The grieving process is so weird. I feel ok most of the time, but then want to
cry, feel it building up, but just can't. But then another tragedy comes along
to open the deep well of pent up tears...

I'm lying in bed when I hear a mournful howl. I know what it is, but I don't
want to admit it. Maybe it will just go away. The raucous African party music
next door has finally died down. The last of the Muslim prayers have finished
at the masjid. All should be calm. But deep down, I know a well loved pet is
slowing giving its life away in the cause of a worldwide rebellion against our
creator. I try and ignore it. Maybe Caramel isn't really suffering. I hear it
again. I grab my flashlight and gently open the door, hoping to not wake up
Miriam.

The porch has been finally cleaned and arranged. We just had all the construction workers over with their families earlier to celebrate the amazing work they've been doing on the Surgery Center here, including our residence. We feasted on chicken, rice and hibiscus tea late into the afternoon before giving them gifts and sending them on their way. Caramel was so sick she didn't even turn to sniff the leftovers we tried to tantalize her with.

Now, I'm crossing that porch under the dim blue bug light cracking with mosquitoes being killed. I walk across the "lawn" which is a melange of sand, crushed brick, and dark earth with scattered trees struggling towards the heavens against the ravages of horse hunger. The smell of decaying malt and rice mixed with horse dung brings a pungent, farmyard smell to the rapidly cooling evening. There is no moon, but the bakery down the street provides the scene with background fluorescent lighting.

My flashlight picks up the splayed out form of a medium sized dog who looks remarkably like a German shepherd except for her flopping ears. She is sprawled out, barely moving except for shallow rapid breathes over an emaciated stomach. She has refused to eat for 2 weeks and we aren't sure why. Nothing has worked: worm meds, antibiotics, new food, French veterinary advice, counsel from "Where there is no Vet", etc.

Her head is lying flat against the ground and her head and mouth is covered with moist dirt as her tongue flops on the ground. Her eyes are half open and her pupils are fixed and dilated. Her mucus membranes are pale and her eyes are cloudy. I gently stroke her head, eliciting the same mournful whine. She is almost gone, but seems to be suffering something. Tears well up, but the dam is held back as I still desperately pray for a miracle for a few minutes and I pet her head and back. Ants have already started crawling on her head and eyes.

Finally, I go back to the house, pull out an ampoule of Valium and a syringe and make my way back to Caramel's prostrate form. I inject her along the nape of her neck and slowly her breathing slows down and stops without further groans. Her body stiffens briefly, and then relaxes. There is no more breathing and her body is limp. The well springs of pent up loss and grief pour out as I sob for countless minutes. I go back inside.

"Sarah, where do you want me to bury Caramel?"

"Is she dead already?"

"Yes."

"How about over by the compost pile near the lime tree? The soil should be soft
there."

I go to the container, open the lock, creak open the doors and pull out a pick and a shovel. The composting soil is rich in odor and easy to unearth. I dig down two feet and return to Caramel's lifeless form. I grab her by her legs, two in each hand and carry her flopping carcass and place it in the grave. I quickly scrape the soil in over her and pack it down.

Gone without a trace except in our broken hearts.




RIP Caramel Summer 2009 - 26 February 2012

As I approach the bridge five miles from Béré I have no thought as to all the
circumstances that would lead to my being in this exact spot at this exact time.
It is only later in looking back that I realize how many things worked together
to make it happen.

My father arrived in Chad over two weeks ago. He had wanted to see Adam's grave in Béré. But a container arrived, the scalded dog broke down and we had no good way to get there. But in the container was an old VW Vanagon Campmobile. Augustin the administrator from Béré, has adopted a daughter from one of his relatives. She has had a mass on her distal fibula for 2 years. They showed up a week ago with xrays showing a bone cyst. I plan to operate on her last Wednesday but it doesn't work out for me to be in Béré. We have two nurses in Béré who want to come work with us in Moundou. Our business manager, David, and I want to interview them in person.




All this and much more leads to us being in Béré today.

In Béré we interview the first candidate. I take Augustin's adopted daughter to
the OR and inject the cyst with a corticosteroid under local anesthesia. No big
deal. But the second applicant is in Kélo. It takes him a while to arrive. The interview drags on and on. I'm anxious to get back to Moundou before sundown. The nurse, Abba, seems like a good one, but his application is incomplete. The rest in in Kélo. I offer to take him to Kélo with us on our way back to Moundou. He agrees but doesn't have money for the return. He asks if we can go see his brother at the district medical office. I'm a little frustrated, but agree. We wait outside for what seems like hours. Finally, we're back on the red road to Kélo.

All this and much more makes us be at the bridge crossing the Tandjilé River at
this precise moment on this specific day.

The approach to the bridge is quite steep and sort of paved. It has sunk down
with time leaving a large bump where the actual bridge begins. I slow down in
anticipation. As I climb up the incline I see a crushed motorcycle lying on its
side against the railing on the other side of the road. A little farther on is
a twisted heap of a man in a uniform. He is completely still and around his
head is a deepening pool of blood. There is a man leaning over him. As I
approach slowly, the man looks up and waves us on. Instead, I stop and
Franklin, my dad and I get out and hurry over to what seems like a lifeless
form.

At first glance I notice the huge laceration on top of his head. He appears to
be breathing, however, and Franklin confirms quickly with his stethoscope. The blood around his head is fresh, bright red and just beginning to clot. I realize now why no crowd has gathered: the accident just happened and there are African killer bees buzzing around. The few people even close have pulled their shirts up to cover their heads. David shouts a warning which we ignore.

The man who had waved us on speaks up. "I'm a policeman off duty. Mark the
time, but I want nothing to do with this."

"That's ok. We'll take him to the hospital."

"C'est bon. Here, take his cell phone."

I take the phone and notice a broken cord dangling off to one side. Dad, Abba and some locals pick up the man as I go back to the car, rip off the plastic we'd used to cover up the broken back window of the Vanagon, and grab Franklin's turban.

"Franklin, do you mind? It'll get ruined..."

"No, go ahead!"

I tell Abba to compress the large laceration on the victim's skull to stop the
bleeding. We place him on the plastic. He appears to be somewhat conscious and starts trying to thrash around. Franklin and Abba stay with him. David decides to wait at the bridge and Dad and I climb in the front. I put the Vanagon in reverse and back down the bridge to where I can turn around. Then we fly back to Béré, the Vanagon's new springs making us almost float over what otherwise would have been a bouncy, bumpy ride.

I honk as we turn down the road to the hospital and the gatekeeper gets the gate open as we pull in.

"Get a gurney!" I shout to the nurses that gather around. We place the wounded man on the gurney and take him to the OR. Abba still holds pressure on his skull. I take off my bloody pants and put on some scrub pants.

After getting a large bore IV running at full speed I order antibiotics. The man is still agitated so we have to hold him on the gurney. I put on some gloves and examine the wound more thoroughly. His skull is crushed with a depressed fragment near the back and a piece of brain pushing through a rip in the dura.

We transfer the man to the operating table while Franklin gets the anesthesia going. I scrub and ask Ndilbe to scrub as well, but just then Abel arrives so I
have him join me instead. The patient is now under general anesthesia with
Ketamine (normally contraindicated in head injury, but since is skull is open it
can release the pressure inside).

I irrigate vigorously the wound, pull out the depressed skull fragment, put the
other pieces back in place and close the scalp in two layers after further irrigation. He doesn't appear to have any other injuries besides a laceration on his right arm. Olen confirms there is no serious intra-abdominal injury with an ultrasound. Franklin and I leave him in the capable hands of Olen and his father-in-law and head home.

We pick up David at the bridge. The wrecked bike has been removed.

"The locals told me the guy was fiddling with his phone right before the accident."

We continue on our way back to Moundou as I start to reflect on how we ended up in the right place at the right time to save a life. Al hamdullilah!

DISLOCATION

"Hey, Justin, you ready? Let's get going." I shout over my shoulder as I reach in the window of the Scalded Dog to open the door. The outside door handle hasn't worked for months. I've just changed into scrubs to look a little more official and gave a pair to Justin as well. He hops in, I fire up the Dog and we bounce out of the gate of the Moundou Adventist Surgery Center.

A Chadian man is accompanying us to show us the way. He'd come that morning after a call from one of my patient's, Ferdinand. I'd operated on Ferdinand months ago for a open tibia fracture. Three days ago, apparently, one of his relatives in a village outside Moundou had gotten in a car accident and now has a "deboitement" which just means a deformity. It could mean anything, but an xray they took the same day reveals a left hip dislocation. They'd called in the traditional bone setters who hadn't been able to reduce it. I sent Ferdinand out to buy two pairs of gloves, a bottle of Ketamine, two ampoules of Diazepam and some syringes.

We lumber along the uneven road past the soccer field to the one paved road in Chad's second largest city and economic capital. Turning right we pass the brewery on our left, a petrol storage facility on our right, the regional medical offices on our left and finally the Cotton Chad plant before crossing the one way bridge across the Logone River. A few kilometers outside of town we turn right off the road just in front of a huge pile of sand and enter a small village with an active little market. Halfway through the market our guide speaks up.

"Turn left here!"

Easier said then done. There is an old woman blocking the path with piles of twisted firewood in bundles. She is cantankerous and loud and refuses to budge. Everyone around is laughing and finally I'm forced to skirt her off the path and around the wood. We twist and turn through various mud huts with thatched roofs before pulling between to buildings into a small courtyard filled with drying millet, chickens, firewood and trash.

Our friend leads us through a low door into a tiny, dirt floored hut. Lying on a lumpy, cotton mattress is a young man in his twenties in obvious pain. His left leg is twisted and shortened. In the corner, at the foot of the bed are four sacs of millet in Nigerian produced bags. A small rickety desk with some papers reveals that the patient is probably a student. Four other male relatives squeeze into the room with Justin and me.

"Bonjour, mon ami," I greet the young man. He manages a weak smile and extends his hand in the obligatory greeting. I call for water and prepare the syringes with the drugs. I wash off both thighs and stick Diazepam in one and Ketamine in the other. As Justin and I chat with the other relatives we watch the medicines slowly take effect. First, our patient stiffens up a little and his eyes start to wiggle back and forth. Then his raises his head slightly and moves it slowly from side to side as he puckers and unpuckers his lips. Then he starts repeating phrases loudly and drunkenly in Ngambai as his mouth grimaces in all sorts of hilarious positions. His eyes bug out and continue to flutter back and forth.

Justin and I can't help but laughing but I can see the relatives don't know exactly how to react. I calmly reassure them that this is typical for Ketamine and it only means the medicines are working.

Finally, he seems completely out of it so I ask Justin to grab the left foot and lean back into it to let his body weight act as traction. I grab the knee and gently rock it back and forth. Suddenly, there is a satisfying pop and the hip slips back into its socket. The leg is now back out to length and straight. I move the leg back and forth and around and it moves freely confirming that it's back in place. I externally rotate it and abduct it and tell one family member to hold it in that position until he wakes up.

We chit chat with the family for 15-20 minutes until I'm reassured that the patient won't have any complications from the anesthesia and Justin and I head home. Our guide accompanies us as he left his motorcycle at the clinic. The crowd that has gathered outside the hut is talking excitedly and waves a cheery goodbye. Arriving back at the clinic, our friend seems like he wants to say something more. Finally, he gets it out.

"What about the costs of fuel and your visit?"

"Don't worry about it, I'm happy to help."

"No, you went out of your way to help us, how much?"

While I really don't want anything, I realize he wants to express his gratitude and this is how things are done here."Ok, you decide."

He reaches in his pocket and pulls out three 2000 franc bills which he gratefully presses into my hands. I'm touched by his gesture and we warmly say our farewells as I give him final instructions.

Three days later, Ferdinand calls me to say the young man is up and walking normally without pain.

MAD

I'm furious. It didn't have to happen. My son didn't have to die. There has been a way to eliminate Malaria that has been available for over 70 years. In fact, the United States and Europe have used it to eliminate this pestilence in their respective countries. In fact, the man who found out it's usefulness received the Nobel Prize since this substance was estimated to have saved over 500,000,000 lives around the world. It's a substance that is cheap to manufacture. It not only kills the mosquitos that transmit malaria but it repels and irritates them so that the majority of insects don't even want to go anywhere near where it has been sprayed. The Anopheles mosquitos that carry the malaria parasite therefore don't get their blood meal necessary to reproduce and slowly die out. Even if the mosquitos are resistant to the powder, it still works by repelling and irritating so that malaria transmission virtually stops. And is lasts a long time. One spray on house walls every 6 months is all it takes to keep the mosquitos carrying the deadliest disease on the planet away from the women and children (and men) sleeping peacefully inside.

At the levels used to control malaria, the substance is not dangerous to humans or the environment. In fact, there has not been a single reported human death as a result of environmental exposure to the insecticide.

Did I mention that it's dirt cheap to produce and was used successfully by the
USA, Italy, Taiwan and other "developed" countries to completely eliminate malaria (which was once a major killer in these places)?

And yet, because of political maneuvering, fierce attacks by the EPA, propaganda, and a pack of lies this substance was banned in most countries. Even though still authorized by the Stockholm Convention for use in malaria control with Indoor Residual Spraying, this material has gained such an unwarranted, nasty reputation that it is hardly used at all in favor of ineffective methods such as impregnated mosquito nets, treatment with anti-malarial medications, drug prophylaxis and research into vaccines.

If this miracle powder had been used like it should have been over the last 70 years the world would be all but rid of a disease that kills millions per year in the developing world...including my 6 month old twin boy, Adam.




It's time to take another look at DDT and bring it back, it's literally killing me that this insecticide is available yet I can't get my hands on it because of political maneuvering and scare tactics by people sitting comfortably in
air-conditioned, malaria free zones making decisions to help control the
population explosion (actually an argument used by one of the people fighting to get DDT banned) by letting the poor of the world continue to die of malaria!

If you want solid info on the debate, look up the book "The Excellent Powder:
DDT's Political and Scientific History".