My life as a cripple began insignificantly enough.
As far as I can tell, it started with digging that latrine last Sunday morning. I must have accidently hit the inside of my right ankle with the pickax. Whatever the cause, by Sunday night it was swollen and painful. By Monday morning, I could barely walk and it was red and angry. I tried to go to work, hobbled around on lightning rounds before I couldn't take the pain.
At the same time, I was hit with the worst attack of Malaria since the first time I got it in 2004. By the time I hobbled home my muscles were twitching so badly and my teeth chattering so hard you'd of thought I was in the midst of a Danish blizzard instead of 110 degree sub-saharan Africa.
I slammed down 8 anti-malarial combo pills straight in from China and huddled under the blankets desperately trying to fight off the cold.
Did I mention my ankle was killing me?
After a day or two, the malaria was better, but as of last night, I hadn't walked in a week.
I'd been hoping there wouldn't be any surgical emergencies as you can imagine. Despite two symphysiotomies performed resting my bum leg on a stool on wheels in order to bring in two floppy, but eventually revivable newborns, things had been relatively calm.
Until last night...
After a leisurely Saturday lounging around with my foot elevated to control the edema listening to David Asherick talk about living in the End of Time, I found myself strangely drawn to the window around 5pm that evening. I picked up my crutches (hand made in Chad and borrowed from a bed-ridden patient) and limped over to the screen door facing the fence between us and the Emergency Room.
It was hard to see because of the two screens and the distance between me and the action, but I saw a group of people gathering hurredly. A couple of push carts moved back and forth. Two people were carrying a stretcher.
I was not surprised to see one of the Intern nurses, Aimée, coming up the path a few minutes later.
"There's a situation," she blurted out, gasping for breath. "There's been a fight at the market. They've brought in a bunch of victims. One woman's dead. A man has a huge knife wound to his neck. This other woman is all beat up around the head and unconscious. There's a baby that's been wounded..."
"Ok, ok, I'll be right there."
I pull on some scrubs as quickly as a cripple can and somehow cram my swollen foot into my crocs and hobble over. Crutches over moist, sandy soil is not easy.
I pull aside the curtain to the ER and see groups of people huddled around bloody clothes with arms and legs sticking out everywhere. Some are on beds, some on the ground. Sarah looks up.
"I think this one is the most critical. She's pregnant too. We can't get the baby's heart beat. She has a huge wound on her head."
In the midst of a bloody pile I see a slender, young Arab girl with a bulging middle sticking out of a brightly colored dress made even more bright by her life's fluid spilled all over it. Her face is irrecognizably swollen, contorted and bloodied. One eye is completely swollen shut and her long, tight braids are matted with the dark, drying human liquid.
Jason tells me one pupil doesn't react well. I don't bother to confirm.
Samedi and Abel have arrived. Simeon is there shortly. Ansley, Kristin, Emily and Jacob are also there.
I start shouting out orders.
"Get IV's started on everyone.
"I want one liter of Ringers running full speed.
"Give them all 2 grams of Ampicilline.
"Where's Stephan? Stephan, get a carton of those 1 L Ringers that just came yesterday.
"Is there a pharmacist? Where's Pierre?"
Andre has arrived and speaks up.
"I'll call him and get him right in," he says already punching in numbers on his cell phone.
"That guy there is probably the second sickest," Sarah shouts across the room as she attaches IV tubing to the arm of the first woman.
A young man is staring at me calmly. His once white pants are now tie dyed in his own color of red wine. A bundle of gauze has been taped under his right jaw on his neck.
I pull it off and see a 10cm laceration cut neatly from right under his chin to under his ear. It's about 5 cm deep and oozing a lot of blood until I push the compresses back in the gaping wound. It doesn't appear he got his jugular or carotid though. And he's breathing fine.
"Nathaneal, come and push on this as hard as you can...right there in the center of the wound. Don't let go."
IVs are running and nurses are frantically mixing up and administering Ampicillin.
"Jacob, you and Jason...et Abel aussi...go get the gurney from surgery...ABEL...LE BRANCARD...AU BLOC!" I yell at Abel since he's almost deaf, but one of our hardest workers and head nurse in surgery.
"Jacob, never mind, Jason and Abel can get the gurney, here take my keys and bring me the ultrasound from my office."
I briefly look at the other two women who are beat up and bruised but otherwise look ok. One is pregnant and I quickly do an ultrasound confirming the fetus is doing well.
Justine walks in with the baby who's mom had been killed, strapped to her back.
"She's not injured at all luckily, we just thought so at first because she was covered with blood."
"C'est bon!" I quip and head off to the OR.
In the OR, the lights aren't on so I hobble into the battery room/solar panel master control room and flip on the switch giving us solar power to light up the OR.
People scrambling around. IVs going up and flowing in. Needles, seringes, gauze, scalpels, instruments, suture, gloves, scissors, razors, shaved braids, and blood, blood everywhere.
After Abel finishes taking off a life's worth of braided African hair in a few minutes time, Samedi gets going suturing up the huge upside down V shaped gash in her scalp. She starts to moan, she had been unconscious we thought.
"Simeon, get her some Ketamine and Diazepam and put her under."
Meanwhile, there's a baby with anemia that no one has been able to find an IV on all day. They'd brought him to me at the house and I had tried putting a needle into the bone marrow of his tibia, but I didn't have the right needle and the others just kept bending. It was about this time that I was called for the mass casualty. Now, the baby i before me again.
"Jacob, give the baby a milliliter of Ketamine IM and strap him into the Papoose."
As Samedi starts suturing up the head wound, I slice into the baby's ankle and dissect down to the saphenous vein. I find it and slide in an IV catheter. We hook up the blood, see it's running in and I suture the wound closed around the IV.
They've now brought in the young man with the neck wound.
"Kristin, you and Ansley take this baby off to peds. Simeon, you and Jackson (Jason) move the man onto this gurney."
"If it wasn't for Allah, I'd be dead." The young man stares at me earnestly, speaking in Chadian Arabic.
"Alhamdullilah!" I reply and he nods and closes his eyes as he starts softly repeating Koranic verses.
I stay seated on my stool as Simeon puts him under anesthesia with the usual meds.
A couple sutures to bring the muscles together after washing it out well and a few loose skin stitches and I'm done.
"ABEL...PANSEMENT!" I point to the gauze bucket and to the man's neck. Abel and I have our own sign language between us. He nods and dives right in.
Meanwhile Emily has brought the ultrasound in to the OR and I do a quick ultrasound on the woman that Samedi has just finished stitching up her scalp. Her fetus is also doing well and at 32 weeks should survive even if the mom dies if we can do a C-section quick enough.
I grab my crutches and swing outside. Sarah is coming from the OR.
"They've just brought in another guy...a Nangjere man. The sous-prefet's truck is out looking for other victims. This one doesn't look too bad."
He's got some cuts on his hand and a stab wound to the shoulder blade that isn't deep. I leave it for Samedi and hobble home with the volunteers.
After a game of Settlers of Catan our second game is quickly interrupted with the arrival of more victims.
This time there're people scattered all over. Camouflaged gendarmes armed with AK47s and Kalishnikovs are unloading people from the truck. I just head straight to the OR and tell them to bring the worst one's in.
Samedi is just finishing up with the man I'd left him.
"James, I just heard the story of how it all started. It started with this guy..."
Apparently, the man was out in his field and saw some cows eating his rice. He challenged the herdsman, an Arab nomad. The nomad started to pull out his bow and arrow so the Nangjere man rushed him and grappled with him. The Arab pulled out his knife and the Nangjere grabbed the blade with his hand (hence the cuts). He quickly let go and the Arab stabbed him in the back. The man fainted and the Arab fled. The women watching assumed the Nangjere man was dead and ran to the market screaming bloody murder. When their relatives heard that their "brother" was dead, they attacked a group of Arab women just leaving the market. Hence our first wave of casualties. Now both sides were on the prowl and apparently a group of Nangjere had headed to the Arab village going from door to door dragging women and children out
and the Arab men were organizing their reprisals. There weren't enough gendarmes to control it so they were just picking up bodies and wounded.
Samedi finished and wheeled the man outside. At some point later on, he wisely dissappeared.
Now, they bring in a wiry Arab with the face of Kobe Bryant who has a huge slash across his right lower chest. It's about 25 cm long and all the way down to the ribs God gave him to protect his liver and lung. The other Arab is a wizened middle aged man with cuts all over. His main complaint is they've taken out his left eye but closer examination reveals a 10cm slash across his cheek and a left eye swollen shut. Small laceration cover his body and arms. An open dislocation of a finger I quickly "pop" back in. He also has a stab wound to his leg which has broken his tibia.
I put the tibia back in place, wash out the wound well, slosh some Betadine of a gauze and place it over the wound.
"Jacob, hold that tight. Jackson, keep pulling on his leg and hold it in this position. ABEL...PLATRE...PPPPLLLLLAAAATTTRRREEE!" He doesn't understand so I point him to the wound which he holds pressure to.
"Jacob, go get all the stuff for a cast. Just like we did last Saturday night: webroll, tubing, plaster, a basin of water, scissors"
"Simeon, Diazepam and Ketamine for this guy too." I point to the man with the chest wound.
"Ashadu Allah illaha ilalallah, wa ashadu ana Muhammador rasullallah." He starts to repeat over and over his Muslim creed until he drifts off. But he doesn't go quietly. He starts to have a reaction to the Ketamine and tenses all up not wanting to breath.
"Sarah, get me some Chlorpromazine." She can't find it.
"Someone get me some from the Pharmacy."
"There is none." replies Samedi. "I needed some last night and we're all out."
Just then Sarah comes out of the inside OR, "I found one ampoule."
The man finally calms down and I do a running subcutaneous suture to bring the muscles and fascia back together and then some loose interrupteds to bring the skin partly together, still allowing it to drain since it's contaminated.
"ABEL...PANSEMENT!" and I turn back to put the cast on the other Arab's leg while Samedi finishes suturing up all the lacerations.
Meanwhile, Kristin and Ansely and Augustin (who's just joined us) are working on another man just brought into the room on a stretcher.
"His intestine is sticking out his side and he's got a ton of cuts."
"Start an IV with Ringers. Simeon, Ampicilline 2g, Gentamycin 4 ampoules, Flagyl 2 bottles! Augustin, urinary catheter. Abel, nasogastric tube!"
I turn back to the fracture and Jacob has already wrapped it well. I wet the plaster and quickly wind it around the leg while Jason holds it in position.
"Hold it there until it's dry."
I turn to the guy on the floor. They've got all the antibiotics and tubes in and an IV is running well.
"Simeon, start the generator. Let's move him into the operating room."
A few minutes later I hop in on one foot having just scrubbed my hands and arms. I dry off and Abel puts on my gowns and gloves. The room is lit just by the two overhead OR lights focused on the betadined abdomen. Jacob slips me my stool and I position myself on the right side of the patient. We drape him and then Augustin prays.
I open him up from his sternum to his belly button and dark blood surges out. I suck it up and start exploring. There's no major gusher anywhere. In fact, I don't see any injury. The liver is fine. There is no stool in the abdomen. The stomach and intestines are undamaged. I pull out the omentum which is what had come out his side and cut off the contaminated part, tying off the vessels. As I can now examine the spleen as well I'm surprised to see no damage to that either. Where's the blood coming from?
Finally, I get Abel to give me a good look at the wound and I see air and blood spurting into the abdomen with each breath. Of course, it's coming from his lung through the punctured diaphragm.
That would also explain his poor oxygen saturation. Duh!
I suture up the diaphragmatic tear. Suck out as much blood as possible. Re-examine the spleen since I can't believe the knife left a 3cm laceration in the diaphragm right over the spleen without touching it, but the spleen is clean. I leave in a drain and close up.
Then I poke in a chest tube, hear the welcome rush of released air and a smattering of blood, hook him up to the water-seal/suction apparatus, suture up the large gash on his arm, the three small gashes on his back, and finally come to the left buttock.
Jacob and Abel hold him as we roll him on his right side. The wound is 15cm long and 10cm deep and bloody. I use a huge needle to bring the deep muscles together and then sew the fascia shut. I leave the skin loosely approximated and Abel and Simeon dress all the wounds.
It's a half hour after midnight when I get home. The truck drives up again an hour later but since no one comes to get me I fall back asleep. At six o-clock, my haggard, yet still beautiful wife shakes me awake.
"Well, they brought in a bunch more Arab women but they all only have minor injuries so I didn't wake you. They also brought in three more bodies. "Do you want to continue antibiotics or anything else on that guy you operated on?"
Oh yeah, post-op orders would be nice. Sarah smilingly holds out an OR order sheet that I quickly fill out.
She comes back at 8am showing me her lab slip.
"Yeah, not only was that the craziest night shift I've ever done, but I had malaria the whole time!"
An hour later, I limp over to the hospital on my crutches to see the patients. Everyone is doing well. All the women are awake, and while in pain and swollen all over are able to sit up and take some water. The neck and chest wound men are also awake and praising Allah. The man with the punctured lung is also stable but not too awake yet.
Just then, a huge group of robed and turbaned Arabs flows in accompanied by a bunch of soldiers with machine guns. They go through and out the back gate to the morgue. I continue to the ER to see the other patients who'd arrived after I'd gone back to bed.
I've just started and Djibrine, the nurse in charge of supervising our district's health centers comes in.
"The governor and the sous-prefet want to see all the wounded."
I find them in the wards packed in with Arabs and gendarmes. I send most of them out with the full support of the sous-prefet except for a couple of guards for the governor and the rest of his team. I show them around as they take town everyone's name and injuries and put them either on the Nangjere or Arab list.
I finally make it home at noon and my ankle has ballooned.
I think I might always be a cripple.
Monday, October 13, 2008
Tuesday, October 7, 2008
Le week-end
Boy, am I glad I went to bed early Friday night!
It was still dark and sticky when I woke up around 4am thanks to the pitter patter of little rat feet running back and forth directly over my head as I lay in a profound sleep. Now, I can't go back to sleep. Every time I'm about to find dreamland again I hear the scurrying or the flapping of a bat outside my screen window. I give up and get up.
I put on a headlamp so I don't wake Sarah with the overhead light and go out to the kitchen table. I grab my French Bible and finish preparing the sermon I'll give in church later on this morning. At 5am I'm finally able to catch a few more winks before the pink early morning light filters in the windows accompanied by the ever vigilant roosters.
I eat a simple breakfast of local peanut butter on toast with guava sauce. meanwhile, Sarah has gone out to feed the horses and locked me in! I stare out the bedroom window waiting for someone to come within calling range. Kitty hops up to the window sill to join me in my quiet contemplation of the African dawn. Some purple, pipe-cleaner type flowers have shot up just outside the screen and a zebra looking bee is buzzing merrily amongst the bristles. Everything is green and the guavas are getting bigger and bigger although they're still very green.
Finally, I spot Emily, a volunteer just arrived yesterday who responds to my please for freedom and unbolts the outside latch on the front door. I pack up my books in a tiny bag and hoist my heavy, hollowed out tree trunk drum to my shoulder and head off to the church.
The ancient French hymns sung off key that come wafting out of the church are soon replaced by a more African rendering as Allah, our new nurse Augustin's 10 year old son, starts pounding out some rhythms on the drum accompanied by my little tambourine.
I have a very interesting discussion with a bunch of young people interested in finding out what Christianity is about. We talk about the Bible and how it came about and who wrote it and why it's important because it's a collection of stories telling us how God interacts with people despite all their warts and wrinkles.
Then I preach my sermon in French with Nangjere translation. Afterwards, Simeon is waiting for me outside.
"There are a couple of patients you should come see."
I hurry home, change into scrubs and mosey off to the hospital.
Our friend, Polycarpe, the child with the bleeding disorder we've been transfusing almost every week for the last few months is having severe abdominal pain. He also had some bloody diarrhea. I'd been saving the plasma part of other people's blood transfusions by storing them in the kerosene freezer. Yesterday, they were supposed to thaw it out, let any remaining red blood cells filter out and give Polycarpe the plasma. It hadn't been done. I quickly hook him up to the plasma and give him some
malaria treatment. I hope to avoid another transfusion.
A three year old child with a hemoglobin of 4.3 g/dl still hasn't got a blood transfusion. Seven family members have been tested with no one who can give her the blood she needs. Her blood type is B-, the same as me. I just gave blood last week, but what the heck. I tell Simeon to call the lab guy, find an IV and I'll be back.
I figure I'd better eat something first. I go home and Sarah has heated up yesterday's eggplant spaghetti sauce. We eat and then I drink another liter of water and head back to the hospital.
Mathieu is waiting for me. I lie down on the examining table in my office as Mathieu prepares the blood bag, wraps a tourniquet around my arm, uses alcohol soaked cotton to wipe off the skin over the big vein in the middle of my arm and slides in a huge needle effortlessly into the vein. I pump my fist to make the blood go out faster and I've quickly filled up the 450ml bag. Mathieu takes out the needle and puts a cotton ball over the puncture wound. I flod my arm up, sit up and get ready to go.
"Already?" Mathieu asks, astonished. "Aren't you dizzy?"
"No, I just ate and drank a bunch so I'm fine."
I head out the door and meet Sarah at the house where she's already saddled my horse, Bob. Sarah takes off on her horse, Pepper, while the volunteers follow on foot. I change into jeans, grab some water bottles and jump on Bob. Allah, my drumming friend from this morning is coming with me. I swing him up by his arm into the saddle behind me and we take off at a trot. Allah bounces around and we have to stop and walk often but eventually we catch up with the others.
The rice fields are completely swamped and the path is nothing but a swath of still water meandering amongst the rice stalks already starting to bend at the neck from the weight of their kernels.
It's blazing hot and the water splashing up from Bob's hooves is a welcome, mild relief from the sweltering heat.
The river has way overflown it's banks swallowing up all the familiar landmarks except a few trees bravely sticking their branches up from the swirling eddies. We wade out towards the current through what used to be a large field leading down to the cattle crossing. Jason, Jacob and Nathaneal have already almost reached the current as I start out and they are quickly swept downstream. I find the current and swiftly catch up to them where they rest holding onto some branches sticking out of the water as the water rushing by makes it sound like we're in a mountain stream rather than a flat river winding through the African bush.
I'm vaguely scared of hippos, though they probably won't like the fast current, and am again glad there are no longer crocs in these rivers.
After several bends we pull ourselves up the bank by grabbing onto piles of tall grasses and follow the sketchy, grown paths through the bush on the bank of the river trying to be as loud as possible to scare off vipers. Back where Sarah and the others are playing with some of the Chadian kids, the guys and I head up river just a tad where we see a tree coming out of the river near the bank and then bending out conveniently at a right angle where we can jump off.
After some jumps to test the depth, we dive and do back flips venturing ever higher on ever thinner branches until we've exhausted the possibilities.
Heading home on Bob with Allah I have a hard time holding the horse back as he smells his dried corn at home already! Packs of mosquitoes buzz along with us in the twilight as the sun has gone down over half an hour ago. Finally, Allah can't take any more so once we hit the first huts of the village he gets off and I let Bob go rushing off through the approaching night with the wind whipping around me leaving the mosquitoes far behind.
I arrive in time to see Augustin returning from church. He informs me that Samedi is looking for me as there was a motorcycle accident.
I quickly pull off the muddy saddle and harness from Bob, open the door, strip off my soaked jeans, take a fast shower and pull on scrubs to head over to the hospital.
The ER is dimly lit by it's one fluorescent bulb crowded with buzzing insects. A small pool of blood has formed at the foot of the bed where the middle aged, portly woman lies with her left ankle at an impossible angle like it's been shifted completely towards the middle. A blood soaked gauze pad is tied on tightly over the lateral ankle where I assume the bone came poking out. She has no other injuries.
They've also just brought in another elderly woman in a push cart who I can tell needs an amputation just by the smell and the sight of the left foot wrapped in dirty rags over a mud soaked gauze wrap. Sure enough, cutting off the rags and gauze reveals wet, blackened toes with the calloused skin on the sole peeling off and a large, pus filled central wound on top revealing the tendons and bones.
The guy driving the motorcycle that had fallen over causing the woman's broken ankle has a swollen hand with probably some fractures. As I wait for the two women to pay for their surgeries, I quickly apply a combo plaster and fiberglass cast to the man's hand and wrist, give him some Ibuprofen and tell him to go to Moundou and get some x-rays.
The family of the woman with the broken ankle are having internal conflicts as to who will pay so since the son of the woman with the rotten foot has paid half and put his bicycle on as collateral, we start with her.
Hoping to do a mid foot amputation only I squeeze the blood out of her leg, apply a blood pressure cuff as tourniquet and slice through the bottom of her foot right into a pocket of pus. Her foot is gone. I quickly move up to the middle of the lower leg and slice down to bone. I scrape the tissue off the bone as far up as I can then painfully and slowly saw through the tibia and fibula with a tiny inch long saw that keeps clogging up with wet bone paste. Finally, I get the leg sawed off, identify the major vascular bundles, clamp and tie them and close the muscles and skin over the stump.
The second woman has finally found a solution so we find an IV, give her some Ketamine and Diazepam and I pull her foot down and out into position. The fibula gets stuck on some tissue inside but with some manipulation I free it up and get it into anatomical position. The medial malleolus (the part of the tibia that makes up the ankle joint) is crushed in several pieces. The fibula part of the ankle seems to have only one break, but it's an open fracture. Abel mixes up some diluted bleach solution and I wash it out well. I close the subcutaneous tissues, apply a dressing with Betadine and while I try to hold the foot and ankle in as good a position as possible, Jacob wraps the foot and leg up to the knee with web roll and then applies a plaster cast. I am able to mold the ankle some more and get the foot in a good position. The cast hardens and we take her out to her bed.
It's 11pm.
I go home. I haven't eaten since lunch, since giving blood, since riding to the river, since swimming and jumping off trees, since riding back and since doing two operations.
I'm slightly hungry and am so grateful to find a skillet filled with fried rice and eggs. I devour it. It's only later that Sarah informs me that was supposed to be enough for supper and breakfast the next day.
I fall fast asleep until the rat wakes me up again at 5:30am this time. Sarah and I get up, grab the shovels and pick and go out behind the church to dig a latrine...a typical weekend is half over in Bere, Tchad... Boy, am I glad I went to bed early Friday night!
It was still dark and sticky when I woke up around 4am thanks to the pitter patter of little rat feet running back and forth directly over my head as I lay in a profound sleep. Now, I can't go back to sleep. Every time I'm about to find dreamland again I hear the scurrying or the flapping of a bat outside my screen window. I give up and get up.
I put on a headlamp so I don't wake Sarah with the overhead light and go out to the kitchen table. I grab my French Bible and finish preparing the sermon I'll give in church later on this morning. At 5am I'm finally able to catch a few more winks before the pink early morning light filters in the windows accompanied by the ever vigilant roosters.
I eat a simple breakfast of local peanut butter on toast with guava sauce. Meanwhile, Sarah has gone out to feed the horses and locked me in! I stare out the bedroom window waiting for someone to come within calling range. Kitty hops up to the window sill to join me in my quiet contemplation of the African dawn. Some purple, pipe-cleaner type flowers have shot up just outside the screen and a zebra looking bee is buzzing merrily amongst the bristles. Everything is green and the guavas are getting bigger and bigger although they're still very green.
Finally, I spot Emily, a volunteer just arrived yesterday who responds to my please for freedom and unbolts the outside latch on the front door. I pack up my books in a tiny bag and hoist my heavy, hollowed out tree trunk drum to my shoulder and head off to the church.
The ancient French hymns sung off key that come wafting out of the church are soon replaced by a more African rendering as Allah, our new nurse Augustin's 10 year old son, starts pounding out some rhythms on the drum accompanied by my little tambourine.
I have a very interesting discussion with a bunch of young people interested in finding out what Christianity is about. We talk about the Bible and how it came about and who wrote it and why it's important because it's a collection of stories telling us how God interacts with people despite all their warts and wrinkles.
Then I preach my sermon in French with Nangjere translation. Afterwards, Simeon is waiting for me outside.
"There are a couple of patients you should come see."
I hurry home, change into scrubs and mosey off to the hospital.
Our friend, Polycarpe, the child with the bleeding disorder we've been transfusing almost every week for the last few months is having severe abdominal pain. He also had some bloody diarrhea. I'd been saving the plasma part of other people's blood transfusions by storing them in the kerosene freezer. Yesterday, they were supposed to thaw it out, let any remaining red blood cells filter out and give Polycarpe the plasma. It hadn't been done. I quickly hook him up to the plasma and give him some
malaria treatment. I hope to avoid another transfusion.
A three year old child with a hemoglobin of 4.3 g/dl still hasn't got a blood transfusion. Seven family members have been tested with no one who can give her the blood she needs. Her blood type is B-, the same as me. I just gave blood last week, but what the heck. I tell Simeon to call the lab guy, find an IV and I'll be back.
I figure I'd better eat something first. I go home and Sarah has heated up yesterday's eggplant spaghetti sauce. We eat and then I drink another liter of water and head back to the hospital.
Mathieu is waiting for me. I lie down on the examining table in my office as Mathieu prepares the blood bag, wraps a tourniquet around my arm, uses alcohol soaked cotton to wipe off the skin over the big vein in the middle of my arm and slides in a huge needle effortlessly into the vein. I pump my fist to make the blood go out faster and I've quickly filled up the 450ml bag. Mathieu takes out the needle and puts a cotton ball over the puncture wound. I flod my arm up, sit up and get ready to go.
"Already?" Mathieu asks, astonished. "Aren't you dizzy?"
"No, I just ate and drank a bunch so I'm fine."
I head out the door and meet Sarah at the house where she's already saddled my horse, Bob. Sarah takes off on her horse, Pepper, while the volunteers follow on foot. I change into jeans, grab some water bottles and jump on Bob. Allah, my drumming friend from this morning is coming with me. I swing him up by his arm into the saddle behind me and we take off at a trot. Allah bounces around and we have to stop and walk often but eventually we catch up with the others.
The rice fields are completely swamped and the path is nothing but a swath of still water meandering amongst the rice stalks already starting to bend at the neck from the weight of their kernels.
It's blazing hot and the water splashing up from Bob's hooves is a welcome, mild relief from the sweltering heat.
The river has way overflown it's banks swallowing up all the familiar landmarks except a few trees bravely sticking their branches up from the swirling eddies. We wade out towards the current through what used to be a large field leading down to the cattle crossing. Jason, Jacob and Nathaneal have already almost reached the current as I start out and they are quickly swept downstream. I find the current and swiftly catch up to them where they rest holding onto some branches sticking out of the water as the water rushing by makes it sound like we're in a mountain stream rather than a flat river winding through the African bush.
I'm vaguely scared of hippos, though they probably won't like the fast current, and am again glad there are no longer crocs in these rivers.
After several bends we pull ourselves up the bank by grabbing onto piles of tall grasses and follow the sketchy, grown paths through the bush on the bank of the river trying to be as loud as possible to scare off vipers.
Back where Sarah and the others are playing with some of the Chadian kids, the guys and I head up river just a tad where we see a tree coming out of the river near the bank and then bending out conveniently at a right angle where we can jump off.
After some jumps to test the depth, we dive and do back flips venturing ever higher on ever thinner branches until we've exhausted the possibilities.
Heading home on Bob with Allah I have a hard time holding the horse back as he smells his dried corn at home already! Packs of mosquitos buzz along with us in the twilight as the sun has gone down over half an hour ago. Finally, Allah can't take any more so once we hit the first huts of the village he gets off and I let Bob go rushing off through the approaching night with the wind whipping around me leaving the mosquitos far behind.
I arrive in time to see Augustin returning from church. He informs me that Samedi is looking for me as there was a motorcycle accident.
I quickly pull off the muddy saddle and harness from Bob, open the door, strip off my soaked jeans, take a fast shower and pull on scrubs to head over to the hospital.
The ER is dimly lit by it's one flourescent bulb crowded with buzzing insects. A small pool of blood has formed at the foot of the bed where the middle aged, portly woman lies with her left ankle at an impossible angle like it's been shifted completely towards the middle. A blood soaked gauze pad is tied on tightly over the lateral ankle where I assume the bone came poking out. She has no other injuries.
They've also just brought in another elderly woman in a push cart who I can tell needs an amputation just by the smell and the sight of the left foot wrapped in dirty rags over a mud soaked gauze wrap. Sure enough, cutting off the rags and gauze reveals wet, blackened toes with the calloused skin on the sole peeling off and a large, pus filled central wound on top revealing the tendons and bones.
The guy driving the motorcycle that had fallen over causing the woman's broken ankle has a swollen hand with probably some fractures. As I wait for the two women to pay for their surgeries, I quickly apply a combo plaster and fiberglass cast to the man's hand and wrist, give him some Ibuprofen and tell him to go to Moundou and get some x-rays.
The family of the woman with the broken ankle are having internal conflicts as to who will pay so since the son of the woman with the rotten foot has paid half and put his bicycle on as collateral, we start with her.
Hoping to do a midfoot amputation only I squeeze the blood out of her leg, apply a blood pressure cuff as tourniquet and slice through the bottom of her foot right into a pocket of pus. Her foot is gone. I quickly move up to the middle of the lower leg and slice down to bone. I scrape the tissue off the bone as far up as I can then painfully and slowly saw through the tibia and fibula with a tiny inch long saw that keeps clogging up with wet bone paste. Finally, I get the leg sawed off, identify the major vascular bundles, clamp and tie them and close the muscles and skin over the stump.
The second woman has finally found a solution so we find an IV, give her some Ketamine and Diazepam and I pull her foot down and out into position. The fibula gets stuck on some tissue inside but with some manipulation I free it up and get it into anatomical position. The medial malleolus (the part of the tibia that makes up the ankle joint) is crushed in several pieces. The fibula part of the ankle seems to have only one break, but it's an open fracture. Abel mixes up some diluted bleach solution and I wash it out well. I close the subcutaneous tissues, apply a dressing with Betadine and while I try to hold the foot and ankle in as good a position as possible, Jacob wraps the foot and leg up to the knee with web roll and then applies a plaster cast. I am able to mold the ankle some more and get the foot in a good position. The cast hardens and we take her out to her bed.
It's 11pm.
I go home. I haven't eaten since lunch, since giving blood, since riding to the river, since swimming and jumping off trees, since riding back and since doing two operations.
I'm slightly hungry and am so grateful to find a skillet filled with fried rice and eggs. I devour it. It's only later that Sarah informs me that was supposed to be enough for supper and breakfast the next day.
I fall fast asleep until the rat wakes me up again at 5:30am this time. Sarah and I get up, grab the shovels and pick and go out behind the church to dig a latrine...a typical weekend is half over in Bere, Tchad...
Skillet filled with fried rice and eggs. I devour it. It's only later that Sarah informs me that was supposed to be enough for supper and breakfast the next day.
I fall fast asleep until the rat wakes me up again at 5:30am this time. Sarah and I get up, grab the shovels and pick and go out behind the church to dig a latrine...a typical weekend is half over in Bere, Tchad...
It was still dark and sticky when I woke up around 4am thanks to the pitter patter of little rat feet running back and forth directly over my head as I lay in a profound sleep. Now, I can't go back to sleep. Every time I'm about to find dreamland again I hear the scurrying or the flapping of a bat outside my screen window. I give up and get up.
I put on a headlamp so I don't wake Sarah with the overhead light and go out to the kitchen table. I grab my French Bible and finish preparing the sermon I'll give in church later on this morning. At 5am I'm finally able to catch a few more winks before the pink early morning light filters in the windows accompanied by the ever vigilant roosters.
I eat a simple breakfast of local peanut butter on toast with guava sauce. meanwhile, Sarah has gone out to feed the horses and locked me in! I stare out the bedroom window waiting for someone to come within calling range. Kitty hops up to the window sill to join me in my quiet contemplation of the African dawn. Some purple, pipe-cleaner type flowers have shot up just outside the screen and a zebra looking bee is buzzing merrily amongst the bristles. Everything is green and the guavas are getting bigger and bigger although they're still very green.
Finally, I spot Emily, a volunteer just arrived yesterday who responds to my please for freedom and unbolts the outside latch on the front door. I pack up my books in a tiny bag and hoist my heavy, hollowed out tree trunk drum to my shoulder and head off to the church.
The ancient French hymns sung off key that come wafting out of the church are soon replaced by a more African rendering as Allah, our new nurse Augustin's 10 year old son, starts pounding out some rhythms on the drum accompanied by my little tambourine.
I have a very interesting discussion with a bunch of young people interested in finding out what Christianity is about. We talk about the Bible and how it came about and who wrote it and why it's important because it's a collection of stories telling us how God interacts with people despite all their warts and wrinkles.
Then I preach my sermon in French with Nangjere translation. Afterwards, Simeon is waiting for me outside.
"There are a couple of patients you should come see."
I hurry home, change into scrubs and mosey off to the hospital.
Our friend, Polycarpe, the child with the bleeding disorder we've been transfusing almost every week for the last few months is having severe abdominal pain. He also had some bloody diarrhea. I'd been saving the plasma part of other people's blood transfusions by storing them in the kerosene freezer. Yesterday, they were supposed to thaw it out, let any remaining red blood cells filter out and give Polycarpe the plasma. It hadn't been done. I quickly hook him up to the plasma and give him some
malaria treatment. I hope to avoid another transfusion.
A three year old child with a hemoglobin of 4.3 g/dl still hasn't got a blood transfusion. Seven family members have been tested with no one who can give her the blood she needs. Her blood type is B-, the same as me. I just gave blood last week, but what the heck. I tell Simeon to call the lab guy, find an IV and I'll be back.
I figure I'd better eat something first. I go home and Sarah has heated up yesterday's eggplant spaghetti sauce. We eat and then I drink another liter of water and head back to the hospital.
Mathieu is waiting for me. I lie down on the examining table in my office as Mathieu prepares the blood bag, wraps a tourniquet around my arm, uses alcohol soaked cotton to wipe off the skin over the big vein in the middle of my arm and slides in a huge needle effortlessly into the vein. I pump my fist to make the blood go out faster and I've quickly filled up the 450ml bag. Mathieu takes out the needle and puts a cotton ball over the puncture wound. I flod my arm up, sit up and get ready to go.
"Already?" Mathieu asks, astonished. "Aren't you dizzy?"
"No, I just ate and drank a bunch so I'm fine."
I head out the door and meet Sarah at the house where she's already saddled my horse, Bob. Sarah takes off on her horse, Pepper, while the volunteers follow on foot. I change into jeans, grab some water bottles and jump on Bob. Allah, my drumming friend from this morning is coming with me. I swing him up by his arm into the saddle behind me and we take off at a trot. Allah bounces around and we have to stop and walk often but eventually we catch up with the others.
The rice fields are completely swamped and the path is nothing but a swath of still water meandering amongst the rice stalks already starting to bend at the neck from the weight of their kernels.
It's blazing hot and the water splashing up from Bob's hooves is a welcome, mild relief from the sweltering heat.
The river has way overflown it's banks swallowing up all the familiar landmarks except a few trees bravely sticking their branches up from the swirling eddies. We wade out towards the current through what used to be a large field leading down to the cattle crossing. Jason, Jacob and Nathaneal have already almost reached the current as I start out and they are quickly swept downstream. I find the current and swiftly catch up to them where they rest holding onto some branches sticking out of the water as the water rushing by makes it sound like we're in a mountain stream rather than a flat river winding through the African bush.
I'm vaguely scared of hippos, though they probably won't like the fast current, and am again glad there are no longer crocs in these rivers.
After several bends we pull ourselves up the bank by grabbing onto piles of tall grasses and follow the sketchy, grown paths through the bush on the bank of the river trying to be as loud as possible to scare off vipers. Back where Sarah and the others are playing with some of the Chadian kids, the guys and I head up river just a tad where we see a tree coming out of the river near the bank and then bending out conveniently at a right angle where we can jump off.
After some jumps to test the depth, we dive and do back flips venturing ever higher on ever thinner branches until we've exhausted the possibilities.
Heading home on Bob with Allah I have a hard time holding the horse back as he smells his dried corn at home already! Packs of mosquitoes buzz along with us in the twilight as the sun has gone down over half an hour ago. Finally, Allah can't take any more so once we hit the first huts of the village he gets off and I let Bob go rushing off through the approaching night with the wind whipping around me leaving the mosquitoes far behind.
I arrive in time to see Augustin returning from church. He informs me that Samedi is looking for me as there was a motorcycle accident.
I quickly pull off the muddy saddle and harness from Bob, open the door, strip off my soaked jeans, take a fast shower and pull on scrubs to head over to the hospital.
The ER is dimly lit by it's one fluorescent bulb crowded with buzzing insects. A small pool of blood has formed at the foot of the bed where the middle aged, portly woman lies with her left ankle at an impossible angle like it's been shifted completely towards the middle. A blood soaked gauze pad is tied on tightly over the lateral ankle where I assume the bone came poking out. She has no other injuries.
They've also just brought in another elderly woman in a push cart who I can tell needs an amputation just by the smell and the sight of the left foot wrapped in dirty rags over a mud soaked gauze wrap. Sure enough, cutting off the rags and gauze reveals wet, blackened toes with the calloused skin on the sole peeling off and a large, pus filled central wound on top revealing the tendons and bones.
The guy driving the motorcycle that had fallen over causing the woman's broken ankle has a swollen hand with probably some fractures. As I wait for the two women to pay for their surgeries, I quickly apply a combo plaster and fiberglass cast to the man's hand and wrist, give him some Ibuprofen and tell him to go to Moundou and get some x-rays.
The family of the woman with the broken ankle are having internal conflicts as to who will pay so since the son of the woman with the rotten foot has paid half and put his bicycle on as collateral, we start with her.
Hoping to do a mid foot amputation only I squeeze the blood out of her leg, apply a blood pressure cuff as tourniquet and slice through the bottom of her foot right into a pocket of pus. Her foot is gone. I quickly move up to the middle of the lower leg and slice down to bone. I scrape the tissue off the bone as far up as I can then painfully and slowly saw through the tibia and fibula with a tiny inch long saw that keeps clogging up with wet bone paste. Finally, I get the leg sawed off, identify the major vascular bundles, clamp and tie them and close the muscles and skin over the stump.
The second woman has finally found a solution so we find an IV, give her some Ketamine and Diazepam and I pull her foot down and out into position. The fibula gets stuck on some tissue inside but with some manipulation I free it up and get it into anatomical position. The medial malleolus (the part of the tibia that makes up the ankle joint) is crushed in several pieces. The fibula part of the ankle seems to have only one break, but it's an open fracture. Abel mixes up some diluted bleach solution and I wash it out well. I close the subcutaneous tissues, apply a dressing with Betadine and while I try to hold the foot and ankle in as good a position as possible, Jacob wraps the foot and leg up to the knee with web roll and then applies a plaster cast. I am able to mold the ankle some more and get the foot in a good position. The cast hardens and we take her out to her bed.
It's 11pm.
I go home. I haven't eaten since lunch, since giving blood, since riding to the river, since swimming and jumping off trees, since riding back and since doing two operations.
I'm slightly hungry and am so grateful to find a skillet filled with fried rice and eggs. I devour it. It's only later that Sarah informs me that was supposed to be enough for supper and breakfast the next day.
I fall fast asleep until the rat wakes me up again at 5:30am this time. Sarah and I get up, grab the shovels and pick and go out behind the church to dig a latrine...a typical weekend is half over in Bere, Tchad... Boy, am I glad I went to bed early Friday night!
It was still dark and sticky when I woke up around 4am thanks to the pitter patter of little rat feet running back and forth directly over my head as I lay in a profound sleep. Now, I can't go back to sleep. Every time I'm about to find dreamland again I hear the scurrying or the flapping of a bat outside my screen window. I give up and get up.
I put on a headlamp so I don't wake Sarah with the overhead light and go out to the kitchen table. I grab my French Bible and finish preparing the sermon I'll give in church later on this morning. At 5am I'm finally able to catch a few more winks before the pink early morning light filters in the windows accompanied by the ever vigilant roosters.
I eat a simple breakfast of local peanut butter on toast with guava sauce. Meanwhile, Sarah has gone out to feed the horses and locked me in! I stare out the bedroom window waiting for someone to come within calling range. Kitty hops up to the window sill to join me in my quiet contemplation of the African dawn. Some purple, pipe-cleaner type flowers have shot up just outside the screen and a zebra looking bee is buzzing merrily amongst the bristles. Everything is green and the guavas are getting bigger and bigger although they're still very green.
Finally, I spot Emily, a volunteer just arrived yesterday who responds to my please for freedom and unbolts the outside latch on the front door. I pack up my books in a tiny bag and hoist my heavy, hollowed out tree trunk drum to my shoulder and head off to the church.
The ancient French hymns sung off key that come wafting out of the church are soon replaced by a more African rendering as Allah, our new nurse Augustin's 10 year old son, starts pounding out some rhythms on the drum accompanied by my little tambourine.
I have a very interesting discussion with a bunch of young people interested in finding out what Christianity is about. We talk about the Bible and how it came about and who wrote it and why it's important because it's a collection of stories telling us how God interacts with people despite all their warts and wrinkles.
Then I preach my sermon in French with Nangjere translation. Afterwards, Simeon is waiting for me outside.
"There are a couple of patients you should come see."
I hurry home, change into scrubs and mosey off to the hospital.
Our friend, Polycarpe, the child with the bleeding disorder we've been transfusing almost every week for the last few months is having severe abdominal pain. He also had some bloody diarrhea. I'd been saving the plasma part of other people's blood transfusions by storing them in the kerosene freezer. Yesterday, they were supposed to thaw it out, let any remaining red blood cells filter out and give Polycarpe the plasma. It hadn't been done. I quickly hook him up to the plasma and give him some
malaria treatment. I hope to avoid another transfusion.
A three year old child with a hemoglobin of 4.3 g/dl still hasn't got a blood transfusion. Seven family members have been tested with no one who can give her the blood she needs. Her blood type is B-, the same as me. I just gave blood last week, but what the heck. I tell Simeon to call the lab guy, find an IV and I'll be back.
I figure I'd better eat something first. I go home and Sarah has heated up yesterday's eggplant spaghetti sauce. We eat and then I drink another liter of water and head back to the hospital.
Mathieu is waiting for me. I lie down on the examining table in my office as Mathieu prepares the blood bag, wraps a tourniquet around my arm, uses alcohol soaked cotton to wipe off the skin over the big vein in the middle of my arm and slides in a huge needle effortlessly into the vein. I pump my fist to make the blood go out faster and I've quickly filled up the 450ml bag. Mathieu takes out the needle and puts a cotton ball over the puncture wound. I flod my arm up, sit up and get ready to go.
"Already?" Mathieu asks, astonished. "Aren't you dizzy?"
"No, I just ate and drank a bunch so I'm fine."
I head out the door and meet Sarah at the house where she's already saddled my horse, Bob. Sarah takes off on her horse, Pepper, while the volunteers follow on foot. I change into jeans, grab some water bottles and jump on Bob. Allah, my drumming friend from this morning is coming with me. I swing him up by his arm into the saddle behind me and we take off at a trot. Allah bounces around and we have to stop and walk often but eventually we catch up with the others.
The rice fields are completely swamped and the path is nothing but a swath of still water meandering amongst the rice stalks already starting to bend at the neck from the weight of their kernels.
It's blazing hot and the water splashing up from Bob's hooves is a welcome, mild relief from the sweltering heat.
The river has way overflown it's banks swallowing up all the familiar landmarks except a few trees bravely sticking their branches up from the swirling eddies. We wade out towards the current through what used to be a large field leading down to the cattle crossing. Jason, Jacob and Nathaneal have already almost reached the current as I start out and they are quickly swept downstream. I find the current and swiftly catch up to them where they rest holding onto some branches sticking out of the water as the water rushing by makes it sound like we're in a mountain stream rather than a flat river winding through the African bush.
I'm vaguely scared of hippos, though they probably won't like the fast current, and am again glad there are no longer crocs in these rivers.
After several bends we pull ourselves up the bank by grabbing onto piles of tall grasses and follow the sketchy, grown paths through the bush on the bank of the river trying to be as loud as possible to scare off vipers.
Back where Sarah and the others are playing with some of the Chadian kids, the guys and I head up river just a tad where we see a tree coming out of the river near the bank and then bending out conveniently at a right angle where we can jump off.
After some jumps to test the depth, we dive and do back flips venturing ever higher on ever thinner branches until we've exhausted the possibilities.
Heading home on Bob with Allah I have a hard time holding the horse back as he smells his dried corn at home already! Packs of mosquitos buzz along with us in the twilight as the sun has gone down over half an hour ago. Finally, Allah can't take any more so once we hit the first huts of the village he gets off and I let Bob go rushing off through the approaching night with the wind whipping around me leaving the mosquitos far behind.
I arrive in time to see Augustin returning from church. He informs me that Samedi is looking for me as there was a motorcycle accident.
I quickly pull off the muddy saddle and harness from Bob, open the door, strip off my soaked jeans, take a fast shower and pull on scrubs to head over to the hospital.
The ER is dimly lit by it's one flourescent bulb crowded with buzzing insects. A small pool of blood has formed at the foot of the bed where the middle aged, portly woman lies with her left ankle at an impossible angle like it's been shifted completely towards the middle. A blood soaked gauze pad is tied on tightly over the lateral ankle where I assume the bone came poking out. She has no other injuries.
They've also just brought in another elderly woman in a push cart who I can tell needs an amputation just by the smell and the sight of the left foot wrapped in dirty rags over a mud soaked gauze wrap. Sure enough, cutting off the rags and gauze reveals wet, blackened toes with the calloused skin on the sole peeling off and a large, pus filled central wound on top revealing the tendons and bones.
The guy driving the motorcycle that had fallen over causing the woman's broken ankle has a swollen hand with probably some fractures. As I wait for the two women to pay for their surgeries, I quickly apply a combo plaster and fiberglass cast to the man's hand and wrist, give him some Ibuprofen and tell him to go to Moundou and get some x-rays.
The family of the woman with the broken ankle are having internal conflicts as to who will pay so since the son of the woman with the rotten foot has paid half and put his bicycle on as collateral, we start with her.
Hoping to do a midfoot amputation only I squeeze the blood out of her leg, apply a blood pressure cuff as tourniquet and slice through the bottom of her foot right into a pocket of pus. Her foot is gone. I quickly move up to the middle of the lower leg and slice down to bone. I scrape the tissue off the bone as far up as I can then painfully and slowly saw through the tibia and fibula with a tiny inch long saw that keeps clogging up with wet bone paste. Finally, I get the leg sawed off, identify the major vascular bundles, clamp and tie them and close the muscles and skin over the stump.
The second woman has finally found a solution so we find an IV, give her some Ketamine and Diazepam and I pull her foot down and out into position. The fibula gets stuck on some tissue inside but with some manipulation I free it up and get it into anatomical position. The medial malleolus (the part of the tibia that makes up the ankle joint) is crushed in several pieces. The fibula part of the ankle seems to have only one break, but it's an open fracture. Abel mixes up some diluted bleach solution and I wash it out well. I close the subcutaneous tissues, apply a dressing with Betadine and while I try to hold the foot and ankle in as good a position as possible, Jacob wraps the foot and leg up to the knee with web roll and then applies a plaster cast. I am able to mold the ankle some more and get the foot in a good position. The cast hardens and we take her out to her bed.
It's 11pm.
I go home. I haven't eaten since lunch, since giving blood, since riding to the river, since swimming and jumping off trees, since riding back and since doing two operations.
I'm slightly hungry and am so grateful to find a skillet filled with fried rice and eggs. I devour it. It's only later that Sarah informs me that was supposed to be enough for supper and breakfast the next day.
I fall fast asleep until the rat wakes me up again at 5:30am this time. Sarah and I get up, grab the shovels and pick and go out behind the church to dig a latrine...a typical weekend is half over in Bere, Tchad...
Skillet filled with fried rice and eggs. I devour it. It's only later that Sarah informs me that was supposed to be enough for supper and breakfast the next day.
I fall fast asleep until the rat wakes me up again at 5:30am this time. Sarah and I get up, grab the shovels and pick and go out behind the church to dig a latrine...a typical weekend is half over in Bere, Tchad...
Monday, September 29, 2008
Police
It's strange, because if I'd been in the US and the same thing happened, I'd be scared spitless. It happened like this...
I'm in N'Djamena to pick up Sarah from the airport. My friend and fellow AHI board member, Chief Justice Aimé, has lent me his Toyota 4-Runner. I take Sarah and her Danish sidekick, Nathaneal, to the central market. I park right in front of the Grand Mosque, just ahead of where the taxis pick up and let off passengers. I roll down the windows and sit back to watch the passersby.
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A few kids come up with their metal bowls asking for alms for the mosque. I chat a little with them in my broken Arabic. One sticks his hand in and is fascinated by seeing the locks go up and down with just the push of a button. Finally, I can't get rid of them, even with the usual "Allah eftah" (God will provide) which should be followed by an "Amin" but instead these kids just say "Ma fi" (no way). Finally, I grab a bowl and toss it to the side and put on a fierce expression. They get the hint.
A young, beak-nosed Arab greets me from behind on the left. I turn my head and greet him back. As I turn back I see Sarah coming up to the window. She's just finished changing money and is about to head out to buy vegetables.
"Who was that guy and what was he doing by the window?"
"Nothing, he was just saying 'Hi'."
"Oh, he just looked suspicious."
"Don't worry about it. See you in a bit."
She heads out again with the green army duffel bag accompanied by Nathaneal.
A brand-new dark green pick up approaches from the left. "Police" is written in bold letters across the door. There are machine gun toting gendarmes in the back and a camo-wearing man with a maroon beret sticks his head out the passenger window, spots me, turns back and says something in Arabic. I hear the word "Nasara" (foreigner or "whitey") and the truck pulls in just in front of me and parks.
"Oh, boy," I think. "Here we go again."
Sure enough, the beret man and a couple of Kalishnikov bearers hop out and approach the right side of the 4-Runner. I'm a bit surprised, however, by their next move.
A young, gap-toothed teenager with his old school Russian automatic weapon opens the passenger door and gets in beside me, his gun slung loosely by his left side.
"Let's go to the police station!" barks the beret-wearing man, obviously in charge. "You're illegally parked."
I guess if I had recently arrived in Tchad I might be soiling my britches at this point, but for some reason I'm not afraid, just exasperated. I try not to sound angry and frustrated as I reply that I didn't know I was illegally parked since there is no sign and I've seen others park there often before.
The chief doesn't budge. I try a new tactic.
"I can't go because my wife is in the market and how will she know where I've gone and how will I find her?" I can see he's not convinced. "Now that you've done your job of informing me that one can't park here, I'll just move the car. Tell me where I can park and thanks for the warning, I won't park here again."
"You can park there on the other side."
I start up the car and back up and cross the one-way traffic to the other side right in front of the mosque, which seems to me a more likely spot to have a "no parking" sign, but I keep this thought to myself.
My passenger is still with me grinning stupidly at me from time to time.
The head honcho follows us over.
"Well, now that you've told us about Madame," he begins the negociations. "We'll let you off easy this time with just a 6000 francs fine."
I then pull out what I think is my ace. I reach into the glove compartment and pull out an invitation signed by the president of the republic to the year end meeting of the Supreme Court.
"This isn't even my car," I suggest. "Do you really want to haul off one of the supreme court justice's cars? One who's intimate with the Head of State himself?"
"Well, you're the one driving it now!" he retorts, "So it's you who gets to pay the fine."
What is it those Frenchies say? Touché?
At this point, a young man approaches me from the left with a bag of something.
"Are you Dr. James from Bere?"
"Yes." I reply, grateful for the distraction as time is an important element of the bargaining process.
"I've been looking all over for you. I'm the son of the man with the broken femur you operated on last week. I tried to find you earlier at the Mission guest house but I was told you weren't there. Then, my dad told me you were at the National Security Counsel office but I barely missed you there too."
"Yeah, I was there registering our new volunteer for the hospital. He just came back from Denmark with my wife. I called your dad back and told him to have you meet me here."
"So what's up with the gendarmes?"
I explain the situation to him and he starts up with explaining how I'm new to town and don't know the rules and that I'm the big doctor from Bere who just operated on his dad who is also a gendarme and one of there compatriots, etc.
The chief officer seems to be convinced...a little.
"Well, since you didn't really know and since you're here helping us out, we'll only make you pay 3000 francs."
My new friend has now gone over to the other side to talk more intimately with the police. He starts off in French but the officer quickly switches to Arabic saying he doesn't want me to hear their negociations. Unfortunately for him, I now understand a little Arabic and reply in Arabic that I understand him fine, thank you very much for asking.
He looks at me surprised and starts to laugh good-naturedly.
"Well, you obviously have money since you're driving a car so just share some with us for our tea."
"I have no money," I respond in Arabic. "If I did, why would I come from Bere on motorcycles and the common market car?"
The young, ugly, armed gendarme next to me now has a huge gap-toothed grin. He shakes his finger at me in wonder "You...you...you..." and gets out. They all walk off shaking there heads and laughing. Right before getting into their truck they turn one last time and offer a friendly wave goodbye.
As I thank my new friend and offer to carry his sack of homemade pasta to his convalescing dad, Sarah returns with Nathaneal.
It's then I realize that my cell phone has been stolen. In talking more with Sarah, it seems the guy she saw was on the right side of the car and was just pulling his head out of the window. Apparently, his partner greeted me from behind on the left so I'd turn my head long enough for the other guy to reach in the open window and take the cell phone from the central console. A slick manoeuvre.
Just when I thought Tchad was gettting boring!
I'm in N'Djamena to pick up Sarah from the airport. My friend and fellow AHI board member, Chief Justice Aimé, has lent me his Toyota 4-Runner. I take Sarah and her Danish sidekick, Nathaneal, to the central market. I park right in front of the Grand Mosque, just ahead of where the taxis pick up and let off passengers. I roll down the windows and sit back to watch the passersby.
.jpg)
A few kids come up with their metal bowls asking for alms for the mosque. I chat a little with them in my broken Arabic. One sticks his hand in and is fascinated by seeing the locks go up and down with just the push of a button. Finally, I can't get rid of them, even with the usual "Allah eftah" (God will provide) which should be followed by an "Amin" but instead these kids just say "Ma fi" (no way). Finally, I grab a bowl and toss it to the side and put on a fierce expression. They get the hint.
A young, beak-nosed Arab greets me from behind on the left. I turn my head and greet him back. As I turn back I see Sarah coming up to the window. She's just finished changing money and is about to head out to buy vegetables.
"Who was that guy and what was he doing by the window?"
"Nothing, he was just saying 'Hi'."
"Oh, he just looked suspicious."
"Don't worry about it. See you in a bit."
She heads out again with the green army duffel bag accompanied by Nathaneal.
A brand-new dark green pick up approaches from the left. "Police" is written in bold letters across the door. There are machine gun toting gendarmes in the back and a camo-wearing man with a maroon beret sticks his head out the passenger window, spots me, turns back and says something in Arabic. I hear the word "Nasara" (foreigner or "whitey") and the truck pulls in just in front of me and parks.
"Oh, boy," I think. "Here we go again."
Sure enough, the beret man and a couple of Kalishnikov bearers hop out and approach the right side of the 4-Runner. I'm a bit surprised, however, by their next move.
A young, gap-toothed teenager with his old school Russian automatic weapon opens the passenger door and gets in beside me, his gun slung loosely by his left side.
"Let's go to the police station!" barks the beret-wearing man, obviously in charge. "You're illegally parked."
I guess if I had recently arrived in Tchad I might be soiling my britches at this point, but for some reason I'm not afraid, just exasperated. I try not to sound angry and frustrated as I reply that I didn't know I was illegally parked since there is no sign and I've seen others park there often before.
The chief doesn't budge. I try a new tactic.
"I can't go because my wife is in the market and how will she know where I've gone and how will I find her?" I can see he's not convinced. "Now that you've done your job of informing me that one can't park here, I'll just move the car. Tell me where I can park and thanks for the warning, I won't park here again."
"You can park there on the other side."
I start up the car and back up and cross the one-way traffic to the other side right in front of the mosque, which seems to me a more likely spot to have a "no parking" sign, but I keep this thought to myself.
My passenger is still with me grinning stupidly at me from time to time.
The head honcho follows us over.
"Well, now that you've told us about Madame," he begins the negociations. "We'll let you off easy this time with just a 6000 francs fine."
I then pull out what I think is my ace. I reach into the glove compartment and pull out an invitation signed by the president of the republic to the year end meeting of the Supreme Court.
"This isn't even my car," I suggest. "Do you really want to haul off one of the supreme court justice's cars? One who's intimate with the Head of State himself?"
"Well, you're the one driving it now!" he retorts, "So it's you who gets to pay the fine."
What is it those Frenchies say? Touché?
At this point, a young man approaches me from the left with a bag of something.
"Are you Dr. James from Bere?"
"Yes." I reply, grateful for the distraction as time is an important element of the bargaining process.
"I've been looking all over for you. I'm the son of the man with the broken femur you operated on last week. I tried to find you earlier at the Mission guest house but I was told you weren't there. Then, my dad told me you were at the National Security Counsel office but I barely missed you there too."
"Yeah, I was there registering our new volunteer for the hospital. He just came back from Denmark with my wife. I called your dad back and told him to have you meet me here."
"So what's up with the gendarmes?"
I explain the situation to him and he starts up with explaining how I'm new to town and don't know the rules and that I'm the big doctor from Bere who just operated on his dad who is also a gendarme and one of there compatriots, etc.
The chief officer seems to be convinced...a little.
"Well, since you didn't really know and since you're here helping us out, we'll only make you pay 3000 francs."
My new friend has now gone over to the other side to talk more intimately with the police. He starts off in French but the officer quickly switches to Arabic saying he doesn't want me to hear their negociations. Unfortunately for him, I now understand a little Arabic and reply in Arabic that I understand him fine, thank you very much for asking.
He looks at me surprised and starts to laugh good-naturedly.
"Well, you obviously have money since you're driving a car so just share some with us for our tea."
"I have no money," I respond in Arabic. "If I did, why would I come from Bere on motorcycles and the common market car?"
The young, ugly, armed gendarme next to me now has a huge gap-toothed grin. He shakes his finger at me in wonder "You...you...you..." and gets out. They all walk off shaking there heads and laughing. Right before getting into their truck they turn one last time and offer a friendly wave goodbye.
As I thank my new friend and offer to carry his sack of homemade pasta to his convalescing dad, Sarah returns with Nathaneal.
It's then I realize that my cell phone has been stolen. In talking more with Sarah, it seems the guy she saw was on the right side of the car and was just pulling his head out of the window. Apparently, his partner greeted me from behind on the left so I'd turn my head long enough for the other guy to reach in the open window and take the cell phone from the central console. A slick manoeuvre.
Just when I thought Tchad was gettting boring!
Friday, September 26, 2008
Roadtrip
"I dont' know, I really want to pick you up in the airport, but it'd be hard now. It's pouring down rain, the roads are already bad, the car doesn't start, I'd have to go by motorcycle and public transport. I'd like to see you as soon as possible, but I'm exhausted, plus the extra expense...couldn't you just take a taxi from the airport and then come back on public transport?"
Sarah is supposed to arrive tomorrow in N'Djamena, but with the rainy season and all, I try to excuse myself. Deep down, I feel I should go to meet her though, but she doesn't have to know that!
I haven't decided for sure one way or another, but I get a text message from her later that evening telling me she understands and I should feel free to not come to pick her up, I'll just owe her a ton of back rubs later!
I call Ndilbe, our nursing student who has just finished his 3 month internship and is ready to go back to N'Djamena.
"We leave tomorrow at 5am. Can you arrange some motos for us?"
At 3am, Augustin knocks on my door.
"There's a kid in respiratory distress, can you come see him."
Sure. I haven't been able to sleep anyway thinking about surprising my wife at the airport.
The kid is grunting, wheezing, retracting and has nasal flaring. Severe asthma. I open my office and find a few vials of expired Xopenex that we put in the nebulizer. I tell Augustin to give him some Dexamethazone IM while I hook up the machine.
The kid suddenly comes alive and it's all the mom and I can do to hold him and the mask in close enough proximity for some of the medication to get in his lungs. Despite his best efforts, something must be getting in those tiny lungs as he starts to breath easier. I tell Augustin to start a Quinine drip for malaria, add some Ampicillin in case it's pneumonia that provoked the attack and return home.
I'm too wired now for sure to go back to sleep for a few minutes so I make some egg gravy and toast and finish packing my small backpack, a skirt and t-shirt for Sarah and an army duffle bag to bring back fresh vegetables from the N'Djamena market.
The predawn glow appears. It's cool and humid and a little haze rests across the African plain. Two old Nigerian motorcycles with dim headlights waxing and waning with the speed of the engine and spewing out white, burned-oil-smelling exhaust, limp up to the front gate.
Ndilbe wraps himself up in a turban and we strap on our bags to the back of the motos with old bicycle innertubes.
We're off, with the cool air whipping gritty humidity into our faces.
The road is one long series of mudpuddles with improvised footpaths around most of them extending sometimes into the rice fields. Often we have to just plow through green, muddy water up to midway on the tires. We cross the new bridge and down the other side where the gravel buttress has mostly fallen away with the rains leaving a small middle section carved up with a few metal beams tied together with steel cable barely holding things together. We're through the barrier at the bottom and pass through Tchoua on our way to the hippopotamus lake.
The elevated road through the lake with a central drainage pipe is pock marked with a million ruts carved out by heavy trucks and a billion ridges carved out by the draining rainwater. It's confounded by being made of clay, slickened by the rains making it a bumby slip and slide experience wondering when we'll just slide down into that wide open hippo mouth.
The last stretch before Kelo is completely submerged and we plow our way through and wind our way through the early morning mud streets lined with tiny mud brick shops just yawning a good morning to another day of fasting in this month of Ramadan. A few lonely robed figures stroll through the red tinged early morning fog as we finally hit the pavement and pull up to the "bus station" on the side of the road opposite the air compressor and rickety wooden tables lined with various shapes and sizes of glass bottles filled with an assorted variety and mixture of fuels.
.jpg)
After paying the moto taxi-men and for our bus tickets, a young, turbaned man approaches and greets us. He is chewing on the typical Ramadan teeth cleaning stick. It's the son of the builder constructing our new junior high in Bere. He's on his way to Cameroon to study. I buy some bananas and then confirm his fasting by offering him one which he politely refuses.
We get on the bus and have two of the back four seats. Ndilbe takes one window and I take the other. Next to Ndilbe is another flowing robed, turbaned Muslim spitting occasionally out the window to keep from violating one of the Five Pillars by inadvertantly swallowing his saliva. A fully covered and veiled Muslim woman with dark gloves and stockings makes her way down the aile towards the back. A young Arab in front of me seems concerned that this obviously pious woman may be forced to sit by an obviously foreign and thus necessarily infidel white man. He shouts in Arabic to Ndilbe and the other man to move over which they do.
.jpg)
"Da bas adil" he responds nodding his approval as the deeply perfumed, modest example of virtue makes her way to the seat as far away from me as possible in the same row on a tiny bus. I'm relieved too.
The rest of the four hours passes quickly with a "Tale of Two Cities" and an occasional nap to keep me busy. We arrive without incident in the midst of a vusy market in N'Djamena.
I had planned to catch a taxi straight to the mission guest house, but decide to go with Ndilbe instead and try and arrange to see his nursing school and pay the school fees for the next year.
We walk down the crowded, noisy market street and turn the corner. We try and catch a taxi, but as we're putting our bags in the back, three people have got in the back seat and two in the front. There's only one space left. We start arguing as we have to travel together since I don't know how to get to Ndilbe's place. The woman in the back who'd stolen my spot doesn't budge and just smirks in reply. Finally, a young Muslim girl is kind enough to get out of the front seat leaving me crammed next to a very large woman occupying the other "half" of a tiny Peugot taxi passenger seat.
The trip is short and we take another road with a drainage ditch in the middle filled with small, bare-footed boys searching for something in the muck.
We open the gate to the house and enter the courtyard where we thankfully dump our bags under a shade tree and I thankfully relieve a very overworked bladder in the corner latrine.
The woman of the house, the wife of one of Chad's chief justices, generously lets me use her car which takes us on a bumby ride through the suburbs of N'Djamena to a Goudi looking three story structure where two secretaries sit doing their nails and gossiping in front of empty adminstration offices. Strike out!
I then get a call from Babana Benzaki who has arrived from Nigeria. A former Muslim, originally from Tchad, who converted to Christianity while studying in Nigeria and who is in his last year of public health at Babcock University, Benzaki has come to get the financial support voted on by the last AHI committee. We have many very interesting conversations about health, life and God. In the meantime, Kaitama shows up to get the letter I brought from his brother and Dieudonne shows up from work so we can discuss how I'm going to take off the lipoma from his neck tomorrow and how maybe in return he can let me borrow his car to pick up Sarah from the airport.
It also happens to coincide with the birthday of the four year old son of the Chief Justice who's mom had prepared a birthday feast even though she had invited no one. With nothing but a couple of boiled eggs and some bananas in my stomach since 4:30am I am more than happy to be part of the celebration! We finish off with a deep red Jus d'Osei (Hibiscus flower tea) and some strong, cold homemade Ginger drink.
I finally head to the guest house in the judge's Toyota Four-runner for a few hours rest before the 9pm arrival of my Danish wife.
I stand patiently outside the barred entrance to the baggage claim as various "important" people are let through while others are kept out. Finally, they seem to be letting down their guard and I slip through with the next batch let in.
I wait in front of the door leading to the immigration booths. I had glanced in quickly to see if I saw Sarah's red head without her seeing me and I succeeded. Finally, after an eternity, she appears at the door and looks at me with a shocked look and then starts laughing and saying "no, no, no, I can't believe it." Unfortunately for me, it's not a pleasant surprise at seeing me that has brought on this reaction but shock at seeing my recently smoothly shaven scalp that makes her incredulous. She is very cute with her long red hair pulled up in back with a few ringlets of curls escaping to the sides to run down her cheeks and forehead. I give her a warm hug and breath in the fresh smell of her hair as I kiss her head. It's good to have her back and definitely worth it all!
Sarah is supposed to arrive tomorrow in N'Djamena, but with the rainy season and all, I try to excuse myself. Deep down, I feel I should go to meet her though, but she doesn't have to know that!
I haven't decided for sure one way or another, but I get a text message from her later that evening telling me she understands and I should feel free to not come to pick her up, I'll just owe her a ton of back rubs later!
I call Ndilbe, our nursing student who has just finished his 3 month internship and is ready to go back to N'Djamena.
"We leave tomorrow at 5am. Can you arrange some motos for us?"
At 3am, Augustin knocks on my door.
"There's a kid in respiratory distress, can you come see him."
Sure. I haven't been able to sleep anyway thinking about surprising my wife at the airport.
The kid is grunting, wheezing, retracting and has nasal flaring. Severe asthma. I open my office and find a few vials of expired Xopenex that we put in the nebulizer. I tell Augustin to give him some Dexamethazone IM while I hook up the machine.
The kid suddenly comes alive and it's all the mom and I can do to hold him and the mask in close enough proximity for some of the medication to get in his lungs. Despite his best efforts, something must be getting in those tiny lungs as he starts to breath easier. I tell Augustin to start a Quinine drip for malaria, add some Ampicillin in case it's pneumonia that provoked the attack and return home.
I'm too wired now for sure to go back to sleep for a few minutes so I make some egg gravy and toast and finish packing my small backpack, a skirt and t-shirt for Sarah and an army duffle bag to bring back fresh vegetables from the N'Djamena market.
The predawn glow appears. It's cool and humid and a little haze rests across the African plain. Two old Nigerian motorcycles with dim headlights waxing and waning with the speed of the engine and spewing out white, burned-oil-smelling exhaust, limp up to the front gate.
Ndilbe wraps himself up in a turban and we strap on our bags to the back of the motos with old bicycle innertubes.
We're off, with the cool air whipping gritty humidity into our faces.
The road is one long series of mudpuddles with improvised footpaths around most of them extending sometimes into the rice fields. Often we have to just plow through green, muddy water up to midway on the tires. We cross the new bridge and down the other side where the gravel buttress has mostly fallen away with the rains leaving a small middle section carved up with a few metal beams tied together with steel cable barely holding things together. We're through the barrier at the bottom and pass through Tchoua on our way to the hippopotamus lake.
The elevated road through the lake with a central drainage pipe is pock marked with a million ruts carved out by heavy trucks and a billion ridges carved out by the draining rainwater. It's confounded by being made of clay, slickened by the rains making it a bumby slip and slide experience wondering when we'll just slide down into that wide open hippo mouth.
The last stretch before Kelo is completely submerged and we plow our way through and wind our way through the early morning mud streets lined with tiny mud brick shops just yawning a good morning to another day of fasting in this month of Ramadan. A few lonely robed figures stroll through the red tinged early morning fog as we finally hit the pavement and pull up to the "bus station" on the side of the road opposite the air compressor and rickety wooden tables lined with various shapes and sizes of glass bottles filled with an assorted variety and mixture of fuels.
.jpg)
After paying the moto taxi-men and for our bus tickets, a young, turbaned man approaches and greets us. He is chewing on the typical Ramadan teeth cleaning stick. It's the son of the builder constructing our new junior high in Bere. He's on his way to Cameroon to study. I buy some bananas and then confirm his fasting by offering him one which he politely refuses.
We get on the bus and have two of the back four seats. Ndilbe takes one window and I take the other. Next to Ndilbe is another flowing robed, turbaned Muslim spitting occasionally out the window to keep from violating one of the Five Pillars by inadvertantly swallowing his saliva. A fully covered and veiled Muslim woman with dark gloves and stockings makes her way down the aile towards the back. A young Arab in front of me seems concerned that this obviously pious woman may be forced to sit by an obviously foreign and thus necessarily infidel white man. He shouts in Arabic to Ndilbe and the other man to move over which they do.
.jpg)
"Da bas adil" he responds nodding his approval as the deeply perfumed, modest example of virtue makes her way to the seat as far away from me as possible in the same row on a tiny bus. I'm relieved too.
The rest of the four hours passes quickly with a "Tale of Two Cities" and an occasional nap to keep me busy. We arrive without incident in the midst of a vusy market in N'Djamena.
I had planned to catch a taxi straight to the mission guest house, but decide to go with Ndilbe instead and try and arrange to see his nursing school and pay the school fees for the next year.
We walk down the crowded, noisy market street and turn the corner. We try and catch a taxi, but as we're putting our bags in the back, three people have got in the back seat and two in the front. There's only one space left. We start arguing as we have to travel together since I don't know how to get to Ndilbe's place. The woman in the back who'd stolen my spot doesn't budge and just smirks in reply. Finally, a young Muslim girl is kind enough to get out of the front seat leaving me crammed next to a very large woman occupying the other "half" of a tiny Peugot taxi passenger seat.
The trip is short and we take another road with a drainage ditch in the middle filled with small, bare-footed boys searching for something in the muck.
We open the gate to the house and enter the courtyard where we thankfully dump our bags under a shade tree and I thankfully relieve a very overworked bladder in the corner latrine.
The woman of the house, the wife of one of Chad's chief justices, generously lets me use her car which takes us on a bumby ride through the suburbs of N'Djamena to a Goudi looking three story structure where two secretaries sit doing their nails and gossiping in front of empty adminstration offices. Strike out!
I then get a call from Babana Benzaki who has arrived from Nigeria. A former Muslim, originally from Tchad, who converted to Christianity while studying in Nigeria and who is in his last year of public health at Babcock University, Benzaki has come to get the financial support voted on by the last AHI committee. We have many very interesting conversations about health, life and God. In the meantime, Kaitama shows up to get the letter I brought from his brother and Dieudonne shows up from work so we can discuss how I'm going to take off the lipoma from his neck tomorrow and how maybe in return he can let me borrow his car to pick up Sarah from the airport.
It also happens to coincide with the birthday of the four year old son of the Chief Justice who's mom had prepared a birthday feast even though she had invited no one. With nothing but a couple of boiled eggs and some bananas in my stomach since 4:30am I am more than happy to be part of the celebration! We finish off with a deep red Jus d'Osei (Hibiscus flower tea) and some strong, cold homemade Ginger drink.
I finally head to the guest house in the judge's Toyota Four-runner for a few hours rest before the 9pm arrival of my Danish wife.
I stand patiently outside the barred entrance to the baggage claim as various "important" people are let through while others are kept out. Finally, they seem to be letting down their guard and I slip through with the next batch let in.
I wait in front of the door leading to the immigration booths. I had glanced in quickly to see if I saw Sarah's red head without her seeing me and I succeeded. Finally, after an eternity, she appears at the door and looks at me with a shocked look and then starts laughing and saying "no, no, no, I can't believe it." Unfortunately for me, it's not a pleasant surprise at seeing me that has brought on this reaction but shock at seeing my recently smoothly shaven scalp that makes her incredulous. She is very cute with her long red hair pulled up in back with a few ringlets of curls escaping to the sides to run down her cheeks and forehead. I give her a warm hug and breath in the fresh smell of her hair as I kiss her head. It's good to have her back and definitely worth it all!
Sunday, September 14, 2008
Shocking
I stand at the foot of her bed. Kristin and Augustin are the nurses on duty and the three nursing students, Ndilbe, Honoré and Innocent are gathered around, white coats spotless, notebooks and charts in hand.
The patient has just come out of surgery two days ago for a walled off, perforated appendicitis. At first glance, she seems to be doing fine. She's staring at me with understanding eyes and breathing rapidly but easily. Then, I notice beads of sweat all over her chest, face and arms. I pull off my stethescope from around my neck and press it against her thorax. The heart beat is rapid and irregular. She's mid thirties and shouldn't have heart disease. What is it?
I look at the chart. Her vital signs there are listed as normal. Then I notice that she's been still kept NPO (nothing to eat or drink) but hasn't got IV fluids in 24 hours. I quickly have the nurse put up some Ringer's lactate IV solution. I think maybe she's dehydrated and has some electrolyte imbalances. We can now at least check his potassium thanks to the Danes and I go ahead and give him a little expired Magnesium that I've been hording in my little stash in the pharmacy.
Then, I remember the heart monitor/defibrillators that our two young volunteers for the summer brought over. I go to the OR stock room and find one that still has a charged battery despite never being charged since arrival in Tchad three months ago.
I hook it up to the patient. The screen is so small and the heart beat so fast it's hard to tell for sure, but it looks like atrial fibrillation or atrial flutter.
.jpg)
She's gotten a couple liters of fluid and the magnesium and now the potassium comes back normal. She seems stable enough so I leave the monitor hooked up but turn it off to save battery and move on to the next patient. Maybe she'll come out of it on her own.
It's 9:30am.
After finishing rounds and seeing the first batch of ER patients I perform a hernia operation with mosquito net mesh and repair to my office for some ultrasounds.
Augustin knocks on the door.
"Ca ne va pas," he says "Bed 10 is in respiratory distress."
I hurry over to the ward, worried that she's already dead (which is what "ca ne va pas" usually means coming out of a nurse's mouth). Fortunately, not only is she still alive, but she's consious and not really in respiratory distress. However, as I turn on the monitor, I see that her heart beat is still 150-160 and irregular. I feel I should do something but it's been a long time since I've had to deal with cardiac patients and I'm not exactly in the best equipped place to deal with it.
I hurry back my office to look up my little "cheat sheet" on electrical cardioversion. It tells me I should sedate the patient first if possible, put the defibrillator on "sync" and start with 100J. Ok, I feel a little better, it's starting to come back.
I hook up the defibrillator pads, give her some Valium IV, turn on "sync" and see the little dots appear over the QRS complexes on the EKG, turn the knob to 100J and hit charge. I hear the whirring of the charge and then it's ready. But now, I don't know how to make it decharge. I look all over and see nothing. Great.
I turn everything off, take off the pads and return to the OR where I find the paddles with their large, curly-cue phone cable like cords. I hook it into the defibrillator, check out the little buttons and place one over her sternum and the other on her left side under her armpit.
"Everyone back," I announce. "Don't touch the bed or anything!"
She's still staring up at me wondering what the heck I'm doing (as do I). I see that everything is well sync'ed. I hit the charge button and then the two "shock" buttons. Just like in the movies or on TV she bounces a little off the bed, her head thrown back, and then flops back down. The EKG makes a big wave, a brief flat-line and then a normal rhythm of 110 beats per minute starts to play across the little green screen.
I almost can't believe it. I know it's supposed to work according to all I've read and been told in my ACLS courses, but come to think of it, even in the US I don't think I've ever been present for a synchronized cardioversion.
My heart is full with thanks to God for bringing everything together to make it possible for us to save this woman's life first with the operation and then with what I had considered mostly useless defibrillator monitors.
Shocking!
The patient has just come out of surgery two days ago for a walled off, perforated appendicitis. At first glance, she seems to be doing fine. She's staring at me with understanding eyes and breathing rapidly but easily. Then, I notice beads of sweat all over her chest, face and arms. I pull off my stethescope from around my neck and press it against her thorax. The heart beat is rapid and irregular. She's mid thirties and shouldn't have heart disease. What is it?
I look at the chart. Her vital signs there are listed as normal. Then I notice that she's been still kept NPO (nothing to eat or drink) but hasn't got IV fluids in 24 hours. I quickly have the nurse put up some Ringer's lactate IV solution. I think maybe she's dehydrated and has some electrolyte imbalances. We can now at least check his potassium thanks to the Danes and I go ahead and give him a little expired Magnesium that I've been hording in my little stash in the pharmacy.
Then, I remember the heart monitor/defibrillators that our two young volunteers for the summer brought over. I go to the OR stock room and find one that still has a charged battery despite never being charged since arrival in Tchad three months ago.
I hook it up to the patient. The screen is so small and the heart beat so fast it's hard to tell for sure, but it looks like atrial fibrillation or atrial flutter.
.jpg)
She's gotten a couple liters of fluid and the magnesium and now the potassium comes back normal. She seems stable enough so I leave the monitor hooked up but turn it off to save battery and move on to the next patient. Maybe she'll come out of it on her own.
It's 9:30am.
After finishing rounds and seeing the first batch of ER patients I perform a hernia operation with mosquito net mesh and repair to my office for some ultrasounds.
Augustin knocks on the door.
"Ca ne va pas," he says "Bed 10 is in respiratory distress."
I hurry over to the ward, worried that she's already dead (which is what "ca ne va pas" usually means coming out of a nurse's mouth). Fortunately, not only is she still alive, but she's consious and not really in respiratory distress. However, as I turn on the monitor, I see that her heart beat is still 150-160 and irregular. I feel I should do something but it's been a long time since I've had to deal with cardiac patients and I'm not exactly in the best equipped place to deal with it.
I hurry back my office to look up my little "cheat sheet" on electrical cardioversion. It tells me I should sedate the patient first if possible, put the defibrillator on "sync" and start with 100J. Ok, I feel a little better, it's starting to come back.
I hook up the defibrillator pads, give her some Valium IV, turn on "sync" and see the little dots appear over the QRS complexes on the EKG, turn the knob to 100J and hit charge. I hear the whirring of the charge and then it's ready. But now, I don't know how to make it decharge. I look all over and see nothing. Great.
I turn everything off, take off the pads and return to the OR where I find the paddles with their large, curly-cue phone cable like cords. I hook it into the defibrillator, check out the little buttons and place one over her sternum and the other on her left side under her armpit.
"Everyone back," I announce. "Don't touch the bed or anything!"
She's still staring up at me wondering what the heck I'm doing (as do I). I see that everything is well sync'ed. I hit the charge button and then the two "shock" buttons. Just like in the movies or on TV she bounces a little off the bed, her head thrown back, and then flops back down. The EKG makes a big wave, a brief flat-line and then a normal rhythm of 110 beats per minute starts to play across the little green screen.
I almost can't believe it. I know it's supposed to work according to all I've read and been told in my ACLS courses, but come to think of it, even in the US I don't think I've ever been present for a synchronized cardioversion.
My heart is full with thanks to God for bringing everything together to make it possible for us to save this woman's life first with the operation and then with what I had considered mostly useless defibrillator monitors.
Shocking!
Saturday, September 13, 2008
Insomnia
I've had a nice relaxing day. I slept in, thanks to a sleeping pill, did an
appendectomy, came home and watched The Gospel of John on DVD, played the
guitar, cooked some beans and rice, fed the horses, went to evening prayer
and read "Le Comte de Monte Cristo" until 10pm when my eyes were so heavy I
knew I'd fall asleep immediately.
Boy, was I wrong.
At first, the earplugs seem to drown out all noise and the bed is so
comfortable. It's not even too hot. I feel myself sinking into the bed and
a deep sleep. But then, slowly, the ear plugs un plug a little and the
sounds of children's squeals and shouts breaks through. The drum beats waft
over the full-moon lit night. I start to feel a little cold. I pull on the
sheets. Then my muscles feel a little stiff. I stretch them out. I start
to toss and turn. Then I feel hot and take the sheets off. My thoughts
start to pour in on themselves.
Maybe I should've taken out that inflamed Cecum instead of just draining the
peri-appendiceal abscess. I'll probably have to operate tomorrow and it'll
be complicated and who knows what will happen.
Is that a knock on the door? I pull out my earplugs. Nothing. Then a
faint, "tap, tap, tap" of knuckles on sheet metal. I pull off the eye shade
and the other ear plug. I fumble for some shorts and stumble out to the
door, the way lit by the incandescent blue of the bug lamp. It's Samedi.
"The young man with the snake bite. His dad wants to take him home. I told
him I can't release him without the doctor's orders. I tried to explain to
him to wait until the morning, but he says that everyone in the neighborhood
is saying that his son is dead, so he wants to take him home."
"What kind of excuse is that?" I think to myself then reply to Samedi,
"have him sign the form that he's leaving against medical advice. We're not
a prison, we can't force anyone to stay. The dad doesn't even care that his
son is better and if he was going to die he would've done it the first day
or two?"
"I've tried to reason with him," Samedi replies. "Even Pierre and the lab
guy tried to talk to him. He's totally beyond reason."
"Ok, bon travail!"
I try to return and hope that now I'll be able to sleep.
At first, I think it'll work. But then the thoughts start to come in,
unwanted worries crowd my head. The kid's voices keep penetrating the
silence of the ear plugs. Medical and surgical cases keep parading through
my subconscious along with preoccupations that I should have done things
differently or maybe I should've done this and not done that. Then, I start
thinking about the projects I want to do, all the preventative measures that
could be taken. What are we going to do about malaria? Will DDT spraying
ever happen? What about the TB and AIDS patients? Will I ever get time to
train the village health care workers like I want to? What about the
Moundou project? How are the volunteers going to work out? Am I giving
them enough direction? Am I being too controlling?
As I fitfully fall into a light slumber, the tossing and turning continues
as I continually wake up, my heart beating fast having dreamt once again
that I'm having to flee something...that I need to escape something that is
chasing me and almost finds me except miraculously, they somehow overlook my
obvious hiding place. It's a recurrent nightmare.
Thoughts in French wander in about the Count of Monte Christo and what I've
just read. Is that a knock on the door? I pull out the right earplug.
"Oui?" I ask. I look out the small bedroom window onto the porch. The
moon illuminates the door. There's no one there.
I'm cold again. Now I'm hot. Oh, it's so comfortable on my back as I
stretch my legs out. Now it's uncomfortable. Maybe on my side. I
should've taken a sleeping pill.
I pull out my earplugs. The dancing and singing and playing has stopped.
The crickets and frogs are blasting a cacophony around the house. Somewhere
a rooster crows. His friends answer from all over the neighborhood. A tint
of red lights up the windows. Dawn is on it's way. I get up, turn on the
computer and write this email...
appendectomy, came home and watched The Gospel of John on DVD, played the
guitar, cooked some beans and rice, fed the horses, went to evening prayer
and read "Le Comte de Monte Cristo" until 10pm when my eyes were so heavy I
knew I'd fall asleep immediately.
Boy, was I wrong.
At first, the earplugs seem to drown out all noise and the bed is so
comfortable. It's not even too hot. I feel myself sinking into the bed and
a deep sleep. But then, slowly, the ear plugs un plug a little and the
sounds of children's squeals and shouts breaks through. The drum beats waft
over the full-moon lit night. I start to feel a little cold. I pull on the
sheets. Then my muscles feel a little stiff. I stretch them out. I start
to toss and turn. Then I feel hot and take the sheets off. My thoughts
start to pour in on themselves.
Maybe I should've taken out that inflamed Cecum instead of just draining the
peri-appendiceal abscess. I'll probably have to operate tomorrow and it'll
be complicated and who knows what will happen.
Is that a knock on the door? I pull out my earplugs. Nothing. Then a
faint, "tap, tap, tap" of knuckles on sheet metal. I pull off the eye shade
and the other ear plug. I fumble for some shorts and stumble out to the
door, the way lit by the incandescent blue of the bug lamp. It's Samedi.
"The young man with the snake bite. His dad wants to take him home. I told
him I can't release him without the doctor's orders. I tried to explain to
him to wait until the morning, but he says that everyone in the neighborhood
is saying that his son is dead, so he wants to take him home."
"What kind of excuse is that?" I think to myself then reply to Samedi,
"have him sign the form that he's leaving against medical advice. We're not
a prison, we can't force anyone to stay. The dad doesn't even care that his
son is better and if he was going to die he would've done it the first day
or two?"
"I've tried to reason with him," Samedi replies. "Even Pierre and the lab
guy tried to talk to him. He's totally beyond reason."
"Ok, bon travail!"
I try to return and hope that now I'll be able to sleep.
At first, I think it'll work. But then the thoughts start to come in,
unwanted worries crowd my head. The kid's voices keep penetrating the
silence of the ear plugs. Medical and surgical cases keep parading through
my subconscious along with preoccupations that I should have done things
differently or maybe I should've done this and not done that. Then, I start
thinking about the projects I want to do, all the preventative measures that
could be taken. What are we going to do about malaria? Will DDT spraying
ever happen? What about the TB and AIDS patients? Will I ever get time to
train the village health care workers like I want to? What about the
Moundou project? How are the volunteers going to work out? Am I giving
them enough direction? Am I being too controlling?
As I fitfully fall into a light slumber, the tossing and turning continues
as I continually wake up, my heart beating fast having dreamt once again
that I'm having to flee something...that I need to escape something that is
chasing me and almost finds me except miraculously, they somehow overlook my
obvious hiding place. It's a recurrent nightmare.
Thoughts in French wander in about the Count of Monte Christo and what I've
just read. Is that a knock on the door? I pull out the right earplug.
"Oui?" I ask. I look out the small bedroom window onto the porch. The
moon illuminates the door. There's no one there.
I'm cold again. Now I'm hot. Oh, it's so comfortable on my back as I
stretch my legs out. Now it's uncomfortable. Maybe on my side. I
should've taken a sleeping pill.
I pull out my earplugs. The dancing and singing and playing has stopped.
The crickets and frogs are blasting a cacophony around the house. Somewhere
a rooster crows. His friends answer from all over the neighborhood. A tint
of red lights up the windows. Dawn is on it's way. I get up, turn on the
computer and write this email...
Wednesday, September 3, 2008
Fixin da bone
Considering I'd only done it once before in my life, it's hard to believe that this is the third time this month I'm slicing open a thigh. This one should be the hardest one to date.
Abel helps me stretch a sticky, yellow plastic covering over the thigh where we'll cut to try and get to the unhealed femur. As I poise with the scalpel over the now yellow window of thigh in the surgical field the first two cases flash through my mind.
The first was a large man hit by a motorcycle two years ago. His twin brother came to our hospital for some other reason and then asked me if I could do anything for his brother whose leg had healed badly leaving him crippled hobbling around with the aid of a crutch thanks to his now shortened right leg. Surprisingly, the traditional method of bone setting hadn't worked leaving him only with a circomferential scar where they had attached a cord too tightly.
Maybe it was the twin angle, but I told him to have his brother see me when I'd be in N'Djamena next. Sure enough he showed up with several sets of xrays showing his femur shortened by 4 cm and angled at about 25 degrees. It was well healed though. When he came to Bere I was able to break the two fragments apart and then put him in traction to pull it out to length. He's been here for a month now.
The second was an 8 year old girl referred by the first patient. In fact, she was his niece or something, also with a right femur fracture 3 months old due to a motorcycle hitting her. Basically the same procedure and she's been here for a couple weeks now. She also ended up with malaria needing a blood transfusion. She is stoic and looks me directly in the eyes every time I do rounds lifting out her hand solemnly for the obligatory greeting and exchange of "Ca va's". I look forward to seeing her every day.
As I slice through the yellow plastic, the black skin and the light yellow fat turning quickly red with blood, I think again that this one won't be as easy...
Again another call came to me while I was in N'Djamena last week saying he also had heard that we'd operated successfully on two of his relatives with right femur fractures and he hoped we could do the same for him who had the same problem. Yep, the right femur broken by a motorcycle hitting him while he was riding a bicycle.
As I held up the xrays in the faint rays of light filtering through the slats of the ER windows I could tell instantly that this was complicated. The two fragments of the femur were separated by about 4-5 cms with a separate fragment also to the side and no evidence of any type of callous or new bone formation anywhere. It was a year already after the accident. His fracture had also been an open fracture with a draining would for 3 months before it closed. As I looked again at the thigh I saw the healed scars from where the bone shard had pierced the skin. As I picked up his leg I found he had an extra joint mid-thigh. I could move his lower leg in all for directions without his hip moving at all. Not good!
I cut through the fascia and the red muscle wells up into the wound as Abel retracts. As I continue down through the muscle, I see the fibers twitch and retract. I hit some nice arteries and scramble to clamp them off. I call for a suture and tie off the bleeders. I can feel the proximal fragment of bone with a muscle spilling over it down into a cavity where the other bone has to be somewhere. I keep digging until I find the distal part of the femur. There is about 2 inches of muscle and a ton of scar tissue all around. I try to free it up with various instruments: scalpel, scissors, periosteal elevators and various others. I get into part of the scar tissue that has walled off some yellow inflammatory liquid like a cyst. It is clear though and happily doesn't look infected. The distal part just doesn't want to free itself.
I'm kind of a little nervous as I know somewhere around the back or medial side of that deep bone are the big arteries and veins that supply the leg. I don't want to have to resort to a Celox miracle again.
I have the scar tissue freed up superiorly, medially and laterally, but behind the bone I just can't seem to get to it. Finally, I find some dangerous looking pincher-like instrument and manage to grasp the fragment and pull it up enough to cut off the scar tissue keeping it from moving.
I then grab some Rongeurs and start ripping and tearing and biting and cracking off pieces of calloused bone over the two unhealed ends. Finally, I'm down to pretty fresh, raw, bleeding bone. Klevin and Gabrielle have been taking turns putting some traction on the foot and now I really have them tug with all they've got. The bones are still overlapped by a centimeter. I wedge in a chisel and with my prying and the boys' pulling the distal part finally slips over the proximal and meshes together with all the sharp edges left after my gnawing at them.
As Klevin and Gabrielle maintain tension on the leg I suture closed the fascias and the skin and place a sterile dressing.
I then take out a sterile, threaded pin about 20cm long and put one end into a very not sterile cordless drill. I make a small incision on the skin over the tibia and pull the trigger. The pin barely moves, the battery is weak. It makes it a few millimeters into the bone before conking out completely. I ask for the other battery. It is even deader since the charger hasn't been plugged in. I try an old rusty hand drill. Doesn't move at all. Finally, I send Gabrielle to my house to get another cordless drill. After a long five minutes he's back and I drill through the bone, nick the skin on the other side and let the pin work it's way halfway through before detaching the drill. I then attach a U-shaped wire onto it so we can attach a bag of sand to work as traction to keep the leg out to length.
.JPG)
After transferring him from the OR to his bed and attaching the sand bag, I do the final manoeuver, I put two empty Ceftriaxone vials over the sharp edges of the pin, make sure the legs are the same length and go home.
Abel helps me stretch a sticky, yellow plastic covering over the thigh where we'll cut to try and get to the unhealed femur. As I poise with the scalpel over the now yellow window of thigh in the surgical field the first two cases flash through my mind.
The first was a large man hit by a motorcycle two years ago. His twin brother came to our hospital for some other reason and then asked me if I could do anything for his brother whose leg had healed badly leaving him crippled hobbling around with the aid of a crutch thanks to his now shortened right leg. Surprisingly, the traditional method of bone setting hadn't worked leaving him only with a circomferential scar where they had attached a cord too tightly.
Maybe it was the twin angle, but I told him to have his brother see me when I'd be in N'Djamena next. Sure enough he showed up with several sets of xrays showing his femur shortened by 4 cm and angled at about 25 degrees. It was well healed though. When he came to Bere I was able to break the two fragments apart and then put him in traction to pull it out to length. He's been here for a month now.
The second was an 8 year old girl referred by the first patient. In fact, she was his niece or something, also with a right femur fracture 3 months old due to a motorcycle hitting her. Basically the same procedure and she's been here for a couple weeks now. She also ended up with malaria needing a blood transfusion. She is stoic and looks me directly in the eyes every time I do rounds lifting out her hand solemnly for the obligatory greeting and exchange of "Ca va's". I look forward to seeing her every day.
As I slice through the yellow plastic, the black skin and the light yellow fat turning quickly red with blood, I think again that this one won't be as easy...
Again another call came to me while I was in N'Djamena last week saying he also had heard that we'd operated successfully on two of his relatives with right femur fractures and he hoped we could do the same for him who had the same problem. Yep, the right femur broken by a motorcycle hitting him while he was riding a bicycle.
As I held up the xrays in the faint rays of light filtering through the slats of the ER windows I could tell instantly that this was complicated. The two fragments of the femur were separated by about 4-5 cms with a separate fragment also to the side and no evidence of any type of callous or new bone formation anywhere. It was a year already after the accident. His fracture had also been an open fracture with a draining would for 3 months before it closed. As I looked again at the thigh I saw the healed scars from where the bone shard had pierced the skin. As I picked up his leg I found he had an extra joint mid-thigh. I could move his lower leg in all for directions without his hip moving at all. Not good!
I cut through the fascia and the red muscle wells up into the wound as Abel retracts. As I continue down through the muscle, I see the fibers twitch and retract. I hit some nice arteries and scramble to clamp them off. I call for a suture and tie off the bleeders. I can feel the proximal fragment of bone with a muscle spilling over it down into a cavity where the other bone has to be somewhere. I keep digging until I find the distal part of the femur. There is about 2 inches of muscle and a ton of scar tissue all around. I try to free it up with various instruments: scalpel, scissors, periosteal elevators and various others. I get into part of the scar tissue that has walled off some yellow inflammatory liquid like a cyst. It is clear though and happily doesn't look infected. The distal part just doesn't want to free itself.
I'm kind of a little nervous as I know somewhere around the back or medial side of that deep bone are the big arteries and veins that supply the leg. I don't want to have to resort to a Celox miracle again.
I have the scar tissue freed up superiorly, medially and laterally, but behind the bone I just can't seem to get to it. Finally, I find some dangerous looking pincher-like instrument and manage to grasp the fragment and pull it up enough to cut off the scar tissue keeping it from moving.
I then grab some Rongeurs and start ripping and tearing and biting and cracking off pieces of calloused bone over the two unhealed ends. Finally, I'm down to pretty fresh, raw, bleeding bone. Klevin and Gabrielle have been taking turns putting some traction on the foot and now I really have them tug with all they've got. The bones are still overlapped by a centimeter. I wedge in a chisel and with my prying and the boys' pulling the distal part finally slips over the proximal and meshes together with all the sharp edges left after my gnawing at them.
As Klevin and Gabrielle maintain tension on the leg I suture closed the fascias and the skin and place a sterile dressing.
I then take out a sterile, threaded pin about 20cm long and put one end into a very not sterile cordless drill. I make a small incision on the skin over the tibia and pull the trigger. The pin barely moves, the battery is weak. It makes it a few millimeters into the bone before conking out completely. I ask for the other battery. It is even deader since the charger hasn't been plugged in. I try an old rusty hand drill. Doesn't move at all. Finally, I send Gabrielle to my house to get another cordless drill. After a long five minutes he's back and I drill through the bone, nick the skin on the other side and let the pin work it's way halfway through before detaching the drill. I then attach a U-shaped wire onto it so we can attach a bag of sand to work as traction to keep the leg out to length.
.JPG)
After transferring him from the OR to his bed and attaching the sand bag, I do the final manoeuver, I put two empty Ceftriaxone vials over the sharp edges of the pin, make sure the legs are the same length and go home.
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