I pick up Miriam and we walk over to the hospital. It's almost time for morning
staff worship. I sit down on a wooden bench that creaks under my slender frame.
There are already several groups of people gathered waiting for consultations or
just sitting doing...who knows what. I see Abel come out of the Men's ward
walking purposefully towards me. Severine is close behind with a furrowed brow
and several patient charts clutched in her right hand. I slip Miriam around my
waist and rise to meet them as they are obviously coming to see me.
"The patient admitted yesterday...swollen face...just like the last one...not
breathing well...blood coming out of his mouth..." Abel can hardly get the
words out. I follow him quickly to the ward and see a group of 6-8 people
gathered around a skinny man lying on the gurney. He's pasty and breathing
shallowly and rapidly. His eyes are closed. One woman is already wiping tears
from her eyes. They think he's death warmed over. I have to agree.
"Get these people out of here and take him to the minor procedure room!" I
order and Severine and Abel go rushing off. I check his pulse which is thready
and weak. Miriam just stares, interested in all the goes on around her. His
teeth are blood tinged and there is a putrid smell everywhere. I palpate his
swollen left cheek and neck and it is bouncy and fluctuant. He's not doing
well.
Patrice and Abel come back with a gurney and work on getting him transferred I
take Miriam home. Sarah is out tying up the horses for their daily grazing so I
knock on Deborah's door and ask if she can watch Miriam since there's an
emergency at the hospital. Her husband, Dr. Roger, is a Congolese doctor newly
arrived from Koza Hospital in Northern Cameroon to help us out.
I rush back and find the man already on the operating table and the lights on.
Abel is desperately trying to find an IV. The blood pressure monitor can't find
a blood pressure. The pulse oximeter can't find a pulse. But he is still
breathing and his heart is slowly beating. Not a good sign considering his
heart should be racing. Patrice is on the other arm now. No one can find an
IV. I run to the OR and get out a central line kit. I slap Betadine on his
groin, put on sterile gloves and tear open the kit. I put on the drape, arrange
the guide wire, grab the syringe and needle and palpate his femoral artery. He
has a pulse which is good for two reasons: 1) he's alive and 2) that means I
should be able to find the femoral vein medially.
I slowly introduce the needle pulling back slightly. I take it all the way down
with no flash of blood. I slowly draw back and am rewarded with a sudden gush
of dark blood in the syringe. I stabilize the needle with my left hand and
remove the syringe. I grab the guide wire and thread it in. I pull the needle
over the guide wire and reach for the scalpel. I make a small skin nick over
the wire and plunge in the dilator. Blood wells out as I remove the dilator
over the wire and thread in the four lumen catheter. Meanwhile, Abel has
finally found a peripheral IV. We attach IV antibiotics to the peripheral IV
and three IV bags of saline and a bag of whole blood to the central line.
After about 5 minutes, we get a blood pressure: 74/38. Still very low but at
least it's something. The pulse oximeter has also picked up a pulse and he has
good oxygen saturation. I grab the scalpel from the central line kit and move
into attack position on the neck. The patient can't tolerate anesthesia and
he's mostly unconscious anyway. I stab and cut as putrid pus and dark dead
muscle and blood clots well out of the wound. The odor is horrifying and the
necrotizing wound is deep all the way around the angle of the mandible up under
his tongue and under the mandible down his neck. I cut away dead muscle and
with my finger pull out gangrenous debris from all the different cavities of the
abscess. FInally, I rinse out with diluted bleach and back the wounds with
gauze.
He's now awake with a normal blood pressure. His pulse is still slow which is
weird. Must have something going on with his heart but he's able to talk and
sit up now so we take him back to his bed.
Then I do rounds. There are a lot of empty beds. That's unusual. I comment to
Ruphine, the nurse in charge of the wards.
"Looks like there wasn't too much business over the weekend. Good to have some
slow days once in a while." Then I walk out and see hordes of people standing
around, lying on mats, in various stages of suffering waiting to be seen.
As I enter the post op recovery room the nurses inform me that there is another
strike at the government hospital. But this time, unlike last time, there is
not even any emergency care. They've evacuated the patients and closed the
hospital.
That's when things start to get interesting. Fortunately, we have no scheduled
surgeries. Both Roger and I start helping Juliette out with the mountain of
patients she has to consult.
I see a 13 month old with painful urination and fever. He has phimosis (his
foreskin is almost completely closed shut). I prescribe antibiotics and do his
circumcision later that afternoon. There is an 80 year old blind Arab with
difficulty urinating and symptoms of malaria. I order a urinary catheter and IV
quinine and his family runs off to buy the meds while he lies comfortably on one
of the gurneys. The next patient has to be carried in. I place her on a gurney
as well. She is 3 months' pregnant with malaria and anemia. I order blood
transfusion and IV Quinine and Anatole gets busy testing her husband who is the
only family with her. THey came from N'djamena, the capital. He has a strong
hemoglobin so I tell Anatole to take two units of blood from him and then we'll
give her a third from our stock in the fridge.
The next woman was seen last year in Bere at our hospital there and had an
ultrasound with a pelvic mass. She left without treatment and is back now. I
order a repeat of the ultrasound. I then go to the ultrasound on the boy with a
urinary infection to make sure he doesn't have a bladder stone which he doesn't.
The family then goes to pay for the circ. The woman does have a mass and I fill
out a form so she can pay for an operation.
In the mean time, Juliette has found two men each with massive inguinal hernias
that I squeeze and push and finally reduce. I fill out operating sheets for
them as well. Another woman with infertility has come back with the xray of her
uterus (hysterosalpingogram) but then informs me that she doesn't want to get
pregnant now anyway because she's at the Police Academy and if she's pregnant
they'll send her home. I wish her well and tell her to come back when she wants
to try and have kids.
The boy with the infected open fracture of both his forearm bones is back. I
look at his wound which is getting better. His arm has no swelling and the
wounds look superficial. I do the dressing and leave the nurses to put on the
splint. Then I see the young boy I did an intramedullary rod on last week. His
wound looks good and he's walking already. He's smiling and happy as his dad
swings him off the table. He'll be back in a week to have his stitches out.
Gombo is also back. He had an old, open, infected tibia fracture that I put a
metal rod in and has been hooked up to a vacuum dressing machine for weeks until
his wound finally closed over the bone. He just left last week and comes back
daily for regular dressings. The wound is very superficial and the bone is well
covered. He's laughing and joking with me as usual in Arabic.
"Next week I'll see you on the football field!" He smirks.
"Tamam, illa baiden, inshallah!" I reply (Perfect, until later, God willing.)
Roger has just finished a D&C and is seeing some more patients. A woman has
come in in labor with her first pregnancy. Roger has got the IV going and
examined her. She's at 7cm and has strong contractions. I show him how to use
our fetal doppler machine and we verify that the child has a strong heart beat.
Abel comes to tell me they have the woman with lipomas on both hips and she's
ready for surgery. I prep the first hip, put on sterile gloves and drape it
with towels. Roger comes to assist. The lipoma turns out to be like a thick
American pancake in size with lots of fingers hard to dissect out and a lot of
bleeding. Her high blood pressure doesn't help as I can hear the cut arteries
hissing as the blood spurts out. I finally finish the first side, put in a
drain with a suction apparatus attached. Now I only have to repeat the same
thing on the other side. I have to admit I've muttered more than a few un
missionary-like words as my expectations of an easy lipoma have been far from
met.
Finally, at 1:30 pm I'm at home for a late lunch of rice and soybeans. I barely
start when I see Abel at the door.
"We have an infant we've tried to find an IV on all morning. We've poked him in
every arm and leg all over and used up 5 IV catheters without success. He has
anemia and malaria and needs blood."
"Ok, I'll be right there." I woof down the rest of my food and head back. I
open the container and pull out an pediatric central line kit. I inject the kid
with Ketamine, prep the groin with Betadine and open the kit with sterile
gloves. This kit is simpler than an adult one and seems to have been sent to
Africa because people didn't like it in the USA. At least that's what I assume
after I struggle with the kit for over half an hour. Usually the tough part is
finding the vein. In this kid I find the vein right off the bat and thread in
the guide wire easily. But there is no dilator and the tip of the catheter is
not beveled and it refuses to go in. I pull out the guide wire and realize it
wasn't in the vein. It's all crumpled up. I find the vein again easily. I put
the other end of the guide wire in and this time it goes in so smoothly there
can be no mistaking it's in the vein. But the catheter won't go in. I try and
try. Nothing. I pull out the guide wire which is still straight. So it was in
the vein. I try again and hit the artery.
I hold pressure and prep the other groin. I find the left femoral vein as well
but have the same trouble. I try and try multiple times with no success.
Either the guide wire won't go in, or the catheter won't. Finally, I bend the
other end of the guide wire and have to go get another kit. I find a slightly
different kit with a dilator and this time it goes right in on the first try.
We hook up the transfusion and IV Quinine drip and I move on.
I see a woman with three months of cough and weight loss. She's HIV negative,
has very reduced lung sounds and crackles on her left side, huge liver and
spleen and a racing heart. She probably has TB but with the general hospital
closed there's no way to confirm with sputum samples or x-ray and there's no
legal way to get her medication. I hospitalize her with IV antibiotics in case
it's a pneumonia, malaria treatment (because we're in Chad) and have her family
go to the market where I've heard you can find TB meds being sold, probably
stolen from the hospital.
Another man comes in with what sounds like Asthma and pneumonia. He's very sick
so I hospitalize him, give him antibiotics and steroids and have his family go
to an outside pharmacy for an inhaler. We have no nebulizer or inhalers here.
I really want to get finished and go play basketball with my friends. I spent
most of yesterday helping them put up the two new backboards we'd made from old
packing crates and leftover one-day-church materials. There was only one full
court in all of Moundou (population 500,000) and it's cracked and rough and only
had one backboard and the other one was low, angled back and had a bent rim. So
I was really looking forward to being among the first to play full court in a
long time. Mondays usually everyone is there too so the competition is good.
And I need the exercise.
But time is ticking away. It's 3:30. I have the circumcision to do. I blaze
through it. Then I have two extractions to do. I numb one then call in the
other and numb her. Then I bring back the first one and pull out his rotten
molar. Then I call back the second and pull out her rotten lower canines. It's
4:15pm. Maybe I'll make basketball yet.
The night nurse comes' in. "There's some accident victims just came in." I
follow him from the minor procedure room to post-op recovery. There is a tall,
lanky young man with his left pant leg rolled up and a gnarly swollen, scraped
up knee to my left. He looks stable and another nurse is cleaning the wound.
The second patient is straight ahead and has gauze wrapped around some bloody
bandages on his feet and a traditional splint over his right thigh and knee.
Sitting next to him is another young man with a traditional wrapped cardboard
splint over his lower leg and ankle.
It appears they were in an accident last night and went someplace where the
lacerations on the man's foot were sutured. THen they went to the bone setter
who did his work. The young man had antibiotics before going to get his
cardboard splint applied. I prepare an operating sheet for the man with the
femur fracture. I don't have an x-ray but I know it's broken and he says it's
shattered distally so I he needs surgery. I'll figure it out intra-op. The
young man the bone didn't come out but there is a wound over the fracture. I
need to make sure. I unwrap the cardboard and take it off. I see a mass of
dried, ground up roots over the shin. I get a basin of water and soak and
scrape off the clump. There is a very tiny wound where a bone fragment may have
pierced the skin. I order some more antibiotics and he'll be prepped as well
for surgery in a few days. I put on a posterior splint and dressing in the
meantime.
The family comes to say they've found another clinic with an xray and they are
open still. The driver who caused the accident is back with his truck to take
them there. We load them all up and they drive off. They come back later to
say there is not xray there. They want to go to Bebalem hospital several hours
away to get an xray. They seem to be fixated on it. I tell them it's not worth
it and we can operate without xray if need be. I've done it before in Bere.
I'm not sure if they're convinced. We'll see tomorrow.
While I was waiting for them to come back, I saw young, drunk woman with a large
laceration on her forehead. It's all the way down to bone. I rinse it out, put
in local anesthetic and staple the wound shut.
Finally, I'm ready to go home. It's a quarter till 7pm and fortunately, Miriam
is still up. When she sees me walk in, her eyes light up and she gets down from
Roger's lap where she's been sitting and waddles over to me while Sarah follows
with the IV pole. We read some books on the couch. She laughs and giggles as I
make funny noises and different voices. Finally, after 3-4 books, she reaches
for a new teddy bear in the toy basket and looks it over carefully. Then she
hands it to me. I kiss it and hug it. She points to the bedroom with her non
IV hand and grunts. I understand and stand up.
"Do you want to go see Bamse?" Bamse is the teddy bear she always sleeps with.
She nods and holds out her hand. I walk with her hand and hand to the bedroom,
take the IV bottle off the pole and attach it to the hook in the wall over the
bed and lift her up and under the mosquito net. I give her Bamse and she grabs
him and snuggles as she lays her head back on her pillow.