Fuel

I'm looking for fuel. Not just any fuel, that I could find anywhere. All along Moundou's one paved road are small rickety wooden tables stacked with old whisky, gin and wine bottles filled with various colors of gasoline and diesel. No, I'm looking for Moundou's one working gas station: such as it is. It hardly stands out. Two bright new fuel pumps stand just outside one of the hundreds of other brick stores with rusting sheet iron doors opening onto dark painted wooden counters in front of an endless supply of haphazard new and used parts and products. There are also two old pumps with glass tubes and a hand pump that fills up the tubes which are then emptied of their specific quantity of fuel out a second hose. It's hard to recognize until you're almost past it and there is barely room for a care to get off the pavement and onto the dirt as motorcycles, bicycles and pedestrians weave in and out in a weird rhythm interrupted by the occasional black exhaust spewing battered diesel truck.



Today, I can't seem to find it. I'm driving slow, peering out the window of the Hiace mini-bus when I spot the two old pumps but no new ones! Just past the pumps on a stool is my friend, Mahamat, wearing a Chadian National Football team jersey. He waves to me and I screech to a halt and back up.

"As salaam aleikum!" I greet Mahamat.

"Wa aleikum as-salaam," he replies and then adds. "You're looking a little lost, what's up?"

"Yeah, I was looking for your gas pumps, but they're gone!"

"We just moved across town last week. I'm here just to orient my clients. Do you need gas?"

"Yes, I was looking for you, but you found me instead!"

"Come, I'll take you to my new place." With that, Mahamat hops into the passenger side and we do a u-turn and head back towards the surgery center.

Mahamat is plump with a ready grin and is a huge football fan. Apparently, in the day, he was quite the player as well and still gets out occasionally.

"How long have you been in the new place?"

"Just a week, God has blessed us. I came from N'Djamena a few years ago, and didn't know what I would do, but here I am."

"Yes, with God's help you have succeeded. He meant for you to come here."

"It's true. Our business will continue to grow, inshallah."

I turn and smile. "Yes, we must always say that, if God wills. We don't know what will happen even tomorrow."

Mahamat grins as he chews on his tooth cleaning stick trying to keep his mind off food until Ramadan ends at sundown. "So many people want to plan out their whole lives, but it's only the right now that God has given us."

"Yes, you're right."

"I thought I saw you yesterday evening." Mahamat changes the subject slightly.

"Yes," I reply. "I came into town with my wife looking for something to eat. We found some great beans and rice after sundown. I prefer simple things, the things that God has made rather than things from a can or box."

Mahamat looks at me in surprise. "You are a true believer, that's for sure." He laughs and keeps chewing on his stick as we pull up to his new gas station.

Tire

I walk over to the mini-bus, my muscles aching and my back burned. I've just been out in the hot sun all putting in the plumbing for our house at the new surgery center in Moundou so the builder can pour the floor and keep things moving. I glance at the rear tire and see it's gone mostly flat. It's had a slow leak for a while, but this is going flat quicker than normal. Sarah and I hop in, I start her up and we pull out onto Moundou's one paved road.

In the round about ahead is the statue of an African woman next to a large, homemade water jar reaching out half a calabash of water to us thirsting passersby. Just past the effigy I spot a yellow tank with a motor and old belt on top. A tire repair shop. I screech to a halt and look down the dirt embankment to a teetering brick wall where someone has stretched out a ragged tarp between a tipped up push cart steadied with palm fronds and an old metal sign. The tarp is attached to it's supports with old inner tube that allows it to toss and turn at the whim of the wind offering varying degrees of shade.

Under the tarp a man is stretched out asleep on a board balanced precariously on each end by two old tires.

"Hey, anyone working today or are you closed?" I shout out in French in the man's general direction. He sits up and smiles and walks up to us.

"My back tire is low and needs to be repaired," I say to the man as I step out of the van and around to the back passenger side. He nods and mumbles.

"TWENTY THOUSAND? Are you crazy?" I respond incredulously.

The man smiles and laughs. "No, no! TWO thousand, not twenty." He walks over towards his homemade tools scattered all over the ground. "Twenty thousand, that's practically the price of a new tire. No, I would never say that."

I agree with a nod and a grin and the man gets to work jacking up the van to take off the tire.

"Mind if I sit in your shade?" I ask. He tells me to go right ahead and then when he sees Sarah still sitting in the van, he motions that she should join me, which she does.

We both quietly read until I see he has the tire off the rim. I get slowly to my feet and saunter on over where the man shows me a nail poking through the rubber.

"That's what made the tire go down quick, put there must be another hole somewhere because it has had a slow leak for awhile."

"Sure, no problem."

I go back and resume reading my friend Franklin Cobos' book about his experiences in Chad in 2008 called "It Could Be Worse." Little do I know how pertinent his title will seem in retrospect.

The man calls me over and points out a piece of bailing wire that he also found in the tire. He patches both with old pieces of inner tube and glue. I figure he's about done, but return to my reading anyway. After 20 more minutes I see him still struggling to inflate the tubeless tire. I see him walk away across the paved road and return 5 minutes later with a back of flour. I stop reading and watch closely. He puts it in a bowl and deftly mixes in a little water till he's created a very sticky dough. Then he smears it around the edge of the tire. I get up and stand nearby watching in typical Chadian fashion. As he tries to inflate the tire with the air hose the dough puffs out in a couple places like a kid trying to make bubbles with chewing gum.

"I need more flour." The man states matter-of-factly and takes off again soon returning with double the amount of flour. He repeats the procedure until practically the whole tire is white with dough. I wonder if it sits enough on the hot Chadian pavement if it'll turn into bread and stop up the holes. It still doesn't inflate after multiple trials interspersed with reapplication of the dough.

"I'll go see a brother who can help." With that he takes off with the tire back towards where we came from, rolling the white doughy mass in front of him until he's out of sight. I go back to my book. Finally, he comes back and shows me an inflated tire with pieces of plastic jutting out around the edges in between the lumps of dough. It seems to be holding air, though, so I nod my approval and he remounts the tire.

"Four thousand francs." He demands.

"Whoa, buddy, we agreed on two thousand, here take it."

"NO! I fixed two holes, two thousand per hole!"

"The extra work wasn't patching the hole, it was taking the tire off and trying to re-inflate it! That's not my problem that you didn't know what you were doing and had to take it elsewhere!"

I hold out the two thousand franc note. He looks at it in scorn. "Either four thousand or you keep your money!"

"Take it!" I try to give it to him, when he refuses I put it in his cardboard box and go around to the driver's side. The man comes to the passenger side and reaches across Sarah and grabs a hack saw sitting on the console between the seats. Sarah grabs the hacksaw as well and almost falls out of the car wrestling with the man until he wrenches it from her grasp. Meanwhile, I've quickly gone back around and take the saw back, twisting it out of his hands.

"Now you're going to steal something or what!?" I motion for some people across the street to come over as witnesses and intermediaries. I motion Sarah to get back in the van and try to close the door behind her. He pushes his butt in the way. I push him out and close the door but he reopens it and wedges himself in there again. I push him out again with a hip thrust and this time lock the door and manage to close it while boxing the man out as I lift the handle on the door so it stays locked.

Meanwhile, a small crowd has gathered and the man starts shouting out in Arabic about not having eaten anything all day because it's Ramadan, the Muslim fast. I switch over to Arabic and shout out a few things about that he'd agreed to two thousand and then tries to change his mind and steal our saw and molest my woman. The man just keeps repeating the same things over and over even as other Chadians try to reason with him and motion me to just go. So I get in, hope desperately the van will start (which it does) and take off without a look back, hoping desperately that the plastic and dough holds up at least till I get out of view.

WELL

I finish as quickly as I can at the hospital. Lightening rounds and a couple of simple operations and I find myself heading towards where my heart has been all morning. I open the back gate and step into the bush. Grass is starting to push it's way up through sand transforming this desert into it's annual reawakening an African savannah. This year the rains have started early and have been regular. No one is talking about famine this time. I walk across the field towards the church and pass a couple of sticks stuck in the ground that serve as goal posts for the afternoon soccer matches between the neighborhood kids.

In the distance, I spot Jamie amongst a crowd of African children surrounding a small metal brace towering out of the masses. The slow chug and then roar of a pull started diesel motor breaks the silence as I see a motor slowly rising along the supports towards the top. As I draw near I see a metal pipe attached to the bottom of the motor and some huge plastic tubes coming off the bottom running to another small motor that has just been started as well. Coming out of this motor is an even larger, green hose going into a pit filled with muddy water which is starting to disappear as the metal pipe starts turning, the motor is lowered and sand filled muddy water pours out from under the apparatus, down a channel, into a small pit for collecting the larger debris and then through another canal into the big water pit.

A well is being drilled before my very eyes!

As the motor gets to the bottom of the rig, it is shut off. The pipe is loosened from the motor and then locked in a brace that will keep it from slipping forever into the bottom of the water reservoir. The motor is then restarted and hand cranked up enough to screw in another pipe and continue the process of up and down, up and down with the drill bit getting progressively further towards a clean water source. I take off my scrub shirt, roll up my scrub pants, take off my sandals and jump into the muddy fray.

Suddenly, one kid yells to another kid to start the water pump. We haven't attached the other pipe yet and a powerful jet of clay filled water spurts out on Jamie, Doulgue and I covering us from head to toe in mud. Everyone starts laughing while we silently plot our revenge.

Finally, the well is 85 feet deep. We slowly and excruciatingly reverse the process to remove the pipes one by one. Finally, the drill bit is out. We bring in the large plastic pipe that will be the well casing. It is bright blue and the first one to go down as little slits all along it to let water, but not soil in. We have to modify the end so it will go in easier by cutting out triangular wedges with a hacksaw and heating up the plastic with a propane stove so we can bend the end closed. We then lower it into the pit and hold on while another one screws into the end. None of them want to screw in until we realize we have to grease it well for it to work as the plastic just grips itself.

We have 3-4 ten foot lengths in when we discover that the threads are bad. Now we have to try and pull it back out to unscrew that last one. It's difficult as the muddy water in the hole wants to suck it in and now the pipe is covered in clay and quite slippery. We finally wedge it with a large adjustable wrench and a plethora of hands but it feels like it'll slip away at any second. We manage to finally unscrew the old one and screw on a new one and slowly lower it back until we have 8 sections in for a total of 80 feet.

It's revenge time. The first boy sees me coming and backs away laughing...right into the arms of Doulgue. We haul him over and baptize him in the sump pit as a fitting celebration of the arrival of clean water for our elementary school and junior high. We go home sunburned, tired and very satisfied.

Anesthesia Nightmare

The woman was gored by a bull. Not just any bull, a Chadian bull with 3 foot long horns. And she was gored in the mouth, straight through her palate into her nasal cavity. But that was months ago. Now, she's just a wizened old lady who'd like to swallow her porridge without it coming out her nose. I have her open her mouth and I shine in a light. There's a small hole, slightly smaller than one centimeter right in the center of the roof of her mouth. I poke around with a clamp. There's some green stuff; looks like bean leaf sauce for lunch.

We prepare her for surgery. She has high blood pressure. Three days and three medications later her blood pressure is mostly controlled. We wheel her into surgery.

There are four medications God has reserved as gifts for the third world. One of those is Ketamine. It is dirt cheap, can be given through an IV or into a muscle, dissociates the person from their conscious brain yet doesn't hinder breathing, swallow or gag reflexes. It also increases heart rate and blood pressure (both generally good things during surgery) and dilates bronchioles in the lung increasing oxygenation. It allows us to do most major surgical procedures without intubation, ventilators, or other complicated anesthesia equipment. Too good to be true? Well, there are a few drawbacks...

Simeon gives the woman some atropine to dry up her secretions since Ketamine tends to make one salivate and shed a lot of tears. He also gives her Valium since people on Ketamine can have vivid dreams, visions or even nightmares. This is especially true on emergence from anesthesia. Valium should blunt that. So far so good.

I have put on sterile gloves and arranged the instruments on the tray. I'm ready for the patient to be knocked out. Simeon slowly injects one milliliter of Ketamine. I watch as her eyes start to twitch and then she goes out. Then she contracts her abdomen, chest and neck in a huge grunt and stops breathing. I can hear the beep beep of the pulse oximeter in the background as her oxygen saturation goes slowly but surely down. This happens sometimes with Ketamine for a few seconds. I sit tight. She still doesn't breathe. I start doing some chest compressions to move a little air in and out of her lungs. Simeon is keeping her airway open. Her sats come up a little, but are still very low. Usually, the person starts breathing right about now, or rather a few seconds (or is it minutes) ago.

I decide to intubate. Simeon opens the drawer filled with about 10 different laryngoscope handles and light sources and over 20 different lighted blades. I grab the one I want, it doesn't light up. I try changing blades. Nothing. I'm starting to panic as I go through all the handles and blades and not a single one works. We have the endotracheal tubes ready, but no way to see the vocal cords to put them in. Meanwhile the patient isn't breathing because she's all tensed up from a reaction to the Ketamine. Her sats are going way down in the background with that annoying little beep.

I see in the bottom of the drawer a laryngoscope I've never seen before. It's made of green plastic and the blade is rigidly attached to the handle which is hollow with no top. It's just a long tube attached to the blade. On the side is written, use laryngoscope light source (or something like that). Inspiration (or desperation) comes. I yell to James (the medical student/EMT from the states).

"Get me that headlamp over there on the wall. Turn it on and shine it down this handle!"

It works, a little light at the tip of the blade lights up. I quickly jam it into her mouth and see her vocal cords! I grab the ET tube. I try to put it in but her mouth is tense and the tube bends. I forgot the guide wire. I quickly fumble in the drawer and bend the wire back into shape and jam it down the ET tube.

"James, put your hand right here and push her cricoid down and to her right!" I can't see the cords. Finally, a swollen, tight little hole with two white flaps opening and closing pathetically shift into view. I thrust in the tube and it passes into the trachea.

"Blow up the cuff with that syringe!" I yell to the other medical student, Jonathan. I attache the bag to the tube and start pumping air into the patient's lungs. I see a reassuring vapor in the tube with each exhalation and an even more reassuring increase in the tone of the pulse ox which says she is now being well oxygenated.

I give the bag to James while I put on fresh gloves and make two incisions about half a centimeter from the hole in the woman's palate. Jonathan and Abel retract and Abel suctions while I free up the tissue from the bone and then move the two flaps to the center and suture them over the hole made by the bull horn.

Fifteen minutes after the surgery is over I'm able to extubate the woman and she soon breathes normally with normal oxygen saturation.

Note: No supplemental oxygen was used in the filming of this nightmare due to unavailability.

Central Africa Republic

It starts with a hum, then a buzz followed by an ever increasing noise that soon identifies itself as an unavoidable telephone ringtone that is a poor imitation of the William Tell Overture. Sarah walks over to the shelf, grabs the small silver object and passes it to me. I open it up and glance at the screen: an unknown number.

"Hallo?" I query.

"As salaam alek." A deep cheery voice greets me in Arabic.

"Wa alekum as salaam." I respond.

"It's me, Mahamat Shadara," the voice continues. "You operated on my leg, remember?"

"Yeah," I do remember him and have wondered how he was doing. "Kikef?" I ask back in Arabic.

"I'm bringing a brother from Central Africa with two broken feet." I'm assuming that he's using the colloquial expression meaning two broken legs.

"Ok, where are you?"

"We just left Moundou and are almost at Kelo. We're coming to Bere. He needs to be operated on today."

"Ok, ok," I try not to promise to operate today since I have no real idea what his problem is. "Bonne route!" I hang up.

Several hours later, as Sarah and I are finishing up some pasta salad along with an episode of "House, MD" the phone rings again.

"We've arrived at the hospital." It's Mahamat Shadara's voice again.

"D'accord, j'arrive." I finish my meal and my distraction and head over to the ER.

There is an old beat-up Toyota pickup in the middle of the courtyard between the ER and the OR. I assume the patient is in the back. A large Chadian walks over to me with just a slight limp using a cane. He holds out his massive hand and grasps mine in a firm grip as a huge smile lights up his face.

"Docteur, as salaam alekum."

"Wa alekum as salaam, yom katir..." The Arabic greetings continue on for several minutes before we walk over to see the patient.

A foul odor wafts up from the back of the truck where a weak looking man looks like he's barely hanging on. His head is propped way up on a pillow. Yellow shorts cover his waste and a dirty white sports jersey can't hide the thin arms and partially healed scratches. An old piece of foam probably carved from a used mattress is between his legs which are both twisted out at impossible angles. As I suspected, he probably has bilateral tibia fractures. Both are covered in layers of old matted cloth surrounding reeds and all covered in gentian violet. The flies buzzing and his burning hot skin confirm my suspicions that one if not both of the fractures is open and severely infected.

"How long since the accident?" I demand.

"Xamstachar, fifteen days," Mahamat confirms. "He came all the way from the Central African Republic. I brought him here because you helped me so much if anyone can help him it's you."

I'm not so sure, but I get the process rolling.

"Dinah," I call out to the pharmacist. "Call Abel, Simeon, Samedi, Abre and Youlou. We have an emergency surgery and I need there help immediately."

The family members along with our medical students grab the metal spring bed without legs that the man is lying on and lift him out of the bed of the truck. We bring him into the OR. Sarah and Salomon each find an IV and start pouring in antibiotics and IV fluids. I start cutting away the layers of old cloth and reeds around the fractures and uncover a hardened layer of what looks like dried roots, probably some traditional bone treatment. The right leg has some superficial wounds that look like scrapes or pressure sores from the binding. No bone is showing and it looks like the fracture is closed. Good news for him.

Meanwhile Samedi has arrived and is putting in a urinary catheter while Simeon is cutting away the wrappings on the left leg. Henri has come and done a hemoglobin which is 5.7 g/dl. He needs blood. Henri goes to get the stuff to cross match his blood and hopefully find donors among his family members since we have no blood bank. The left leg is completely open with bone fragments jutting out and dirty, peat moss like flesh around the wound edges. Pus and an awful odor pour out of the injury. There is also a green looking gash along the outside of his left knee. There's no way to save that leg and we need to amputate immediately.

Henri comes back. The patient has O negative blood, one of the rarest types and the one type that can't take anything but that one type of blood. None of the family is O negative. We'll have to operate without blood. Simeon brings a blood pressure cuff and a large elastic wrap. I start at the toes of his left leg and wrap tightly to try and squeeze as much blood out of the leg as possible and back into his circulation. Then Simeon pumps up the blood pressure cuff around his upper leg which acts as a tourniquet.

We wheel him into the OR where I quickly slice through the thigh muscles down to the bone. Pus gushes out. Right along the bone is more of that green, necrotic tissue. I saw through the bone and toss the leg into the trash can which gets knocked over. Youlou rapidly puts it back right while I try to chase down and cut out all the necrotic looking tissue. I also find the main artery, vein and nerve and clamp and tie them off. Once the debridement is done and we are down to healthy looking muscle, I ask Simeon to gently let down the tourniquet. Samedi and I spot the bleeders and clamp them off while Simeon reinflates the cuff to stop any oozing. I tie off the vessels, pack the wound deeply with diluted bleach soaked gauze and wrap the whole wound up tightly with an Ace wrap.

Simeon lets down the tourniquet and the dressing stays dry. I move to the right leg which I cast from toes to thigh after cleaning and dressing the wounds. I'll cut a window in the cast tomorrow so we can do dressing changes and if the wounds clear up then I may put in an intramedullary rod. Right now it's too much for him in his weakened condition. As we turn him to clean him off, I notice pressure sores over his sacrum which I also debride and dress. Finally we wheel him out to the wards.

I don't know how he stayed alive for 15 days in that condition, but people here are tough. I hope he makes it through the night.

High Risk OB

It all started with the usual knock on the door at 3AM. Faka, the charge nurse for the night team, is outside as I open the screen door. A dim flashlight illuminates his face as he looks up from a patient's carnet.

"A woman just came in with presentation of the umbilical cord. She's been in labor at home since yesterday. The were no fetal heart tones. She had some bleeding but it stopped."

"What time did she come in?" I interrupted.

"Just 20 minutes ago." Faka replied.

"Was it a normal vertex presentation?"

"I think so."

"Go and find out. Since the baby's already dead and the bleeding has stopped, if the fetus is head down, then she can deliver normally."

"Ok." Faka moves off into the night as the crickets, frogs and pigeons take over with the usual Chadian night sounds.

I decide to stay up until Faka comes back. I read for a while but after half and hour I assume the woman has already delivered or is doing well so I go back to sleep.

After worship, Faka gives his report to the rest of the staff.

"...and the woman still hasn't delivered and has no contractions."

I stifle my frustration and announce that we'll all go to see the patient right after the rest of the morning report.

The woman is in a dark room. The electricity is off. I go to the OR and hit the remote start for the generator. I come back to labor and delivery and find the woman in a clean room behind a blue curtain on a delivery bed with no mattress under a noisy fan.

The umbilical cord is sticking out between her legs. The abdomen is a weird shape. On closer inspection, the placenta is also half hanging out and the odor of rotting flesh wafts up into my unprotected nostrils. I examine the woman and find a hand sticking out next to the placenta and umbilical cord. This woman has three reasons to need a c-section four hours ago: placenta previa, cord prolapse and transverse presentation.

A few minutes later in the OR I have Abel douse the cord and placenta with Betadine while Samedi and I scrub. The infant's skin is already peeling off as I pull the limp form out of the abdominal incision. I leave the skin partially open to prevent infection and we clean up.

Prudence is waiting for me outside the OR.

"A woman just came in. This is her 5th pregnancy and she's been trying to deliver at home since yesterday morning. I can't exactly tell what the presenting part is."

"Ok, I'm coming." I slip off my OR shoes and into my sandals as I turn the corner and down the outdoor veranda to the maternity ward.

At first I also can't tell what part of the baby I'm feeling till my finger goes into the child's mouth.

We quickly prepare her for a c-section as well. As I open the uterus I can tell the fetus was stressed as a thick green fluid oozes out. I pull the baby out but the head is huge and her lower uterine segment thin and about to rupture due to prolonged labor. The baby is soon crying as Prudence uses the bulb suction and briskly dries and stimulates him. Meanwhile I repair the tears in the paper thin uterus and finally control the bleeding. I rinse out the abdomen well and close.

A few hours later, Prudence comes to get me again.

"This woman has been bleeding a lot." She tells me as we make the now familiar trip to labor and delivery.

On entering the room I see a woman breathing rapidly, somewhat dazed and covered with blood all over her legs and waist.

As we prepare her for surgery, the lab checks a hemoglobin: 7.8 g/dl (normal is over 14) We do a type and cross and find out unfortunately that she is O negative, one of the rarest blood types and one that can only take O negative, no other type. As I slice down the midline of her lower abdomen, the lab guys are desperately checking the blood types of all the relatives of the woman. None of the staff is O negative and we have no blood bank so we hope someone that came with her will have the same type.

As I open the abdomen I see a blotchy uterus with cracks on the surface oozing diluted red blood. After nine other deliveries the uterus just can't take much more. There are dark bruises around the edges and the fundus. As I open the lower segment a dead baby pops out followed by a large grapefruit sized blood clot. Abruptio placentae where the placenta separates too early causing massive hemorrhage between it and the uterine wall. That explains why she's oozing from everywhere: she has no platelets or clotting factors left.

Since the oozing won't stop and the uterus looks as if it's been beat up, I decide to take it out. It is rather simple to do but after it's out, despite by sutures, the wound edges just keep bleeding and bleeding. I try everything I know but nothing works. Her blood is so diluted it almost looks like pink lemonade. In desperation I ask for a packet of Celox, ignoring the large "for external use only" on the package I poor the powder over the bleeding edges in the pelvis and hold pressure with a compress. The problem is there's nothing to hold pressure to. Even with the Celox applied several times there is just too much oozing for my comfort, especially considering I have no blood to give her and she started out low. Finally, I take a large lap sponge, pack it into her pelvis and close the fascia and skin around the blue cord attached to one corner of the gauze that hangs out the skin.

As I watch her being wheeled out to the wards I'm sure it's the last time I'll see her alive. Later that evening I go to check on her. She's moaning and groaning and not really responsive. I grab 2 liters of IV fluids from the OR and let them pour in. WHen the first one is in, I change to some 10% glucose. She starts to at least make some sense. I ask her family to interpret what she's saying in her local dialect.

"She's in a lot of pain."

I order some IV pain medication and go home. At least with the pain medication, she'll die peacefully.

The next morning, she's still alive and so I have the family give her some water and porridge. Later that afternoon, the lab finally finds a family member with the right blood type and she gets one unit of blood. It's not nearly as much as she need's but it's better than nothing. The next morning, she's swollen and edematous but alert. I take her back to the OR and take out the lap sponge and reclose the abdomen under general anesthesia. Today, she is still critical but sits up with help and is taking some water and more porridge.

Maybe she'll make it after all.

Whimper

I stare down at the man. It's almost midnight. His name is David. He's almost 60 years old, but has the muscular build of a middle aged athlete. I took out his enlarged prostate three days ago. Up till now he's had a completely unremarkable post-op course. In fact, he's done better than expected. He was already up walking, eating, clear urine in the foley bag, etc. Now, things have changed.

His eyes are half open, pupils constricted, eyes slowly wandering away from the flashlight. He whimpers and whines like a beaten dog cowering in a corner. His heart beat is a little fast, but otherwise vital signs are normal. He is snoring. Just that evening, according to his son, he drank some water and had some porridge. Then he started mumbling incoherently out of the blue.

I have the nurse, Faka, find an IV and start a drip of 10% glucose. I look down at him. He continues to moan in a pitiful way as if he's extremely afraid. I wonder at my reaction. I want to feel something good, but all I feel is that I wish he would stop being so pitiful and that I wasn't woken out of a deep sleep and have to be here to see him like this. I'm disgusted and angry in my feelings while in my head I'm thinking, why can't I love him? But I feel nothing. I pray silently that my feeling will change.

As the glucose runs in, David starts to wake up. Faka then starts another IV in the other arm and gets some normal saline running. David starts to have purposeful movement and mumbles something. His son says he wants some water to drink. We lift his head up a little and he swallows have a glass of water. The IV on the right with the normal saline is pouring in. I notice that the glucose on the left is running slowly. I see that the IV is infiltrated.

I stop the glucose and when the saline is all in I switch the rest of the glucose over to the right. David wakes up even more. He mumbles something else in his native tongue. I ask his son to interpret.

"He says his ancestors are calling out to him from the grave and he's afraid."

I suggest we pray for him. They are all in agreement. I grab his hand and David holds mine tightly. At the end, I tell the son to ask him if he needs anything.

"He says he wants some porridge."

"Go ahead."

They lift him up again and his wife gives him some porridge which he swallows easily. He then remains sitting up on his own. The family has visibly relaxed. David is now able to understand and respond to my questions in French as well. I tell him that now that he's better I'm going back home to sleep, but I'll keep praying for him.

As I walk back in the moonlit night, the cool breeze echos the tranquility of my soul. I fall back to sleep immediately. In what seems like the next instant, I hear a knock on the door. It's Faka.

"Our guy is dead. Not fifteen minutes after you left. Out of the blue."

I hear the wails and cries of the family waft across the lawn from the hospital. I sit in my chair in the blue light of a bug lamp. I want to cry, but no tears come, only questions that will never be answered.