10 July 2016


06 November 2013

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

"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.


"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

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

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.

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