Thursday, October 20, 2005
An Africian Experience
A small group from Markham Woods Church went to Bere Adventist Hospital in Tchad a central African country. We know this country here in America as Chad. Our destination is a remote hospital. There were 14 of us going on this adventure. We were nurses, a doctor, a carpenter, construction contractors, accountant, computer engineer, and others. The primary purpose of our trip was to do maintenance on the buildings, deliver medical equipment and provide in-service training to the staff.
Sunday, September 11, 2005
Navigating the mind
I lie on the couch. My arms stick to my bare chest. My eyelids are so heavy I can't keep them open. Hens cluck outside, their chicks tweeting alongside. Andr� shouts something in Moundan, which sounds like Chinese badly spoken. In the distance, thunder threatens to disrupt the heavy heat that hangs in the air like a cobweb stretching desperately to ensnare its next victim. The taste of M & M's rests in my mouth like a sticky, sweet film of scum on top of a stagnant pool where mosquitoes breed ready to spread their deadly curse of malaria across our small village.
Thoughts flit through my head hoping not to be caught by anything that might make my consciousness stay awake.
I glide through the wards in my mind as in a misty cave lit dimly by torchlight. There to the left is a smiling face of a well-looking woman with a cast on her right leg. She smiles, holds out her hand and says, "lapia". Three small children play some game with a plastic bag at her bedside.
To the right, Lona leads me to the new arrival. An elderly woman betraying her age by her silver hair rather than by her skin and body lies stretched on her back. I examine her abdomen and write prescriptions in her little health record which is carved out of a school notebook and called a carnet.
I enter the next room barely noticing the cracked blue dingy paint and ceiling panels hanging like moss from an ancient cave. Under a white mosquito net sits the Business Manager of the Mayor's office. His knee wound has become infected post-op leaking out pasty remnants of his gout deposits like toothpaste gone really, really bad. I unwrap and change the dressing.
I proceed to the next mosquito net cocoon hiding not a butterfly but a man lucky to be alive, yet very much so despite lying in his own stool which is leaking out of a poorly done colostomy on his left abdominal wall. Five days ago I was intimately acquainted with his abdominal contents from midnight until 6:00 am as I first unwrapped, then removed his dead sigmoid colon which had twisted on itself in a bizarre act of suicide called a volvulus. He is eating, has no pain, wound is clean, drains removed yesterday and colostomy functioning despite being done wrong (as learned by post op reading on the subject).
I move to the outside door passing our tall, thin friend with a left leg that I was sure he would lose when he first arrived. His thigh wound is still rather large but beefy red with no swelling or signs of infection. Of course, after two months at home and only our pitiful attempts at physical therapy, he is a long ways from bending his knee normally. But he has his leg...
I walk under the porch and across a surprisingly clear walkway lacking the normal proliferation of mats and bright colored Arabic rugs. I enter the dungeon of pediatrics.
Darkness and the smell of urine and old pus assault my senses. The smells soon disappear in the amazing adaptability of the body and the darkness by simply opening the sheet metal shutters. A row of red beds stretches in what seems like infinity interrupted by a smattering of mosquito nets and tubing hanging haphazardly from a varied assortment of poles, sticks and protuberances. I feel I should have a treasure map in my hand, a hat on my head, a whip by my side and a wry smile playing about my lips if I intend to navigate well this ancient tomb.
I notice that the second bed to the left has a new child. The one who'd occupied that bed the previous five days sticks out in my mind. A tiny 8-month-old with the typical fever, diarrhea, vomiting and anemia was admitted, diagnosed with malaria and severe anemia, and treated with IV Quinine and a blood transfusion. But despite all that, this tiny thing continued to hang on the edge of eternity. Each day brought no improvement. Her Arab father continually sought what to do and was quick to buy the necessary treatments. His love was contagious.
But the diarrhea continued. The refusal to breastfeed was discouraging. The fast heart rate and breathing was ominous. Finally, two days ago I noticed a change, but not the one I was expecting or hoping for. I noticed a small piece of white paper or animal hide folded many times and tied to her wrist. Then, I took note of the heavy bundle of leather pouches tied around her neck. I spoke to the father.
"Are you a Muslim?"
"Yes."
"Do you believe in the one true God?"
"Yes."
"Do you believe He is all powerful?"
"Yes."
"Then why do you put your confidence in these fetishes to save your child's life? If it is Allah's will she will die, if it is Allah's will she will live but you may give credit to the fetishes rather than Allah if she does. Why not take them off and put your trust in the all-powerful one God?"
"Doctor, you are right."
I pray with them. I walk away. I come back the next day and the child is well. The child has no pouches or things tied around her. They go home that same day.
I continue on pediatrics and remember what happened two weeks ago at the end of the cavern. A mother lying on the floor begins to writhe and twist and moan. I feel instantly this is something supernatural. Through a nursing student as translator we pray for her. She calms down. We speak with her.
She used to know God. Then, a catastrophe struck. She lost her husband and faith at the same time. She visited a witch doctor. The "seizures" started. We pray for her again, assuring her that our God is all powerful and she can be free. She is calm. Her child is still sick, though.
The next day, she is gone along with her child.
I return to the present. I find my way through the maze of sick children and return home. I pass through whirlwind of email trying to get students ready to enter nursing school, sending the chauffeur to get IV fluids at Lai across the barge-less and bridge-less swollen Logone River, going to church, getting called out to see a woman with a likely kidney infection and going home to find some peace with George MacDonald's "The Princess and Curdie" and M & M's leads me to an exhausted flop on the couch where I drift back into an endless cycle of thoughts buzzing through my head like mosquitoes in search of Malaria-free victims to infect...
Thoughts flit through my head hoping not to be caught by anything that might make my consciousness stay awake.
I glide through the wards in my mind as in a misty cave lit dimly by torchlight. There to the left is a smiling face of a well-looking woman with a cast on her right leg. She smiles, holds out her hand and says, "lapia". Three small children play some game with a plastic bag at her bedside.
To the right, Lona leads me to the new arrival. An elderly woman betraying her age by her silver hair rather than by her skin and body lies stretched on her back. I examine her abdomen and write prescriptions in her little health record which is carved out of a school notebook and called a carnet.
I enter the next room barely noticing the cracked blue dingy paint and ceiling panels hanging like moss from an ancient cave. Under a white mosquito net sits the Business Manager of the Mayor's office. His knee wound has become infected post-op leaking out pasty remnants of his gout deposits like toothpaste gone really, really bad. I unwrap and change the dressing.
I proceed to the next mosquito net cocoon hiding not a butterfly but a man lucky to be alive, yet very much so despite lying in his own stool which is leaking out of a poorly done colostomy on his left abdominal wall. Five days ago I was intimately acquainted with his abdominal contents from midnight until 6:00 am as I first unwrapped, then removed his dead sigmoid colon which had twisted on itself in a bizarre act of suicide called a volvulus. He is eating, has no pain, wound is clean, drains removed yesterday and colostomy functioning despite being done wrong (as learned by post op reading on the subject).
I move to the outside door passing our tall, thin friend with a left leg that I was sure he would lose when he first arrived. His thigh wound is still rather large but beefy red with no swelling or signs of infection. Of course, after two months at home and only our pitiful attempts at physical therapy, he is a long ways from bending his knee normally. But he has his leg...
I walk under the porch and across a surprisingly clear walkway lacking the normal proliferation of mats and bright colored Arabic rugs. I enter the dungeon of pediatrics.
Darkness and the smell of urine and old pus assault my senses. The smells soon disappear in the amazing adaptability of the body and the darkness by simply opening the sheet metal shutters. A row of red beds stretches in what seems like infinity interrupted by a smattering of mosquito nets and tubing hanging haphazardly from a varied assortment of poles, sticks and protuberances. I feel I should have a treasure map in my hand, a hat on my head, a whip by my side and a wry smile playing about my lips if I intend to navigate well this ancient tomb.
I notice that the second bed to the left has a new child. The one who'd occupied that bed the previous five days sticks out in my mind. A tiny 8-month-old with the typical fever, diarrhea, vomiting and anemia was admitted, diagnosed with malaria and severe anemia, and treated with IV Quinine and a blood transfusion. But despite all that, this tiny thing continued to hang on the edge of eternity. Each day brought no improvement. Her Arab father continually sought what to do and was quick to buy the necessary treatments. His love was contagious.
But the diarrhea continued. The refusal to breastfeed was discouraging. The fast heart rate and breathing was ominous. Finally, two days ago I noticed a change, but not the one I was expecting or hoping for. I noticed a small piece of white paper or animal hide folded many times and tied to her wrist. Then, I took note of the heavy bundle of leather pouches tied around her neck. I spoke to the father.
"Are you a Muslim?"
"Yes."
"Do you believe in the one true God?"
"Yes."
"Do you believe He is all powerful?"
"Yes."
"Then why do you put your confidence in these fetishes to save your child's life? If it is Allah's will she will die, if it is Allah's will she will live but you may give credit to the fetishes rather than Allah if she does. Why not take them off and put your trust in the all-powerful one God?"
"Doctor, you are right."
I pray with them. I walk away. I come back the next day and the child is well. The child has no pouches or things tied around her. They go home that same day.
I continue on pediatrics and remember what happened two weeks ago at the end of the cavern. A mother lying on the floor begins to writhe and twist and moan. I feel instantly this is something supernatural. Through a nursing student as translator we pray for her. She calms down. We speak with her.
She used to know God. Then, a catastrophe struck. She lost her husband and faith at the same time. She visited a witch doctor. The "seizures" started. We pray for her again, assuring her that our God is all powerful and she can be free. She is calm. Her child is still sick, though.
The next day, she is gone along with her child.
I return to the present. I find my way through the maze of sick children and return home. I pass through whirlwind of email trying to get students ready to enter nursing school, sending the chauffeur to get IV fluids at Lai across the barge-less and bridge-less swollen Logone River, going to church, getting called out to see a woman with a likely kidney infection and going home to find some peace with George MacDonald's "The Princess and Curdie" and M & M's leads me to an exhausted flop on the couch where I drift back into an endless cycle of thoughts buzzing through my head like mosquitoes in search of Malaria-free victims to infect...
Sunday, September 4, 2005
Speaking in Tongues the hard way...
Tout le monde,
Speaking in tongues would come in real handy right now. Apparently, in early post-Jesus days, His disciples were given the instantaneous ability to speak fluently languages they'd never known before. Here we just struggle along hoping to understand a few words of what's said around us.
Chad has 130 languages and dialects and two official languages: French and Chadian Arabic.
Before coming, I felt if I could just learn French I'd be fine. Who wants to learn some obscure language anyway? Wrong...
Most of our staff speak a minimum of 5 languages including French, Arabic and a smattering of local languages. The dialects heard commonly if not daily at the hospital are Nangjere, Moundan, Foulb� and Ngambai.
Without Rahama I'm lost. I call a patient in. It's a Fulani woman. She is dressed in bright colored frilly blouse and wide skirt. She has dreads, a nose ring, and multiple leather pouch fetishes hanging around her neck. She carries a baby strapped on her back with another bright cloth that completely clashes but somehow seems right. Her husband is wearing a tattered light blue arabic robe with a white turban wrapped amply around his neck. I begin.
"Al salaam alekum"
"Wa alekum al-salaam"
"Inti af�?"
And then she spouts off in Foulb�. Her husband translates into Chadian Arabic, Rahama translates into French and hopefully I understand. Rahama has a gift of translation because she's done it long enough that she knows what I want and so if the person doesn't answer the question right instead of just translating she'll continue to clarify with the person till the answer comes to the question asked. With other translators it often turns into a long, painfully slow process of back and forth translation.
I go on rounds. I've heard certain things translated enough that I have picked up some key Nangjer� phrases. I approach a one and a half year old with Malaria. I ask the mom...
"Ba ma balou ga?" (Has he vomited, upchucked, heaved, honked, ralphed, lost his lunch, tossed his cookies, puked, blown chunks, or spewed?)
"Balou di" (None of the above)
"Ba ma sua kouba?" (Does he breastfeed?)
She responds with a nod and a click in the throat.
"Ka kang" (Any more IV fluids left?)
"Kang di" (There's nothing)
"Xalas, ma ere 'ya ba" (He's done with his treatment, he's discharged)
But then grandma comes in and starts to greet me in the long drawn out African style and all I can do is smile and say "lapia" over and over without understanding a thing.
Gueltir knocks on the door. He's arrived to give me my first official Nangjer� lesson. We open the songbook. I can sing a ton of songs but not understand a word. I think it's time to change. We start with the blessing at the front. It's only 4 short lines, but one hour later we have exhausted ourselves trying to help me understand it. The problem is that Nangjer� is so simple and grammatically different from English or French that they are used to translating the meaning of phrases but not words so I never really know what a word means. I made him tell me even if it didn't make "sense" or wasn't good English (our exchange is that Gueltir gets to practice his English). Our other hang-up today is that kà, ka, ka' and 'ka all have different pronunciations and meanings (at least he says they sound different...it's all one and the same to me).
Sarah and I learn languages differently. She learns by ear. She listens, hears, talks and learns...the way we all learn our first language when we are kids...but she may not be able to tell you why a certain thing is said a certain way...just like not everyone who speaks English can teach it. She has an amazing gift and already speaks Danish, English, German, Spanish and French fluently as well as a little Croation, Hebrew, Chadian Arabic and Nangjer�.
I, on the other hand, need books. I need to understand the structure and grammar, the why. That's why Nangjer� is so difficult. There are no books and no dictionary.
With Chadian Arabic I'm having more success. I've bought a book of grammar, a dialogue book and a dictionary. Three nights ago I found myself in the throes of exhilarated language study the kind of which I hadn't enjoyed since my three months in France at the language institute of Collonges.
I had looked up a word in the dictionary. That had it in several phrases. I saw another word I'd wanted to know the meaning of. I looked that up which sent me off to find out the meaning of two other words...etc, etc. I stayed up late with just a candle feeling the thrill of search and discovery. That's why that ending is there. That's what that phrase is they say all the time..."Marra wahid" means completely or till the end...ah ha! Yeah, it's sounds geeky, but when you love languages...
So, I'm starting to feel better. Maybe this speaking in tongues will come even if it is the hard way.
I'm back at work rounding on peds again. I'm feeling pretty cocky after my night with the Chadian Arabic dictionary and my first Nangjer� lesson with Gueltir. I approach the first patient.
"Ba ma balou ga?" Blank stare. Ok, no Nangjer�.
"Hu gai giddif?" Arabic maybe? Blank stare...
"Docteur," a nursing student ventures, "She only speaks Ngambai..."
I give up...
James
Speaking in tongues would come in real handy right now. Apparently, in early post-Jesus days, His disciples were given the instantaneous ability to speak fluently languages they'd never known before. Here we just struggle along hoping to understand a few words of what's said around us.
Chad has 130 languages and dialects and two official languages: French and Chadian Arabic.
Before coming, I felt if I could just learn French I'd be fine. Who wants to learn some obscure language anyway? Wrong...
Most of our staff speak a minimum of 5 languages including French, Arabic and a smattering of local languages. The dialects heard commonly if not daily at the hospital are Nangjere, Moundan, Foulb� and Ngambai.
Without Rahama I'm lost. I call a patient in. It's a Fulani woman. She is dressed in bright colored frilly blouse and wide skirt. She has dreads, a nose ring, and multiple leather pouch fetishes hanging around her neck. She carries a baby strapped on her back with another bright cloth that completely clashes but somehow seems right. Her husband is wearing a tattered light blue arabic robe with a white turban wrapped amply around his neck. I begin.
"Al salaam alekum"
"Wa alekum al-salaam"
"Inti af�?"
And then she spouts off in Foulb�. Her husband translates into Chadian Arabic, Rahama translates into French and hopefully I understand. Rahama has a gift of translation because she's done it long enough that she knows what I want and so if the person doesn't answer the question right instead of just translating she'll continue to clarify with the person till the answer comes to the question asked. With other translators it often turns into a long, painfully slow process of back and forth translation.
I go on rounds. I've heard certain things translated enough that I have picked up some key Nangjer� phrases. I approach a one and a half year old with Malaria. I ask the mom...
"Ba ma balou ga?" (Has he vomited, upchucked, heaved, honked, ralphed, lost his lunch, tossed his cookies, puked, blown chunks, or spewed?)
"Balou di" (None of the above)
"Ba ma sua kouba?" (Does he breastfeed?)
She responds with a nod and a click in the throat.
"Ka kang" (Any more IV fluids left?)
"Kang di" (There's nothing)
"Xalas, ma ere 'ya ba" (He's done with his treatment, he's discharged)
But then grandma comes in and starts to greet me in the long drawn out African style and all I can do is smile and say "lapia" over and over without understanding a thing.
Gueltir knocks on the door. He's arrived to give me my first official Nangjer� lesson. We open the songbook. I can sing a ton of songs but not understand a word. I think it's time to change. We start with the blessing at the front. It's only 4 short lines, but one hour later we have exhausted ourselves trying to help me understand it. The problem is that Nangjer� is so simple and grammatically different from English or French that they are used to translating the meaning of phrases but not words so I never really know what a word means. I made him tell me even if it didn't make "sense" or wasn't good English (our exchange is that Gueltir gets to practice his English). Our other hang-up today is that kà, ka, ka' and 'ka all have different pronunciations and meanings (at least he says they sound different...it's all one and the same to me).
Sarah and I learn languages differently. She learns by ear. She listens, hears, talks and learns...the way we all learn our first language when we are kids...but she may not be able to tell you why a certain thing is said a certain way...just like not everyone who speaks English can teach it. She has an amazing gift and already speaks Danish, English, German, Spanish and French fluently as well as a little Croation, Hebrew, Chadian Arabic and Nangjer�.
I, on the other hand, need books. I need to understand the structure and grammar, the why. That's why Nangjer� is so difficult. There are no books and no dictionary.
With Chadian Arabic I'm having more success. I've bought a book of grammar, a dialogue book and a dictionary. Three nights ago I found myself in the throes of exhilarated language study the kind of which I hadn't enjoyed since my three months in France at the language institute of Collonges.
I had looked up a word in the dictionary. That had it in several phrases. I saw another word I'd wanted to know the meaning of. I looked that up which sent me off to find out the meaning of two other words...etc, etc. I stayed up late with just a candle feeling the thrill of search and discovery. That's why that ending is there. That's what that phrase is they say all the time..."Marra wahid" means completely or till the end...ah ha! Yeah, it's sounds geeky, but when you love languages...
So, I'm starting to feel better. Maybe this speaking in tongues will come even if it is the hard way.
I'm back at work rounding on peds again. I'm feeling pretty cocky after my night with the Chadian Arabic dictionary and my first Nangjer� lesson with Gueltir. I approach the first patient.
"Ba ma balou ga?" Blank stare. Ok, no Nangjer�.
"Hu gai giddif?" Arabic maybe? Blank stare...
"Docteur," a nursing student ventures, "She only speaks Ngambai..."
I give up...
James
Friday, August 19, 2005
Numb
I stare blankly at the small hand and arm. I sit on a stool in front of a delivery bed. My hands hang at my side. My whole body feels heavy. My eyes would close if they could to banish the sight forever from my consciousness. Before me, on the floor sits a large, green plastic basin. In the basin are some bloody pieces of gauze, a few blood clots and disembodied arm and hand. The arm is perfect. The nails, the tiny fingers, the palm creases, the forearm and elbow are all perfect...except for being a deep purple and totally detached at the upper arm. There is no accompanying body. I sit here numb in front of its mother waiting for the rest of "it" to come out. My mind drifts as the minutes drag by...
I am pulled to the door by a rattling banging of fist on metal. My wife, Sarah, has left for N'Djaména. The monsoon rains pound the tin roof mercilessly. David, the night watchman, stands outside all but swallowed up in a bright yellow rain slicker.
"Bon soir, David."
He doesn't reply, just reaches solemnly into his jacket and pulls out a worn half of a paper notebook we call a "carnet" or portable medical record.
I read inside. Young woman. First pregnancy. Dates unknown. Bleeding since 4pm, 2 hours ago. Cervix dilated at 3-4cm. IV started with normal saline. Refer to Doctor.
I give the carnet back to David. "J'arrive."
I pull on my scrubs. So much for a quiet, rainy evening reading in my favorite chair. I go next door and quickly down some cold spaghetti and eggplant sauce and tell the medical students, Carol and Sara, what's going on.
I slip on my sandals, pull my hooded sweatshirt low and step into the downpour. The ground has disappeared. I slosh through water up to my ankles following the moonlight splayed across a million tiny circles splashing on the surface. It is a lovely dream about to become a nightmare.
I reach the shelter of the overhang beside the operating room and enter the hospital ward turning right into labor and delivery. The first surprise is that I see Rahama there. I think how nice of her to come help at night. She never does that. David, the nurse, is with a small frightened girl. She is completely naked her legs sprawled at weird angles on the table. Pools of blood stretch along each side of the bed. Clots with a few pieces of gauze are on top in between her legs. She writhes but doesn't really speak.
I ask how far along she is. Rahama replies that she's about 4 months. I then realize that this is Rahama's daughter. David is just finishing putting in the IV. The IV fluids drip in. I ask for gloves. Normally there are always gloves in L&D. There are none. I inexplicably start to become very nasty. I start to talk coldly to Rahama and David asking how come there are no gloves when I left a ton before I went on vacation. I tell them cruelly how they always just use stuff up. I feel very out of control and realize it but somehow don't care. I am bothered, frustrated, and in over my head.
David rushes off to the Garde room and brings me some gloves. I try to examine inside the girl. She won't move into the right position. She doesn't understand French. Then, she doesn't seem to understand the translation. She fights, squirms and I can't even begin to examine her. I start to yell how we're trying to help you but we need some cooperation. Rahama starts to yell at her, too. Nothing. We struggle. Rahama starts to slap her. Finally, I can examine her. There are clots but no real active bleeding. Must be an incomplete abortion.
I run out to get the instruments to do a curettage under spinal anesthesia. The rain intensifies. I give David a urinary catheter to put in her. He can't get it in. I try to help without gloves getting blood all over my hand. I call for gloves. There are none. There is no gauze. I wash my hands off. David continues to struggle with the catheter. I start to rain down deprecations on the entire lack of adequate staff and materials and how can we work under these conditions. David has no luck. Carol brings me some gloves. I finally get the catheter in. The girl has continued to struggle and get hit in the face by Rahama.
She is turned on her side and the spinal needle doesn't want to go in. The puncture starts to bleed. We have no gauze. Sara runs to surgery. I wait, seething. I wipe off the blood and am able to get the anesthesia in at last. The girl quickly relaxes and actually falls asleep during the rest of the procedure...exhausted.
I am able to examine her easily now and after dilating the cervix discover that the fetus is more like 7 months than 4. I can't do a D&C. We listen for fetal heart tones. There are none. On exam it feels like a breech presentation. I try to deliver the first leg and after pulling it out, find it's really the arm. Now I'm stuck. This position will never allow the dead fetus to come out. I don't want to do a c-section since the baby's already dead. I try to push the arm back in. The humerus cracks, but it goes in. I try to turn the infant inside. No luck. I feel sick at the thought that enters my head. I might have to pull it out piece by piece. I reach inside...
The arm is out again. It is a deep bluish purple and perfect. I grab some scissors and cut through the skin. Three cuts and I'm through. I drop the arm and I gaze in a weird slow motion sequence as it slowly spins through the air to bounce in the bottom of the basin splashing up a few drops of dark blood. I reach inside and able to pull the head down which has been doubled almost completely backwards over its little back. What now? The cervix is still only 5cm dilated...I place my hand on her uterus through the abdominal wall and feel only rare uterine contractions. I stop, dejected, and stare blankly at the small, detached arm and hand in the green basin on the floor in the pool of blood, clots and gauze...
We send David, the night watchman, to find Anatole to get Oxytocin from the lab fridge. The girl still sleeps. Rahama sits quietly. She looks at me and says, "I don't know what I'm going to do. The expense for all this falls on me and I don't know what I'll do..." Rahama always lives in debt, barely scraping by, getting advances on her salary to try and feed her husband, kids and relatives who depend on her. With the famine, the increased prices and her own crops from last year being burned up, she lives in constant anxiety about how to make ends meet. This is the straw that may break the proverbial camel's back. I sense her desperation.
The oxytocin arrives. The girl awakes. She is shivering only covered by a thin sheet. I grab my sweatshirt and lay it on her. Rahama tries to protest saying it'll get all bloody. I say not to worry about it. The girl snuggles under and goes back to sleep. I stay for 45 minutes with my hand on the uterus monitoring the contractions and adjusting the oxytocin till she has regular contractions and I'm sure she won't have tetany that could lead to a rupture of her uterus. Rahama has washed the instruments. The blood still lies pooled on the floor and table but has started to dry. Rahama says she'll monitor her closely now to make sure the contractions don't get out of hand. I head back home. The rain has stopped. My feet have been pickled in my soggy shoes. The puddles are still there. My forearm and hands are cramping from reaching trying to pull and tug and turn a dead baby...my mind has effectively walled it off so that I'm still in dream land as I slosh home, wash up and crash into an empty bed with a feeling of emptiness so complete that I can't even think of anything to worry about but fall into a deep, troubled sleep...
I am pulled to the door by a rattling banging of fist on metal. My wife, Sarah, has left for N'Djaména. The monsoon rains pound the tin roof mercilessly. David, the night watchman, stands outside all but swallowed up in a bright yellow rain slicker.
"Bon soir, David."
He doesn't reply, just reaches solemnly into his jacket and pulls out a worn half of a paper notebook we call a "carnet" or portable medical record.
I read inside. Young woman. First pregnancy. Dates unknown. Bleeding since 4pm, 2 hours ago. Cervix dilated at 3-4cm. IV started with normal saline. Refer to Doctor.
I give the carnet back to David. "J'arrive."
I pull on my scrubs. So much for a quiet, rainy evening reading in my favorite chair. I go next door and quickly down some cold spaghetti and eggplant sauce and tell the medical students, Carol and Sara, what's going on.
I slip on my sandals, pull my hooded sweatshirt low and step into the downpour. The ground has disappeared. I slosh through water up to my ankles following the moonlight splayed across a million tiny circles splashing on the surface. It is a lovely dream about to become a nightmare.
I reach the shelter of the overhang beside the operating room and enter the hospital ward turning right into labor and delivery. The first surprise is that I see Rahama there. I think how nice of her to come help at night. She never does that. David, the nurse, is with a small frightened girl. She is completely naked her legs sprawled at weird angles on the table. Pools of blood stretch along each side of the bed. Clots with a few pieces of gauze are on top in between her legs. She writhes but doesn't really speak.
I ask how far along she is. Rahama replies that she's about 4 months. I then realize that this is Rahama's daughter. David is just finishing putting in the IV. The IV fluids drip in. I ask for gloves. Normally there are always gloves in L&D. There are none. I inexplicably start to become very nasty. I start to talk coldly to Rahama and David asking how come there are no gloves when I left a ton before I went on vacation. I tell them cruelly how they always just use stuff up. I feel very out of control and realize it but somehow don't care. I am bothered, frustrated, and in over my head.
David rushes off to the Garde room and brings me some gloves. I try to examine inside the girl. She won't move into the right position. She doesn't understand French. Then, she doesn't seem to understand the translation. She fights, squirms and I can't even begin to examine her. I start to yell how we're trying to help you but we need some cooperation. Rahama starts to yell at her, too. Nothing. We struggle. Rahama starts to slap her. Finally, I can examine her. There are clots but no real active bleeding. Must be an incomplete abortion.
I run out to get the instruments to do a curettage under spinal anesthesia. The rain intensifies. I give David a urinary catheter to put in her. He can't get it in. I try to help without gloves getting blood all over my hand. I call for gloves. There are none. There is no gauze. I wash my hands off. David continues to struggle with the catheter. I start to rain down deprecations on the entire lack of adequate staff and materials and how can we work under these conditions. David has no luck. Carol brings me some gloves. I finally get the catheter in. The girl has continued to struggle and get hit in the face by Rahama.
She is turned on her side and the spinal needle doesn't want to go in. The puncture starts to bleed. We have no gauze. Sara runs to surgery. I wait, seething. I wipe off the blood and am able to get the anesthesia in at last. The girl quickly relaxes and actually falls asleep during the rest of the procedure...exhausted.
I am able to examine her easily now and after dilating the cervix discover that the fetus is more like 7 months than 4. I can't do a D&C. We listen for fetal heart tones. There are none. On exam it feels like a breech presentation. I try to deliver the first leg and after pulling it out, find it's really the arm. Now I'm stuck. This position will never allow the dead fetus to come out. I don't want to do a c-section since the baby's already dead. I try to push the arm back in. The humerus cracks, but it goes in. I try to turn the infant inside. No luck. I feel sick at the thought that enters my head. I might have to pull it out piece by piece. I reach inside...
The arm is out again. It is a deep bluish purple and perfect. I grab some scissors and cut through the skin. Three cuts and I'm through. I drop the arm and I gaze in a weird slow motion sequence as it slowly spins through the air to bounce in the bottom of the basin splashing up a few drops of dark blood. I reach inside and able to pull the head down which has been doubled almost completely backwards over its little back. What now? The cervix is still only 5cm dilated...I place my hand on her uterus through the abdominal wall and feel only rare uterine contractions. I stop, dejected, and stare blankly at the small, detached arm and hand in the green basin on the floor in the pool of blood, clots and gauze...
We send David, the night watchman, to find Anatole to get Oxytocin from the lab fridge. The girl still sleeps. Rahama sits quietly. She looks at me and says, "I don't know what I'm going to do. The expense for all this falls on me and I don't know what I'll do..." Rahama always lives in debt, barely scraping by, getting advances on her salary to try and feed her husband, kids and relatives who depend on her. With the famine, the increased prices and her own crops from last year being burned up, she lives in constant anxiety about how to make ends meet. This is the straw that may break the proverbial camel's back. I sense her desperation.
The oxytocin arrives. The girl awakes. She is shivering only covered by a thin sheet. I grab my sweatshirt and lay it on her. Rahama tries to protest saying it'll get all bloody. I say not to worry about it. The girl snuggles under and goes back to sleep. I stay for 45 minutes with my hand on the uterus monitoring the contractions and adjusting the oxytocin till she has regular contractions and I'm sure she won't have tetany that could lead to a rupture of her uterus. Rahama has washed the instruments. The blood still lies pooled on the floor and table but has started to dry. Rahama says she'll monitor her closely now to make sure the contractions don't get out of hand. I head back home. The rain has stopped. My feet have been pickled in my soggy shoes. The puddles are still there. My forearm and hands are cramping from reaching trying to pull and tug and turn a dead baby...my mind has effectively walled it off so that I'm still in dream land as I slosh home, wash up and crash into an empty bed with a feeling of emptiness so complete that I can't even think of anything to worry about but fall into a deep, troubled sleep...
Saturday, August 13, 2005
All things new...
Everyone,
I was on my way. A strange mixture of emotions coursed through me...fear, excitement, anxiety, courage, hope, wonder, tentativeness, anticipation...I was back on the road to B�r�.
Arriving in N'Djam�na I had been struck by a profound sense of change in the air. Not just because of the time change, the culture change, the first world to third world change--no, things really were happening in Tchad's capital. We entered the airport and found everything under construction. The days were cool and rainy. Everything was green, transformed by the wet season. We'd left a desert, we found an oasis. Even the trash and smells seemed content to be temporarily hidden behind the new life bursting all around.
Sarah and I arrived with a colleague of mine from medical school, Troy Dickson, and his wife, Kim. I met Pastor Job and was thrilled with his warm, prodigal-son embrace. We registered Troy and Kim with the national security and went to the Grand Mosque to change money.
As we circled the one way street counterclockwise around the center of Islam in N'Djam�na we looked for our friend. Sure enough, he emerged from the crowd of white robed, white capped African Arabs reclining on mats in front of an empty store front.
"Al-salaam alekum."
"Wa alekum al-salaam. How are you my friend? Come, lets have some Cokes together."
We--Bichara, Job, and I--closed and locked the truck, then marched off behind our regular black market dealer. We removed our shoes, crossed the mats between the still reclining Muslims and into the empty cement room behind. We reclined on our mats as another robed Arab brought us our sodas. I carefully sipped mine and we made small talk about my trip and what was happening in N'Djam�na and Tchad in general. Apparently the roads are getting paved, the president was sick in France but is back now, and business is improving slowly.
After 15 minutes or so, I remark that I have some money to change. I ask what the going price is. I say I'd heard we were up to 530 francs per dollar. Job quickly pipes up with, "560 per dollar". Our friend immediately agrees to 530. Thus begins the bargaining. Finally, we seem at an impasse at 540. We aren't satisfied. I pull out the calculator and do some quick figures.
"Mon ami, you will make 400,000 francs (~$800) on this deal at 540 per dollar. You will admit that is a lot. If you give it to us at 550 you will still make 200,000 francs. Not bad for a few minutes work?"
He smiles broadly and nods while motioning with his hand to give him the dollars. We count it all out, I put the francs in a brown paper bag and stuff it to the bottom of my backpack. We rise to leave.
"Au revoir..." he waves.
"Agodt afe" I reply and we're off directly to the bank to deposit it. The black market has saved us approximately $2000 that would've been lost in the bank and we've established a valuable relationship.
After picking up twin medical students, Carol and Sara that night we are off to B�r� the next morning. Prior to departure, we arrange Job's plane ticket to Kenya and the finances for the start of his master's in International Development which will start the end of August.
In those brief days in N'Djaména I have heard many rumors that have plagued my mind leading to my anxious anticipation to get to Béré.
We enter Kélo by the southern roundabout instead of through the back way through the market. The landscape has been incredible: luscious green plains, full rivers, millet, rice, corn and other crops pushing to the sky which is deep blue with puffy white clouds. The only thing missing is herds of antelope, zebras, giraffes and elephants. We leave the pavement in K�lo plunging into red mud with numerous puddles spray painting the truck with a slimy coat. The roundabout takes us by the K�lo Hospital. The rumors are true: it is closed. Not a living thing can be seen.
The government health care workers are on strike. They haven't been paid in 5 months. The two hospitals closest to Béré--Kélo and Lai--are closed. Our staff is at half strength with only three nurses and one lab tech. We have gone back to Tchadian civil war era times with the three stalwart "pillars"--Anatole, Samedi, Lona--holding down the fort as they have over the years.
However, even with this grim news, a sense of excitement continues to build as we approach Béré. I recognize everything, yet it's all changed. I've never experienced this drastic change since I missed the slow transformation of the rains and have left the extreme of 130 degree weather and brown, dead landscapes for an instantaneous, 2 month change to lush tropical with 70-80 degree weather. I am excitedly filling in Troy, Kim, Sara and Carol on this and that memory associated with this and that. I am coming home.
We stop 8 km from Béré to see the hippos. We climb out and down to the edge of the river. Not 100 yards away are 7-8 large hippos showing off with grunts, gap-toothed yawns and impressive lunges out of the water. Slowly, some local passersby stop to see the strangers. We chat easily about the rains, the crops, the meanness of the hippo in general and about Marty, the fisherman bit by one of these same hippos over a year ago. Apparently, they all know him and are eager to report on his continued good health.
We hit the road, cross the river on the barge, and slosh through the muddy roads till we see the "Welcome to Béré" sign with the hospital's water tower visible over the mango trees in the distance. An indescribable feeling moves through my body, a combination of chills, warmth and the strange desire to cry and run and laugh at the same time.
As we pull in we see some of the staff in front of the church on benches. Friday evening worship is in full swing. They wave furiously and get up hurriedly to meet us in front of the house. André's grin stretches from ear to ear as he emerges from behind a large, 40 foot blue container sitting on our front lawn. He is shaking his head in joy as he embraces me with the biggest bear hug ever. In fact he can't stop laughing and hugging me. The others crowd around shaking hands, smiling, asking a million questions a minute. Bichara tries to stoically take charge of unloading our bags as there is general pandemonium. I glance over at the hospital and see two beautiful outdoor bathrooms for the patients and staff, a new walkway between Pediatrics and the rest of the hospital so we don't have to walk in the mud anymore.
André manages to get in a few words. "We weren't sure if we'd be able to finish the roofs or not...the container...what a challenge...God held back the rains as we struggled to unload all day...just after reloading it poured down...the strike...Lona, Anatole, Samedi, David...working hard...we've been blessed with the new government nurse, Josu�....you can't believe what a leader he is..." And on and on he goes.
I verify later, the roofs on the hospital ward, labor and delivery and operating room have all been repaired. My heart is filled with joy. Everyone has pulled through in my absence without a doctor, half-staffed and yet they have managed to not only not go backwards but have made a huge push forwards. Andr� sits me down two days later and explains all the important decisions, resolution of staff conflicts and other administrative things he's done and my heart swells with thankfulness.
Yes, God's hand is definitely in this place...I am relieved to see how little they really need me, yet how much they really want me...we're back, ready or not...
James
I was on my way. A strange mixture of emotions coursed through me...fear, excitement, anxiety, courage, hope, wonder, tentativeness, anticipation...I was back on the road to B�r�.
Arriving in N'Djam�na I had been struck by a profound sense of change in the air. Not just because of the time change, the culture change, the first world to third world change--no, things really were happening in Tchad's capital. We entered the airport and found everything under construction. The days were cool and rainy. Everything was green, transformed by the wet season. We'd left a desert, we found an oasis. Even the trash and smells seemed content to be temporarily hidden behind the new life bursting all around.
Sarah and I arrived with a colleague of mine from medical school, Troy Dickson, and his wife, Kim. I met Pastor Job and was thrilled with his warm, prodigal-son embrace. We registered Troy and Kim with the national security and went to the Grand Mosque to change money.
As we circled the one way street counterclockwise around the center of Islam in N'Djam�na we looked for our friend. Sure enough, he emerged from the crowd of white robed, white capped African Arabs reclining on mats in front of an empty store front.
"Al-salaam alekum."
"Wa alekum al-salaam. How are you my friend? Come, lets have some Cokes together."
We--Bichara, Job, and I--closed and locked the truck, then marched off behind our regular black market dealer. We removed our shoes, crossed the mats between the still reclining Muslims and into the empty cement room behind. We reclined on our mats as another robed Arab brought us our sodas. I carefully sipped mine and we made small talk about my trip and what was happening in N'Djam�na and Tchad in general. Apparently the roads are getting paved, the president was sick in France but is back now, and business is improving slowly.
After 15 minutes or so, I remark that I have some money to change. I ask what the going price is. I say I'd heard we were up to 530 francs per dollar. Job quickly pipes up with, "560 per dollar". Our friend immediately agrees to 530. Thus begins the bargaining. Finally, we seem at an impasse at 540. We aren't satisfied. I pull out the calculator and do some quick figures.
"Mon ami, you will make 400,000 francs (~$800) on this deal at 540 per dollar. You will admit that is a lot. If you give it to us at 550 you will still make 200,000 francs. Not bad for a few minutes work?"
He smiles broadly and nods while motioning with his hand to give him the dollars. We count it all out, I put the francs in a brown paper bag and stuff it to the bottom of my backpack. We rise to leave.
"Au revoir..." he waves.
"Agodt afe" I reply and we're off directly to the bank to deposit it. The black market has saved us approximately $2000 that would've been lost in the bank and we've established a valuable relationship.
After picking up twin medical students, Carol and Sara that night we are off to B�r� the next morning. Prior to departure, we arrange Job's plane ticket to Kenya and the finances for the start of his master's in International Development which will start the end of August.
In those brief days in N'Djaména I have heard many rumors that have plagued my mind leading to my anxious anticipation to get to Béré.
We enter Kélo by the southern roundabout instead of through the back way through the market. The landscape has been incredible: luscious green plains, full rivers, millet, rice, corn and other crops pushing to the sky which is deep blue with puffy white clouds. The only thing missing is herds of antelope, zebras, giraffes and elephants. We leave the pavement in K�lo plunging into red mud with numerous puddles spray painting the truck with a slimy coat. The roundabout takes us by the K�lo Hospital. The rumors are true: it is closed. Not a living thing can be seen.
The government health care workers are on strike. They haven't been paid in 5 months. The two hospitals closest to Béré--Kélo and Lai--are closed. Our staff is at half strength with only three nurses and one lab tech. We have gone back to Tchadian civil war era times with the three stalwart "pillars"--Anatole, Samedi, Lona--holding down the fort as they have over the years.
However, even with this grim news, a sense of excitement continues to build as we approach Béré. I recognize everything, yet it's all changed. I've never experienced this drastic change since I missed the slow transformation of the rains and have left the extreme of 130 degree weather and brown, dead landscapes for an instantaneous, 2 month change to lush tropical with 70-80 degree weather. I am excitedly filling in Troy, Kim, Sara and Carol on this and that memory associated with this and that. I am coming home.
We stop 8 km from Béré to see the hippos. We climb out and down to the edge of the river. Not 100 yards away are 7-8 large hippos showing off with grunts, gap-toothed yawns and impressive lunges out of the water. Slowly, some local passersby stop to see the strangers. We chat easily about the rains, the crops, the meanness of the hippo in general and about Marty, the fisherman bit by one of these same hippos over a year ago. Apparently, they all know him and are eager to report on his continued good health.
We hit the road, cross the river on the barge, and slosh through the muddy roads till we see the "Welcome to Béré" sign with the hospital's water tower visible over the mango trees in the distance. An indescribable feeling moves through my body, a combination of chills, warmth and the strange desire to cry and run and laugh at the same time.
As we pull in we see some of the staff in front of the church on benches. Friday evening worship is in full swing. They wave furiously and get up hurriedly to meet us in front of the house. André's grin stretches from ear to ear as he emerges from behind a large, 40 foot blue container sitting on our front lawn. He is shaking his head in joy as he embraces me with the biggest bear hug ever. In fact he can't stop laughing and hugging me. The others crowd around shaking hands, smiling, asking a million questions a minute. Bichara tries to stoically take charge of unloading our bags as there is general pandemonium. I glance over at the hospital and see two beautiful outdoor bathrooms for the patients and staff, a new walkway between Pediatrics and the rest of the hospital so we don't have to walk in the mud anymore.
André manages to get in a few words. "We weren't sure if we'd be able to finish the roofs or not...the container...what a challenge...God held back the rains as we struggled to unload all day...just after reloading it poured down...the strike...Lona, Anatole, Samedi, David...working hard...we've been blessed with the new government nurse, Josu�....you can't believe what a leader he is..." And on and on he goes.
I verify later, the roofs on the hospital ward, labor and delivery and operating room have all been repaired. My heart is filled with joy. Everyone has pulled through in my absence without a doctor, half-staffed and yet they have managed to not only not go backwards but have made a huge push forwards. Andr� sits me down two days later and explains all the important decisions, resolution of staff conflicts and other administrative things he's done and my heart swells with thankfulness.
Yes, God's hand is definitely in this place...I am relieved to see how little they really need me, yet how much they really want me...we're back, ready or not...
James
Monday, May 30, 2005
A walk with Gueltir...
Bonjour,
Gueltir sets a brisk pace. We're walking side by side down the dusty streets of Béré. There are no street signs, no pavement, no sidewalks, no traffic lights, no signs, no evidence that we are in the 21st century. We walk past mud brick huts with people in front lying under mango trees on woven reed mats, pounding millet in crude wooden mortar-and-pestles, carrying big bundles of firewood on their heads, cooking over open fires, and a host of other activities that could place us anywhere from after the Flood to the present. In essence, Béré has managed to capture timelessness...at least until a motorcycle drives by or a man crosses the path with his world-band radio blaring.
We are headed to visit one of the junior high schools in Béré. There are two mixed junior highs, a Catholic girls only junior high and one full-fledged high school bursting at the seams with 1500 students meeting in crude mud buildings or in "hangars" constructed of woven reed walls and roof supported by crooked sticks stuck in the ground. The one we are going to visit is a private one built in 2001 which Gueltir says has been all but abandoned as the owner is occupied with other things in N'Djaména. Besides, for the moment, all the teachers are on strike everywhere except at Gueltir's school. None have been paid for three months. Fortunately, with some help from the US, our teachers are paid every month...a rare thing in Tchad.
We arrive at the Junior High. It's pathetic. The three mud brick buildings surround a courtyard with an open, empty well in the center. To the left and to the right, the buildings have three rooms each, side by side. Straight ahead is the administration building with two rooms. The doors are made from thin wood frames with green painted corrugated roofing nailed on. They hang haphazardly, "locked" precariously with tiny padlocks that come apart when unlocked. Inside, the uneven dirt floors support some rickety benches and tables leaning crazily at all different angles because of the floor. Most have been eaten by termites. Two walls have windows. The side facing the courtyard has windows made of the same material as the doors and they can be opened. The opposite side is made of mud bricks crisscrossed to leave openings in between for air circulation. The roofs are corrugated tin balanced on twisted sticks tied to the bricks with metal bands. One wall is painted black to serve as a chalkboard.
The ad building has one desk, a small bookshelf with a couple of empty chalk boxes on it, a locked trunk and a locked cabinet. A small chair leans precariously against the wall. I tell Gueltir I'm amazed at the conditions. He wonders what I mean saying this is great compared to how he learned sitting under mango trees and temporary shelters. In fact, on the way here, we passed a school and a church that were made entirely of mats. How can the Tchadians hope to become more educated when they have to learn without books, without good facilities and often without teachers (who are on strike half the year it seems)?
We finish and head across town, through the market as it closes up, and on to the house of one of the local "house doctors". He welcomes us into his courtyard, brings out chairs, and invites us to sit. One by one the members of the household come to greet us. The women bow to the ground and extend their hand to shake with the other hand supporting it at the elbow in a sign of deep respect. Our friend's wife brings us a metal bowl of water and a table is called for. We begin to discuss the local gossip. It appears everything is known about everyone. He wonders why I didn't leave to go to Koumra this morning with André. He thought I'd left. I just found out about it last night and decided it was too late to go. Apparently, he knew I was supposed to go before I did. We move on to the raising of ducks, how to plant fruit trees with bull horns buried beside, when the rain will come and a variety of other topics.
The pastor of the Evangelical Church #2 joins us. He is Dimanche's dad (Dimanche is one of our nurses provided by the state). We pass to another round of greetings and acknowledgements.
Finally, I get around to the purpose of our visit. I tactfully mention that we are all here for the health of the community and that one thing I've noticed is that kids often get referred late for treatment of malaria. In fact, we just finished rescuing a small, one-year-old girl that had been treated by him for several days before coming to the hospital. I say that it's something in general we see that kids just don't do well with malaria unless they're hospitalized. He seems to understand. In fact, he seems happy at the exchange. I don't bother to mention that I think he has no right to be treating patients at all since he is not trained except in basic CPR and first aid. He's still going to continue to treat patients at his home. In fact, in the middle of the conversation, someone comes up and greets him as "doctor." All we can do is try and help him to not hurt people.
It's getting dark. We bid goodbye. Our friend accompanies Gueltir and I just till the main road. Without a guide, I'd be lost in the maze of paths and huts. He promises to come see me soon at the hospital. Gueltir and I head home. We pass an outdoor cabaret. The warm rumble of muffled conversation floats over the air along with the smell of local brew. Surrounding the cabaret are the small time vendors. Each has a small table with a kerosene lamp, small plastic sacs of tea and sugar and detergent and oil along with cigarettes, small crackers and various other items. Over head is a mat supported on four sticks poked into the ground. Business is booming. We continue on through the dark streets bereft of any artificial light until we see the fluorescent glow of the hospital through the trees and we know we are home.
James
Gueltir sets a brisk pace. We're walking side by side down the dusty streets of Béré. There are no street signs, no pavement, no sidewalks, no traffic lights, no signs, no evidence that we are in the 21st century. We walk past mud brick huts with people in front lying under mango trees on woven reed mats, pounding millet in crude wooden mortar-and-pestles, carrying big bundles of firewood on their heads, cooking over open fires, and a host of other activities that could place us anywhere from after the Flood to the present. In essence, Béré has managed to capture timelessness...at least until a motorcycle drives by or a man crosses the path with his world-band radio blaring.
We are headed to visit one of the junior high schools in Béré. There are two mixed junior highs, a Catholic girls only junior high and one full-fledged high school bursting at the seams with 1500 students meeting in crude mud buildings or in "hangars" constructed of woven reed walls and roof supported by crooked sticks stuck in the ground. The one we are going to visit is a private one built in 2001 which Gueltir says has been all but abandoned as the owner is occupied with other things in N'Djaména. Besides, for the moment, all the teachers are on strike everywhere except at Gueltir's school. None have been paid for three months. Fortunately, with some help from the US, our teachers are paid every month...a rare thing in Tchad.
We arrive at the Junior High. It's pathetic. The three mud brick buildings surround a courtyard with an open, empty well in the center. To the left and to the right, the buildings have three rooms each, side by side. Straight ahead is the administration building with two rooms. The doors are made from thin wood frames with green painted corrugated roofing nailed on. They hang haphazardly, "locked" precariously with tiny padlocks that come apart when unlocked. Inside, the uneven dirt floors support some rickety benches and tables leaning crazily at all different angles because of the floor. Most have been eaten by termites. Two walls have windows. The side facing the courtyard has windows made of the same material as the doors and they can be opened. The opposite side is made of mud bricks crisscrossed to leave openings in between for air circulation. The roofs are corrugated tin balanced on twisted sticks tied to the bricks with metal bands. One wall is painted black to serve as a chalkboard.
The ad building has one desk, a small bookshelf with a couple of empty chalk boxes on it, a locked trunk and a locked cabinet. A small chair leans precariously against the wall. I tell Gueltir I'm amazed at the conditions. He wonders what I mean saying this is great compared to how he learned sitting under mango trees and temporary shelters. In fact, on the way here, we passed a school and a church that were made entirely of mats. How can the Tchadians hope to become more educated when they have to learn without books, without good facilities and often without teachers (who are on strike half the year it seems)?
We finish and head across town, through the market as it closes up, and on to the house of one of the local "house doctors". He welcomes us into his courtyard, brings out chairs, and invites us to sit. One by one the members of the household come to greet us. The women bow to the ground and extend their hand to shake with the other hand supporting it at the elbow in a sign of deep respect. Our friend's wife brings us a metal bowl of water and a table is called for. We begin to discuss the local gossip. It appears everything is known about everyone. He wonders why I didn't leave to go to Koumra this morning with André. He thought I'd left. I just found out about it last night and decided it was too late to go. Apparently, he knew I was supposed to go before I did. We move on to the raising of ducks, how to plant fruit trees with bull horns buried beside, when the rain will come and a variety of other topics.
The pastor of the Evangelical Church #2 joins us. He is Dimanche's dad (Dimanche is one of our nurses provided by the state). We pass to another round of greetings and acknowledgements.
Finally, I get around to the purpose of our visit. I tactfully mention that we are all here for the health of the community and that one thing I've noticed is that kids often get referred late for treatment of malaria. In fact, we just finished rescuing a small, one-year-old girl that had been treated by him for several days before coming to the hospital. I say that it's something in general we see that kids just don't do well with malaria unless they're hospitalized. He seems to understand. In fact, he seems happy at the exchange. I don't bother to mention that I think he has no right to be treating patients at all since he is not trained except in basic CPR and first aid. He's still going to continue to treat patients at his home. In fact, in the middle of the conversation, someone comes up and greets him as "doctor." All we can do is try and help him to not hurt people.
It's getting dark. We bid goodbye. Our friend accompanies Gueltir and I just till the main road. Without a guide, I'd be lost in the maze of paths and huts. He promises to come see me soon at the hospital. Gueltir and I head home. We pass an outdoor cabaret. The warm rumble of muffled conversation floats over the air along with the smell of local brew. Surrounding the cabaret are the small time vendors. Each has a small table with a kerosene lamp, small plastic sacs of tea and sugar and detergent and oil along with cigarettes, small crackers and various other items. Over head is a mat supported on four sticks poked into the ground. Business is booming. We continue on through the dark streets bereft of any artificial light until we see the fluorescent glow of the hospital through the trees and we know we are home.
James
Monday, May 23, 2005
From Sarah
I'm sitting in our living room with Djongjabe, the 5 year-old daughter of Pierre, the cassier. She's enjoying herself with paper and crayons. Last year she lived with me for almost two months. It all began when she would come and sit by me in church. Her family felt sorry for me that I slept alone (in this culture, being alone = by yourself is the worst possible thing that can happen to you.) They suggested "lending" me their daughter for company and help. I loved the idea. And apparently, so did Djongjabe! We would eat together, do the dishes together, shower together and she would sleep next to me. In the morning I would send her out the door to go to preschool, and she would come back late afternoon. We didn't speak the same language but got along just fine. I dare say she understood my Danish pretty well, and I usually figured out what she meant when she spoke her native language, which is Mundange. Besides, tickling never needed translation.
This idyllic evening makes me think of some of the extremes I have experimented here at the hospital. I have been in several situations, where if I had known about them, I probably would not have wanted to come. I have certainly done things I would NEVER have thought I would....
It was during one of my night shifts. A shift that begins at 2PM when everybody leaves and only the guard nurse is left to take care of all hospitalized patients, what comes in the ER and any deliveries.
A woman comes in for her delivery. She's alone. The husband is nowhere to be found, and for some reason she has no sister, mother, aunt cousin or neighbor with her. I recognize her - her little son was treated for tuberculosis some months earlier. I examine her. She still has a little ways to go. I check on the other hospitalized patients in between. Early morning comes and I expect the woman to deliver anytime soon. She's dilated and has a few good contractions. The head is right there.
After morning worship I give report about the night's events and hand over the woman to Rahama who is experienced in delivering babies. I go back to house and hope the goats and children will be quiet and keep away from my windows so I can get some rest.
I'm getting relaxed and ready to doze off, when the watch man calls me from outside the window "Sarah, you have to come up to the hospital. They have an emergency and need you to take care of the delivery". The delivery? That should have been over long ago? It's almost noon?! I worry if there had been any signs of complications I missed out on during the night?
On my way to the hospital I pass a group of people who have found a shady spot to sell their matches, spices and little plastic bags with sugar and salt. "Lapia" I say, knowing how not greeting people almost is taken as an insult. A teenage girl rises to follow me. She asks where I'm going, although everybody knows I mostly just walk the path between the house and the hospital. Often when I have bought something with her, she has kept the change and only by insisting and getting the help of onlooker have I got back the money she owed me. My thoughts are with the woman who has not yet delivered. What can be wrong? I'm no midwife! Just a plain RN.
Arriving at the hospital, I notice all the people gathered outside the OR. Some emergency has happened and someone is being operated. The other nurses are in there.
I arrive at the door to the delivery room. I notice the teenage girl is still behind me as I open the door. I turn and tell her to stay outside. I walk in to find the woman in great pain and to older women from the church are by her side. The husband has not showed up, neither have any relatives or friends. My mind is racing as I examine her again. Why hasn't she delivered yet? The contractions are good, there seem to be space enough for the baby to come out.... I get distracted by the sound of the door slamming. The teenage girl walks in. I widen my eyes in surprise and tell her this is not an entertainment show and she has to leave. I return to the woman. I wish I had someone to ask for help. Are there even sterile instruments around? Did anyone survey her or was she left alone when I went home?
As I turn to see if I have what I need nearby, I see the teenage girl, who has now found a comfortable place to sit down and watch! As I feel the stress of being thrown into a situation outside my competence, being tired and feeling alone, I raise my voice to make it even more clear to this girl that I meant what I said. I mobilized all my patience and explain again why she is not allowed to watch. I even tell her "PLEASE, go outside!" I know I can't concentrate on this delivery while she is sitting there.
She tilts her head, smiles subtly and says: "What if it doesn't PLEASES me to go outside?"
I'm beyond amazed! I need to get this girl out! I know I can't get violent...I look down on my gloved hand, covered with bloody vaginal secretion from examining the woman. I look sternly at the girl and walk towards her with my hand raised. As I get to her, she looks at me like she couldn't care less. I wipe my hand off on her cheek and neck, amazed at my self and she hadn't already left!!! She widens her eyes, turns and leaves. As I turn to the woman my eyes meet the two older women. They smile knowingly and nod. I think "WHAT did I just do???"
We tell the woman to PUSH and get this over with. The two older women have done this so many times before. They scold and slap her (why didn't I think of that...) and she starts to push better. Shortly after, a healthy baby comes out, I tie the cord and dry him off, extremely relieved. Everything goes well, the placenta comes out, the uterus goes hard and small, all bleeding stops.
The two women from church promise to look after the mom, and help her breastfeed. I walk to the OR. The head nurse has come out. I drag him aside and say I have something to confess. Somehow I'm sure they will not have anything to do with a nurse who smears bloody vaginal secretions over people. After telling him about the incident, he laughs hard and says "You did the right thing - she had it coming!" I can't believe my own ears.
After getting some sleep, I laugh too. And think of how much I'm learning about myself in this place, being driven beyond anything I've ever been before. Of course I have never had to things like this before, in Denmark I've never had strangers refuse to leave the delivery room.
Here, one has to be creative...
Sarah
This idyllic evening makes me think of some of the extremes I have experimented here at the hospital. I have been in several situations, where if I had known about them, I probably would not have wanted to come. I have certainly done things I would NEVER have thought I would....
It was during one of my night shifts. A shift that begins at 2PM when everybody leaves and only the guard nurse is left to take care of all hospitalized patients, what comes in the ER and any deliveries.
A woman comes in for her delivery. She's alone. The husband is nowhere to be found, and for some reason she has no sister, mother, aunt cousin or neighbor with her. I recognize her - her little son was treated for tuberculosis some months earlier. I examine her. She still has a little ways to go. I check on the other hospitalized patients in between. Early morning comes and I expect the woman to deliver anytime soon. She's dilated and has a few good contractions. The head is right there.
After morning worship I give report about the night's events and hand over the woman to Rahama who is experienced in delivering babies. I go back to house and hope the goats and children will be quiet and keep away from my windows so I can get some rest.
I'm getting relaxed and ready to doze off, when the watch man calls me from outside the window "Sarah, you have to come up to the hospital. They have an emergency and need you to take care of the delivery". The delivery? That should have been over long ago? It's almost noon?! I worry if there had been any signs of complications I missed out on during the night?
On my way to the hospital I pass a group of people who have found a shady spot to sell their matches, spices and little plastic bags with sugar and salt. "Lapia" I say, knowing how not greeting people almost is taken as an insult. A teenage girl rises to follow me. She asks where I'm going, although everybody knows I mostly just walk the path between the house and the hospital. Often when I have bought something with her, she has kept the change and only by insisting and getting the help of onlooker have I got back the money she owed me. My thoughts are with the woman who has not yet delivered. What can be wrong? I'm no midwife! Just a plain RN.
Arriving at the hospital, I notice all the people gathered outside the OR. Some emergency has happened and someone is being operated. The other nurses are in there.
I arrive at the door to the delivery room. I notice the teenage girl is still behind me as I open the door. I turn and tell her to stay outside. I walk in to find the woman in great pain and to older women from the church are by her side. The husband has not showed up, neither have any relatives or friends. My mind is racing as I examine her again. Why hasn't she delivered yet? The contractions are good, there seem to be space enough for the baby to come out.... I get distracted by the sound of the door slamming. The teenage girl walks in. I widen my eyes in surprise and tell her this is not an entertainment show and she has to leave. I return to the woman. I wish I had someone to ask for help. Are there even sterile instruments around? Did anyone survey her or was she left alone when I went home?
As I turn to see if I have what I need nearby, I see the teenage girl, who has now found a comfortable place to sit down and watch! As I feel the stress of being thrown into a situation outside my competence, being tired and feeling alone, I raise my voice to make it even more clear to this girl that I meant what I said. I mobilized all my patience and explain again why she is not allowed to watch. I even tell her "PLEASE, go outside!" I know I can't concentrate on this delivery while she is sitting there.
She tilts her head, smiles subtly and says: "What if it doesn't PLEASES me to go outside?"
I'm beyond amazed! I need to get this girl out! I know I can't get violent...I look down on my gloved hand, covered with bloody vaginal secretion from examining the woman. I look sternly at the girl and walk towards her with my hand raised. As I get to her, she looks at me like she couldn't care less. I wipe my hand off on her cheek and neck, amazed at my self and she hadn't already left!!! She widens her eyes, turns and leaves. As I turn to the woman my eyes meet the two older women. They smile knowingly and nod. I think "WHAT did I just do???"
We tell the woman to PUSH and get this over with. The two older women have done this so many times before. They scold and slap her (why didn't I think of that...) and she starts to push better. Shortly after, a healthy baby comes out, I tie the cord and dry him off, extremely relieved. Everything goes well, the placenta comes out, the uterus goes hard and small, all bleeding stops.
The two women from church promise to look after the mom, and help her breastfeed. I walk to the OR. The head nurse has come out. I drag him aside and say I have something to confess. Somehow I'm sure they will not have anything to do with a nurse who smears bloody vaginal secretions over people. After telling him about the incident, he laughs hard and says "You did the right thing - she had it coming!" I can't believe my own ears.
After getting some sleep, I laugh too. And think of how much I'm learning about myself in this place, being driven beyond anything I've ever been before. Of course I have never had to things like this before, in Denmark I've never had strangers refuse to leave the delivery room.
Here, one has to be creative...
Sarah
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