Jugular

The dark blood suddenly gushes out of the neck wound like a hot spring bubbling up from the ground. I had hardly slept the night before anticipating the complexities of operating on this man's neck. He had a mass bulging out under his right mandible which looked like a bunch of large grapes with bearded skin stretched tightly over them. The mass was smooth and lumpy and about the size of a large grapefruit.


He'd been to many other hospitals who'd told him there's nothing that can be done.

The surgery started off bad with a difficult intubation. I put the laryngoscope into his mouth only to find myself faced with a looming open esophagus and no vocal cords in sight. I pulled up with all my strength, tried repositioning the head, had someone try and push his voice box down, all to no avail. Finally, I blindly inserted the tube above where I could see the esophagus and pulled out the guide wire. As my cousin Jenny filled up the cuff with air and my cousin John attached the ambu-bag I looked for the telltale signs of vapor on the tube. Then, Jenny verified that there were breath sounds.

Unfortunately, at this time his oxygen saturation started to fall as his pulse jumped up to 172 beats per minute. I listened to his lungs and they were clamped down like a severe asthma attack. I quickly asked Simeon to give him some IV steroids and Chelsey to run to the pharmacy for some bronchodilators. It was about this time he started to grunt and clench his jaw and hands while straining like he was going to burst through some invisible barrier like the Incredible Hulk transforming himself into the Green Monster. I shouted at Simeon who quickly gave him more Diazepam on top of the Ketamine.

Finally, after about 30 minutes, we had him sedated enough, airways open enough and heart rate down enough to start the hard part of the case.

I had dissected the skin off the mass and was working my way around the lateral side underneath the tumor when I got into the jugular vein.

As the blood gurgles into the wound I quickly put my finger over it with a gauze pad between me and the large vein carrying most of the blood from the head. I pause for a moment. What do I do now? I'm definitely in uncharted territory. I calmly ask Johnny to put on some sterile gloves and hold pressure on the wound. As he holds the man's lifeblood from escaping under his finger I continue to methodically and painstakingly dissect the rest of the mass off the mandible, the voice box, the trachea and the carotid artery and other deep muscular neck structures. An hour later, the mass is out.

Johnny's fingers are paralyzed in position and totally numb.

I ask him to gently take off pressure. Blood surges into the surgical field. He quickly presses back down.


It's then I remember my old friend, Erling Oksenholt pulling me into his office in Oregon in May and showing me a short video. In the video, a gloved hand is poised over a pig's groin. A sharp scalpel suddenly lunges down slicing through the porker's femoral artery. As blood spews from the wound the gloved hand quickly piles on gauze and holds down fiercely. Then, just as quickly, the gauze is withdrawn and a white powder is poured into the wound and the gauze and pressure is quickly reapplied. A note on the bottom of the screen says "five minutes later" as the scene shifts slightly. The gloved hand releases pressure and gently pulls up the gauze. There is no bleeding.

I also remember that Erling gave me some packets of this miracle powder (Celox) that I had left with my cousin John to bring with him when he came three days ago.

I yell to Brian to run over and check the bags that he and John brought and see if he couldn't find any. Meanwhile, John and I continue to wait and hold pressure. Brian comes back at first to say he didn't find any. Jenny and Chelsey go to help him look. Finally, Brian comes back with a small, white plastic bag with Celox in big red letters. Brian opens the sack and I say, "ready" and lift off the gauze as he quickly pours in the powder and I reapply pressure. Five minutes later I lift off the guaze and see white powder in the wound but no bleeding.

Johnny has been reading the instructions and says that now I should irrigate the powder out of the wound which I do. At the end I am trying to wipe out the last fragments and the blood gushes forth again. We repeat the process and the second time I'm a little gentler.

It holds and I close the muscles and skin, wrap his head and neck in a loose ace wrap and then send him off to ICU attached to a ventilator (whoops, dreaming again). Instead, I take out his endotracheal tube and send him out to the hot, sticky wards where his family will fan him with homemade woven fans and we'll hope he wakes up and his throat doesn't swell up too much so that he can't breathe.

Two days later he's complaining of a sore throat but sitting up, breathing normally and taking liquids. His neck has virtually no swelling at all.

Window

The thunder rolls. A cool breeze bursts through the window ruffling the papers on the table. I'm sitting, staring out my window at life in Bere as the sun goes down behind the house. The red sunset reflects off the mango tree leaves poking up like heads of broccoli above the pale tan of the mud brick walls of my neighbors lots. The thatch roofs of the huts add no color but rather texture and ruggedness. A gentle rain sprinkles down. The sky is a steel grey.

People pass by on the path that runs 20 feet from where I sit behind mosquito screen and iron bars. Finally, a little rest from a long 24 hours of hospital work.

It started yesterday evening after the lights came on with a simple testicular abscess that we drained in the OR by removing his testicle. Afterwards, I was reminded how often unusual things come in pairs.

The nurse calls me to see an old man with urinary retention who had gone to a health center where they tried to insert a catheter into his bladder but came up with blood instead and couldn't get it in. They referred him to us. I see him now with a huge round mass in his lower abdomen: a distended bladder holding a liter or two of pee. I try half-heartedly for a few minutes knowing that a false track has probably been created leaving me with no option except to drain his bladder through his abdominal wall.

Then, I remember an instrument I saw among the bag of weird, mostly useless instruments brought by one of our volunteers. I hurry home and come back with an instrument looking like a torture device from the dark ages. It's a metal tube with a tee at the end and perpindicular to the tee a spout curving out. on top is a round top on a piston connected to a four-sided razor sharp spearhead poking out the opposite end.

I inject some local anesthetic above the pubic bone of the old gentleman, make a small skin incision and then poke and twist the torture device straight in until I feel a "pop". I pull back the piston and bloody, foul-smelling urine jets out the spout all over the bed and partly in the basin we'd arranged for it to go in. I then slide a rubber tube down the spout into the bladder and pull the torture device out. I tie the tube in place and attach it to a drain bag and send him to the ward after examining his prostate with a gloved (duh) finger and confirming that it's monstrously enlarged.

Outside my window, a fat lady mosey's on by pushing a push cart. Chickens peck the ground looking for insects while trying to escape the amorous advances of a strutting, cocky rooster.


Last night at 11pm, the twin of old man with the large prostate and urinary retention comes in. Same story, went to health center, tried to put in catheter, got blood, sent to the hospital. This time I'm ready and quickly repeat the same suprapubic insertion of the drainage tube under local anesthetic with the severe-looking trocar.

The rain continues to fall outside as a woman walks her friend out the gate of her courtyard half way down her path to the main path. As the saying goes here in Tchad, if I accompany you out then my blessing goes with you. She stops and shakes hands and her tall lanky friend saunters away down the path glancing casually around and greeting the two boys bringing the cows back in from grazing. A sharp smack with a long stick ensures that the cows keep up a healthy trot and stay in line.


The morning brings a pair of hernias. Not too unusual except that both have associated hydroceles. We do them with the generator running, but since it's kind of a mutant, handicapped generator, it can only do a few things at a time so we operate without lights (except for sunlight through the opaque glass brick "windows") so we can run the a/c and keep from dying from heat stroke and falling into an open groin wound.

In between cases, a 10 year old boy comes in after being attacked by a bull on the outside of his upper arm. A superficial 10cm U-shaped wound looks like it was cut with a knife or razor blade. How he avoided massive injury with those big horns I'll never know. I suture him up under general anesthesia and then do the second hernia/hydrocele combo.

A few hours later, another 10 year old boy comes in with a wound to his armpit from another bull's horn. This one is also superficial having missed his blood vessels and lungs. Those bulls need to practice their goring, they're attempts are pathetic. I let Simeon suture this one up while I grab a bite to eat.

A large woman waddles by outside my house as I sit and take in the calm evening scene around my house. On her head are carefully balance an enormous pile of bound reeds. I'll never cease to be amazed...where this path joins the main road in front of the hospital a group of about six kids hops, skips and talks animatedly to each other as they head away from me. A tiny girl in a tattered pink dress does semi-cartwheels, her bare feet flailing in the air before tumbling over on her back.


As I'm about to go home a little after 3pm, one of the nurses comes to see me to say that one of the kids on pediatrics is pooping blood. I go over to see one of the kids we'd treated for meningitis and malaria as well as giving a blood transfusion for anemia. She was doing better this morning according to the family and had finished the treatment. She always looked a little drowsy to me, but I guess I just chocked it up to being worn out from all that's happened. For some reason, it did strike me, though, especially looking back.

She is 4 months old, very cute, and with devoted parents.

She is resting face down on her moms lap, her butt cheeks in the air, her legs hanging down and dark red, partially coagulated blood coming out of her anus. I've never seen what I'd learned about in medical school as red currant jelly stool but this looks like it. I refresh my mind with a quick look up in my ER book and am convinced it's what's called intusseception (when the small intestine gets swallowed up by the large instestine creating obstruction).

We take her to the OR. She looks so tiny on that large table. She only weighs a little over 10 lbs (5 kg). Abel finds an IV, Simeon administers the anesthetic and after prayer I open up the thin skin of her belly with much trepidation.

Some red inflammatory fluid bubbles out along with most of her small instestines. I search for where her small intestine joins her large bowel and don't find what I expect. Instead, I find a deep red, almost black gangrenous appendix that fortunately hasn't ruptured. I perform an appendectomy and close her tummy up.

As I hand her back to her parents, tubes coming out from all over, I can't help but hope that one day soon, she too will be attempting cartwheels down the streets of Bere...

Flashlights

I find myself bumping along the supposedly paved streets of N'Djamena in a Hilux pickup so thrashed that you wouldn't believe it could still be running unless you've lived in Chad and seen the miraculously still running majority of Chadian vehicules limping along the highways and byways of the African plain. Sitting next to me is Enock, a squat, heavily muscled slowly turning to fat nursing student flashing a toothy grin complete with gold glint.

Whatever the case, he has been reminded of an unbelievable story that he now shares with me.

Several years ago, his son became deathly ill with severe abdominal pain. He was rushed to the health center who appropriately referred him to the National Reference Hospital in the capital, N'Djamena. They were fortunately living there at the time and were able to get him there quickly.

It was the middle of the night.

Trying to manoeuvre through the crazy ER with people piled all over the place already cost him some "tea" and "soap" money but finally he was seen by a doctor who confirmed the diagnosis: acute appendicitis.

He was scheduled for surgery that very night.

As Enock and his wife huddled together praying, the surgery team wheeled their son away through the swinging doors on a gurney. All they could do was sit and wait...

Until a half hour later, when all the lights went out.

Of course, there was instant confusion and they heard an orderly fumbling through the halls and bursting through the doors of the operating room. In a frantic rush he bumped into Enock.

"Are you the father of the boy with appendicitis?" He demanded.

"Yes, what's going on?"

"We're in the middle of the case, your son's belly is open and we have no light."

"Yeah, I noticed...what..."

"Hurry out to the market and buy some flashlights...HURRY!"

Enock rushed out, down the stairs, out the door of the hospital, hailed a motorcycle taxi, raced to the market, luckily found someone open, bought two flashlights and hurried back.

The surgeons then continued their life saving procedure and a week later Enock's son was home safe and sound.


Only in Chad.

Kids

The dust kicks up a small puff of powder with each tread of my foot. The clear blue, cloudless sky leaves no hint of the massive showers soon to hit. Travis, Justin and I are hoofin' it to the river while Sarah and Chelsey ride on Bob and Pepper, our two horses. It has been exceptionally hot this year reaching into the 130's Fahrenheit and even higher in the A/C-less furnace we used to call our operating room. As the sun bakes my brain I try to desperately keep it alive with frequent sips from my camelback. After about 45 minutes we are in a groove but suddenly feel a cool gust. I look up and notice that out of nowhere behind us is now this gray, hazy area in the sky blotting out the trees and dusty terrain to the northeast.

Plip-plop. The first drops plump into the parched soil of the path. Soon we are almost shivering as a cold rain pelts us just as we arrive at the river with the pack of local boys we've picked up like groupies at a rock concert. We are famous. After all, we are "Nasara" the most interesting thing to happen in these parts in a long while for sure.

The river actually feels warm after the cold rain. The clean sandy bottom is just a couple feet under the surface and I have to lie down completely to get covered. I drift along with the surprisingly fast current till I hit a slightly deeper section. I grab a breath and dive. As all other sounds mute instantly I am made keenly aware of the gnashing of teeth sound of fish feeding and the soothing melody of raindrops on water. I wish I could stay under forever.

As I come up, I spot our groupies who have stripped down to their birthday suits and are splashing around in the shallow end. I decide to have some fun. I jump up and crash through the water chasing them as they flee in all directions, terrified of the white beast from the deep. For me it's just a game so I'm shocked when I actually catch one and he's crying and screaming his brains out with a petrified look on his deer in the headlights stare.

I grab him, throw him over my shoulder and run back to the river where I toss him in. He comes up unsure and when he realizes I'm not going to torture or eat him he hesitantly starts to smile as his comrades in arms hoot and holler from the shore.


Several minutes later, I repeat the same thing, sure this time they'll realize it's all just a game. I chase down the chaplain's son, a boy well known to me who seems to like me and has never been afraid of me before...until now. As I pound my barefeet up the bank and through the ruts leading down to the river I find myself gaining on him easily. Just as I'm about to catch him, he rounds a small bush and does a face plant as his feet slip on the wet clay. Before I can laugh I follow him in a crash landing slide into home reaching out at the last minute to tag the plate by grabbing his leg.

As I stand up I am shocked to hear him shrieking in terror. "Je ne veux pas!!! Je ne veus pas!!! I don't want to..." I'm shocked. I try to calm him down. I definitely let go of him and try to tell him I'm not going to do anything and to stop screaming. He completely ignores me. Anyone within a mile must be sure that someone is torturing and killing something as he squeals like a stuck pig.

He is clutching desperately to a clump of grass as I back away. He won't let go even as I return to the river to wash off.

It's another brutal reminder of the differences in culture as I can only reason that here boys aren't used to rough-housing or playing with adults. In fact, about the only contact they have with an adult is if he is going to beat them or punish them in some way. So even though I've never given him a reason not to trust me and he just saw that I was just playing with his friend, he was sure something horrible was about to happen to him.

I weep for the kids of this country who are so often abandoned and neglected and left to fend for themselves even for the food they eat and grow up learning not to trust and that fear is the only way to interact with others.

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...