sarah's great but she is just a GIRL after all.
(I guess that's a good place to stop...27...where have I heard that number before?)
Paix et tranquilité á tous...et que tous vos reves soivent realisés...
Well, here's to disappointment. If you expect this to be inspiring or moving, please just delete and move on. All I can think of now is what I wish was different about the situation I'm in. Basically this is going to be one big "poor me" session. Here's my wish list:
1. One night to not have to sleep in my own sweat (or someone else's), to be cool enough to cover up and snuggle down in my own comfortable bed. While I'm at it how about sleeping inside instead of out on the porch because it's even hotter inside.
2. One day without having to eat rice, beans or lentils. One day where all I eat is fresh stuff (fruit, salad, yogurt, a sandwich,...)
3. One afternoon at the beach. One surf session even if there are no waves. I just want to paddle out and sit on my board and feel that anticipation that no matter how flat it is a great wave with my name on it is about to roll in. If it could be cold where I had to where my wetsuit and my fingers were so cold afterwards I couldn't hardly get out of the wetsuit or zip up my pants...that'd be sweet...
4. One meal without flies...
5. Grass...one day without staring at, walking on, and breathing dust.
6. Air conditioning
7. Flushing toilets all the time
8. Electricity just one full day when I could plug in my computer when I needed to use it or turn on the fan or listen to music besides 6:30pm to 10pm.
9. Water I could drink from the tap. One shower when I could just throw my head back and drink up some cold fresh water straight, unfiltered, un-partially-refrigerated-with-old-cabbage-smell-on-the-bottle
10. One day of speaking only English with everyone I met...no French, no Arabic and definitely no Nangjere.
11. One day when I could actually have at my disposal all I needed to make the diagnosis.
12. One ICU stay for one patient so one patient who should live...could.
13. One consult with a specialist, any specialist I wanted.
14. One day when I could give the patients all they needed without worrying about whether they'd paid for it or not.
15. One day when I could trust that what I'd ordered would actually be done by the nurses as I ordered it.
16. One of mom's home cooked meals.
17. A game of hoops...with a few weeks ahead of time to get back in shape for it.
18. One day without seeing armed soldiers.
19. One day without being stared at.
20. One hour of privacy without kids standing outside my windows staring in.
21. One trip to town in anonymity without hearing one single "NASARAH"...
22. A vehicle I could take anywhere I wanted, anytime I wanted.
23. One church service with music that moved me.
24. One email session without bugs on the screen.
25. One less trip to N'Djaména for administrative business.
26. One hospital administrator so I didn't have to be it.
27. One guy friend I could just hang out with, shoot hoops with, laugh with, etc...Sarah's great but she is just a GIRL after all.
(I guess that's a good place to stop...27...where have I heard that number before?)
Paix et tranquilité á tous...et que tous vos reves soivent realisés...
Sunday, May 9, 2004
La guerre...et la paix
War and Peace could've been written here in Tchad...except not much about peace. It's just routine to here in the morning report of the activities of the "Gard" that a woman came in who'd been beaten by her husband, or her brother or uncle, or her husband's other wife, or her sister, etc. As I mentioned before, about a month ago, tribal warfare broke out in N'Djaména near where the Busl brothers were staying as a whole quarter was shut down by armed police shooting tear gas and bullets while inside the warring members bludgeoned each other with clubs, machetes, bush knifes, tools, bicycles and anything else they could get there hands on and swing at someone. That same week a man was walking near the Busl's house and was jumped on by thugs from a tree who knifed him and left him for dead. The next morning he was still alive surrounded by curious onlookers who when asked why they didn't help him shrugged and said, "we don't know him." Another was stoned to death on a close side street. You remember well the knife fight that happened inside our own hospital right outside the door where I was trying to take care of an infant with Tetanus and another with seizures from severe Malaria.
So, where's the peace? Not yet. This last Thursday I was suddenly called from rounds by shouting. Our chauffeur, Bichara, had just driven up outside the halfway built hospital wall. He'd been out with the district vaccination program at the same time as some of the agricultural community decided to retaliate for what they felt was an unfair decision in a land dispute with the arab nomad cattle traders. A bunch went to the nearby Gendarmerie and when the Gendarmes pulled out their guns one tried to wrest the rifle away only to be shot in the stomach. Then the other Policemen went crazy leaving at least two dead and multiple wounded. All this happened right in front of Bichara who then helped load five wounded into the back of our pickup and bring them to the Bere Adventist Hospital. By the time I arrived a huge crowd had gathered as usual to gawk. Dr. Eric Davy and Dr. Cathy Castillo are visiting from Ventura where I trained so it was just like being in residency...except we were unloading dirty Tchadians with blood soaked clothing from the back of a beat up truck instead of a well equipped ambulance with paramedics who'd already started IVs and applied dressings. No, this was raw carnage, the casulties of war straight from the battlefield.
I quickly questioned the wounded--who were all conscious--where they were injured (at first I thought they'd all been stabbed as knifings are more common here) and three had been hit in the legs, one in the belly and the last in the arm. Blood smeared the bed of the truck as I commandeered several staff to bring stretchers and take away the one shot in the stomach first. All seemed pretty stable on first look and listen to heart and lungs before being carried away. We actually had gloves which was a bonus.
We took Belly Boy to the OR while I grabbed IV catheters, tubing and IV fluids from the Pharmacy. Eric had just taken one shot in the leg to the Salle de Gard (ER). He was bleeding pretty profusely and looked like the bullet had gone through the femur shattering it. Anatole was with him and they were in good form so I moved on. In the Minor Procedure room we had two others who'd been shot in the leg. On the procedure table was a man who'd been shot through the front of the thigh bursting out the back of his knee with some fat and a shredded nerve or tendon hanging out. He couldn't move his foot and was writhing in pain as Cathy washed out the wound. Dr. Claver was there assessing the other who'd been shot in the hamstrings but seemed to not have hurt anything serious.
I went into the OR. Belly Boy had a soft belly, a fast heart rate, a normal blood pressure and a bullet hole entering his right lower quadrant of his abdomen exiting his right posterior flank. I started an IV quickly and started fluids pouring in, shot him up with antiobiotics and Valium, arranged the instruments, scrubbed and about 25 minutes after his arrival I opened his abdomen. I sliced from sternum, around belly button and down close to his pelvis. The small intestine came pouring out but there was no blood or fecal material. I fished around his lower belly identifying a hematoma where the bullet had passed by without entering his abdomen. Then I checked carefully the colon, appendix, liver, spleen and finally ran the small intestine from end to start without finding any injuries. I then sewed the fascia and skin closed and unscrubbed.
While he woke up I went to check on the others. The two in the minor procedure room had IVs running, antibiotics in and dressings in place. They were sweating like crazy in the stuffy tin roofed chamber so I had them moved to hospital beds and went to see the one in the ER. Eric had placed a sandbag on his leg to stop the bleeding but the table was still covered. We lifted off the sandbag, removed the dressing, packed it with gauze in the small anterior hole where the blood was pouring out of and placed a pressure dressing with the sandbag again. We snagged a bed from the medicine ward, rolled it outside under the porch and moved the patient there while a crowd of about thirty gathered around to see what the three "Nasara" docs would do. Since we don't have any equipment for traction or orthopedic surgery (nor an xray for that matter) we placed a plaster cast around his lower leg, tied a rope around it, looped it over the end of the bed and lashed the sandbag to it. The leg was out to length and didn't look rotated so we left it assuming it was reduced. The pressure dressings had managed to stop the bleeding.
I'm starting to wonder why I said it was ok for Cathy and Eric to come. It had been so calm here with just some nice easy malaria cases, a couple of hernias, etc. The first night they arrived was right when I'd decided to take a young man to surgery who had severe pelvic pain with peritoneal signs and vomiting I thought was either vomiting or appendicitis. Unfortunately, Eric scrubbed with me and it transformed from and easy appendectomy to a Sigmoid Volvulus (when the last part of the colon twists around itself causing obstruction and compressing the blood supply sometimes causing gangrene) requiring a partial bowel resection and reanastamosis. Even more unfortunately, due to lack of appropriate post-op care he died two days later. We have no ICU, not enough nurses, and not a good system to make sure the patients family get the treatments prescribed so the nurses can give them. For example, IV fluids and antibiotics where not bought and therefore not given for the first 24 hours. Afterwards, I donated a few and even bought some antibiotics for him but it was too late and he died of sepsis and dehydration. It can be very frustrating and discouraging when it's something so "simple" over there but so "complicated" here.
But seriously having colleagues here has been great. Docs I can trust, consult and conspire with and discuss things with. Not to mention Cathy's a chef and Eric is my surfing buddy who taught me how to catch waves two years ago when we were working together at the Ventura County Medical Center. He even brought a surfing video! It's good to be inspired even though I'm in a country without a coast about as far as one can get from the ocean. Eric also shares my passionate hatred of the rooster who wakes us up every morning way too early. He actually pegged it yesterday with a well aimed shoe thrown from where he was sleeping on the porch.
I've been learning some Danish as Sarah and her mom talk constantly in that little known tongue. For example, Gootmorn means good morning. Tak means thank you. "Coon Girl" means could do (and has become Sarah's new nickname)!
So, Sarah and I headed out to the river yesterday. Me on the pedals, her relaxing easily on back. I'm so out of shape and the bike's tires are flat. Needless to say I was struggling. The over 100 degree weather didn't help. Sweat was pouring off. My thighs were burning...and my butt...let's just say that a bike seat here is really a torture device. Lona's oldest son and one of Pastor DeGaulle's sons caught up to us and passed us easily...you can tell I was working hard and getting no where.
We finally arrived. It was so good to plunge into that muddy, warm water. I gave a bried introductory swimming lesson to DeGualle's son and went off to play in the current. As I rested under the shade of the opposite bank, my feet and legs in the water still, Lona's son called and asked where Sarah was. I didn't see her. I got a little nervous when Lona's son yelled back that he thought she'd headed downstream. He and I took off. The stream got shallow quick and we crossed and climbed the footpath to the side. Up ahead the stream wound around a corner with grassy banks sticking into the meandering stream in between volcanic rock and scrub trees leading to the African plain. No sight of Sarah. We rounded another corner and there she was. She was striding nonchalantly in the ankle deep but wide stream with here long curly red hair flowing and her bright white skin reflecting the sun off her baby blue bikini. All along the banks were scores of very dark, curious children. Ahead was a ford where groups of Arabs gathered in long robes and turbans while similarly attired boys herded cattle across. Sarah seemed to be oblivious to the stir she was creating.
I ran up to her and joined her as we passed the groups of Arabs (who I'm sure approved of her "modest" clothing). We continued around the bend as she asked some of the kids if there was deep water and they said it was just ahead. We had to detour to the bank as a boy running along above the stream warned us of fishing line marked with white plastic waving in the breeze off of sticks stuck in the sand. He also said there were hippos ahead so we decided to stop. I faced downstream on my back and she faced upstream on her tummy. We just sat and talked as I stared at her thinking how improbable all this was to be in the middle of a stream in Africa with a beautiful redhead surrounded by Arabs. I turned around on my belly and but my arm around her. She had goosebumps (from the cold not from me...) and we sat and talked for about half an hour watching huge cargo trucks gun it across the ford followed by pickups packed with turbaned arabs splashed, sprayed, spun and twisted across. The cattle were sometimes obstinate running from the water just right before entering sending the arab boys running and shouting and waving their sticks. Finally, as the sun started to go down we had to go back...uneventfully (except for my almost dying trying to pedal the 7 kilometers while being completely out of shape).
War and Peace...
So, where's the peace? Not yet. This last Thursday I was suddenly called from rounds by shouting. Our chauffeur, Bichara, had just driven up outside the halfway built hospital wall. He'd been out with the district vaccination program at the same time as some of the agricultural community decided to retaliate for what they felt was an unfair decision in a land dispute with the arab nomad cattle traders. A bunch went to the nearby Gendarmerie and when the Gendarmes pulled out their guns one tried to wrest the rifle away only to be shot in the stomach. Then the other Policemen went crazy leaving at least two dead and multiple wounded. All this happened right in front of Bichara who then helped load five wounded into the back of our pickup and bring them to the Bere Adventist Hospital. By the time I arrived a huge crowd had gathered as usual to gawk. Dr. Eric Davy and Dr. Cathy Castillo are visiting from Ventura where I trained so it was just like being in residency...except we were unloading dirty Tchadians with blood soaked clothing from the back of a beat up truck instead of a well equipped ambulance with paramedics who'd already started IVs and applied dressings. No, this was raw carnage, the casulties of war straight from the battlefield.
I quickly questioned the wounded--who were all conscious--where they were injured (at first I thought they'd all been stabbed as knifings are more common here) and three had been hit in the legs, one in the belly and the last in the arm. Blood smeared the bed of the truck as I commandeered several staff to bring stretchers and take away the one shot in the stomach first. All seemed pretty stable on first look and listen to heart and lungs before being carried away. We actually had gloves which was a bonus.
We took Belly Boy to the OR while I grabbed IV catheters, tubing and IV fluids from the Pharmacy. Eric had just taken one shot in the leg to the Salle de Gard (ER). He was bleeding pretty profusely and looked like the bullet had gone through the femur shattering it. Anatole was with him and they were in good form so I moved on. In the Minor Procedure room we had two others who'd been shot in the leg. On the procedure table was a man who'd been shot through the front of the thigh bursting out the back of his knee with some fat and a shredded nerve or tendon hanging out. He couldn't move his foot and was writhing in pain as Cathy washed out the wound. Dr. Claver was there assessing the other who'd been shot in the hamstrings but seemed to not have hurt anything serious.
I went into the OR. Belly Boy had a soft belly, a fast heart rate, a normal blood pressure and a bullet hole entering his right lower quadrant of his abdomen exiting his right posterior flank. I started an IV quickly and started fluids pouring in, shot him up with antiobiotics and Valium, arranged the instruments, scrubbed and about 25 minutes after his arrival I opened his abdomen. I sliced from sternum, around belly button and down close to his pelvis. The small intestine came pouring out but there was no blood or fecal material. I fished around his lower belly identifying a hematoma where the bullet had passed by without entering his abdomen. Then I checked carefully the colon, appendix, liver, spleen and finally ran the small intestine from end to start without finding any injuries. I then sewed the fascia and skin closed and unscrubbed.
While he woke up I went to check on the others. The two in the minor procedure room had IVs running, antibiotics in and dressings in place. They were sweating like crazy in the stuffy tin roofed chamber so I had them moved to hospital beds and went to see the one in the ER. Eric had placed a sandbag on his leg to stop the bleeding but the table was still covered. We lifted off the sandbag, removed the dressing, packed it with gauze in the small anterior hole where the blood was pouring out of and placed a pressure dressing with the sandbag again. We snagged a bed from the medicine ward, rolled it outside under the porch and moved the patient there while a crowd of about thirty gathered around to see what the three "Nasara" docs would do. Since we don't have any equipment for traction or orthopedic surgery (nor an xray for that matter) we placed a plaster cast around his lower leg, tied a rope around it, looped it over the end of the bed and lashed the sandbag to it. The leg was out to length and didn't look rotated so we left it assuming it was reduced. The pressure dressings had managed to stop the bleeding.
I'm starting to wonder why I said it was ok for Cathy and Eric to come. It had been so calm here with just some nice easy malaria cases, a couple of hernias, etc. The first night they arrived was right when I'd decided to take a young man to surgery who had severe pelvic pain with peritoneal signs and vomiting I thought was either vomiting or appendicitis. Unfortunately, Eric scrubbed with me and it transformed from and easy appendectomy to a Sigmoid Volvulus (when the last part of the colon twists around itself causing obstruction and compressing the blood supply sometimes causing gangrene) requiring a partial bowel resection and reanastamosis. Even more unfortunately, due to lack of appropriate post-op care he died two days later. We have no ICU, not enough nurses, and not a good system to make sure the patients family get the treatments prescribed so the nurses can give them. For example, IV fluids and antibiotics where not bought and therefore not given for the first 24 hours. Afterwards, I donated a few and even bought some antibiotics for him but it was too late and he died of sepsis and dehydration. It can be very frustrating and discouraging when it's something so "simple" over there but so "complicated" here.
But seriously having colleagues here has been great. Docs I can trust, consult and conspire with and discuss things with. Not to mention Cathy's a chef and Eric is my surfing buddy who taught me how to catch waves two years ago when we were working together at the Ventura County Medical Center. He even brought a surfing video! It's good to be inspired even though I'm in a country without a coast about as far as one can get from the ocean. Eric also shares my passionate hatred of the rooster who wakes us up every morning way too early. He actually pegged it yesterday with a well aimed shoe thrown from where he was sleeping on the porch.
I've been learning some Danish as Sarah and her mom talk constantly in that little known tongue. For example, Gootmorn means good morning. Tak means thank you. "Coon Girl" means could do (and has become Sarah's new nickname)!
So, Sarah and I headed out to the river yesterday. Me on the pedals, her relaxing easily on back. I'm so out of shape and the bike's tires are flat. Needless to say I was struggling. The over 100 degree weather didn't help. Sweat was pouring off. My thighs were burning...and my butt...let's just say that a bike seat here is really a torture device. Lona's oldest son and one of Pastor DeGaulle's sons caught up to us and passed us easily...you can tell I was working hard and getting no where.
We finally arrived. It was so good to plunge into that muddy, warm water. I gave a bried introductory swimming lesson to DeGualle's son and went off to play in the current. As I rested under the shade of the opposite bank, my feet and legs in the water still, Lona's son called and asked where Sarah was. I didn't see her. I got a little nervous when Lona's son yelled back that he thought she'd headed downstream. He and I took off. The stream got shallow quick and we crossed and climbed the footpath to the side. Up ahead the stream wound around a corner with grassy banks sticking into the meandering stream in between volcanic rock and scrub trees leading to the African plain. No sight of Sarah. We rounded another corner and there she was. She was striding nonchalantly in the ankle deep but wide stream with here long curly red hair flowing and her bright white skin reflecting the sun off her baby blue bikini. All along the banks were scores of very dark, curious children. Ahead was a ford where groups of Arabs gathered in long robes and turbans while similarly attired boys herded cattle across. Sarah seemed to be oblivious to the stir she was creating.
I ran up to her and joined her as we passed the groups of Arabs (who I'm sure approved of her "modest" clothing). We continued around the bend as she asked some of the kids if there was deep water and they said it was just ahead. We had to detour to the bank as a boy running along above the stream warned us of fishing line marked with white plastic waving in the breeze off of sticks stuck in the sand. He also said there were hippos ahead so we decided to stop. I faced downstream on my back and she faced upstream on her tummy. We just sat and talked as I stared at her thinking how improbable all this was to be in the middle of a stream in Africa with a beautiful redhead surrounded by Arabs. I turned around on my belly and but my arm around her. She had goosebumps (from the cold not from me...) and we sat and talked for about half an hour watching huge cargo trucks gun it across the ford followed by pickups packed with turbaned arabs splashed, sprayed, spun and twisted across. The cattle were sometimes obstinate running from the water just right before entering sending the arab boys running and shouting and waving their sticks. Finally, as the sun started to go down we had to go back...uneventfully (except for my almost dying trying to pedal the 7 kilometers while being completely out of shape).
War and Peace...
Sunday, April 25, 2004
Why...
I am once again reminded of why I'm here. The path meanders through the mud brick huts of Béré. The clouds are splayed across the huge Tchadian sky like someone took a huge white paintbrush and made a few bold strokes across the deep blue canvas of the evening sky. Behind me walks a pretty red-headed Danish nurse with a train of over twenty African children each vying to either hold her hand or hold the hand of one who's holding her hand. In front of me is the hut of Lazare, the hospital's janitor, which has no roof. He stands up from behind a woven grass matt wall where he has been meditating facing the setting sun. The sun appears to be setting backwards as its top half is covered by a huge cumulus cloud while it's lower half stretches to almost touch the horizon. Above the cloud the filtered sunbeams stream out in hazy rose-colored rays. There is no noise except the chattering of children in Nangjere. I feel a hand in mine. It's a one-armed boy who loves to just hang out at our porch and look in the window to watch us eat or whatever. I've been teaching him a few English phrases which he loves to repeat.
"What's up, dude?" I say.
"Nothing, bruddah..." he replies with a toothy grin.
A three-year old girl with a very dirty worn shirt about 10 times to big hanging loosely over a swollen belly comes up munching a green mango skin and all. She starts louding repeating "Lapia, lapia" over and over as she tries to give me a sideways "five" with her open palm. She laughs when I start repeating "Lapia" with her.
There is a group of boys, the sons of some of the nurses who always love to just hang out around the house. I always speak to them in English but they love it. I grab them and throw them together to the ground as we wrestle and they squeal in joy covered with dust. One of Lona's sons usually runs around naked (except in church) and always just stares up at you and insists that I am all his. He gets jealous if I let someone else sit on my lap besides him.
As I was saying, Sarah and I were on the path through Béré back towards the hospital. We'd just come from the entertainment of the month in our "city" of 60,000 inhabitants...a soccer match with a visiting team from "far away". The field is a lumpy patch of hard packed dirt with a small line carved out around and tattered flags on sticks planted at the corners to mark its boundaries. The goal posts are so twisted that once I was sure there would've been a goal if they'd used straight wood to make them. The field is actually better delineated by the crowd pressing just up to the playing field about 5-10 people deep without benches or stands or anything. To make sure the boundaries are respected several gendarmes in varying types of army uniforms patrol the boundaries. One carries an old automobile fan belt which he swings in the general direction of anyone close to the line as he yells for the crowd to back up. One actually hits a young boy with a canvas army canteen belt. They are helped by a local in Arab robes and turban sporting Oakley-type shades, a cigarette loosely in his mouth and bunch of straw that he weilds as a weapon. He almost caused a fight amongst the players when he got in the way of a throw-in from out of bounds (the player accidentally hit him in the head with the ball bouncing out of bounds again).
For entertainment, a ghetto blaster belts out Nigerian tunes with classic African rhythms while a dude straight from "Solid Gold" wearing tight bell-bottoms and a brown corderouy shirt jitterbugs in the corner of the field when he's not "helping" the gendarmes keep order. I think he's actually the pastor's son but I'm not sure. An old man with missing and rotten teeth who looks vaguely familiar comes up calling out "Docteur, lapia".
"Lona muga" I reply.
"Lapia, kubang" he responds while vigorously shaking my hand.
"Lapia" I repeat as I've just reached the extent of my Nangjere.
Most have been drinking. I make sure to stay close to Sarah and her friend, Julie. As the only white people in the audience we are also part of the entertainment. Sometimes I wish I could just blend in but like it or not I'll always be a celebrity here. Kids crowd around as an old Nangjere Grandma continually makes commentary on the soccer match. Sarah is a child magnet...I'm glad as it takes some of the attention from me. I may be tall and blond but her very fair skin and wild curly long red hair outdoes me in the "notice me" factor...especially here.
We've been sleeping outside. It's too hot indoors as the tin roofs and cement block walls just hold the heat in. On Sarah's porch I've rigged a rope to sling my mosquito net from while she has had someone make a framework of rebar that she ties her's to. We've been blessed with a very slow week at the hospital. While hippo bites, cattle gorings, falls from mango trees, getting crushed by ox carts, knifings and such are exciting it's been nice just to have a few cases of malaria and some infections to deal with lately. Also, Dr. Claver has been away which means the TV hasn't been running with people around all the time. We also haven't had any foreign visitors here this week so overall it's been quiet. God seems to know just when I need a break.
So, Sarah and I have been sleeping outside. One night something happened that made me feel like a teenager all over again. She had just shared with me some very personal things. She was at a vulnerable point. She was afraid. I wanted to show her that nothing she'd said had changed the way I feel about her. I said, "give me your hand" and she slipped it under her mosquito net and into mine. Then I prayed for her. Afterwards, I just let my hand stay there. She didn't pull away. I felt the same adolescent thrill I hadn't felt in a long time as she slowly caressed my fingers. We lay there in silence enjoying the moment. The stars were out in full force. The moon was a crescent right above Venus just like the symbol of Islam. A cool wind was blowing away the heat of the day. The pigs and goats even respected the moment as there were no gruntings or bleatings in the background. I felt suddenly as if a huge load that had tried to crush me had been lifted and I felt I could sink through the mattress and slip into a sleep that would last for days while at the same time my heart thrilled to her simple touch...
This place, Béré, continues to be such a strange and wonderous and mystifying and unforgettable mix of agony and ecstacy and is truly the experience of a lifetime...
"What's up, dude?" I say.
"Nothing, bruddah..." he replies with a toothy grin.
A three-year old girl with a very dirty worn shirt about 10 times to big hanging loosely over a swollen belly comes up munching a green mango skin and all. She starts louding repeating "Lapia, lapia" over and over as she tries to give me a sideways "five" with her open palm. She laughs when I start repeating "Lapia" with her.
There is a group of boys, the sons of some of the nurses who always love to just hang out around the house. I always speak to them in English but they love it. I grab them and throw them together to the ground as we wrestle and they squeal in joy covered with dust. One of Lona's sons usually runs around naked (except in church) and always just stares up at you and insists that I am all his. He gets jealous if I let someone else sit on my lap besides him.
As I was saying, Sarah and I were on the path through Béré back towards the hospital. We'd just come from the entertainment of the month in our "city" of 60,000 inhabitants...a soccer match with a visiting team from "far away". The field is a lumpy patch of hard packed dirt with a small line carved out around and tattered flags on sticks planted at the corners to mark its boundaries. The goal posts are so twisted that once I was sure there would've been a goal if they'd used straight wood to make them. The field is actually better delineated by the crowd pressing just up to the playing field about 5-10 people deep without benches or stands or anything. To make sure the boundaries are respected several gendarmes in varying types of army uniforms patrol the boundaries. One carries an old automobile fan belt which he swings in the general direction of anyone close to the line as he yells for the crowd to back up. One actually hits a young boy with a canvas army canteen belt. They are helped by a local in Arab robes and turban sporting Oakley-type shades, a cigarette loosely in his mouth and bunch of straw that he weilds as a weapon. He almost caused a fight amongst the players when he got in the way of a throw-in from out of bounds (the player accidentally hit him in the head with the ball bouncing out of bounds again).
For entertainment, a ghetto blaster belts out Nigerian tunes with classic African rhythms while a dude straight from "Solid Gold" wearing tight bell-bottoms and a brown corderouy shirt jitterbugs in the corner of the field when he's not "helping" the gendarmes keep order. I think he's actually the pastor's son but I'm not sure. An old man with missing and rotten teeth who looks vaguely familiar comes up calling out "Docteur, lapia".
"Lona muga" I reply.
"Lapia, kubang" he responds while vigorously shaking my hand.
"Lapia" I repeat as I've just reached the extent of my Nangjere.
Most have been drinking. I make sure to stay close to Sarah and her friend, Julie. As the only white people in the audience we are also part of the entertainment. Sometimes I wish I could just blend in but like it or not I'll always be a celebrity here. Kids crowd around as an old Nangjere Grandma continually makes commentary on the soccer match. Sarah is a child magnet...I'm glad as it takes some of the attention from me. I may be tall and blond but her very fair skin and wild curly long red hair outdoes me in the "notice me" factor...especially here.
We've been sleeping outside. It's too hot indoors as the tin roofs and cement block walls just hold the heat in. On Sarah's porch I've rigged a rope to sling my mosquito net from while she has had someone make a framework of rebar that she ties her's to. We've been blessed with a very slow week at the hospital. While hippo bites, cattle gorings, falls from mango trees, getting crushed by ox carts, knifings and such are exciting it's been nice just to have a few cases of malaria and some infections to deal with lately. Also, Dr. Claver has been away which means the TV hasn't been running with people around all the time. We also haven't had any foreign visitors here this week so overall it's been quiet. God seems to know just when I need a break.
So, Sarah and I have been sleeping outside. One night something happened that made me feel like a teenager all over again. She had just shared with me some very personal things. She was at a vulnerable point. She was afraid. I wanted to show her that nothing she'd said had changed the way I feel about her. I said, "give me your hand" and she slipped it under her mosquito net and into mine. Then I prayed for her. Afterwards, I just let my hand stay there. She didn't pull away. I felt the same adolescent thrill I hadn't felt in a long time as she slowly caressed my fingers. We lay there in silence enjoying the moment. The stars were out in full force. The moon was a crescent right above Venus just like the symbol of Islam. A cool wind was blowing away the heat of the day. The pigs and goats even respected the moment as there were no gruntings or bleatings in the background. I felt suddenly as if a huge load that had tried to crush me had been lifted and I felt I could sink through the mattress and slip into a sleep that would last for days while at the same time my heart thrilled to her simple touch...
This place, Béré, continues to be such a strange and wonderous and mystifying and unforgettable mix of agony and ecstacy and is truly the experience of a lifetime...
Sunday, March 28, 2004
The way I really feel...
Everyone,
I sit here in my small 8x10 foot room on a pillow against the wall. There are no chairs. There is a small night stand in one corner and a foam mattress that is caved in with a too big makeshift goldenrod sheet on it. A mosquito net hangs from the ceiling. The cement floors are swept clean (yesterday). It's hot. I have a fever as well...Malaria...again. A Fanta bottle half filled with water sits by the door. The closet is filled with all my possessions.
I try to sleep. It's too hot...I drench the sheets. I think of what I face...if it was just the patients, the medicine, the surgeries, it would be enough. But it's so much more than that.
I need to build a wall around the hospital to keep out the pigs which have taken over and to provide security for the patients and hospital staff. I can't afford the $20,000 price that is by far the cheapest we've come across with four different entrepeneurs.
I just got a letter from the auditors saying that the hospital owes them ~$35,000. No one here has any idea what that's for and we certainly can't afford it. I just got an email saying it was mailed out Feb 2 and why haven't I answered. If I want they can just fax it too me and I can fax it back. Do they have any idea where I am? Do they think I have a fax out here? In Béré? In the middle of nowhere with no telephones and no electricity much less faxes.
This email I'm sending over the satellite phone...the government wants me to pay $2400/year to have it here. Then they "nicely" agreed to lower it to $400/year...I refused...and I didn't have the money anyway. They said come back when you've calmed down and we'll work things out.
There's a team coming in June to build us much needed lodging. I'm supposed to get the foundation laid and all the materials on hand so they can come in and build it in a two-week period. That's great...but it's a lot of work for me...
The government is supposed to provide us with medications each year. We haven't gotten 2003's supply yet, but supposedly 2004 should be here. I had to decide what medicines and supplies we would need for a whole year so we can be well stocked without having to waste medicines like the last few years when we've burned thousands of dollars of expired, unused meds. Meanwhile, we are running out and I have to buy a little here and a little there to keep us functioning without buying so much that when the year supply comes we'll be overstocked.
I'm working on a program to include the village health care workers and village clinics in a program to treat tuberculosis adequately through Directly Observed Therapy. I'm supposed to organize all this so that the patients can get treated at home and just go daily to see a clinic worker or village health care worker.
I'm working on a program to try and test pregnant women for HIV and treat them during labor to prevent transmission to the child as part of the Ministry of Health's agreement with us. They have allocated $16,000 to us for research and the fight against HIV/AIDS that we will lose if we don't use it.
There is a volunteer here filming a film of the hospital which is fantastic but just adds a little stress. Likewise for a medical student who just arrived to spend a month. We have not adequate housing for them. They are both staying in Sarah's place while she sleeps in the same room with 3 Tchadian girls across the way. We all have to eat too...we are trying to find someone to cook and clean for us.
People also come to me daily looking for work. The pastor wonders when we'll be able to pay him to be the Chaplain as well so he doesn't have to earn his living by cutting reeds to make mats with. His salary would be only $50-75 per month.
I'm trying to get a proposal done to get a solar panel system for the hospital so we can have electricity during the day for light and especially for the lab to do their work...also to cut down on the wear and tear and expense of the generator. People hear I'm in the market (somehow) and came to me today to offer to sell me some panels.
Another man comes today asking if Sarah's still interested in renting a horse from him and also if he can catch a ride with us next time we go to N'Djaména.
The lab wants me to get the light fixed in there so they can work at night for emergencies without having to use a lantern or flashlight.
It's now black in the room...the generator is off for the night. The kids are singing outside. The TV is blaring a soccer match in French as Dr. Claver runs it off his battery. The sweat drips off my face and into my lap. I feel the weight of it all. Can it really be done? Is it too much? Somehow, despite it all, the thought of leaving never enters my head. I think I'm just too stubborn.
A day in the office means seeing patients, having people walk in with lab results, nurses telling me they're sick, people asking for work, an emergency case, this problem with that hospitalized patient, this meeting we need to arrange...
Which reminds me...there's the Management Committee to plan and run, the next AHI Tchad committee to organize and chair, the budget to work on with André...
Oh, and there's the water tower that is leaking and needs to be welded, the latrines and showers for the patients that need to be built, the chauffeur that I had to sit down with a talk to after giving him a formal letter stating why we are not pleased with the job he's doing, and then there's the nurse who just can't seem to get things done and is aggressive to the patients (one night the night watchmen had to come to his rescue so that the patients didn't beat him up)...we need to send him back to the district (he's lent to us by the government)...
So, now that I've got all that off my chest...let me just lie down in my sweat, put my earplugs in so the dogs, pigs, kids and roosters don't keep me awake, and sleep peacefully away wondering what tomorrow will bring and not knowing how it'll all get done but knowing that somehow it will and somehow I'll enjoy it and wonder how I got so lucky to be here doing things that I could never have dreamed up or invented and experiencing life...
I just wish I'd stop sweating and yes, Mom, I'll start taking Malaria prophylaxis again...
I sit here in my small 8x10 foot room on a pillow against the wall. There are no chairs. There is a small night stand in one corner and a foam mattress that is caved in with a too big makeshift goldenrod sheet on it. A mosquito net hangs from the ceiling. The cement floors are swept clean (yesterday). It's hot. I have a fever as well...Malaria...again. A Fanta bottle half filled with water sits by the door. The closet is filled with all my possessions.
I try to sleep. It's too hot...I drench the sheets. I think of what I face...if it was just the patients, the medicine, the surgeries, it would be enough. But it's so much more than that.
I need to build a wall around the hospital to keep out the pigs which have taken over and to provide security for the patients and hospital staff. I can't afford the $20,000 price that is by far the cheapest we've come across with four different entrepeneurs.
I just got a letter from the auditors saying that the hospital owes them ~$35,000. No one here has any idea what that's for and we certainly can't afford it. I just got an email saying it was mailed out Feb 2 and why haven't I answered. If I want they can just fax it too me and I can fax it back. Do they have any idea where I am? Do they think I have a fax out here? In Béré? In the middle of nowhere with no telephones and no electricity much less faxes.
This email I'm sending over the satellite phone...the government wants me to pay $2400/year to have it here. Then they "nicely" agreed to lower it to $400/year...I refused...and I didn't have the money anyway. They said come back when you've calmed down and we'll work things out.
There's a team coming in June to build us much needed lodging. I'm supposed to get the foundation laid and all the materials on hand so they can come in and build it in a two-week period. That's great...but it's a lot of work for me...
The government is supposed to provide us with medications each year. We haven't gotten 2003's supply yet, but supposedly 2004 should be here. I had to decide what medicines and supplies we would need for a whole year so we can be well stocked without having to waste medicines like the last few years when we've burned thousands of dollars of expired, unused meds. Meanwhile, we are running out and I have to buy a little here and a little there to keep us functioning without buying so much that when the year supply comes we'll be overstocked.
I'm working on a program to include the village health care workers and village clinics in a program to treat tuberculosis adequately through Directly Observed Therapy. I'm supposed to organize all this so that the patients can get treated at home and just go daily to see a clinic worker or village health care worker.
I'm working on a program to try and test pregnant women for HIV and treat them during labor to prevent transmission to the child as part of the Ministry of Health's agreement with us. They have allocated $16,000 to us for research and the fight against HIV/AIDS that we will lose if we don't use it.
There is a volunteer here filming a film of the hospital which is fantastic but just adds a little stress. Likewise for a medical student who just arrived to spend a month. We have not adequate housing for them. They are both staying in Sarah's place while she sleeps in the same room with 3 Tchadian girls across the way. We all have to eat too...we are trying to find someone to cook and clean for us.
People also come to me daily looking for work. The pastor wonders when we'll be able to pay him to be the Chaplain as well so he doesn't have to earn his living by cutting reeds to make mats with. His salary would be only $50-75 per month.
I'm trying to get a proposal done to get a solar panel system for the hospital so we can have electricity during the day for light and especially for the lab to do their work...also to cut down on the wear and tear and expense of the generator. People hear I'm in the market (somehow) and came to me today to offer to sell me some panels.
Another man comes today asking if Sarah's still interested in renting a horse from him and also if he can catch a ride with us next time we go to N'Djaména.
The lab wants me to get the light fixed in there so they can work at night for emergencies without having to use a lantern or flashlight.
It's now black in the room...the generator is off for the night. The kids are singing outside. The TV is blaring a soccer match in French as Dr. Claver runs it off his battery. The sweat drips off my face and into my lap. I feel the weight of it all. Can it really be done? Is it too much? Somehow, despite it all, the thought of leaving never enters my head. I think I'm just too stubborn.
A day in the office means seeing patients, having people walk in with lab results, nurses telling me they're sick, people asking for work, an emergency case, this problem with that hospitalized patient, this meeting we need to arrange...
Which reminds me...there's the Management Committee to plan and run, the next AHI Tchad committee to organize and chair, the budget to work on with André...
Oh, and there's the water tower that is leaking and needs to be welded, the latrines and showers for the patients that need to be built, the chauffeur that I had to sit down with a talk to after giving him a formal letter stating why we are not pleased with the job he's doing, and then there's the nurse who just can't seem to get things done and is aggressive to the patients (one night the night watchmen had to come to his rescue so that the patients didn't beat him up)...we need to send him back to the district (he's lent to us by the government)...
So, now that I've got all that off my chest...let me just lie down in my sweat, put my earplugs in so the dogs, pigs, kids and roosters don't keep me awake, and sleep peacefully away wondering what tomorrow will bring and not knowing how it'll all get done but knowing that somehow it will and somehow I'll enjoy it and wonder how I got so lucky to be here doing things that I could never have dreamed up or invented and experiencing life...
I just wish I'd stop sweating and yes, Mom, I'll start taking Malaria prophylaxis again...
Monday, March 22, 2004
Wait, hurry up I'm not patient yet...
Tout le monde,
As I sit here finishing off my nutritious, delicious evening meal of Southwestern barbecue goulash with Paul I think back to one word to describe N'Djaména (besides Sodom, Gomorrah, Babylon, frustrating, filthy, dangerous, corrupt, etc) it's BUREAUCRATIC. (Actually the goulash is just corn, old rice and burnt lentils...hence the "Southwestern" flavor).
So I'm in N'Djaména. I'm waiting as usual. All I want is some fabric to have some extra surgical gowns and drapes made. I've come to the "Grand Marché" (Great Market) where one can buy everything from dried beans to pharmaceuticals to door locks to plastic pitchers to dried flowers for making "Jus d'Osais" to axes to radios to turbans to cloth to shoes to...I've come here to the fabric section and they've run off somewhere. A boy passes wearing the long flowing Muslim robes with a small bowl balanced perfectly on his head. I'm sitting with Bichara who has his legs crossed contemplating the passersby. He orders a glass of red tea from a turbaned vendor and then buys one for me as well. As I try to balance to glass in my hand without burning myself with the tea-heated-glass a pair of Arab women with brightly colored wraps and shawls pass by giggling in Arabic which Bichara translates as "So, Nasara [whitie], you drink tea, too?" Hee-hee-hee. Several Arabs across the street start the ritual washing for prayer. The prayer mats are rolled out and taking a small plastic pitcher they carefully wash first the hands and forearms then the face and lastly the feet and ankles moving them onto the mat when finished. All is done with a fluidity and grace that comes from doing this five times a day for the last who knows how many years. It is a communal event as an old man will be joined by a merchant who'll be joined by a passing youth. They will stand together facing east. They will bow together. They will pray together...shoulder by shoulder. Finally, the man comes back with the thick green cloth I've been looking for and we move on...
I'm just trying to make photocopies. The place said only 30 Francs per copie so I couldn't pass it up. I sit on thinly covered pole chairs...not comfortable. The generator has been fired up for me. I'm trying to copy 200 "Dossiers" or medical charts so we can document things at the hospital. That took forever yesterday with me finally coming back this morning only to find it still not done. I then gave them a Nangdjere (Béré's local language) song book so we can turn our church service into a local language speaking church rather than a foreign French/whitey church. I gave it to them at 8am and it's 10am and still not done. So I wait...at least they call me by name now...Oh, here comes Bonaparte...what's he doing here? He just seems to be everywhere. He's going to help us lay the foundation for the staff housing we'll be building in June with the help of a group from the states...he seems to show up everywhere...I greet him and continue waiting...
I'm in the bureau of the State Police. I came here yesterday to have a paper signed authorizing Paul to film us in Béré. It was already signed by two other offices. This is the last signature. I was told to come back at 0930AM today...then noon. It's now 2pm. The office is sparse with three desks. Behind one works the secretary, a wiry man with a little gray and purposeful movements who is always coming and going, bringing and taking papers...I'm not sure if he really does anything with them. It's hot but a little breeze comes in the doorway right where I'm sitting next to a large woman reading the Bible in French. She's in Genesis and says she's going to read through it all when I ask her if it's interesting what she's reading. The other desk has another large woman behind it reading some other book. I make small talk. They don't seem to mind their reading being interrupted. The man comes back and says he can't find my paper amongst the visa requests. I say that's because it's a request for authorization to film. He says "Oh that shouldn't have taken any time at all...I thought it was a visa request." He comes back in two minutes with the paper signed and puts the all important "cachet" on it and I'm outta there...
Ah yeah, the omnipotent "cachet" or rubber stamp. One cannot survive here in Tchad without it. I'm just beginning to discover it's secret powers. Paul and I went to register him with the National Security Office. He filled out a small form and we wait. Then the guy starts to ask me some questions. He seems suspicious. What is he doing here? Where will he stay? Who's responsible? Give me the address. I write down my name and the PO box of the hospital. He still has a scowl of disapproval on his face. Then, thinking quickly I reach for my secret weapon. To the untrained eye it is simply a piece of wood with some carved rubber pasted on the end. To the one who has wisdom...it is power. I place the rubber stamp in the ink and stamp it down forcefully on the paper in purple ink. The man's face lights up. He smiles approvingly and shows me a stack of similar papers all with a variety of stamped ink. He returns in 1.5 minutes with the document approved having placed his own stamp in Paul's passport...he is now legally in Tchad!
I go later to the Central Referral Hospital for the country. I'm dressed in cargo pants, a t-shirt and tennis with uncombed scraggly hair. I say I'm the Medical Director of the Béré Hospital...for some reason the guard says he doesn't believe me...where are my credentials. I start to panic. I don't have any. They've all believed me before because I'm white. I need to see the director of Women's Health there. Then, I remember my secret weapon. I pull out my "cachet" and present it reverently to the guard. He nods knowingly for me to enter. Once again, rescued by the power of the "cachet"!
It's so good to be back in Béré. The first day back I released 13 people from the hospital. They were all complaining about having no space and patients sleeping on the floor but there were patients who hadn't been seen in almost a week and had been ready to leave for several days. Saturday, I cleaned house some more. Unfortunately, the baby I'd operated on just before leaving for N'Djaména had died. The boy with the skull injury though was awake and eating. He won't see out of his right eye though and he has lid lag. I casted his tibia/fibula fracture and sent him to another hospital for an xray. Things were smoothing out...until the "Sunday of Pregnancies from Hell"...
I rounded and did clinic while Dr. Claver did a C-section. No big deal. Then about midday three women came in to labor at once. One was tiny with a huge baby that then didn't progress. I did a symphysiotomy so her pelvis would open up and she still took forever to deliver and required an episiotomie as well. Then the baby wasn't breathing and was floppy. We mouth to mouth suctioned with a tube and I took a bag-valve-mask and tried breathing. THe heartbeat was slow. Sarah was listening and air wasn't going in. I adjusted and finally air started going in. The baby was limp and blue. Then the heartbeat picked up. Then the baby opened it's eyes with a look like a deer in headlights and coughed a few times. Some of the ever-present onlookers murmered "its a miracle." I had to agree. The baby is still alive today. I then went and had supper and was talking with Sarah outside in the early evening when the "Gard" came to tell me about a woman who'd just arrived with the baby's arm sticking out. Things were looking up though because the baby kept waving it's hand to let us know he was still hanging in there! At 9pm I was called to see her. At 1030pm we'd finished mopping up the mess from the c-section and the woman was already in recovery with a healthy baby girl. I really prayed for that one though because first of all the baby just didn't want to come out of the uterus and secondly I nicked the uterine artery with a suture needle and it bled like stink. I just pressed on it with gauze and tried to calm my panic. I asked for a suture hoping my voice wouldn't crack and was able to control it without much blood loss. Whewwww...I then returned to see the last woman in labor who had also not progressed despite adequate contractions. The woman and baby were big, but the pelvis was small...time for another symphysiotomie. After the procedure she pushed twice and the baby was screaming almost before it hit the mattress and the cord was clamped. By then it was midnight and I didn't even want to deal with the woman who'd just come in with a retained placenta after a home delivery. Fortunately, I didn't have to since I didn't find out about it till the next day! Oh, yeah, today, the next day. I woman comes in by oxcart from one of the outlying health clinics for a breech presentation (butt first instead of head). Another C-section, which fortunately went smoothly with another screaming, healthy kid.
Today, the men from Lai came who'd offered to give us another estimate on a wall to enclose the hospital. The pigs just keep getting more numerous and fearless and the hospital is a zoo. I spoke with the Architect of the government project that we have partnered with as well as the engineer in charge of the implementation. They had planned to give us $60,000 for a wall but not until the second phase which would be at some unknown time after the first phase which will start in September and include a new operating block. I felt we couldn't wait and had seen a beautiful fence around the Catholic school here made of 3 feet of brick with a cement and rebar header imbedded with another 3 feet of heavy chain link fencing on top. It was strong, durable, funcitional and yet open and not prison or concentration-camp like since you could see through and know what was happening inside. And, most importantly it was much cheaper. So these 2 guys from Lai gave me an estimate today of $26,000. Still way too expensive but I think we can negotiate as the Catholic Sisters got a much better deal. I think if we had $18-20,000 we could enclose the hospital, keep out the animals and extra people, keep in the patients, start to really clean things up and provide a hospitable environment as well as move forward with other projects such as providing mattresses and mosquito nets. Without a wall those things just walk away. Then, the government has said they will use the $60,000 to build us a new hospital ward which we also desperately need. I think it could really work out for the best if we can somehow raise the money for the wall.
Your encouraging letters mean more than I can say to each personally. They keep me going knowing I'm not alone out here but that there are people all over the world praying for us here at the little lost hospital of Béré.
As I sit here finishing off my nutritious, delicious evening meal of Southwestern barbecue goulash with Paul I think back to one word to describe N'Djaména (besides Sodom, Gomorrah, Babylon, frustrating, filthy, dangerous, corrupt, etc) it's BUREAUCRATIC. (Actually the goulash is just corn, old rice and burnt lentils...hence the "Southwestern" flavor).
So I'm in N'Djaména. I'm waiting as usual. All I want is some fabric to have some extra surgical gowns and drapes made. I've come to the "Grand Marché" (Great Market) where one can buy everything from dried beans to pharmaceuticals to door locks to plastic pitchers to dried flowers for making "Jus d'Osais" to axes to radios to turbans to cloth to shoes to...I've come here to the fabric section and they've run off somewhere. A boy passes wearing the long flowing Muslim robes with a small bowl balanced perfectly on his head. I'm sitting with Bichara who has his legs crossed contemplating the passersby. He orders a glass of red tea from a turbaned vendor and then buys one for me as well. As I try to balance to glass in my hand without burning myself with the tea-heated-glass a pair of Arab women with brightly colored wraps and shawls pass by giggling in Arabic which Bichara translates as "So, Nasara [whitie], you drink tea, too?" Hee-hee-hee. Several Arabs across the street start the ritual washing for prayer. The prayer mats are rolled out and taking a small plastic pitcher they carefully wash first the hands and forearms then the face and lastly the feet and ankles moving them onto the mat when finished. All is done with a fluidity and grace that comes from doing this five times a day for the last who knows how many years. It is a communal event as an old man will be joined by a merchant who'll be joined by a passing youth. They will stand together facing east. They will bow together. They will pray together...shoulder by shoulder. Finally, the man comes back with the thick green cloth I've been looking for and we move on...
I'm just trying to make photocopies. The place said only 30 Francs per copie so I couldn't pass it up. I sit on thinly covered pole chairs...not comfortable. The generator has been fired up for me. I'm trying to copy 200 "Dossiers" or medical charts so we can document things at the hospital. That took forever yesterday with me finally coming back this morning only to find it still not done. I then gave them a Nangdjere (Béré's local language) song book so we can turn our church service into a local language speaking church rather than a foreign French/whitey church. I gave it to them at 8am and it's 10am and still not done. So I wait...at least they call me by name now...Oh, here comes Bonaparte...what's he doing here? He just seems to be everywhere. He's going to help us lay the foundation for the staff housing we'll be building in June with the help of a group from the states...he seems to show up everywhere...I greet him and continue waiting...
I'm in the bureau of the State Police. I came here yesterday to have a paper signed authorizing Paul to film us in Béré. It was already signed by two other offices. This is the last signature. I was told to come back at 0930AM today...then noon. It's now 2pm. The office is sparse with three desks. Behind one works the secretary, a wiry man with a little gray and purposeful movements who is always coming and going, bringing and taking papers...I'm not sure if he really does anything with them. It's hot but a little breeze comes in the doorway right where I'm sitting next to a large woman reading the Bible in French. She's in Genesis and says she's going to read through it all when I ask her if it's interesting what she's reading. The other desk has another large woman behind it reading some other book. I make small talk. They don't seem to mind their reading being interrupted. The man comes back and says he can't find my paper amongst the visa requests. I say that's because it's a request for authorization to film. He says "Oh that shouldn't have taken any time at all...I thought it was a visa request." He comes back in two minutes with the paper signed and puts the all important "cachet" on it and I'm outta there...
Ah yeah, the omnipotent "cachet" or rubber stamp. One cannot survive here in Tchad without it. I'm just beginning to discover it's secret powers. Paul and I went to register him with the National Security Office. He filled out a small form and we wait. Then the guy starts to ask me some questions. He seems suspicious. What is he doing here? Where will he stay? Who's responsible? Give me the address. I write down my name and the PO box of the hospital. He still has a scowl of disapproval on his face. Then, thinking quickly I reach for my secret weapon. To the untrained eye it is simply a piece of wood with some carved rubber pasted on the end. To the one who has wisdom...it is power. I place the rubber stamp in the ink and stamp it down forcefully on the paper in purple ink. The man's face lights up. He smiles approvingly and shows me a stack of similar papers all with a variety of stamped ink. He returns in 1.5 minutes with the document approved having placed his own stamp in Paul's passport...he is now legally in Tchad!
I go later to the Central Referral Hospital for the country. I'm dressed in cargo pants, a t-shirt and tennis with uncombed scraggly hair. I say I'm the Medical Director of the Béré Hospital...for some reason the guard says he doesn't believe me...where are my credentials. I start to panic. I don't have any. They've all believed me before because I'm white. I need to see the director of Women's Health there. Then, I remember my secret weapon. I pull out my "cachet" and present it reverently to the guard. He nods knowingly for me to enter. Once again, rescued by the power of the "cachet"!
It's so good to be back in Béré. The first day back I released 13 people from the hospital. They were all complaining about having no space and patients sleeping on the floor but there were patients who hadn't been seen in almost a week and had been ready to leave for several days. Saturday, I cleaned house some more. Unfortunately, the baby I'd operated on just before leaving for N'Djaména had died. The boy with the skull injury though was awake and eating. He won't see out of his right eye though and he has lid lag. I casted his tibia/fibula fracture and sent him to another hospital for an xray. Things were smoothing out...until the "Sunday of Pregnancies from Hell"...
I rounded and did clinic while Dr. Claver did a C-section. No big deal. Then about midday three women came in to labor at once. One was tiny with a huge baby that then didn't progress. I did a symphysiotomy so her pelvis would open up and she still took forever to deliver and required an episiotomie as well. Then the baby wasn't breathing and was floppy. We mouth to mouth suctioned with a tube and I took a bag-valve-mask and tried breathing. THe heartbeat was slow. Sarah was listening and air wasn't going in. I adjusted and finally air started going in. The baby was limp and blue. Then the heartbeat picked up. Then the baby opened it's eyes with a look like a deer in headlights and coughed a few times. Some of the ever-present onlookers murmered "its a miracle." I had to agree. The baby is still alive today. I then went and had supper and was talking with Sarah outside in the early evening when the "Gard" came to tell me about a woman who'd just arrived with the baby's arm sticking out. Things were looking up though because the baby kept waving it's hand to let us know he was still hanging in there! At 9pm I was called to see her. At 1030pm we'd finished mopping up the mess from the c-section and the woman was already in recovery with a healthy baby girl. I really prayed for that one though because first of all the baby just didn't want to come out of the uterus and secondly I nicked the uterine artery with a suture needle and it bled like stink. I just pressed on it with gauze and tried to calm my panic. I asked for a suture hoping my voice wouldn't crack and was able to control it without much blood loss. Whewwww...I then returned to see the last woman in labor who had also not progressed despite adequate contractions. The woman and baby were big, but the pelvis was small...time for another symphysiotomie. After the procedure she pushed twice and the baby was screaming almost before it hit the mattress and the cord was clamped. By then it was midnight and I didn't even want to deal with the woman who'd just come in with a retained placenta after a home delivery. Fortunately, I didn't have to since I didn't find out about it till the next day! Oh, yeah, today, the next day. I woman comes in by oxcart from one of the outlying health clinics for a breech presentation (butt first instead of head). Another C-section, which fortunately went smoothly with another screaming, healthy kid.
Today, the men from Lai came who'd offered to give us another estimate on a wall to enclose the hospital. The pigs just keep getting more numerous and fearless and the hospital is a zoo. I spoke with the Architect of the government project that we have partnered with as well as the engineer in charge of the implementation. They had planned to give us $60,000 for a wall but not until the second phase which would be at some unknown time after the first phase which will start in September and include a new operating block. I felt we couldn't wait and had seen a beautiful fence around the Catholic school here made of 3 feet of brick with a cement and rebar header imbedded with another 3 feet of heavy chain link fencing on top. It was strong, durable, funcitional and yet open and not prison or concentration-camp like since you could see through and know what was happening inside. And, most importantly it was much cheaper. So these 2 guys from Lai gave me an estimate today of $26,000. Still way too expensive but I think we can negotiate as the Catholic Sisters got a much better deal. I think if we had $18-20,000 we could enclose the hospital, keep out the animals and extra people, keep in the patients, start to really clean things up and provide a hospitable environment as well as move forward with other projects such as providing mattresses and mosquito nets. Without a wall those things just walk away. Then, the government has said they will use the $60,000 to build us a new hospital ward which we also desperately need. I think it could really work out for the best if we can somehow raise the money for the wall.
Your encouraging letters mean more than I can say to each personally. They keep me going knowing I'm not alone out here but that there are people all over the world praying for us here at the little lost hospital of Béré.
Friday, March 5, 2004
I'm finally a real missionary!
March 5, 2004
Salut a tout le monde,
I finally feel like a real missionary. Yesterday, I awoke not feeling the greatest. Sarah and I had just had an important talk concerning trust where we were learning a little to trust each other by sharing some personal things. Unfortunately, that went late. So I attributed my tiredness and soreness to that. Also, it has been very hot here, over 100 F. That must be why I've been sweating so much the past few days. Anyway, at morning report, the "Garde" (Jean Bende) reported on several cases where he had done treatments we'd discussed many times before as inadequate. Then, he talked about a Pediatric case that should have been hospitalized that was sent home. Then, another case that he put on "observation" because, as he said, only the "Médecin" (moi) can hospitalize. That was the last straw. I exploded. I tore him apart. I told him that they've been hospitalizing patients for years without me. I asked the charge nurse how many patients he had personally hospitalized the day before. He said "three." I continued until he spoke up very hurt and said he could tell I was displeased with his work and he'd worked virtually without sleep and if I wanted he would just go back to the District and not work at the hospital any more. I told him he was tired, he should leave and rest and we'd talk later.
That afternoon I did a mastectomy (removal of a breast) on a man (!) with a mass there. During the surgery all my muscles began to ache. I began to have a stomach ache. My head began to kill me. I had a strange premonition I was about to become a true missionary. I finished the surgery and went straight to the lab and had them do the "gout d'espece". Sure enough, it was positive. I finally had Malaria. I was kind of excited even though it meant I'd lost the bet with Sarah and owed her my last bar of dark Swiss chocolate. I got some Fansidar and Quinine from the Pharmacy and headed home to rest. I felt like...well I better not use that word...let me see, oh yes, I can say "awful". But let me tell you...the sleep was sweet. Aside from not being able to hear well and the worsening of my pounding headache (both side effects of Quinine) I felt great. It was the first time in a long time I got a prolonged sleep. The next morning I felt wonderful (but still couldn't hear well...it's like having partial earplugs in).
I also had to to reflect.
At morning report we had worship and then I got up and apologized to Jean Bende. He reported that he too had thought about it a lot and felt like the Devil was trying hard to divide us and he didn't know what to do so he was very glad to accept my apology. Today was the most relaxed day I've had with the best interactions among the staff that I've seen. It was like everyone let out a long sigh that lasted all day long...
To top it off we got our autoclave working just by a little trial and error to figure out the two different knobs! Now we can actually operate with sterile instruments, gowns and drapes.
As for the Malaria...what's the big deal really...:)
Salut a tout le monde,
I finally feel like a real missionary. Yesterday, I awoke not feeling the greatest. Sarah and I had just had an important talk concerning trust where we were learning a little to trust each other by sharing some personal things. Unfortunately, that went late. So I attributed my tiredness and soreness to that. Also, it has been very hot here, over 100 F. That must be why I've been sweating so much the past few days. Anyway, at morning report, the "Garde" (Jean Bende) reported on several cases where he had done treatments we'd discussed many times before as inadequate. Then, he talked about a Pediatric case that should have been hospitalized that was sent home. Then, another case that he put on "observation" because, as he said, only the "Médecin" (moi) can hospitalize. That was the last straw. I exploded. I tore him apart. I told him that they've been hospitalizing patients for years without me. I asked the charge nurse how many patients he had personally hospitalized the day before. He said "three." I continued until he spoke up very hurt and said he could tell I was displeased with his work and he'd worked virtually without sleep and if I wanted he would just go back to the District and not work at the hospital any more. I told him he was tired, he should leave and rest and we'd talk later.
That afternoon I did a mastectomy (removal of a breast) on a man (!) with a mass there. During the surgery all my muscles began to ache. I began to have a stomach ache. My head began to kill me. I had a strange premonition I was about to become a true missionary. I finished the surgery and went straight to the lab and had them do the "gout d'espece". Sure enough, it was positive. I finally had Malaria. I was kind of excited even though it meant I'd lost the bet with Sarah and owed her my last bar of dark Swiss chocolate. I got some Fansidar and Quinine from the Pharmacy and headed home to rest. I felt like...well I better not use that word...let me see, oh yes, I can say "awful". But let me tell you...the sleep was sweet. Aside from not being able to hear well and the worsening of my pounding headache (both side effects of Quinine) I felt great. It was the first time in a long time I got a prolonged sleep. The next morning I felt wonderful (but still couldn't hear well...it's like having partial earplugs in).
I also had to to reflect.
At morning report we had worship and then I got up and apologized to Jean Bende. He reported that he too had thought about it a lot and felt like the Devil was trying hard to divide us and he didn't know what to do so he was very glad to accept my apology. Today was the most relaxed day I've had with the best interactions among the staff that I've seen. It was like everyone let out a long sigh that lasted all day long...
To top it off we got our autoclave working just by a little trial and error to figure out the two different knobs! Now we can actually operate with sterile instruments, gowns and drapes.
As for the Malaria...what's the big deal really...:)
Don't worry...
Everyone,
I've got some letters from people who are worried about me...don't worry. I'm trying simply to be real and honest. To say that things are always rosy, exciting and rewarding here would be a lie. But just because I share them doesn't mean that there is any less joy, happiness or fulfillment in being here. I could have shared the same feelings probably from any point in my life. We live in a world that is full of doubts, fears, rejection, disappointment and disillusionment. That is what living in this world is...no matter where we are. But that doesn't mean that God doesn't also fill up each day with visions and reminders of how things are supposed to be. It doesn't mean that I am not satisfied to the core. It doesn't mean that I'm not at peace. Au contraire, I can say that not a day goes by that I don't humbly thank God for bringing me here. I also have not lost my respect for the highest levels of medical care just because I jokingly describe what we have to do sometimes here in order to save lives. We would love to have all the equipment, all the clean and sterile conditions, all the availability of specialized services and specialists, etc to practice medicine at the high standard that I have been well trained to do. But I have had to sacrifice a little professionally as well. While I try to inspire and little by little improve the standard of care here, most of the time I find myself doing things that I know is below the standard I am used to and would love to incorporate here. We slowly work towards that objective but in the meantime we do our best and God does intervene...that doesn't mean I practice below the standards available to me here just thinking "Oh God will help." I work hard and with joy to bring the highest standard of care possible here knowing that it will still be lower than the standard I am used to but that I always hold that higher standard up in my mind as guiding light.
If you would prefer I not share my struggles as well as my successes I can limit my stories to the miracles and write only when I am on top of the world so that everyone can be at ease. However, I would prefer to paint a realistic picture without making anyone too anxious...never for a moment has the thought of leaving or not wanting to be here entered my head. As far as fatigue is concerned, this is nothing compared to what I have endured the last 5 years of my life in the clinical years of medical school and residency. Yet even during those five years I can look back with nothing but joy and satisfaction and thanks for what I experienced. Here I have never gone a night without sleep and most nights I get at least 6 hours. And when I am up I feel it is for a good reason, not like residency or medical school when sometimes I was up just because that was part of the process or initiation or "we had to do it so, so do you" attitude that is found in medical education. When one is up knowing he's saving a life not just writing in some chart or standing by observing on feels satisfied and one is less fatigued. Also I've never slept more at peace in my entire life. When I lie down I go directly to sleep whereas for most of my life up till now I've always brewed on things before falling asleep.
The bottom line is, please, keep praying for us but know that I am not only surviving fine but have really never been more satisfied in my life...I'm just sharing bits and pieces and sometimes the bits will be the doubts and fears that can come and sometimes the pieces will be the tremendous successes, surprises and satisfaction that also come each and every day.
I have learned the secret, when in plenty or in want...I can do all things through Him who gives me strength (Phil. 4)
I've got some letters from people who are worried about me...don't worry. I'm trying simply to be real and honest. To say that things are always rosy, exciting and rewarding here would be a lie. But just because I share them doesn't mean that there is any less joy, happiness or fulfillment in being here. I could have shared the same feelings probably from any point in my life. We live in a world that is full of doubts, fears, rejection, disappointment and disillusionment. That is what living in this world is...no matter where we are. But that doesn't mean that God doesn't also fill up each day with visions and reminders of how things are supposed to be. It doesn't mean that I am not satisfied to the core. It doesn't mean that I'm not at peace. Au contraire, I can say that not a day goes by that I don't humbly thank God for bringing me here. I also have not lost my respect for the highest levels of medical care just because I jokingly describe what we have to do sometimes here in order to save lives. We would love to have all the equipment, all the clean and sterile conditions, all the availability of specialized services and specialists, etc to practice medicine at the high standard that I have been well trained to do. But I have had to sacrifice a little professionally as well. While I try to inspire and little by little improve the standard of care here, most of the time I find myself doing things that I know is below the standard I am used to and would love to incorporate here. We slowly work towards that objective but in the meantime we do our best and God does intervene...that doesn't mean I practice below the standards available to me here just thinking "Oh God will help." I work hard and with joy to bring the highest standard of care possible here knowing that it will still be lower than the standard I am used to but that I always hold that higher standard up in my mind as guiding light.
If you would prefer I not share my struggles as well as my successes I can limit my stories to the miracles and write only when I am on top of the world so that everyone can be at ease. However, I would prefer to paint a realistic picture without making anyone too anxious...never for a moment has the thought of leaving or not wanting to be here entered my head. As far as fatigue is concerned, this is nothing compared to what I have endured the last 5 years of my life in the clinical years of medical school and residency. Yet even during those five years I can look back with nothing but joy and satisfaction and thanks for what I experienced. Here I have never gone a night without sleep and most nights I get at least 6 hours. And when I am up I feel it is for a good reason, not like residency or medical school when sometimes I was up just because that was part of the process or initiation or "we had to do it so, so do you" attitude that is found in medical education. When one is up knowing he's saving a life not just writing in some chart or standing by observing on feels satisfied and one is less fatigued. Also I've never slept more at peace in my entire life. When I lie down I go directly to sleep whereas for most of my life up till now I've always brewed on things before falling asleep.
The bottom line is, please, keep praying for us but know that I am not only surviving fine but have really never been more satisfied in my life...I'm just sharing bits and pieces and sometimes the bits will be the doubts and fears that can come and sometimes the pieces will be the tremendous successes, surprises and satisfaction that also come each and every day.
I have learned the secret, when in plenty or in want...I can do all things through Him who gives me strength (Phil. 4)
Wednesday, March 3, 2004
I must speak...
I am weak. As I lie here on the first carpet I've felt in two months with a welcome fan whirring overhead to chase the suffocating heat away; as I lie here without the ever-present dust suffocating and making it hard to breath; as I lie here having eaten more than I should for consecutive meals for the first time in a long time; as I lie here having chosen to lie here over going to church; as I lie here I have time to truly think and reflect for an extended period of time and I am afraid. An uncontrollable fear descends on me. I think of where I am and I want to be elsewhere. I think of what I have done, not done and what I face and I know I cannot face it alone. As you have heard so many tales of excitement, adventure, sorrow and joy you may have been tempted to think that somehow you couldn't do that. Let me tell you that's exactly what I think: I can't do that. I know that everything in my nature rebels against what I am doing, where I am doing it and why I am doing it. But when I do it, somehow the strength is there and everyday in some unexpected way there is joy as well.
I think of the young man who consistently approaches me about work. He is about 18 years old, married with a couple of kids. He wants to be my gardiner. I say we would like a garden but without a fence or wall the goats and pigs will make short work of it, come back to me when we have a fence or wall. He keeps coming back anyway..."just to make a social visit." He brings tomatoes and lettuce from his own garden...they are impressive. He comes one time when I'm with Bichara, the chauffeur, with the smell of alcohol on him. After he's gone Bichara, a strong Muslim, shrugs in disgust at anyone who drinks or smokes. Later, he approaches me after a long day of work and says that he has not eaten in 5 days. Everyone asks what kind of man he is to have taken a wife when he can't provide. He has looked for work. There is none. Isn't there some work he can do for me. I say that the only need I have is for laundry. I've already given the work to Bruno. He says that he'd approached me first to ask about doing laundry or gardening. That is possible. I acknowledge that with my poor French I may not have understood that from him. He says Bruno has other work already. It's true. Dr. Claver pays him $40/month to clean, guard, cook for him. I pay Bruno $1/week to do my laundry once a week. This guy offers to do it for 50 cents. He's desperate. He asks me to have pity on him. He's been coming to the Adventist church he says. Shouldn't Christians help other Christians. I acknowledge that. Inside I feel he only comes to church because he thinks it will help his cause. But I don't want to judge. I say that I will talk to Bruno and see if he's willing to give it up. He's not. That night I happen to come to the hospital and he's in the ER with his wife who has a cut over her left eye. He says she fell. Both the catholic nun who's with me and I think its because he hit her. When I see him next he gets me at a busy time. I'm annoyed. It seems like no way out and I'm tired of being bothered. I tell him so. I haven't seen him since.
Did I do the right thing? Maybe he is a drunk. Maybe he beats his wife. Maybe he comes to church just to get some work (he hasn't been back since.) So logically I did the right thing. Then I read about Jesus and think what he would've done and this guy is exactly who Jesus welcomed, hung out with, healed, and served. If I start helping people everyone will start to crowd around thinking the rich white man is the answer. It will never end if I start. Then I read that Jesus also was bothered. When he started healing people crowded around and never would let him have a moments peace. Even when he tried to have some quiet time with his disciples they found him. What did Jesus do? He had pity on them. What did this guy ask of me? To have pity on him.
These are the difficult things I am faced with all the time. It's not just the medical work or administration or finances that is challenging. It is the myth that the white man is always rich and a source of gifts, hand outs, money and work. I want to break that tradition. I want them to recognize me as someone who has come to work with them side by side as their equal not as just some magician or philanthropist. How do I do that and yet still not ignore their cries for help when I CAN help them? Where do I draw the line? These are not easy questions...the expectations are high...the myth is deeply rooted...
I'm in N'djaména now and I see the hopeless position many feel because of the corruption of the government. A man's car breaks down in front of the president's mansion at night. He gets out to look under the hood and is shot down. The president hands out lists of people he doesn't want around and bounty hunters collect $100 a head for their deaths. A neighbor of Jabel, Jared and Caleb happens to walk onto a street that has been shut down so the president can drive through. She is beaten within an inch of her life. He has been in power for 14 years as a "democratically elected" president and is not about to step down. The US supports him because of the oil deal recently struck. Two days ago I went to the bank. To get there we were redirected down small dirt lanes packed with people who had to find another way around the main road whick was being cleared off for the president. Shops along the route had to close down. People had to evacuate. We got to the bank finally with the last few blocks on foot. We finish and walk out only to be gestured back in by a soldier in camo bearing an AK47 saying go inside it's dangerous out here. We go inside just as about 10 brand new SUVs, Humvees, and Jeeps bearing soldiers and large machine guns go flying by at about 90-100 mph through the soldier-lined, empty streets. The people starve and beg and are helpless as the illiterate relatives and tribe members of the president live in luxury.
And yet, still life goes on at Béré. A woman very pregnant with twins comes in with a kidney infection. She gets up one evening to use the restroom and discovers a small foot sticking out below. She tells Felix who runs to tell me. We get things ready for an emergency ceasarian. Someone runs to borrow the small generator from UNICEF while we go ahead and get started. It's pitch black but fortunately I have my trusty head lamp. Sarah assists me...very well except for the brief moment when she almost faints due to the diarrhea she's had caused by Amebiasis...but she stands strong and finishes! As I open the uterus I realize how nice it would be to have suction as a hugh gush of amniotic fluid rushes out to join all the blood already in the operating field. I reach in the bloody puddle and find the first baby. I pull the leg out of the vagina and into the uterus and then do a breech extraction. She is fine. I then break the other bag of water. Also a breech presentation who I deliver with a little more difficulty. He is fine too. I then try and see what's going on down in the uterus with all that fluid and blood. Somehow God helps me to sew it together so that the bleeding stops and we finish the surgery. All three are in fine shape. As I'm about to close the skin the generator shows up and roars to life...thanks.
I get called another day for a strange case. A young man about 17 or 18 years old had been hospitalized here in December after being stabbed in the upper right chest and treated with a drainage bag for blood in the chest around the lung. Now he has right upper abdominal pain, a large tender liver, a rapid strong pulse and veins on his right abdomen, chest and neck that are bulging. I think this has to be something different as the chest wound was so long ago and looks healed. I did a quick but not complete exam, gave him IV fluids, hospitalized him and went home. I saw him the next day and the right side of his face was swollen up and when listening to his heart I noticed it was really displaced to the left and had a massive heart murmur that sounded like mitral regurgitation. THen I thought maybe he had heart failure from Rheumatic Heart disease or something else. Fortunately, God will help even sometimes stupid and blind physicians to make the right diagnosis so that they can actually help their patients. I listened to his lungs and found that their were no lung sounds over his right chest and it was dull when I percussed it with my fingers. I had the family buy a syringe and needle and stuck it into is chest withdrawing brownish liquid. The lab told me it was almost all white blood cells indicating infection. Since we have no chest tubes for tube thoracostomies here I found a piece of rubber tubing about the right size (large) and cut small holes in the sides. Having heard one of our Thoracic Surgeons in Ventura talk about how unnecessary it is to have a sterile tube ("spit on it before you insert it") I took him to surgery, gave him Ketamine, sliced a hole over a rib, and poked a clamp over the rib and through the muscles into the chest cavity. Immediately, the coffee-colored fluid shot out across the room under a lot of pressure. I put in the tube and then slowly took off about 3-4 liters of that fluid and saw his heart return to normal, the swelling in his face go down, and his engorged veins flatten out. Not having the appropriate equipment for putting the tube to suction or water seal I tried to rig something but ended up having to just stick the end in a huge jar of water so fluid and air could escape but air couldn't get back in. He's doing fine now.
Dr. Claver is back so that gives me some breathing room to be here in N'DJaména to get the materials needed to repair the generator, buy medicinces and get stuff for the lab. We had just finished our last blood-typing reagents to save two kids who came in with severe anemia from Malaria. The materials I bought yesterday is the first use I have made of the funds donated by you to the hospital through AHI. Now, we can continue to do life saving blood transfusions for patients like these kids with malaria and the woman who had the retained placenta and needed three units of blood during her emergency hysterectomy and who went home in good health but would've gone home in a coffin without the transfusion. Also, now we can test the blood for Hepatitis B and C (as well as HIV which we were already able to do thanks to a national AIDS prevention program) before transfusion. We can also now check the hemoglobin to see how anemic patients are rather than relying on how pale their conjunctiva are to decide if they should be transfused. I purchased pregnancy tests as well so we can diagnose pregnancy earlier rather than waiting till its obvious. We also got test tubes and other materials needed for the lab to help us with diagnosing parasites and other infections. The lab is key as it is our only adjunct to history and physical right now for diagnosis. Also, a well-running lab will help generate money for the hospital.
We should also soon be able to sign the contracts for the staff and get them the salaries they deserve for the work they do based on local pay scales (nothing by Western standards).
I think of the young man who consistently approaches me about work. He is about 18 years old, married with a couple of kids. He wants to be my gardiner. I say we would like a garden but without a fence or wall the goats and pigs will make short work of it, come back to me when we have a fence or wall. He keeps coming back anyway..."just to make a social visit." He brings tomatoes and lettuce from his own garden...they are impressive. He comes one time when I'm with Bichara, the chauffeur, with the smell of alcohol on him. After he's gone Bichara, a strong Muslim, shrugs in disgust at anyone who drinks or smokes. Later, he approaches me after a long day of work and says that he has not eaten in 5 days. Everyone asks what kind of man he is to have taken a wife when he can't provide. He has looked for work. There is none. Isn't there some work he can do for me. I say that the only need I have is for laundry. I've already given the work to Bruno. He says that he'd approached me first to ask about doing laundry or gardening. That is possible. I acknowledge that with my poor French I may not have understood that from him. He says Bruno has other work already. It's true. Dr. Claver pays him $40/month to clean, guard, cook for him. I pay Bruno $1/week to do my laundry once a week. This guy offers to do it for 50 cents. He's desperate. He asks me to have pity on him. He's been coming to the Adventist church he says. Shouldn't Christians help other Christians. I acknowledge that. Inside I feel he only comes to church because he thinks it will help his cause. But I don't want to judge. I say that I will talk to Bruno and see if he's willing to give it up. He's not. That night I happen to come to the hospital and he's in the ER with his wife who has a cut over her left eye. He says she fell. Both the catholic nun who's with me and I think its because he hit her. When I see him next he gets me at a busy time. I'm annoyed. It seems like no way out and I'm tired of being bothered. I tell him so. I haven't seen him since.
Did I do the right thing? Maybe he is a drunk. Maybe he beats his wife. Maybe he comes to church just to get some work (he hasn't been back since.) So logically I did the right thing. Then I read about Jesus and think what he would've done and this guy is exactly who Jesus welcomed, hung out with, healed, and served. If I start helping people everyone will start to crowd around thinking the rich white man is the answer. It will never end if I start. Then I read that Jesus also was bothered. When he started healing people crowded around and never would let him have a moments peace. Even when he tried to have some quiet time with his disciples they found him. What did Jesus do? He had pity on them. What did this guy ask of me? To have pity on him.
These are the difficult things I am faced with all the time. It's not just the medical work or administration or finances that is challenging. It is the myth that the white man is always rich and a source of gifts, hand outs, money and work. I want to break that tradition. I want them to recognize me as someone who has come to work with them side by side as their equal not as just some magician or philanthropist. How do I do that and yet still not ignore their cries for help when I CAN help them? Where do I draw the line? These are not easy questions...the expectations are high...the myth is deeply rooted...
I'm in N'djaména now and I see the hopeless position many feel because of the corruption of the government. A man's car breaks down in front of the president's mansion at night. He gets out to look under the hood and is shot down. The president hands out lists of people he doesn't want around and bounty hunters collect $100 a head for their deaths. A neighbor of Jabel, Jared and Caleb happens to walk onto a street that has been shut down so the president can drive through. She is beaten within an inch of her life. He has been in power for 14 years as a "democratically elected" president and is not about to step down. The US supports him because of the oil deal recently struck. Two days ago I went to the bank. To get there we were redirected down small dirt lanes packed with people who had to find another way around the main road whick was being cleared off for the president. Shops along the route had to close down. People had to evacuate. We got to the bank finally with the last few blocks on foot. We finish and walk out only to be gestured back in by a soldier in camo bearing an AK47 saying go inside it's dangerous out here. We go inside just as about 10 brand new SUVs, Humvees, and Jeeps bearing soldiers and large machine guns go flying by at about 90-100 mph through the soldier-lined, empty streets. The people starve and beg and are helpless as the illiterate relatives and tribe members of the president live in luxury.
And yet, still life goes on at Béré. A woman very pregnant with twins comes in with a kidney infection. She gets up one evening to use the restroom and discovers a small foot sticking out below. She tells Felix who runs to tell me. We get things ready for an emergency ceasarian. Someone runs to borrow the small generator from UNICEF while we go ahead and get started. It's pitch black but fortunately I have my trusty head lamp. Sarah assists me...very well except for the brief moment when she almost faints due to the diarrhea she's had caused by Amebiasis...but she stands strong and finishes! As I open the uterus I realize how nice it would be to have suction as a hugh gush of amniotic fluid rushes out to join all the blood already in the operating field. I reach in the bloody puddle and find the first baby. I pull the leg out of the vagina and into the uterus and then do a breech extraction. She is fine. I then break the other bag of water. Also a breech presentation who I deliver with a little more difficulty. He is fine too. I then try and see what's going on down in the uterus with all that fluid and blood. Somehow God helps me to sew it together so that the bleeding stops and we finish the surgery. All three are in fine shape. As I'm about to close the skin the generator shows up and roars to life...thanks.
I get called another day for a strange case. A young man about 17 or 18 years old had been hospitalized here in December after being stabbed in the upper right chest and treated with a drainage bag for blood in the chest around the lung. Now he has right upper abdominal pain, a large tender liver, a rapid strong pulse and veins on his right abdomen, chest and neck that are bulging. I think this has to be something different as the chest wound was so long ago and looks healed. I did a quick but not complete exam, gave him IV fluids, hospitalized him and went home. I saw him the next day and the right side of his face was swollen up and when listening to his heart I noticed it was really displaced to the left and had a massive heart murmur that sounded like mitral regurgitation. THen I thought maybe he had heart failure from Rheumatic Heart disease or something else. Fortunately, God will help even sometimes stupid and blind physicians to make the right diagnosis so that they can actually help their patients. I listened to his lungs and found that their were no lung sounds over his right chest and it was dull when I percussed it with my fingers. I had the family buy a syringe and needle and stuck it into is chest withdrawing brownish liquid. The lab told me it was almost all white blood cells indicating infection. Since we have no chest tubes for tube thoracostomies here I found a piece of rubber tubing about the right size (large) and cut small holes in the sides. Having heard one of our Thoracic Surgeons in Ventura talk about how unnecessary it is to have a sterile tube ("spit on it before you insert it") I took him to surgery, gave him Ketamine, sliced a hole over a rib, and poked a clamp over the rib and through the muscles into the chest cavity. Immediately, the coffee-colored fluid shot out across the room under a lot of pressure. I put in the tube and then slowly took off about 3-4 liters of that fluid and saw his heart return to normal, the swelling in his face go down, and his engorged veins flatten out. Not having the appropriate equipment for putting the tube to suction or water seal I tried to rig something but ended up having to just stick the end in a huge jar of water so fluid and air could escape but air couldn't get back in. He's doing fine now.
Dr. Claver is back so that gives me some breathing room to be here in N'DJaména to get the materials needed to repair the generator, buy medicinces and get stuff for the lab. We had just finished our last blood-typing reagents to save two kids who came in with severe anemia from Malaria. The materials I bought yesterday is the first use I have made of the funds donated by you to the hospital through AHI. Now, we can continue to do life saving blood transfusions for patients like these kids with malaria and the woman who had the retained placenta and needed three units of blood during her emergency hysterectomy and who went home in good health but would've gone home in a coffin without the transfusion. Also, now we can test the blood for Hepatitis B and C (as well as HIV which we were already able to do thanks to a national AIDS prevention program) before transfusion. We can also now check the hemoglobin to see how anemic patients are rather than relying on how pale their conjunctiva are to decide if they should be transfused. I purchased pregnancy tests as well so we can diagnose pregnancy earlier rather than waiting till its obvious. We also got test tubes and other materials needed for the lab to help us with diagnosing parasites and other infections. The lab is key as it is our only adjunct to history and physical right now for diagnosis. Also, a well-running lab will help generate money for the hospital.
We should also soon be able to sign the contracts for the staff and get them the salaries they deserve for the work they do based on local pay scales (nothing by Western standards).
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