Update

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

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

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


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

Slippery when bloody

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


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

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

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

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

All day long she moaned and thrashed and screamed.

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

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

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

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

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


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

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

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

I"m drained but not discouraged.

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

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

Couscous and Goat

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

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

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

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

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

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

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

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

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

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

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

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

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

Perforated peptic ulcer.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GROSS PICTURE OF THE DAY

Stumbling

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

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

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

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

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

I wonder if I can find the way.

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

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

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

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

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

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

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

Five hernia patients wait patiently outside the operating theater.

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

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

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

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

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

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

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

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

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

The dawn is about to break.

How to Relieve Urinary Retention

It all started with a normal day's rounds at the hospital. I slip on my white coat over my scrubs and Snapper Jack's sweatshirt (believe it or not, it does get cold in Tchad), lock up my office and head out to the wards.

I walk through the wards and notice a crowd lounging around outside. A quick exit, a loud "rounds are starting everyone who's with a patient come in, all other visitors leave" and with a few agressive gestures and much repeating and translating most everyone clears out leaving the hospital with a rare moment of relative tranquility (maybe it helps that I spent an hour last night chasing out squatters with a broom handle).

Not for long. The pediatric ward and emergency room have been vacated so the leaky roof and moth-eaten ceiling can be replaced leaving us with all the patients crammed into already over-burdened wards.

I start with Pediatrics. The nurse in charge, Deuhibe, gathers the charts and calls the nursing students. The charge nurse, Jacob, joins us along with Camila, the Danish medical student and we start seeing the kids.

As I come to the last of the peds patients, a skinny ten-year-old boy with bulging eyes staring at us blankly, the child suddenly repeats his performance of yesterday that made me call the chaplain to see if he was demon-possessed.

He somehow manages to combine three extraordinary moves into one well-polished fluid motion perfected by years of habit and accompanied by a blood-curdling cry like a banshee being bit by a thousand bees.

In one simultaneous gesture the boy flips from his back to a kneeling position thrusting his anus up into the air, reaches his hand around his back and sticks it into his butt, and realises a stream of urine that thrases around like a fire hose out of control and that would make a race-horse proud. All the time he writhes around like a cat in a bag and screams like someone is slowly skinning him alive.

I'm shocked and unnerved. I quickly grab his arms removing his hand from his butt, flip him over and pin him to the urine soaked mattress. I notice the urine is tinged with pus. I ask for his lab results as he moans and groans and struggles uselessly. His stool test is normal and his urine not surprisingly shows an abondance of white blood cells.

For some strange reason (years of being a resident and hearing surgeons drill it into my brain) I decide to do a rectal exam. I quickly call for a glove and feel inside the child's rectum. Where his prostate should be is a large, hard, smooth mass that is somewhat oblong moving towards his bladder.

An ultrasound confirms a calcified mass in his bladder.

An hour later I poise over the boy's lower abdomen with a scalpel as Abel prays. A few slices later and I'm in his bladder. Even though I kind of expect it chills still run up and down my spine and my arm hairs stand on end as I reach a gloved finger into the bladder and touch the large urinary calculus.

It's so large compared to the small kid's bladder that it is quite difficult to extract. I finally open the wound more and slip some forceps around it and squeeze it out like a diffucult childbirth. There on the table before me is an 3 inch by one inch long kidney bean shaped stone.



After closing the bladder and belly and leaving it to catheter drainage I realize that the boy is actually quite smart and creative after all.

The weight of the stone caused urinary obstruction through gravity pulling it down to block the urinary outlet. When his bladder got so full he couldn't stand the pressure of the retention he flipped over, anus in the air so gravity and a well-placed rectal finger would push the stone off the exit releasing a high pressure urinary stream bringing relief but causing excruciating pain at the same time.

Who know's how long he's suffered with that? The parents say for all his life despite going to many hospitals and staying months. What's the difference in ours?

God helping me make a difficult diagnosis and bringing all the elements together to be able to confirm the diagnosis (ultrasound) and perform the surgery (equipment, generator, trained staff, instruments, autoclave, suture, etc. etc.)

So next time you have difficulty peeing, might I suggest a certain routine...

How to...Hernia

Ladies and Gentlemen! Welcome to this next addition of "How to...in Tchad"

Tonight's topic is one that is very dear to all of our hearts and a constant source of revenue for our parent organization, the Bere Adventist Hospital: How to have a hernia in Tchad.

In order to have a really sizable hernia, one that is noticeable even when wearing pants (or one that requires you to give up pants and wear a skirt) one must ignore the hernia one's entire life. It is also helpful to come from an agriculture tradition requiring years of hard, back-breaking labor bent over in a rice field.

One should let it get so big that ones entire collection of small intestines and part of the colon should be able to fit inside if one makes an effort. Making that effort is much more easily achieved under the influence of the local brew. One has many to choose from: cochette (rice wine), arguile (millet wine with a touch of methanol), bili-bili (who knows what fermented in a tasty beverage) as well as your more exotic beer.

If one is going to be operated on, it is much better to wait until after a hard day of bargaining at the market and a serious evening imbibing. Then, through various silly manoeuvres only achievable when dead drunk, one is able to achieve that mass excursion of intestines, colon and sometimes bladder into the hernia sac.

This usually makes if very difficult to push back in (especially when one is draped over a bench with the last calabas of rice wine in hand). This delay allows for swelling of the intestines and sacs to occur leading to what's known as incarceration or strangulation, big words meaning that one will die if not operated on soon!

The best thing to do at this point is to call for your cousin, slash drinking buddy and have him spend your last penny on a motorcycle ride through the bush in the dark so that one can arrive after midnight at the hospital, drunk and penniless.

Not to worry, the surgeon may be groggy, grumpy and disgruntled to find you have nothing to pay with, are sloppily drunk and babbling on the ER table and are alone with an equally smashed and useless cousin, but he will be sure to operate on you to save your life. That way, you don't have to wait for surgery or maybe even pay for it. You never know, those white folks are such suckers!

After a nice, pleasant Ketamine induced dream with a nightmare awakening with all your inhibitions making you see all those things you've repressed and regretted over the years, you wake up on a bloody plastic sheet covered loosely with a hospital gown and an IV dripping into your arm. You start to feel some serious pain in your left groin. You look down and feel a bandage. Feeling lower you realize your left testicle is missing. None of your family has come yet and not only are you waking up from surgery but you have a hangover.

Oh, and that supposed benefit about not paying, the sneaky doctor has gone and left the hernia on your right unfixed so that you'll have to pay him before leaving or the same thing might happen again and suddenly it's looking like it might be better to just have it done electively!

Well, that's it, folks, thanks for tuning in. Next weeks How to...well you just might need a wheelbarrow to carry it in.

Teenage pregnancy

She is, unfortunately, one of many. Fifteen years old. A child. Tiny. Married and pregnant with a huge baby. She has been in labor for days. This morning she finally went to a health center where they tried to extract the baby with a vacuum suction applied to the baby's scalp. When that didn't work they referred her here.

It is all too common. Women usually marry as teenagers. Not just among the Muslims, but among the Nangere. Some even get pregnant before having their first period. Children having children. Small children having large babies. They don't come out easy.

In the "modern world", a woman with a small pelvis and a baby who's head is too big to come out will have a c-section. Every pregnancy thereafter, she will have excellent pre-natal care with early ultrasounds to determine the exact dates of the pregnancy so an elective c-section can be performed when the fetus is mature enough and before labor begins. After 3-4 children, she will have a tubal ligation and live happily ever after.

In Tchad, a woman with a small pelvis and a big baby will have no prenatal visits. She'll work in the fields until labor starts when she will be transported to a mat on a dirt floor in a dark mud hut. There she will labor under the supervision of an older, experienced traditional birth attendant...sometimes for days. Then, like our girl, she may get to a health center or a hospital before dying. Often, she will be buried with her unborn child never having left the village.

Supposing, she does make it to a hospital. The well-meaning obstetrician or surgeon or generalist will do a c-section. Sometimes he saves the baby but he usually saves the mom. All is well and good. 4-5 days later, the woman goes home. 9-12 months later she is at term with her next pregnancy and labors at home. This time, her uterus has a weak spot at the area of the scar which hasn't even had time to fully heal. Maybe she'll make it finally to the hospital again for another c-section (depleting again the family's meager resources) but maybe she'll tear her uterus with the force of the contractions against the unyielding bones of her pelvis and she'll bleed to death internally.

If she does make it for the second c-section, the process will repeat itself until she is either dead or abandoned by her husband as being too much of a drain. Who wants a woman who can only have 3-4 kids anyway? A quarter to a half of them will probably die before the age of 5, so one must have at least 8-10 kids in order to have 4-6 alive into adulthood.

So, at the Bere Hospital, thanks to a technique considered brutal, archaic and cruel by the turned up noses of the western obstetrical ward, we prepare our 15 year old for a symphysiotomie.

We take her to the OR, attach her to the monitors. She has low blood pressure and a very fast pulse. We give her antibiotics, IV fluids and call for a blood transfusion.

The problem is, she has been abandoned by her husband and most of her family. Her mom already paid most of her money at the health center and then the rest to put her on an hour long motorcycle ride to the hospital. She only has five dollars. We can't let her die, so when the mother promises that the rest of the family are coming, we don't believe her for one instant but set her up for surgery.

However, now that she needs blood, we find her mom is not compatible and since there is no blood bank we rely on family members to donate. None of our volunteer staff is compatible either. We are forced to do our best.

We shave and prep the pubic area. I inject the local anesthetic. A urinary catheter has been placed. IV fluids are running. Heart rate is 140 and blood pressure 80/40. I slice down to the cartilage and with my other hand displacing the urinary catheter (and thus the urethra) inside, I slowly incise the fibers from top to bottom being careful not to enter the bladder or vagina. Abel and Simeon have the legs flexed and externally rotated. On cue from me, they spread the legs down and the pelvis pops open with a load "crack".

As blood gushes out of the wound, I stuff two gauze pads down to stem the bleeding. I then am forced to cut an episiotomie and apply our own vacuum delivery device to the head. She has no strength left to push and the baby's scalp won't hold the vacuum. The head still won't come out.

I ask Simeon to put some Oxytocin in the IV fluids and to open it wide up. Slowly, the uterus contracts and pushes the head out little by little as I gently tug with the vacuum on the baby's head. Finally, the head pops out with a gush of thick dark meconium (baby's pooped inside mommy). The neck is strangulated with a tight nuchal cord that I can barely slide over the head. Finally, the shoulders and arms slip out and the rest of the body slides out quickly.

I check the umbilical pulse. Nothing. The baby has been dead for a while. The placenta quickly follows thanks to the Oxytocin still running and her uterus forms up nicely. She's bleeding from where we cut her quite a bit. I stuff in a bunch of gauze sponges and then pull out the sponges from the syphysiotomie wound.

I irrigate the wound and close it in two layers. I then suture up the episiotomie. She continues to bleed. Simeon checks her hemoglobin: 5.1 g/dl. Very low. Still no blood for transfusion.

I check all inside and finally find a tear up around her urethra. When I suture it the bleeding finally stops. She is sweating and a little delirious. Heart rate still 140s and blood pressure 90/50 now after several liters of fluid.

We have no choice but to send her out to the ward and hope the family members come quickly.

That evening, at about 8pm, Liz comes to talk to me about several patients. She mentions that the girl has low blood pressure, a fast heart rate and now a fever of 40 Celsius. She is wavering in and out of consciousness and is sweating profusely.

I tell Liz to give her Chloramphenical (maybe she's septic from the prolonged labor) and IV Quinine (maybe she has malaria on top of it) and IV fluids (she is still volume depleted). After Liz leaves, I take a long drink of water and something impels me to go see her myself.

I find her like Liz said. She is almost in fatal shock. Only blood will help. I help Liz get the medicines and IV fluids going.

The mother keeps wringing her hands and asking "Loe ne mega?" "Loe ne mega?" What's going on? What's going on? I tell her "Koubra kang ddi" There is no blood. She runs off. Liz and I continue our work.

The mother soon comes back with the brother of the young man who we'd just amputated his leg. He's been with us for several weeks. He and another man say they are willing. The other man just gave a pint for his relative two days ago but is willing again. We find his blood isn't compatible.

Then we think of Allison, the volunteer at the Evangelical Mission who's staying with us for a week while the other missionaries (Rich and Anne) are in N'Djamena. We call her and both she and the brother of the amputee are compatible. People don't just give blood to non-relatives but this man is encouragingly different, going against the cultural pressure and ignorance we are surrounded with to save the life of a stranger.

After two units of blood, the next morning she is a different person. She is up moving around with normal vital signs and has eaten some porridge for breakfast. Her uterus is firm, the wounds look good and she is hardly spotting at all.

Liz comes in at 5 am the next morning to give her her Quinine and finds her cold and stiff. Four family members are around her and haven't noticed. Liz informs them and they begin the death wail immediately, bundle up the corpse and head home.

A parent's worst nightmare

I couldn't believe my ears. It was surreal. I didn't really feel any panic or anything, but I felt a calm, cold-blooded realization of what I needed to do.

My vacation was about to be cut short.

Ok, so you couldn't really call it a vacation, Sarah and I had come to the Koza Hospital as part of an exchange with Drs. Greg and Audrey who were now in Bere. We had now been in Northern Cameroun for just a day over two weeks but compared to Bere, it was a definite, much-needed break.

In those two weeks, I did 6 surgeries at Koza. Greg did 37 at Bere. I sat around all afternoon reading and watching movies while sipping cold drinks and eating homemade ice cream with a fan and a swampcooler as my constant companions while Greg and Audrey hardly saw the light of day and came home to Kerosene lamps and lukewarm tapwater.

This morning, I'd been woken out of my electric fan-cooled sleep by the nurse and ended up doing a crash c-section to save a distressed baby's life. Now, Greg's calm voice is speaking through my cell phone (yeah, even here in the African bush) telling me that one of our student missionaries (who we call Esther because there's just to many Sarah's) has severe abdominal pain and has vomited several times. Greg goes on to say that she has peritoneal signs and a positive Typhoid Fever test. She's been on IV fluids, antibiotics and morphine since yesterday. He doesn't know if she should be evacuated or what.

Fortunately, thanks to Gary Roberts' airplane, I have the luxury of saying, "I'll be right over, let me just quickly pack my bags and I'll see you in a few hours."

It's a Saturday morning and it's going to be a long day.

I quickly go over to the church right across from the house and find Yves, the administrator, to inform him of the situation. He is sitting on one of the front rows, so I drag him outside to break the news. He is understanding and wishes us bon voyage. After saying good-bye to Jacques and Calda, Sarah and I pack our bags and about 30 minutes after the phone call, Gary's wife, Wendy, is driving us out to the grass airstrip.

We take down the string "fence" Gary has guarded the plane with, detach the moorings, load up the barrels of fuel and our small backpacks, strap ourselves in and Gary fires up the single prop, we taxi (bump) across the grass and are soon banking sharply right en route to Garoua. An uneventful landing, flight plan and missed immigration agents (lucky for us since we didn't have visas) and we are heading to Moundou. Less than three hours from Koza and we land in Moundou where we have a little friendly discussion (heated argument) with customs ending in the usual way (laughs and hand pumping).

20 minutes, and a little flying lesson for James later we are circling Bere International watching Rich race down the airstrip on his motorcycle looking for goats, cows and soccer goal posts which could make our landing a little more bumpy.

"See that second path over the strip right before the little mound halfway down? That's where we'll try to put down in order to miss that little bump. We could circle around again, but this is faster..."

Gary says as my stomach gets left somewhere over to the right as be bank sharply left and downward towards the swath cut from the Chadian bush. Seconds later we are taxiing up to the quickly gathered crowd of mostly kids awaiting our arrival.

After the plane is unloaded, draped and secured and the watchmen posted, Anne kindly drives us over to the hospital in their Land Cruiser.

Greg is waiting for us dressed casually in jean shorts and a scrub top and large sandals. We go inside where the back room has been transformed into an intensive care of sorts with one patient, three doctors and three nurses, and multiple auxiliary staff (the other student missionaries) crowding around to help in any little way possible.

I slowly enter with my Sarah at my side. Esther (the other Sarah) gives us a weak, Morphine-influenced smile and says "hi". I ask her a few questions.

Apparently, her pain started yesterday morning early but she thought maybe it was just part of her monthly cramps. So she got on a motorcycle and took a little jaunt over to Kelo with a couple of the other volunteers. Curiously, the bumpy, bouncy ride did little to alleviate her pain. On her return, she had a typhoid test done which was sort of positive (they're sometimes hard to interpret and often have both false positives and false negatives). She was started on antibiotics and then IV fluids after she vomited. She had no urinary symptoms and bowel function was normal. She ate a little something at night. Her pain was equal on both sides of her pelvis. The pain increased with movement, tapping on the lower belly and "rebound tenderness".

Greg, Audrey, Sarah and I go to the next room to discuss what to do. She has evacuation insurance and with Gary's plane we could have her in N'Djamena maybe in time for the midnight, once-a-day flight to Paris. There is no hospital in Tchad I would prefer her to go to over ours (especially with Greg, a board-certified general surgeon there). We agree it could be typhoid fever, but that would usually have a longer course. While there are some atypical features I ask, "what if it is appendicitis"? In that case, she should be operated on ASAP, and an evacuation won't be fast enough to keep her from perforating with all the life-threatening complications. We continue to discuss, finally, I ask Greg, "If she was not a foreigner, would you operate on her." After a few moments, he says, "yes, I definitely would." So we are decided that if she chooses to stay in Bere, we'll open her up.

Now, Greg spends a long time explaining to Esther the options and she wisely calls her parents. With the time change, we at first only able to get through to her mom who wisely tells her that the decision is hers. Esther doesn't take long to say that here in Bere she is surrounded by friends and people she knows and the thought of flying to Europe (even accompanied by another of our volunteers who works in France and is leaving next week anyway) and being operated far away from anyone she knows, that thought scares her and she'd rather be operated on her in Chad.

So, the decision is made. Hans, Sonya and Christina go to prepare the OR and make sure everything is as clean and arranged as possible. Liz, Christina and Sarah prepare Esther for her operation.

Greg, Audrey and I wait just in the outer room of the operating block. Once the decision is made, I am anxious to get started. Greg calms me down. We'd already waited an hour or so for her to be able to talk to her father. At about 10pm we are finally ready to start.

I sit Esther up, wipe Betadine across her back, put on sterile gloves and inject a spinal anesthetic. We lay her down and Greg and I leave to respect her privacy while Audrey and the other girls prep the operating site and Audrey drapes her in sterile fashion. Greg and I scrub and when the all clear is given, enter the operating room. Contemporary Christian praise music is going in the background as Greg and I put on our gowns and gloves and Greg moves to the left side and asks for the scalpel.

We then pray officially once again (one of many continual prayers going up since our arrival) and we check to see if the anesthesia has taken effect. It isn't working completely, just giving her some warm tingling feelings in her legs, so Sarah gives her some Ketamine to go on top of her Diazepam and Greg slices from her pubis to just below her belly button.

As we enter the peritoneum, we get a small surge of liquidy pus from the pelvis. We know now, we've made the right decision. It just remains to be seen exactly what's the source. We irrigate and suction out the pus. As I retract, Greg examines the left tube and ovary, the uterus and then the right tube and ovary. Everything is completely normal. He moves over to the cecum and as his fingers work some inflamed tissue free, out pops a very angry appendix right about to burst. With a couple quick clamps, the vessels are clamped, cut and tied. The base of the appendix is then clamped and stick tied twice and sliced off. A lot more irrigation and suction and we close the fascia and skin. It's taken less than an hour, the anesthesia was completely uncomplicated and we take her home to the "ICU" 30 minutes praising God all the way!

If she had been evacuated, she would certainly have perforated either in Gary's plane or in the Air France plane. Amazingly enough, the best care available for her in the world at that moment in her life was found at the Bere Adventist Hospital.

(Story told with the permission of Sarah "Esther")

Airborne

The Land Cruiser crashes through the six foot high millet over a windy bumby trail towards the airstrip.

It's a cool Chadian morning just after 6:00 AM.

Rich has picked up Dr. Bond, Sarah and I from the hospital and brought us out here with our pilot, Gary Roberts. We finally burst on to the airstrip with just a tinge of pink lining the wisps of clouds barely clinging to the night before being swept away by the new day.

The plane looks tiny against the backdrop of grassy airstrip hacked from the African bush. Using well placed whacks with long switches a few kids guide some scattered goats across the strip halfway down.

A single prop, four-seater, our plane is about to go international.

Bond is a little nervous and plies Gary with all kinds of questions about flight hours, how many accidents, how much fuel the plane carries, is he going to check if there's water in the fuel, etc. As Gary takes off the tarps and I help him unattach the tie downs Bond is trying to visually inspect the plane from top to bottom. Dressed in his sport coat and sporting wild black hair streaked with gray and the beginnings of a bushy mustache, Bond looks like India's version of Albert Schweitzer.

Finally, luggage weighed and packed, we squeeze ourselves in the fuselage and strap ourselves in.

The engine fires up sending in a burst of "air conditioning" through the open windows. Last minute checks in place, the windows close and Gary turns the plane around away from the sunrise. Gary then reopens a window and yells to the night watchmen to run ahead and pull the stick "goal posts" out of the strip/soccer field so we can take off.

When all is clear, a pull of the throttle lurches us forward and we quickly pick up speed as we bump and bounce across the airstrip and in no time we are airborne as Bere drops out from below us and we take a sharp turn over the trees to buzz the hospital.

It's amazing to see how really small our 20,000 strong village really is. Just a bunch of mudhuts so well camoflouged by the mango trees and millet patches that you can't hardly see anything until the tin roofs of the church, school and finally hospital come into view.

Seeing that tiny clump of trees with a few tin roofs jutting up it's hard to believe that anyone would want to be treated there much less that people would come as far away as Lake Chad and Abeche on the border of Darfur to be operated on in our collection of ragged buildings.

Soon we are crossing a patchwork quilt of rice, millet, peanut and sweet potato fields. The artwork is more of the style of Barcelona's Gaudi with natural lines of trails, islands of trees and a symmetry more geographic than geometric.

We soon pick up the Logone river and follow it's course. Along the banks we see the tiny beehive-shaped, rounded tents of the Arab nomads with herds of cattle and a few horses scattered along the banks. Periodically the glassy surface is broken by the smooth gliding of a wooden log canoe and it's fishermen on their way or already casting their handwoven nets in the shallow, fish-rich waters.

We follow the Logone up and finally see the Tandjile snake it's way up and join it's fast flowing waters right before Koyom and the Pentocostal Hospital. We buzz it's airstrip and notice it's unusable.

Then we pick up altitude, leave the Logone behind and the African plane becomes a distant network of fields, forests and tiny villages.

Finally, we pick up Tchad's other major river, the Chari and follow that all the way to N'Djamena where the Logone and the Chari become one.

One doesn't even notice N'Djamena till one is right on top of it. It's just a large village lost amongst the trees. If it wasn't for the occasional 5-10 story building and the bridge across the Chari and the fact that I knew that's where the Logone joins in I wouldn't have been sure it was N'Djamena. I don't think there is any other capital village in the world like N'Djamena.

The airport is right across the river and has a single runway. There are two other planes pulled up at the airport. We land easily and taxi up the the MAF hangar. Probably the world's smallest international airport (a fact proven later on when we land in Garoua, Cameroun's international airport).

After a few days getting visa's and wasting time trying unsuccessfully to talk to the appropriate authorities to get Gary permission to fly on a permanent basis in Tchad we take off for Cameroun.

Cameroun is unremarkable for about 30 minutes until we hit the national park at Waza where we scare off some herds of antelope and giraffes. I finally feel like I'm really in Africa although some Elephants and Lions would be nice, too.

As we approach Garoua we hit some mountains and Gary flies us between two flat topped plateaus in a valley. The descent combined with an approaching storm and the mountains makes for a bumpy ride that threatens to loosen the tenous hold on my breakfast that I'd been maintaining since N'Djamena.

Sarah had already let up a sickening vomit smell from the back seat. Fortunately, Gary kindly provided us with vomit bags for the flight.

I think it's hypoglycemia as we haven't really eaten well the last few days. We couldn't find any place to stay in N'Djamena until someone finally opened us up a dorm room that hadn't been cleaned in months and didn't have a kitchen. So we were forced to eat off the streets which is slim pickins in N'Djamena (we had to content ourselves with boiled eggs, french rolls and fish soup).

After an uneventful landing and take off for formalities in Garoua, we head into the mountains. The beauty of the rugged cliffs rising from the rich green valleys sprinkeled with fields of corn and millet and wizard hat-like pointed roofed huts is impossible to describe.

Gary calls Maroua Airport to check in and the controller is shocked to hear we're going to Koza since no one has landed there in over 20 years but Gary assures her that the airstrip has been repaired.

One mountain plateau is so broad we dreamed aloud of building a hospital and airstrip on top of it...and it is not exaggerating.

Finally, we climb the last pass and look into Koza's valley. We approach the airstrip. I get the idea Gary is going to land because he goes so low but he's running out of airway. At the last minute he cranks the throttle and whips up over the tree tops before banking hard left and back around. Apparently, he was only looking for cows and holes that kids have dug to find mice to eat.

We circle around again and make a very bouncy jungle strip landing without any problem in time to greet the crowd of kids running up followed by a gang of bikers. By the time we have stopped and started to tie down our two guardians are there with sticks keeping the kids a safe 2-3 feet away. The crowd is so thick it is literally a sea of smiling, laughing and waving faces.

Gary's wife Wendy drives up in Greg and Audrey Shank's pick-up truck and Sarah and my 3 week adventure at the Koza Adventist Hospital (before returning to Bere) is about to begin...