26 December 2013

A VERY MERRY TCHADIAN CHRISTMAS


A VERY MERRY TCHADIAN CHRISTMAS

December 25, 2013 at 9:39pm
Joyeux Noel!!!


Waaasssuuuppp Christmaaaaaaaasss!



Tchadian Christmas dinner 



Family tradition

10 November 2013

KIDS

I don't know why I wake up crying, it seems to be my habit of late. But then
again, it's not that surprising as everyday I'm seeing such suffering and death.
I feel sorry for Andrew, our family practice resident.  He hasn't seen much
death before and he's taking it hard.  But then again, when did I stop taking it
so hard? Or maybe I just bury it quick and it comes back out in the early
morning tears.

Two days ago, there was the two year old with malaria.  She'd been sick for a
long time and finally came in to the general hospital where they found she had
severe anemia.  They didn't have the reagents to do a blood transfusion so they
sent her to us.  We gave her blood and three days of IV quinine. The nurse came
to get me at night.

"She's not breathing well."  I knew that already.  I'd seen her earlier. We'd
given her antibiotics, glucose, quinine, blood.  I couldn't think of anything
else to do. Besides, her liver was very enlarged: the worst prognostic sign in
malaria. The next day, Andrew saw her on rounds and was worried, as well he
should have been. He did even more.  Put her on oxygen, gave her a little bolus
of IV fluids and stronger antibiotics.  She died shortly thereafter.  He came
back to the house. He'd been crying.  I was trying to recover from the week long
marathon of trying to save lives accompanied by a sore throat, diarrhea,
headache and fever.  Andrew then went back to comfort the family until they took
the body away.

Then today came. Another baby with malaria and not doing well.  Andrew sat and
bagged him and gave him oxygen and monitored him and gave him steroids then
heard crackles in his lungs and gave him a diuretic with no response.  His
kidneys and lungs and liver were failing.  He somehow hung on for hours...and
then died right after a four year old with: surprise, surprise...malaria. And
then one thinks of the fact that developed countries have eradicated malaria
using DDT and then jumped on the political bandwagon to ban it for the rest of
the world that continues to suffer and die from it at extraordinary levels.  I
really don't care if it does wipe out some bird species (it doesn't, by the
way.)

We all need a break.  After Miriam and Noah wake up from their afternoon nap we
go out for a walk to the river.  Sarah has Noah in the Baby Bjorn, securely
hanging in front of her as happy as can be.  Miriam has her pink Tinkerbell
swimsuit on with an aqua Swedish sun dress on over it.  She's riding on my
shoulders singing away. Andrew and Rodney plod along besides us in shorts.  We
cross the main road to many a curious stare of passing motorcyclists.  Just
across the street some young military guys are sitting on the leaning,
half-broken down wall surrounding the Armée Nationale Tchadienne (ANT in
French!) barracks.  They yell out greetings and wave.

Around the corner we hear the silence from the city power plant as Moundou
remains without power for some unknown reason. Crossing another main, almost
deserted road, we arrive in the swampy fields next to the river where the brick
making men are hard at work, sweaty, shirtless bodies glistening in the
afternoon sun as they tramp out mud, collect straw and slap the mixture into
their crude brick forms.

We finally find a way through the maze of bricks to the river.  There is a
solitary tree on a small hill with piles of sand and gravel around being sold to
push cart workers carrying it to some construction site.  We descend the small
slope into a tiny little bay of calm water next to the swiftly flowing, shallow,
wide Logone River.  The Logone is one of Chad's two main perennial rivers
joining together at the capital, N'Djamena, before emptying into the astonishing
Lake Chad which has no outlet to the ocean yet stays fresh and not salty like
the Dead Sea or the Great Salt Lake.


The water is amazingly cold.  Miriam at first is afraid but then wades out
slowly to me with a silly grin on her face.  She soon wants to go back to Mommy
and Noah who are leaning against a sand pile.



 

Andrew and I wade out into the swift current and then swim across to a sand bar,
barely making the end of it as the current rapidly takes us down river.  We then
walk back up the sand bar past where we put in so we can make it back to our
cove.  There is nothing on the sandbar but a few driftwood pieces and some
chicken hawks and pigeons.  A few dugout canoes ply the waters checking their
fishing nets. We swim back.  Miriam is ready for some more play time in the cove
and giggles and laughs as she jumps up and down on me and spins around crazily.



I crash on the couch at home and almost fall asleep before getting up to make
supper.  We are just watching a Jesus Culture video, about to sit down to eat,
when Josephine comes knocking on the door.

"There's a little boy who was just hit by a motorcycle.  He's unconscious with a
large wound on his head."

"I'm coming right over." I pull scrubs over my shorts and t-shirt and jog over
to the hospital.  A five-year-old is lying on the bed covered in sand stuck to
the blood on his head. He is agitated and left side is twitching in a focal
seizure.  His right temple has a 5 cm laceration.  There doesn't appear to be
any skull fracture and his pupils are equally round and reactive to light.
Remadji is just starting an IV when a couple of Chinese show up at the door.
One man is crying holding his deformed right arm and the girl is speaking French
with a Chinese accent.

"This man is serious.  He hurt his arm playing basketball. It's come out."

I usher them in to a bed and feel his shoulder which has an anterior
dislocation.  I go to the OR, get 5mL of Ketamine and give it to him in his left
deltoid.  Then I go back to the boy who has the IV now and is getting diazepam
for his seizure.  His breathing sounds labored so I open his airway by putting
an OR gown under his shoulders and check his O2 sats.  They're 78% so I rush to
the OR and bring back our one O2 concentrator.  Quickly the sats go up to
98-100%.  The father speaks to me in Arabic.

"Look at his leg, is it broken?"

"Which one?" I ask back in Arabic.

"The left one, there."  I check it and it's fine.  But when I check the right
one it is obviously a mid-shaft femur fracture.

"That one's ok, but this one is broken."  I have the father hold the leg out to
length while I get an ace wrap and tie the two ankles together to temporarily
keep the leg from shortening. "If he comes out of his coma, we can fix the leg,"
I inform the dad.

Meanwhile the Chinese basketball player is out.  The man with him doesn't speak
French so I try English.

"Hold his arm under the pit," I show him what I mean and he understands.  I put
traction on the arm and after a few minutes I feel the humeral head pop back
into joint.  I check it and there is no more deformity and full range of motion
of the joint.  I recheck the boy and his pupils are still reactive and he's not
seizing and his O2 sats are normal.  I go home and watch "Capitalism: A Love
Story" with Andrew.  Then I go back to check on the boy.  He is still agitated
but more awake, not seizing, normal pupils and doesn't need oxygen anymore.  I
go back home and crash.

06 November 2013

24 HOURS

I've just got into bed when the familiar clap-clap comes at the door.  It's
Josephine.

"Doc, the general hospital has referred another patient with anemia.  They say
they've tried to find the IV but can't so they sent him to us."

This is starting to get to be a chronic story: the huge government hospital
which is supposed to be Southern Tchad's regional referral hospital, is now
regularly referring us patients not only for surgery, but for blood transfusions
and complicated obstetrics as well.  Just two days ago they referred a woman
with a hemoglobin of 1.6 g/dL who had been bleeding at home for two weeks after
a home delivery.  It was midnight when I started two large bore IV's to get
blood running and her blood came out like water with a little red food coloring.
Not only was she alive, but talking and with bulging veins...

"How old is he?" I ask Josephine.

"Three."

"Ok, I'll be right there." I pull on scrubs, grab my flashlight, walk across the
lawn and through the gate to the hospital.  I veer left instead of going to the
clinic and open up the storage container.  Inside, my flashlight helps me find a
pediatric central line kit among the piles of surgical and orthopedic supplies.
I walk over to the recovery room where a young girl is lying panting on a
gurney, her eyes closed and sweat beading her forehead.  I take her back to the
OR, give her a shot of Ketamine and feel her bounding femoral pulse.  I prep
with Betadine and open the central line kit.  I put on sterile gloves, place the
drape, prepare the guidewire, fit the introducer needle to a syringe and palpate
the femoral artery again with my left forefinger.  I go just medially and after
about 5 slow insertions and withdrawals of the needle, I hit a gush of dark
blood.  I hold the needle firmly in my left hand and gingerly take off the
syringe.  Blood trickles out as I pass the guidewire into the vein.  I nick the
skin with a scalpel and pass a 9cm 24G catheter over the guidewire before
pulling it out and attaching the blood transfusion.

Josephine bursts into the OR and starts rummaging through the bundles of suture
kits and dressing change instruments.

"What's going on?" I ask.

"The second woman in labor...she's breech and about to deliver!"

I quickly put on a sterile dressing, take off my gloves and hurry down the hall
to the tiny labor and delivery room just off the recovery room. A large woman is
lying down, legs bent up with a scrotum and anus poking out of the birth canal.

"Don't push, Madame!" I shout as I hurriedly put on some simple gloves.
"Josephine, do you have the instruments and the bulb suction?"

"Yes, it's right here!"

"Ok, Madame, go ahead and push with the next contraction..." I don't need to
tell her twice.  As the scrotum and butt cheeks advance out I slip a finger
around the thigh and pull the top leg out.  THen I twist the body around so the
back leg is now on top and pull that one out too.  Putting the tiny feet between
the fingers of my right hand I pull until the body is out to the armpits.  Then
I deliver the anterior arm, swinging it down over the chest.  I twist the baby
around so the undelivered arm is now on top and slide that one down and out too.
I put my left index finger in the baby's mouth to flex the head and pull the
baby out in a slippery burst of meconium stained amniotic fluid.  I suction out
the mouth as the baby gasps but doesn't cry.  I clamp and cut the cord and take
the baby to the resuscitation table where I  vigorously rub and slap until the
baby is screaming.

"Josephine, go get some oxytocin and give her an IM shot..."

"Doc," interrupts Josephine. "Better take a look...I think there might be
twins..."

Sure, enough, the woman looks as if she hasn't delivered anything.  I examine
her again and find a bulging amniotic sac next to  the first boy's clamped
umbilical cord.  I break the bag of water in a gush of bloody fluid and feel the
next baby's head. She doesn't have contractions, so we start an oxytocin drip
and once the contractions start I give her the green light.

"Come on, Madame, time to get this baby out."  I expect it to take some time
since the baby's head is so high up inside and maybe things aren't completely
dilated since the first baby came out breech.  But with one massive heave and
grunt the baby almost flies out in a splurt.  Another boy who is also quickly
dried, suctioned, slapped and made to cry a heartening scream at the new world.

I turn my attention to the other woman in labor.  She's been there all day.  Her
bag of water broke at 9AM and she's had good, solid contractions but no cervical
change.  She had a previous c-section 8 years ago and hasn't been pregnant since
(rare in Africa.)  I decide she's had a fair trial of labor and another
c-section is indicated.  I call in Abel and Daniel who soon have her prepped and
ready.  The spinal I gave isn't working so I have Daniel prepare a little
Ketamine and when I'm poised with the knife and we've prayed I give him the go
ahead.  In about 30 seconds, the woman is out and I slash down to the uterus and
peel back the bladder from the lower uterine segment which is quite thin.  I
enter the uterus and expand the incision laterally and superiorly.  The baby
comes out fairly easily but once we've clamped and cut the cord and handed him
off to Daniel and once I've pulled out the placenta I see geysers of blood
gushing out of both sides of the wound where it has extended into some serious
artery action.

I clamp them all off with ring clamps and suture the uterus closed.  There is a
small bleeder in the middle that I snag with a figure of 8 suture using 0
Chromic.  Then I notice another oozer on the left and when I try to suture that
it just oozes more.  THen I notice the whole side of the uterus is swollen with
blood clots just under the surface.  I have to tie several figure of 8's all the
way up and down until the bleeding actually stops. Then I close her up and go to
check on the three new babies.  The twins have already breast fed and another
patient has just arrived.

A nurse from the Refugee Camp in Goré on the Central African Republic border was
in a motorcycle accident at 7pm and had an open tibia fracture.  It was washed
out and splinted and he was given antibiotics and got one of the UNHCR Land
Cruisers to bring him to us, over 50 miles away. It's now about midnight, so I
give him some IV fluids and Valium and set him up for surgery at 7:30AM.

6:00AM comes way to soon and I'm up, eat oatmeal and go up to the hospital. I
give a short worship for the staff and patients about Jesus healing Peter's
mother and then go do rounds.  The hospital is packed to overflowing.  It seems
like every other bed is filled with a child getting a blood transfusion for
severe anemia secondary to Malaria.  Most of the other beds are orthopedic
patients recovering from surgery or healing chronic wounds.

I put in an IM rod into the Refugee Camp nurse's tibia, take out a large uterus
with a molar pregnancy, do a hernia repair with mosquito net, perform a D&C,
pull a tooth, do about 10 ultrasounds, see patients with HTN and Diabetes,
prepare a man with hydrocele for surgery, hospitalize a 9 year old with
recurrent urinary infection, treat a middle aged man with hypertensive heart
failure, eat lunch with my family, treat some more patients with Malaria,
Typhoid Fever, Dysmenorrhea, infertility, first trimester bleeding, completed
miscarriage, chronic knee pain, tell about 10 people to go on a whole food plant
based diet, pray with some patients and am about to get ready to go home when a
man gets carried in from the general hospital.

He'd been sitting there for 3 days getting a few shots now and then with an open
tibia fracture.  Finally, the chauffeur who hit him and is responsible for
paying his medical care decided to bring him to us since they weren't doing
anything for him.  He pays for a third of it so we start preparing the patient
while the driver goes to the market to find the rest of the  $135 dollar
surgery.

So much for basketball today, I think, as I glance up at the clock which reads
4:15pm.  We take the young man back to the OR and place the IM rod through a
crushed distal tibia fracture. Finally, I'm able to go home to see my kids.  As
I walk through the door I yell out, "Miriam?! Hey you!"


My 2 year old daughter with the wild, curly blond hair pulled back in two
haphazard pony tails, looks up, squeals and then starts dancing up and down over
some wooden bear pieces on the ground while laughing hysterically.  I plop onto
the couch and start laughing with her as she looks at me with a goofy grin and
then runs off around the corner with her tongue wagging back and forth babbling
in her best imitation of a turkey's gobble.

10 October 2013

CATASTROPHE


I'm deep in the belly when the catastrophe starts.  I've already started
dissecting the descending colon off the grossly enlarged and inflamed left
kidney when suddenly I can't see anything.  The man's stomach comes popping out
of the abdominal wound and his abs tense up so that all the rest of the
intestines and the enlarged spleen block off any view I used to have of the
diseased kidney.  The man is retching and dry heaving.

"Can't see or do anything here, can't you give him something?" I shout at
Patrice, our nurse doing anesthesia.  Thus starts a long, labored process of me
trying to hold in guts on one end while trying to verbally direct anesthesia on
the other.  Finally, I have to break scrub and tend to the man as his oxygen
saturation has plummeted.

His jaw is rigid and his whole body tense and he's refusing to breathe.  This is
why Ketamine isn't used often in the developed world.  Alcoholics just don't do
well on it.  We're pounding him with Valium, Thorazine, Promethazine, Ketamine,
trying to get his body to relax so he'll take a breath.  But now he has vomit
spilling out of his oral airway and nose.

"Suction!" I scream as I try in vain to tilt his head back and open his mouth
against his strong muscular contractions.  Finally, I get a suction tip into his
mouth and aspirate the yellow, bilious liquid out.  I can barely get in a
laryngoscope but fortunately it's enough as I see the vocal cords wide open.  I
slip in an ET tube and start bagging.  His sats finally come up to decent, but
not ideal as yellow froth bubbles up in the tube.  I suction out the tube  and
lungs but it keeps coming.  He's aspirated and this is not good.

And I still have an open belly and most of a difficult surgery ahead of me.  I
scrub back in.  The abdomen is still rigid.  Finally, after 5 doses of Valium,
one each of Thorazine and Promethazine and two bottles of Ketamine, things are
relaxed enough to operate but his sats are still not good and I'm afraid he'll
die on the table.  There is lots of oozing in the operating field so I decide
that careful dissection just won't do in this situation.  I reach in my hand and
peel off the kidney all around it's lateral and posterior aspects and pop it up
into the wound.  I pack the kidney bed and put three clamps across the pedicle
where I know the major vessels and ureter are.  I cut out the kidney and toss it
onto the mayo stand.  I stick tie the pedicles, irrigate the abdomen, place a
drain and close up.

As I scrub out to check on the anesthesia part, the man is now completely
relaxed and his sats are normal.  He has a bag of blood running and has used up
over 10L of Ringer's Lactate. We wait about 30 minutes until he starts to make
some movements with his mouth.  I take out the NG tube and then extubate him.
He does fairly well on just oxygen so we take him out to post-op recovery.

There, the woman with the thyroid mass who is intubated now needs the oxygen so
we are forced to switch back and forth between the two patients since we have
only one oxygen concentrator.  When one patient's sats go down we give them
oxygen for a few minutes until it comes up and by then the other's sats are
dropping so we switch.

The next day, Roger comes to see me about a patient who has an intestinal
obstruction that was hospitalized yesterday.  The man is gaunt with a swollen,
air filled tender belly.  I go see Juliette who hospitalized him with Malaria
and constipation yesterday.   He hasn't had a stool or gas in 10 days.  When I
ask her why she didn't tell me about this patient she says it is because I was
so busy with the complicated case yesterday and then she forgot to tell me
afterwards.



They have no money and are obviously poor so we just take him to the OR bloc
even though he hasn't paid. When I open the peritoneum, gas and a foul odor
escapes.  THere is over 3 liters of putrid pus in the abdomen.  His cecum is
necrotic with a hole oozing brown, gritty stool.  The appendix is normal.  I
dissect out the cecum, ascending colon and terminal ileum and remove them.  I
then reattach the ileum to the rest of the ascending colon, wash out the abdomen
with liters and liters of tap water, place three drains and close up.

Fortunately, his anesthesia went without any catastrophes.

26 September 2013

NECROTIZING

I'm just sickened. I'm wracking my brain trying to see why I didn't see it
sooner.  Hindsight is 20/20. Yesterday, Dr. Roger comes up to me after staff
worship.

"You should come see bed 11. Last night at nine, they called me and he had a
wound that erupted in his groin."

"Bed 11?"

"You know, the man with the double fracture, tibia and femur..."

We walk the short distance to the men's ward and enter the dimly lit room.  Just
to my right is a man I recognize well.  Three days ago, Saturday, I operated on
him for a floating knee where the distal femur and the proximal tibia were just
shattered.  Sunday, he was doing well.  Monday, he was groggy, but the nurses
said he'd had so much pain the night before they'd injected him with a
tranquilizer and a narcotic.  I assumed it was just that.  He was arousable and
his vital signs were normal.  His femur fracture was an open fracture that had
been sutured at the government hospital three days before coming to us.  At
surgery, the wound was very traumatic, but didn't look infected like many that
I've seen.  The wound looked good on Monday, though there was some
serosanguinous drainage on the dressings.  There was no odor.  Tuesday, I let
Dr. Roger do rounds while I operated.

Today, he looks like death warmed over.  His breathing is shallow, his eyes are
closed, his skin is sallow and he's lying in a pool of foul smelling maroon
liquid.  I pull back the sheet and his groin is covered with gauze soaked in
brown liquid and around the edges is poking out peeling, necrotic tissue.  The
side of his leg is also weeping with skin sloughing off over dark, dead looking
flesh: necrotizing fasciitis.

"Go get the gurney, quick!" I call to Appolinaire who has accompanied us. 
"Roger, how did it look yesterday?"

"The wound was clean with only some clear, reddish discharge.  No odor. The only
thing I noticed was some swelling of his upper thigh but I thought it was just
from the trauma and surgery.  Then, they called me last night and I saw this
nasty wound in his groin so I dressed it..."

"You should've called me last night..."

We rush him to the OR.  Anesthesia is not necessary as the man is in a coma. 
His blood pressure is really low, but curiously, his heartbeat is normal.  We
get him on oxygen, open his airway with an oral cannula, find two large bore
IV's, start pumping him full of isotonic fluids, inject him with powerful
antibiotics and grab the amputation kit.  I don't bother scrubbing, just put on
sterile gown and gloves.  I grab the scalpel, but then hesitate as I'm not sure
exactly where to start.  Finally, I just begin slicing down through dead skin at
mid thigh, identifying and clamping off the large vessels as I find them
(although many are already thrombosed).  When I get down to bone I just pull out
the IM nail with the knee and the lower leg attached.  I'm really glad now that
I didn't put in the fixating screws in the distal part of the rod.  Then I peel
back the muscles as far as I can and try to cut through the femur with an
extremely dull, hacksaw-looking bone saw.  I toss the piece into the trash and
then start attacking necrotic tissues.

I start with cutting away dead skin.  I get all the way up the back of his leg
to the top of his hip bone before I hit bleeding skin edges.  Then around the
front into his groin I remove his scrotum and half the skin of his penis before
moving up to his pubis where I finally hit live tissue.  I clamp and cut off his
left testicle.  I remove the skin of his anterior thigh.  The only  good skin is
a small patch on his posterior thigh.  I then start cutting off the green
colored fascia and olive, pussy muscle until I find red, bleeding tissue.

Meanwhile, the anesthesia team keeps pouring in IV fluids.  I place a foley
catheter and get some dark colored urine out.  I dip some lap sponges in
antiseptic liquid (diluted cresyl) and drape the raw stump before wrapping it in
gauze.  It takes another half hour of reanimation before he's stable enough to
take out to post-op recovery.

If he makes it, it'll be a miracle.  Meanwhile, I'm left thinking of all the
things I could've done differently to recognize it sooner before it led to this
catastrophe.

Looks like another sleepless night...


16 September 2013

ON THE ROAD AGAIN

Early Saturday, I find myself driving my Vanagon up and down the rolling hills
just northeast of Moundou.  Everything has transformed itself from desert brown
to jungle green.  Patches of red earth show out between the lush tropical
vegetation.  The air is cool.  The sky is blue and dotted with puffy white
clouds.

As if I didn't have enough work already, I'm off to seek and heal that which was
wounded.

Yesterday, I came out of surgery and found David talking on the phone.

"When was the accident?  She has a broken femur?"  My ears pick up.

"David, who is that?"

"Abbas..." he whispers.

"Let me talk to him."  David passes me the phone.

"Abbas, it's Dr. James, someone broke their leg?"

"Yeah, it's my niece," Abbas voice replies on the other end. "She was in a
motorcycle accident last night.  She and two other women were walking along the
road and some guy came and knocked them into a ditch."

"It's the femur?"

"Yes."

Contrary to my usual cautious, take-it-safe attitude I reply spontaneously,
"I'll come get her tomorrow with my van.  She needs to be operated on."

"That's what I told them too, but they've already called the traditional bone
setter and he's set it.  But I'll talk to them.  You should come."

The next morning, I grab my passport, a little money and two jugs of water.  I
open the gate, drive the Vanagon out onto the road and come back to close the
gate when I see David on the verandah of my house.

"Bon jour!" I greet him.

"Salut! Where are you going?"

"Off to Abbas' village like we talked about yesterday."

"But Abbas called me this morning to say that the village elders decided they
wanted to wait a couple weeks and see how the traditional method works."

"David, when were you going to tell me?  What if I'd left earlier like I
planned?  Never mind..." I go drive the Vanagon back inside and shut the gate.
I go shake David's hand and we have a little small talk.  In the back of my
mind, though, I'm starting to regret not going.  I was kind of excited about
getting out to the bush again and see a new village.

"David, I think I'm going to go anyway.  No matter what the case, talking to the
village elders, trying to persuade them, seeing Abbas' village, it'll be an
enriching experience for me."


I get back in the Vanagon, attach the two wires off the ignition, hold in the
button for the glow plugs for 20 seconds and then touch the loose wire to the
two connected wires and the diesel engine roars to life.  What can I say, the
Vanagon has become Tchadian!

So I find myself on the road from Moundou to Kelo.  Abbas told me the village
was 31 km past Kelo on the road to Bongor.  He said when I get to Batchoro I
should call him.  I note the mileage as I leave Kelo and calculate that about 20
miles should equal 31 km.  I'm at 165 so at 185 I should about be there.  I
don't see any signs for Batchoro but when I get to Gang I'm at 185 miles so I
call Abbas up.

"Salut! I'm at Gang..." I inform him.

"What?! You've gone to far, turn around and I'll go wait for you at the side of
the road."

I do a three point turn on the narrow main highway of Tchad and head back.
Within a mile or two I see Abbas waving by a straw mat covered rude shelter by a
sign saying Teleou. I pull off the road next to the shelter and sign, lock the
doors and greet Abbas.

 

"Ça c'est le village," Abbas points to the sign. "We have to walk through water
to get there." He points to his pants rolled up to his knees and his sandals in
his hands.  I follow suit and soon we are wading up to mid-calf along what used
to be a road.  After a few hundred feet we hit dry ground again and Abbas points
to a rudimentary brick structure half built up to the tops of the windows over
to the right behind the school.

"That's the clinic the village is building with their own resources.  There's no
medical care for over 20 miles in any direction."

We continue through small paths around huts, millet fields, pigs, cows,
chickens, goats, kids and winding fences until we come to a few chairs and
benches arranged under a mango tree.  Some of the elders are already there and
we go around shaking hands.  Most don't speak French, only Marba.  Abbas motions
that we should go on a little further.


"Let's go see the patient," he says leading me into a courtyard and through a
cloth hanging over the door of a hut where 5 women scurry out of the way,
grabbing their millet paste and sauce as they go.  A young teenage girl lies on
a mat on a dirt floor with bricks stacked around what must be the fractured leg
as it it wrapped in an Ace Wrap and other bandages.  It looks to be straight and
out to length.  She has a urinary catheter draining into a dish.

"Who put in the foley?" I ask Abbas.

"The local nurse."

"Did the bone break the skin?"

"No."

"Ok, let's go talk."  We duck back outside and return to under the mango tree
where the meeting will take place.  Many more elders have gathered.  They motion
me to a seat next to a younger guy who will act as my interpreter.

We sit around in silence for awhile. It seems they are waiting for me to speak.
I start explaining the complications that can arise from lying too long in one
position and the advantages of being operated and having a metal rod stuck in
the femur so she can start mobilizing the day after surgery.

The man who seems to be the chief elder breaks in.  He talks a lot about how
happy and honored they are to have me come, blah, blah, blah.  Then he talks
about having a lot of confidence in their bone setter and they'd like to see how
it works for 2-3 weeks before trying something else.

"Yes, I saw that he is very competent.  The bone is aligned and the leg is out
to length.  It could heal like that.  However, the muscles of the thigh are very
strong and will likely pull it out of position. In any case, she'll suffer a lot
having to lie there without moving for several months..."

The arguments and debate go on like this in a calm, respectful manner for awhile
until I finally make a breakthrough.

"You know how in the past you had to mill your rice by hand?  Wasn't it nice
when people brought machines to run the rice mills?  Didn't you suffer before?
Wasn't that development good?  Didn't it relieve a lot of suffering even though
the result was the same?  That's the same way with this new method of treating
fractures, it relieves a lot of suffering."  I hear chuckles and see a lot of
nods and smiles around the circle.  They then get up and go off to discuss among
themselves.

"Doctor," my translator leans over to speak to me directly. "The real problem is
finances. All their rice from last year is gone, and the harvest is still a
month or so away. They don't have anything to pay for it.  They're afraid it
will be very expensive since your surgery center is private."

Now I understand.  "C'est vrai, we are private, but we are also non-profit and
our prices are very low so that even the poor can afford them.  But I understand
it's a difficult time in the village, we'll find a solution."

When the elders come back I address them directly. "I know it's a difficult
time.  Here's what I propose: I'll pay for the surgery and then after the
harvest, I'll come back and you can find a way to repay me."

Everyone is then very happy and things get moving.  An ox cart is brought pulled
by two bulls.  The girl is brought out by 6 men carrying her gently and placing
her on a sheet in the ox cart.  They go off and we follow on foot.  I take a
brief tour of the "clinic" and then we meet them at the Vanagon.  She is soon
loaded in and we head back to Moundou.  Abbas accompanies me as well as two
family members who will stay with the girl post-op.



The surgery is done that afternoon without too many complications.  The distal
fixating screw is a little frustrating, causing some non-missionary like words
to escape my lips.  Other than that, all is routine until Dr. Roger bursts into
the OR as I'm starting to close up.

"This young girl just came in," he exclaims breathlessly, speaking rapidly as is
his custom. "She swallowed some unknown object and no can't breath."

"Are you sure she swallowed it? Sounds like she may have got it in her airway.
Go listen for stridor."

Roger comes back shortly.  "She has stridor."

"Ok, I'm almost done, I'll be right there."  I finish quickly and go see a 8 or
9 year-old in respiratory distress, agitated, with nostrils flaring and
whistling sounds coming from her throat.  We hurry her back to the OR where I
inject her with Ketamine in her thigh.  Soon she is out.  I finally find a
laryngoscope that works and insert it into her mouth.  I pull the tongue left
and see the epiglottis.  I lift up and into view comes a green plastic circular
object with spikes along the rim sitting right on top of her vocal cords.  I
reach in and grasp it with some forceps and pull it out.  It's the middle
section of a plastic flower with a centimeter or two of stem that had gone into
her trachea.  Needless to say she's breathing better now.



I go show the family and then head home for a much needed nap.

10 September 2013

ANOTHER DAY...

September 9, 2013 at 8:09pm
The day starts off good enough.  I only woke up drenched in sweat a couple
times.  Must mean my malaria is getting better.  The weekend I was out flat with
chills and fevers and the lovely taste of Quinine.  But this morning, I feel
good.  The call to prayer from the local mosque penetrates even through my
earplugs and wakes me at 4:30.  I get up, pull on some shorts and a t-shirt,
grab a flashlight and go out to the porch.  There isn't even the faintest trace
of dawn but it must be close or my Muslim brothers wouldn't be calling us to
prayer yet.  I pull on my minimalist toed running gear and head out for a jog.
The roads aren't too muddy and I can avoid most mud puddles.  It feels good to
get some blood flowing to my muscles.  I come back, stretch and take a shower.

Since Sarah's still in Denmark not only am I medical director and surgeon, but
housewife as well.  I pull the half dried clothes hanging all over the furniture
in the house and move them out to the clothes line.  I take some dirty towels
over the the clinic to wash them in the only washing machine we have...in the
sterilization room.  I have another load that I put in last night.  I get that
one out and put the new load in and am getting ready to go back home when a
strange sounds finally penetrates my consciousness.  It's the sound of someone
breathing their very last: labored, raspy, gurgling, if you've heard it you know
what I mean.  I turn down the hall and into the post-op recovery room.

A young Arab lies on a gurney in a brown Muslim robe.  He has two IVs hanging
from the ceiling. He's comatose and his skin is scalding to the touch.  I glance
at the IV fluids.  On a bottle of glucose solution is penned the words "Quinine
1 ampoule 05h00" which means 600mg of a very dangerous yet life-saving
medication was started at 5:00AM.  It should take 4-8 hours to run in to avoid
the serious consequences like low blood sugar, irregular heart rate and death.
It's completely empty.  I look at the clock on the wall.  It reads 5:30AM.  We
have a problem here.

Daniel and Larpeur come to my aid as we quickly hang up concentrated glucose
solutions and pour in IV fluids. I have an intern go get the keys from Dr. Roger
and when he comes back I go to the OR and get the pulse oximeter.  His oxygen
saturation is 44%.  It should be over 90% at least.  I open his airway.  No
change.  I hurry back to the OR and come back with an oral airway and the oxygen
concentrator.  Neither has much effect.  I really don't want to intubate him as
that seems to almost surely be a death sentence here since we have no
ventilators.

But finally, I can't resist and I hurry and get the laryngoscope, ET tube and
stylet from the OR.  Meanwhile, Daniel has brought suction.  Even that hasn't
helped is oxygen.  I push the bed out, slide a blanket under his shoulders to
tilt his head down and kneel down to get low enough to see.  I slide in the
curved blade to the right of his tongue and lift up.  Blood and secretions fill
the oropharynx.  I call for suction and clear out the gunk.  I can see the
epiglottis but I can't get in deep enough to lift up and see the vocal cords.  I
use the ET tube to push the epiglottis to the side and I can see the cords but
when I move to put it in the epiglottis falls back down.  Finally, I just go for
it as I have a visual in my head of the angle it should be and slide the tube
in.  I pull out the stylet, inject air in the port to inflate the cuff of the
tube and attach a bag-valve mask.  The man coughs and bloody mucus fills the
tube.  Daniel hands me the suction catheter and I suck out a ton of bloody crud.
Finally, I can bag him and slowly the sats come up but I keep having to take
breaks to suction out the red stuff that keeps coming.


At last, it seems like his lungs are clearer and his sats are at least in the
80's.  I slow down my bagging and let his respiratory drive kick back in.  I let
Daniel start assisting the breathing and when I'm satisfied I take my laundry
and head back home.  I inform the two PA students that their next ICU patient is
ready for them and they go up to take over for Daniel.  Meanwhile, my breakfast
is getting cold.  I grab the rest of the oatmeal from the pot and sit down with
my computer to Skype Sarah and Miriam in Denmark.  The connection is sketchy but
I do get to see them and hear them some.  Miriam is forgetting English I think
as she really only speaks to me in Danish.  I'll have to correct that little
error when they get back.

I go up to the hospital at about 7:30 and we soon start the first case which is
a difficult distal tibia fracture where the bone has just been shattered.
Getting the IM nail in isn't too hard and neither are the distal fixating screws
because the piece of bone right over where I'm going to put them in is missing
so I can see the rod directly in the medullary canal.  But that only leaves one
cortex to hold the nail in place so the reduction isn't as solid as normally.  I
finish up and we prepare the next case.



An elderly alcoholic starts us off in the right way with a difficult Ketamine
anesthesia.  We finally get him under and then I slice open his upper belly to
get a look at his gall bladder.  Sure enough it's distended with at least two
decent sized stones in the base. I start to dissect off the liver and of course
get into a lot of oozing which along with a difficult anesthesia means I have a
hard time keeping the intestines away and really can't see very well.  Not
exactly the conditions you want for a difficult surgery.  I end up spending a
lot of time repositioning retractors, sucking and sopping up blood and just
holding pressure.  Finally, I get down to the base, clamp off the artery and
cystic duct and remove the beast.  Then I have to deal with the oozing liver.  I
try pressure.  Not bad, but not good enough.  I try surgicel.  Again, not good
enough.  Then, against my inner voice I try suturing the liver.  Big mistake.
Leads to even more bleeding.  Finally, I remember my basic first aid and just
hold pressure for about 10 minutes while Roger puts in a drain and we all sit
around a bit.  At last, the bleeding is virtually stopped and we close.

While we wait for the latest amputation candidate who just arrived after months
of an infected leg at home, I decide to do a simple hydrocele.  Oh, I forgot,
we're in Tchad.  I know better than to say something will be simple.  Even
worse, I was bragging to our students and volunteer nurses that we'd be done
before 3PM (in 15 minutes).  So of course it's all inflamed and stuck and bleeds
and finally I just rip the whole sucker out, hack off half of the nasty scrotal
skin and tie off the bleeders and suture it all up and a bloody mess.  But when
I'm done, it actually has no bleeding and doesn't even look too much like a hack
job.  I do the famous James scrotal wrap and he's a new man!


When I first saw the young man's leg, I could tell it needed amputation because
despite the thick layer of gauze I could see that it looked skeletal and the
smell told me it was wet gangrene.  But when I unwrap it in the OR I'm blown
away.  After all these years I can still be shocked and almost (I said almost)
nauseated.  Black dry gangrenous skin covers the bones of the foot with an
absence of flesh to fill it out.  A  brown fibula sticks out completely nude at
the ankle with grotesque twist to the ankle joint.  Dead flesh hangs in shards
with pus dripping from the ends of the dangling shards.  Finally, at the knee
there is some semblance of normal contour but it's spongy skin and muscle filled
with pus just to above the knee and extending up the back until at last I see
what looks like enough normal tissue to be able to do a mid thigh amputation.


After prayer, with a tourniquet up (did I mention he has a hemoglobin of 6?) I
slice down rapidly to bone and then continue around to the back until all the
flesh is separated from the femur.  I then peel the proximal tissues off the
bone as far up as I can and my assistant retracts the muscle and skin back while
I take the ancient, hack-saw looking bone saw and with a lot of sweat and
grunting finally am able to get through the bone.  The blade might be a little
dull at this point.  I then find and tie off the bleeders, debride some nasty
tissue on the posterior part, pack a bleach soaked gauze up the back of the leg
to kill any residual germs, cover the wound with gauze and wrap it in an Ace
bandage.

I take a final look at our Muslim friend and he's breathing on his own through
the endotracheal tube and seems to be stable at least.  I look briefly at the
other post-op patients who also are doing well and go home at last.