Fracture

The man is lying on the twisted gurney in obvious pain. His relatives and friends stand around panting, trying to catch their breath. They've just hauled him in off the back of the pick-up where he had bounced up and down and all around on the pothole-filled dirt road from Lai.

I bend over his left leg and gently lift the blood soaked rags.

A Betadine browned compress with a bright red bloody center is all that stands between me and the fracture. I gingerly lift it up to see the bright white shard of bond sticking up from a black spider-webbed mass of sutures ineffectively attempting to hold the wound together.

It's been three days since he fell of the gravel truck.

A piece of cardboard is bent around the back and sides of the legs and tied on with string in a lame effort to stabilize the broken tibia.

"We have to operate, clean out the wound and try to get the fracture stabilized."

The family understands and willing forks over the $60 necessary for the surgery, medications, hospital stay, etc.

After knocking him out with a heavy dose of "Special K" (Ketamine) and Valium I have my sister Chelsey grab his foot and pull.

"Lean into it, let your body weight do the work, not your arms," I tell her.

Simeon is at the head of the gurney. We are in the OR prep room with a pulse oximeter attached to monitor our anesthetized patient. Simeon has also given the antibiotics.

Meanwhile, i prepare a 5 liter basin of diluted bleach solution and open up a tray of sterile instruments. The procedure is not sterile as the sand and gravel inside the wound testify, but I guess sterile-to-start-with instruments isn't a bad idea.

I cut all the old sutures and bend the foot down and back so the bone fragment sticks out more allowing me to put my finger behind the bone and with the help of a bulb syringe start to wash out the debris.

After five liters, the wound is fairly clean. I cut off any dead looking tissue and then try and reduce the fracture. A huge posterior piece of the bone is not there, probably removed in Lai, meaning the bone is trying to balance itself on the half centimenter anterior segment. It doesn't work very well but with Simeon now pulling and Chelsey putting medial pressure on the lower segment and lateral pressure on the upper segment it stays pretty well.

Then I have to try and close a gaping 10 cm wound. I use heavy suture with special mattress type sutures and little by little it mostly closes but under a lot of tension. Who knows if it'll hold up, but it's the best I can do.

Then, I pull out an external hard plastic shell for lower leg fractures I picked up last year at my old haunt in Ventura County, California and strap it around the leg to stabilize the fracture.

Amazingly, three days later, the wound is still holding together with no signs of infection and the fracture is more or less still in a good orientation to heal. Maybe a miracle will happen again...

HIV premie

I tried to tell her. I warned her so many times. I told her of the potential consequences. But she just wanted to do what felt right in the moment. She just wanted to have a baby.

She's only a child still herself; 19 years old but looks 13 or 14. She has AIDS, has already been treated for tuberculosis for 8 months and is on antiretroviral therapy. She's unmarried.

Now, she sits in my office cradling affectionately a tiny premature baby boy. All the books on HIV management tell me that if possible, the baby should not be breast fed, but formula fed to avoid the risk of HIV infection through the milk. However, this tiny, malnourished life needs all the help it can get. Despite her obvious thrill at being a mom and holding a baby in her arms, she has no clue what sacrifice taking care of this baby will mean so that it grows up healthy and HIV-free. She has been underfeeding him, feeding him "when he's hungry."

"So he tells you when he's hungry?" I gently chide trying to use humor to get her to realize it's her responsability to feed him regularly whether he "wants" it or not.

It does seem she is doing some things right: washing and boiling the bottle, using only clean water to mix the formula. I decide to continue the formula but I decide to hospitalize her to try and get her help with the idea of regular feedings and what's the appropriate amount. Of course, nurses who are trained to suture, treat emergencies, deliver babies and give shots and start IVs, like our locals, haven't been exposed to the other side of nursing, the educational, daily needs assessment, et cetera kind.

As I look into the gaunt, yet strangely peaceful and trusting face of this four pound premie, I fear his days are numbered

Farcha

As I step out of the plane the heat hits me smack in the face. The hazy, orange low lit airstrip of the Hassan Djamous International airport rises to meet me as I descend the portable stairs onto the tarmac. A brief passport and visa check later and I'm waiting for my bags which never arrive. Odei, Hans and Levi are there to meet us. The team from Florida is with us as well as my sister, Chelsey and, of course, Sarah. Everyone else's bags has arrived so we load up the truck and Rick, Hans and I climb in the back on top of the luggage for a dimly lit ride through downtown N'Djamena to the mission guest house at TEAM.

After some spaghetti and watermelon, I take a cold shower to try and cool down a little. By not drying off and letting the fan evaporate the water on my skin I am able to at least lie down and sleep fitfully. By 6:00am I can no longer sleep and the sheets are soaked with my sweat.

True to his promise, Odei is there to meet me at 8:30 to take me to his church in Farcha. The pounding rhythm of a homemade drumset fashioned out of various tin cans and scraps of metal welded together and covered with goat skins guides the three different choirs in their diverse African chants that course through the blood bringing one into an awareness of the divine.

Afterwards, Odei and I hop on his motorcycle and swerve through the dips and humps of the unpaved city streets towards the district hospital. One of his friends has been hospitalized that week. We first pull over to a shack made of woven reeds where a 12 year old boy is selling water in a bag. We rip open the edges and guzzle half a liter each down our parched throats.

To turn into the hospital we must carefully navigate a ditch filled with putrid water and covered in slime. A variety of bottles and cans struggle desperately to stay above the surface as the gook relentlessly tugs them under. We turn past a rickety, iron framed chain link gate hanging off a couple of badly attached hinges and into the small courtyard of the District Hospital of Farcha.

Peeling yellow paint, twisted hand rails and crumbly cement steps lead us past a few customers lounging on torn mats under the shade of a few gnarled bushes almost resembling trees.

The well-tiled hallway branches immediately off left and right while straight ahead is a tiny courtyard filled with plastic bags, IV tubing and littered with paper that has all tumbled off a pile of trash from an overstuffed metal barrel that has been cut in half. A few Chadians wearing white coats means that there are a few nurses present. Odei greets several of them and we are oriented down the dimly lit hall to the left. We peer into a dark room filled with a few beds, less mattresses and lots of visitors wearing brightly colored robes and head scarves surrounding a few patients hooked up to IVs suspended from windows, a couple of rickety IV poles and even the ceiling.

Odei's friend is outside we're told so we head to the back where some stray dogs scrounge through the piles of refuse around the smoky outdoor kitchen.
We finally find our man under a tree with a few buddies. After some extended greetings and joking around we discover that his malaria is being sort of treated but his chronic cough hasn't even been suspected of being tuberculosis. We give some suggestions, shoot the breeze some more and finally get up to leave.

The next day, after an early morning departure from N'Djamena, I find myself back in Bere which I suddenly appreciate so much more after the shock of the Farcha Hospital in the capital. And we're off...

Update

Thanks for all the prayers. The fighting in Tchad never came close to Bere and now things have calmed down and are back to "normal" even in the capital, N'Djamena.

Sarah and I are now in Denmark starting our furlough. We left a few weeks earlier than planned, not due to the fighting in Tchad but due to personal burn-out. We hope and pray this furlough will renew our strength allowing us to return to Tchad. We are encouraged by a surgeon, Dr. Surin (aka Dr. Bond) who has committed to a year in Bere which will help tremendously. If we could just find one more physician of any specialty to help us then the prospects are indeed bright for Bere and Tchad and Sarah and I can continue our dream of dedicating our lives to working there.

Again, we thank God for all of you who remembered us and prayed for us during the last year and especially these last few weeks during the crisis.


James & Sarah
PS The gross picture was of some unknown foot tumor that we'd wanted to operate on a year before when Dr. Warren DeKraay was with us. We amputated below the knee and five days later he went home on crutches very happy and waiting for complete healing so he can get a prosthesis in Moundou.

Slippery when bloody

As the woman thrashes around on the table we try to grab her to keep her from falling to the ground and from biting herself but with all the blood smeared everywhere she is as slick as a greased watermelon in a swimming pool...


I was sitting peacefully at home when the nurse first came to call.

"A young pregnant woman just arrived in a coma. Her blood pressure is high, she has a fever and we can't find the baby's heartbeat."

I gave some instructions for further tests and things to examine, put her on a quinine drip and hoped it wasn't pre-eclampsia.

The next morning, I saw her during rounds and she was writhing around in bed with four people trying to hold her down. We got the results for the tests for pre-eclampsia and they were negative. She had a little malaria but not that much. I continued her on the quinine, checked the fetal heartbeat myself and confirmed that the baby was already dead. I then ordered the nurses to provoke labor and deliver the child.

All day long she moaned and thrashed and screamed.

That evening the nurse came to get me again. The woman was in the delivery room lying half naked on the table with her mom and aunt holding her arms and legs and the nurse keeping her from pulling out her IV. She was crying as if being tortured and it was all we could do to keep her from biting her hands and arms and falling to the floor. She wasn't having good enough contractions so I adjusted the Oxytocin drip. The thoughts that started to come into my mind I tried to ignore but finally couldn't.

"I think she's being bothered by evil spirits." I blurted out.

The nurse, Gilbert, translated into Ngambai for the family and we started to discuss what that meant and how the only treatment was prayer because no amount of IV drips, medications or even surgery can exorcise a demon (yes, we had to explain that!)

Finally, Gilbert prayed long and hard in Ngambai and I finished with a prayer in French begging God to keep his promise in Luke 4 that he came to deliver the prisoners and set the captives free. A few minutes later she was calm and snoring. I left to go home.

Now I find myself back in the same room with an even wilder patient. She has delivered the still-born and now the placenta has been stuck for 45 minutes. She is stiffening her legs, lolling her head and wildly waving her arms as we try to hold onto that slippery, bloody mess.


I put on some gloves and try to reach inside to pull out the placenta but she clamps her legs together. The women are shouting at her in Ngambai and I'm trying to pry her leg apart with one arm as I try to grab the placenta with the other. Finally, frustrated, I reach up and grab her chin and shake her while screaming, "Let me help you!" She calms a little letting me get my hand in the uterus, grab the placenta and pull it out before all hell breaks loose again.

Now she starts to bleed heavily. I'm calling for meds as Liz and Sonya rush to get them and try to hold on to her as the blood coursing from within makes her more and more slippery. The thrashing as covered her legs and back and belly. I try to massage her ritually and ornamentally scarred abdomen but her powerful rectus muscles are contracted as she resists with all her might. Without time to think and scared that this demon is trying to kill her by keeping me from stopping the bleeding I reach up and slap her face and shake her again while pleading with her to let me help. She calms a little and starts asking "Khalas? Khalas?" (Is it finished? Is is over?) I'm able to massage her uterus and it starts to firm up a little but I'm forced to press my fist down between her rectal muscles as to keep pressure on it as she starts to contract and thrash again.

Liz comes back with the Methergine and Oxytocin but the intramuscular shots start an even crazier bout of thrashing. Finally, we give her some Chlorpromazine to try and calm her. At last, the bleeding slows down. It's 3:30am and I've been with her for 45 minutes. I come back to the house, plug in some quiet music as I feel like Martin Luther having fought the devil physically.

I"m drained but not discouraged.

The next day, Gilbert tells me that they've finally discovered why she was possessed. Apparently, even though she never went to the Marabout, her relatives went to the witch doctor to find out why she was sick and were told that someone had put a fetish curse on her. I referred her to Noel, our chaplain.

A day later and much prayer later, she is sitting up in bed.

Couscous and Goat

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

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

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

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

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

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

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

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

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

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

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

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

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

Perforated peptic ulcer.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GROSS PICTURE OF THE DAY

Stumbling

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

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

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

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

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

I wonder if I can find the way.

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

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

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

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

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

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

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

Five hernia patients wait patiently outside the operating theater.

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

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

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

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

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

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

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

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

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

The dawn is about to break.