A million thoughts tumble and whirl through my head like the rocks and pieces of smashed bricks tossed by the kids outside. Just like the mango tree outside assaulted by the kids with their missiles, I feel under constant attack. If enough things are thrown your way, no matter how well you may be grounded, some are sure to hit and damage if not cause you to fall off entirely and crash through the leaves and branches to the ground. It's an incessant battering of small things that keep my mind in a jumble and my thoughts from differentiating between what's important and what's simply annoying and pointless.
A deep anger has surfaced over that the last couple days. I don't know why. It can't be explained by one thing. Maybe it's the million small demands everyday. Maybe the feeling of being used by your friend who is helping renovate your hospital. Maybe it's the insults hurled at you by the woman when you ask why they're stealing huge bags full of your mangos to then go and sell to you a few hundred yards away. Maybe it's the kids who steal your barbed wire and poop in your tool shed. Maybe it's the sheep spending the night under your window bleating and screeching their heads off. Or maybe it's simply the goat peeing like a racehorse right outside waking you up wondering what faucet has been opened right next to your mattress. Maybe it's the feeling of never being able to get away or have a moment to yourself when you're not being watched. Maybe it's the patients' lack of gratitude. Maybe it's the feeling of being in over your head and doing things to people that you're not qualified to do simply because there is no one else. Maybe it's the lack of directness. Maybe it's the gossip. Maybe it's the forced friendliness. Maybe...
Maybe it's the unexpected which one has come to expect...like the case that makes your anger disappear and reminds you why you are here...
The woman is severely pregnant. I say that because I've never seen a bigger pregnant belly on anyone...and she's not that big a woman. Of course, she doesn't really know how long she's been pregnant. The uterine height measures 43 cm. That means she either has too much fluid, too much baby or too many babies (twins). Without an ultrasound I'm just guessing, but I think I did hear two different heartbeats so my guess is on twins. Oh, did I mention she's HIV positive? We had identified her on normal screening a few months ago and had explained to her what that means for her pregnancy and child and how we can try to prevent her child from getting infected. She had been pretty regular in coming to prenatal visits but had been absent for awhile. Now she's huge.
Her cervix seems favorable so we decide to try and induce her labor. We start her on our protocol for prevention of mother to child transmission of HIV and start the induction. It doesn't work. We then schedule her for a c-section. She says she needs to go home and will come back later...she doesn't.
A week later, two nights ago, she comes back. I'm so dead asleep I don't even hear the night watchman knocking. It's Sarah who wakes me up. I step groggily to the door after fumbling for my head lamp in the dark. I ask David what's going on. He replies with the classic, "a case at the hospital..." I say I'll be right there.
As I walk over I enjoy probably my only moments of true silence and tranquility when I'm awakened at 01:00 am for an emergency. The air is cool and still. There is no moon and hardly any stars. It's pitch black. And there's no sound.
I arrive to find that it is the same woman who's come back in labor with the face of the baby as the presenting part instead of the normal back of the head. There's no question. The baby can't come out that way and a c-section will help prevent transmission of the HIV to the baby. I ask why she hasn't come back sooner for the surgery. She said she couldn't find the $40 to pay for it. Dimanche, the nurse on Garde duty, says that in desperation the woman has just told her the real story.
Apparently, she was the third wife of a man who died a year and a half ago of AIDS. As the third wife with only small children and the stigma of a husband dead of AIDS she was abandoned to care for her kids without help. As a result she's been selling herself to men for 50 cents each time. With 6-7 customers a day, even while pregnant, she is able to put food on the table. Suddenly, in the early morning of a dark Tchadian night all my confusion, anger and frustration disappears as a dose of cold reality makes things starkly clear in an instant.
We prepare immediately for surgery...as I enter the dark OR lit only by the weak light of my headlamp I feel very strange as the story unfolding resembles my own beginnings in many ways and yet is the extreme opposite at the same time.
March 29, 1973. A beautiful, tall 22 year old blond is in the hospital to deliver. The pregnancy has been uneventful. Now her labor has stalled. The doctor orders an x-ray (in the days before ultrasound's ready availability). When the doc gets the results he asks the young, nervous husband to step outside. As the door closes behind him he catches a phrase that causes his heart to skip. "Well, the X-ray doesn't show the entire abdomen, but there's at least two in there."
I grab a green cloth bundle. I open it carefully revealing two folded green surgery gowns and a drape showing their years of use and reuse. The instruments are peaking out from underneath. I open two sets of 8 1/2 gloves, a scalpel and four sutures (3 for the caesarian and one for tying her tubes) and fold them with sterile technique onto the instrument table. I set another pair of gloves, a spinal needle, a syringe with needle and a vial of lidocaine on another table...ready for the spinal anesthetic.
The doctor decides to do a c-section on the young woman with "at least two" as he labor has stalled and the x-ray reveals that it is a breech/vertex presentation with locking chins. The young woman is my mother. What must have been going through her mind that day almost 32 years ago as the doctors prepared her for surgery. Suddenly, instead of her first child she's faced with her first two kids at once...at least two. She doesn't know exactly how many she'll have when she wakes up from the anesthesia, but it'll be at least twins.
We bring the woman in, place the anesthetic and cut down quickly pulling out two screaming, vigorous twin boys in one of the few uncomplicated c-sections that we do here. As I wipe the first one down quickly to remove the HIV infected blood as quickly as possible I feel very weird, kind of detached as I think how such a simple thing might be the difference between life and a slow death from AIDS for him. That strange, normal, red blood all over the operating field and dripping onto the floor is filled with a strange thing that is not alive yet can quickly take over a body making it waste away into one of the most dreaded diseases of our day.
I walk back to the house post-op thinking of my own birth, the tragic death of my twin over 3 years ago, and the uncertain future of the two most recent twin arrivals on our planet resting in the care of their prostitute, HIV infected mom. I realize again, that maybe one reason I was brought here was for these untouchables, the outcasts of our day, the HIV infected person living in poverty in the third world. Already, they are most cherished patients even though currently there isn't much I do for them except to be sure that they feel the presence of a person who isn't afraid to touch them and has no fear of their disease or the person that carries it. I'm honest with them, I don't try to ignore their disease and I give them hope when everyone else has given up on them.
The next two days will be filled with exhaustion, rising frustration, unrelenting challenges, but for that moment I feel the presence of God giving me a purpose and reminding me of the reason I have been sent to this apparently God-forsaken place...
James
Friday, March 18, 2005
Saturday, March 5, 2005
Chant
It starts out with a single haunting voice chanting out a rhythmic song in Nangjere...a gourd filled with seeds quickly picks up the beat and fills in with a soft shooshing like gravel on a beach tossed by the waves. After a few lines a drum made from a hollowed out log covered with still hairy goat skin picks up in an off-beat as all the voices begin to echo the words of the leader. Then a low thumping fills it all out hitting you right in the chest with an alternating deep boom boom boom and a higher pitched hollow knocking as a small boy beats a long, hollow square pyramid made of lead that he also raises up and down off the floor to change tones.
It's hypnotic and I'm exhausted. My body slouches forward. My elbows on my knees, my eyes close. My feet can't help tapping and my hands softly tap involuntarily even though they don't have the strength for a real clap. My head bobs slightly up and down as my thoughts drift back to this morning...
"Lona wants to see you about some Maternity patient," Sarah shakes me awake.
It's been a long night. My malaria smear was positive again yesterday and after my second dose of quinine I was afraid I'd mixed up meds and took a tranquilizer because I found myself fighting my way out of a dark hole that wanted to suck me down into its depths never to wake again. Then, some people came on motorcycles and began talking and eating loudly right outside our window. I was so groggy, however, I couldn't make sense of anything and thought they were patients coming to complain that we'd stolen the pumps off their bikes they'd left as surety for the payment of their hospital debts. I drifted in and out of my fogginess all night without really feeling rested. Lying in a pool of sweat doesn't help.
I get up, shower, and put on a pair of cords and a shirt. I grab the car keys as I plan on going to Kalmé to bring the church members to join us for our first communion since I've been here. Our pastor from K�lo arrived last night at well.
I see Lona as I enter the hospital and he tells me it's just a pregnant woman with Malaria who wants to go home after two days in the hospital. I agree. Apparently, Jean, the man whose hydrocele we took out had a fever. I check on him and he has a small wound abscess. I open it up and pack it. I head over to Peds to check on the Malaria kids.
I walk in to our one bright spot on campus with it's newly painted cartoons on the walls (thanks to Sarah and Becky). Little James looks at me with a mixture of curiosity and fear. He's one of the first baby's I delivered here and probably the first of several now to bear the strange name of James. He's doing fine and I send him home...
....I'm nudged back to the reality of a Nangjere worship service as a small girl in tattered rags climbs onto the crude wooden bench without a back. She nudges herself between Sarah and I and gives me the hugest, whitest grin ever. I'm soon back into my swaying trance as I can hear the sound of the motorcycle pulling up in my reverie...
Lona and I go over to find that one of the health centers has referred a pregnant woman with a breech presentation (the baby's in position to come out butt first). I check the heartbeat and it's slow...I check to see if it's maybe the mother's but as I do it slowly picks up till it's back to a normal fetus' 150-160/minute. The baby is obviously in distress. The abdomen looks a little weirdly shaped but I think it's probably just a really full bladder. I know we don‚t have much time to get the baby out if we want to save him.
I send Koumabas to find Samedi. Jacob is already there and Dimanche shows up to relieve Lona of night duty so he helps me get the woman on a stretcher and carry her quickly into the OR. Sarah arrives at that moment and I see Koumabas who says Samedi is on his way.
I grab one of the green wrapped Cesarian bundles and through it on the instrument tray table and unwrap it in sterile fashion. I open onto the table two pairs of sterile gloves, a scalpel blade and 3 sutures. Sarah has started the IV and is letting fluids run in quickly. Lona turns the woman over on her side and I open a syringe and spinal needle onto a sterile field made with a glove package. I wipe down the woman's back with Betadine. She can't really double over and has tensed her back muscles. This will be hard. I put on the gloves, draw up the lidocaine, find the intervertebral space and push in the needle. Thank God clear fluid comes out on the first try. I inject the anesthetic and pull it all out as Samedi (who's just arrived) turns the woman on her back and lowers the head of the bed.
I put in a urinary catheter and find pure blood...a ruptured uterus probably. I really know we don't have much time now if the baby is to live. I do a quick scrub, gown and glove, and drape the abdomen. I nod to Samedi. He prays in Nangjere and I grab the 22 blade scalpel and in two strokes am through the fascia down to muscle. I quickly cut the fascia with scissors than poke through the muscles with my fingers and pull them apart to the sides. I keep digging and pulling with my fingers until I enter the abdominal cavity. I find a baby's back. The uterus is torn in the lower anterior segment. There is a lot of clots but not much active bleeding.
I reach my hand down the baby's back to it's butt and raise it out. Then I swing out the legs one at a time and then pull out the body. Each arm is then delivered, a finger put in the mouth to keep the baby's chin on his chest and the head comes out easily. He's huge and broad shouldered. I clamp and cut the cord. He's limp. I hand him to Sarah. There is no cry.
I return my gaze to the woman and pull the uterus out of the belly onto the abdominal wall. I keep in the back of my mind waiting for a baby's cry...it doesn't come.
"Bag the baby," I cry. "Oxygen, oxygen, oxygen" Of course, we don't have any but at least by breathing in room air to the baby some oxygen will hopefully get into his circulation.
The uterus is torn down through the cervix and partially into the bladder. Fortunately, there's almost no bleeding as all the edges are covered with clot.
"Is there a heartbeat?" I yell to Sarah. "No, nothing, she replies."
"Keep bagging...Jacob, il faut stimuler l'enfant...frapper les pieds ou quelque chose comme éa..."
I suture the bladder together and then the cervix over it up to the muscular wall of the uterus...
"There's a faint heartbeat," Sarah calmly mentions. Dimanche has come in. She grabs the baby by his feet and swings him back and forth upside down while supporting his head and neck with the other hand. Still no cry.
"Keep going."
I cut off the clot till the uterine muscle starts bleeding again. I clamp the arteries and suture it closed.
"He wants to cry, he's sucking on the suction and he's opened his eyes." Still no cry.
I suture the peritoneum over the uterine wound and tie her fallopian tubes. I suture the fascia and skin and turn to the baby.
He's still floppy and with blotchy skin but he's staring, has a great heartbeat and starts to breath on his own. We smack his feet, rub his back, grind his sternum and rub his mandibular angles a few more times and then give him to his mom where he actually starts to breast feed a little...
The music continues to surge through me down all my nerves causing many involuntary motions. Sarah pokes me and says to look at Joseph. Our 60 year old grounds keeper with the wizened, white-scruffy-bearded face wearing a pink shirt and maroon pants is up dancing with arms raised right in the face of the percussionists working them into an even more profound musical experience. The chills go down my spine and arms to my legs. People may say it's just malaria but I sense a connection to something unseen...Sarah nudges me again. Andre is on stage with a massive smile on his face and one up raised arm pumping the air...tears well in my eyes as I sense that in this small place somehow we have touched something beyond our comprehension and that on the other side too they are rejoicing as somewhere close by a small life continues against all odds...
James
It's hypnotic and I'm exhausted. My body slouches forward. My elbows on my knees, my eyes close. My feet can't help tapping and my hands softly tap involuntarily even though they don't have the strength for a real clap. My head bobs slightly up and down as my thoughts drift back to this morning...
"Lona wants to see you about some Maternity patient," Sarah shakes me awake.
It's been a long night. My malaria smear was positive again yesterday and after my second dose of quinine I was afraid I'd mixed up meds and took a tranquilizer because I found myself fighting my way out of a dark hole that wanted to suck me down into its depths never to wake again. Then, some people came on motorcycles and began talking and eating loudly right outside our window. I was so groggy, however, I couldn't make sense of anything and thought they were patients coming to complain that we'd stolen the pumps off their bikes they'd left as surety for the payment of their hospital debts. I drifted in and out of my fogginess all night without really feeling rested. Lying in a pool of sweat doesn't help.
I get up, shower, and put on a pair of cords and a shirt. I grab the car keys as I plan on going to Kalmé to bring the church members to join us for our first communion since I've been here. Our pastor from K�lo arrived last night at well.
I see Lona as I enter the hospital and he tells me it's just a pregnant woman with Malaria who wants to go home after two days in the hospital. I agree. Apparently, Jean, the man whose hydrocele we took out had a fever. I check on him and he has a small wound abscess. I open it up and pack it. I head over to Peds to check on the Malaria kids.
I walk in to our one bright spot on campus with it's newly painted cartoons on the walls (thanks to Sarah and Becky). Little James looks at me with a mixture of curiosity and fear. He's one of the first baby's I delivered here and probably the first of several now to bear the strange name of James. He's doing fine and I send him home...
....I'm nudged back to the reality of a Nangjere worship service as a small girl in tattered rags climbs onto the crude wooden bench without a back. She nudges herself between Sarah and I and gives me the hugest, whitest grin ever. I'm soon back into my swaying trance as I can hear the sound of the motorcycle pulling up in my reverie...
Lona and I go over to find that one of the health centers has referred a pregnant woman with a breech presentation (the baby's in position to come out butt first). I check the heartbeat and it's slow...I check to see if it's maybe the mother's but as I do it slowly picks up till it's back to a normal fetus' 150-160/minute. The baby is obviously in distress. The abdomen looks a little weirdly shaped but I think it's probably just a really full bladder. I know we don‚t have much time to get the baby out if we want to save him.
I send Koumabas to find Samedi. Jacob is already there and Dimanche shows up to relieve Lona of night duty so he helps me get the woman on a stretcher and carry her quickly into the OR. Sarah arrives at that moment and I see Koumabas who says Samedi is on his way.
I grab one of the green wrapped Cesarian bundles and through it on the instrument tray table and unwrap it in sterile fashion. I open onto the table two pairs of sterile gloves, a scalpel blade and 3 sutures. Sarah has started the IV and is letting fluids run in quickly. Lona turns the woman over on her side and I open a syringe and spinal needle onto a sterile field made with a glove package. I wipe down the woman's back with Betadine. She can't really double over and has tensed her back muscles. This will be hard. I put on the gloves, draw up the lidocaine, find the intervertebral space and push in the needle. Thank God clear fluid comes out on the first try. I inject the anesthetic and pull it all out as Samedi (who's just arrived) turns the woman on her back and lowers the head of the bed.
I put in a urinary catheter and find pure blood...a ruptured uterus probably. I really know we don't have much time now if the baby is to live. I do a quick scrub, gown and glove, and drape the abdomen. I nod to Samedi. He prays in Nangjere and I grab the 22 blade scalpel and in two strokes am through the fascia down to muscle. I quickly cut the fascia with scissors than poke through the muscles with my fingers and pull them apart to the sides. I keep digging and pulling with my fingers until I enter the abdominal cavity. I find a baby's back. The uterus is torn in the lower anterior segment. There is a lot of clots but not much active bleeding.
I reach my hand down the baby's back to it's butt and raise it out. Then I swing out the legs one at a time and then pull out the body. Each arm is then delivered, a finger put in the mouth to keep the baby's chin on his chest and the head comes out easily. He's huge and broad shouldered. I clamp and cut the cord. He's limp. I hand him to Sarah. There is no cry.
I return my gaze to the woman and pull the uterus out of the belly onto the abdominal wall. I keep in the back of my mind waiting for a baby's cry...it doesn't come.
"Bag the baby," I cry. "Oxygen, oxygen, oxygen" Of course, we don't have any but at least by breathing in room air to the baby some oxygen will hopefully get into his circulation.
The uterus is torn down through the cervix and partially into the bladder. Fortunately, there's almost no bleeding as all the edges are covered with clot.
"Is there a heartbeat?" I yell to Sarah. "No, nothing, she replies."
"Keep bagging...Jacob, il faut stimuler l'enfant...frapper les pieds ou quelque chose comme éa..."
I suture the bladder together and then the cervix over it up to the muscular wall of the uterus...
"There's a faint heartbeat," Sarah calmly mentions. Dimanche has come in. She grabs the baby by his feet and swings him back and forth upside down while supporting his head and neck with the other hand. Still no cry.
"Keep going."
I cut off the clot till the uterine muscle starts bleeding again. I clamp the arteries and suture it closed.
"He wants to cry, he's sucking on the suction and he's opened his eyes." Still no cry.
I suture the peritoneum over the uterine wound and tie her fallopian tubes. I suture the fascia and skin and turn to the baby.
He's still floppy and with blotchy skin but he's staring, has a great heartbeat and starts to breath on his own. We smack his feet, rub his back, grind his sternum and rub his mandibular angles a few more times and then give him to his mom where he actually starts to breast feed a little...
The music continues to surge through me down all my nerves causing many involuntary motions. Sarah pokes me and says to look at Joseph. Our 60 year old grounds keeper with the wizened, white-scruffy-bearded face wearing a pink shirt and maroon pants is up dancing with arms raised right in the face of the percussionists working them into an even more profound musical experience. The chills go down my spine and arms to my legs. People may say it's just malaria but I sense a connection to something unseen...Sarah nudges me again. Andre is on stage with a massive smile on his face and one up raised arm pumping the air...tears well in my eyes as I sense that in this small place somehow we have touched something beyond our comprehension and that on the other side too they are rejoicing as somewhere close by a small life continues against all odds...
James
Tuesday, March 1, 2005
1 March 2005
I can't explain it except to say there are weird things in the world and forces of evil that try and mess with people's minds...
It started innocently enough. David gave sign-out to the team about what happened overnight. A few patients had fevers but overall all the hospitalized patients were doing well. Furthermore, he received no outside cases and had no deliveries until a woman showed up 20 minutes before we started morning report.
The woman had apparently been out walking in the dark to relieve her self and then fell after stepping in a small hole. The family found her several hours later and brought her in as soon as possible.
We finish by assigning posts to the staff for the day and praying. I grab my "doctor's bag" (an old army tan shoulder bag) and head off on rounds. We go to see the new patient first.
She's lying in bed on her back with coarse breathing. She appears semi-comatose with some drool coming out her mouth and a pool of urine under her. She moans and barely moves her extremities but otherwise is unconscious. Both pupils are normal and reactive. She has no evidence of trauma and on further questioning the family says she apparently fell beside the hole but it wasn't the hole that caused her to fall. Her vital signs and heart, lung and abdomen exams are normal.
I order a malaria smear and some other tests. I continue my work for the day while waiting for results.
Awhile later I get the malaria results back which are positive; all other tests are unremarkable. I order a quinine drip and go back to work.
At 1pm I go into the OR to repair a hernia on an elderly gentleman. As I am gowned up and about to start Zachary walks in to tell me that the woman has died. No one is surprised, apparently. Now the true story comes out.
The man I am currently operating on is the woman's brother. When he sold a cow to pay for the operation, she protested and said she wouldn't go and see him in the hospital if he used the money for the surgery. He left his village to come to B�r� yesterday in order to be at the hospital early. She had regrets later and went outside to follow him and be with him after the surgery. That's when, to no one's surprise she fell down and, shortly afterwards, died. That is what the people here expect to happen if you do something that you later regret...you'll die.
So, of course, the solution is to never regret anything. That's why I never hear apologies because it doesn't really matter what you do as long as your not sorry for it you won't be struck down by whoever it is you believe does the striking!
I'm slowly learning little by little why I feel frustrated...I'm in a serious culture clash...not just American-Tchadian, but my own personal cultural differences. If I do something I like to be thanked. I will stay up all night, be totally wasted, work while sick with Malaria, do whatever it takes if you'll only appreciate it. But the Nangjere language doesn't even have the word "thanks"...they've borrowed "merci" from the French but still rarely say it. And now I've discovered that while I easily forgive and forget, and will often apologize myself when wrong in an effort to reconciliate...here, that is not only culturally not done, but considered dangerous as one could die if he has regrets, apologizes or tries to make things up or reconciliate!
As they say in Nangjere, "Kai, Kai, Kai" or in French "�a, �a, �a"...or in English, "dude, what's up wid dat?"...
I somberly return to the dead woman's brother lying on the operating table, covered with a green drape, and continue the surgery, find the hernia sac, tie it off, close up the defect, suture the layers closed and clean up...will I never cease to be surprised by this place...?
James
It started innocently enough. David gave sign-out to the team about what happened overnight. A few patients had fevers but overall all the hospitalized patients were doing well. Furthermore, he received no outside cases and had no deliveries until a woman showed up 20 minutes before we started morning report.
The woman had apparently been out walking in the dark to relieve her self and then fell after stepping in a small hole. The family found her several hours later and brought her in as soon as possible.
We finish by assigning posts to the staff for the day and praying. I grab my "doctor's bag" (an old army tan shoulder bag) and head off on rounds. We go to see the new patient first.
She's lying in bed on her back with coarse breathing. She appears semi-comatose with some drool coming out her mouth and a pool of urine under her. She moans and barely moves her extremities but otherwise is unconscious. Both pupils are normal and reactive. She has no evidence of trauma and on further questioning the family says she apparently fell beside the hole but it wasn't the hole that caused her to fall. Her vital signs and heart, lung and abdomen exams are normal.
I order a malaria smear and some other tests. I continue my work for the day while waiting for results.
Awhile later I get the malaria results back which are positive; all other tests are unremarkable. I order a quinine drip and go back to work.
At 1pm I go into the OR to repair a hernia on an elderly gentleman. As I am gowned up and about to start Zachary walks in to tell me that the woman has died. No one is surprised, apparently. Now the true story comes out.
The man I am currently operating on is the woman's brother. When he sold a cow to pay for the operation, she protested and said she wouldn't go and see him in the hospital if he used the money for the surgery. He left his village to come to B�r� yesterday in order to be at the hospital early. She had regrets later and went outside to follow him and be with him after the surgery. That's when, to no one's surprise she fell down and, shortly afterwards, died. That is what the people here expect to happen if you do something that you later regret...you'll die.
So, of course, the solution is to never regret anything. That's why I never hear apologies because it doesn't really matter what you do as long as your not sorry for it you won't be struck down by whoever it is you believe does the striking!
I'm slowly learning little by little why I feel frustrated...I'm in a serious culture clash...not just American-Tchadian, but my own personal cultural differences. If I do something I like to be thanked. I will stay up all night, be totally wasted, work while sick with Malaria, do whatever it takes if you'll only appreciate it. But the Nangjere language doesn't even have the word "thanks"...they've borrowed "merci" from the French but still rarely say it. And now I've discovered that while I easily forgive and forget, and will often apologize myself when wrong in an effort to reconciliate...here, that is not only culturally not done, but considered dangerous as one could die if he has regrets, apologizes or tries to make things up or reconciliate!
As they say in Nangjere, "Kai, Kai, Kai" or in French "�a, �a, �a"...or in English, "dude, what's up wid dat?"...
I somberly return to the dead woman's brother lying on the operating table, covered with a green drape, and continue the surgery, find the hernia sac, tie it off, close up the defect, suture the layers closed and clean up...will I never cease to be surprised by this place...?
James
Tuesday, February 8, 2005
Death
It's early in the morning. I can't sleep even though it was a late night. I keep thinking back to yesterday. What could I have done differently? Why did it turn out the way it did?...
It started off innocently enough: a breakfast of potatoes and eggs hurriedly eaten so I could run off the make worship at 7:30. Andre read from the Psalms and we discussed being able to tell God everything we're thinking...even if it's nasty stuff like wanting bad things to happen to people and being extremely frustrated and confused. I guess that's what I've been doing since last night...
The report of the overnight guard nurse was uneventful. One kid admitted with Malaria. No problems with the hospitalized patients.
We pray and head off to work. Pediatrics is always first on the list for rounds. Now, instead of being depressing walking into a small dark room with dirty walls and floors littered with mats, wire charcoal cooking baskets, pots and pans and variously brightly colored cloths covering patients lying on mattressless metal beds with metal mesh as a base, now we walk into a brightly painted ample ward with fish, hippos, huts and horses painted on the walls along with colorful sketches done by some of the kids.
The first one is a 9 month old with Malaria. Doing fine, starting to breastfeed again, heart not beating too fast. The next is similar but anemic. Already transfused once, she's doing better but still has a really fast heartbeat and is somewhat pale. I'd ordered a repeat Hemoglobin on her yesterday which the parents still haven't done. Then there's the kid with an infection in the bone of his leg that had lasted four months. We'd unroofed the infected bone, left drains in and casted the leg to support the weakened bone. He seems to be doing better...at least his appetite has increased and there's hardly any liquid in the drains and it doesn't smell like it did at first. The next one is a 4 year old with Malaria and four different parasites in his intestines. He's fine and we send him home. We also send home a 6 year old with severe scoliosis who'd broke his ribs playing soccer...I guess he doesn't know he's supposed to be handicapped. The final patient is a little girl with burns on her abdomen and both thighs who had been treated at home for two weeks with a traditional goat hair paste and then came to us mostly healed but with a few infected places that now are almost completely closed after dressing changes and antibiotics. She's also our resident artist and has the cutest shy smile ever. She helps us as usual by carefully taking off her bandages to let us see the wounds.
Then, off to see the adults with their variety of post-partum, Malaria, diabetic foot post amputation of toes, and Koko, who will soon be the reason I am up typing this email.
Koko has been sick for 2 months. He came to us when I was in Denmark about to get married and was treated for Malaria. At the time he'd already been losing weight for one month. He then when to Kélo and was treated for Malaria once, then hospitalized later and treated for Malaria and Amoebas. Then, he came back on Thursday of last week and was treated for Malaria again and then Typhoid Fever. I just saw him for the first time Sunday. Yesterday was Monday. He's thin and somewhat wasted. It's his stomach that bothers him. Yesterday he was eating a little but his stomach was swollen and very tender. He had bowel function. Overnight his bowel function stopped and he started vomiting a lot. He looks bad. His stomach is bloated and doughy and filled with air but soft and tender all over but not extremely so. I suspect perforation from Typhoid or Tuberculosis or HIV with something else even weirder...I'd thought about operating on him yesterday and I think the same today...I'm uncomfortable with it though, he might die during surgery in his weakened state...but will it give him his only chance?
So I just order a CT Scan and get an Infectious Disease and Surgery consult (oh wait, I must've drifted off to sleep there and been dreaming...)...Instead I ask everyone to leave and ask him if he's ever tested positive for HIV. He says he's never been tested. We don't have any tests right (except for emergency blood transfusions) now but he says he does want to be tested if they become available. After getting the CT, ultrasound, and extensive lab test results back I...(wake up, James...) I decide he has something that needs to be operated on and even if he doesn't survive the surgery I'm pretty sure he won't survive if I don't operate. I don't feel comfortable with the decision but then decisions here are rarely simple as we don't have much to work with except clinical signs and a gut instinct...
I move on to consultations where I see a plethora ranging from constipation to hypertension to loss of appetite to testicular mass to miscarriages with products of conception needing to be pulled out to lipomas to hemerroids to Malaria to infertility to too much fertility (two women come in wanting tubal ligations: one has 8 kids, the other 9). I also spend some time supervising the nurse doing consultations and teaching the nursing student. My desk is piled with books that I have to consult frequently.
Andre passes me and says, "Make sure that guy you want to operate on doesn't die during surgery." Thanks, André, I'll be sure to remember that. Why would he say that anyway?
I finally make it home at 3pm for a lunch of fresh millet cinnamon bread and rice with one of Salomon's famous sauces. Sarah, Nathan and I play a few rounds of Rummy to while away the time. We're supposed to have a Managing Committed meeting but no one shows up.
At 6pm we bring Koko to the operating room, prep him, give him Ketamine, open his skin and find a seriously thickened peritoneum and a balled up mass of small intestine stuck together and to the abdominal wall. A thick greenish fluid comes out. Everything is covered with white dots. Tuberculosis. I free up some of the adhesions, irrigate well, leave in two drains and close up. He's doing fine. We wait for him to wake up. Pulse is fine. Blood pressure is fine. Oxygen saturation is fine. We have no cardiac monitor. He doesn't want to wake up. His kidneys have stopped putting urine into his catheter bag. His heart rate slows. His O2 sat drops. We have nothing really. We start bagging him and doing CPR. His O2 sat comes back. We give him the couple of medicines we have: Atropine and Bicarbonate. No pulse. Nothing. We do CPR for 20 minutes. He's dead. André's a prophet.
We pull out his drains, IVs and catheter. I call in the Guard Nurse who gets the head of the family. About 50 people are waiting just outside. They go to get a car to take the body. Nathan, Sarah and I wait with the body. Nathan offers me some Oreos. I accept. I'm drained and sickened. They finally come. As soon as they pull up the wailing and howling starts. Women flailing their arms and crying "Whoooo Whoooo whooo" and "Baaahooooh, baaaahhhhooooo"! I'm suddenly scared. I slink off in the moonless night to the small side gate as the truck piles high with many live bodies and one dead one. I watch from a distance in the dark. It's creepy. There are drum beats and slowly distancing primal howls and wails. I go back and eat some sauce and rice...I talk to Andre...apparently everyone but me knew Koko was HIV positive...I sleep fitfully...
James
It started off innocently enough: a breakfast of potatoes and eggs hurriedly eaten so I could run off the make worship at 7:30. Andre read from the Psalms and we discussed being able to tell God everything we're thinking...even if it's nasty stuff like wanting bad things to happen to people and being extremely frustrated and confused. I guess that's what I've been doing since last night...
The report of the overnight guard nurse was uneventful. One kid admitted with Malaria. No problems with the hospitalized patients.
We pray and head off to work. Pediatrics is always first on the list for rounds. Now, instead of being depressing walking into a small dark room with dirty walls and floors littered with mats, wire charcoal cooking baskets, pots and pans and variously brightly colored cloths covering patients lying on mattressless metal beds with metal mesh as a base, now we walk into a brightly painted ample ward with fish, hippos, huts and horses painted on the walls along with colorful sketches done by some of the kids.
The first one is a 9 month old with Malaria. Doing fine, starting to breastfeed again, heart not beating too fast. The next is similar but anemic. Already transfused once, she's doing better but still has a really fast heartbeat and is somewhat pale. I'd ordered a repeat Hemoglobin on her yesterday which the parents still haven't done. Then there's the kid with an infection in the bone of his leg that had lasted four months. We'd unroofed the infected bone, left drains in and casted the leg to support the weakened bone. He seems to be doing better...at least his appetite has increased and there's hardly any liquid in the drains and it doesn't smell like it did at first. The next one is a 4 year old with Malaria and four different parasites in his intestines. He's fine and we send him home. We also send home a 6 year old with severe scoliosis who'd broke his ribs playing soccer...I guess he doesn't know he's supposed to be handicapped. The final patient is a little girl with burns on her abdomen and both thighs who had been treated at home for two weeks with a traditional goat hair paste and then came to us mostly healed but with a few infected places that now are almost completely closed after dressing changes and antibiotics. She's also our resident artist and has the cutest shy smile ever. She helps us as usual by carefully taking off her bandages to let us see the wounds.
Then, off to see the adults with their variety of post-partum, Malaria, diabetic foot post amputation of toes, and Koko, who will soon be the reason I am up typing this email.
Koko has been sick for 2 months. He came to us when I was in Denmark about to get married and was treated for Malaria. At the time he'd already been losing weight for one month. He then when to Kélo and was treated for Malaria once, then hospitalized later and treated for Malaria and Amoebas. Then, he came back on Thursday of last week and was treated for Malaria again and then Typhoid Fever. I just saw him for the first time Sunday. Yesterday was Monday. He's thin and somewhat wasted. It's his stomach that bothers him. Yesterday he was eating a little but his stomach was swollen and very tender. He had bowel function. Overnight his bowel function stopped and he started vomiting a lot. He looks bad. His stomach is bloated and doughy and filled with air but soft and tender all over but not extremely so. I suspect perforation from Typhoid or Tuberculosis or HIV with something else even weirder...I'd thought about operating on him yesterday and I think the same today...I'm uncomfortable with it though, he might die during surgery in his weakened state...but will it give him his only chance?
So I just order a CT Scan and get an Infectious Disease and Surgery consult (oh wait, I must've drifted off to sleep there and been dreaming...)...Instead I ask everyone to leave and ask him if he's ever tested positive for HIV. He says he's never been tested. We don't have any tests right (except for emergency blood transfusions) now but he says he does want to be tested if they become available. After getting the CT, ultrasound, and extensive lab test results back I...(wake up, James...) I decide he has something that needs to be operated on and even if he doesn't survive the surgery I'm pretty sure he won't survive if I don't operate. I don't feel comfortable with the decision but then decisions here are rarely simple as we don't have much to work with except clinical signs and a gut instinct...
I move on to consultations where I see a plethora ranging from constipation to hypertension to loss of appetite to testicular mass to miscarriages with products of conception needing to be pulled out to lipomas to hemerroids to Malaria to infertility to too much fertility (two women come in wanting tubal ligations: one has 8 kids, the other 9). I also spend some time supervising the nurse doing consultations and teaching the nursing student. My desk is piled with books that I have to consult frequently.
Andre passes me and says, "Make sure that guy you want to operate on doesn't die during surgery." Thanks, André, I'll be sure to remember that. Why would he say that anyway?
I finally make it home at 3pm for a lunch of fresh millet cinnamon bread and rice with one of Salomon's famous sauces. Sarah, Nathan and I play a few rounds of Rummy to while away the time. We're supposed to have a Managing Committed meeting but no one shows up.
At 6pm we bring Koko to the operating room, prep him, give him Ketamine, open his skin and find a seriously thickened peritoneum and a balled up mass of small intestine stuck together and to the abdominal wall. A thick greenish fluid comes out. Everything is covered with white dots. Tuberculosis. I free up some of the adhesions, irrigate well, leave in two drains and close up. He's doing fine. We wait for him to wake up. Pulse is fine. Blood pressure is fine. Oxygen saturation is fine. We have no cardiac monitor. He doesn't want to wake up. His kidneys have stopped putting urine into his catheter bag. His heart rate slows. His O2 sat drops. We have nothing really. We start bagging him and doing CPR. His O2 sat comes back. We give him the couple of medicines we have: Atropine and Bicarbonate. No pulse. Nothing. We do CPR for 20 minutes. He's dead. André's a prophet.
We pull out his drains, IVs and catheter. I call in the Guard Nurse who gets the head of the family. About 50 people are waiting just outside. They go to get a car to take the body. Nathan, Sarah and I wait with the body. Nathan offers me some Oreos. I accept. I'm drained and sickened. They finally come. As soon as they pull up the wailing and howling starts. Women flailing their arms and crying "Whoooo Whoooo whooo" and "Baaahooooh, baaaahhhhooooo"! I'm suddenly scared. I slink off in the moonless night to the small side gate as the truck piles high with many live bodies and one dead one. I watch from a distance in the dark. It's creepy. There are drum beats and slowly distancing primal howls and wails. I go back and eat some sauce and rice...I talk to Andre...apparently everyone but me knew Koko was HIV positive...I sleep fitfully...
James
Tuesday, February 1, 2005
I'm back!
I'm back. I've been nervous. What can I expect? I've been in the cold, north, developed world for one month now. What will it be like in the hot, dry, desert of poor Tchad? Will it be hard to readapt?
I descend from the Air France plane onto the runway in N'Djam�na. I'm excited. The air is cool and dry with that distinctive Tchadian odor (not a bad one) that first caused me to feel that Tchad was where I was supposed to go so long ago when I first came here in November of 2002. I'm thrilled to hear Tchadian Arabic again as I wait for my passport to be signed and easily grab my luggage. Of course, this time I'm not alone as I've come back to Tchad no longer a batchelor.
I don't know if there really is a change or just my own perspective has changed, but it seems N'Djam�na is less dirty and there is more of a hopeful atmosphere in the air. There are more foreigners on the streets now. Things seem more available in general. On the way down to Bere all the police checkpoints have disappeared. The road to B�r� has started to be graded to make up for the damage caused by the transport trucks during the rainy season. The hippos are still there. The barge across the Tandjilé River has become a bridge again as the water level has dropped. The sign saying "Bienvenue � Bere" hasn't changed. There's the white water tower and before you know it we are back.
I find that everything is familiar. I have truly come home. Good, bad, ugly, warts, quirks, frustrations, joys, beauty, simplicity, filth, all the contradictions that Bere is, it is still home now.
The peace lasts only a short time. At first, everyone is just thrilled and excited to have Sarah and me back. There are congratulations all around on the wedding. Life is good. But, then slowly but surely everyone starts to realize they don't have to be responsible any more, the Doctor/Administrator is back. I swore that this time I wouldn't let them stress me out. However, little by little people subtly place their problems, grievances and other things before me...I wouldn't mind if it wasn't a constant barrage of things that people could handle and have been handling fine in my absence. The place didn't fall apart when I was gone, it functioned fine and there were even a lot of improvements. The fence around the housing has been started, the rehab of the clinic building continues to advance (the roof is on and most of the ceiling redone), the TB ward has been repainted, latrines were built. So why now does everyone seem helpless and overjoyed at the prospect of dumping any and every little problem in my lap?
Andre, who I've been counting on and has come through in my absence as acting administrator suddenly can't do anything without coming and asking my permission first. His report for our AHI committee was poorly prepared and confusing and just downright wrong and unreflective of the actual financial situation. The lab guys come to me yesterday to say they've started having to wash and reuse the slides since they are out...of course, they didn't bother to mention they were getting low. The government has been out of HIV tests for two months now as apparently they are selling them on the side to make a profit leaving us helpless in the face of the epidemic.
And of course, there are the medical challenges. A boy comes in with a swollen face, legs and belly from losing protein from his kidneys (nephrotic syndrome) caused by Malaria. We treat the Malaria and start him on something that might help his kidneys. Two days ago I come to see him for the first time since I was in N'Djam�na for AHI board meetings and as he goes to pull off his shirt so I can listen to his heart and lungs he starts having problems. At first we laugh because he has intertwined his two shirts so his arms are trapped. Then, we realize he's having problems because he's having a generalized siezure.
He's finished treatment for Malaria and hasn't had a fever so it's probably not that or another infection. It could be sodium or calcium or other metabolic disturbances but are lab can't perform any of the tests that would be reflex in the states. Of course, we have not CAT Scan or MRI. So I just give him some valium, assume it's low sodium because one of the nurses gave him a diuretic while I was gone as I notice. I give him an oral sodium rich mixture to be given when he wakes up and pray. It's a helpless feeling. I don't know if I'll see him the next morning.
The next patient in our newly painted peds ward is a 12 year old with a wound on his leg for four years. The x-ray shows massive deformation of the femur from infection in the bone...it's into the knee. Chances of saving the leg are poor.
Then Rahama mentions that the boy who I thought we'd miraculously saved last year is draining from a similar wound in his leg. He'd fallen from a mango tree shattering his jaw and giving him an open femur fracture. We'd wired his jaw, cleaned out and immobilized his femur. His jaw had healed normally and it appeared the leg had too. Now apparently the openness of the fracture had let in an infection that has now manifested itself. Very discouraging...we'd wanted to send them to a higher center but they'd refused just as they refuse to come in now...
Then, there's the girl who'd been burned two weeks ago and just came in covered with a goat hair paste. Fortunately, surprisingly that paste works pretty well and most of the burns had healed. Only a small section behind and in front of her left thigh is infected and needs more "standard" wound care. She's doing well.
Another difficult case: a girl who had a longstanding Parotid gland abscess that now has developed into a fistula leaking digestive juices. They won't go anywhere else. What do I do?
Not to mention the three women who came in Saturday. One with the placenta covering the opening of her uterus so the baby can't come out. Of course, the baby's already dead and her hemoglobin is 4 (normally over 12). We operate...she does well but another dead baby is always discouraging. Of course, I come out of surgery just to find another woman with the umbilical cord hanging out and the baby also already dead...she delivers the corpse a few hours later. Only one woman, a tiny 14 or 15 year old Arab nomad, delivers a live baby. We have to cut an episiotomy and bring the baby into the world with a vacuum attached to its head to suck it out. The baby comes out screaming and is completely alive in every way as if to spite the death that has been so ominously hanging around.
We have the staff over to see pictures of the wedding. There's a picture of me swinging off a playground rope in Madrid. I jokingly say that this is a picture of a monkey we saw. Koumabas says "Ah bon?" (really?) The funny thing is, he's serious. Everyone laughs and explains it's really me. Later on, there are pictures of Sarah and me in the Paris Airport stuffing grapes in our cheeks and lips just to be silly. I say again that this is a monkey we found in the airport. Amazingly, Koumabas again says seriously "Ah bon?" Everyone is incredulous. "Koumabas, it's the doctor!" "Ah bon?" says Koumabas...it's hard not to survive when you have moments like that...
Like it or not...I'm back!
James
I descend from the Air France plane onto the runway in N'Djam�na. I'm excited. The air is cool and dry with that distinctive Tchadian odor (not a bad one) that first caused me to feel that Tchad was where I was supposed to go so long ago when I first came here in November of 2002. I'm thrilled to hear Tchadian Arabic again as I wait for my passport to be signed and easily grab my luggage. Of course, this time I'm not alone as I've come back to Tchad no longer a batchelor.
I don't know if there really is a change or just my own perspective has changed, but it seems N'Djam�na is less dirty and there is more of a hopeful atmosphere in the air. There are more foreigners on the streets now. Things seem more available in general. On the way down to Bere all the police checkpoints have disappeared. The road to B�r� has started to be graded to make up for the damage caused by the transport trucks during the rainy season. The hippos are still there. The barge across the Tandjilé River has become a bridge again as the water level has dropped. The sign saying "Bienvenue � Bere" hasn't changed. There's the white water tower and before you know it we are back.
I find that everything is familiar. I have truly come home. Good, bad, ugly, warts, quirks, frustrations, joys, beauty, simplicity, filth, all the contradictions that Bere is, it is still home now.
The peace lasts only a short time. At first, everyone is just thrilled and excited to have Sarah and me back. There are congratulations all around on the wedding. Life is good. But, then slowly but surely everyone starts to realize they don't have to be responsible any more, the Doctor/Administrator is back. I swore that this time I wouldn't let them stress me out. However, little by little people subtly place their problems, grievances and other things before me...I wouldn't mind if it wasn't a constant barrage of things that people could handle and have been handling fine in my absence. The place didn't fall apart when I was gone, it functioned fine and there were even a lot of improvements. The fence around the housing has been started, the rehab of the clinic building continues to advance (the roof is on and most of the ceiling redone), the TB ward has been repainted, latrines were built. So why now does everyone seem helpless and overjoyed at the prospect of dumping any and every little problem in my lap?
Andre, who I've been counting on and has come through in my absence as acting administrator suddenly can't do anything without coming and asking my permission first. His report for our AHI committee was poorly prepared and confusing and just downright wrong and unreflective of the actual financial situation. The lab guys come to me yesterday to say they've started having to wash and reuse the slides since they are out...of course, they didn't bother to mention they were getting low. The government has been out of HIV tests for two months now as apparently they are selling them on the side to make a profit leaving us helpless in the face of the epidemic.
And of course, there are the medical challenges. A boy comes in with a swollen face, legs and belly from losing protein from his kidneys (nephrotic syndrome) caused by Malaria. We treat the Malaria and start him on something that might help his kidneys. Two days ago I come to see him for the first time since I was in N'Djam�na for AHI board meetings and as he goes to pull off his shirt so I can listen to his heart and lungs he starts having problems. At first we laugh because he has intertwined his two shirts so his arms are trapped. Then, we realize he's having problems because he's having a generalized siezure.
He's finished treatment for Malaria and hasn't had a fever so it's probably not that or another infection. It could be sodium or calcium or other metabolic disturbances but are lab can't perform any of the tests that would be reflex in the states. Of course, we have not CAT Scan or MRI. So I just give him some valium, assume it's low sodium because one of the nurses gave him a diuretic while I was gone as I notice. I give him an oral sodium rich mixture to be given when he wakes up and pray. It's a helpless feeling. I don't know if I'll see him the next morning.
The next patient in our newly painted peds ward is a 12 year old with a wound on his leg for four years. The x-ray shows massive deformation of the femur from infection in the bone...it's into the knee. Chances of saving the leg are poor.
Then Rahama mentions that the boy who I thought we'd miraculously saved last year is draining from a similar wound in his leg. He'd fallen from a mango tree shattering his jaw and giving him an open femur fracture. We'd wired his jaw, cleaned out and immobilized his femur. His jaw had healed normally and it appeared the leg had too. Now apparently the openness of the fracture had let in an infection that has now manifested itself. Very discouraging...we'd wanted to send them to a higher center but they'd refused just as they refuse to come in now...
Then, there's the girl who'd been burned two weeks ago and just came in covered with a goat hair paste. Fortunately, surprisingly that paste works pretty well and most of the burns had healed. Only a small section behind and in front of her left thigh is infected and needs more "standard" wound care. She's doing well.
Another difficult case: a girl who had a longstanding Parotid gland abscess that now has developed into a fistula leaking digestive juices. They won't go anywhere else. What do I do?
Not to mention the three women who came in Saturday. One with the placenta covering the opening of her uterus so the baby can't come out. Of course, the baby's already dead and her hemoglobin is 4 (normally over 12). We operate...she does well but another dead baby is always discouraging. Of course, I come out of surgery just to find another woman with the umbilical cord hanging out and the baby also already dead...she delivers the corpse a few hours later. Only one woman, a tiny 14 or 15 year old Arab nomad, delivers a live baby. We have to cut an episiotomy and bring the baby into the world with a vacuum attached to its head to suck it out. The baby comes out screaming and is completely alive in every way as if to spite the death that has been so ominously hanging around.
We have the staff over to see pictures of the wedding. There's a picture of me swinging off a playground rope in Madrid. I jokingly say that this is a picture of a monkey we saw. Koumabas says "Ah bon?" (really?) The funny thing is, he's serious. Everyone laughs and explains it's really me. Later on, there are pictures of Sarah and me in the Paris Airport stuffing grapes in our cheeks and lips just to be silly. I say again that this is a monkey we found in the airport. Amazingly, Koumabas again says seriously "Ah bon?" Everyone is incredulous. "Koumabas, it's the doctor!" "Ah bon?" says Koumabas...it's hard not to survive when you have moments like that...
Like it or not...I'm back!
James
Wednesday, January 26, 2005
Tchadian/Danish/American Wedding...
My vacation started out in typical Tchadian fashion. I was scheduled to leave for Denmark on Tuesday evening to get married. By Tuesday morning the chauffeur hadn't returned from N'Djaména. So I found myself biting back the tears and preparing myself for the Danish winter by racing along before daylight on the back of Andre's motorcycle on the bumpy route from Béré to Kélo. All I had was my small backpack and a secret dread that with taking public transport from Kélo to N'Djaména I wouldn't make my flight and maybe was destined afterall to nevere marry...I'm this close, but until those words are said I can't be sure.
We arrive in Kelo after 1 1/2 hours. My eyes will remain bloodshot and teary for three days from the cold wind and dust. We pull into an open courtyard filled with milling, robed arabs and an array of Toyota mini-buses in varying stages of being overloaded. We notice one is mostly loaded and appears about to leave for N'Djaména. André leads me over to a thatch roofed, no-walled shelter supported by four twisting former small trees. An turbaned, bearded arab speaks to me in French tinged with a gutteral Arab accent. I buy a hand written ticket. I sit on the front seat after tossing my backpack on top of the other luggage already in the rack. I happen to sit next to one of André's wife's classmates from nursing school. Then I notice my backpack being loaded onto another bus. I go out to protest and find they want to switch me to another bus because they've "overbooked". I protest but to no avail. Then, André returns and with the help of his wife's friend they convince them I can squeeze in since I'm trying to make my flight.
So I spend the next 7 hours with one butt cheek on a hard bench and the other free floating in the air by the sliding door. Wedging me in is the young arab assistant to the chauffeur who opens and closes the door barely packing him in against me. MY legs have to be forced left and cannot move at all. I find solace in conversation with the nursing student and in reading all of the biography of Paul Farmer, MD called Mountains Beyond Mountains which proves to be quite inspiring.
After many stops, I nourish myself with a green papaya carved up at an Arab "watering hole" (tea and warm milk stand) with a borrowed knife. I also eat two bananas I've brought with me and a couple of doughnuts cooked in a deep fat pan over coals by the side of the road.
We have a blowout that causes no harm to the vehicule. We put on the spare and then stop at the next town to replace the innertube. Quite an interesting process when done by hand.
Finally, we arrive in N'Djaména. The bus station is part of the eastern market. Fortunately, I see we pass Pasteur Job's house which is only about 5-6 blocks from the bus stop. I grab my pack and try to ignore the constant stares and cries of "nasara". Pasteur Job is with the group from Loma Linda who came to do a dental survey. His relative tries to grab a taxi but finds it too expensive until I go sit out of site until he bargains for a fair price. We travel to the Big Central Market where we change taxis normally but we pay the dude a little extra to take us near the airport. I've arrived in time.
It feels very weird to be boarding the plane. I realize this is the first time I'm boarding a plane in a third world country in order to take a vacation and not return from one or go home. This is my home...I will be back. The guy wants to take my backpack from me carrying it on. As I desperately try to make it fit in the sizing apparatus he finally just smiles, shrugs and motions me on...I'm grateful as I'll be flying Air Chance (France).
The flight to Paris is quick. I'm kind of in a dream world as I view the modern world for the first time in a year but it's not as strange as I thought it would be. I get on the flight to Denmark and start my vacation...
Just a few tidbits...
Danish weddings have some different traditions than American ones. The groom and best man are on stage before it starts and everyone including bride and groom sit during most of the ceremony. This was cool as it allowed me to leave the Best Man seat empty in honor of my brother, David, who I always knew would be my best man...alas he was killed on September 3, 2001 in a car accident.
Then the Groom rises at the time the wedding starts to wait for the bride. Normally she should make him wait 5-10 minutes and only if she's wicked will she make him wait 15. I waited over 20 minutes! Later, she explained it was because her brother insisted on stopping and washing the car after it traveled down the dirt road from her house to the main road...yeah, right,...she's a tough one:)
Then there is both a general reception for everyone and a wedding dinner where only the closest of friends and family are invited. This dinner is a big deal, much more important than the actual ceremony. We had an amazing 7 course meal and everyone had speeches all prepared to roast and toast the bride and groom. The differences in culture was topped off by my being attacked by the guys and held down while the toes of my socks were cut off!
For a brief glimpse into the whole vacation visit Click Here http://www.geocities.com/appeltwin1
Tomorrow, Sarah and I return to Tchad...
Bonne Annee!
James
We arrive in Kelo after 1 1/2 hours. My eyes will remain bloodshot and teary for three days from the cold wind and dust. We pull into an open courtyard filled with milling, robed arabs and an array of Toyota mini-buses in varying stages of being overloaded. We notice one is mostly loaded and appears about to leave for N'Djaména. André leads me over to a thatch roofed, no-walled shelter supported by four twisting former small trees. An turbaned, bearded arab speaks to me in French tinged with a gutteral Arab accent. I buy a hand written ticket. I sit on the front seat after tossing my backpack on top of the other luggage already in the rack. I happen to sit next to one of André's wife's classmates from nursing school. Then I notice my backpack being loaded onto another bus. I go out to protest and find they want to switch me to another bus because they've "overbooked". I protest but to no avail. Then, André returns and with the help of his wife's friend they convince them I can squeeze in since I'm trying to make my flight.
So I spend the next 7 hours with one butt cheek on a hard bench and the other free floating in the air by the sliding door. Wedging me in is the young arab assistant to the chauffeur who opens and closes the door barely packing him in against me. MY legs have to be forced left and cannot move at all. I find solace in conversation with the nursing student and in reading all of the biography of Paul Farmer, MD called Mountains Beyond Mountains which proves to be quite inspiring.
After many stops, I nourish myself with a green papaya carved up at an Arab "watering hole" (tea and warm milk stand) with a borrowed knife. I also eat two bananas I've brought with me and a couple of doughnuts cooked in a deep fat pan over coals by the side of the road.
We have a blowout that causes no harm to the vehicule. We put on the spare and then stop at the next town to replace the innertube. Quite an interesting process when done by hand.
Finally, we arrive in N'Djaména. The bus station is part of the eastern market. Fortunately, I see we pass Pasteur Job's house which is only about 5-6 blocks from the bus stop. I grab my pack and try to ignore the constant stares and cries of "nasara". Pasteur Job is with the group from Loma Linda who came to do a dental survey. His relative tries to grab a taxi but finds it too expensive until I go sit out of site until he bargains for a fair price. We travel to the Big Central Market where we change taxis normally but we pay the dude a little extra to take us near the airport. I've arrived in time.
It feels very weird to be boarding the plane. I realize this is the first time I'm boarding a plane in a third world country in order to take a vacation and not return from one or go home. This is my home...I will be back. The guy wants to take my backpack from me carrying it on. As I desperately try to make it fit in the sizing apparatus he finally just smiles, shrugs and motions me on...I'm grateful as I'll be flying Air Chance (France).
The flight to Paris is quick. I'm kind of in a dream world as I view the modern world for the first time in a year but it's not as strange as I thought it would be. I get on the flight to Denmark and start my vacation...
Just a few tidbits...
Danish weddings have some different traditions than American ones. The groom and best man are on stage before it starts and everyone including bride and groom sit during most of the ceremony. This was cool as it allowed me to leave the Best Man seat empty in honor of my brother, David, who I always knew would be my best man...alas he was killed on September 3, 2001 in a car accident.
Then the Groom rises at the time the wedding starts to wait for the bride. Normally she should make him wait 5-10 minutes and only if she's wicked will she make him wait 15. I waited over 20 minutes! Later, she explained it was because her brother insisted on stopping and washing the car after it traveled down the dirt road from her house to the main road...yeah, right,...she's a tough one:)
Then there is both a general reception for everyone and a wedding dinner where only the closest of friends and family are invited. This dinner is a big deal, much more important than the actual ceremony. We had an amazing 7 course meal and everyone had speeches all prepared to roast and toast the bride and groom. The differences in culture was topped off by my being attacked by the guys and held down while the toes of my socks were cut off!
For a brief glimpse into the whole vacation visit Click Here http://www.geocities.com/appeltwin1
Tomorrow, Sarah and I return to Tchad...
Bonne Annee!
James
Saturday, December 11, 2004
Thursday
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
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
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