INNOCENCE

It all started out innocent enough, but it certainly didn't end that way.

It is the last day with my family for a few weeks.  Sarah goes to saddle up the
horses for a trip to the river.  She wants Flicka to get out and get used to the
wide world out there.  After all, she is a week old now. I pick up Miriam from
her nap, change a nasty diaper and get her swimsuit on.  Sarah picks up Noah and
feeds him.  I put my foot in the stirrup and swing up onto Libby.  It's been
about half a year since I rode a horse and it's good to be back in the saddle.
Miriam is with Sarah on Pepper while Sarah's mom, Eva, straps Noah on to her
chest with the Baby Bjorn.  Joyalene, our volunteer nurse, and Jean, Miriam's
Chadian buddy round out the team for the excursion to the river.

Once out the gate, Flicka panics and starts running back and forth.  It's like
she can't even recognize her mom.  Some guys on there way to play soccer grab
Flicka and wrestle her to the ground before I can ride up on Libby and have them
release her.  I realize Flicka's not ready so I take her and Libby back in the
compound and head back out on foot.  Half way to the river, Miriam is tired of
horseback riding and so she rides on my shoulders instead.  Once at the river, I
wade out in the shallow, but swift moving brown water to the middle of the river
where there is an even shallower sand bar where Miriam can play.  The water is
already starting to go up.  There must be rain already in Central African
Republic at the source of the Logone River.




Eva wades out with a naked Noah and then Sarah comes out after setting Pepper
out to graze, taking pictures as she comes.  A perfect picture of tranquil
African family innocence...



"Hey!  Stop! Come back! Help!" I hear Joyalene's cries from the river bank.  I
run as quick as I can through the shallow river to the bank.  Joyalene has
disappeared but she soon returns.

"Sorry, I didn't see...I just lost the camera...I mean it got stolen.  This guy
just came up behind me and took it right from under me and I just wasn't fast
enough."

"Which way did he go?" I ask as I quickly pull my pants on over my swimming
shorts and mount Pepper.  Several young boys are there and say they can identify
the thief.  I tell the oldest to get on behind me and he struggles up and then
hangs on for dear life as we gallop off.  The river bank is dotted with holes
from the brick makers digging for good clay.  Around the holes are squarish
pyramids of bricks, mostly fired, some in the process or about to be fired.
There are plenty of bushes, mostly thorny and a few trees.  Too many hiding
places.  I search back and forth for about thirty minutes asking students
studying, women gardening and men making bricks but only one man claims to have
seen the thief running off.  I figure he's long gone but still spend about half
an hour searching since one man said he didn't think he was gone but was just
hiding in the brush.

Finally, I head back.  The boy behind me says he knows the guy and that he works
washing motorcycles in the river right next to where we were swimming.  I see
Sarah and the rest heading back on foot as I trot up to a group of men washing
motorcycles on the bank.  There is also a cluster of naked men washing up all
lathered in soap.  The crowd also includes some kids and some women making and
selling food as well as the customers waiting for their bikes to be cleaned.

"Bon soir," I greet the group in general. "Ça va?"

The men respond with appropriate greetings but as I continue to explain that
we've been robbed and that I've been told that the thief was one of them there
attitude changes.  They start speaking to the boy behind me in N'gambai and he
quickly gets down.  I can tell by their tone and non-verbal language that they
are not happy with him for having told me that the thief was one of them.  I
continue to explain that we don't want any trouble we just want the camera back.
All the thief has to do is return it by tomorrow (we're just down the road) and
we won't report it to the gendarmes.  In the midst of all this I become suddenly
aware of why cavalry was so important in the old days.  I feel so much safer
sitting on the back of a horse than if I was in the same situation on foot.

As if to increase my awareness of this advantage, suddenly two small, thin dudes
in fatigues and one of similar size in jeans and a white shirt come up and start
yelling at one of the men talking to me.  They are shouting in Arabic and soon
start trying to hit the man with army belts they've pulled off their uniforms.
One of them has a thin metal rod and they are striking out at him.  The man is a
giant, obviously one of the Sara, and he acts quickly.  He moves over to where
the women were cooking and grabs a metal kettle which he uses to defend himself.
He doesn't strike back but moves away and uses the kettle as a shield while he
quickly tries to defend himself in Arabic from whatever they are accusing him
of.

I am no longer the center of attention.  I sit in the saddle and watch until
things seem to calm down without anyone getting really hurt.  Then I turn slowly
away and trot over to the road.  I catch up with the group at the paved road
which we cross and arrive home with no innocence lost, just a cheap digital
camera.

The nurse is waiting for me at home.

"A four year old girl was just brought in.  The victim of rape by a 10 year old.
She's ok but has some rectal bleeding..."

With a heavy heart I change into scrubs and walk slowly over to the hospital to
see the precious little thing that has just lost her innocence...

BACK

There's an immediate difference. There's no mistaking a Tchadian. After 12 hours
direct from Washington DC to Addis Abiba with no problems I start to notice the
Tchadian presence.  Some scruffy, bearded men in long robes walk by as I sit
during the four hour layover trying to console my screaming-bloody-murder 2
month old son. Finally, at boarding I worm my way between sandaled, robed,
turbaned sleeping men as the staccato of Tchadian Arabic hits my ear. I catch
many words but most of the meaning still escapes me.  But the music of that
language unique to Tchad takes me instantly back after a five month hiatus for
the birth of my second born son.

Suddenly, the sleeping mass of Arabs awakens as the boarding call is made.
There is suddenly a huge press of people, each vying with all his cunning and
might to be the first on the plane.  Sarah is laughing and shaking her head.

"It's like they're trying to squeeze into a 22 passenger mini-bus where first
come first serve rules!"

We wait towards the back until the Ethiopian Airlines personnel motion us to the
front.

"Children first," says a green uniformed man as he walks us past the check point
and pushes his way through the crowd still struggling to be the first on.

We get to our seats, the bulk head just behind first class.  We have been placed
on either side of the aisle. Since there are only four oxygen masks in each row,
two lap babies can't be sitting side by side.  But there is an Arab woman with a
one-month-old in Sarah's seat accompanied by a female relative.  In my seat is a
man holding crutches who smiles and points to his right knee.

"I've just been operated on and have to sit here."

"i have two children under two and I need to sit here," I reply with a smile.
"Look at my boarding pass.  Why don't you move over to the window seat, it's
empty."

The man is gracious and I help him get up gingerly and move over.  Then, Sarah
sits in the middle seat and I sit in the aisle seat which was originally ours.



A woman comes up.

"That's my seat over there," she is large and in charge and won't take no for an
answer.  She starts calling out how she's a woman and isn't going to take any
more of this abuse from men.  She's an African women's lib force to be reckoned
with.  The man with the crutches moves over to the other aisle by the Arab
woman, the baby and the friend.

But all is not well.  A young, healthy man in a bright blue robe with an evil
smile comes up to Sarah, points to the seat and his boarding pass and asks her
to move.

"She's got a small baby and it's only because..." But I'm interrupted by the
flight attendant who grabs the man's boarding pass and writes a new seat number
on it.  She only speaks English, he only speaks Arabic and a little French.  He
is not so easily dismissed.

"I need this seat, it's mine," the man insists in broken French.  The woman just
shakes her head and points.  There is a log jam around our seats which are the
first ones in economy and the flight attendants are not happy.  I almost think
we're at either an impasse or a fight when the man finally gives in, laughs and
moves back.

Then another flight attendant comes back and says that we are too many in our
row.  With the militant Woman's rights advocate in the corner, Sarah, Miriam,
Noah and I that makes five and there's only four oxygen masks.  Sorry, no
exceptions.  I then explain that we are only here because the woman across the
aisle took our seat.  The flight attendant asks her to move.  She refuses.  I
think another fight will break out when a man leans over from the seat behind
the woman and explains to her in Arabic that they will give her three seats in
the back so she has a place for her baby.  She's still frowning and shaking her
head but she and her crew vacate the premises.




I'm back in Tchad and I haven't even arrived yet!

The blast of 120 degree Fahrenheit weather that hits me as I step out of the
airplane in N'Djamena reminds me why I usually try to take my annual break in
March and April, the hottest months of the year in Sub-Saharan Africa.  Noah is
not pleased either.  We spend the next few days at the Durand farm just outside
of N'Djamena where Noah takes his screaming to a new, literally feverish pitch.
The first night is literally hell until I figure out that he's just too hot and
stick him on the floor of the shower and dump water over him.  Almost
immediately, he calms down but the next few days are a battle trying to keep a
jet-lagged, exhausted, over-traveled, heat stroking newborn calm and cool.
Sometimes he gets so agitated he can't even breastfeed without a few screams
thrown in every few minutes.  It's not till we get to Moundou and in a rhythm on
the second day that he settles back into the nice boy that he usually is.

After Miriam's nap on Saturday, Dr. Roger (a Congolese physician who covered for
me at the Surgery Center during our break), Daniel and I head out to the river.
I put on Miriam's swimsuit, a cloth diaper and a sun dress.  She begs to ride on
my shoulders so I heave her up, we head across the compound, out the door,
across the soccer field, past the men lying on mats waiting for someone to come
need their tire fixed, across the street, down the dirt road towards the city's
generators which are miraculously working today, through the weave of paths
between the piles of fired mud bricks, down a trench and out to the edge of the
river.



The Logone is one of Chad's two main rivers which joins with the Chari River at
N'Djamena before emptying into Lake Chad.  It flows year round, but now at the
height of the dry season is really shallow, though still very wide.  I wade out
a hundred meters or so, never coming over my belly button and Miriam and I
settle on a sand bar covered with 10-20 inches of clear, fast-flowing water.




Miriam quickly is playing games, throwing sand, digging, splashing and laughing.




After about half an hour, Sarah shows up on horseback and comes out to join us.
As the sun starts to head towards the horizon, Miriam gets back in the saddle
and I hand Miriam to her.  Roger, Daniel and I then return on foot.



Home at last!

GRIM

It's starts with a clap clap dragging me out of a dream into a sticky world of
sweat soaked pillows and fans desperately trying to circulate the early morning
coolness.  I somehow manage to find some pants and bumble my way through the
dark to the front door.  If it was knocking it might just be the dog scratching
himself or wagging his tail as he leans into our rattly steel front door.  But a
clap clap means a human, and most likely a nurse.  Sure enough, standing about
ten feet off the front door to the side I see the outline of a white coat just
as the Muezzin warms up for the Fajar prayer.

"Bonjour!"  I greet Frederic.

"Docteur, the woman in the recovery room, she's complicating..."  Translation: 
better go quickly as the patient is about to pass on to a different place.

I hastily throw on my scrubs and slip on my crocs just as Roger comes out of the
guest room with the keys.

"You might need these..."

"C'est vrai...merci..."  I mumble as I snag the keys and rush past.

The woman is in her early 20's and came in with severe pre-eclampsia and a 33
week pregnancy.  She had seemed stable the day before and we wanted to give some
medicines to help the baby have a better chance of breathing well after delivery
so we delayed the c-section one day until yesterday morning.  As soon as we
wheeled her into the operating room her oxygen saturations and her level of
consciousness started to drop.  I intubated her and we bagged her through a
quick cesarean.  Fortunately, the baby did well.  The mother did not.  She had
fluid on her lungs and we have no ventilator and wouldn't breath on her own
through the tube.  We spent two hours with her in surgery breathing for her and
trying to get her kidneys to take the fluid of her lungs.  Finally, I was able
to extubate her but then had to quickly reintubate.  Finally, we got her on
oxygen and sating well when sitting up.  She remained, however, in a coma.

So now I come in and she is just making some last gasps for air.  I start
breathing for her with a bag-valve-mask and call for 50% Dextrose solution.  Her
blood pressure is now low but the nurse already has some IV fluids running.  I
put in a large line in her femoral vein and we pour in the Dextrose.  After the
Dextrose goes in, she starts breathing on her own and I just support her a
little.  Her blood pressure is ok.  I add antibiotics and IV Quinine since she
has a fever of 40 degrees Celsius.  FInally, I get her on a mask.  Her oxygen
saturation is low but not critical.  I go home to eat quickly and come back. 

The bed is empty.  She's dead.

After worship, an ambulance arrives with a woman referred from the General
Hospital.  They're still on strike so the Obstetrician has referred a tiny
pregnant girl with her first pregnancy to us for management.  The baby's heart
beat is normal, the head is down and engaged and she's at 5 cm dilatation.  But
she has no contractions.  I have the mid-wife start some oxytocin.  I leave to
go pay the school fees for Daniel, one of the nursing students we're supporting. 
He'd bought a motorcycle with the money supposed to be used for his tuition and
so we've had him sell it.  He couldn't find a buyer so finally I buy it off him
and give it to the local pastor.  Then I make sure I go in person to pay the
school directly so there's no more "confusion."

On the way back I decide to stop at the Evangelical Mission station and ask some
plumbing advice.  We've had no water in the main surgical building for five days
and dirty laundry and instruments are piling up.  Abel is doing his best to wash
things by hand with buckets brought in from the outside hand pump but things are
starting to get out of control.  After a long discussion with Paul we think that
maybe frogs have got in the line and are blocking the pvc pipe.  I go back to
the Center and bring the compressor to see if I can blow out the blockage.  I
check on the woman and the oxytocin drip is almost all finished and there is no
baby's heartbeat.  I bring in the ultrasound and see a faint flicker of the
cardiac muscle.  Maybe it's not too late!

We rush her back, splash on betadine and hurriedly put on gowns and gloves.  I
open the abdomen with one slice, knick the uterus and tear it open with my
fingers.  The baby is deep in the pelvis with a deformed head.  He comes up and
I clean out the airway, clamp and cut the cord and hand him off to Juliette and
Abel.  I hear no reassuring cry as I stitch up the uterus, fascia and skin.  I
look over.  The baby is lying still.

Dead.

I finish and go back to plumbing.  I check all the faucets and nothing is
plugging them directly at the exit port.  I open the valve back to the water
tank and close all the other faucets except the one in the recovery room.  I
thread in a plastic pipe with a connector on the other end to attach to the
compressor line.  I wrap a disposable glove around the opening to partially seal
it, grab the whole mess with my left hand and attach it to the compressor with
my right.  It seems most of the air enters while some hisses out around my
fingers.  I detach the compressor and pull out the tube.  A welcoming rush of
muddy water comes out quickly cleaning up.  I go and try all the other faucets. 
We have water back!

I go home and eat lunch.

I do a repair on a Petit's hernia under local anesthesia which reminds me of the
first time I tried that in Bere thinking it was simple lipoma and ended up
cutting into the bowel and having to suture that while Sarah assisted me. 
Unfortunately, no one was assisting the beans on the stove back home and we came
back starving to find a smoke filled house and half cooked charred lunch/supper
waiting.

This time, things went smoothly.  When I come out, Roger points me to a man who
just arrived with sepsis.  He has a hard, nasty, blistering masse on his lower
abdomen and the anterior pubic soft tissue is as hard as a rock.  His lower
extremities have massive pitting edema and his penis and scrotum are also
grossly swollen.  This man needs surgery rapidly.

We rush him back. find two large bore IV's, pour in isotonic solutions and give
him triple antibiotic therapy.  I slice into and around the mass trying to
figure out what it is.  Finally, I just excise it exposing a gray strip of pus
filled, dead rectus abdominis muscle that I excise.  In doing so, I enter the
peritoneal cavity and purulent liquid surges out.  I call for suction and
aspirate over three liters of hot fluid.  His whole body is burning up.  We tie
off the bleeders, I sew up the fascia over the peritoneum and we pack the wound
with large lap sponges and wrap the lower abdomen with a large ACE bandage.  We
now have a blood transfusing running in as well while Abel and I clean up the
blood and fluid covering the table and floor.  His blood pressure has stayed
normal throughout as well as his oxygenation.  His heart rate is slightly fast
as is to be expected.  I feel he's stable enough and we wheel him out to the
recovery room.

I go home, make a smoothie, pick Miriam up from her nap and we play until Mom
comes home.  Then I change into shorts, jump on my bike with the basketball
lashed to the back with old innertube strips and head to the local high school
to play some ball.  After five games, two hours and liters of sweat I come home
in the dark.  We eat and put Miriam down for the night at her regularly
scheduled 7pm and Sarah goes to do laundry at the Center.  She comes back in 10
minutes.  The man I just tried to save has just died.  The family members and
nurses hadn't even noticed yet but when Sarah was walking by she noticed he was
still warm but not breathing.

Dead.

TABASKI

I wake up late...relatively.  It's after 6am.  What's wrong?  Oh yeah, I didn't
hear the muezzin at 4:15am.  At 6:30am, though I hear loud speakers warming up
on the soccer field in front of our Surgery Center.  Then comes blasting "Allahu
Akbar!  Allahu Akbar!  La ila illa Allah!"  (God is the Greatest!  God is the
Greatest! There is no god but God!) over and over again.  That's right, today is
the big Muslim feast (eid) of Tabaski when they celebrate God providing a sheep
in place of Abraham's son who was going to be sacrificed as a demonstration of
Abraham's faith in God.


Yesterday, Sarah had noticed them painting lines on the soccer field so that
everyone could be organized facing east towards Mecca.  I want to catch it on
film so I charge the battery, grab the camera and Miriam and head out.  It's
about a quarter till 7am and already the Muslim faithful are gathering sitting
quietly on mats fingering beads or reciting verses from the Qur'an.  I go to the
other side near Moundou's one paved road and get some pictures facing the
Center.  More and more cars and motorcycles are arriving.  Everyone is dressed
in new dresses or robes.  The boys sit with the fathers in front and the girls
with the mother's in back.

 

I go back to the center.  It's 7:10 and we're already late for our own staff
worship.  I grab the Bible and open to Genesis 16.  I share with our staff and
the patients' family members who gather to listen how God made promises to
Ishmael and his descendants--including the Muslims of today--that God would
bless them.  Then I pointed out that just like today many cultural things
separate us, just like in Jesus' time with the Samaritan woman at the well in
John 4 where each group had a different place of worship, we today, Christians
and Muslims, have different places of worship (churches and mosques) but that in
the last days, Jesus says the true worshipers of God will not be limited to
places but will worship him in Spirit and in Truth.  I pointed out that even
though Ishmael was sent into the desert to the East away from Isaac, when
Abraham died the two brothers reconciled and came together to bury their father.
It's a symbol of what God wants to happen in the last days:  Christians and
Muslims coming together, embracing their differences and worshipping together in
Spirit and in Truth.

Then I went to work.  On rounds, I suddenly have an idea.  I ask who can go buy
us a sheep.  One of the nursing interns offers to go.  I continue seeing
patients until he comes back.

"Sheep are hard to find and they are selling for 60,000 to 70,000 francs (about
$120-140)."

"I guess we can't do that.  I have 40,000 francs here.  I was sure that would be
enough."  I'm disappointed, because I thought it'd be great to feast with the
patients and their families who are far from home and missing the festivities.
I move on.

I finish and head to the clinic.  Ernest accosts me.

"I know some people in town.  The Muslims don't want to buy sheep from the
N'gambaye so they should have some in your price range."

I give him 32.000 francs and he goes off.  I finish and head home for lunch.
Salomon comes in from the hospital and says that Ernest couldn't find any sheep
for under 80.000 francs.  I'm discouraged again.  I go to see Ernest.

"Don't worry.  I know some people in my village.  It's only 15 km from here and
there's a guy who has a bunch of sheep.  I'm sure we can get one for 30.000 or
so."

"Great!  I'll go get the keys."


I come back and Ernest hops in the passenger seat while I fire up the diesel
modified VW Vanagon Campmobile.  We roar out of town, across the single lane
bridge on the road to Doba and through the bush until we pass the toll booth and
enter Koutou Beti.  We stop under a tree where a woman is selling some kind of
roots piled high in metal bowls.  Ernest converses with her in N'gambaye and
then points across the road.

"She's got a sheep at her house over there.  Let's go take a look."

I leave the Vanagon on the side of the road with the windows down and the doors
unlocked.  No one can figure out how to open it's doors anyway.  Besides,
there's nothing inside to steal.  Although I have a sneaking suspicion that's
not really a danger here.

We walk through some sesame and millet fields and into a little compound of mud
brick huts with thatched roofs.  The woman brings in a small sheep on a rope and
quickly leaves with it after a brief heated discussion with Ernest.

"Whats' up?"  I ask.

"That one's too small.  She says she has a bigger one back there."  We walk over
to a tall, spindly tree with tiny leaves.

"This tree is a medicinal plant.  The leaves are great for treating malnourished
kids and the fruits can be used to decontaminate wells during cholera
epidemics."

"What's it's name?"

"I only know it in our local language."

"Is it Meringa?"

"Yes."

The woman comes back with the sheep.  Ernest grabs it's spine and palpates along
it's back.

"This one's too skinny.  Let's go."

We had back through the fields to the car.  We head a few hundred meters down
the road and someone flags us down.  Ernest talks with her briefly in N'gambaye
then turns to me.

"They've got a bigger sheep back over there."

I drive a little further and we walk a short distance into another similar
compound where I am ushered into the seat of honor:  a rough wooden chair under
a mango tree.  Ernest sits on a bed frame to one side while the chief of the
compound brings over a tiny wooden bench he sits on.  He's got a sly smile on
his face and he and Ernest are soon in a good natured dialogue.  A short, stocky
youth appears leading a ram with half curved horns.  The banter between Ernest
and the owner picks up in heat but there are still smiles and laughs as the
bargaining intensifies.

The starting price of 45.000 is quickly boo-hooed by Ernest who offers 20.000.
Then the drama continues as each presents his arguments until finally we arrive
at 30.000 at which the man acts as if he's being robbed at gunpoint as he
reluctantly puts it in his pocket.  He can't hide a smile though as I offer my
hand.

"The patients at the hospital thank you."

And we're off.  We cross the bridge, pass the CotonTchad plant, circle the round
about, pass the regional medical offices and turn left at the military soccer
field and into our compound.  The sheep has managed to untie himself.  Ernest
reties him up.  I cross over to Abakar who's become a close friend after being
with us for almost two months for an open tibia fracture on wound vacuum therapy
attached to a suction machine 24/7.

"We need a Muslim to slaughter the sheep so it's appropriate for everyone.  Any
suggestions?"

Abakar points to a man lying on a mat nearby.  "He can do it."  He yells
something over to the man, something about having a knife or not.  I tell Abakar
we have knives and the man jumps up and helps us lead the sheep over into our
yard.  We tie him up near the wall under a small tree.  Sarah brings two knives.
The Arab rolls up his pants legs under his robe and tests the sharpness of the
knives with his thumb.  He chooses the long, slender one.

He unties the sheep and moves it out into the sun.  He grabs the head, lays it
on its side, places his foot over the back legs and has me hold the front legs.
He pronounces a quick prayer and slits it's throat rapidly with a back and forth
sawing motion while saying "bismillah" (in the name of God.)  Blood spurts
upwards from the two severed carotid arteries and there is some gasping from the
sliced open trachea.  The sheep quivers and lies still.  Then the butcher shakes
its tail back and forth eliciting more muscle spasms until all is quiet.


Then he goes to work.  The skin is quickly half way off in an expert fashion
when another Arab comes and takes over.  He quickly demonstrates even more skill
and the sheep is rapidly skinned and sliced into pieces with legs, ribs and back
in one bowl and guts in another.  The stomach has been emptied of it's partially
digested grass and the gallbladder, feet and head removed.  Everything else is
fair game.

Salomon and eye take the meat inside and wash and gut it into manageable pieces.
Salomon has a fire going with pieces of tin roofing as a "grill".  I mix in
minced garlic and taco seasoning and the meat is cooked to perfection despite
this being my first time cooking meat.

Sarah has bought 45 baguettes and made a soup out of the vertebra and vegetables
and we head over to the hospital.  We go to each patients bed and give them a
baguette and some meat and wish them health and a merry feast.  The response is
overwhelmingly positive, especially among the Muslims who seem surprised at a
Christian celebrating their feast with them.  They all wish us many blessings.

Then what staff has come to feast with us gather on the veranda of the Surgical
Suite and we divide the rest among ourselves.  As everyone is eating, I ask
Idriss and another Muslim who are eating with us to explain the meaning of the
feast.  Neither one wants to, so I offer to explain it if Idriss--who speaks
fluent French and Arabic--will translate.  I then tell the story as related in
the Qur'an of how God came to Ibrahim in a dream and told him to sacrifice his
son, the promised son, at a certain place.  Ibrahim then asks his son the next
day what he thinks of the dream.  The son replies that it must be God's will and
so they go to the place where God then provides a sheep, called a great
sacrifice, instead of Ibrahim's son.

I then explain that this is why whenever we eat sheep on this feast day, it's to
remember that God is merciful and gracious as each chapter (surah) in the Qur'an
opens with "Bismillah Ar-Rachman Ar-Rahim (in the name of God the most gracious,
the most merciful.)"  so we can be reminded that if it wasn't for God's grace
none of us would have a chance to enter paradise.  That leads us into a long
discussion on why there are such differences and conflicts between Christians
and Muslims these days.  Patrice speaks up.

"It's because most Muslims don't read and/or understand the Qur'an and most
Christians don't read and/or understand the Bible."

"That's true," I interject.  "If Christians read the Bible they could never
fight because Jesus was clear that one should love one's enemies, pray for those
who persecute and do good to those who wrongfully use us.  Then he tells us to
turn the other cheek.  So, a Christian who fights a Muslim is one who has never
read or understood the teachings of the Bible."

Thediscussion continues on for a while in a very reconciliatory and peaceful
fashion until our Muslim friend gets up and shakes my hand.

"It was God's will that my brother be operated on here.  Wherever I go I'm going
to have the brothers in the Mosques pray for you and this center.  We need you
here in Tchad.  I'm going to pray now.  It's time for the evening prayer.  God
bless you."

"Amin."

STRIKE II

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.

MASS

I don't want to operate.  I know the operation is hopeless.  The kid's going to
die.  But the father is pleading.  He's been to so many hospitals in so many
countries for over a year since his son became sick.  As I look at the huge mass
covered with gnarly, massive blood vessels on the teenager's upper thigh I'm
scared.  I'm pretty sure if I attempted to remove it he would die on the
operating table.

It's a Friday and I decide to hedge and hope for the best:  that I can give
enough sedatives that the kid will fade away peacefully over the weekend.  So I
promise to try and operate on Monday.  I tell the father as clearly as I can
that there are only two possibilities:  one, we'll succeed (which I doubt) and
two, he'll die in the operating room under anesthesia with no suffering.  Either
way, it's in the child's best interests.

The father seems to understand and agrees.

I hospitalize the boy and give him an antipsychotic, a nausea medicine that is
famous for knocking one out, a morphine derivative and valium, a powerful
sedative.  I order it to be given around the clock and hope that he'll drift
into a sleep he'll never wake up from.

I spend all weekend praying desperately for him to die but overall for God's
will to be done.  I'm seriously frightened of having to do this surgery.

It doesn't work.  Monday morning I come into do rounds and the boy is lying
comfortably in bed (as comfortable as one can be with such a monstrosity on
one's leg).  He does say he slept well this weekend, though.

So I take him to the OR.  It takes a whole team of staff and students to get him
situated so I can place the spinal and then try and prep and drape the leg. 
Someone has to try and hold the leg so I rig up an IV tubing around his ankle
and up over the overhead lights that allows someone to hold it up and maneuver
it.  The mass is too big to slide through our drape's hole so there's really no
way to isolate it as I'll have to go all the way around his pelvis front and
back in order to amputate it through the pelvic bone.  It's going to get
contaminated, but then I figure he'll probably die during the case anyway.



His hemoglobin is only 6 (about a third of normal) and I decide not to transfuse
him since I expect he won't survive the operation.  I start anterior and slice
down over the iliac crest.  I'm supposed to be able to enter the abdomen that
way and tie off the large blood vessels that feed the leg.  There are huge veins
on the surface that I have to carefully ligate as I dissect down.  I soon find
that as I suspected the mass has entered his pelvis and the anatomy is very
distorted.  I slowly try and make my way down and finally find the large blood
vessels which are stuck to the mass.  It's difficult to get them off but I
finally do and tie them well.

I turn the leg a little and start into the groin and around the back.  It's slow
and tedious with a lot of bleeding.  But the kid stays stable the whole time.  I
keep wondering when his body will just quit.  I've spent over six hours already
on the case and am starting to think he won't die.  I take off the leg finally
but he's bled so much his blood pressure finally starts to go down.  But since
the leg is off I feel I should try and save him now.  I order blood to start
running in both  arms.  I order Patrice to give him Ephedrine to make his blood
pressure go up.  It doesn't work.  His pulse is slowing but he's still
spontaneously breathing.  We give him Adrenaline and his heart beat and blood
pressure normalize.  I close up the massive wound by bringing the skin flap from
the buttocks all the way across to his abdominal wall.

I wrap up the wound and send him out.  The result was not what I expected and
I'm a little disappointed.  I know the tumor has spread and he's not going to
live.  Did I do the right thing?  I'm not sure but I felt so calm and as if God
was with me the whole case I have to feel that it was His will.

I call in the father to see his son.  He takes one look at his kid with only one
leg and his face falls.

"I didn't know you were going to amputate.  If I'd known that, I'd have taken
him home.  Better to die that to live with only one leg.  We're cattle herders,
how's he going to move with the herd?  I wish I'd known, I'd have refused."

I wish I'd known, I'd certainly not have spent the last seven hours in the OR...

MERDE

The word escapes from my lips subconsciously.  "Merde!"  (pardon my French)
Somehow swearing seems so much easier in a foreign tongue.  Besides, I try to
limit my non-missionary words to the OR.  But this is an exceptional case.  My
whole body has just been covered with raw sewage.  How did this happen?

Yesterday, I'm coming home from the hospital and Sarah comes out to greet me.

"I just saw a couple of patients taking their patient home.  They say they can't
stay where there are no toilets." 

I wince.  It's embarrassing but true.  A month ago, the toilet stopped up.  We
had to tear it out and redo it without the nice odor trap.  It worked until two
weeks ago when the septic tank overflowed from the hospital toilets into our
yard.  The rain has been heavy, raising the water level to 2-3 feet from the
surface.  That coupled with the large number of patients we've been seeing just
overwhelmed our way too small septic system.  We had to shut down the toilets
for about a week.  The patients had to go outside and pee and poop in the tall
grass between our center and the football pitch.  It didn't exactly endear us to
our neighbors and we had a lot of complaints.  Finally, we got some guys to
shovel the sewage out by hand and carry it in buckets outside to a large hole
they dug in the ground.  All this happened at night.

The next morning, the septic was already half full with water.  We reopened the
toilets.  Within two days it was overflowing again.  This time, we decide to do
it right.  David, our business manager goes to the mayor's office.  They have a
truck and a pump and a tank.  They only wanted over two month's nurses' salary
to do the job.  David turned it down.  Then I had a brilliant idea.

"David, we have the water pump for the well drilling outfit.  We also have those
large plastic storage tanks we're not using.  Go rent us a truck and get a
couple guys and we'll pump out the septic into the plastic tanks and cart it off
into the bush with the truck.  No problem..."

David gets the truck and hires 8 guys who come out decked in OR masks and OR
gloves.  I laugh at their silly over cautiousness.  The first problem is that
the back gate of the truck has been screwed shut with a heavy angle iron.  We
manage to finally get the rusty bolts off.  I fire up the pump and one of the
guys dumps the heavy green hose with the large filter into the septic tank while
another is mounted on the truck with the white hose in the top opening of the
receptacle.  Nothing happens.  I remember we need to prime the pump.

Someone fetches water while I unscrew the top.  We pour in the water till it's
full and then I screw the top back down.  I'm kind of proud of myself.  Without
me they wouldn't be able to do this.  I'm getting kind of cocky.  We fill up the
plastic container and the septic is still two thirds full.  The guys get ready
to drive out and get stuck in the mud right in front of our porch.  We manage to
dig and then push them out and they're off.

After 20 minutes or so, the truck returns and we get set up.  I grab the pull
start and let it rip.  The motor fires right up.  The sewage is about half way
up the exit tube and won't seem to go the rest of the way.  I laugh good
naturedly and go to perform my trick again.  I slowly unscrew the cap, I hear
some air escape but still nothing happens.  I unscrew a little more.  The other
guys have fled, what are they afraid of?  I mock their fear and give the cap one
final, fatal twist.

BOOM!  The cap shoots into the air and raw sewage spews 20 feet into the air
after jetting directly up my nose, in my eyes and into my mouth.  I'm soaked
from head to toe in the foulest, brownest liquid imaginable.  The guys I've been
so recently mocking are standing safely 20 feet away, dry and laughing their
heads off.

"Merde!"  I ejaculate in reaction as I jump back.  Then I start laughing too.  I
deserve it.  Meanwhile, Daniel has kept his head and jumps in to flip the off
switch on the motor and the putrid fountain ceases watering our trees and grass.

I walk slowly back to the house trying to keep my scrubs from touching my skin. 
I reek.  I undress completely on the porch and take a long hot shower with lots
of soap and shampoo before the stench finally comes off.  Meanwhile, the guys
finish the job without further complication despite my absence. 

The toilets are back up and running that evening and I'm a bit more humble.