Games Tchadians Play

The woman is in the OR for emergency surgery. Sarah comes to inform me that the family has only paid 15,000 francs ($30) of the 25,000 francs ($50) required. I tell Samedi and Abel to hold on. I'll see about that. I slip off my OR shoes and into my crocs, slide my mask down my face, push open the screen door and put my game face on.

As I approach the beacon of light coming out of the pharmacy window in an otherwise dark ad building I see a tall, lanky Tchadian in a dark tan matching pants and short-sleeved button down shirt. He slowly turns at the noise of my entrance and looks me up and down. His face is familiar. He's one of the former teachers at our elementary school. His name is Amos (pronounced Ah-moh). I can tell he's sizing me up. Let the games begin.

With a look of disdain on my face I march up to Amos. "What's the meaning of this? I hear you haven't paid for the surgery yet!"

Amos looks at me with a shocked and hurt look on his face. "What do you mean? I've just paid 10,000 francs."

I look at the pharmacist, Koumabas, who nods with his goofy half grin. He's enjoying the match.

I turn back to Amos in feigned disgust. "Do you realize that you should pay 25,000 francs. Do you think 10,000 is equal to 25,000? Aren't you a teacher? That's basic math!"

Amos responds coolly without blinking. "Oh it's ok. I'll just pay the rest tomorrow. Go ahead and do the surgery. You can trust me."

I laugh caustically. "Everyone says that but we've found that if they don't pay before the surgery they never pay after. Find a solution!" I pretend to turn away.

"But we're different. Maybe other people don't pay, but we will. You know us."

"Yes, I do. That's why you need to pay ahead of time. Look, we want to save your sister's life. We're ready to operate. We're only waiting on you!" I've played my trump card. Out of the corner of my eye I see Koumabas nod approvingly. He's enjoying this immensely.

"Ok ok." Amos pretends to concede defeat. "I have my bicycle outside. Can I just leave that as collateral to prove I'll pay later?"

"Let's see it." Amos quickly drags in a rusty, bent and twisted carcass of a bike with missing pedals and a torn up seat.

"Here it is." Amos smiles smugly, sure he's won.

Koumabas just shakes his head and chuckles. "Ca la! No way. That's worth 10,000 francs at best! That's not enough!" I've found a tag team partner in this traditional Tchadian sport.

I narrow my eyes, fixing them on Amos. "Don't you have a cell phone? You could leave that as collateral as well and then we can get going on saving your sister's life. We're only waiting on you, you know!"

Amos looks shocked. "I don't have a cell phone. I'm just a poor teacher." He looks like a puppy with his tail between his legs begging for bread at the table.

I turn away again. "Oh well, I guess we'll just have to wait. We're all ready and everything. Just waiting on you." I fold my arms across my chest and lean casually against the wall.

"Ok, ok." Amos starts to lose his composure. "David, come quickly!" Our night watchman comes in and extends his hand towards Amos holding a tiny cell phone in his outstretched palm.

"David, is that yours?" I ask. I don't want Amos to cop out by forcing our staff to cover for him. I won't lose that easily.

"No, no. It's mine." Amos doesn't even blink at the outright lie he just told me. But then again, I haven't exactly been telling the whole truth either.

"Thanks, Amos, you did the right thing." As I turn to leave I stop and look back. "By the way, I've already done my part. We've finished the operation and took out the twisted ovary with its tumor. She's doing fine and just waiting for you to come out of surgery. Too bad I had to play this game to get you to do your part."

Ah yeah, victory is always sweet in this Tchadian game of bluffing and bargaining. Poker's got nothing on it.

Poop

Silently the man slips stealthily through the shadows of a dark Chadian night. The Bere Adventist Hospital has become his temporary domain. His child is hospitalized for severe malaria and a blood transfusion is slowly dripping life back into his fever wracked body. The man has sinister motives. He really needs to go.

The hospital has had trouble for years with patients relieving themselves in piles on the ground in the tradition of the African bush. Despite the availability of latrines, the smell and foreignness of the cement structures is revolting to someone used to the pleasant peacefulness of natural surroundings and soft grass or sand. In the 90's a resourceful night watchman named Jairus made successful war on the perpetrators by taking the pile in a rubber gloved hand and moving from bed to bed wiping some of the stool on each bed until someone confessed or turned in the guilty party who then had to go out and bury the leftover turds.

The problem only got worse with the building of a fence around the hospital in 2004.

Now, this evening, maybe the tide will turn as our unknown man makes his way quietly past the operating theater to the outside water faucet. Taking a comfortable position squatting flexing and stretching his thigh muscles the man pulls down his pants and stretches out his hands to get a firm grip on the metal water pipe coming out of the cement slab he has chosen as his receptacle. Suffering from a common Chadian ailment, his knuckles turn white as he strains to force out the poop hardened in his dehydrated and constipated colon. A sigh of relief accompanies the success of his mission until a bright light suddenly blinds him and a harsh cry of "Ca c'est quoi?!!" brings to an end his devious deed.

Literally caught with his pants down the man hurriedly tries to cover his naked manhood as Jean-Jacques, our vigilant gatekeeper hauls him roughly to his feet. It's a little after midnight but our new administrator, Augustin, comes immediately from home.

Punishment is swift. The gendarmes are called. The man is forced to pick up his ca-ca and stuff it in his pocket before being escorted off to prison. He was last seen weeding the flower garden in front of the jail.

euthanasia

"The pain started suddenly at 4 o'clock this morning." The man stretched out before me on the gurney is in obvious distress. His abdomen is swollen and he's gasping for air. I look at his carnet. His name is Gaouna.

"How was he yesterday? Was he sick at all?" I ask through his brother who interprets from French to Ngambai and back again.

"Yeah, yesterday he was fine, but this morning, the pain started right here," he points to the epigastric region of the patient.

I examine the belly. It's firm but not tense. When I tap with my fingers it sounds hollow, full of air. Gaouna winces in pain with each touch: peritoneal signs. His breathing is shallow and his heart is rapid and his pulse weak. It sounds like a perforated ulcer. The ER had started an IV so I tell Abel to give Gaouna triple antibiotics, call in Samedi from home and go see the last of the ER patients while the OR staff preps for an immediate laparotomy.

The family doesn't have money to pay but they are well to do and leave their motorcycle at the hospital as collateral for future payment.

I finish in the ER and come back to the operating theater. I enter the room. Gaouna is lying on the OR table. Two IVs of Ringer's Lactate are raised high on IV poles running in fast into both arms. A foley catheter has about 300 cc of dark urine. His arms are stretched out on the arm boards and tied down as if he's about to be crucified. Gaouna's eyes are closed and his breathing is even shallower and more rapid. The beep of the pulse oximeter tells me instantly he's not getting enough oxygen. I glance at the numbers. He's at 60% saturation, way below the accepted norm. I'm afraid Gaouna is not going to make it. Maybe we're too late.

We have no oxygen, so I decide to intubate him. I grab a cardboard box off a top shelf. Inside is a mix of all our endotracheal tubes. I select one I think will work. I test the cuff with a 10cc syringe of air while Abel pulls out the laryngoscopes. In my hurry I forget to prepare suction or put in a stylet. I check the laryngoscope and the light works. Abel injects 2mL of ketamine and I insert the blade in the patients mouth. The light isn't working. I pull it out tap it a little, take the blade off and put it back on the laryngoscope handle. It works again. I put the instrument back in his mouth and lift up the tongue. I briefly see the vocal cords before a mass of saliva obscures my view. I call for suction and try to put in the breathing tube anyway. It bends down away from the vocal cords. I reach behind me and quickly leaf through a drawer in the anesthesia cart to find a stylet for the tube. I put it in and bend it into a distal hook to help me put the tube into the trachea. I try again and this time am successful. I put on a bag to the tube after blowing up the cuff and start to breathe for our dying patient. His saturation comes up to 85%. I give the bagging over to Samuel and go scrub. Samedi and Abel have already prepped and draped the abdomen. I'm sure that with release of the abdominal tension, Gaouna's breathing will improve.

I take the large scalpel and am quickly in the abdomen as a surge of dark red, slimy fluid surges out. We quickly suction out over 3 liters of fluid. The intestines look injected and angry but don't seem to be gangrenous. I start to explore and soon discover the real problem. As I cut up the abdominal wall to expose more of the contents a purplish, lumpy, alien-looking mass pops out of the right upper quadrant. Gaouna has end-stage liver cancer. Inside I'm furious. As I quickly try to close up the useless operation, many thoughts whirl through my head. How could the family deceive us? Of course, Gaouna's been sick for months if not years. Without CAT scans and other diagnostic equipment we base so much of our diagnosis on history and physical exam. This surgery could've been avoided. Now in all likelihood he'll die before making it out of surgery. How could God have let me make such a big mistake costing so much money for Gaouna's family and so much time and personnel resources for the hospital?

I've never closed up a surgery quicker. I take over from Samuel and take the bag off the breathing tube. Gaouna's sats go down to 57% but stabilize as he starts breathing on his own. I just want to get him out of here alive. I take out the ET tube and we transfer Gaouna to the gurney and wheel him out to the wards. I explain to the one family member who's there but it's not the same one who gave me false information.

An hour later, Pierre comes to inform me that Gaouna has "rendu l'ame" (given up his spirit). I'm not surprised. By this time, I've had more time to reflect. What if we wouldn't have operated? Gaouna may have lived several more days or even weeks. But he would've suffered. We have no real good pain medication. In hospital, we can give some pentazocine which is OK but not great. As far as pills, we only have Ibuprofen and Paracetamol (a medication like Tylenol). Instead of a slow, painful death, but operating on him we let him slip away in a Ketamine coma without any suffering. Sure, the operation didn't save his life, it just saved him from a torturous death. So maybe it was the right decision after all.

James

Dancing

Suddenly, Samedi jumps to his feet. He has just finished translating my story of the Samaritan woman who meets Jesus by the well. We are in front of a packed house. Daniel, a school teacher, has just gotten up to sing in his tribal language, Kera. The rhythm is catchy and many heads are bobbing. The drums are pounding and Samedi can't hold back any longer. His overweight, yet strong, body has lost it's flexibility as he stomps to the small group surrounding Daniel and raises his fist pumping into the air. He circles around with the inner foot pounding out the beat as his body weaves back and forth. Bruno jumps up. The smallest of Pierre's boys, he has stayed to same size since he was 13 and despite being almost 18, he still has that pre-teen look. His energetic body bounces up alongside Samedi his knees bobbing up and down and both arms raised. Doulgue slides in smoothly stepping fluidly in and out of the dancing circle. The beat intensifies. Lam is whipping the drum as if it was a delinquent child while Allah lifts up his chin staring to the sky as his little hands flap in a furious blur all over the surface of the goat skin drum head. Koumakoy sets his drum down and hauls his lanky, athletic body across the aisle to join the fray, his shoulders bobbing up and down as his bent arms are held in closed fists against his chest.

It started with me telling stories of a woman caught in adultery and brought before Jesus and that same woman washing Jesus' feet with her tears at a dinner party. The young people around me seemed shocked at a God that would love that much. I finally went around and reluctantly got all of them to admit that God loved them just as much. Then the festivities began. Pierre's second oldest daughter and three friends got things off to a slow start as the younger girls were embarrassed to dance and the older girl was embarrassed to be dancing by herself. Amos then kicked things off in Nangjere with a furious rendition of "Kukusebur ne Jesu Christi" as Tabitha rounded it up with a raised, twirling fist and a high pitched "Ayyyee yi yi yi yiiiiiiiiiii." A flat song in English with the guitar and several Chadians singing in bad Nigerina English was soon forgotten as the same group kicked up their heels and clapped their hands to a up beat French song accompanied by a tight, but simple guitar stacatto.

Doulgue jumps up and looks directly at me. "It's not only Nangjere that can sing Nangere songs. James, come here." Grinning from ear to ear and throughly loving the first truly spontaneous church service I've ever been a part of I stand up and walk over to him, my brightly colored matching pants and shirt swishing as I walk. It's a song about Peter walking on water and we belt it out at the top of our lungs as Amos and a couple others join us. I'm not much of a dancer but I find my head, shoulders, and legs unable to resist the pull of the rhythm. We finish strong to many hearty amens. Degaulle's daughter stands up in the back, her baby hanging from her breast and lets out a high pitched wail. Antoinette echos from the back row of the choir, keeping herself hidden shyly behind the kids in front, but she can't hide her smile as Tabitha finishes off the response with a piercing cry that can only be appreciated by those who have lived in an African village.

We go into the early afternoon, much later than usual as group after group gets up to sing. We have sung in English, French, Nangjere, Ngambai, and Kera. No one has understood everything, but everyone has been moved.

That afternoon finds me on the new bridge staring down into the muddy, swirling water below. A crowd has gathered and I can't back down. I step up on the railing and launch myself out. My outstretched arms smack the water hard 30 feet below as the current quickly sweeps me under the bridge. I swim over to the support posts and find an eddy in the center. I rest briefly before striking out for the shore and clambering up the stony bank. Back on the bridge, someone shouts out "Lapia." I turn and see Marty smiling in the midst of the crowd along the rail.

Marty has survived a hippo attack and tuberculosis and looks in perfect health.

I rush over and grab his hand with both of mine shaking it vigorously as I greet him in Nangjere.

I call Jamie and Tammy over.

"Hey, this is the guy in the documentary that was bitten by the hippo!"

Carson and Michelle come over. Tim and Melody join us as well. All the foreigners want to shake his hand. I tell the crowd that Marty is famous in the United States, that's why all the white folk want to greet him. Everyone laughs as a local man translates my French into Nangjere. As everyone gets there picture taken with Marty I think how ironic this is. Usually it's the foreigners who are the center of attention that everyone wants to stare at or greet. Now, it's a poor fisherman who just happens to have been bitten my a hippo right before a film student came to make a documentary of our hospital. The film won some awards and was shown all over in the Adventist Church in the US and Denmark. Because of that film, many people gave money to support the hospital allowing it to become one of the best in the country.

I walk back over to Marty and the man who translated before.

"Tell Marty that while getting bit by a hippo was a tragedy, that God used that experience to help the hospital to become what it is today thanks to the film that he was in. Despite all he suffered, God turned it around to help many more people who are suffering."

As the man translates, Marty looks at me with a warm smile out of his small, bearded face. He nods and shakes my hand before walking off down the bridge.

James

Moundou

I think my hand is stuck. I've been sticking it up the pipe trying to clear out 30 years of junk in the drain but I couldn't get it up far enough. Now, I'd managed to twist and angle my arm just right but now I can't get it out. I almost panic, but I twist turn and finally, scraping the skin off my knuckles on the rough cement, my dirty hand pops out.

Jamie and I are in Moundou putting the plumbing in the new surgery center. Everything has had to be redone.

We go to the local Quincaillerie or hardware store. Everything that you thought you could never find in Chad is stacked from floor to ceiling in a dusty, brick warehouse. We spend hours hunting down all we need. A large Arab in a simple white Jallibiya and a well trimmed gray beard walks in. He is the owner, Mahamat.

"As-salaam alekum. Wa alekum as-salaam. Inta afe? Afe, taybin? Al hamdullilah. Mashallah." And the greetings are over. He walks behind the counter. We continue shopping. After early afternoon prayers, Mahamat returns.

"You...eat..." he starts in broken French and then switches over to Arabic. "We want to you to eat with us. What do you think?" He almost seems sure we'll refuse. He is pleasantly surprised by my profuse response.

"Shukran, shukran, it would be an honor, thank you."

He calls outside to the others and ushers us into a tiny side room under the overhead office built high in the corner of the warehouse. We are seated and a huge platter is slung on the table before us. Piles of fluffy rice fill one huge bowl. A cast iron pot from Nigeria holds the steaming goat meat sauce while a shallow bowl to the side is bursting with a fresh tomato and onion salad. Surprisingly, we are given spoons to eat with as generous portions are heaped into our bowls. Jamie, the vegetarian, digs right in ripping the goat meat off the bones. Our host comes in last and there are no more chairs. We try to rise and give him ours, but he insists. A special bowl of cumin flavored yogurt sauce is placed in front of him along with a plastic bag filled with fluffy flat bread the size of large crepes.

Mahamat wishes us "bon appetit" and grabs a pancake. He bunches the whole thing into his hand leaving the ragged edges pointing out with which he mops up some yogurt sauce and shoves the whole mess into his hand. When we are all finally able to resist his efforts to get us to eat more he reaches outside the door and pulls a plastic bottle of wild honey off the shelf. He dumps some more rice in a bowl and covers it with honey. He tells me to dip in and try. When I say I like it and go for more he shakes his head and pulls the bowl over to him. Then he motions to one of his workers to pour me some of my own. I can't figure out if he just really wants to eat it all himself or doesn't want to have too much direct contact with an infidel.

Mahamat rises and thanks us again. "The French are always too busy. The Chinese sometimes take a snack or something, but this is the first time I've eaten a meal with a client here in my shop. Vraiment, merci beaucoup. Merci, merci, merci." He continues to thank us. He is quite pleased and so are we to be so honored.

We return to the job site.

I'm in the new operating room. I grab the jackhammer with the drill attachment. I lean into it and as it engages a puff of cement dust bursts out of the floor until it turns red when it hits the compacted earth beneath the slab. I slip out the drill bit, put in the small chisel bit and feel the vibrations up my arm and shoulder as the chirping and cracking of cement fills the room.

That night I find myself sitting on a hard stool under the stars in front of Antoine's house. The moon is 3/4 and provides enough light to eat the tiny, twisted potato like tubers covered with cabbage and peanut sauce. Antoine seems discouraged. The junior high that he runs has a drop in enrollment. I try to encourage him. We have brought some building materials that are still piled in the shipping container. Once we finish with the clinic, we can maybe help him with a couple of new buildings. Also, I hope to get a volunteer to help teach English to give his school an edge over the competition. I tell him that God has a plan and won't abandon something He has started.

The ladder is a little unsteady as I get to the top rung. There was no attic hole left in the new ceiling but one angle at the corner of the roof has been left open. I think I can squeeze through. I reach my hands up and grab the truss. I pull up as my feet kick out in mid air. I get to my waist and my tiny butt almost gets stuck but I slither through. I hop from truss to truss dragging the loops of plumbing pipe that I punch through the holes down to the sterilization room and consulting rooms below. The sweat makes the cobwebs stick easier as I try not to fall through the fragile ceiling below.

We pull up the van outside a brightly painted wooden shelter. Their are cartoon images of fish, chicken and millet painted garishly on the corners. Inside a crowd is loosely seated around a selection of differently sized rickety tables and wobbly benches. There is a tiny one open right in the middle. Someone, maybe a waiter, quickly wipes off the plastic mat covering the wood with his bare hand leaving a mixture of spilled beer and salad juice on the surface. Jamie and I sit down and nod hello to those sitting at other tables just a few inches from ours. Most seem to have liter bottles of Gala beer in various stages of consumption. The two men dressed in suits next to us are dipping their hands into a common bowl of lettuce and tomatoes covering some kind of meat.

"What's good to eat here?" I ask one of the men.

"Mutton ribs and salad's what we're having, c'est tres bon!"

"Merci."

We order two servings from the overweight Tchadian woman in charge of the kitchen carved out of one corner of the room. The sounds of popping oil and the smells of wood fire smoke waft out from the clatter of cast iron pots and cooking utensils.

A man approaches selling watches and cheap sunglasses. In the far corner, a man is stretching a piece of cloth between his hands to show a woman how strong it is. Several other woman are looking on eagerly as they sip their beers. A large man who looks more Nigerian than Tchadian comes up behind me and holds out a package of medication over my shoulder and in front of my face. There is a picture of a smiling black man on a yellow and red backdrop with "Super King" emblazoned boldly across the front. In small letters underneath I see the generic name for what is known in other circles as Viagra. I turn to look at the man who raises his eyebrows and winks.

"Super King?"

"Non, merci, I'm deja un Super King," I joke with him as I shake my head.

Disappointed he moves on to greener pastures.

Our meal has arrived. The cook holds out the traditional plastic basin with a plastic pitcher and brown soap for hand washing. I rip off pieces of tender, savory flesh off the sheep ribs, topping it off with lettuce, tomato and onion drenched in a vinaigrette. A small pile of grilled yellow chilies adds some spice to the mix. I was it all down with some Top pineapple soda and then help Jamie finish off the last of his meat.

Sign

It's 3;46 AM and I can't sleep. My eyes are bloodshot and heavy, my head pounds, but I can't sleep. Jet lag is at it again. As I huddle under the blankets to keep from freezing in the airconditioned hotel room in Richland, Washington it's hard to imagine that just a few sleepless days ago I was in the bush of the Sahel. A six hour bus ride from Bere to N'Djamena, a 5 hour overnight flight to Paris arriving at 6AM followed by 45 minutes to Amsterdam and a direct flight across Greenland and Canada to Seattle where I met Greg. We grab a rental car and head over the mountains covered with pines and firs into the central valley with it's rolling golden hills, small farming towns and fresh, cold cherries. Following a smaller river down we hit the Columbia River in the TriCities and we've arrived for the SIGN conference.

I get out of bed at about 4:30, strap on my running shoes and head out the door. The night is just beginning to turn a lighter shade of black but the well-lit streets need no natural light and guide me across the street, around the middle school with it's sprinklers caressing it's well manicured lawns, soccer and football fields, up a side street, off the road up a grassy slope and onto the riverside walking trail. The scent of sage, mountain misery, pine and fir wafts across the early morning breeze which would've surely chilled me if not for the vigorous sweat I've already worked up in my out of shape body. A grove of trees and dense shrubbery gives me only glimpses of the dark, alabaster surface of the river until I turn a corner and see an opening leading down a pebbly bank onto a small sandy beach. I stumble down and after some pushups squat on the sand to reflect.

Yesterday, I found myself surrounded by an international aura of languages swirling around me: Urdu, Hindi, Vietnamese, Slavic, Arabic, French, Spanish, and a wide variety of English from Nigeria, Cameroon, Tanzania, Kenya, India, Bangladesh, Mongolia, England and the wide variety of American accents. There is the slender Dr. Shah with his ample gray beard and thin, fierce face with a long pointed nose from Pakistan describing doing more than 1000 intramedullary nails for long bone fractures starting during the terrible earthquake in northern Pakistan and continuing on today in some of the most remote areas of the world. There is the dignified, dark skinned Dr. Faruque from Bangladesh speaking calmly out from under his mop of black hair and half smile. Dr. Shahab from Peshawar lectures us elegantly on bomb blast injuries, his portly figure fitting well in his classy suit framing a jolly face encompassed in a well trimmed white beard outlining his dark features. I find myself being guided through the machine shop where intramedullary rods, screws and instruments are made at a fraction of the competitors prices but with the same levels of quality control. I enter into a workshop where 20 artificial femurs and an equal number of tibias await our inexperienced hands.

I am led through the process by an orthopedist from Vietnam who explains how to attach the guiding frame to the rod and adjust it so the distal fixing screws will be able to be placed without intraoperative imagery. I am shown the technique of insertion with frequent side to side sweeps interspersed with gentle taps of the mallet. The whole process of guided drilling, finding the slot in the nail and inserting the screws is simple and elegant allowing most lower limb long bone fractures to be treated with the highest standard of care in the world without needing the normal high-tech equipment or even electricity! I go over the process many times in the next few days until I've mastered it. Of course, real bone covered with real flesh on a real person will be different but I'm confident I can do it...inshallah.

SIGN was started 10 years ago by Dr. Zirkle, an american orthopedist who has spent his life in developing countries with the idea of equality of fracture treatment around the world. By the end of 2008 SIGN had over 144 programs in 49 countries involving over 3000 surgeons who have performed over 36,000 operations. Now, Chad and the Bere Adventist Hospital will make it at least 50 countries. We have been given the instruments, our first set of 30 intramedullary nails, a cordless drill with sterile cover, training videos, wound suction treatment systems and the full support of the SIGN team...all on faith that we will raise the money to help cover the costs of this equipment.

Anyone interested in knowing more or donating to this program in the name of Bere Adventist Hospital can contact SIGN at www.sign-post.org.

James

Moonlight

I could never have imagined that things would turn out they did.

As I stare out into the moonlight filtering through the flamboyant tree branches casting shifting shadows with every breath of wind, as I hear the soft shuffle and breathing of our sweat-flecked horses outside the stable, as I draw my gaze back to the pile of pineapple carvings in front of the cutting board and bring the ice-cold pineapple to my mouth and slowly savor crunching into the juicy morsel, as I think back over the past few days I find it incredible to think of how this afternoon ended...I can only call it an unexpected grace, a surprising joy, a metaphysical moment when all things good come together out of the midst of all things wrong.

As I gallop through the forest, grasping Pepper's mane as fiercely as I hold to the reins; as I stand up in the stirrups and hug my body to the horse's powerful neck; as the leaves slap my face and a branch rips through the skin of my shoulder; as the full moon lights up the sandy trail like a river of silver stretching lazily out before me through the dark shadows of the trees; as my sweat soaked shirt clings to my back; as I am surrounded by the silence of an African evening in the bush I find myself carried way beyond the horrors, sorrows and sufferings of the last few days.



I can hardly remember the strong features of the handsome Arab man staring steadfastly upward with a look of incomprehensible peace as he is lugged up the ramp to the operating room in a vinyl stretcher with wooden handles held firmly in the grips of a dozen turbaned comrades his mangled body wrapped in a blood soaked turban in stark contrast to the serenity of his gaze. I almost forget the hours of working on his bilateral open fibula and tibia fractures uncovered on his right by a flap of skin running from his heel and achilles tendon up his calf and across the top of his foot revealing the anatomy of the muscles, tendons, ligaments and bones as I can only barely remember from Anatomy lab in medical school. The almost can't bring up the vague memory of him calmly complaining of neck pain since he can't move or feel the rest of his body is a silent grace to him allowing us to work on his tattered limbs without anesthesia after framing his chiseled face in a cervical collar. I thought I'd never survive the emotional roller coaster of the myriads of swishing robed, turbaned men and brightly wrapped head scarved women that filed incessantly in and out, many of the men leaving with tears unashamedly rolling down their cheeks as I had to console them to leave all in Allah's hands as only He can know the day of our death and we should trust Him. The memories flood in of fighting my way through crowds and over colorful mats and rugs to try and do his complicated dressings after spending what seemed like ages of emotional energy trying to get the swarming family and friends to respect visiting hours and hospital policies. When his paralysis didn't get better after three days I was almost relieved when the nurse came to get me yesterday morning to say "Ca ne va pas" and I arrived in time to see his unconscious, but still dignified face take it's last shallow breaths and feel his heart beat in his neck slow down and become weak. He was bound for a long road of suffering in this environment as a quadriplegic and it was certainly God's mercy that laid him to sleep.

As I stand on the bank of the river, looking down on the swirling eddies of the brown, engorged river; as I see the sun slowly set behind the great branching trees of the African plain; as I turn around and see the full moon rising through a circle made by two rounded trees and a small hill; as I watch the slow transformation of the day into moonlit night; as I feel the wet of the river slowly drying on my body; as I watch Stefan desperately trying to capture the moment on film; as Eddie slowly makes his way upstream against the current; as I pull on my jeans over my moist swimming suit and prepare for the ride home; as untangle Pepper from the bush I've tied him to I am amazed at how quickly depression and overwhelming burnout can be replaced by wonder and marvel and ecstasy.



Can it be that only this morning I found myself deep in a belly under the ribs carefully cauterizing a gallstone filled gallbladder from the liver of an elderly, lighter-skinned Muslim man? Is it possible that yesterday I was about to throw up and finally gave in and started taking malaria treatment only to go out immediately and take out an ovarian tumor stuck to all the intestines, omentum and uterus? Is it possible that only two days ago I didn't think I'd make it through the morning much less the weak because of fatique I refused to believe was another bout of Plasmodium falciparum destroying my blood cells? Is it possible that only three days ago the hospital was full to overflowing while we spent all of a Sunday afternoon filling it up with sick babies needing blood transfusions and malaria treatment? Is it possible that only four days ago I spent all Saturday in the OR with two motorcycle accidents needing emergent orthopedic intervention? Is it possible considering how things later turned out?

I come back from work almost collapsing. It's been another day of neverending hospital rounds, complicated surgeries, ER patients, ultrasounds all pleasantly muffled with the ringing of Quinine in my ears. I feel a little nauseated and drink some cold water. I sit down and finish reading "Flying Doctor of the Philippines". I just want to sleep, but decide I better go out and feed the horses to keep my wife happy. The next thing I know I'm in the saddle trotting past the mud huts of Bere, around the pond, through the forest and onto the river road mounted on Pepper while Stefan rides Bob and Eddie rides Libby. Out into the open Stefan and Eddie cluck their horses into a gallop. I can feel Pepper tensing beneath me and I give him the releasing cry and squeeze and he quickly closes the gap and passes the others through a mud puddle as Bob goes left and Libby goes right around it. We're in the open now and I slow down. We arrive quickly at the river ride down the ridges gauged out by the rain leading to the cattle crossing and then climb up the hill next to it. A quick assessment confirms the possibilities and Eddie and I strip down and race off the cliff arms and legs flailing wildly before crashing into the swift moving current below. It's not enough for Eddie, so we find ourselves pulling our reluctant bodies up the bank using exposed tree roots before climbing up the tree as high as possible with still a path clear of branches to the rushing waters below. I crouch on two diverging limbs my hands in front as I propel myself through the gap, past the other branches below and into the welcoming arms of the cool, refreshing liquid beneath. I'm glad there are no crocs and lions in this part of Africa.


As Eddie and I climb up the bank for the last time after multiple jumps from different levels, Stefan's face is glowing. It's hard to believe just last night he was talking about maybe wanting to leave. Now all he says is, "the only thing that could make this better would be a little ice cream."

Later as I walk through the cool of the moonlit evening from my house to his carrying the plate of chilled fruit I think to myself, "well, cold pineapple could arguably be as good or better..."

Then the clapping comes again...it's Salomon...

"There's an old man peeing blood since this morning..."

And I'm off to the hospital as the moonlight leads the way.