FIRST DAY

I slept surprisingly well...until the muezzin wakes me up at 4:30am with the call to prayer. I slip on my minimalist running shoes and slip out the rusted, banged up door into a dirt street already starting to be overgrown with grass from the plentiful rains. I practice my barefoot running technique, landing on the balls of my feet, not letting my heels touch the ground as I try and feel, rather than see the path in the dim light of the fluorescent bulbs from the mosque. I circle the football pitch several times and then walk home. I'd woken up dreaming about running through a hospital and now I'm walking back to the first day of work at our new hospital/surgery center in Chad's second largest city.

Things start slowly. We all realize how many little things we've forgotten to prepare for as we call in our first patient, Jeremie, who suffers from a left inguinal hernia. Where's the cotton? Anyone seen any alcohol? How can we start an IV without a tourniquet? Has anyone bothered to make a list of prices for medicines? We don't actually have the popular antibiotic I prescribe for pre-op prophylaxis. 15 Chadians, 3 Americans and a Korean all running around like chickens with our heads cut off.

Sarah comes in holding a stoic Miriam who gives me a shy smile when she sees me and turns her head in to mommy's safe bosom. "Gustave [the night watchman] want's his two boys circumcised."

"Ok, thanks." I walk outside. "Hey, Gustave, which one do you want to go first?"

"Djim..."

"Ok, bring him in."



Djim gives me a big smile when he hears me call his name and waddles over his hand out to give me five. That smile quickly turns into blubbering and screaming when I ask Gustave to take his clothes off. He knows somethings up as we struggle to bring him into the minor procedure room while the rest of the team continues to prepare Jeremie for his hernia repair. Djim is writhing and screeching on the bed as Cindy, our volunteer anesthetist from California draws up some Ketamine and increases his yells with a quick intramuscular injection. The medicine quickly has it's effect as Djim drifts off into a quite dissociative state with his eyes open and twitching back and forth but nobody's home.

I leave Dr. David Lee to do the circumcision and go back to the pre-op room. Honoré comes out of the consultation room. "We have a military guy, one of those who was guarding the governor yesterday at the opening ceremonies, who just came in with severe malaria. He's vomiting all over the place, can we hospitalize him?"

I think for a second. I've wanted to limit ourselves to surgery, but the fact is, right now we have 30 empty beds. I nod in agreement as Abel comes out of the room.

"We don't have any emesis basins and the guy's retching all over the place." I hurry out to the container that doubles as our stock room and unlock and open the heavy, iron door. I hand Abel 5 emesis basins.

"We need some tourniquets, too." We go into the back and finally find some cheap rubber ones on the bottom shelf. I hand Abel 3 and we go back to the pre-op room after locking up behind us.



Jeremie is now ready so we take him back, Cindy does the spinal and David and I scrub for our first case in this OR. It feels good to again be slicing through skin and see the blood well up in the wound as I reach for hemostats and stop the bleeding. It's been almost a year and a half since I've really done any surgery but it's like riding a bike. I feel as if no time has passed. And since I've changed my diet drastically, my hands, wrists and fingers are pain free with no sign of my rheumatoid arthritis. We quickly find the hernia sac, dissect it out and invaginate it back into the abdomen. I then find an indirect hernia as well which I ligate and remove. Then we do a normal repair with surgical mesh (since we forgot to go to the market and get mosquito net which is what we usually use to repair hernias).

As I peel off my gown and gloves, Tirmon, our Chadian medical student rushes in. "Come look at this kid, he's not doing well." I follow him out to the recovery room where the delicious, musky smell of Arabic women greets my nostrils just before I come around the curtain and see the two veiled women huddled over a still form on the bed. The younger one, who appears to be the mother is trying to close his eyes the way they do when a child dies. I can't tell at first if the boy is breathing or not but as I place my hand on his warm chest I feel the pounding of a racing heart and the shallow breathes of a very sick child. I check his conjunctiva, which are pale, and quickly order IV Quinine, a hemoglobin and a blood sugar.

The nurses quickly get to work as this is the Chadian Health Care system's bread and butter: a child with severe malaria hovering on the brink of the grave. The blood sugar is low normal and his hemoglobin is 5.7 and I want to transfuse. The only problem is that while we can type his blood and find a donor, we have no bags to draw the blood in so that we can give the child the life giving red liquid.

As we explain to the two women, an old Arab man comes in and quickly states that the child's father isn't there, the mother just got back from Egypt where she had a demon cast out of her and all the other family members are sick so they can't give. They will go see if they can buy some blood at the general hospital. We have to agree and a cousin goes rushing off on a motorcycle while we move the child to the hospital ward.

Somewhere along the way I manage to eat lunch and see some patients referred by
Honoré/Tirmon/Antatole who have been tag-teaming the consultations. I find a young boy with a hernia and an undescended testicle, see a patient I'd operated on last year for a tibia fracture who needs a follow-up x-ray, and a man with long-standing diabetes who gets a long lecture from me on how he can cure his diabetes with a low-fat, vegan diet.

I get a call from Kay, an American friend who lives a few blocks away. "Did you lose your dog?" As a matter of fact, I haven't seen Charlie all day. We'd just got him from Matthias, a German missionary going home on permanent return. "Someone just showed up on my doorstep saying they have the German's black dog."

"Ok, have them bring him over." Fifteen minutes later, I'd forgotten about it and am going home when I see Kay and three unknown Chadians. One of them, a short man with a significant scar on his left forehead, reaches out his hand and greets me.

"I work in security and when I saw your big black dog menacing children I used all my skill to grab him and tie him up. Then I gave him milk and meat and brought him back to you."

"Uh, ok, thanks. How much do I owe you for the milk and meat?"

"7000 francs." Three days salary for a skilled laborer like a mason? I don't think so. I feign anger (which is quite easy in the moment."

"Don't be ridiculous. Be serious. If you'd told me the truth, I'd have been willing to thank you with a little something but you're seriously exaggerating...why don't you just go ahead and take the dog back. He's been nothing but trouble anyway." And thus starts a long process of yelling, arguing, discussing, debating, and including as many bystanders as possible with their opinions. It quickly becomes apparent that no kids were menaced (the dog wouldn't hurt a flea), it wasn't difficult to catch him (he practically was licking the man's hand), they didn't run all over town spending money on moto-taxis (they found him within a few blocks, one rode to Kay's house on a bike, and Kay walked back with them and then here without breaking a sweat), and that he hadn't been given much milk or meat if any (Kay reported that Charlie about fainted from hunger/thirst in the two block walk from where she found him). I ask Antoine how much I should give them.

"I dont' know," he looks sheepish. "2000 francs?"

"Wow, you're generous, I only wanted to give them 1000 francs." I go home, put a 2000 franc note in my pocket and go back to find the three men attacking Antoine's character and threatening him in Ngambaye, the local language.

"Look, don't be angry with him, be angry with me. I only wanted to give you 1000 francs but thanks to him I was going to give you 2000. Now I'm not so sure." The small man with the scar continues to pretend to be angry. Another, skinny one seems to realize they better take the money and run and quickly holds out his hand. They are now all smiling at me but as they turn and see Antoine they start scowling, pointing and threatening again as they walk out the gate.

I go home for a drink of water.




I arrive back at the clinic in time to be called over by Antoine for a school committee meeting, run to the Catholic radio station for a supposed interview which is rescheduled for tomorrow and back to the Center where I find Sarah who hands me Miriam. Miriam seems to like hanging out with me as I walk to the wards to check on our four newly hospitalized patients (another kid has meanwhile been hospitalized with malaria and malnutrition). Tirmon accompanies me. Jeremie is doing well and I tell his family to give him something to drink. They are always afraid to give even water after a surgery, even a simple one like a hernia repair. The soldier with malaria has stopped vomiting and seems to be doing well on his second dose of IV Quinine.




I move over to the Arab boy with anemia and Ernest reports that he just had a
seizure. He does appear to be in a post-ictal state but his breathing and heart rate are ok.

"Djiba almi be sukkar," I ask the mother in Arabic to bring some water with sugar. She mixes a sugar cube in a small tea glass and as she holds it to the boys lips his eyes open and he sputters but manages to get most of it down.

"Anti almi ayyi ma wakit." I inform them they should keep giving him sugar water regularly. He hasn't eaten all day and is at high risk for hypoglycemia.

Just then I look out the door of the hospital ward and see a pack of kids, boys and girls, in a wide variety of soccer attire, knee length socks and cleats come tramping by shouting and laughing. They huddle around the hose just behind the
patient bathrooms.

"Hey, what's going on? Get out of here! This is a hospital!" Many voices clamor in reply that they're just getting water and no one seems interested in paying attention to what I'm saying. I move out of the hospital ward towards the mass and push my way towards the faucet where the group is passing around a large metal bowl filled with water that they are busily slurping from. Miriam is still tranquilly resting in the crook of my right arm. I push in still yelling and being ignored till I grab the metal bowl and douse the nearest ones with it. They all start moving out quickly as I follow explaining loudly how rude and annoying they are and how dangerous it is to just barge into a hospital like this. One of the stragglers apologizes while most just give me dirty looks over their shoulders as they cross the campus and exit the large gate to the front. I follow them out to pronounce a final epithet as they head up the street to a construction site to get some water.






I go back into the courtyard and Ernest comes up to me. "I just got a call. There's been a major accident. A mini-bus crashed and five people where killed
immediately. There's a truck coming now with many others who were wounded as well as the five corpses. I call in the team and we wait around. Finally, after over half an hour, I decide to wait at home. They never show up. I end the day with a mango/pineapple/banana/peanut butter smoothie and an episode of "House, M.D." and fall asleep as the rain comes pouring down.