Couscous and Goat

The couscous steamed in the belly of the goat is quite tasty if a little undercooked. I spoon another mouthful garnished with a piece of flesh ripped off the greasy leg bone on my plate.

How else would one welcome someone as important as the Minister of Health.

That morning started off with trying to desperately tear myself out of bed. Between 80 plus surgeries this month including 24 in a five day stretch last week and working on stripping out the inside of the ambulance that had been used as a storage shed for any spare part containing massive amounts of old oil, I'm needless to say, exhausted.

Sarah has warmed up the Danish cauliflour gravy over yesterday's mashed potatoes and "Ocean Platter". Our nurse, Job, exhorts us in morning worship from Acts 13 and we talk about quinine drips for kids in staff meeting.

It's during this encounter that someone calls to say that the Minister of Health will be driving through Bere at 11:00am or so and could we please all be there.

Sure, no problem, is that 11 o'clock African time?

I spend some time with Andre and Noel discussing the spiritual battle facing us and how we can help each other to keep from being taken out by our enemy.

As I head to the OR for the first case, Sarah corners me as I pass the door to the temporary ER (the old one is having it's roof replaced).

"Could you come see this patient? He has peritonitis."

Unfortunately, she's right. Pain for a week, severe since this morning. Vomiting, jumps and grimaces when I tap on his belly. Tender inside when I do a rectal exam.

His wife pays for the surgery and we wheel him in. The 20 year old woman born without a vagina, the old man with the hernia and the even older man who can't pee because of his huge prostate will have to wait.

Within 20 minutes of diagnosis, my knife is slicing through skin, muscle, fat, blood vessels, fascia and peritoneum to let out a bubbly gush of slimy green fluid over some angry, blotched loops of small intestine.

I enlarge the incision to the sternum with scissors and after sucking up all the goo I find the small hole in his stomach letting it all out.

Perforated peptic ulcer.

I put in some silk sutures along the perforation but don't tie them. Then I drag in a piece of omentum and tie it over the hole with the sutures.

Lots of irrigating and sucking and washing and rinsing and aspirating later I close up.

It's only 11:00. Since it's African time, maybe I have time for a prostate before going to meet the Minister.

Abel and Simeon, a viciously efficient OR team have the patient out, the OR cleaned and prepared and the grandpa sitting on the table ready for his spinal anesthetic almost before I turn around.

As soon as the lidocaine is in his spinal canal we lay him down, lower the head of the table, strap him in for the ride, prep his belly and groin with Betadine and I scrub with our Danish medical student, Camila.

After Abel's prayer I cut down horizontally to the bladder and incise it vertically letting out a stream of blood tinged urine. Camile grabs suction while I enlarge the bladder incision. Simeon pulls out the foley catheter while I stick my finger in to feel the mass of prostate bulging into the bladder.

I insert my index finger into the prostate where the urine should normally go out and with the pressure of the finger tip start to shell out the prostate. I sweep around. My fingers start to cramp from the pressure and awkward position as my body twists and contorts over the patient trying to get my finger in deep enough to go all the way around.

It pops out and I fish it out of the bladder. Simoen inserts the large 3 way foley catheter that I guide through the crater left where the prostate should be. Camile aspirtates the blood that wells up while Simeon inserts 30cc into the ballon to tamponade off the bleeding.

I suture the bladder, fascia and skin and Simeon has the bladder irrigation running as blood tinged flood flows out into the urine bag.

12:34 and I might have time to catch the Minister of Health.

Sonya and I walk over to the District Medical Office where a large (for Tchad) convoy of 6 or 7 cars is parked along main street in the red dirt of Bere.

A group of raggedy Red Cross volunteers with various qualities of red cross painted shirts collects outside the offices while out back under the mango tree the big boys gather.

I pass the camouflage-wearing, turban-toting soldier with his AK47, go through the chainlink and sit on the edge of a chair next to my wife. In the low slung, neon green, fake velvet chair of honor is a simply dressed, tall, sun-glass-wearing Tchadian I assume is the Minister of Health.

A camera man makes sure to video the proceedings as two woman come in bearing the two couscous stuffed goats on platters, anatomy complete minus the heads.

A greasy, finger stuffing, soda popping 15 minutes later the Minister gets up for his speech.

"We have been touring the country to get a better idea of the conditions that you, our frontline health care workers, work under. We've been all over the south-central region for a week seeing hospitals from Doba to Koumra to Sarh to Lai and now Bere."

"There are less than 400 physicians in all of Tchad, less than 4000 nurses and less than 200 midwives. This is why Tchad has some of the worst maternal child statistics in the world."

With that and many other encouraging words, they take their leave. They are in a hurry since word has come this morning that the united rebel forces are already in Ati vowing to make N'djamena and overthrow the President.

No one is worried too much yet because the European Union special forces have started arriving since yesterday and the rebels aren't strong enough. At least no one is fleeing N'Djamena yet for the bush which everyone takes as a good sign.

So I return to round on the hospitalized patients, schedule another hernia and a vaginal hysterectomy for prolapsed uterus coming completely out hte vagina, draw out cloudy spinal fluid on an infant already struggling with malaria and severe anemia (hemoglobin of 4.6) and head home.

Even after the couscous and goat I still crave some of my wife's Danish home-cookin'...

GROSS PICTURE OF THE DAY

Stumbling

I stumble through the dark as I pull on my socks, lace my shoes and slip on my sweatshirt. As I open the gate I almost trip over a pile of human excrement. The darkness is almost complete. Only an occasional star sneaks through the thick layer of angry clouds.

A dry, icy desert wind is blowing across the plain chilling me to the bone.

As my eyes adjust I can barely make out the faintest trace of the path where the white sand makes a slight distinction between itself and the dark flora of the sahel.

I start to jog hesitantly as I fight to keep from tripping and falling.

The only thing breaking the monotony of the obscurity are two dark red glows of distant brush fires illuminating the horizon like a dragon's nostrils.

I wonder if I can find the way.

My thoughts begin to tumble on themselves like stones forever caught in the undertow of a river's eddy.

A seven day old born at home, probably on a dirt floor with a razor blade and some old twine to take care of the umbilical cord. Now I see him in my mind face pinched, eyes squinting, hand clenched, lost forever in the dark clutches of tetanus.

A woman, almost unconscious, breathing fast and shallow, her pregnant belly tender and swollen with blood and a dead fetus from a ruptured uterus. A c-section and hysterectomy later she is rapidly being transfused to desperately save her life. A week later I have her belly open again in front of me with intestines glued together with the destructive inflammation of blood clots. Multiple blood transfusions later I'm forced to open her skin wound to let out the post operative infection.

A small girl with a swollen belly returns to see us after two successful courses of treatment for Burkitt's lymphoma but who decided to not come back for her further doses and now has a spleen and pelvis filled with knotty tumours.

A slender, beautiful 11 year old is back hospitalized after the surgery to remove her rotting lower leg bone sticking out wasn't complete enough to remove the year old infection.

A 22 year old woman with a small baby dies of heart failure due to a heart rhythm disturbance we are unable to diagnose and treat due to lack of equipment and medication.

Another 7 day old has parents who refuse to be hospitalized with fever and a swollen belly and then comes back one day later on death's door.

Five hernia patients wait patiently outside the operating theater.

A woman is referred from a health center 2 days after being diagnosed with appendicitis and treated with aspirin and worm medicine.

A tall, striking 19 year old HIV positive woman comes back with her one and a half year AIDS baby who's bloody diarrhea just won't let up. Her husband is out of town on "business".

A man comes in with small, non-itchy blisters all over his body and is found to have HIV and syphilis.

Drums, drums in the deep pound out a solemn, enchanting rhythm through the night as wails and shrieks waft over the village of Bere like sulfurous trails of smoke below piercing red eyes.

And I'm just talking about yesterday as I stumble once again through the pre-dawn darkness.

I stop by a twisted, gnarled stunted tree trunk with a few branches and scattered leaves. I pause to stretch and as I do the sadness, frustration, fear and inadequacy that has been exploding out in shocking anger now bursts on the scene in deep, uncontrollable sobs as the tears pour down my cheeks.

I continue on, straining to see the road ahead, trying to cry as my out of shape lungs suck in the dry, cool air. My hands are deep in my sleeves and my hood is up desperately trying to chase out the chill.

I pass the first great tree and then turn around at the second according to my habit.

The path is a little clearer. A steel grey sky is starting to peer through the clouds. I pick up speed as I head for home.

The dawn is about to break.

How to Relieve Urinary Retention

It all started with a normal day's rounds at the hospital. I slip on my white coat over my scrubs and Snapper Jack's sweatshirt (believe it or not, it does get cold in Tchad), lock up my office and head out to the wards.

I walk through the wards and notice a crowd lounging around outside. A quick exit, a loud "rounds are starting everyone who's with a patient come in, all other visitors leave" and with a few agressive gestures and much repeating and translating most everyone clears out leaving the hospital with a rare moment of relative tranquility (maybe it helps that I spent an hour last night chasing out squatters with a broom handle).

Not for long. The pediatric ward and emergency room have been vacated so the leaky roof and moth-eaten ceiling can be replaced leaving us with all the patients crammed into already over-burdened wards.

I start with Pediatrics. The nurse in charge, Deuhibe, gathers the charts and calls the nursing students. The charge nurse, Jacob, joins us along with Camila, the Danish medical student and we start seeing the kids.

As I come to the last of the peds patients, a skinny ten-year-old boy with bulging eyes staring at us blankly, the child suddenly repeats his performance of yesterday that made me call the chaplain to see if he was demon-possessed.

He somehow manages to combine three extraordinary moves into one well-polished fluid motion perfected by years of habit and accompanied by a blood-curdling cry like a banshee being bit by a thousand bees.

In one simultaneous gesture the boy flips from his back to a kneeling position thrusting his anus up into the air, reaches his hand around his back and sticks it into his butt, and realises a stream of urine that thrases around like a fire hose out of control and that would make a race-horse proud. All the time he writhes around like a cat in a bag and screams like someone is slowly skinning him alive.

I'm shocked and unnerved. I quickly grab his arms removing his hand from his butt, flip him over and pin him to the urine soaked mattress. I notice the urine is tinged with pus. I ask for his lab results as he moans and groans and struggles uselessly. His stool test is normal and his urine not surprisingly shows an abondance of white blood cells.

For some strange reason (years of being a resident and hearing surgeons drill it into my brain) I decide to do a rectal exam. I quickly call for a glove and feel inside the child's rectum. Where his prostate should be is a large, hard, smooth mass that is somewhat oblong moving towards his bladder.

An ultrasound confirms a calcified mass in his bladder.

An hour later I poise over the boy's lower abdomen with a scalpel as Abel prays. A few slices later and I'm in his bladder. Even though I kind of expect it chills still run up and down my spine and my arm hairs stand on end as I reach a gloved finger into the bladder and touch the large urinary calculus.

It's so large compared to the small kid's bladder that it is quite difficult to extract. I finally open the wound more and slip some forceps around it and squeeze it out like a diffucult childbirth. There on the table before me is an 3 inch by one inch long kidney bean shaped stone.



After closing the bladder and belly and leaving it to catheter drainage I realize that the boy is actually quite smart and creative after all.

The weight of the stone caused urinary obstruction through gravity pulling it down to block the urinary outlet. When his bladder got so full he couldn't stand the pressure of the retention he flipped over, anus in the air so gravity and a well-placed rectal finger would push the stone off the exit releasing a high pressure urinary stream bringing relief but causing excruciating pain at the same time.

Who know's how long he's suffered with that? The parents say for all his life despite going to many hospitals and staying months. What's the difference in ours?

God helping me make a difficult diagnosis and bringing all the elements together to be able to confirm the diagnosis (ultrasound) and perform the surgery (equipment, generator, trained staff, instruments, autoclave, suture, etc. etc.)

So next time you have difficulty peeing, might I suggest a certain routine...