Ecodome Chad

I stand in the darkness of the hut and tears stream down my sunburned, dirt caked cheeks. My body has reached it's limits and now my spirit has too. I've been living and working in an African village in Eastern Chad for a week now. My bed has been the packed earth of the village chief's courtyard. My food has been left over rice sweetened with a little sugar and peanut oil interspersed with a few cucumbers and the occasional boiled goat organs. My shirt has been the same one I've worn every day out on the construction site and it's ripeness cannot be described, only experienced.

I came out packed like a sardine with 5 other large Americans and a Chadian chauffeur named Issa Mahamat (Jesus Mohammed) over 900km of mostly bad subsaharan roads on a trip that lasted over 14 hours. That night I call Mahamat Saleh Abakar, our host and patron, to inform him of our safe arrival at his house in Abeche. He is his usual jovial self. I have no indication of the tragic news that will awaken me next morning before 6am. Arlo leans into my mosquito net and with a quavering voice gives me the bad news.

"James, Mahamat Saleh is dead."




"What?" I'm still groggy and wonder if I'm in dream land until the sobs and wails coming from around the courtyard jolt me awake. "Are you serious?"

"Yeah, we just got a call from N'Djamena. He went to open the mosque at 4am and then, after praying went back to bed. He never woke up. They found him cold."

I get up and move out onto the sand of the courtyard towards the short brick wall separating it from the walkway to other parts of the compound. Issa Mahamat comes up to me with tears in his eyes.

"Mahamat Saleh mot," he bemoans in Arabic as he shakes his head in disbelief.

I'm assured later by the family that this won't undermine the project but that the whole family is behind us in the creation of this health center. We pick up the "Chef de Terre" (Land Chief) of the area who accompanies us out to the village where we are introduced to the chief and his second in command. We set up camp and go out to the job site where Arlo has already dug the foundations for the Ecodome we will hopefully build in the next week.



Monday I am occupied with visiting local authorities back in Abeche while the team gets working. Arlo has identified three locals, Naim, Aimé and Richard who we will soon realize are indispensable for the success of this project. They are not only amazingly hard workers but are of impeccable character. Naim especially always has a smile on his face as he motivates the local workers to move ever faster and stronger. Then as we rest in the unbearable midday heat he prepares our simple fare along with the obligatory tea. Later he helps translate, count out and distribute pills and make it possible for me to see hundreds of patients at night after our evening work session. He is tireless, humble and dedicated to his faith. None of all these responsabilities can make him miss even one of his five daily prayers. He studied Arabic in the university and can read and write it fluently as well us understand completely the Qur'an. Like any true student of the Qur'an he was led to study the other ancient scriptures as well and is familiar with the Injil and the teachings of Jesus. While at the university, he organized a dramatic troupe to do street theater to promote social awareness, health principles and to point out corruption at the hospital and elsewhere. He is one of those men in whom one instantly recognizes veiled greatness.



Aimé and Richard are quieter and more subdued yet no less hard working and dedicated in all areas of life.

Wednesday I am on the wall filling a superadobe bag and I suddenly feel as if have no strength. I'd had diarrhea once that morning but no other symptoms. Now my whole body is aching and my skin is on fire. I am drained. I manage to finish the row and then wobble down the hill to the cattle watering hole where I jump in after stripping off down to my underwear. I find temporary relief in the coolness of the shallow muddy pond. I go back to the compound and am flat out on my back for the next two days. I start treatment with antibiotics and Flagyl for amebas. I've used up all my malaria medication in treating sick kids in the village. I send someone Thursday into Abeche to buy me some and after one treatment that evening am feeling better the next day.

I have seen such suffering. No clean water, hardly any food, sick kids with pus filled eyes everywhere. Malaria, diarrhea, skin wounds, blind adults from cataracts. My simple supply of pills is soon gone and the needs are overwhelming. I get more in Abeche on Friday and that night see 50 of the 130 signed up to see me. I have no where to consult but on a mat, often with a flashlight to guide me and Naim and the village chief at my side as assistants. Saturday afternoon, I try to see the almost 100 that remain. As it gets dark I go to get my headlamp and it's gone. I flip out. Exhaustion has taken it's toll. I pack up what little meds remain and close shop. Many have come from miles away to see me. My missing head lamp just gives me an excuse to escape from the overwhelming needs that have pushed my body to it's limits.




That morning, we'd decided to hike to and climb a nearby mountain. We almost died of heat exhaustion. One of our group, Brian, had to turn back early. On the way back on a simple path through the millet fields we hear a voice thundering from under a nearby tree.

"Don't come over here unless you want to get naked and wait till the moon comes out." I glance over and see a hairy, naked body leaning with one arm casually against the trunk. Fortunately, the intervening millet stalks blur the details. In our own delirious state, none of us thinks it abnormal as we are just trying to survive ourselves. We wave goodbye and continue back to the village. It's only after downing a few liters of water and some porridge that I start to panic. We sort of realized that it wasn't good so we'd sent out Issa Mahamat and Naim along with Brian's son, Bradon in the truck to try and find him.

The locals are chastising us for our carelessness. The truck comes back with out Brian. Naim and Issa are covered from head to foot in sand. The car got stuck in the sand and had to be dug out. We head out again. I hope I can find that tree again and that Brian hasn't moved. We finally find the small path and sure enough there's Brian still under the tree. He was smart enough to recognize his limits and stayed out of the sun and heat thus saving his life.



So, Saturday night, I'm exhausted from working all week, having amebas and malaria, almost dying of heat stroke, not eating enough and seeing too much suffering. So, I find myself standing in the dark crying, bemoaning my weakness yet feeling at the end of my resources. These people have lived like this their whole lives and I am done after a week. And now I've turned away dozens of suffering people because I just can't go on.

"Father God, forgive me my weakness, only you can make me strong."

Shadow Proves the Sunshine

I never thought I'd be jealous of Pierre's parka. I didn't think it possible, but the tingling in my fingertips is making me wonder if frostbite is possible in sub-saharan Africa. The goose bumps on my arms, the ache in my legs from too much shivering and the chattering of my teeth under my beanie assure me that it is related to cold. It probably doesn't help that I'm only wearing sandals, cargo pants and a scrub shirt that are all soaked with rain and spattered with mud.

I'm staring at the smattering of white hairs in Abakar's almost shaven head just inches from my rain spattered glasses. His bare arms are thin as he whines out the motorcycle engine, plowing fearlessly through mud puddles up to our seats at times. As we slip and slide and almost fall several times, his only response is a hearty chuckle and a shaking of the head.



We'd left Moundou early this morning in a pounding thunderstorm beating ferociously on the old Toyota mini-bus. My mind flashes back to Youlou's funeral yesterday evening.

Anatole, Tchibtchang, Christophe, Youlou's cook and I turn down a muddy street in Moundou and stop in front of a brick wall near a sign that says "The Dove, Medical Care Center" with a picture of the young Youlou, untouched by the neck cancer that would almost kill him and leave him permanently scarred with a raspy voice from surgery and radiation. We enter the courtyard where twisted sticks have been pounded in the ground to support tarps over numerous mats and a few chairs for the well wishers. We solemnly greet all those present.

We sit down. I feel extremely sad. Anatole explains that we wanted to come sooner but an early morning rain and lack of a vehicle forced us to go by motorcycle later in the day. I stare at the large vein on the back of my hand. I slowly push it up and down under the pliable skin. Youlou's cook has started wailing over on the mats with the other women. Normally, I think their mourning cries are artificial and fake. Today I'm envious as they are able to let out their sorrow while I feel it weighing me down, brimming to the surface but not able to escape.

Anatole moves over to a hut where Youlou's mom waits with a couple other women. I follow him. We take off our shoes, move across the sand and onto a mat. A wrinkled, tough woman she is shaking her hands up and down and rocking back and forth, moaning. Her right hand is missing it's middle finger that has recently been amputated and is covered with a Betadine soaked elastic bandage. As Anatole starts offering his condolences in N'Gambai, I just absorb the sadness of Youlou's mom as the tears start to just brim offer and spill silently onto my arabic robes over my crossed legs. I start sniffing and use my amble sleeve as a Kleenix.

That evening we eat beans, rice and grilled meat by the light of a Kerosene lamp on wooden stools by the side of the night market. After finishing it off with some tea, we go to the our almost finished Surgery center, pull out some gurney mattresses and sit around laughing, joking and shooting the breeze for hours until I fall into a fitful sleep.






In Kelo the next day we find moto taxis but immediately get poured on so just before leaving town we pull under a woven mat shelter and wait out the storm. I pull some old beignets out of my back pack and we dunk them in some hot tea. I feel slightly guilty scarfing down the donuts and slurping the hot drink in front of the group of Ramadan fasting Muslim moto taxi men. One of the taxi men is our neighbor from Bere and one of my HIV patients. He's been healthy on ARVs for over three years now. He's wearing a world war two era Russian fur hat. I'm extremely jealous as I shiver in my soaked scrub shirt under the constant drip-drip of the leaking shelter.

Back to the present I see Anatole's driver's invention has fallen down and started flopping. To keep water from entering his exhaust pipe, he'd attached a length of innertube and tied it to his luggage rack so the smoke poured up Anatole's back and over his shoulder renewing his diminishing levels of carbon dioxide in his blood. Now it's fallen down and writhes around like a snake with it's head cut off, still spewing foul emissions.

At the lake where our local hippos usually reside we get off the motos and wade through almost waist deep water while the motos follow in dugout canoes. One of the canoe "drivers" is Marty, the man who was bit by the hippo in March 2004 featured in the documentary film "Unto the Ends." He greets us and it proud to show off some of his scars. He seems to be in perfect health and grins from ear to ear until I take a picture of him with Anatole upon which he transforms into the typical serious African dictator pose.



Arriving in Bere, my Muslim driver breathes out a prayer of thanks to God as he offers one last chuckle and shake of his head. The sun is shining and I'm almost warmed up on the outside but completely renewed on the inside.

Gone

Youlou's gone. Sunday morning. Barely responsive. Tubes sticking out everywhere. No family. Brother arrives. Call from Moundou. Cousin's a doctor. Knows him well. Has treated for years. Yes, HIV+, he knows. Evacuate. Ambulance arrives. Put Youlou on a stretcher. Out the door. In the Land Cruiser. Anatole and Augustin accompany. Gone.

The baby's gone. Bottle feeding. Changing poopy rags. Burping. Soothing. Sweet. Calm. Sunday evening. Mother's still denying. Local chief comes. Doesn't recognize. Operated patient does. My mother's relative. She's coming. Washes. Feeds. Mom sitting up. Drinks. New wrap. Uncle will come. 50 kilometers away. One more evening. Crying. Washing. Preparing milk. Sucking bottle. Morning. Knock, knock. This is the uncle. Over to Augustin's. Baby brought out. Sit in chairs. Recount stories. Mom AWOL. Family unaware. Went to market. Never came back. Gone.

Baby in box. Take out. Give to uncle. Merci beaucoup. Gone.

Monday afternoon. Woman in labor. Not progressing. Husband demands surgery. We stall. No progress. To the OR. Prep and scrub. Fat baby. Cries. Uterus closed easily. No complications. Back to ward. Wash hands. Go home. Evening. Oscar comes. Knock, knock. Breathing gone.

Rush. Run. Don't look panicked. Pupils dilated. Inner eyelids pale. No blood. No pulse. Occasional gasp. Chest compressions. Oscar take over! Call Delfine! Get a gurney! Run to OR. Scramble for Adrenaline. Nursing student! Draw up adrenaline. Broke and spilled. Take another. Broke again. Another. Finally. IV push. Heart beat. A little pulse. Push on chest. Air moves in. And out. Dump on stretcher. Run to OR. Open fridge. Take blood. O negative. Cold. Run it in. More adrenaline. Delfine! Another IV! Call lab. Blood type. Anatole comes. Blood sugar. Normal. Breathing on own. Heart beat. 140 per minute. No blood pressure. Oxygen sats normal. More blood. Hydrocortisone. Stop adrenaline drip. IV fluids. No urine output. One hour. Breathing well. Out to ward. Stress gone.

Move to bed. Woman speaks. Wants to sit up. Turn around. Crank handle. Raise head. Breathing bad. No pulse. No heartbeat. Adrenaline twice. Gone.

Tuesday morning. Call from Moundou. Youlou. Getting better. Coma gone.

Tuesday evening. Ring, ring. Anatole. 6:30pm. Youlou dead. Gone.

Knock, knock. Anatole. Samedi. Come in. Sit down. Have some tea. Almost seven years. Hundreds of deaths. Samedi, over 30 years. Anatole over 25 years. Cholera. Liquid diarrhea. Up to knees. Wear boots. 1996 epidemic. Family won't help. 24 perfusions. Doxycycline. Doctors without borders. Money. In other's hands. Gone. Only Samedi and Anatole. Bury the dead. Stuff cotton in nose, mouth, anus. Even at night. Family doesn't help. Only Samedi and Anatole. 24 hours a day. Three months. Never got sick. Many others gone.

Measles epidemic. 1987. Samedi. Four children. Measles. Family emphatic. Don't treat. Samedi ignores. Penicillin for each. Eye drops. Citrus. All live. Many patients. Hospital full. Father of four. Loses two today. Loses two tomorrow. All gone.

1983. Black September. Curfew. Anatole and friend. Thrown in jail. Come out. Beat or killed. Three days. Finally released. Village of Bere. Hospital empty. Village gone. Samedi in one house. Anatole in another. No electricity. By themselves. Protecting. Watching. Guarding. Anatole gone. Samedi 24 hours a day. One week. No one else. Next week. Anatole alone. Doctor taken hostage. Samedi captured. Night. African bush. Military. We'll kill. Who's that? We're with you. Who's that? Nurse. Samedi? Let him go. Samedi runs. Gone.

Funeral. Youlou. Tomorrow. Let's go. Ok. Good night. Walk to gate. Laugh. Why are we alive? My brother dead. Same car. I'm alive. Anatole and Samedi. Alive. Back to house. Stars. Cloudless sky. No moon. Tears flow. Sobs wrack. So many...gone.

Unwanted

It's the barking that first wakes me up. Of course, I'd just fallen asleep. Is Caramel just barking at shadows or is there a nurse at the door. Then I hear the sound that has replaced the fear-provoking sound of my residency pager: the gentle "tap, tap, tap" of a finger on a sheet metal door.

I roll out of bed trying not to disturb Sarah (as if she could sleep through the racket), pull on some scrub pants and head out to the porch. A headlamp outside the scree confirms my suspicions: they want me at the hospital.

It's Oscar, one of our new nurses. He did several nursing school rotations at our hospital and was always one of the sharpest students. The problem is that he still looks like a student, a junior high student. It doesn't help that his one lazy eye always makes you wonder if he's really looking at you or not.

"We just got a case referred from the health center," Oscar begins holding out a small piece of paper with some scribbling and the ink from a rubber stamp marking it as official. "Femme psychose." I have to have him repeat it and then finally look at the paper where I recognize that the patient is referred for being a "female psychosis."

"She's nine month's pregnant and is crazy," Oscar continues. "She won't let any of us examine her. The baby's head is half way out but she just writhes and shrieks and doesn't push."

"Ok, ok, I'm coming." I go back inside, pull on a dirty scrub shirt, grab my flashlight and keys and walk back out under the full moon.

As I enter labor and delivery, I see a crowd of nurses and nursing students standing around laughing and joking just beyond the curtain that separates our one delivery bed from the three postpartum beds. The woman is quite large, looks young and has a blank stare on her face as she gazes at the wall, her back arched behind her and her obviously pregnant belly shoved out proudly in front.

I send everyone else out except Delfine, the nurse responsible for labor and delivery this evening. I go over to the side of the bed where the young woman is staring.

"Lapia." I greet her. She rambles something off in Nangjere that I don't understand.

"Bebe gei age." I tell her the baby wants to come out.

"Bebe kang ddi." She denies that there is a baby. I decide not to provoke her. I'm not sure what to do. If I even try to come close to touch her she screams, tenses up and pulls away.

"I have to poop!" The girl continues in Nangjere.

"Ok, go ahead," I place a bed pan under her. "Do it in here."

She pushes it away indifferently. I put some gloves on, still uncertain as to how to proceed. I can't really knock her out because the baby's respiration will be depressed. Yet at the same time, I'm worried that the baby's oxygen is being compromised by his not coming out fast enough. What to do?

Every time the woman has contractions she stretches out her legs, squeezes her buttocks and arches her back: not the classic pushing technique I remember from medical school. Amazingly, after a couple more contractions she actually pushes the head all the way out. Even more remarkable, she turns on her back, spreads her legs and allows me to grab the head and pull the baby out. He is curled up, great tone and starts to scream immediately. I clamp and cut the cord and give the baby to Delfine. Fortunately, the mother is still being slightly accommodating and the placenta delivers almost immediately. Plus she has no tears and her uterus is well contracted with no bleeding so we don't have to touch the mom and freak her out.

As I turn back to the baby, Delfine is finishing tying off the cord. We dry him off as best we can and wrap him in the only thing the mother has available: her head scarf. I go to present him to his mom and she turns away, again denying that she has a child. Now what? I call in Anatole who happens to be there with one of our staff members who is sick. He tries to talk to her in Nangjere and Ngambai but just gets nonsense replies. Still, none of her family has shown up, which is unusual in Africa. I pick up the baby in my arms and go to see Augustin, our administrator. He calls up the health center that referred her. As he talks to them, one of his family, a young teenage girl has taken the newborn from me and is cooing and giggling at him in the chair across the room.

"The woman you referred has delivered, but no family has shown up and she doesn't want the baby. What's the story?"

Apparently, she came from a village down the road called Dabegue. She just showed up and was so uncooperative that the nurse at the health center put her on his motorcycle and dumped her at the hospital. That's all they know. And no one has shown up for her there either. One of the other nurses on duty, Seraphim, is from Dabegue. I take the child back and go to see him in the pediatric ward.

"Seraphim, there's this crazy woman from Dabegue who just delivered, is all alone and doesn't want her baby. I'm trying to figure out what to do with the baby. Would you mind coming and seeing if you know her?"

He agrees and we set off across the darkened campus to the Maternity ward. The woman is still staring off into space. Seraphim goes around and gets a good look at her.

"Nope, I don't know her." I try again to present the mother her baby but she turns away in indifference.

So I take the baby home. I walk into the bedroom and place the bundle by Sarah.

"Hey, look what I brought you." She half opens her eyes and in the light of the flashlight takes in the baby.

"You're kidding! What's going on?" I explain the story but tell her to go back to sleep, I'll take care of it.

I leave the package on the bed and go over to Tammy and Jamie's.

"Hey, do you guys have a bottle and some infant formula? I just brought home a baby that a mentally challenged woman doesn't want . Since she has no family with her I figured I'd keep him tonight and see what we can figure out in the morning."

Jamie comes out and chats while Tammy scurries around in the kitchen and finally comes out with a bottle and matching nipple.

"Do you have any formula as well?"

"Actually I do. I'm helping feed that orphan baby across the street and they're coming tomorrow to get the can but I guess you can use some tonight."

"Ok, thanks." I go home and put some water on the stove to heat up. I fix some formula and put the rest in a plastic storage bin, mix in some colder water until it's just right and try and wash the newborn nastiness off the little guy. I give him some formula (he doesn't want much) and then wrap him in a blanket and pack him in a cardboard box on the couch.

As I lie in bed again trying to go back to sleep only one thought enters my head: "now what?"

Tobacco

"Docteur, mind if I interrupt?" Desiré pokes his head into the OR. Actually, I do mind because I'm trying to take out a large cecal mass that is hovering right on top of the major artery going down to the right leg while Sarah is trying to keep the patient alive with an Adrenaline drip.

"Yeah, go ahead," I say as I briefly look up before getting back to careful dissection. All I hear is mumbling, something about a boy and a horse and falling and a clavicle. Must be a clavicle fracture, not urgent.

"Ok, I'll come and see him later." I keep working and eventually am able to get out most of the mass and reattach the patient's small intestine to his large bowel. However, his heart rate and blood pressure keep tanking without the Adrenaline so we find a good rate for the drip, send up a quick prayer and release him out to the wards for lack of an ICU.

I've forgotten about the boy who fell off the horse until Desiré spots me from far away as I try to escape back home and calls me back to the ER.

I leave the darkness of the overcast sky to enter the even deeper obscurity of the ER who's light isn't working. I see a pre-teen boy, well formed and conscious sitting up on a dilapidated bed. He has a 5 cm open wound below his clavicle that is filled with nasty green clumps of grass or something. It's then I get the real story. He was riding from the fields with his throwing knife, fell off and stabbed himself in the upper chest. Well at least he seems to still be breathing. I go to my office and bring back my stethescope. Breath sounds seem to be equal bilaterally and he is in no respiratory distress. The wound looks deep, but maybe it didn't make it to his lungs. We take him to the OR for exploration.

After starting an IV, giving antibiotics and a sedative, I examine the wound. I pull out the clumps of dark green crushed leaves mixed with blood and dirt.


"What is this, some kind of traditional medicine?" I ask Samedi. He goes out and inquires of the family and then comes back into the OR chuckling.

"Doc, it's tobacco leaves."

I'm stunned. Tobacco? What will I see next? I try to wash it all out. The wound is deep but slanted up so it goes almost to the clavicle but not straight in thus avoiding the lung. If it would've gone any deeper it may have his the subclavian artery or vein and he'd be dead.

I leave a drain deep and close the muscle and fascia leaving the skin open with a diluted bleached soaked dressing.

I go to check on the previous patient. We have nursing students currently so I'd assigned one to take vitals every 10 minutes (exceptional for here). It's actually been done and the patient has maintained a normal heart rate and blood pressure. The IV bag is almost empty so I mix up another 500ml with 2 mg of Adrenaline and get it running at about the same rate by eyeballing it.

I leave him in God's hands.

The next morning he's talking and asking to have some water to drink.

Lies

The knock on the door is all too familiar. The case is not. A well built young man in his mid twenties lies on the ER bed with his legs curled up in obvious pain. He as all the symptoms of acute appendicitis. What is unusual is that he's only been sick for three days and the excruciating pain localizing to his right lower quadrant started at 4:00 am this morning. It's just a little after 6:00 am on a Sunday. He actually came in to the hospital almost right away. He didn't wait!

I open him up with a McBurney incision and find an appendix with the last two centimeters flaming red but non-perforated. I think this is probably the first non-perforated appendicitis I've operated on in 7 years here in Chad. Unlike the others, he should have an uncomplicated recovery and go home in a couple days. As I close up the skin incision I notice through the glass block windows of the OR that outside has turned dark and I can hear the rain pounding on the tin roof. This year, the rain started early and has been consistent and heavy. I head outside to do rounds as the cool wind and rain forces everyone under shelter.

The surgery ward is saturated with complicated wounds and post-op cases or patients who've come from far away and with the rains having destroyed all roads into Bere, it is unthinkable to send them home and have them come back in a week for suture removal. We'll just have to keep them until they can go home definitively.

On the medicine ward I find a not too uncommon sight. An elderly woman is sitting on the hospital bed with an IV hanging off her arm attached to an empty bag of IV fluids that once had Quinine in it. On the floor next to her bed is a half folded mat with a baby asleep on it surrounded by two young women and a young man eating a traditional meal. They break off a piece of millet paste and dip it into the slimy, green leafy sauce using two fingers and the thumb of the right hand. The man gets up when we approach while the women continue dipping and eating.

"Ca va?"

"Oui, ca va."

"Do you know the hospital rules?"

"Yes."

"Ok, how many family members can stay with the patient?"

"Two."

"How many of you are there?"

"Two."

"Do I look stupid? I can count. How many of you are there?"

"Three but one of them is outside."

"Where are we, inside or outside?"

"Inside."

"Do I look stupid? Where is the woman, inside or outside?"

"Inside, but she just arrived this morning."

"Really? Who let her in?" I go to the door and call the gatekeeper who is standing in the rain swallowed up in his army green poncho.

"Jean-Jacques, did you let this person in this morning?"

"No, she must have been in here already."

I turn to the family member and ask him, "When did she come?"

"Ask her."

Seraphim, one of our nurses' aides asks the woman in Nangjere when she got here.

"Nanga," she replies and even I understand that doesn't mean today, that means yesterday.

"My friend," I ask the man. "How many more lies are you going to tell today that are so easy to verify as false? Are you going to tell us you're the president of Chad? Or maybe Barack Obama?"

But I can tell by the look on his face that my attempt at humor has escaped him.

I finish rounds just in time to be called to labor and delivery where a woman has been in prolonged labor at the health center and was referred since 2 am. She arrives at 10am. I examine her and find that the baby is trying to come out face first and it just isn't working. We do a see section and pull out what looks like a little alien with his eyes bugging out, forehead swollen and molded by the pelvis and his face edematous and red. But he does start crying and moving with some vigorous efforts at reanimation by Sarah and Anatole and looks like he'll be fine. I wonder how long it'll take him before the culture teaches him that lying is ok as long as it's used to give excuses for not doing what you should be doing and to protect yourself from something that might turn out to be shameful.

But for right now, he's just like any other newborn, he just wants oxygen followed by a good breast feeding.

Crutch

I sigh. I can't help it. I've seen too much. Too many children die, too often. And this is just another sad case. The nurse hands me the carnet. A seven year old who was amputated here in May during my vacation. Now he's back with tumors everywhere according to the nurses' initial evaluation. Diagnosis: metastases. I motion for the nurse to bring in the child. He practically skips into the room, if one can skip on crutches. He's almost bouncy until he looks up at me and then turns his head down and slightly to the left as he shyly looks back up with a small grin revealing two missing front teeth. He is way too cute to be dying.

I heave him up onto the exam table and first teach him how to give me five. At first he is reluctant. After all, he's been taught to shake people's hand and slapping is kind of a bad thing. But after some encouragement, he gets into it and really lays it on as his face lights up. I lie him down and pull down his shorts. His left testicle is swollen, looks like a hydrocele. His right leg is amputated above the knee and the wound has scarred down well. However, the leg above the amputation is swollen and the groin is filled with large, mobile masses. His lower abdomen also has numerous palpable masses swelling out his stomach.

My face falls. I'm about to turn to the father shaking my head to tell him there's nothing we can do but I decide to do something desperate and hope for a miracle. We do actually have one chemotherapy agent: cyclophosphamide which we use to treat Burkitt's lymphoma. Burkitt's is very common here and very treatable with a few doses of Cyclophosphamide spread out in cycles of three weeks. It usually presents with a large mass in the upper or lower jaw but can present elsewhere. After one dose, the mass usually shrinks remarkably and after 2-3 doses it is usually visually gone. Even though I'm almost positive this is not Burkitt's I figure it won't hurt to try.

The boy is hospitalized and the first perfusion given. I see him the next morning and his abdominal masses have all but disappeared and the groin masses have shrunk remarkably. He went home 5 days later much improved. Yesterday he came back and got his second dose. This afternoon I saw him and can hardly feel any mass in his groin. All the other masses have completely disappeared. I don't know what it was and I'm pretty sure our treatment shouldn't have worked. But all I really care about is that this really cute boy is getting better against all odds.