Béré Adventist Hospital

SHAKING

2012-01-22T07:11:00.007+01:00

I approach the well guarded building slowly. There's a Chadian behind the bulletproof glass. I pull out my documents and slide them under the security port. I decide to speak in English instead of French.

"I'm here to report the death of my son."

The man checks my passport and then motions me to go through the door to the left. I pass through the metal detector and another man escorts me across the compound with its barbed wire, satellites and heavy security. We approach a door in a wall. A metal panel is slid back from a metal grate. A man quickly verifies that I'm with a known entity and opens the door. We walk across a sidewalk through well manicured lawns and into an air conditioned waiting room in front of another bulletproof glassed office.

A short, well-dressed American with a red beard gives me a smile while a tall Chadian briefly looks over his shoulder.

"Ça va?" the American asks.

"Ça va," I reply as I approach the window. I pass him my passport, Adam's passport and the death certificate from the Bere Adventist Hospital. "I'm here to report the death of my son, I was told it needed to be reported." My voice is hollow and void of emotion.

The red-haired man's smile disappears and he would have paled if that would have been possible with his fair skin. His hands start to tremble. "I'm sorry. Ummm,... I'm very sorry." He kind of stands there and starts looking at the documents. I can tell he's nervous.

"The person who normally handles these things is not here today. I've never done this before. Ummm...." He scans the papers again in his trembling hands.

"Should I just have a seat over there?" I ask trying to ease the mans obvious discomfort.

"Yeah, yeah, of course. I'll just go look things up. Have a seat."

I sit in the very clean, tiled floored, air conditioned, empty waiting room. I pick up a Chadian daily newspaper in French and start reading to distract myself with hearing about the President's long, boring speech in Moundou on December 1st. Back when life was completely different and I was the father of twins.

After 5 minutes or so, the American escorts me back to an office. He tries to find the paperwork on the computer and we make small talk. Then he leaves. I'm numb. I see Adam's passport tossed casually on the desk. I'm in the middle of another sterile room, neatly organized, air conditioned, no dust, so out of place in this raw, wild country. But even America can't keep it completely at bay. Out the window I see that dust covered spider webs have taken over all the angles of the iron bars meant to keep things well controlled and safe. The grout in the tile is dirty despite their efforts to maintain their purity.

I stare but I'm not really seeing much. My gut tells me that something is wrong but my mind has suppressed it so I can't feel. I just sense an emptiness. I feel like I'm in a movie. Like I'm about to be interrogated and maybe I should flee. But on the computer screen in front of me I see an official State Department document open reminding me of the reality. Splashed across the top in clean, crisp computer pixels is a name: Adam David Bindesboll Appel. And all the other concrete information needed to provide official documents to make sure it's real and there's no doubt or room to think it might be a dream or a nightmare to awaken from:

Date and Time of Death: December 31, 2011 7:15AM
Cause of Death: Complications of Malaria
Location of Body: Buried on Bere Adventist Hospital grounds between Kelo and Lai

The document is ready. The red-bearded man is back. He turns the dial on the safe and pulls out the huge seal to stamp it official.

"How many copies do you want? You can have up to 10 for free."

"I think that three will be enough."

I hear the squeaking of the machine and the crunching of the paper as it is crimped into the seal of the US government making it official.

"Again, my condolences," the man's hands are still shaking as they shake mine. He escorts me back to the room with the metal detector. All the Chadians in the room look at me with compassion in their eyes as they firmly grasp my hands.

"Mes condolances." I walk out into the reality of the Chadian heat and slowly make my way back to my car, some official documents clutched in my hands.

PAUSE

2012-01-12T04:26:00.002+01:00

I've stayed home from work this morning. I just don't have the energy to go in.
Waking up at 2-3 AM every morning is taking it's toll. I'm exhausted. Yet, I
can't sleep. I need a distraction. I open my computer and start watching "The
Bourne Identity." I'm part way into the gripping story when Sarah has to leave
to run some errands.

"Miriam is out on the mat on the porch, check in on her every once in a while."
She kisses me briefly and heads out the door, winding her head scarf as she goes.

I'm intensely interested in the movie, but being there for Miriam is more
important. I put the movie on pause and go out to the porch. I am rewarded by
a crooked grin from my favorite little girl. I can always come back to the movie later...

Later that night, as I lie in bed next to Sarah and we talk about Adam, I have a
flash of insight. All those things I miss about Adam, all those things I miss
being able to do with him, is simply put on pause. I will watch him crawl for
the first time. I will hear his first words. I will see him grow and develop.
I will get to teach him things. Just not right now. Adam's story is interesting, but for the sake of more important things (and God only know exactly what and why), Adam's story has been put on pause.

I don't mind waiting to watch a TV show or game I've recorded or years for a
movie sequel, yet I some how think that waiting to enjoy certain moments with
those I love and miss is too much. I'm too impatient. Maybe I need to follow
my friend, the Imam's advice: "Sheelah saboor, Allah bas yaarfah. Sheelah
saboor." (Have patience, God only knows. Have patience.)

Suddenly, verses from the Bible come flashing into my mind:

"...and by faith he still speaks, even though he is dead...All these people were
still living by faith when they died. They did not receive the things promised:
they only saw them and welcomed them from a distance. And they admitted that they were aliens and strangers on earth...They were longing for a better country--a heavenly one...By faith Moses...chose to be mistreated along with the people of God rather than to enjoy the pleasures of sin for a short time. He regarded disgrace for the sake of Christ as of greater value than the treasures of Egypt, because he was looking ahead to his reward...Some faced jeers and flogging, while still others were chained and put in prison. They were stoned; they were sawed in two; they were put to death by the sword. They went about in sheepskins and goatskins, destitute, persecuted and mistreated...They wandered in deserts and mountains, and in caves and holes in the ground. These were all commended for their faith, yet none of them received what had been promised." (Hebrews 11)

"Therefore, I urge you brothers...to offer your bodies as living sacrifices...to God." (Romans 12:1)

"Now if we are children then we are also heirs--heirs of God...if indeed we share in his sufferings in order that we may also share in his glory. I consider that our present sufferings are not worth comparing with the glory that will by revealed in us...For in this hope we were saved. But hope that is seen is no hope at all. Who hopes for what he already has? But if we hope for what we do not yet have, we wait for it patiently...And we know that in all things God works for the good of those who love him, who have been called according to his purpose." (Romans 8:17-28)

"Blessed are the poor...Blessed are those who mourn...Blessed are the meek...Blessed are those who are persecuted...Blessed are you when people insult you..." (Matthew 5)

"Greater love has no one than this, that he lay down his life for his friends.
You are my friends...If the world hates you, keep in mind that it hated me first...Remember the words I spoke to you: 'No servant is greater than his master.' If they persecuted me, they will persecute you also. (John 15:13-20)

"Therefore since we are surrounded by such a great cloud of witnesses, let us throw off everything that hinders and the sin that so easily entangles, and let us run with perseverance the race marked out for us. Let us fix our eyes on Jesus, the author and perfecter of our faith, who for the joy set before him endured the cross, scorning it's shame...Consider him who endured such opposition from sinful men, so that you will not grow weary and lose heart...Endure hardship as discipline; God is treating you as sons...God disciplines us for our good, that we may share in his holiness. no discipline seems pleasant at the time, but painful. Later on, however, it produces a harvest of righteousness and peace for those who have been trained by it." (Hebrews 12:1-11)

"What shall we say in response to this? If God is for us, who can be against us?...'For your sake we face death all day long...' For I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God..." (Romans 8:31-39)

So, my life with Adam has been put on pause...but it will be continued in a short while...and this story has no end...

EMPTY

2012-01-10T16:33:00.001+01:00

I wake up. Miriam is moaning softly in her crib. It's 3am. I wonder if she's
missing Adam. She probably doesn't even know what she's missing, just that
something is different and she can't figure it out.

In the background, the heavy, rapid beat of tribal drums and chanting provides a
mournful backdrop. It is initiation time when the youth of animistic Chad forge
their alliances with the powers of darkness that reign. The full moon casts an
eery light to the shadows in my bedroom as the mosquito net seems to draw its
tentacles around my exhausted body.

Images burst across my memory of my little boy, I ache deep in my gut, but I
can't feel much. The tears no longer come. Despair grips me and a boiling rage
builds in my soul. My mind battles for reason and hope, but it's a losing
battle. It's become routine: 2 or 3am and I'm not going back except to a
fitful, vivid dream filled tossing and turning with a million "what ifs"
crashing through my head.

But that will drive me insane. I get up and get a drink of water. The drums
have started again. I didn't notice they'd stopped. Dogs howl mournfully in
the background. Night insects and birds fill in the mournful backdrop of this
never-ending night. Maybe I'll wake up tomorrow and have to squeeze out of bed
in between Adam's mosquito net covered crib and my own mattress. Maybe he'll
wake me up early with his cries of hunger or need for companionship. Maybe when
I reach in to pick him up he'll lift his head and gurgle out a sigh of
contentment as he gives me a lopsided grin. Maybe after a snack he'll fall back
asleep for a while only to awaken again flopping and thrashing his legs,
desperate to develop and be on the move.

Or maybe he'll sleep in a dark, cold box under a red flowered tree with his
premature sister a few feet away in a jar not to wake up for days or months or
years or centuries or millennia. Maybe slowly but surely his parents will get
on with their lives, vaguely remembering from time to time as an unexpected ache
creeps into their otherwise busy day. Or maybe they won't recover. Maybe
they'll give up, tuck their tail between their legs and slink on home to live
lives of quiet desperation. Right now all I see is darkness, the dark night of
the soul has begun and God only knows where it will lead.

If only I could cry...

MISSING ADAM

2012-01-08T01:33:00.003+01:00

My whole body aches. We've just come back from a horseback ride to the river. I rode Libby across to the island and than left her to munch grass while Matt, Daniel and I waded and swam to the far shore. Now I'm back home and feeling the fact that I haven't exercised in weeks. So I'm lying on a mat on the back porch staring at the tin roofing...and I'm missing Adam. I miss him snuggling up to me when he's really tired. I miss his gnawing my finger to comfort himself. I miss massaging his chest as his head wags back and forth as he fights sleep. I miss his cooing and clutching my fingers. I miss his snorts as he realizes lunch is about to be served. I miss hearing him attack Sarah's breast taking in more air than milk. I miss his drunken look as he emerges after a feeding and stares around dazed and happy. I miss his series of three crescendoing burps after eating. I miss watching him startle himself with an extra loud belch.

I miss his cries of frustration as he wants to crawl but can't just quite coordinate it all yet. I miss his pushing up on his back legs and flopping forward in a vain attempt to capture whatever object is before him. I miss his lunging onto Miriam in a playful brawl that she doesn't appreciate as well.

I miss him sitting and staring at Miriam while playing with her hand. I miss him looking across the mat, seeing his sister and smiling his dorky grin.

I miss that grin. The full open mouth with the tongue stuck straight out and the eyes bright. I miss his chortle as I tickle him. I miss him not knowing whether to laugh or cry as I try to entertain him when he's tired. I miss his staring into my face and rapidly extending both arms and legs and letting them drop on the floor as he looks to me for approval. I miss him doing something and looking my way and smiling shyly when he realizes I'm watching and cheering him on.

I miss his surprised look as his whole body tenses when the first water of his bucket bath hits his head. I miss him pretending to want his mashed sweet potatoes only to swirl them around in his mouth, mix them with his saliva and either let it drool out slowly or spit it out with a pleased look in his eye. I miss his fast moves to knock the spoon out of my hand or grab the bowl and smear sweet potatoes all over his face, hands and feet. I miss him grabbing his feet and putting his toes in his mouth so he can suck his big toe. I miss my dreams for him. I miss the fact I'll never know what his hair color will really be. Will it be curly or straight? Will his eyes change or stay blue? What will his first words be? Dada? Mama? I miss seeing him crawl, stand, walk, run, jump, play, sing, make up stories, shoot hoops, learn languages, travel in the vanagon, listen to tales from the Bible, learn to read himself...I miss all the things I planned to do with my firstborn son. I miss having him hang around the operating room. I miss having him tag along in clinic. I miss taking him to the river. I miss bringing him his first pony. I miss it all.

Yeah, I miss Adam a lot. In the words of a song I wrote when my twin brother, David, was killed in a car accident 10 years ago: "But I miss you, I want you back right now,...to hear you laugh out loud. My tears flow uncontrollably, so fast, I cannot even see. But still I know...I'll see you again. No matter how long that may be. I'll see you again. Though right now, it all seems a dream. The Lord and His promises are sure. He's faithful, our hope is secure. I'll see you again."

MEANING

2012-01-03T15:33:00.002+01:00

There is no meaning in it all, and yet my mind struggles to find some answers and explanations. Of course, they will all fail, but I must try anyway or drown in hopelessness. Maybe that's why I wake up so early and can't sleep. I'm searching for some consolation, for some meaning. My body is tense and needs release. But the tears are dried up...until they spring forth at some memory, for some reason.

I lay Miriam to sleep last night. She's exhausted. She's had malaria for God's sake. She was swamped by visitors trying to console her parents. She was surrounded by sobbing and wailing and tears. She couldn't sleep in all that. So now we're in a familiar setting. Her crib and mosquito tent are unchanged. She has the quiet of her corner. So I lay her down to sleep, to rest in peace.
She's unafraid. She knows I'll wake her up in the morning. She knows she's safe. She knows I'll be there. She drifts into silence. She knows nothing of what I'm suffering all through the night as I think of my little boy, pale and cold in that box surrounded by the damp, African soil.

He was on borrowed time. He shouldn't have even been born. Sarah and I have had unexplained infertility for years. Thanks to modern science, Adam came to us after sitting in a freezer for months. Then his little body developed in the womb of his mother. But the enemy was already at work. Through his wild movements we have come to know so well, he managed to wrap his umbilical cord into a true knot that if pulled tight would cut off his precious supply of oxygen coursing through his mother's blood, crossing the placenta and entering his body through those umbilical blood vessels.

Sarah went into active labor a month early. Then her labor stopped. If she had gone till term, in all Adam's wiggling and kicking he may have pulled that knot tight and been stillborn. Or if her labor had progressed, as he was squeezed out the birth canal, the knot may have tightened and killed him or given him brain damage. But God intervened and stopped Sarah's labor progression and Adam and Miriam were born by c-section, healthy, screaming and eyes wide open.

His life was a miracle, a gift. He was on borrowed time the whole six months of his precious life. "The Lord giveth and the Lord taketh away, blessed be the name of the Lord." (Job 1:21)

Is God really so cruel if he's just a Father putting his child to sleep for the night only to wake him in the morning? "For his anger is but for a moment; his favor is for a life-time: weeping may tarry for the night, but joy cometh in the morning." (Psalms 30:5)

"Brothers, we do not want you to be ignorant about those who fall asleep, or to grieve like the rest of men who have no hope...for the Lord Himself will come down from heaven...and the dead...will rise first. After that, we who are still alive...will be caught up together with them..." (1 Thessalonians 4:13-17)

Unfortunately, it's still night where I'm at...

GRIEF

2012-01-02T21:43:00.010+01:00

I'm lying flat on my back on the veranda. Dusk has settled. The stars are not out in force yet, but the half moon and it's bright under star are straight over head. Among the dark tangled branches a few fruit bats flap silently across the clearing, temporarily blocking out the moon. Darkness settles in as I feel a gnawing in my gut and the need to release my anguish. But the tears won't come. My mind wanders to a million memories. It's only Monday but Friday already seems a lifetime ago.

I've already started to feel the waves of grief mixed with a calm peace that ebb and flow like the tides that Tchad has never seen. A few incidents stick out.

I'm in the tiny office off the waiting room with Sarah and Miriam. Miriam is half-way through her treatment. She has just finished an hour of cooing, flopping, half-crawling and wrapping herself in her IV tubing. Now, she's sleeping, her legs hanging off the edge of the mattress face down and slightly turned to the side away from the her left arm which is encased in tape, an armboard and an elastic wrap to keep that precious IV access going.

I hear the sounds of French with an Arabic accent outside.

"I just want to see James and give him my condolences."

"He's at the house," replies an unknown informant.

Through the broken slats and ragged curtain on the window I see a couple of Muslim hats on top of well-known faces as they turn to head in the wrong direction. I take the route through the waiting room and from the door yell out, catching the two men's attention.

"AS SALAAM ALEKUM!" The two muslims turn and smiles light up their faces as they give the traditional reply: "Wa alekum as salaam." One is a contractor who remodeled the Bere Hospital ER and built some staff housing. The other is the local imam.

The Imam is dressed in a light blue robe with embroidery on the chest. He has a white, flat topped hat on his head and a checkered middle eastern scarf around his neck. One eye is blind and almost shut and a scraggly white beard graces his chin as a smile crinkles up his lined face.

"This is the way of the world," the imam continues in Arabic after we have shook hands and exchanged the appropriate long greetings. "This is the way of the world. Only Allah knows why these things happen. Only He knows."

"Al hamdullilah," I reply.

"My heart hurts with your heart," the imam continues, first touching his chest and then moving his hand out pointing at my chest. "My heart grieves with your heart. Only Allah knows why. May Allah be praised."

"Mashallah," I intone my head down as I shake and hold the Muslim leader's outstretched hand.

"Where's Sarah?" the imam asks.

"Inside. Come." We walk back together as both men offer me more words of encouragement and condolences. Inside, I check and find Sarah is sleeping.

"Don't worry," says the imam with a smile. "Allah will give you more children. This is the world. There is loss. Allah gives and Allah takes away. Let's pray."

Both Muslims stand with their hands outstretched to receive Allah's blessings as the imam leads us in a prayer of praise and consecration. When he has finished we all bring our hands to our faces to accept the blessings from God.

That evening, my uncle, a Christian pastor calls me on the phone also offering his encouragement and condolences. He also ends with prayer. During the prayer I realize that this is a rare moment. I have been blessed by both Isaac and Ishmael. For an instant, around a tragedy, the two brothers have stopped fighting and helped the hurting. I am moved to tears, which is quite easy these days.

The next morning, Miriam's 3 days of IV Quinine are finished. She has no fever and is back to her normal self. We pack up the van in truly Tchadian style with baggage to the ceiling, three American volunteers, one Tchadian patient and his two family members (plus small child), one Tchadian nursing student, one Tchadian cook, our two Tchadian adopted daughters (Yahdang et Djongyahbo), Sarah, MIriam and I. Before getting in, the three of us make a final pilgrimage to the two graves under the red flowered tree.

Then we head out in an eery fog. The whole country seems to be mourning with us as a white haze drifts in and out of the dried grasses, half burned fields and cracked clay. Passing a lake, some massive rounded backs rise out of the mist, nostrils flaring as a herd of cattle is driven by. The chill lasts until we are safely back in Moundou wondering what do we do now?

Then we head out in an eery fog. The whole country seems to be mourning with us as a white haze drifts in and out of the dried grasses, half burned fields and cracked clay. Passing a lake, some massive rounded backs rise out of the mist, nostrils flaring as a herd of cattle is driven by. The chill lasts until we are safely back in Moundou wondering what do we do now?

ADAM

2012-01-01T06:30:00.007+01:00

The moon has gone down. I walk in the dark with only the stars and the promises of yore to light my way. I make my way past the silent benches that all day held crowds singing in French and Nangjere as the drums pounded out their mournful beat. My body is as limp as the pillow I carry. Every last tear has been wrung from my eyes. I make my quiet pilgrimage to the site of my greatest sorrow. I enter the room that holds so many memories. As I open the rickety lock I remember locking that same door from inside as I cared for two little African babies struggling for their lives while outside men fought to end each others. The faint odor of bat guano greets my nostrils and makes me think of the time the winged mammal hit the fan and landed on the face of the baby fighting for breathe in the clutches of an asthma attack. I shine my light on the IV slowly dripping into the arm of my sweet little daughter, Miriam, as she tosses and turns in a fitful slumber. Sarah lies by her side in the mosquito net softly comforting her one remaining child. It seems like an eternity already since the morning when two babies wiggled and squirmed and flipped and grinned and giggled and squealed together in that same tent.

Sarah woke me up less than 24 hours ago. "The twins are really active and I'm having a hard time. Can you come over?" I arrived to see Adam staring at me with a silly grin right before flipping off the mattress between it and the net and letting off a howl of frustration.

"You should have seen them. They both woke up, looked across the mat, grinned and tried desperately to crawl to each other," said Sarah.

We'd arrived in Bere the day before. Thursday night, Adam had a fever of 104. We were in N'Djamena and I bought a rapid malaria test. It was negative. I wasn't convinced. I opened a capsule of Artemesia, poured it on his mashed sweet potatoes and fed him despite his obvious preference for medicine-less food. The next morning, I fed him another dose and we loaded up the scalded dog and were on our way to Bere by 6:30am. By 2:30pm, both Adam and Miriam had been diagnosed with falciparum malaria and started on IV Quinine. Through the night, they each got two of the every 8 hour doses.

I start Miriam's next IV perfusion and turn to Adam. I let 150 mL of 10% glucose solution run from the IV bottle into the pediatric reservoir on his IV tubing. The tubing has special air traps to avoid any accidental entry of air into Adam's veins. I pull out 0.5mL to flush his IV and then carefully measure 90mg (0.3mL) of quinine and inject it into the top of the reservoir of 150mL. I open up the IV, see that it was running well and slow it down to a drip.

I turn to look at Miriam and talk to Sarah.

"Is that a seizure?" Sarah interrupts our conversation and we turn to look at Adam. He's not breathing. We start CPR. I run and get some 50% glucose solution, afraid of low blood sugar. I text Olen who is there in minutes. Still no breathing. Olen confirms a heartbeat, slow and irregular, but there. Olen gets a bag valve mask and starts breathing for him while I do chest compressions and Sarah continues to give glucose. Anatole arrives and checks the blood sugar. It's high from all the glucose we've been giving him. We try Adrenaline in ever increasing doses. His heartbeat never picks up. Every once in a while he grimaces, groans, struggles for a couple breathes, giving us hope. We work on him for over an hour. His heartbeat disappears. His pupils are fixed and dilated. I'm praying desperately for a miracle. We stop.

Deja vu.

How many years ago did the same thing happen to my friend Gary and his little boy Caleb?

It's 8:00 am and my life has suddenly changed for the worse. Sarah and I hold Adam's still warm body. I desperately kiss his neck, my tears know no bounds.
My cries echo across the campus to join the thousands of others I've heard over the years in this corner of Africa. Will I never again see his tongue half
hanging out of his silly grin? Will he never again wrap his legs around my arms, brining my fingers to his mouth as he softly coos? Will he never again thrash his arms in legs while staring at me with a look of pride and joy? Will he never again take up the airplane position looking around for confirmation of his abilities? Not in this life.

A day long ritual of African mourning begins as the news spreads like wildfire through the village. People come to offer their condolences. Miriam becomes agitated with all the visitors. I wrap Adam's body in my green and black
checked Arabic head scarf and carry him over to the house where friends have arranged to let the mourners come in and visit. All day long the songs sung in rhythmic Nangjere drift in as people make their way to where I am sitting on a thin Nigerian mattress. So many people, so much collective pain and loss. Salomon comes in and hugs me. A flood of tears bursts forth as I remember him holding Adam so many times as we ate together in Moundou, enjoying one of his famous sauces. Frederic kneels down and holds my hand long and hard in an undulating shake of sympathy. Just last year I was at his house as he held his son who had just died. The mother of the boy across the street who fell down a well and died crouches and holds my hand as we share tears of sorrow and she offers words of comfort and hope.

The steady stream of people brings me a steady stream of tears as I shake and hold the black calloused hands of so many people who's lives have been filled with loss. The strength of the grip and the power of the muscular arms of both men and women combined with their roughened feet tell a thousand tales of woe. Their is no awkwardness. They've done this before a thousand times. Tears come from faces I've never seen before. But we now have a common bond of tragedy. The only ones who seem uncomfortable are some of the westerners, but their warm embraces make up for the lack of familiarity with death.

Gary and Wendy fly in from Zakouma just in time for the English portion of the day long wake. Hymns of hope sung gently and powerfully by the many musicians in our group of Nasaras warm my soul as Sarah holds Adam's now cold and stiffening body.

"When the trumpet of the Lord shall sound and time shall be no more...when the roll is called up yonder I'll be there." The rollicking song brings bursts of tears from Gary, Wendy, Sarah and I as we remember Caleb's favorite song and the other little foreigner buried in Bere what seems like ages ago. Now it's time for last good byes. Sarah and I bring Adam's long little body into the house and place it gently in the casket made by Jamie just this morning. I kiss his cold brow one last time and we put on the lid.

The pathfinders are outside to carry the body to the grave site. Under a little tree in front of our old house in Bere lies a volcanic stone with a little plaque that says "Dinah Bindesboll Appel". Next to it is a deep, rectangular hole waiting for our second child to return to the African dust. Noel gives a stirring eulogy reminding us of the day when God will say "Viens" to both death and the devil and both will be done away with forever. Then God will turn to Sarah and James and say, "Here's Adam." And to Gary and Wendy, "Here's Caleb." And the innocents will be restored to their rightful place.

But for now, we miss him terribly...

RIP Adam David Bindesboll Appel, June 25-December 31, 2011

Planes, Trains, and Automobiles

2010-12-25T06:52:00.006+01:00

It's surprisingly cold for a Chadian morning. I'm glad for the fleece that Olen has lent me. I swing my backpack filled with Christmas gifts onto my back, grab my computer bag and head out to where Jonathan has left us his motorcycle.

Olen tries to start the bike unsuccessfully. The ignition is hanging down to the side by it's wires and despite all our efforts it won't start. Even Frederic can't get it going. Finally, the engine sputters to life only to die within a few seconds. In the ensuing silence we hear the sounds of the "scalded dog" rumbling up the road from Bendele. Gary is borrowing the Toyota minivan to go to Moundou so he gives us a ride to the market.

I sit on a wooden bench as the bush bus taxi roars up from Lai, swinging from side to side. There is a mad rush for the door as there are only five places and about twenty of us waiting.

"Hey, we have tickets since yesterday!" I shout out in French to the man holding the list.

"Ca c'est vrai," he replies and makes everyone come back out. He reads of the list and my name is first on the list followed closely by Philip's. I squeeze down the aisle to a seat that has been rigged to fold down into the corridor with a tiny seat back that folds up. It's worn and the padding has all but disappeared. If I shift my weight around I can almost get my butt off the metal poles making up the skeleton of the chair. It's going to be a long trip.

A large woman pushes down the aisle making me stand up and lift the seat to let her in behind me. She is yelling in Nangjere that she can't sit there, it's broken. Many people yell back until she grudgingly accepts her fate and plops in behind me. A toothless man bangs on the window. Tobacco breath pours into the bus as he tells me to give him money to put my bags on top. I start yelling back and move out the crowded bus to the outside where I lift my bag up to the roof rack myself as the crazy man yells to his colleague not to tie it on and the chauffeur yells at me to get back in and let him handle it.

As we get bouncing down the dirt road to Kelo, I have a pleasant conversation with Philip about his film project on Samedi and his plans for the future. In Bongor we stop for a 15 minutes. I cross the road, avoiding the weaving motos. I buy two yogurts in small plastic bottles. As we get moving again, the fat woman behind me asks me in Nangjere if she can have it when I'm done. I give it to her. When Philip finishes his yogurt, the beautiful, thin girl sitting next to me asks for it almost causing a small war between her and the fat woman who wanted both.

In N'Djamena, I jump off and head for the latrine. My bladder is about to explode. The hole in the ground is no longer a hole. It is completely filled with human waste and urine is lying in puddles around the edge and flowing out under the tin roof nailed haphazardly on as a door. I empty my bladder and get out of there as fast as possible. Philip and I sit in a bench in the shade drinking cold Hibiscus tea as we wait for Fatchou.

Dr. Fatchou walks up with a big smile on his dark, wrinkled face and begins talking a thousand miles an hour about all his projects as he hustles us into to his beat up Camry. We drive around Chad's capital as he shows us his old office at the National Leper Program and his new one down by the river. FInally, he drops us off at Farcha at David and Sarah the Swede's house/cheese factory.

Sarah greets us and invites us in to some cold meat and french fries left over from their lunch which we devour. On TV that night I see that a huge snowstorm has closed or limited flights to many European airports including Paris, Copenhagen and Frankfurt. Not good news for my plans for tomorrow. I sleep well despite the incessant barking of the dogs and the dive bombing of mosquitos in my ears. The next morning one of David's workers takes me around on a moto. I'm supposed to meet the DIrector of the Organization of Health Services in Chad. He shows up an hour and fifteen minutes late to our meeting. Good thing I was 30 minutes late so I didn't have to wait long. After hearing a 30 minute diatribe on national politics I turn in the papers for the Moundou Surgery Center, remind him of his promise to go on a mission to see our problematic Distric Medical Officer and ask a question about our project in Eastern Chad.

I hand in the photocopies of mine, Gary and Jonathan's passports to Aime so he can help us get authorization to fly to the Chad side of Darfur where the Sultan has invited us to reopen some medical work there. Now I have barely enough time to catch my plane. I tear off my Arabic Djallabiya, put on pants and a t-shirt, grab my back pack and computer bag again and Sarah drops us off at the airport.

In the line out Chad's one international gate I spot a short Phillipino girl I recognize! Caitlin was a volunteer at the Koza Hospital who I met just a few weeks ago. We chat and I find out she's heading to England before going to Bangladesh. In Addis Abeba I part ways with Philip who's headed to Washington, D.C. and Caitlin. I wander the airport and watch a movie to make the 5 hour layover pass quicker. My flight to Rome leaves at 20 minutes after midnight. I spend the 4 hours talking about Africa and NGO's and what kind of hope is there with a Swedish girl working for Unicef and an Indian businessman from Zanzibar.

In Rome I realize I not only don't have a ticket for the rest of my trip but I don't even know what airline I'm on. Sarah's brother Kim bought the tickets and the next leg is either at 9:35 to Zurich or at 12:15 to somewhere in Germany. I try SwissAir first but they have no reservations for me. I then try Lufthansa but they can't find me on flights either to Frankfurt or Zurich. Finally, they find me on a flight to Munich at noon. The agent with the cute Italian accent comes to help me check in at the automatic check in modules. Suddenly, as if having a brilliant idea, she turns to me and asks me if I'd like to go to Munich now. There's a flight leaving at 6:10 and if I hurry I can make it.

I run, barely catch the flight and find myself descending into Germany at a little after 8am as the sun is just barely sneaking over the snow capped peaks illuminating the snow dusted fields and rooftops of Munich. Inside the airport, I find a flight to Copenhagen that leaves at 10:45am. My flight is scheduled for 2:30pm. I head to the gate. The woman at the counter is not too optimistic.

"We usually can't modify this type of ticket," the woman says in English with just the slightest German accent. "But I'll see what I can do."

Munich has free hot chocolote, hot milk or hot coffee and not having eaten breakfast I down about 10 cups of hot chocolate mixed with hot milk. And I wait. The woman calls me up to the counter.

"I've put you on standby, but just leave the ticket here."

I go back down to sit. Soon the flight is delayed, not due to snow like I'd expect since 30% of flights into Copenhagen have been canceled, but rather due to "technical problems." The woman motions me back up to the counter.

"I've given you a seat, but just leave the boarding pass here, I need to..." Her voice wanders off. She seems distracted. I thank her and go sit back down.

The plane keeps getting delayed. Finally, at 11:50 we're ready for boarding. I go up to the counter.

"Here's your ticket, but there are kids sitting around you and I'd like to get them all together. Just wait a minute." I sit back down again. I wonder if I'll actually get on the flight after all.

Finally, the woman motions for me to come back up. "I hope you don't mind, I had to put you in Business class."

Oh yes, I mind terribly. Give me my ticket! I think as I calmly reach out for the boarding pass and settle in comfortably for a well hydrated and well nourished flight to the land of the Vikings. Instead of being delayed like many European holiday travelers or even having my flight canceled, instead I arrive 4 hours earlier than scheduled!

My friend Henrik is there to pick me up and takes me to his apartment near the train station. I get a bite to eat finally for the first time that day. A cheese a red pepper sandwich with Thousand Island dressing has never tasted so good! Henrik, Pernille and I take the closest train to the main station where I buy a ticket for my 4 1/2 hour train ride to Aalborg.

I descend the elevators to Quay 7 and enter into the chaos of the holiday travel season complicated by record low temperatures and snow fall. The train pulls up 20 minutes late and a surge of humanity rushes the door creating a standstill that lasts almost half and hour as we push and struggle to get on the train bursting at the seams with Danes (and others) trying to get home for Christmas. If it had been 40 degrees Celsius warmer I'd have thought I was in a crowded Indian or African train station rather than a European one. I finally managed to wedge into the doorway, make it up the stairs and stand with my back pressed into the wall of the entryway. Suddenly, everyone starts rushing out, not in a panic but rather quickly. I hear a Dane speaking English and ask him what's going on.

"There's smoke, a fire maybe, it's ok, we have to get off." Just then Henrik and Pernille come back up and explain that now we have to evacuate the quay as well. The train station is now more crowded than ever and rush hour is about to start. Another announcement tells those of us without reserved seats to not get on a train but they'll send a bus. We go and change my ticket for one that leaves tomorrow at 6:50am and go back to the apartment. Pernille later finds out that her sister took 10 hours to travel to Vejle, a trip that normally takes 2 1/2 hours! Instead of spending my evening in stop and go traffic all night to northern Jutland I spend it wandering the beautiful, snow covered, Christmas decorated streets of Denmark's capital culminating in a magical promenade through Tivoli which has been transformed into a winter wonderland.

A good night's sleep behind me I step out into the dark streets of Copenhagen where a gently falling snow welcomes me. My face is almost frozen off by the time I walk to the train station and get on the train to Aalborg in normal, organized fashion. I don't have a seat, but there are three fold-down seats in front of the bathroom. One of them is occupied by a Ghanian girl who immigrated to Denmark 7 years ago and is now studying Optometry. We have a stimulating conversation about the positive and negative aspects of life in Africa versus the West. After 2 hours she gets off and I find a regular seat where I stretch out my legs, watch a couple movies and enjoy the snow covered farming scenes rushing by outside the window.

Kim, Sarah's brother, meets me at the train station in Aalborg.

"James, this is Eva, a film student. We have to film something. It shouldn't take more than an hour and then I have some shopping to do. Then we'll go surprise Sarah." I jump into the car, glad to get out of the cold. Kim takes us to the edge of the fjord next to a cargo ship unloading grain into a 12 story silo. We take a tiny elevator to the top of the silo and enter a long room with pipes and rumbling machinery bringing the grain up and dumping it in the huge storage tanks. At the other end is a small door leading out to a spiral exit stairway and a fabulous view of North Jutland's largest city and industrial center. The fjord is iced over, but the ice is starting to crack leaving the surface like a kaleidoscope of ice chunks with tiny lines of dark green ocean in between.

Kim goes up and down while Eva films and then they switch places. My role is to try and stay warm as I wrap the scarf Henrik lent me tighter and tighter around my frostbitten, running nose as my glasses fog up. Finally, Kim goes to get his shopping done while I'm supposed to help Eva. This consists of my tired, hungry body going up and down 12 stories of snow covered stairs outside a concrete silo in below freezing weather (not counting the wind chill factor) not once, not twice but 2 1/2 times!

Finally, we head off the 40 minute car drive to Ostervra. We pull up outside Sarah's mom's apartment. The door is open. I don't knock. I'm in the entry way. The door to the living room is closed. I open it. I still don't see anyone. I go around the corner to the kitchen and there, stretched out on the couch, covered with a blanket facing me is a curly, red headed Dane. Her eyes widen. Her hands fly to her mouth.

"No way, are you serious? Is it really you?" She gasps in surprise, then in Danish tells her mom to come from the kitchen and see what's here.

And thus ends an incredible journey, and begins a very merry Christmas season indeed.

Cold

2010-12-11T14:32:00.002+01:00

I sit in the cold of a Cameroonian morning here in the mountains of Koza. The sunlight is beginning to stream through the dust covered windows, seeming to sift slowly to the floor with the ever present dust in the start of the dry season.

I wait. The lab guy should be coming any time. My body is weary and my back aches. Will I have to give blood or not? The result of the hematocrit will tell me. My mind wanders. Did yesterday really happen? It's kind of all blurred together. In my head, I'm back in the OR yesterday...

We're getting started late. I'm a little frustrated as I try to occupy my time straightening up the counter that serves as the anesthetist's work station. I'm alone with the patient stretched out on the bed barely covered with a skimpy hospital gown. This is going to be a long, tough surgery and it's already approaching noon. The system here is archaic. The patient's family must pay for the surgery, then go to the pharmacy and get all the supplies needed for the surgery since the OR has almost nothing there. Then they have to go to the lab to get tested and give blood. All this could've and should've been done yesterday or at least early this morning. Finally, the nurse himself had to go get the supplies because no one oriented the family members where to go and what to do.

Finally, I stand with scalpel poised in hand, flanked by two congolese doctors, Roger and Solomon. I start the incision in the old, midline c-section scar. I decide to repair the vesico-vaginal fistula first. Urine has been leaking from a hole in her bladder through her vagina for over a year since she was operated on in Maiduguri, Nigeria. Sometimes, after a difficult delivery or as a result of a surgery on the uterus, the bladder can be damaged creating what's called a fistula, or a hole so that the woman has no control over her urination, but leaks pee constantly.

I open the bladder and spot the fistula. I cut out the mucosa and free up the tissues and then close the deep vaginal layer, the bladder wall muscle and finally the mucosa of the bladder in three separate layers. I suture up the bladder and extend the abdominal incision all the way to her chest. My back is already starting to hurt as the ancient operating table will only raise itself so high, not nearly enough for a scrawny, six-foot-five man. I have to lean way in as I dissect the colon off the enlarged, non-functioning left kidney. It must have been chronically infected as well since there is a lot of inflammation that makes dissecting and identifying the ureter and the large blood vessels difficult.

After hours, I've finally mostly freed it up, but the blood vessels remains in a mass of inflammatory tissue. I've just damaged the kidney and it starts to bleed dark blood. A lot. I hold pressure and tell the staff to get the blood transfusion running. Ganava calmly tells me there's been a mistake, the family never actually gave blood, that was for the next patient. I'm incredulous. I would've never operated on such a big case without having blood available. I send Elissa running to the lab to check this patient's blood type and see if there's any blood from other surgeries left in the fridge.

After what seems like an eternity, Elissa comes back with the blood typing reagents and a bag of O + blood. Sure enough the woman is O + as well so we get one bag running. I release the compression on the kidney and dark blood wells up again. I send up a quick prayer and go for broke. I sweep my fingers behind the kidney and tear it loose from the adhesions holding it in until just a stalk remains attaching it to the circulatory system of the body. In that stalk is the vein and artery. I put a clamp across the whole mess and then a second one almost on the kidney and cut the kidney off and lift it out. The bleeding has stopped. I then leisurely double tie the blood vessels under the clamp, pull out all the gauze holding the intestines at bay, making sure to get them all and close up.

I do a hernia next and then we all eat for the first time since breakfast as Caitlin and Elissa have brought back some beans, rice, eggplant and dinner rolls from the house. They also have a case of Fanta and Coke. Since there's not bottle opener I try something I saw someone do once. I place the cap over a metal edge and hit the top of the bottle several times until I break off the glass. I gingerly drink from the now sharp edged bottle the renewing sugary mix.

The final case is a young 30 year-old-woman with advanced cervical cancer. I feel it's worth a shot at least in opening her up to see if the cancer is resectable. Since we don't have CAT scans or other ways to see the extent of the spread, an exploratory surgery is the only way. Unfortunately, I soon realize that the cancer has surrounded the ureters and blood vessels and started to erode into the bladder and rectum. By this time, she is oozing dark blood from many small wounds in the uterus that are two friable to suture. I hold pressure for a long time, but in some surgicel and a drain and close up. Fortunately, she has three bags of blood: two B+ corresponding with her blood type and one O+ that is also compatible. We get the first bag in quickly and get the second one running as we take her out to the hospital ward.

I go to see the first woman we operated on and she really needs more blood but there's none available except the one bag of O+ for the woman with the cancer. I make a tough decision. Both need the blood, but the woman with the cancer has an incurable disease. I go in to see the family. I explain that her cancer is inoperable and she has a few months to live at best. After some translation from French into Mafa they understand and express their thanks that we at least tried. I offer to pray for them and the nurse prays in Mafa. They all warmly shake my hand. I then explain that we are going to take the last bag of blood and give it to someone else. At first they resist, but finally agree after much time spent explaining.

I give the bag to the nurse and head home, weary, walking gingerly because of my back pain and ready for some Ibuprofen and a hard cold floor to stretch my back out on.

After a wonderful, but too short night's sleep I hear a knock on the door. The nurse needs my on the surgery ward. It's the woman with the cervical cancer. Her blood pressure is 90/50. That doesn't worry me to much. She is awake and alert, but her heartbeat is fast. Her conjunctiva are a little pale. The drain has put out over 200cc of blood overnight but her abdomen is soft. I prescribe IV fluids and tell them to call the lab guy for a hematocrit. I told him to come give me the results directly at home. If she needs blood, my B- blood will be the first bag she gets.

So I wait, in the cold, bare feet and short-sleeved to know my fate early this Saturday morning in the mountains of the Extreme North of Cameroon...

AMA

2010-12-05T16:03:00.001+01:00

In many ways, being in Cameroon is like a vacation. I came down from N'Djamena with Dr. Roger and Dr. Solomon, our two congolese doctors who'd just joined us in Chad but were chased off by the psychopathic behavior of our local District Medical Officer who threatened to throw them in jail the first day they arrived if he saw them in the hospital. It's been 6 weeks of running around trying to meet all the requirements he's listed despite the fact that the local Regional Medical Officer (his boss) and the governor gave the docs the ok to start practicing. Finally, since the Koza Hospital in Northern Cameroon has been without a doc for 3 months, I brought them here where we have been welcomed with open arms by all the local authorities, the hospital staff and the local church who all keep thanking God for answering their prayers and providing them with doctors so they don't have to refer c-sections an hour away over bumpy mountain roads to the nearest public hospital which is sketchy at best if they don't die en route.

So, I've felt an oppressive load fall off my shoulders, a load I wasn't even completely aware of until I was in an atmosphere where people were happy to have me and do everything to help rather than menace and threaten and coerce and intimidate. All in all, it's been embarrassing because in 7 years in Chad it's the first time I've ever had a real problem with a Chadian, and to have it happen when I finally find some young doctors willing to come and help me, it's discouraging as well. But, then again, Koza has it's own difficulties as well.

I walk into the surgery ward the first day in Koza. A young boy had fallen out of a tree 3 days ago and cut open his upper lip. I take off the bandage and see that the nurses have done an excellent job of suturing what seems to have been quite a complex laceration. I notice that besides his swollen face, the boy is favoring his right arm which is wrapped in some rags with sticks tied together in a splint around the entire forearm.

"Does he also have a broken arm?" I ask the nurse who rushes over to look.

"I don't know what that is, some traditional bone setter must have snuck in here last night. It wasn't there yesterday."

The boys' father, a short, man standing straight with a white skull cap and a dirty blue robe smiles pleasantly and confirms the nurses questionings.

I unwrap the arm to take a look. The arm slightly swollen and tender over the distal radius. It seems to be reduced well. A simple fracture.

"We can put a short arm cast on it for three weeks and it should heal fine." I get ready to move on, but the father says something harshly in Mafa, his mother tongue. I don't understand a word and look questioningly at the nurse who looks sheepish.

"He says, no plaster. He's had it once on his arm all the way to the shoulder, but he didn't bring the kid here for the broken bone, just the cut lip. The bone setter says that in two weeks he'll take off the sticks look at it and proclaim it healed so he prefers that. No plaster."

"Did the cast work for him when he broke his arm years ago?" The nurse translates for the father who smiles and nods while moving his arm briskly in all directions and flexing to show he has no problems as he spouts off some shotgun sentences in Mafa.

"He says he has no pain and can work all day in the fields for years...but no plaster for his son."

I spend about another 15 minutes trying to reason with the man who just keeps smiling and refusing the nice doctor who just doesn't have a clue about broken bones and how fast they can heal in the hands of the right witch doctor. I move on.

That evening I go to the ER to see a pregnant woman with high blood pressure. She says she is 8 months pregnant and has swelling in her legs. In fact, her legs are extremely edematous and she is hugely pregnant. I examine her belly and while she doesn't have pain or bleeding, i feel the fetal presenting parts so well I'm afraid of a ruptured uterus. She says she has been having contractions for 3 days. I bring out the ultrasound and find that there is no ruptured uterus, but rather two healthy twins at term. With the added complication of twins, the fact that they are at term and her pre-eclampsia, I decide the best thing is to do a c-section, take out the twins with as little risk as possible and treat the pre-eclampsia as well by removing the pregnancy.

I calmly call over the woman's mother and explain. She is categorically against it. She says they have to wait for the father and the husband. The husband is in Nigeria and the father is in the village 10 km away. I nurse asks her is she has a phone number. Yes, but her phone's battery is dead. I borrow a phone and try to call the husband. No answer. The nurse calls the father. No answer. I recommend the mother go get the father so we can operate tonight. 10km on a moto taxi is not far. She refuses. Says it's dangerous at night. I have them sign a paper saying they refused treatment and go home to sleep.

The next morning I see the woman and her mom. She says she went to the village but didn't bring back the father. Soon the husband shows up. He seems educated and understands my reasons for wanting to do a c-section but says without the father's ok, he can't agree to it. The mother told the nurse last night she doesn't understand why we want to operate. Her daughter is walking, eating, talking and doesn't seem sick. When asked why they came to the hospital then, she had no good answer.

Finally, later in the morning, they take the girl home. I find out later that they must have thought I was an idiot since I tried to show them the edemas and blood pressure to show that the girl was really sick. Apparently, one nurse told me that night at the house, the Mafa know that if you have edemas, it's because you're going to have twins. So I was trying to tell them the edemas were caused by a sickness when they knew perfectly well it was just the twin pregnancy that caused that and that obviously I didn't know a thing and couldn't be trusted.

That same night, I see a 13 year old girl with classic symptoms and signs of acute appendicitis. I sit the father down on a bench in the ER in front of the nurse who translates as the girl writhes in pain on the bed behind me. The father listens attentively and then tells me that she has worms, maybe tenia, and that she needs some good bark or roots. I explain again. He says, ok, just give her some pills tonight and we'll see how she does tomorrow. I'd already started an IV and I pointed out that she was still in obvious pain. He countered with the fact that it was probably because she was sneaking off with some boy getting pregnant or something. Another wasted half and hour later and I go home as the father insists that the nurse take out the IV and let them take her home where she can get some appropriate witchdoctor cure for what ails her.

At least one story has a happy ending as the next morning the other family members bring the girl back saying she was crying all night long and they want her to be operated on which we do without complications and send her off to a hopefully speedy recovery as we hope and pray the young pregnant girl somehow either delivers ok at home or comes back before the twins are dead or she's in a coma or seizing.

But at least they all like me here...so far...

Roadside

2010-11-11T03:45:00.003+01:00

I've blown a head gasket, literally and now I'm sitting on a bench by the side of the road. My scrub shirt sticks to my back; it's soaked. The front is covered with grease. I've been on the road since 4am. I'm 30 km from my destination, N'Djamena, and I'm not going anywhere soon. The car has been overheating for the last 100 km. Every 20 km or so, I add 1-2 liters of water to the radiator. I pull over in this nice village under the shade of some trees and pour in my water. Now it won't start, and it's making a real funny noise I've never heard before. The "Scalded Dog" is known for funny noises, but this is definitely new, wrong and we're not going anywhere.

To my left is a water pump. I've been searching those out all day to fill up my two water bottles and one jug for the constant replenishing of the radiator. Just a couple stops back I found one and freed it from tyranny.

I'd pulled up in the shade. Thatch roof tops poking through the bush let me know there was a village there and therefore probably water. A young man passes as I gingerly and slowly remove the radiator cap to let the steam out slowly.

"Is there any water here?"

"Sure just 10 meters farther on."

I finish filling the radiator, close the seat back over the engine, hop in, start her up and drive to the well. Someone has put a bolt across so the handle won't move up and down, thus impeding access to water someone in Europe or the West paid good money to provide these people with. I'm suddenly on a short term mission with easily obtainable objectives. The young man is unperturbed and just takes my water bottles to his house where he probably has stocked up a supply. Meanwhile, I go get my socket set.

The bolt doesn't stand a chance against two 12 mm sockets and it is soon in may hands. I wait until the young man comes back and with a leer on my face I show him the bolt right before launching it across the road into a dense thicket.

"NO ONE SHOULD LOCK UP WATER!" With my mission accomplished, I get back in the van and drive off into the sunset.

Back in the present I watch a little kid bouncing up and down on the handle trying to get the water to come out. He's only about 3 or 4 years old but already has his chores. Another kid about his age is trying to catch the unsteady stream in an old 5 liter oil jug as the excess runs off into a stagnant pool in front of a small store. The water is green with algae and littered with plastic bags and tin cans. The store has a veranda made of a straw mat balancing precariously on some gnarled tree branches stuck in the ground. There are three old fired clay water jars covered with metal plates with an upside down plastic cup on top and a plastic teapot at the base of the jar.

One man, covered from head to toe in sand has just descended from the dump truck across the street which is filled with...you guessed it, sand. He walks up and greets the group of robed and turbaned men on the mat.

"As salaam aleikum!"

"Wa aleikum as salaam!"

He goes and shakes each man's hand in turn before sitting before one of the jars and washing his arms to the elbows, his feet to mid calf and his face, ears and mouth. He's preparing for mid day prayers, but he's a little late.

When I first realized I was stuck I felt kind of awkward. I kind of mill around before sitting on the small bench in front of some mats. I greet an old man in Arabic and ask him about the food in the clear plastic garbage pails on the rickety, homemade table.

"There's donuts here." He points to the middle pail.

"What's this?" I motion towards the bucket to my left that has some whitish meatball looking things swimming around in a red sauce. "Is it meat? Fish?" My Arabic is limited.

"Fish, yes fish." His face brightens up, communication has happened.

I decide to pass for now and I go get a small watermelon from the van.

"Do you have a knife?" I ask the old man, knowing the answer as no respectable Arab would be seen anywhere without one.

The man graciously smiles and pulls up his robe, unsheathing a homemade dagger about a foot long. Looks kind of like a toy and feels light in my hand, but it's razor sharp and cuts through the watermelon like butter.

I haven't eaten all day and hardly drunk anything since I contaminated my water bottles with radiator fluid. I devour one quarter of it, but start to feel awkward. I've been here long enough that some good things have rubbed off on me. No respectable African, much less a Muslim would think of eating alone in front of people. I slice up the other half into manageable portions, arrange it on a tray a little girl has brought out and offer it to the old man and those resting with him on the mat.

"Faddal," I say in Arabic motioning him to partake. As I sit on the bench the munching and slurping behind me is reward enough for the tiny sacrifice of my coveted watermelon.

As I finish my piece at my leisure, I realize why the others are hurrying as the call to prayer rings out from the mosque across the street and men get up from all over where they've been resting in the hot afternoon son and make there way across for the 2nd of the 5th daily ritual prayers. The roadside is suddenly empty and quiet with only the occasional "Allahu akbar" ringing out over the microphone from the Imam. Then, after a few minutes, the roadside is a bustling, noisy thoroughfare again.

Soon, an old French army Land Cruiser with it's all important yellow license plate pulls up. Out jump two Chadians I've never seen before. We greet each other and they get to work. A mass of rope is pulled out and quickly untangled and doubled then quadrupled and lashed from a hook on the front of my van to the rear bumper of the land cruiser.

"You, go forward. Me, I drive." The man says in poor French with a heavy Arabic accent. I oblige, having not really wanted the daunting task of driving a car being towed by a rope on roads barely wide enough for two vehicles and crowded with broken down trucks, cows, goats, pigs, pedestrians and bicycles and motorcycles weaving in and out amongst the whole mess. Not to mention the potholes.

And so, without even a look back or a fond farewell, I say goodbye to my roadside friends.

Timing

2010-11-09T01:30:00.002+01:00

Bad timing. Just when I really needed it, the van refuses to start. So much for the "scalded dog." I really need to go to N'Djamena to get the two new doctors from Congo their work permits. The local Police Commissioner has volunteered to help (for a small per diem of $80/day) and we can't refuse. His brother is second in command at the Police Headquarters in the capital that hands these things out. If he goes with us, we get the visas easily. If we refuse his help, he calls up his brother to slow the whole process down or even refuse.

I send them on ahead. I'm sure the van can be easily fixed. It was running perfectly when I parked it last Friday. Besides, Jamie's back and knows this car backwards and forwards.

All Monday passes and Jamie and I can't figure out why it won't run. We check everything we can think of. There's good compression, spark, fuel getting to the carburetor, etc but it doesn't want to start.

"I have a feeling I wasn't supposed to travel today, Jamie." I say with a touch of frustration. "Maybe one day we'll realize why. It must not be the right time."

I go home and go to sleep early. I must have fallen deeply asleep because when I finally hear the banging on the door I am totally disoriented in the dark room, barely lit by a pale blue bug lamp.

"Yeah, hallo." I shout groggily out the window in the general direction of the screened in porch's door. "C'est qui?"

"Hey, it's me, Cory." I recognize Jamie's son's voice. "Brichelle, is really sick in a lot of pain in her stomach and she's been vomiting. We tried to bring her to you first but no one answered our knock. She's at the hospital, can you come quickly.

I sense the urgency in Cory's voice and as I slip on the slightly used scrubs hanging over the end of the bed I wonder how I could've missed the knock. I must be getting out of my light sleeper mode. For seven years I've been woken up at all hours of the day and night for emergencies here in Chad and never not heard the call. At least until recently. This is the second time now in the last few weeks that I've slept through someone banging on my door.

I walk into the ER and Tchibtchang points me to the cubicle where Brichelle, Jamie's young teenage daughter lies in obvious discomfort. The signs and symptoms are classic for acute appendicitis. Even in my groggy state of trying to wake up, I recognize that. But the words come out kind of heavy. I must not have been very convincing because Tammy laughs loudly and hollowly, desperately hoping she misheard.

"Are you kidding? Appendicitis!?" I definitely would've woken up to that voice. "James, what does that mean...?"

"Well, I'm serious. She has acute appendicitis and the only treatment is an operation."

I can see Tammy is taking this hard, but Brichelle is calm and seems to just be glad that something is going to be done immediately for her severe pain. I call in Samedi, Simeon and Abel as we take Brichelle to the OR. Tammy accompanies us inside and makes sure that things are kept modest. Samedi arrives first and sits to start an IV on her right arm. I take the left and am happy to see she has great veins. I don't want to mess this one up. But I do, twice missing fat veins right in front of my face. Meanwhile, Samedi has the other IV up and running so I motion him over and he quickly finds the second IV and starts to give the antibiotics. Abel and Simeon are there but now there's the problem of the urinary catheter. Tammy has promised Brichelle privacy but there are only male nurses and doctors. We send Cory to the other side of town to get Wendy.

Meanwhile, we've prepped the OR, prepared the instruments and Samedi has scrubbed. Brichelle is on the OR table and we've given her Diazepam to relax her. We can't wait for the catheter. Then I remember, Lucie's on duty. She's not one of our best nurses, but I'm pretty sure she can put in a foley catheter. Besides, I'll be there to supervise. Lucie comes immediately and gets the urinary catheter in quickly, just as Wendy arrives.

I scrub and Samedi helps me on with gown and gloves. We drape the abdomen. It feels weird to have white skin under the drape. As I make my small incision in her right lower quadrant, I notice how even though the surface looks so different, just millimeters in under the slight pressure of a sharp scalpel and the blood, fat, muscle, and other tissues is exactly the same on black and white. I've made my incision a little high so I have to dig down to find where small and large bowel join until finally an inflamed appendix pops into view. I quickly clamp and tie the vessels and the stump after amputating that weird little intestinal appendage. I sew up the fascia, subcutaneous tissues and skin and apply some dermabond over the subcuticular suture.

The next morning, I go to see her at the hospital before getting on the public bus for N'Djamena. If not for the bad timing of having the car not start I wouldn't have been there to operate on Brichelle. That evening she goes home and rapidly recovers.

A week later, Jamie and Gary having exhausted their vast reserve of mechanical knowledge without success, the van still isn't running. It's a big mystery. Saturday morning I get a call from the vice-president of Chad's constitutional advisors. I met him a couple weeks ago. He is Muslim and a true believer. We talked about God for over an hour as he invited us to come to his village near the Sudanese border and look into helping his people in the area of health care. He tells me he's talked to the sultan who is excited to meet us. Can I come sometime this week?

So, I need a way to get to N'Djamena quickly as our meeting is tomorrow at noon. Jamie calls Maccabé, a local mechanic from Kelo who's helped him before. We go over the engine from top to bottom again. He's found a few things he thinks are wrong and assures me the car will start. We get it all put back together, and no change. Just as I'm about to throw in the towel, Maccabé reaches for the distributor.

"Have they checked this out?" Before I can reply that "Yes, of course we have..." Maccabé has reached under with a wrench and loosened it up. He puts the key in the ignition and starts up the car. With a little twist of the distributor, the engine roars to life. It looks like the timing of the spark plug firing was a little off. A few more adjustments and the vehicle is ready to go for my early departure tomorrow.

Imagine that, it was all about timing...=

CATS

2010-11-06T13:59:00.003+01:00

I'm lying on the floor. It's my back again. After a long day as a tall person in world made for short people the only relief I get is stretching out on the cold cement floor. Our newest little companion, Garfield, is lying on my chest purring contentedly. He's finally stopped whining and meowing now that he feels he's the center of my attention.

I'm waiting for them to call me from the hospital. A young man previously operated on in April 2006 is back with a swollen tender belly...all the signs of intestinal obstruction. I fill out the OR sheet and send the family to the Pharmacy. They say they need to wait for the boy's father. So I finish the rest of my work and come home. Koumabas, the pharmacist, comes in the late afternoon to say the father has come but he's not sure he wants the operation. I walk over there and call the father into my office. He says his son has been operated on already two times, he's not sure about this time. Besides, he says it's too expensive. I look at what has been calculated for the surgery, anesthesia, hospitalization and post-op care: $145. It seems a bit steep to me too. I have Koumabas recalculate. We have two different payment scales. If the patient is in our health district they pay half of what the others pay. It seems, they didn't know he was from Bere. We recalculate: $110. He seems more agreeable and says he'll sell some bags of peanuts in the market tomorrow and pay us if we can wait.

I explain to him that it's urgent, his son needs an operation yesterday. He says he has a motorcycle, but his "brother" took it to the market. I tell Koumabas that when he comes back he should fill out the forms, call the OR team and when the patient is ready have them come and get me.

So, I'm lying with a kitten on my lap on a cool cement floor waiting. A knock comes on the door.

"Oui?"

"Hey, it's Cory, we're having worship at our house later on."

"When?"

"What time is it?"

"6:30."

"Ok, in half an hour or so?"

"Sure."

I get up and straighten up the house and do the dishes. 7:00pm comes and still no call from the hospital. I go over to Cory's. After half an hour or so of beating on a drum, mostly in rhythm with Philip's guitar playing, I figure I better go find out what's going on. As I go outside, I see our original cat, Erling, waiting for me. He follows me to the gate but is impatient and jumps up the wall and through the chain link while I fiddle with the padlock. He rolls around in the grass begging for some attention. I pet him for a few seconds, but have more important things to do. I find Koumabas.

"Salut, ca va? What's up with the OR case?"

"Abel and Enock came, but Simeon is out 20km away in his rice field so they went home to wait for Simeon. I tried to call Samedi, his phone is shut off."

I go to see the young man.

"Have you pooped? Farted?"

"No."

"Ok, come with me."

He slowly gets up and shuffles behind me, his nasogastric tube hanging limply from his right nostril without any collection bag attached, just a little green, bilious fluid resting in the curve of the tube.

I open the OR and place him on a gurney. The generator is already on so I flip on the A/C in the OR so it can cool down from the day's heat and grab an IV catheter, some IV tubing, a bottle of normal saline and a bottle of Metronidazole.

I turn on the dental light adapted as a minor procedure light in the prep room, attach a tourniquet and am pleased to see many nice fat veins pop up on our young patient's arm. I see a monstrous one in the depression on the opposite side of his elbow and figure I'll go for that since there's no way I can miss it. I blow it. I undo the tourniquet, have the youth hold pressure with cotton and find another catheter. I put the tourniquet back on and this time nail a much smaller vein.

As I'm preparing to put in the urine catheter, Samedi shows up followed shortly thereafter by Enock and Abel. Just as I'm getting ready to do the spinal, Simeon arrives and I begin to breath easier now that we have a full OR team. Samedi and Abel scrub and prepare the instruments. I scrub and we drape the patient after Enoch has slathered him in Betadine. After prayer, I decide to start in his lower abdomen. I follow the old scar from his pelvis to his belly button. Swollen small bowel wants to burst out. Many sections are stuck to the abdominal wall and everything is swollen and oozes easily. We are mopping up inflammatory fluid and blood which obscures the surgical field as I try to dissect the small bowel off the abdominal wall so I can open the rest of the belly.

Finally, I'm able to start running the bowel and I find a section that had been cut off by adhesions from the previous surgery and there's a small necrotic section. I try and free up the adhesion but it's impossible. I clamp it off and take out the bad section. I then call for a sterile basin and open up the end of the bowel that is distended. Liquid stool and gas almost explodes out. Samedi and I find the most proximal part possible and with our fingers gently squeeze the stool and gas towards where the bowel is open until we've cleared out almost three liters of watery stool. I clamp the bowel again, Enock takes the basin off the field, we irrigate and place the intestines back in the abdomen. I get a fresh lap sponge under the cut section of intestine and slowly suture it back together in two layers.

We irrigate again with several liters of fluid, place two drains and close the fascia leaving the skin open. I'm exhausted and slip to the OR floor resting against the wall as the others clean up. I then help them transfer the patient to the gurney, turn off the A/C, water pump and OR lights before switching off the generator, and head home.

Erling is waiting for me and I give him the love he deserves before heading home, the cat scampering ahead and then waiting for me until we get to the house. He slips in and then meows as I go inside to get him some peanut clusters. Erling is afraid of Garfield and our other cat Chir, so he stays on the porch crunching happily on his dried peanut paste. I take a shower and then stretch out on the floor again to ease my aching back.

Garfield comes gingerly over, meowing plaintively. I grab him around the chest and place him on my stomach. He curls up contentedly and starts purring as his eyes open and close as only happy cats do.

MUD

2010-10-19T03:28:00.003+01:00

I set up a cell saver and autotransfuseur kit that I found in the back stockroom covered in rat poop. Fortunately, the heavy plastic sealing it's sterility was intact. Simeon searches for a second IV. We give her a spinal anesthetic. The scalpel quickly reveals dark, uncoagulated blood that we suction into the cell saver to give back to the girl later. I scoop out mounds and handfuls of placenta and blood clots finally isolating her right adnexa which I remove between stick ties. I leave in a drain and we start the autotransfusion as well as a bag of O+ blood from the little fridge that serves as our blood bank.

It's now a little after 6 AM. By 6:30AM Ndilbe, one of our nursing students, and I are on the road in the old Hiace mini-bus affectionately known as "scalded dog." I'd just brought it back through a round about road through the bush that was really bumpy but had no water. The main road is still covered with water where the hippos hang out and so people and motorcycles are ferried along the road in dugout canoes. Needless to say, "Scalded Dog" doesn't want to go there. Last night, someone told me of a shorter route that is passable as well. I try to find it. Right after the bridge I turn left at the flag pole and wind through the village until coming to a Y in the road. I'd come from the left last week so I assume the right one is the short cut.

This road is not only shorter, but it's flat, packed sand and we're able to make good time until I come to a 30 foot section of mud. I make a bad decision. I go right and am soon stuck and spinning deeper and deeper in despite four wheel drive. The right front wheel is deep in some watery, slippery clay mud lifting the back left tire up onto some other slippery mud taking the weight off it so neither of the two that are spinning are getting any traction. Ndilbe and I get down and get dirty. We shove sticks underneath, try and scoop out mud. try going forward and try going back. We're in the deep bush and don't see anyone around.

We try our futile efforts for 10 more minutes until we spot an old man coming out of the bush on the road and heading away from us. We call him back and he waddles slowly over. Meanwhile, a middle age, stocky man comes up from nowhere headed to his field with his throwing knife hanging casually over his shoulder. He dives right in and starts hacking away the earth that has stopped up under the axle. He is soon covered with the gray, slimy mess. Before we know it we are surrounded by 10 stout farmers who all just get busy. We push, we lift, we dig, we stuff things under the tires. Finally, we lift the entire care up and stuff branches under the right front tire. Then I put it in 4-wheel low. The same thing starts, just spinning. Then I turn the wheel a little left and with a big push from everyone behind it starts to get traction and then inches slowly out of the mud and onto solid sand.

I think them profusely and hand them two 2000 franc notes to split amongst themselves. They wave good bye and we're on our way.

Just think, if I the woman hadn't of showed up just right before I was going to leave, she probably would've died and as a bonus, our leaving late allowed us to get stuck just in time for the farmers to be on the road heading to their fields! I drive on through the tall grasses and narrow tire ruts in the sand with a silly smirk on my face as I reach into the plastic pail and pull out a square of watermelon.

ALONE

2010-10-16T20:27:00.000+01:00

I sit on the stool in the prep room. My whole body slumps. I stare at the concrete floor. The odor of sweat, blood and chlorine wafts gently towards me. I'm vaguely aware of Simeon and Abel moving past, taking a patient out; moving another in. I don't know if I can get off the stool. I just did a hernia and I don't remember much. My mind was elsewhere. I think I did it well. I hope so, it's one of our employees.

That morning started off alright. I woke up early, took the horses out to graze. I played a few songs on my much neglected guitar. I ate leftover garbanzos and rice. I guess things fell apart when I went to do rounds...

I walk into the courtyard and see two heavily turbaned men walking out with one of our patients' sons. I have a hunch. I call them over and ask them to return to whichever patient they were visiting. See we have a policy that only two family members can stay with each patient except during visiting hours from 3pm to 6pm. We've tried everything to enforce it but it's been a seven year battle. Our most recent strategy is to charge the extra family or friends a $2 overnight fee or fine. It's worked pretty well. Not on these guys though. The argument starts up almost immediately in Arabic.

"You are five with the patient, you are only allowed two."

"Yeah, we just came to visit we're on our way out."

"Do you know when visiting hours are?"

"We just came this morning. We're leaving."

"Now you have to pay a fine because visiting hours aren't until the afternoon."

"We have no money, we're just going now."

"How did you get in?"

"The gatekeeper let us in."

"Did you tell him you were visitors?"

"The other one maybe, not me."

"Yes, they told me they were sick and wanted to get consulted," adds the gatekeeper who's standing right there.

"I don't know, pardon, excuse us...we're going."

"Ok, I forgive you, now go pay the fine."

And on and on in never-ending circles goes the conversation.

Finally, I'm called to see a sick kid in the ER. I tell the gatekeeper not to let anyone in or out until we solve this problem. If they pay the fine, they can go. Five minutes later I come out of the ER in time to see about 20 people flowing in the open gate and the two men claiming to have no money hopping on their new motorcycle and taking off. In my head I can hear them mocking me the whole way home.

It seems silly, but somehow it's symbolic to me. I've been going round and round with this for seven years of staff members telling me it's good to have order in the hospital and respect the rules but no one enforcing except me occasionally creating unnecessary conflicts that drain my spirits. Yet I somehow feel compelled to keep trying. Today, as I do the hernia, though, I can think of nothing but despair and darkness as I think of the hopelessness of anything changing in this twisted world.

So, I sit on the stool. I don't know if I can get off it. Simeon comes up.

"We're ready for the next case."

Somehow, I lift my heavy limbs off the chair and shuffle in. The woman has a large tumor at the end of a pendulous breast reaching to her belly button. I'm not in the mood for careful dissection and a long, drawn out procedure. I stretch the breast out straight off the chest, attach two allis clamps at either end and N'Dilbe stretches the clamps out. I slash through, taking off the breast and mass in 4 or 5 strokes of the scalpel as large arteries squirt out blood everywhere including a major one that smacks me in the forehead and spatters my OR glasses. N'Dilbe holds compresses on the wound as I reach for clamps and clamp off all the blood vessels as the drape gets soaked with blood. It's over in a few seconds. Then I tie them all off and suture it closed. I'm in automatic mode.

My ankle is killing me. I got a rope burn on the opposite side of the ankle where I had the almost year long tropical ulcer that wouldn't heal. I fear it's twin has shown up. My ankle has been swelling up off and on over the last two weeks with red, painful skin all around. When I'm on my feet to long, especially in the OR, I can hardly walk for the pain. I limp home, throw a pillow on the concrete floor and lie there with my leg elevated on the couch. I stare at the ceiling as sweat makes my back stick to the cement.

I forget what drags me back up to see some of the patients. Somehow 2pm arrives and Samedi reminds me I've called a committee meeting. Great, just what I need. I somehow get through it without letting my anger and frustration show too much. I go back to a house empty except for two cats. I lie down all evening but can't get comfortable as my thin frame rests on the hard concrete. My neck hurts. I take some pain killers, brush my teeth and crawl into bed.

Outside the window, on the street by the fence a group of kids is yelling, screaming and laughing harshly and forced. Most parents let their kids run around wild like little goat kids. There's a bright moon and the under 10 party is happening a few meters away. I slip on some cut off scrubs, put my sore ankle into a worn out Croc, grab a stick and a head lamp and head to the gate. I slip out and dark little shapes are milling around me. I start swinging the stick indiscriminately and feel several resounding "thwacks" followed by small yelps as the crowd runs off quickly.

After yelling a little at all the teenagers and adults just sitting around watching, doing nothing I stumble back into the darkness of my house lit only by a bug lamp. I can't feel anything. Deep down I have a sense that at this moment I'm not the model missionary, but after seven years of seeing and participating in extreme suffering and poverty and ignorance I really could care less. I try to pray and read something uplifting but I still feel empty.

I'll probably feel better tomorrow...

Twice

2010-10-08T02:33:00.003+01:00

I somehow feel like I'm missing something but I don't know what. The old man's belly sure gave me reason to think I needed to operate. He had a hernia and talked about it coming out and hurting a lot before he finally stuffed it back in. I thought maybe he had some necrotic bowel or something. His belly was certainly swollen and tender and he'd had no stool for 6 days and no gas for one day.

But now I've opened up a small hole in his abdomen big enough to both get a good look and fit my hand inside to explore with tactile sensation. There's no fluid, no pus, no stool no blood. All the intestines look pink, healthy and clean. The appendix is normal. I run the small bowel which is slightly distended distally but peters off to normal proximally with no twisted areas, no masses, no holes, nothing. The large bowel is quite distended but soft with no lesions or masses that I can see or feel. Maybe it's just constipation after all. It won't be the first time I've operated on severe constipation. But something just doesn't feel right. Against my nagging feelings I close up and then proceed to fix his hernia.

At the end, I clear out his rectum and give him several liters of enema which washes out some hard stool but not much. I hope that will stimulate things. He had a fever so maybe it's just an ileus from malaria.

Everyday for three days I keep hoping I'm right, but he still has no stool or gas and vomits frequently. I can't get the idea out of my head that I've missed an obstructing colon cancer. I hadn't thought of it at the time, until afterwards. I'm wishy washy and don't want to take an old man back to surgery so soon. He looks so frail. I go home. Maybe tomorrow he'll have regained bowel function. My hopes don't comfort me much.

At midnight, Faka, one of the nurses is at the door.

"His belly is really tense, he's vomiting," he says. "I think you should come see him."

"No, just call the OR team," I reply. "We have to take him back to surgery.

I reopen the lower abdominal wound and swollen small bowel spills out. I enlarge the midline incision all the way up to his chest and really explore as Samedi holds the eviscerated bowel covered with lap sponges to keep it from falling off. Abel retracts the lower abdominal muscles away so can get a good look. Still nothing is obvious, but this time I'm a little more thorough and since I'm looking for cancer now, I find it. His sigmoid colon has a small hard mass right in the center of it that is obstructing the flow of stool and gas.

I clamp off the bowel, clamp and tie off the blood vessels and remove the mass. I painstakingly sew the two sections of colon together with two layers of sutures and release the bowel clamps. No leakage. I realize I'll have a hard time closing the abdomen with the swollen small intestine and it would speed recovery of function if I emptied them. It seems like a good idea at the time.

I tie a purse string around where I want to make the hole and get the suction catheter ready. I incise the bowel wall but the suction gets plugged up with a hard chunk and stool starts to spill out everywhere contaminating everything. I quickly try to block the flow with my fingers and get Samedi to hold it while I clear off the suction. It keeps getting blocked so I call for a basin. We don't have any sterile ones, but then we are no longer in a sterile field anyway. I grab the basin and just let the stool pour into it instead of the abdomen. Samedi and I milk the still down from both sides of the hole until the intestines are relatively empty and we have a couple of liters of stool in the basin. I hand it off, wash off my gloves in bleach water and then suture up the hole in the intestine with the previously placed purse string followed by another layer over it. We copiously irrigate the intestines and the entire abdomen with sterile saline until everything looks really clean and we've diluted the pollution.

I insert two drains in the deepest portions of the abdomen to drain off any excess contamination and close up. We then dilate his anus and evacuate much more green liquid badness into the plastic basin until his belly is actually flat and matches the rest of his lean body. I place him on antibiotics and IV fluids and with a final prayer go home 4 hours later.

Arriving home, the adrenaline starts to wear off and I notice my ankle is swollen, red and hot around the rope burn I got 3 days ago. I take some antibiotics myself, soak and elevate it but can't go in to work the next day. Today I hobble out a little and go to see my old man. He's lying in bed asleep. He looks kind of bad but when I shake him awake, his eyes alertly open and he shakes my hand in a firm grip.

"Can I have some tea?" He asks.

His family laughs and says that since yesterday that's all he's wanted. He's a big tea drinker at home, apparently.

"Ok, you can have tea," I reply through the interpretation of the nurse from French into Ngambai. "But only if you sit up."

Despite no pain meds except Tylenol and Ibuprofen on a huge abdominal incision, he lifts himself up with only a little help and looks at me defiantly as I ask the family to bring him porridge and tea.

I examine the wound which is clean. The drains have only clear fluid in them and he has had regular bowel movements 3 times since surgery. As the family hands him the porridge he slurps it up hungrily before spitting out the chunks of rice he doesn't like.

I think he's going to be ok.

Ecodome Chad

2010-10-03T13:40:00.009+01:00

I stand in the darkness of the hut and tears stream down my sunburned, dirt caked cheeks. My body has reached it's limits and now my spirit has too. I've been living and working in an African village in Eastern Chad for a week now. My bed has been the packed earth of the village chief's courtyard. My food has been left over rice sweetened with a little sugar and peanut oil interspersed with a few cucumbers and the occasional boiled goat organs. My shirt has been the same one I've worn every day out on the construction site and it's ripeness cannot be described, only experienced.

I came out packed like a sardine with 5 other large Americans and a Chadian chauffeur named Issa Mahamat (Jesus Mohammed) over 900km of mostly bad subsaharan roads on a trip that lasted over 14 hours. That night I call Mahamat Saleh Abakar, our host and patron, to inform him of our safe arrival at his house in Abeche. He is his usual jovial self. I have no indication of the tragic news that will awaken me next morning before 6am. Arlo leans into my mosquito net and with a quavering voice gives me the bad news.

"James, Mahamat Saleh is dead."

"What?" I'm still groggy and wonder if I'm in dream land until the sobs and wails coming from around the courtyard jolt me awake. "Are you serious?"

"Yeah, we just got a call from N'Djamena. He went to open the mosque at 4am and then, after praying went back to bed. He never woke up. They found him cold."

I get up and move out onto the sand of the courtyard towards the short brick wall separating it from the walkway to other parts of the compound. Issa Mahamat comes up to me with tears in his eyes.

"Mahamat Saleh mot," he bemoans in Arabic as he shakes his head in disbelief.

I'm assured later by the family that this won't undermine the project but that the whole family is behind us in the creation of this health center. We pick up the "Chef de Terre" (Land Chief) of the area who accompanies us out to the village where we are introduced to the chief and his second in command. We set up camp and go out to the job site where Arlo has already dug the foundations for the Ecodome we will hopefully build in the next week.

Monday I am occupied with visiting local authorities back in Abeche while the team gets working. Arlo has identified three locals, Naim, Aimé and Richard who we will soon realize are indispensable for the success of this project. They are not only amazingly hard workers but are of impeccable character. Naim especially always has a smile on his face as he motivates the local workers to move ever faster and stronger. Then as we rest in the unbearable midday heat he prepares our simple fare along with the obligatory tea. Later he helps translate, count out and distribute pills and make it possible for me to see hundreds of patients at night after our evening work session. He is tireless, humble and dedicated to his faith. None of all these responsabilities can make him miss even one of his five daily prayers. He studied Arabic in the university and can read and write it fluently as well us understand completely the Qur'an. Like any true student of the Qur'an he was led to study the other ancient scriptures as well and is familiar with the Injil and the teachings of Jesus. While at the university, he organized a dramatic troupe to do street theater to promote social awareness, health principles and to point out corruption at the hospital and elsewhere. He is one of those men in whom one instantly recognizes veiled greatness.

Aimé and Richard are quieter and more subdued yet no less hard working and dedicated in all areas of life.

Wednesday I am on the wall filling a superadobe bag and I suddenly feel as if have no strength. I'd had diarrhea once that morning but no other symptoms. Now my whole body is aching and my skin is on fire. I am drained. I manage to finish the row and then wobble down the hill to the cattle watering hole where I jump in after stripping off down to my underwear. I find temporary relief in the coolness of the shallow muddy pond. I go back to the compound and am flat out on my back for the next two days. I start treatment with antibiotics and Flagyl for amebas. I've used up all my malaria medication in treating sick kids in the village. I send someone Thursday into Abeche to buy me some and after one treatment that evening am feeling better the next day.

I have seen such suffering. No clean water, hardly any food, sick kids with pus filled eyes everywhere. Malaria, diarrhea, skin wounds, blind adults from cataracts. My simple supply of pills is soon gone and the needs are overwhelming. I get more in Abeche on Friday and that night see 50 of the 130 signed up to see me. I have no where to consult but on a mat, often with a flashlight to guide me and Naim and the village chief at my side as assistants. Saturday afternoon, I try to see the almost 100 that remain. As it gets dark I go to get my headlamp and it's gone. I flip out. Exhaustion has taken it's toll. I pack up what little meds remain and close shop. Many have come from miles away to see me. My missing head lamp just gives me an excuse to escape from the overwhelming needs that have pushed my body to it's limits.

That morning, we'd decided to hike to and climb a nearby mountain. We almost died of heat exhaustion. One of our group, Brian, had to turn back early. On the way back on a simple path through the millet fields we hear a voice thundering from under a nearby tree.

"Don't come over here unless you want to get naked and wait till the moon comes out." I glance over and see a hairy, naked body leaning with one arm casually against the trunk. Fortunately, the intervening millet stalks blur the details. In our own delirious state, none of us thinks it abnormal as we are just trying to survive ourselves. We wave goodbye and continue back to the village. It's only after downing a few liters of water and some porridge that I start to panic. We sort of realized that it wasn't good so we'd sent out Issa Mahamat and Naim along with Brian's son, Bradon in the truck to try and find him.

The locals are chastising us for our carelessness. The truck comes back with out Brian. Naim and Issa are covered from head to foot in sand. The car got stuck in the sand and had to be dug out. We head out again. I hope I can find that tree again and that Brian hasn't moved. We finally find the small path and sure enough there's Brian still under the tree. He was smart enough to recognize his limits and stayed out of the sun and heat thus saving his life.

So, Saturday night, I'm exhausted from working all week, having amebas and malaria, almost dying of heat stroke, not eating enough and seeing too much suffering. So, I find myself standing in the dark crying, bemoaning my weakness yet feeling at the end of my resources. These people have lived like this their whole lives and I am done after a week. And now I've turned away dozens of suffering people because I just can't go on.

"Father God, forgive me my weakness, only you can make me strong."

Shadow Proves the Sunshine

2010-09-03T02:53:00.005+01:00

I never thought I'd be jealous of Pierre's parka. I didn't think it possible, but the tingling in my fingertips is making me wonder if frostbite is possible in sub-saharan Africa. The goose bumps on my arms, the ache in my legs from too much shivering and the chattering of my teeth under my beanie assure me that it is related to cold. It probably doesn't help that I'm only wearing sandals, cargo pants and a scrub shirt that are all soaked with rain and spattered with mud.

I'm staring at the smattering of white hairs in Abakar's almost shaven head just inches from my rain spattered glasses. His bare arms are thin as he whines out the motorcycle engine, plowing fearlessly through mud puddles up to our seats at times. As we slip and slide and almost fall several times, his only response is a hearty chuckle and a shaking of the head.

We'd left Moundou early this morning in a pounding thunderstorm beating ferociously on the old Toyota mini-bus. My mind flashes back to Youlou's funeral yesterday evening.

Anatole, Tchibtchang, Christophe, Youlou's cook and I turn down a muddy street in Moundou and stop in front of a brick wall near a sign that says "The Dove, Medical Care Center" with a picture of the young Youlou, untouched by the neck cancer that would almost kill him and leave him permanently scarred with a raspy voice from surgery and radiation. We enter the courtyard where twisted sticks have been pounded in the ground to support tarps over numerous mats and a few chairs for the well wishers. We solemnly greet all those present.

We sit down. I feel extremely sad. Anatole explains that we wanted to come sooner but an early morning rain and lack of a vehicle forced us to go by motorcycle later in the day. I stare at the large vein on the back of my hand. I slowly push it up and down under the pliable skin. Youlou's cook has started wailing over on the mats with the other women. Normally, I think their mourning cries are artificial and fake. Today I'm envious as they are able to let out their sorrow while I feel it weighing me down, brimming to the surface but not able to escape.

Anatole moves over to a hut where Youlou's mom waits with a couple other women. I follow him. We take off our shoes, move across the sand and onto a mat. A wrinkled, tough woman she is shaking her hands up and down and rocking back and forth, moaning. Her right hand is missing it's middle finger that has recently been amputated and is covered with a Betadine soaked elastic bandage. As Anatole starts offering his condolences in N'Gambai, I just absorb the sadness of Youlou's mom as the tears start to just brim offer and spill silently onto my arabic robes over my crossed legs. I start sniffing and use my amble sleeve as a Kleenix.

That evening we eat beans, rice and grilled meat by the light of a Kerosene lamp on wooden stools by the side of the night market. After finishing it off with some tea, we go to the our almost finished Surgery center, pull out some gurney mattresses and sit around laughing, joking and shooting the breeze for hours until I fall into a fitful sleep.

In Kelo the next day we find moto taxis but immediately get poured on so just before leaving town we pull under a woven mat shelter and wait out the storm. I pull some old beignets out of my back pack and we dunk them in some hot tea. I feel slightly guilty scarfing down the donuts and slurping the hot drink in front of the group of Ramadan fasting Muslim moto taxi men. One of the taxi men is our neighbor from Bere and one of my HIV patients. He's been healthy on ARVs for over three years now. He's wearing a world war two era Russian fur hat. I'm extremely jealous as I shiver in my soaked scrub shirt under the constant drip-drip of the leaking shelter.

Back to the present I see Anatole's driver's invention has fallen down and started flopping. To keep water from entering his exhaust pipe, he'd attached a length of innertube and tied it to his luggage rack so the smoke poured up Anatole's back and over his shoulder renewing his diminishing levels of carbon dioxide in his blood. Now it's fallen down and writhes around like a snake with it's head cut off, still spewing foul emissions.

At the lake where our local hippos usually reside we get off the motos and wade through almost waist deep water while the motos follow in dugout canoes. One of the canoe "drivers" is Marty, the man who was bit by the hippo in March 2004 featured in the documentary film "Unto the Ends." He greets us and it proud to show off some of his scars. He seems to be in perfect health and grins from ear to ear until I take a picture of him with Anatole upon which he transforms into the typical serious African dictator pose.

Arriving in Bere, my Muslim driver breathes out a prayer of thanks to God as he offers one last chuckle and shake of his head. The sun is shining and I'm almost warmed up on the outside but completely renewed on the inside.

Gone

2010-09-01T00:40:00.001+01:00

Youlou's gone. Sunday morning. Barely responsive. Tubes sticking out everywhere. No family. Brother arrives. Call from Moundou. Cousin's a doctor. Knows him well. Has treated for years. Yes, HIV+, he knows. Evacuate. Ambulance arrives. Put Youlou on a stretcher. Out the door. In the Land Cruiser. Anatole and Augustin accompany. Gone.

The baby's gone. Bottle feeding. Changing poopy rags. Burping. Soothing. Sweet. Calm. Sunday evening. Mother's still denying. Local chief comes. Doesn't recognize. Operated patient does. My mother's relative. She's coming. Washes. Feeds. Mom sitting up. Drinks. New wrap. Uncle will come. 50 kilometers away. One more evening. Crying. Washing. Preparing milk. Sucking bottle. Morning. Knock, knock. This is the uncle. Over to Augustin's. Baby brought out. Sit in chairs. Recount stories. Mom AWOL. Family unaware. Went to market. Never came back. Gone.

Baby in box. Take out. Give to uncle. Merci beaucoup. Gone.

Monday afternoon. Woman in labor. Not progressing. Husband demands surgery. We stall. No progress. To the OR. Prep and scrub. Fat baby. Cries. Uterus closed easily. No complications. Back to ward. Wash hands. Go home. Evening. Oscar comes. Knock, knock. Breathing gone.

Rush. Run. Don't look panicked. Pupils dilated. Inner eyelids pale. No blood. No pulse. Occasional gasp. Chest compressions. Oscar take over! Call Delfine! Get a gurney! Run to OR. Scramble for Adrenaline. Nursing student! Draw up adrenaline. Broke and spilled. Take another. Broke again. Another. Finally. IV push. Heart beat. A little pulse. Push on chest. Air moves in. And out. Dump on stretcher. Run to OR. Open fridge. Take blood. O negative. Cold. Run it in. More adrenaline. Delfine! Another IV! Call lab. Blood type. Anatole comes. Blood sugar. Normal. Breathing on own. Heart beat. 140 per minute. No blood pressure. Oxygen sats normal. More blood. Hydrocortisone. Stop adrenaline drip. IV fluids. No urine output. One hour. Breathing well. Out to ward. Stress gone.

Move to bed. Woman speaks. Wants to sit up. Turn around. Crank handle. Raise head. Breathing bad. No pulse. No heartbeat. Adrenaline twice. Gone.

Tuesday morning. Call from Moundou. Youlou. Getting better. Coma gone.

Tuesday evening. Ring, ring. Anatole. 6:30pm. Youlou dead. Gone.

Knock, knock. Anatole. Samedi. Come in. Sit down. Have some tea. Almost seven years. Hundreds of deaths. Samedi, over 30 years. Anatole over 25 years. Cholera. Liquid diarrhea. Up to knees. Wear boots. 1996 epidemic. Family won't help. 24 perfusions. Doxycycline. Doctors without borders. Money. In other's hands. Gone. Only Samedi and Anatole. Bury the dead. Stuff cotton in nose, mouth, anus. Even at night. Family doesn't help. Only Samedi and Anatole. 24 hours a day. Three months. Never got sick. Many others gone.

Measles epidemic. 1987. Samedi. Four children. Measles. Family emphatic. Don't treat. Samedi ignores. Penicillin for each. Eye drops. Citrus. All live. Many patients. Hospital full. Father of four. Loses two today. Loses two tomorrow. All gone.

1983. Black September. Curfew. Anatole and friend. Thrown in jail. Come out. Beat or killed. Three days. Finally released. Village of Bere. Hospital empty. Village gone. Samedi in one house. Anatole in another. No electricity. By themselves. Protecting. Watching. Guarding. Anatole gone. Samedi 24 hours a day. One week. No one else. Next week. Anatole alone. Doctor taken hostage. Samedi captured. Night. African bush. Military. We'll kill. Who's that? We're with you. Who's that? Nurse. Samedi? Let him go. Samedi runs. Gone.

Funeral. Youlou. Tomorrow. Let's go. Ok. Good night. Walk to gate. Laugh. Why are we alive? My brother dead. Same car. I'm alive. Anatole and Samedi. Alive. Back to house. Stars. Cloudless sky. No moon. Tears flow. Sobs wrack. So many...gone.

Unwanted

2010-08-28T21:34:00.002+01:00

It's the barking that first wakes me up. Of course, I'd just fallen asleep. Is Caramel just barking at shadows or is there a nurse at the door. Then I hear the sound that has replaced the fear-provoking sound of my residency pager: the gentle "tap, tap, tap" of a finger on a sheet metal door.

I roll out of bed trying not to disturb Sarah (as if she could sleep through the racket), pull on some scrub pants and head out to the porch. A headlamp outside the scree confirms my suspicions: they want me at the hospital.

It's Oscar, one of our new nurses. He did several nursing school rotations at our hospital and was always one of the sharpest students. The problem is that he still looks like a student, a junior high student. It doesn't help that his one lazy eye always makes you wonder if he's really looking at you or not.

"We just got a case referred from the health center," Oscar begins holding out a small piece of paper with some scribbling and the ink from a rubber stamp marking it as official. "Femme psychose." I have to have him repeat it and then finally look at the paper where I recognize that the patient is referred for being a "female psychosis."

"She's nine month's pregnant and is crazy," Oscar continues. "She won't let any of us examine her. The baby's head is half way out but she just writhes and shrieks and doesn't push."

"Ok, ok, I'm coming." I go back inside, pull on a dirty scrub shirt, grab my flashlight and keys and walk back out under the full moon.

As I enter labor and delivery, I see a crowd of nurses and nursing students standing around laughing and joking just beyond the curtain that separates our one delivery bed from the three postpartum beds. The woman is quite large, looks young and has a blank stare on her face as she gazes at the wall, her back arched behind her and her obviously pregnant belly shoved out proudly in front.

I send everyone else out except Delfine, the nurse responsible for labor and delivery this evening. I go over to the side of the bed where the young woman is staring.

"Lapia." I greet her. She rambles something off in Nangjere that I don't understand.

"Bebe gei age." I tell her the baby wants to come out.

"Bebe kang ddi." She denies that there is a baby. I decide not to provoke her. I'm not sure what to do. If I even try to come close to touch her she screams, tenses up and pulls away.

"I have to poop!" The girl continues in Nangjere.

"Ok, go ahead," I place a bed pan under her. "Do it in here."

She pushes it away indifferently. I put some gloves on, still uncertain as to how to proceed. I can't really knock her out because the baby's respiration will be depressed. Yet at the same time, I'm worried that the baby's oxygen is being compromised by his not coming out fast enough. What to do?

Every time the woman has contractions she stretches out her legs, squeezes her buttocks and arches her back: not the classic pushing technique I remember from medical school. Amazingly, after a couple more contractions she actually pushes the head all the way out. Even more remarkable, she turns on her back, spreads her legs and allows me to grab the head and pull the baby out. He is curled up, great tone and starts to scream immediately. I clamp and cut the cord and give the baby to Delfine. Fortunately, the mother is still being slightly accommodating and the placenta delivers almost immediately. Plus she has no tears and her uterus is well contracted with no bleeding so we don't have to touch the mom and freak her out.

As I turn back to the baby, Delfine is finishing tying off the cord. We dry him off as best we can and wrap him in the only thing the mother has available: her head scarf. I go to present him to his mom and she turns away, again denying that she has a child. Now what? I call in Anatole who happens to be there with one of our staff members who is sick. He tries to talk to her in Nangjere and Ngambai but just gets nonsense replies. Still, none of her family has shown up, which is unusual in Africa. I pick up the baby in my arms and go to see Augustin, our administrator. He calls up the health center that referred her. As he talks to them, one of his family, a young teenage girl has taken the newborn from me and is cooing and giggling at him in the chair across the room.

"The woman you referred has delivered, but no family has shown up and she doesn't want the baby. What's the story?"

Apparently, she came from a village down the road called Dabegue. She just showed up and was so uncooperative that the nurse at the health center put her on his motorcycle and dumped her at the hospital. That's all they know. And no one has shown up for her there either. One of the other nurses on duty, Seraphim, is from Dabegue. I take the child back and go to see him in the pediatric ward.

"Seraphim, there's this crazy woman from Dabegue who just delivered, is all alone and doesn't want her baby. I'm trying to figure out what to do with the baby. Would you mind coming and seeing if you know her?"

He agrees and we set off across the darkened campus to the Maternity ward. The woman is still staring off into space. Seraphim goes around and gets a good look at her.

"Nope, I don't know her." I try again to present the mother her baby but she turns away in indifference.

So I take the baby home. I walk into the bedroom and place the bundle by Sarah.

"Hey, look what I brought you." She half opens her eyes and in the light of the flashlight takes in the baby.

"You're kidding! What's going on?" I explain the story but tell her to go back to sleep, I'll take care of it.

I leave the package on the bed and go over to Tammy and Jamie's.

"Hey, do you guys have a bottle and some infant formula? I just brought home a baby that a mentally challenged woman doesn't want . Since she has no family with her I figured I'd keep him tonight and see what we can figure out in the morning."

Jamie comes out and chats while Tammy scurries around in the kitchen and finally comes out with a bottle and matching nipple.

"Do you have any formula as well?"

"Actually I do. I'm helping feed that orphan baby across the street and they're coming tomorrow to get the can but I guess you can use some tonight."

"Ok, thanks." I go home and put some water on the stove to heat up. I fix some formula and put the rest in a plastic storage bin, mix in some colder water until it's just right and try and wash the newborn nastiness off the little guy. I give him some formula (he doesn't want much) and then wrap him in a blanket and pack him in a cardboard box on the couch.

As I lie in bed again trying to go back to sleep only one thought enters my head: "now what?"

Tobacco

2010-08-28T01:59:00.002+01:00

"Docteur, mind if I interrupt?" Desiré pokes his head into the OR. Actually, I do mind because I'm trying to take out a large cecal mass that is hovering right on top of the major artery going down to the right leg while Sarah is trying to keep the patient alive with an Adrenaline drip.

"Yeah, go ahead," I say as I briefly look up before getting back to careful dissection. All I hear is mumbling, something about a boy and a horse and falling and a clavicle. Must be a clavicle fracture, not urgent.

"Ok, I'll come and see him later." I keep working and eventually am able to get out most of the mass and reattach the patient's small intestine to his large bowel. However, his heart rate and blood pressure keep tanking without the Adrenaline so we find a good rate for the drip, send up a quick prayer and release him out to the wards for lack of an ICU.

I've forgotten about the boy who fell off the horse until Desiré spots me from far away as I try to escape back home and calls me back to the ER.

I leave the darkness of the overcast sky to enter the even deeper obscurity of the ER who's light isn't working. I see a pre-teen boy, well formed and conscious sitting up on a dilapidated bed. He has a 5 cm open wound below his clavicle that is filled with nasty green clumps of grass or something. It's then I get the real story. He was riding from the fields with his throwing knife, fell off and stabbed himself in the upper chest. Well at least he seems to still be breathing. I go to my office and bring back my stethescope. Breath sounds seem to be equal bilaterally and he is in no respiratory distress. The wound looks deep, but maybe it didn't make it to his lungs. We take him to the OR for exploration.

After starting an IV, giving antibiotics and a sedative, I examine the wound. I pull out the clumps of dark green crushed leaves mixed with blood and dirt.

"What is this, some kind of traditional medicine?" I ask Samedi. He goes out and inquires of the family and then comes back into the OR chuckling.

"Doc, it's tobacco leaves."

I'm stunned. Tobacco? What will I see next? I try to wash it all out. The wound is deep but slanted up so it goes almost to the clavicle but not straight in thus avoiding the lung. If it would've gone any deeper it may have his the subclavian artery or vein and he'd be dead.

I leave a drain deep and close the muscle and fascia leaving the skin open with a diluted bleached soaked dressing.

I go to check on the previous patient. We have nursing students currently so I'd assigned one to take vitals every 10 minutes (exceptional for here). It's actually been done and the patient has maintained a normal heart rate and blood pressure. The IV bag is almost empty so I mix up another 500ml with 2 mg of Adrenaline and get it running at about the same rate by eyeballing it.

I leave him in God's hands.

The next morning he's talking and asking to have some water to drink.

Lies

2010-08-23T21:11:00.001+01:00

The knock on the door is all too familiar. The case is not. A well built young man in his mid twenties lies on the ER bed with his legs curled up in obvious pain. He as all the symptoms of acute appendicitis. What is unusual is that he's only been sick for three days and the excruciating pain localizing to his right lower quadrant started at 4:00 am this morning. It's just a little after 6:00 am on a Sunday. He actually came in to the hospital almost right away. He didn't wait!

I open him up with a McBurney incision and find an appendix with the last two centimeters flaming red but non-perforated. I think this is probably the first non-perforated appendicitis I've operated on in 7 years here in Chad. Unlike the others, he should have an uncomplicated recovery and go home in a couple days. As I close up the skin incision I notice through the glass block windows of the OR that outside has turned dark and I can hear the rain pounding on the tin roof. This year, the rain started early and has been consistent and heavy. I head outside to do rounds as the cool wind and rain forces everyone under shelter.

The surgery ward is saturated with complicated wounds and post-op cases or patients who've come from far away and with the rains having destroyed all roads into Bere, it is unthinkable to send them home and have them come back in a week for suture removal. We'll just have to keep them until they can go home definitively.

On the medicine ward I find a not too uncommon sight. An elderly woman is sitting on the hospital bed with an IV hanging off her arm attached to an empty bag of IV fluids that once had Quinine in it. On the floor next to her bed is a half folded mat with a baby asleep on it surrounded by two young women and a young man eating a traditional meal. They break off a piece of millet paste and dip it into the slimy, green leafy sauce using two fingers and the thumb of the right hand. The man gets up when we approach while the women continue dipping and eating.

"Ca va?"

"Oui, ca va."

"Do you know the hospital rules?"

"Yes."

"Ok, how many family members can stay with the patient?"

"Two."

"How many of you are there?"

"Two."

"Do I look stupid? I can count. How many of you are there?"

"Three but one of them is outside."

"Where are we, inside or outside?"

"Inside."

"Do I look stupid? Where is the woman, inside or outside?"

"Inside, but she just arrived this morning."

"Really? Who let her in?" I go to the door and call the gatekeeper who is standing in the rain swallowed up in his army green poncho.

"Jean-Jacques, did you let this person in this morning?"

"No, she must have been in here already."

I turn to the family member and ask him, "When did she come?"

"Ask her."

Seraphim, one of our nurses' aides asks the woman in Nangjere when she got here.

"Nanga," she replies and even I understand that doesn't mean today, that means yesterday.

"My friend," I ask the man. "How many more lies are you going to tell today that are so easy to verify as false? Are you going to tell us you're the president of Chad? Or maybe Barack Obama?"

But I can tell by the look on his face that my attempt at humor has escaped him.

I finish rounds just in time to be called to labor and delivery where a woman has been in prolonged labor at the health center and was referred since 2 am. She arrives at 10am. I examine her and find that the baby is trying to come out face first and it just isn't working. We do a see section and pull out what looks like a little alien with his eyes bugging out, forehead swollen and molded by the pelvis and his face edematous and red. But he does start crying and moving with some vigorous efforts at reanimation by Sarah and Anatole and looks like he'll be fine. I wonder how long it'll take him before the culture teaches him that lying is ok as long as it's used to give excuses for not doing what you should be doing and to protect yourself from something that might turn out to be shameful.

But for right now, he's just like any other newborn, he just wants oxygen followed by a good breast feeding.

Crutch

2010-08-22T15:14:00.004+01:00

I sigh. I can't help it. I've seen too much. Too many children die, too often. And this is just another sad case. The nurse hands me the carnet. A seven year old who was amputated here in May during my vacation. Now he's back with tumors everywhere according to the nurses' initial evaluation. Diagnosis: metastases. I motion for the nurse to bring in the child. He practically skips into the room, if one can skip on crutches. He's almost bouncy until he looks up at me and then turns his head down and slightly to the left as he shyly looks back up with a small grin revealing two missing front teeth. He is way too cute to be dying.

I heave him up onto the exam table and first teach him how to give me five. At first he is reluctant. After all, he's been taught to shake people's hand and slapping is kind of a bad thing. But after some encouragement, he gets into it and really lays it on as his face lights up. I lie him down and pull down his shorts. His left testicle is swollen, looks like a hydrocele. His right leg is amputated above the knee and the wound has scarred down well. However, the leg above the amputation is swollen and the groin is filled with large, mobile masses. His lower abdomen also has numerous palpable masses swelling out his stomach.

My face falls. I'm about to turn to the father shaking my head to tell him there's nothing we can do but I decide to do something desperate and hope for a miracle. We do actually have one chemotherapy agent: cyclophosphamide which we use to treat Burkitt's lymphoma. Burkitt's is very common here and very treatable with a few doses of Cyclophosphamide spread out in cycles of three weeks. It usually presents with a large mass in the upper or lower jaw but can present elsewhere. After one dose, the mass usually shrinks remarkably and after 2-3 doses it is usually visually gone. Even though I'm almost positive this is not Burkitt's I figure it won't hurt to try.

The boy is hospitalized and the first perfusion given. I see him the next morning and his abdominal masses have all but disappeared and the groin masses have shrunk remarkably. He went home 5 days later much improved. Yesterday he came back and got his second dose. This afternoon I saw him and can hardly feel any mass in his groin. All the other masses have completely disappeared. I don't know what it was and I'm pretty sure our treatment shouldn't have worked. But all I really care about is that this really cute boy is getting better against all odds.

Fuel

2010-08-22T04:51:00.008+01:00

I'm looking for fuel. Not just any fuel, that I could find anywhere. All along Moundou's one paved road are small rickety wooden tables stacked with old whisky, gin and wine bottles filled with various colors of gasoline and diesel. No, I'm looking for Moundou's one working gas station: such as it is. It hardly stands out. Two bright new fuel pumps stand just outside one of the hundreds of other brick stores with rusting sheet iron doors opening onto dark painted wooden counters in front of an endless supply of haphazard new and used parts and products. There are also two old pumps with glass tubes and a hand pump that fills up the tubes which are then emptied of their specific quantity of fuel out a second hose. It's hard to recognize until you're almost past it and there is barely room for a care to get off the pavement and onto the dirt as motorcycles, bicycles and pedestrians weave in and out in a weird rhythm interrupted by the occasional black exhaust spewing battered diesel truck.

Today, I can't seem to find it. I'm driving slow, peering out the window of the Hiace mini-bus when I spot the two old pumps but no new ones! Just past the pumps on a stool is my friend, Mahamat, wearing a Chadian National Football team jersey. He waves to me and I screech to a halt and back up.

"As salaam aleikum!" I greet Mahamat.

"Wa aleikum as-salaam," he replies and then adds. "You're looking a little lost, what's up?"

"Yeah, I was looking for your gas pumps, but they're gone!"

"We just moved across town last week. I'm here just to orient my clients. Do you need gas?"

"Yes, I was looking for you, but you found me instead!"

"Come, I'll take you to my new place." With that, Mahamat hops into the passenger side and we do a u-turn and head back towards the surgery center.

Mahamat is plump with a ready grin and is a huge football fan. Apparently, in the day, he was quite the player as well and still gets out occasionally.

"How long have you been in the new place?"

"Just a week, God has blessed us. I came from N'Djamena a few years ago, and didn't know what I would do, but here I am."

"Yes, with God's help you have succeeded. He meant for you to come here."

"It's true. Our business will continue to grow, inshallah."

I turn and smile. "Yes, we must always say that, if God wills. We don't know what will happen even tomorrow."

Mahamat grins as he chews on his tooth cleaning stick trying to keep his mind off food until Ramadan ends at sundown. "So many people want to plan out their whole lives, but it's only the right now that God has given us."

"Yes, you're right."

"I thought I saw you yesterday evening." Mahamat changes the subject slightly.

"Yes," I reply. "I came into town with my wife looking for something to eat. We found some great beans and rice after sundown. I prefer simple things, the things that God has made rather than things from a can or box."

Mahamat looks at me in surprise. "You are a true believer, that's for sure." He laughs and keeps chewing on his stick as we pull up to his new gas station.

Tire

2010-08-20T21:27:00.001+01:00

I walk over to the mini-bus, my muscles aching and my back burned. I've just been out in the hot sun all putting in the plumbing for our house at the new surgery center in Moundou so the builder can pour the floor and keep things moving. I glance at the rear tire and see it's gone mostly flat. It's had a slow leak for a while, but this is going flat quicker than normal. Sarah and I hop in, I start her up and we pull out onto Moundou's one paved road.

In the round about ahead is the statue of an African woman next to a large, homemade water jar reaching out half a calabash of water to us thirsting passersby. Just past the effigy I spot a yellow tank with a motor and old belt on top. A tire repair shop. I screech to a halt and look down the dirt embankment to a teetering brick wall where someone has stretched out a ragged tarp between a tipped up push cart steadied with palm fronds and an old metal sign. The tarp is attached to it's supports with old inner tube that allows it to toss and turn at the whim of the wind offering varying degrees of shade.

Under the tarp a man is stretched out asleep on a board balanced precariously on each end by two old tires.

"Hey, anyone working today or are you closed?" I shout out in French in the man's general direction. He sits up and smiles and walks up to us.

"My back tire is low and needs to be repaired," I say to the man as I step out of the van and around to the back passenger side. He nods and mumbles.

"TWENTY THOUSAND? Are you crazy?" I respond incredulously.

The man smiles and laughs. "No, no! TWO thousand, not twenty." He walks over towards his homemade tools scattered all over the ground. "Twenty thousand, that's practically the price of a new tire. No, I would never say that."

I agree with a nod and a grin and the man gets to work jacking up the van to take off the tire.

"Mind if I sit in your shade?" I ask. He tells me to go right ahead and then when he sees Sarah still sitting in the van, he motions that she should join me, which she does.

We both quietly read until I see he has the tire off the rim. I get slowly to my feet and saunter on over where the man shows me a nail poking through the rubber.

"That's what made the tire go down quick, put there must be another hole somewhere because it has had a slow leak for awhile."

"Sure, no problem."

I go back and resume reading my friend Franklin Cobos' book about his experiences in Chad in 2008 called "It Could Be Worse." Little do I know how pertinent his title will seem in retrospect.

The man calls me over and points out a piece of bailing wire that he also found in the tire. He patches both with old pieces of inner tube and glue. I figure he's about done, but return to my reading anyway. After 20 more minutes I see him still struggling to inflate the tubeless tire. I see him walk away across the paved road and return 5 minutes later with a back of flour. I stop reading and watch closely. He puts it in a bowl and deftly mixes in a little water till he's created a very sticky dough. Then he smears it around the edge of the tire. I get up and stand nearby watching in typical Chadian fashion. As he tries to inflate the tire with the air hose the dough puffs out in a couple places like a kid trying to make bubbles with chewing gum.

"I need more flour." The man states matter-of-factly and takes off again soon returning with double the amount of flour. He repeats the procedure until practically the whole tire is white with dough. I wonder if it sits enough on the hot Chadian pavement if it'll turn into bread and stop up the holes. It still doesn't inflate after multiple trials interspersed with reapplication of the dough.

"I'll go see a brother who can help." With that he takes off with the tire back towards where we came from, rolling the white doughy mass in front of him until he's out of sight. I go back to my book. Finally, he comes back and shows me an inflated tire with pieces of plastic jutting out around the edges in between the lumps of dough. It seems to be holding air, though, so I nod my approval and he remounts the tire.

"Four thousand francs." He demands.

"Whoa, buddy, we agreed on two thousand, here take it."

"NO! I fixed two holes, two thousand per hole!"

"The extra work wasn't patching the hole, it was taking the tire off and trying to re-inflate it! That's not my problem that you didn't know what you were doing and had to take it elsewhere!"

I hold out the two thousand franc note. He looks at it in scorn. "Either four thousand or you keep your money!"

"Take it!" I try to give it to him, when he refuses I put it in his cardboard box and go around to the driver's side. The man comes to the passenger side and reaches across Sarah and grabs a hack saw sitting on the console between the seats. Sarah grabs the hacksaw as well and almost falls out of the car wrestling with the man until he wrenches it from her grasp. Meanwhile, I've quickly gone back around and take the saw back, twisting it out of his hands.

"Now you're going to steal something or what!?" I motion for some people across the street to come over as witnesses and intermediaries. I motion Sarah to get back in the van and try to close the door behind her. He pushes his butt in the way. I push him out and close the door but he reopens it and wedges himself in there again. I push him out again with a hip thrust and this time lock the door and manage to close it while boxing the man out as I lift the handle on the door so it stays locked.

Meanwhile, a small crowd has gathered and the man starts shouting out in Arabic about not having eaten anything all day because it's Ramadan, the Muslim fast. I switch over to Arabic and shout out a few things about that he'd agreed to two thousand and then tries to change his mind and steal our saw and molest my woman. The man just keeps repeating the same things over and over even as other Chadians try to reason with him and motion me to just go. So I get in, hope desperately the van will start (which it does) and take off without a look back, hoping desperately that the plastic and dough holds up at least till I get out of view.

WELL

2010-08-19T21:18:00.001+01:00

I finish as quickly as I can at the hospital. Lightening rounds and a couple of simple operations and I find myself heading towards where my heart has been all morning. I open the back gate and step into the bush. Grass is starting to push it's way up through sand transforming this desert into it's annual reawakening an African savannah. This year the rains have started early and have been regular. No one is talking about famine this time. I walk across the field towards the church and pass a couple of sticks stuck in the ground that serve as goal posts for the afternoon soccer matches between the neighborhood kids.

In the distance, I spot Jamie amongst a crowd of African children surrounding a small metal brace towering out of the masses. The slow chug and then roar of a pull started diesel motor breaks the silence as I see a motor slowly rising along the supports towards the top. As I draw near I see a metal pipe attached to the bottom of the motor and some huge plastic tubes coming off the bottom running to another small motor that has just been started as well. Coming out of this motor is an even larger, green hose going into a pit filled with muddy water which is starting to disappear as the metal pipe starts turning, the motor is lowered and sand filled muddy water pours out from under the apparatus, down a channel, into a small pit for collecting the larger debris and then through another canal into the big water pit.

A well is being drilled before my very eyes!

As the motor gets to the bottom of the rig, it is shut off. The pipe is loosened from the motor and then locked in a brace that will keep it from slipping forever into the bottom of the water reservoir. The motor is then restarted and hand cranked up enough to screw in another pipe and continue the process of up and down, up and down with the drill bit getting progressively further towards a clean water source. I take off my scrub shirt, roll up my scrub pants, take off my sandals and jump into the muddy fray.

Suddenly, one kid yells to another kid to start the water pump. We haven't attached the other pipe yet and a powerful jet of clay filled water spurts out on Jamie, Doulgue and I covering us from head to toe in mud. Everyone starts laughing while we silently plot our revenge.

Finally, the well is 85 feet deep. We slowly and excruciatingly reverse the process to remove the pipes one by one. Finally, the drill bit is out. We bring in the large plastic pipe that will be the well casing. It is bright blue and the first one to go down as little slits all along it to let water, but not soil in. We have to modify the end so it will go in easier by cutting out triangular wedges with a hacksaw and heating up the plastic with a propane stove so we can bend the end closed. We then lower it into the pit and hold on while another one screws into the end. None of them want to screw in until we realize we have to grease it well for it to work as the plastic just grips itself.

We have 3-4 ten foot lengths in when we discover that the threads are bad. Now we have to try and pull it back out to unscrew that last one. It's difficult as the muddy water in the hole wants to suck it in and now the pipe is covered in clay and quite slippery. We finally wedge it with a large adjustable wrench and a plethora of hands but it feels like it'll slip away at any second. We manage to finally unscrew the old one and screw on a new one and slowly lower it back until we have 8 sections in for a total of 80 feet.

It's revenge time. The first boy sees me coming and backs away laughing...right into the arms of Doulgue. We haul him over and baptize him in the sump pit as a fitting celebration of the arrival of clean water for our elementary school and junior high. We go home sunburned, tired and very satisfied.

Anesthesia Nightmare

2010-07-10T04:01:00.000+01:00

The woman was gored by a bull. Not just any bull, a Chadian bull with 3 foot long horns. And she was gored in the mouth, straight through her palate into her nasal cavity. But that was months ago. Now, she's just a wizened old lady who'd like to swallow her porridge without it coming out her nose. I have her open her mouth and I shine in a light. There's a small hole, slightly smaller than one centimeter right in the center of the roof of her mouth. I poke around with a clamp. There's some green stuff; looks like bean leaf sauce for lunch.

We prepare her for surgery. She has high blood pressure. Three days and three medications later her blood pressure is mostly controlled. We wheel her into surgery.

There are four medications God has reserved as gifts for the third world. One of those is Ketamine. It is dirt cheap, can be given through an IV or into a muscle, dissociates the person from their conscious brain yet doesn't hinder breathing, swallow or gag reflexes. It also increases heart rate and blood pressure (both generally good things during surgery) and dilates bronchioles in the lung increasing oxygenation. It allows us to do most major surgical procedures without intubation, ventilators, or other complicated anesthesia equipment. Too good to be true? Well, there are a few drawbacks...

Simeon gives the woman some atropine to dry up her secretions since Ketamine tends to make one salivate and shed a lot of tears. He also gives her Valium since people on Ketamine can have vivid dreams, visions or even nightmares. This is especially true on emergence from anesthesia. Valium should blunt that. So far so good.

I have put on sterile gloves and arranged the instruments on the tray. I'm ready for the patient to be knocked out. Simeon slowly injects one milliliter of Ketamine. I watch as her eyes start to twitch and then she goes out. Then she contracts her abdomen, chest and neck in a huge grunt and stops breathing. I can hear the beep beep of the pulse oximeter in the background as her oxygen saturation goes slowly but surely down. This happens sometimes with Ketamine for a few seconds. I sit tight. She still doesn't breathe. I start doing some chest compressions to move a little air in and out of her lungs. Simeon is keeping her airway open. Her sats come up a little, but are still very low. Usually, the person starts breathing right about now, or rather a few seconds (or is it minutes) ago.

I decide to intubate. Simeon opens the drawer filled with about 10 different laryngoscope handles and light sources and over 20 different lighted blades. I grab the one I want, it doesn't light up. I try changing blades. Nothing. I'm starting to panic as I go through all the handles and blades and not a single one works. We have the endotracheal tubes ready, but no way to see the vocal cords to put them in. Meanwhile the patient isn't breathing because she's all tensed up from a reaction to the Ketamine. Her sats are going way down in the background with that annoying little beep.

I see in the bottom of the drawer a laryngoscope I've never seen before. It's made of green plastic and the blade is rigidly attached to the handle which is hollow with no top. It's just a long tube attached to the blade. On the side is written, use laryngoscope light source (or something like that). Inspiration (or desperation) comes. I yell to James (the medical student/EMT from the states).

"Get me that headlamp over there on the wall. Turn it on and shine it down this handle!"

It works, a little light at the tip of the blade lights up. I quickly jam it into her mouth and see her vocal cords! I grab the ET tube. I try to put it in but her mouth is tense and the tube bends. I forgot the guide wire. I quickly fumble in the drawer and bend the wire back into shape and jam it down the ET tube.

"James, put your hand right here and push her cricoid down and to her right!" I can't see the cords. Finally, a swollen, tight little hole with two white flaps opening and closing pathetically shift into view. I thrust in the tube and it passes into the trachea.

"Blow up the cuff with that syringe!" I yell to the other medical student, Jonathan. I attache the bag to the tube and start pumping air into the patient's lungs. I see a reassuring vapor in the tube with each exhalation and an even more reassuring increase in the tone of the pulse ox which says she is now being well oxygenated.

I give the bag to James while I put on fresh gloves and make two incisions about half a centimeter from the hole in the woman's palate. Jonathan and Abel retract and Abel suctions while I free up the tissue from the bone and then move the two flaps to the center and suture them over the hole made by the bull horn.

Fifteen minutes after the surgery is over I'm able to extubate the woman and she soon breathes normally with normal oxygen saturation.

Note: No supplemental oxygen was used in the filming of this nightmare due to unavailability.

Central Africa Republic

2010-07-05T15:33:00.001+01:00

It starts with a hum, then a buzz followed by an ever increasing noise that soon identifies itself as an unavoidable telephone ringtone that is a poor imitation of the William Tell Overture. Sarah walks over to the shelf, grabs the small silver object and passes it to me. I open it up and glance at the screen: an unknown number.

"Hallo?" I query.

"As salaam alek." A deep cheery voice greets me in Arabic.

"Wa alekum as salaam." I respond.

"It's me, Mahamat Shadara," the voice continues. "You operated on my leg, remember?"

"Yeah," I do remember him and have wondered how he was doing. "Kikef?" I ask back in Arabic.

"I'm bringing a brother from Central Africa with two broken feet." I'm assuming that he's using the colloquial expression meaning two broken legs.

"Ok, where are you?"

"We just left Moundou and are almost at Kelo. We're coming to Bere. He needs to be operated on today."

"Ok, ok," I try not to promise to operate today since I have no real idea what his problem is. "Bonne route!" I hang up.

Several hours later, as Sarah and I are finishing up some pasta salad along with an episode of "House, MD" the phone rings again.

"We've arrived at the hospital." It's Mahamat Shadara's voice again.

"D'accord, j'arrive." I finish my meal and my distraction and head over to the ER.

There is an old beat-up Toyota pickup in the middle of the courtyard between the ER and the OR. I assume the patient is in the back. A large Chadian walks over to me with just a slight limp using a cane. He holds out his massive hand and grasps mine in a firm grip as a huge smile lights up his face.

"Docteur, as salaam alekum."

"Wa alekum as salaam, yom katir..." The Arabic greetings continue on for several minutes before we walk over to see the patient.

A foul odor wafts up from the back of the truck where a weak looking man looks like he's barely hanging on. His head is propped way up on a pillow. Yellow shorts cover his waste and a dirty white sports jersey can't hide the thin arms and partially healed scratches. An old piece of foam probably carved from a used mattress is between his legs which are both twisted out at impossible angles. As I suspected, he probably has bilateral tibia fractures. Both are covered in layers of old matted cloth surrounding reeds and all covered in gentian violet. The flies buzzing and his burning hot skin confirm my suspicions that one if not both of the fractures is open and severely infected.

"How long since the accident?" I demand.

"Xamstachar, fifteen days," Mahamat confirms. "He came all the way from the Central African Republic. I brought him here because you helped me so much if anyone can help him it's you."

I'm not so sure, but I get the process rolling.

"Dinah," I call out to the pharmacist. "Call Abel, Simeon, Samedi, Abre and Youlou. We have an emergency surgery and I need there help immediately."

The family members along with our medical students grab the metal spring bed without legs that the man is lying on and lift him out of the bed of the truck. We bring him into the OR. Sarah and Salomon each find an IV and start pouring in antibiotics and IV fluids. I start cutting away the layers of old cloth and reeds around the fractures and uncover a hardened layer of what looks like dried roots, probably some traditional bone treatment. The right leg has some superficial wounds that look like scrapes or pressure sores from the binding. No bone is showing and it looks like the fracture is closed. Good news for him.

Meanwhile Samedi has arrived and is putting in a urinary catheter while Simeon is cutting away the wrappings on the left leg. Henri has come and done a hemoglobin which is 5.7 g/dl. He needs blood. Henri goes to get the stuff to cross match his blood and hopefully find donors among his family members since we have no blood bank. The left leg is completely open with bone fragments jutting out and dirty, peat moss like flesh around the wound edges. Pus and an awful odor pour out of the injury. There is also a green looking gash along the outside of his left knee. There's no way to save that leg and we need to amputate immediately.

Henri comes back. The patient has O negative blood, one of the rarest types and the one type that can't take anything but that one type of blood. None of the family is O negative. We'll have to operate without blood. Simeon brings a blood pressure cuff and a large elastic wrap. I start at the toes of his left leg and wrap tightly to try and squeeze as much blood out of the leg as possible and back into his circulation. Then Simeon pumps up the blood pressure cuff around his upper leg which acts as a tourniquet.

We wheel him into the OR where I quickly slice through the thigh muscles down to the bone. Pus gushes out. Right along the bone is more of that green, necrotic tissue. I saw through the bone and toss the leg into the trash can which gets knocked over. Youlou rapidly puts it back right while I try to chase down and cut out all the necrotic looking tissue. I also find the main artery, vein and nerve and clamp and tie them off. Once the debridement is done and we are down to healthy looking muscle, I ask Simeon to gently let down the tourniquet. Samedi and I spot the bleeders and clamp them off while Simeon reinflates the cuff to stop any oozing. I tie off the vessels, pack the wound deeply with diluted bleach soaked gauze and wrap the whole wound up tightly with an Ace wrap.

Simeon lets down the tourniquet and the dressing stays dry. I move to the right leg which I cast from toes to thigh after cleaning and dressing the wounds. I'll cut a window in the cast tomorrow so we can do dressing changes and if the wounds clear up then I may put in an intramedullary rod. Right now it's too much for him in his weakened condition. As we turn him to clean him off, I notice pressure sores over his sacrum which I also debride and dress. Finally we wheel him out to the wards.

I don't know how he stayed alive for 15 days in that condition, but people here are tough. I hope he makes it through the night.

High Risk OB

2010-07-02T01:26:00.000+01:00

It all started with the usual knock on the door at 3AM. Faka, the charge nurse for the night team, is outside as I open the screen door. A dim flashlight illuminates his face as he looks up from a patient's carnet.

"A woman just came in with presentation of the umbilical cord. She's been in labor at home since yesterday. The were no fetal heart tones. She had some bleeding but it stopped."

"What time did she come in?" I interrupted.

"Just 20 minutes ago." Faka replied.

"Was it a normal vertex presentation?"

"I think so."

"Go and find out. Since the baby's already dead and the bleeding has stopped, if the fetus is head down, then she can deliver normally."

"Ok." Faka moves off into the night as the crickets, frogs and pigeons take over with the usual Chadian night sounds.

I decide to stay up until Faka comes back. I read for a while but after half and hour I assume the woman has already delivered or is doing well so I go back to sleep.

After worship, Faka gives his report to the rest of the staff.

"...and the woman still hasn't delivered and has no contractions."

I stifle my frustration and announce that we'll all go to see the patient right after the rest of the morning report.

The woman is in a dark room. The electricity is off. I go to the OR and hit the remote start for the generator. I come back to labor and delivery and find the woman in a clean room behind a blue curtain on a delivery bed with no mattress under a noisy fan.

The umbilical cord is sticking out between her legs. The abdomen is a weird shape. On closer inspection, the placenta is also half hanging out and the odor of rotting flesh wafts up into my unprotected nostrils. I examine the woman and find a hand sticking out next to the placenta and umbilical cord. This woman has three reasons to need a c-section four hours ago: placenta previa, cord prolapse and transverse presentation.

A few minutes later in the OR I have Abel douse the cord and placenta with Betadine while Samedi and I scrub. The infant's skin is already peeling off as I pull the limp form out of the abdominal incision. I leave the skin partially open to prevent infection and we clean up.

Prudence is waiting for me outside the OR.

"A woman just came in. This is her 5th pregnancy and she's been trying to deliver at home since yesterday morning. I can't exactly tell what the presenting part is."

"Ok, I'm coming." I slip off my OR shoes and into my sandals as I turn the corner and down the outdoor veranda to the maternity ward.

At first I also can't tell what part of the baby I'm feeling till my finger goes into the child's mouth.

We quickly prepare her for a c-section as well. As I open the uterus I can tell the fetus was stressed as a thick green fluid oozes out. I pull the baby out but the head is huge and her lower uterine segment thin and about to rupture due to prolonged labor. The baby is soon crying as Prudence uses the bulb suction and briskly dries and stimulates him. Meanwhile I repair the tears in the paper thin uterus and finally control the bleeding. I rinse out the abdomen well and close.

A few hours later, Prudence comes to get me again.

"This woman has been bleeding a lot." She tells me as we make the now familiar trip to labor and delivery.

On entering the room I see a woman breathing rapidly, somewhat dazed and covered with blood all over her legs and waist.

As we prepare her for surgery, the lab checks a hemoglobin: 7.8 g/dl (normal is over 14) We do a type and cross and find out unfortunately that she is O negative, one of the rarest blood types and one that can only take O negative, no other type. As I slice down the midline of her lower abdomen, the lab guys are desperately checking the blood types of all the relatives of the woman. None of the staff is O negative and we have no blood bank so we hope someone that came with her will have the same type.

As I open the abdomen I see a blotchy uterus with cracks on the surface oozing diluted red blood. After nine other deliveries the uterus just can't take much more. There are dark bruises around the edges and the fundus. As I open the lower segment a dead baby pops out followed by a large grapefruit sized blood clot. Abruptio placentae where the placenta separates too early causing massive hemorrhage between it and the uterine wall. That explains why she's oozing from everywhere: she has no platelets or clotting factors left.

Since the oozing won't stop and the uterus looks as if it's been beat up, I decide to take it out. It is rather simple to do but after it's out, despite by sutures, the wound edges just keep bleeding and bleeding. I try everything I know but nothing works. Her blood is so diluted it almost looks like pink lemonade. In desperation I ask for a packet of Celox, ignoring the large "for external use only" on the package I poor the powder over the bleeding edges in the pelvis and hold pressure with a compress. The problem is there's nothing to hold pressure to. Even with the Celox applied several times there is just too much oozing for my comfort, especially considering I have no blood to give her and she started out low. Finally, I take a large lap sponge, pack it into her pelvis and close the fascia and skin around the blue cord attached to one corner of the gauze that hangs out the skin.

As I watch her being wheeled out to the wards I'm sure it's the last time I'll see her alive. Later that evening I go to check on her. She's moaning and groaning and not really responsive. I grab 2 liters of IV fluids from the OR and let them pour in. WHen the first one is in, I change to some 10% glucose. She starts to at least make some sense. I ask her family to interpret what she's saying in her local dialect.

"She's in a lot of pain."

I order some IV pain medication and go home. At least with the pain medication, she'll die peacefully.

The next morning, she's still alive and so I have the family give her some water and porridge. Later that afternoon, the lab finally finds a family member with the right blood type and she gets one unit of blood. It's not nearly as much as she need's but it's better than nothing. The next morning, she's swollen and edematous but alert. I take her back to the OR and take out the lap sponge and reclose the abdomen under general anesthesia. Today, she is still critical but sits up with help and is taking some water and more porridge.

Maybe she'll make it after all.

Whimper

2010-07-02T01:24:00.000+01:00

I stare down at the man. It's almost midnight. His name is David. He's almost 60 years old, but has the muscular build of a middle aged athlete. I took out his enlarged prostate three days ago. Up till now he's had a completely unremarkable post-op course. In fact, he's done better than expected. He was already up walking, eating, clear urine in the foley bag, etc. Now, things have changed.

His eyes are half open, pupils constricted, eyes slowly wandering away from the flashlight. He whimpers and whines like a beaten dog cowering in a corner. His heart beat is a little fast, but otherwise vital signs are normal. He is snoring. Just that evening, according to his son, he drank some water and had some porridge. Then he started mumbling incoherently out of the blue.

I have the nurse, Faka, find an IV and start a drip of 10% glucose. I look down at him. He continues to moan in a pitiful way as if he's extremely afraid. I wonder at my reaction. I want to feel something good, but all I feel is that I wish he would stop being so pitiful and that I wasn't woken out of a deep sleep and have to be here to see him like this. I'm disgusted and angry in my feelings while in my head I'm thinking, why can't I love him? But I feel nothing. I pray silently that my feeling will change.

As the glucose runs in, David starts to wake up. Faka then starts another IV in the other arm and gets some normal saline running. David starts to have purposeful movement and mumbles something. His son says he wants some water to drink. We lift his head up a little and he swallows have a glass of water. The IV on the right with the normal saline is pouring in. I notice that the glucose on the left is running slowly. I see that the IV is infiltrated.

I stop the glucose and when the saline is all in I switch the rest of the glucose over to the right. David wakes up even more. He mumbles something else in his native tongue. I ask his son to interpret.

"He says his ancestors are calling out to him from the grave and he's afraid."

I suggest we pray for him. They are all in agreement. I grab his hand and David holds mine tightly. At the end, I tell the son to ask him if he needs anything.

"He says he wants some porridge."

"Go ahead."

They lift him up again and his wife gives him some porridge which he swallows easily. He then remains sitting up on his own. The family has visibly relaxed. David is now able to understand and respond to my questions in French as well. I tell him that now that he's better I'm going back home to sleep, but I'll keep praying for him.

As I walk back in the moonlit night, the cool breeze echos the tranquility of my soul. I fall back to sleep immediately. In what seems like the next instant, I hear a knock on the door. It's Faka.

"Our guy is dead. Not fifteen minutes after you left. Out of the blue."

I hear the wails and cries of the family waft across the lawn from the hospital. I sit in my chair in the blue light of a bug lamp. I want to cry, but no tears come, only questions that will never be answered.

Primitive?

2010-06-21T13:59:00.000+01:00

I should have followed my instinct. Yesterday, Friday, was my first day back at work in Bere. Apparently, during my absence, the nurses have restarted their morning report. I walked in at the end of it. The nurse presenting was one of our sketchier government nurses named Desiré. He had just talked about a man who had constipation for four days. He was just on observation in the ER because he wasn't that sick. Deep down, I thought, I better go look at this patient now with Desiré. But then I thought, well, the nurses have been doing well during my absence, and I'm sure they can recognize and treat constipation. If they want me to see a patient, they usually tell me. So I went about my day and didn't see the patient.

This morning, Samedi comes to see me before 6 AM.

"The patient with constipation wasn't doing well, so the night nurse called me at 2 AM to see him. He was bloated and vomiting so I put in an NG tube but nothing came out."

"Let's go see him."

The middle aged man is sweating and in obvious discomfort, but able to converse normally. His abdomen is swollen and filled with air. He jumps when I tap it with my finger and shake the bed. There is no stool in his rectum but he is quite tender. He obviously needs an operation.

As the abdominal wall splits open under my knife a dark purple mass pops into view. I enlarge the incision and slide out an edematous, necrotic sigmoid colon that has twisted around itself effectively committing suicide. I clamp across where the colon is still healthy on both sides and remove the necrotic bowel. I free up the upper part of the descending colon so it is more mobile and suture it painstakingly to what's left of the rectum. After three hours, a lot of sutures and irrigation, I close the fascia and leave the skin open. As I pull off the surgical drape I discover his bowels are already moving as he's deposited quite the pile between his legs.

After a brief lunch and rest, Sarah and I saddle up the horses who haven't been out in three months. They are eager, yet controllable. I enjoy the thrill of power beneath me as we race to the river.

There's no relief like soaking in cool water on a hot sub-saharan day. Because of the massive rains yesterday, it is also quite humid and my shirt and pants are soaked with sweat after the five kilometer ride. I unsaddle Libby and lead her into the water where she kicks up a whirlpool playfully with her front hoof before wandering back and forth in the cool stream.

Some of the neighborhood kids have finally arrived, brought two by two on Cory's motorcycle taxi. I put them all through the same initiation. If they want to swim out in the middle they have to survive being attacked by me as I throw, spin, toss and tackle them for several minutes to their screams and cries of joy!

As Sarah and I relax a while later, up to our necks in the swift moving water, we spot an Arab crossing the river on his pregnant horse, following his herd of cows back to his village.

"Lalé!" Sarah shouts. No reply.

"As salaam aleikum!" I attempt but no response. This is quite unusual as most people will respond to a salutation.

"Kikef?" I try again. Finally, the man looks at us and seeing us looking at him wonderingly, he sheepishly reaches up to his ears and removes his tiny earpieces from his MP3 player and greets us back!

By now Sarah and I are laughing at the shear ridiculousness of the contrast between primitive and modern. The man laughs back and greets us many times.

Returning to the hospital on horseback we go cross country relishing in the green grass everywhere in between the broad leaved bushes and freshly plowed fields. We get slightly lost but are reoriented when we see the cell phone tower which is right behind the hospital.

That night, Sarah and I walk through a completely dark village, trying to avoid the mud puddles in the path until we get to a hut that has a single fluorescent bulb out front. We turn into a narrow alley and duck under a hangar made with straw mats. There are mud brick benches arranged between the twisted sticks holding up the roof and in the front is a mat in front of a small television. We have come to see the World Cup. Denmark is playing Cameroon and everyone is surprised to see a woman, much less one fanatically cheering and whistling every time Denmark scores a goal. The rest of the room is silent as we lift our arms and shout as Denmark comes back from 1 to 0 to win the game 2 to 1.

Chad, as usual, a country of contrasts, stuck in the past yet in some ways, just as modern as anywhere else in the world.

BACK

2010-06-17T01:47:00.000+01:00

The flight has been uneventful. We spent the night in Paris and now are descending towards N'Djamena. Only a few scattered lights in the darkness of the desert remind us that we are coming into a capital city of a million inhabitants. The warm blast of air that hits me as I step out of the plane and walk down the steps to the tarmac remind me that I have left Scandinavia behind. Despite the fact that we could get there faster by walking as there is only one terminal about 100 feet away we are forced to ride in a bus. As we stand in line in one of the two passport control points I spot David who points us out to the man with him who comes and takes our passports directly to the booth where he stamps them himself. The one conveyor belt in baggage claim is broken so the bags are dumped on the floor as everyone scrambles to reclaim his and mount it on a rickety cart, most of which have broken, missing or twisted wheels.
Our bags are near the end and meanwhile David introduces us to his cousin. She works in Customs and I remember her from last year when she told the other customs agents to stop bothering us as we were in the medical work. She is happy that I remember her. With David's friend leading the way we breeze through all the controls and are soon in David's Land Cruiser heading to his cheese factory.

Suddenly, I hear a screech and the crunch of metal on metal. The UN mini-bus in front of us stops and puts on it's hazards. In the intersection is a mangled motorcycle and a body laid out straight on the pavement showing no movement at all. A small crowd quickly gathers and tries to shake the limp form. He was killed instantly and the car fled the scene. As we move past, turning right at that intersection people stare in our windows shaking their fists and yelling "what are you looking at?"

Down some dirt roads and a metal gate opens to David's horn. He jumps out and starts the generator as we haul in our heavy bags. Two mattresses await us on the living room floor as the fan tries desperately to remind us we are not in an oven. We open the double door to the courtyard where two dogs wag their tails furiously as they cautiously wonder if we'll beat them or pet them.

"How's N'Djamena?" I ask David.

"Things are changing. They no longer allow those small plastic bags in the markets. You get heavily fined and they're strict. If someone offers you something in a plastic bag, everyone will refuse as they don't want to be seen with it either. So the women have been taking the empty cement bags, cleaning them out well and making small bags to put vegetables, sugar and other things in it for their customers."

"That's amazing, is it happening all over the country?"

"Yes, they're strict everywhere."

"That's great!"

"Yeah, and every Saturday from 7 to 10 am no one is allowed to open their business and everyone is supposed to be out sweeping and cleaning things up. In fact, the President of the country was out the first Saturday with his ministers to lead the way. The President was well dressed in a jogging suit and got right to work. The ministers were all in suits thinking it was something symbolic for the TV. But the President kept sweeping for like an hour or an hour and a half. It was hilarious. FIrst the ministers took off their jackets as they wiped the sweat off and tried to keep up. Then ties were being untied and sleeves rolled up. It was NOT what they expected at all."

I fall asleep to the buzz of mosquitoes. It's good to be back.

Complications

2010-06-08T09:51:00.002+01:00

>
> "I've got another patient for you, this time it's really serious."
> Lorraine's voice on the other end of the line sounded panicky. "The
> daughter of one of our pastor's has been hit by a car and her leg's
> broken and there's blood everywhere!"
>
> "Ok, well send her to the hospital." I reply.
>
> "Right. We're at the cellphone tower. They've taken her to a
> traditional bone setter, but I've convinced them they need to come
> to the hospital. We'll be right over."
>
> "Alright. Just tell the nurse or the gatekeeper to come get me when
> you arrive. I'm at home."
>
> So much for a leisurely Saturday. I'd spent the morning telling the
> story of Joseph to a group of teenagers and using it as an example
> of responsible sexuality and speaking to a group of adult Christians
> later about the positive sides of Islam. Then a brisk ride to the
> river to try and cool off. I always forget how just when you think
> it's gotten really hot and unbearable it can just get worse.
>
> I send a text message to Samedi, Simeon and Abel and slowly put my
> scrubs on. As I look out my front porch, I see a truck pull up to
> the hospital. The patient must have arrived. I saunter over and
> see a crowd behind a Toyota Forerunner. Inside is a large, moaning
> woman with tightly coiled braided hair, new clothes and a blood
> soaked wrap around her twisted, swollen left leg.
>
> With many hands making light work she is quickly transferred to a
> gurney and wheeled into the OR. She has an obvious femur fracture
> with a tiny wound telling me the bone had poked out at one point.
> She has a similar wound over her tibia just below her knee but her
> lower leg seems stable. There is also an open fracture of her big
> toe which has been reduced. Her left thigh is twice the size of her
> right one and she's obviously lost a lot of blood already. Her
> heart rate is 150-160 but her blood pressure is holding. We start
> two large bore IVs to try and replace her lost blood volume as
> someone calls the lab tech on duty to test the family and friends
> for possible blood donors. Her heart rate quickly drops to 110-120
> with a couple liters of IV fluid.
>
> After Simeon injects the antibiotics, I give her some Diazepam and
> Ketamine to dull the pain and allow me to place a tourniquet around
> her upper thigh to slow down the blood loss. We quickly wheel her
> into the inner OR, give her a spinal anesthetic and prep and drape
> the leg. WIth the blood supply cut off to the leg by the tourniquet
> I know I only have a limited amount of time to get this operation
> done. I figure it shouldn't be as hard as the many other fractures
> I've operated on recently because this one is fresh. All the
> other's have been old ones with poorly healed bones needing to be
> cut apart, wound contractures, scar tissue, infections and many
> other complications. I should know better than to think something
> will be easy.
>
> After praying, I slice open her thigh over the puncture wound.
> Swollen muscle pops out under pressure. I cut down do the fracture
> and find nothing but shards of crushed bone for about 10-15 cm in
> the middle of her femur. A pre-op x-ray would've been nice, if we
> had a working x-ray machine. Now I have to go by feel as I probe
> the wound with my double gloved finger. I decide to go through the
> knee to insert the rod since she has had so much blood loss and this
> allows me to keep the tourniquet on. As I expose the entry site,
> dark blood spurts out of the knee joint confirming my suspicion that
> she also has a fracture of her upper tibia plateau into her
> articulation.
>
> Using the SIGN technique I just learned in August, I bore into the
> bone and insert the first reamer to clear out the bone marrow in
> preparation for the metal rod I'll use to fix the fracture. Going
> through the distal part of the femur is no problem. But since the
> proximal part is shattered I have a difficult time finding the
> hole. I try and explore with my finger through the other incision
> to guide the reamer but finally realize that bone fragments have
> gotten jambed up the marrow cavity blocking the entry of the reamer
> (and later the nail I want to insert). I have to put it in from
> above. I expose the hip, swab it with Betadine and cut down to the
> bone. The patient is quite large and muscular and the hole is
> deep. I pray desperately as I've already wasted a lot of time and I
> don't have much left on the tourniquet before I have to let her
> start bleeding again. Fortunately, there are two bags of blood up
> and running now.
>
> I insert the awl and find the marrow cavity. "Al hamdullilah" I
> shout as I start the progressive hand reaming. I finally hit the
> largest size that will easily pass and call for the right sized
> rod. I carefully attach the external guide apparatus and twist and
> hammer the rod into the bone. With Youlou pulling on the leg from
> below and Samedi twisting and positioning over the fracture site we
> are able to get the rod into the distal section and stabilize the
> injury. I position the guide pin, incise the skin, place the drill
> guide, drill the first cortex of bone, insert the hand hole enlarger
> and twist in but don't feel it enter the hole of the rod like it
> should. It means I'm a little off. I use the curved hole finder to
> reposition the apparatus and then am able to locate the whole again
> with the next drill guide so I can drill the second cortex. I
> measure the length from cortex to cortex through the drill holes and
> place the first fixation screw. The second one is easier and the
> two proximal ones even easier.
>

Moonlight safari

2010-06-08T09:51:00.001+01:00

>
> "Only in Chad," Gary muses as I swing into the pack of the pickup
> and pull my beanie low over my ears. "No where else could we be
> going out into a game park at night in an open truck with no top or
> windows without a guide and be the only humans around. Only in
> Chad. God bless this rebel country!"
>

Hysterectomy

2010-06-08T09:51:00.000+01:00

>
> I decide to do the surgery outside. It's just to hot inside so I
> borrow our neighbors old table and set it up just outside my front
> porch.
>
> "Should we start an IV?" Sarah asks.
>
> "Nah, just give her an shot of Ketamine, she'll be fine. We'll just
> hold her down well if she starts to move a little...and you can
> always give her another shot."
>
> I hold the patients hand while Sarah gives the Ketamine in the
> muscles of her leg. She squirms and moans but otherwise tolerates
> the shot well. As she starts to drift off to sleep, I inject her
> with an antibiotic.
>
> Jamie and his family and the new doctors, Liz and Tony, help Sarah
> carry the patient and deposit her on the table.
>
> I shave and prep the abdomen, open the box of instruments and put on
> sterile gloves.
>
> "Ok, Allah you hold the left arm, Cory you hold the right. Carson
> if you and Michelle can make sure the legs don't move and are spread
> out well, I think we can get started."
>
> I put the scalpel blade on the handle, grab a compress and start
> cutting through just above her belly button down to her pelvis. I
> get a little off center and at first am a little confused as to
> where I am anatomically. Maybe it's the early evening shadows that
> are playing tricks.
>
> "Does anyone have a head lamp or something?"
>
> "Yeah, here's a brand new headlamp," Liz replies.
>
> Jamie also goes and gets his high powered work flashlight which
> helps a lot. I enter the abdominal cavity.
>
> The uterus is strange. Instead of being short, rounded and compact
> it stretches up through the abdomen and has two long horns. It's
> also very thin. The ovaries are attached at the ends of the horns
> and deep in the belly. I need to do a complete removal of the organs.
>
> "Liz, could you and Tony assist me?"
>
> "Sure, no problem." They both put on disposable gloves and reach in
> to help pull aside intestines and abdominal wall so I can get a
> double clamp on both ovarian stumps. I then clamp the blood vessels
> dangling off the sides of the uterus and place two clamps vagina
> just past the cervix. I cut out the uterus and ovaries together and
> place fixating sutures through the stumps, around and behind the
> clamps and tie everything off.
>
> I close the first layer of abdominal wall.
>
> "Could I get some irrigation, please?"
>
> "Here's a bottle with well water in it, is that ok?" Liz asks.
>
> "Sure, whatever." I reply.
>
> I then close the other layers and the skin with washings with tap
> water in between.
>
> Sarah then brings the plastic funnel and we attach it to our dog,
> Caramel's collar and carry her back into the porch for recovery.
>

Preterm

2010-06-08T09:50:00.001+01:00

>
> I feel her kick for the first time. I've felt other fetuses kick
> before on other pregnant women's bellies, but this time is special.
> The child is mine. A thrill goes through me and a silly grin wraps
> around my face. It's Friday evening, Sarah has malaria and I've
> just started her treatment. Leaving Sarah, who wants to rest, I go
> spend some time with Franklin and boast about my strong, athletic
> little daughter. After a little singing and worship, I return home.
>
> After checking the IV drip with a flashlight and being satisfied
> it's running well, I crawl into bed and fall fast asleep.
>
> A gentle shaking startles me from a profound slumber. My heart
> sinks at Sarah's words.
>
> "I'm all wet down there, what could it be?"
>
> I try to reason that maybe it's urine but my heart tells me
> different. Her bag of water has broke. The pregnancy is only 21
> weeks, too early too survive if she delivers now.
>
> I pull on some shorts, grab a flashlight and head up to the
> hospital. I bring back the portable ultrasound. I place the jelly
> on her belly and confirm my deepest suspicions: our little daughter
> has almost no amniotic fluid around her. However, her heart is
> still beating normally and she is still kicking if not screaming. I
> take the ultrasound back, but halfway there realize I've left my
> keys at home. After making the return trip I pick up my obstetrical
> textbook and try to find the pertinent passages.
>
> It's not encouraging. Most women with preterm rupture of membranes
> and fluid leaking deliver within less than 2 weeks and the outcomes
> are not good. I take the book home and discuss the bad news with
> Sarah. We pray and both toss and turn all night long. Drums pound
> in the distance as someone is mourning a lost loved one. Sarah has
> just a little more leaking through the night and by morning it seems
> to have stopped.
>
> Saturday morning. I give Sarah some yoghurt, hang up some more IV
> fluids and head out to church at 8:30. The doors are shut. It's a
> cool desert morning, but the sun is starting to heat things up. I
> sit in the shade along the rough brick wall in the dust. I'm
> reading a little when I sense a presence beside me. I look up. A
> tall, poorly dressed man stands proudly to my right clutching a
> tattered Bible. As he greets me I recognize him as the husband of
> one of our patients who explained to me yesterday that he's a
> traditional healer from up north.
>
> We start talking. I soon discover he is a man of God if not a
> prophet. He can barely speak French, but his words have a power
> that can only come from above. I confide in him and ask him to pray
> for Sarah. My spirits are uplifted.
>
> After the teaching in the first part of the service, I head home to
> check up on Sarah. She's vomiting and not feeling good. I stay
> with her. I look back at the passages in my obstetrical book and
> see a section saying that if there is at least one pocket more than
> 2 cm deep, than the outcomes are surprisingly better. I go back,
> get the ultrasound and to my joy find a 3 cm pocket and another 2 cm
> pocket. The heart still beats well. Maybe there is hope that Sarah
> won't lose the pregnancy.
>
> We both start to plan. If she hasn't delivered in two weeks we'll
> change our plane tickets and head to Denmark to arrive when the baby
> is 24 weeks and has a chance of living with modern intensive care
> nursing.
>
> We rest all afternoon as I try to control Sarah's nausea and treat
> her malaria.
>
> She starts to have contractions that night. Some bloody discharge
> discourages us again. I sleep only fitfully. When I wake up, Sarah
> informs me the contractions stopped halfway through the night. I
> repeat and ultrasound and our girl is doing fine, if anything it
> seems like there is more fluid inside. Hope rises...then falls as
> the contractions start again after breakfast. Sarah is in agony.
> She is moaning and tossing in pain. She vomits frequently. I try
> anything and everything to control the pain and vomiting. Nothing
> works.
>
> I am at her side almost constantly. She grasps my arms in vice
> grips every time the contractions hit. They are getting closer and
> closer together. She had more bleeding. I'm afraid, but repeat the
> ultrasound. The baby's heart is still beating well. But then a
> contraction hits and I see the heart beat start to slow. I'm losing
> it. It seems almost to disappear, then miraculously, as the
> contraction ceases, the heart slowly picks back up. She's
> suffering. Her heart can't take much more. The cervix is opening.
> It's just a matter of time.
>
> I prepare some towels and basins. I have a bottle of water handy.
> We start to talk of what to do with the body. Where will we bury it
> and what will we use as a coffin. Our conversation is interrupted
> every couple of minutes by severe pain and writhing as I sit
> helplessly by watching my wife suffer, knowing the outcome of her
> suffering will be an extreme loss. There's nothing I can do but be
> with her.
>
> The cervix is dilating. I can feel the bottom of our daughter. She
> is coming out butt first. A few more contractions and Sarah says
> "It's coming!" I reach inside and touch the tiny leg and foot. I
> grasp and gently pull as my daughter enters a world she'll never
> know. Her heart is still beating under my fingers. She fits in the
> palm of my hand. Every part of her is perfect. There are no
> malformations. She has Sarah's nose and my long skinny legs and
> arms. Her mouth is open as she tries to get air into her
> undeveloped lungs which will never be able to extract the oxygen she
> so desperately needs. Her little ears will never hear. Her closed
> eyes will never open. Her heart starts to slow down. But as I
> touch her tiny hand, she curves her fingers in an attempt to grasp
> my gigantic finger. She does this several times. She is getting
> colder. It's all over.
>
> I burst into uncontrollable sobbing. I hold her and watch her and
> examine her every little perfect human part over and over. We take
> pictures. Sarah lays her on her stomach. While she can curl up
> into the tiniest ball, when she's stretched out she's way longer
> than I could've imagined. We wash her, tie off the umbilical cord
> and cut off the placenta. I place her in an old mayonnaise jar and
> seal the lid tightly. I dig a hole under the small tree with the
> red flowers just outside our door. The dry soil is rock hard. I
> use the hose to wet and loosen the dirt. I get down about two feet
> and bury our girl in the soft mud. Sarah shovels in the first few
> piles and I finish. I read from I Thessalonians 4 about the
> resurrection and place a huge, porous stone over the top of the
> little grave as a marker.
>
> It is finished.
>

Zakouma

2010-06-08T09:50:00.000+01:00

>
> It's a cool night in the Sahel. Baboons are howling across the
> wadi. I pull on my beanie and climb in the back of the modified
> Land Cruiser. Cutting off the cab, welding chairs in the bed and
> painting it forest green have made the old rebel attack pickup
> almost unrecognizable. I stand behind the front seat holding onto
> the bar across my chest. Gary fires up the engine and Wendy hands
> me the spotlight plugged into the cigarette lighter. Sarah is
> seated to my right and Cherise lays across Wendy's lap staring into
> the moonlit sky. Except for a group of Tunisian engineers who
> arrived earlier in the evening, we are the only visitors to the
> Zakouma National Park near Am Timan. Exhausted by their 15 hour
> trip, the Tunisians hole up in the restaurant, leaving us alone to
> explore the African night.
>
> In a few minutes we have left the small campground behind and turn
> on the road towards the airstrip. To our right, a pool of water
> houses a couple of crocodiles as an image from earlier in the day
> flashes across my mind of a large jaw and head bursting out of the
> calm waters clutching a mammoth catfish temporarily in its teeth
> before twisting and swallowing the huge mouthful and disappearing
> again into the green depths.
>
> We are looking for eyes. Skimming the spotlight across the surface
> of the grasslands and acacia trees from right to left we seek out
> the night prowlers and resting herds through the reflection of their
> eyes. Groups of reddish green pairs reveal striped antelopes with
> twisted horns as triangular faces stare us down. Smaller
> reflections lead to tiny nimble footed gazelles that skip and hop
> and jump about, frightened by their own shadows. Narrow set eyes
> close to the ground on closer inspection lead to long, slender genet
> cats with their striped bushy tails hunting mice and other critters
> in the short grass around the watering holes as the slither and
> slink close to the ground. Large, bouncing eyes high in trees let
> us know of the presence of Galapagos tree climbers that are to swift
> to follow, appearing and disappearing only to reappear several
> meters away up the branches.
>
> In the vast, green pastures around the water holes that dot the
> wadi, herds of gazelles, deer and antelope rest, graze and cast a
> nonchalant look at the passing human intruders. One herd is guarded
> by a pair of greenish, blue eyes, wide set apart encirceled by horns
> flowing over the sides of the head like a wig over powerful
> shoulders and the stocky body of a water buffalo. Several hundred
> meters further on a group of those evil, green eyes is staring at us
> from the edge of the pond. Without a working four wheel drive, we
> are loathe to pursue, but instead, these fearless creatures make
> their move towards us as they huddle together and move confidently
> and deliberately towards the truck in an oblique manoeuvre meant to
> impress but not threaten.
>
> Huge black and white storks stand awkwardly in the marshes. Great
> herons balance on slender legs before taking off in lumbering
> flight. Small headed, spotted birds that fly like butterflies
> startle up from the road and sides of the road at the approach of
> the headlights. Some seem paralyzed till the last minute when they
> make a desperate flutter to escape right in front of the charging
> grill. Gary actually stops once and manages to get his hands around
> one that I've stunned with the spotlight before it flaps out of his
> palms. Small, big eyed birds reflect the spotlight light wildcats
> temporarily confusing me until the eyes start to take flight. An
> owl stares us down with it's unblinking eyes sitting on a branch
> directly overhead before taking off, its silent wings beating
> noiselessly through the dry and dusty night.
>
> Gary punches the gas and the Land Cruiser lurges forward towards
> some antelopes grazing near the road and a dark, compact, lumbering
> creature holding close to the ground. He enters the road and turns
> to follow directly in our headlights revealing short, powerful legs
> and dense, black fur. A long, thick neck leads to a flattened head
> with a mouse grasped firmly in it's teeth. If there was still any
> doubt, its characteristed back and forth lumbering gait gives it
> away as a badger.
>
> Harder to see than the genets, we get glimpses here and there in the
> distance across the grass of a larger, slinkier striped cat: a
> civit cat. A raccoon like tail disappears into the bush. A panther
> like back end slinks around a corner. We never get a full few, but
> enough to appreciate the grace of this medium sized feline.
>
> We see quite a few giraffes from a distance, but none up close. One
> small herd has a couple of babies only recognizable that far away by
> the reflections of the eyes being so much closer to the ground than
> the adults.
>
> We near the end of our night safari. We pass the mud, thatched
> roofed huts of the village of Zakouma and pull onto the airstrip
> where Gary zig zags across at high speed. We see one hyena lazily
> reclining on the edge of the strip. Coming back out from the hangar
> we see another Galapagos' eyes bouncing quickly away in the
> treetops. Coming back out onto the airstrip I see a group of eyes
> far away. We pursue and find two groups of four hyenas each, all
> lying down in two piles. As we pull within 20 feet, they lumber up
> staring at us with their evil eyes and panting jaws open revealing
> dangerous teeth over their skulking, spotted bodies. The move off
> into the bush, cackling in their high pitched witches' laughs.
>
> At the end of the airstrip we take the road heading back to the
> camp. Out of the corner of my eye I see a big shape pull to its
> feet. I swing the spotlight and just catch a giraffe who has just
> pulled to it's feet 10 meters away. Another giant turns its long
> neck around to stare at us from it's long face before starting to
> walk gracefully away like a couple of long-legged models strutting
> their stuff. They move up to a blob on the ground with a chimney
> pointing to the sky. Rocking forward to get it's hind legs up and
> then backward like a camel the slumbering giraffe gracefully and
> rapidly regains its footing. Picking up speed, the three now gallop
> off in seemingly slow motion their front legs moving like huge
> scissors as their back legs move in tandem to catch up. They
> effortlessly cover huge amounts of ground in each stride. After
> putting a little distance between them and us they move back into
> their most graceful of walks like a couple of movie stars exiting
> the premier in their fur coats.
>
> Several hundred meters later I briefly catch a glimpse of a large,
> black animal staring straight at me. I'm sure it's a baby
> elephant! Gary backs up and tells me to turn off the spotlight as
> it may charge. When we're just across from where I see it, Gary
> plugs in the spotlight...and we see a huge waterbuffalo staring us
> down. Impressive, but not what I hoped to see!
>
> Almost back to camp, we see what looks at first like a dog running
> on the road ahead of us. We approach and when we are within a few
> feet it turns sharply into the bush revealing a Serval cat with it's
> tiny head, spotted body and long, lithe legs and tail. It springs
> away as only a cat can and disappears into the night. Just 100 feet
> from the turnoff into the camp I spot three pairs of eyes to the
> left. One pair lifts up revealing a blood stained snout. I shout
> at Gary and he screeches to a halt and backs up. We turn off the
> road and head straight for a recently killed buck. It's lifeless
> eyes stare back at us from the ground. It's fat stomach spills out
> matted grass where it has been left under the tree where it was
> killed. The two hyenas that dragged it away lift their snouts out
> of the carcass revealing red stained fur all the way down their
> chests. The back leg is missing leaving a mound of tattered flesh
> up to the open abdomen pooled with blood. The neck shows no injury,
> but matted fur suggests maybe a lion killed it before being chased
> off by the hyenas. They are reluctant to leave their meal, but
> slink around in the periphery of our headlights waiting for us to
> leave which we soon do.
>
> The next morning, we drive out to the site and see four hyenas
> fighting over all that's left, a piece of torn leather. Their
> bellies are engorged so they can barely walk. No bones, organs or
> even blood remains....only that tattered hide. One hyena tries to
> make off with it. Another runs up and grabs it in a macabre game of
> tug of war as they run of cackling and chortling into the early dawn
> of a new day in Chad.
>
>

Homemade guns

2010-06-08T09:49:00.000+01:00

>
> "There's a guy in the ER with what looks like a bullet sticking out
> of his face." Franklin told me casually, as if commenting on the
> weather.
>
> "A bullet? Is he stable?" I reply.
>
> "Oh yeah, he's fully conscious, sitting up, talking. He walked in.
> Apparently he was hunting and the rifle backfired or something and
> the bullet went into his right cheek. He came from quite a
> distance. I think it even may have happened yesterday...my French
> isn't that good."
>
> "But it's not too emergent?"
>
> "No, I think it can wait."
>

Mad

2010-06-08T09:48:00.000+01:00

>
> This has been one of my worst days yet. Believe me, I've had my
> share of them. But this definitely ranks (as in stinks) up there
> with the "best" of them.
>
> I could find plenty of excuses for my behavior. For example, we've
> done more surgeries the last 3 weeks than the last 2 months combined
> (including one 7 day stretch where we did 46 major operations). Or
> I could cite the fact that I've had amebic dysentery for the first
> time over the weekend making me feel nauseated, anorexic, fatigued
> and generally miserable for three days.
>
> But I'm tired of excuses, that's all I hear all day long and that's
> what started this day off so badly.
>
> "Enock left at six without giving sign-out, but he said he HAD to go
> to Kelo."
>
> "We don't know why the kid didn't get his blood transfusion, Enock
> left for Kelo and didn't tell us."
>
> "The father left four days ago. He said he'd be back with
> provisions and to donate his blood, but he hasn't come back. Can we
> go home now?"
>
> "Ma'am, your child has a hemoglobin of 3.3, he'll die if he doesn't
> get that blood, besides you've already paid for it anyway and the
> father has the same blood type."
>
> "But he's gone home. It's far away. We have no money."
>
> "Madame, do I need to remind you that you don't have to pay anything
> and we'll find one of our staff to give."
>
> "But my husband isn't here, he went home to...." I cut her off in
> midsentence. Michelle gives blood and soon the child is on his way
> back to health.
>
> "I don't know why this guy's still in the ER. I wasn't the one who
> hospitalized him 4 days ago."
>
> "Haven't you had a night shift and a couple of ER shifts since
> then? You just let him stay even though his wounds were sutured and
> they weren't severe enough for him to need to be hospitalized? What
> about his relative who was also beat up who didn't even need
> sutures? He's also occupied a bed for 4 days in the ER."
>
> As we inform the two nomads who had been beaten up because they
> tried to steal rice and then cut off a guys arm who tried to defend
> his rice, as we tell them they have to leave the hospital now they
> start muttering under their breath.
>
> "YOU didn't do anything for us! Four days in the hospital and
> nothing!"
>
> "What about the 4 wounds we sutured closed and the pills that you
> have been taking and still have?"
>
> "But we didn't get any IVs or shots or anything. Next time, we're
> going to the hospital in Lai!"
>
> "Doctor, the patient is writhing in pain!"
>
> "I have his carnet here for an ultrasound."
>
> "But he's really in bad shape!"
>
> I go outside, a barefoot man covered in dust is standing calmly to
> the side. We walk him over to the ER where I can examine him. I
> look in the carnet, nothing written except abdominal pain. The plan
> is to have him see the doctor and get an ultrasound.
>
> "Ok, let's find out more about his pain."
>
> I start to ask questions but none of the nurses know his dialect.
> They call in a translator who starts translating. It's pain-
> staking. I'm frustrated and walk out yelling over my shoulders.
>
> "Find out all you can about his pain and then come see me!"
>
> Somehow, before I can even get back to my office to do other
> ultrasounds, Sarah is there to present me with the same man's
> carnet. The nurse had managed to stop doing what I asked almost
> before I started and somehow managed to bypass me to get to Sarah
> before I could walk the short distance from the ER to my office.
>
> I storm back yelling at anyone and everyone in my path. I'm totally
> out of control.
>
> A small sampling of my day is sufficient. Needless to say, I'm
> pretty much yelling and shouting and flailing and insulting and
> making a fool of myself all day long.
>
> I get called back to the ER. A man with abdominal pain for 5 days.
> He hasn't pooped in five days either. No vomiting, he ate some
> porridge yesterday but didn't feel like it today. He's lying
> comfortably on the bed. Sounds like constipation to me. A real
> problem here. He has a fever so probably has associated malaria. I
> tell the nurse to prescribe quinine and treat his constipation. As
> I'm about to move on a small urging tells me to examine him more
> closely. I can't explain why. A still, small voice perhaps.
>
> I bend over him. His belly doesn't look too swollen. NOthing you
> wouldn't expect from constipation. If he had a bowel obstruction or
> appendicitis he would've been vomiting by now after 5 days. I push
> and tap. Somewhat tender but doesn't seem to have peritoneal
> signs. I'm still not satisfied. Something inside says that my
> initial impression is wrong. I get a glove and stick my finger up
> his butt. He's more tender on the right side than the left. Maybe
> he does have something.
>
> I decide to operate.
>
> Sarah calls me when the spinal has been done and Samedi and Abel
> have scrubbed and draped the patient.
>
> I enter the OR and notice a pool of yellow fluid on the right side
> of the patient next to the OR table on the floor.
>
> "What's that?"
>
> "Maybe his foley has come out."
>
> Samedi lifts up the sterile drape so we can look. I pull back
> instinctively as I see a huge puddle of liquid stool with floaters
> between his legs. It's been dripping down the drape to the ground.
>
> "Well, I guess it was constipation after all! Looks like the
> relaxation from the spinal was all he needed."
>
> I turn to walk out of the OR. Again, something deep within,
> something that has almost been repressed from my full day of self-
> righteous, angry behavior, that little something makes me turn
> around and speak to Samedi.
>
> "Well, since he's already anesthetized and prepped, we might as well
> have a quick look around inside his belly."
>
> "C'est bon." Samedi nods in agreement. I go outside and scrub.
>
> As I open the belly, nothing jumps out immediately. The intestines
> aren't swollen or inflamed. There's no rush of blood, pus or
> fluid. I start to poke around inside. I"m looking for the appendix
> on the right. I can't find it. Everything looks ok...boom...out
> gushes some thick pus. I open the incision for better exposure and
> peel away the inflamed bowel. With a scoop and a flick of my index
> finger, the ugly looking appendix pops into the surgical field. An
> obvious perforation is at it's tip.
>
> I remove the appendix, irrigate and aspirate the abdomen, place a
> drain and close up.
>
> I spend the rest of the afternoon and evening listening to the night
> shift team bombard me with questions about things the morning team
> didn't do or follow up on and seeing two patients that don't want to
> heal and keep having stool come out of places it shouldn't and
> wondering what I'm going to do as I pass hours in the prep room with
> Samedi, Sarah, Abel and Abre searching for IV access on two infants
> with anemia needing blood transfusions. I spend most of the time
> yelling and throwing things as I can't find the vein or can't thread
> the catheter. Finally, Samedi gets the last one in.
>
> "Halleluia!" I shout and try to go home.
>
> As I close up my office, Rosine is there looking at me sweetly as
> she innocently asks, "Can you help us find an IV? We've been
> searching all afternoon and the kid needs blood..."
>
> How could she have known what she did as I bite her head off with a
> snarl.
>
> "Don't bug me with that. That's not my specialty. I don't find IVs
> very well. That's nurses work. Go find someone else and what ever
> you do, don't call me!"
>
> I go home. As I walk through the door I pause and sobs begin to
> wrack my body. I am filled with anger that want's to explode out of
> me. I don't want it but it's there. I feel betrayed, overwhelmed
> and extremely ashamed of my behavior today.
>
> In spite of this, somehow God spoke to me and made me save a man's
> life instead of relying on my own skills which would've sent a
> perforated appendicitis home to die with a couple of laxatives.
>
> I think I'll ask for forgiveness tomorrow.
>
>

Premature

2010-06-08T09:47:00.000+01:00

>
> I was forced to put in earplugs. I'd tried to think happy
> thoughts. I focused on the pleasant night sounds. In the end, I
> couldn't sleep. The pounding of the drums, not the simple happy
> rhythm of the children singing silly songs in the moon light, but a
> deep, dark, forbidding thumping accompanied by mournful howling,
> this sound I couldn't sleep to. It sent chills down to my entrails
> leaving me feeling ugly and used. The earplugs helped...too much.
> The next thing I know, Sarah is tugging me awake out of the deepness
> of a pleasant unconsciousness into the darkness and chill of an
> early Tchadian morning. It's 3:30AM and Samedi is at the door. I
> stumble over to the screen while pulling on an old pair of scrub
> pants.
>
> "Yeah?"
>
> "Docteur, there's a woman referred from the health center. She's
> seven months pregnant and bleeding. Her skirt is soaked in blood
> but her vital signs are stable for the moment."
>
> "Ok, start an IV, give her ampicilline, place a foley and prepare
> her for a c-section. Call Simeon and Abel. Oh, give her 10mg of
> Dexamethasone IM, first thing. Call me when she's ready."
>
> Earplugs back in, I'm soon back in la-la land. This time my slumber
> is not as profound. It's as if something in my conscious is trying
> to break through. I wonder why I'm still sleeping. Why haven't
> they got me? I get up and pull on a scrub shirt to go with the
> pants I'm still wearing. It's 5AM. I walk up to the hospital as
> the first light of dawn barely illumines my path through the mango
> trees and over the sand covered in horse dung. Even from a distance
> I can see the lights in the OR are on.
>
> I arrive and the woman is still in the delivery room. We bring her
> to the OR, turn on the generator and Samedi scrubs while I shave and
> prep the abdomen. After a spinal anesthetic, the woman is placed
> supine and I scrub as well. After a short prayer I take the large
> scalpel blade and cut into her abdomen cutting the fascia and
> tearing the muscle and peritoneum apart to get to the uterus. After
> deflecting the bladder away, I nick the uterus with the scalpel and
> push a curved clamp inside releasing a fountain of clear amniotic
> fluid. As suspected, she has a placenta previa where the placenta
> covers the exit and starts to bleed profusely when labor starts.
>
> I reach my hand inside the uterus and find a tiny little head way
> high above the placenta. Samedi pushes and the tiny, premature
> infant slips into the world. She grimaces and flexes her arms and
> legs. Her skin is underdeveloped and translucent revealing all her
> underlying blood vessels. Samedi clamps the cord, I cut it and we
> hand the little girl to Abel. We soon here a shrill little scream
> as the girl opens her lungs to that life giving oxygen. As I suture
> the uterus closed I have Abel turn off the fan in the OR and cover
> the baby up. We have no baby warmer and I'm afraid she'll get cold.
>
> I finish sewing up the skin and I take of my gown, clean up the
> blood and mess around the woman and go see the newborn.
>
> She's cold and has a slow heart beat. I pump her chest a few times
> and the heart beat comes back up. I put a tube in her nose and give
> her some glucose water. I have Abel go tell the family to boil some
> water. We'll heat her up that way. Meanwhile I pick up the tiny
> form that fits easily in my two hands and place her naked body
> against my stomach under my shirt. I'll use my own body heat to
> warm her. After a few minutes I feel a response. She starts to
> move more and make some weak cries. I pull out the feeding tube and
> suction out her mouth and nose as she's regurgitated some of the
> glucose water. I feel her stretch her tiny feet against my belly.
> Her hands are grasping. She's reflexively searching for her
> mother's milk. I curl her up in a ball and hold her close flipping
> her around like a burger on the grill to make sure she gets cooked
> on both sides.
>
> I go out to check on the hot water several times and the family says
> everytime that it's ready but it never is. Finally, I can't wait.
> The morning chill is too much. I take her home, held tight against
> me under my flimsy scrub shirt covered with a woman's wrap around
> skirt the family gave me. I knock on Tammy and Jamie's door. Tammy
> lets me in and when I explain quickly heats up water as Cory and
> Brichelle come to help. We put hot, but not scalding water in a
> plastic basin and put the girl in. She seems to like it and kicks
> and stretches. She's breathing well and has a strong heartbeat.
> Her limbs are quickly warmed up as we replenish the hot water
> supply. I gently hold her head up so her mouth and nose stay in the
> air to gulp down that important oxygen.
>

Perforation

2010-06-08T09:36:00.000+01:00

>
> It must be bad. They only call me out of church for real
> emergencies. I gather my books and walk out on the dusty dirt floor
> to a bright late Tchadian morning. Noel and Pierre are waiting for
> me. I don't see a nurse anywhere. What's going on?
>
> "Abel's in-laws have just informed him that his fiancee will come to
> him tonight to become his wife. He has nothing to prepare a wedding
> with but wonders if we'll do a dedication for him in church."
>
> After much discussion it is decided that the women of the church
> will prepare a goat that I will provide and we'll do a wedding
> ceremony at his house tomorrow evening. He has no family here, so
> we will be his family.
>
> That afternoon, I'm too tired to go to the river. It's a good
> thing. Tchibtchang comes calling with the traditional "clap-clap"
> at my door.
>
> "There's a father who brought his son in for a blood transfusion for
> severe anemia and malaria. After we drew his blood to give to his
> child, he told us his hernia popped out in route on the motorcycle.
> We can't get it back in."
>
> I accompany him to the hospital and see Simeon and Abel already
> waiting.
>
> "Aren't you supposed to be preparing to receive your bride tonight?"
>
> Abel chuckles loudly with a huge, toothy grin. "No, tonight she
> comes to my house but I'm not supposed to be there until tomorrow
> night...so here I am!"
>
> A quick look reveals that this hernia is not going to be reduced
> without surgery.
>
> Just then Augustin One comes in. "There's a guy who's been gored in
> the butt by a bull."
>
> "Ok, bring him over." I take a look and fortunately the gore wound
> is to the side and back of the anus missing the intestines. It's
> pretty deep though so I order antibiotics and we prepare for the
> hernia.
>
> Simeon gives the spinal anesthetic while Abel scrubs. I prepare the
> surgical field with Betadine and then scrub. Abel puts my gown on
> and snaps my gloves into place. A few scalpel strokes later and we
> see a dark mass of intestines. I open the sack and there is already
> some dark, coagulated blood in the mesentery but the intestines
> still look viable. I push the squishy, slippery mass of bowel back
> into the abdomen and close the sack. He also has a hydrocele and
> since his left nut is good I take out the hydrocele, testicle and
> all. I sew a piece of mosquito net over the weak spot in the muscle
> and close the skin.
>
> The man with the anal wound is stoic. I give him local anesthesia
> and close the wound in four layers leaving the skin loosely
> approximated. I tell him to soak in salt baths four times a day and
> go home.
>
> Later that evening, Augustin One asks me to see a little girl who
> was treated here a month ago for malaria. She now has abdominal
> swelling. I approach the bed in pediatrics and see a thin little
> six year old with bright eyes who looks tired but not too acutely
> ill. Her belly seems slightly swollen but is soft and non-tender.
> She has diarrhea so I put her on Chloramphenicol and Metronidazole
> and go home.
>
> The next day, Sunday, I lazily do rounds around noon. Melodie asks
> me to see a girl on pediatrics she feels isn't doing well. Her
> glucose is a little low but she's awake. She just doesn't want to
> eat. It's the same girl I saw last night. She is alert but refuses
> to eat. The diarrhea has all but stopped but her belly seems more
> swollen. I examine her and the belly is soft and she doesn't flinch
> or anything when I touch her. I look in her face and something in
> her gaze tells me there's something serious going on. I feel a
> strong impression that I should operate on her. I feel bad because
> this means I'll probably miss Abel's wedding. I tell the father and
> he agrees. Koumabas calls in Simeon and Samedi.
>
> In the OR, Samedi has already scrubbed and the little girl is lying
> resignedly on the operating table. I feel a sudden panic. Why am I
> operating on her? Maybe she has abdominal TB. I run to my office
> and bring in the portable ultrasound. The images reveal a full
> bladder and a lot of stool but no intra-abdominal fluid. Well at
> least it's not abdominal TB. I'm still uncertain but feel committed
> now to the operation. I scrub and join Samedi at the surgical field.
>
> We all bow our heads and I pray in French "God, we're not sure
> what's going on with this girl. We just pray we are doing the right
> thing. Help this operation to be a success and this little girl to
> recover her health completely afterwards."
>
> I cut through the skin and fascia below the belly button. The
> peritoneum seems thickened and I'm not sure if the intestine is
> stuck. I enlarge the incision to above the belly button and make it
> into the abdominal cavity. A gush of liquid stool spurts out under
> pressure as we try to suck it up. I'm at first afraid I've
> punctured the bowel but as the stool spills everywhere over the
> surgical drapes I soon see that she must have had a perforated
> intestine. I can't believe she didn't have pain but am relieved we
> decided to operate. Samedi sucks out the stool as we irrigate and
> search for the damaged section. My finger digs into an inflammatory
> mass and a clump of green, peat moss looking stool slithers out.
> We've found the hole. I pull out the mass, clamp and cut it out.
> It's in the distal ileum. I then suture the two parts of good
> intestine back together, rinse out the belly with liters of fluid,
> put in two drains and close the fascia and partially close the skin.
>

Games Tchadians Play

2009-11-16T14:39:00.000+01:00

The woman is in the OR for emergency surgery. Sarah comes to inform me that the family has only paid 15,000 francs ($30) of the 25,000 francs ($50) required. I tell Samedi and Abel to hold on. I'll see about that. I slip off my OR shoes and into my crocs, slide my mask down my face, push open the screen door and put my game face on.

As I approach the beacon of light coming out of the pharmacy window in an otherwise dark ad building I see a tall, lanky Tchadian in a dark tan matching pants and short-sleeved button down shirt. He slowly turns at the noise of my entrance and looks me up and down. His face is familiar. He's one of the former teachers at our elementary school. His name is Amos (pronounced Ah-moh). I can tell he's sizing me up. Let the games begin.

With a look of disdain on my face I march up to Amos. "What's the meaning of this? I hear you haven't paid for the surgery yet!"

Amos looks at me with a shocked and hurt look on his face. "What do you mean? I've just paid 10,000 francs."

I look at the pharmacist, Koumabas, who nods with his goofy half grin. He's enjoying the match.

I turn back to Amos in feigned disgust. "Do you realize that you should pay 25,000 francs. Do you think 10,000 is equal to 25,000? Aren't you a teacher? That's basic math!"

Amos responds coolly without blinking. "Oh it's ok. I'll just pay the rest tomorrow. Go ahead and do the surgery. You can trust me."

I laugh caustically. "Everyone says that but we've found that if they don't pay before the surgery they never pay after. Find a solution!" I pretend to turn away.

"But we're different. Maybe other people don't pay, but we will. You know us."

"Yes, I do. That's why you need to pay ahead of time. Look, we want to save your sister's life. We're ready to operate. We're only waiting on you!" I've played my trump card. Out of the corner of my eye I see Koumabas nod approvingly. He's enjoying this immensely.

"Ok ok." Amos pretends to concede defeat. "I have my bicycle outside. Can I just leave that as collateral to prove I'll pay later?"

"Let's see it." Amos quickly drags in a rusty, bent and twisted carcass of a bike with missing pedals and a torn up seat.

"Here it is." Amos smiles smugly, sure he's won.

Koumabas just shakes his head and chuckles. "Ca la! No way. That's worth 10,000 francs at best! That's not enough!" I've found a tag team partner in this traditional Tchadian sport.

I narrow my eyes, fixing them on Amos. "Don't you have a cell phone? You could leave that as collateral as well and then we can get going on saving your sister's life. We're only waiting on you, you know!"

Amos looks shocked. "I don't have a cell phone. I'm just a poor teacher." He looks like a puppy with his tail between his legs begging for bread at the table.

I turn away again. "Oh well, I guess we'll just have to wait. We're all ready and everything. Just waiting on you." I fold my arms across my chest and lean casually against the wall.

"Ok, ok." Amos starts to lose his composure. "David, come quickly!" Our night watchman comes in and extends his hand towards Amos holding a tiny cell phone in his outstretched palm.

"David, is that yours?" I ask. I don't want Amos to cop out by forcing our staff to cover for him. I won't lose that easily.

"No, no. It's mine." Amos doesn't even blink at the outright lie he just told me. But then again, I haven't exactly been telling the whole truth either.

"Thanks, Amos, you did the right thing." As I turn to leave I stop and look back. "By the way, I've already done my part. We've finished the operation and took out the twisted ovary with its tumor. She's doing fine and just waiting for you to come out of surgery. Too bad I had to play this game to get you to do your part."

Ah yeah, victory is always sweet in this Tchadian game of bluffing and bargaining. Poker's got nothing on it.

Poop

2009-11-06T06:19:00.001+01:00

Silently the man slips stealthily through the shadows of a dark Chadian night. The Bere Adventist Hospital has become his temporary domain. His child is hospitalized for severe malaria and a blood transfusion is slowly dripping life back into his fever wracked body. The man has sinister motives. He really needs to go.

The hospital has had trouble for years with patients relieving themselves in piles on the ground in the tradition of the African bush. Despite the availability of latrines, the smell and foreignness of the cement structures is revolting to someone used to the pleasant peacefulness of natural surroundings and soft grass or sand. In the 90's a resourceful night watchman named Jairus made successful war on the perpetrators by taking the pile in a rubber gloved hand and moving from bed to bed wiping some of the stool on each bed until someone confessed or turned in the guilty party who then had to go out and bury the leftover turds.

The problem only got worse with the building of a fence around the hospital in 2004.

Now, this evening, maybe the tide will turn as our unknown man makes his way quietly past the operating theater to the outside water faucet. Taking a comfortable position squatting flexing and stretching his thigh muscles the man pulls down his pants and stretches out his hands to get a firm grip on the metal water pipe coming out of the cement slab he has chosen as his receptacle. Suffering from a common Chadian ailment, his knuckles turn white as he strains to force out the poop hardened in his dehydrated and constipated colon. A sigh of relief accompanies the success of his mission until a bright light suddenly blinds him and a harsh cry of "Ca c'est quoi?!!" brings to an end his devious deed.

Literally caught with his pants down the man hurriedly tries to cover his naked manhood as Jean-Jacques, our vigilant gatekeeper hauls him roughly to his feet. It's a little after midnight but our new administrator, Augustin, comes immediately from home.

Punishment is swift. The gendarmes are called. The man is forced to pick up his ca-ca and stuff it in his pocket before being escorted off to prison. He was last seen weeding the flower garden in front of the jail.

euthanasia

2009-11-03T06:20:00.000+01:00

"The pain started suddenly at 4 o'clock this morning." The man stretched out before me on the gurney is in obvious distress. His abdomen is swollen and he's gasping for air. I look at his carnet. His name is Gaouna.

"How was he yesterday? Was he sick at all?" I ask through his brother who interprets from French to Ngambai and back again.

"Yeah, yesterday he was fine, but this morning, the pain started right here," he points to the epigastric region of the patient.

I examine the belly. It's firm but not tense. When I tap with my fingers it sounds hollow, full of air. Gaouna winces in pain with each touch: peritoneal signs. His breathing is shallow and his heart is rapid and his pulse weak. It sounds like a perforated ulcer. The ER had started an IV so I tell Abel to give Gaouna triple antibiotics, call in Samedi from home and go see the last of the ER patients while the OR staff preps for an immediate laparotomy.

The family doesn't have money to pay but they are well to do and leave their motorcycle at the hospital as collateral for future payment.

I finish in the ER and come back to the operating theater. I enter the room. Gaouna is lying on the OR table. Two IVs of Ringer's Lactate are raised high on IV poles running in fast into both arms. A foley catheter has about 300 cc of dark urine. His arms are stretched out on the arm boards and tied down as if he's about to be crucified. Gaouna's eyes are closed and his breathing is even shallower and more rapid. The beep of the pulse oximeter tells me instantly he's not getting enough oxygen. I glance at the numbers. He's at 60% saturation, way below the accepted norm. I'm afraid Gaouna is not going to make it. Maybe we're too late.

We have no oxygen, so I decide to intubate him. I grab a cardboard box off a top shelf. Inside is a mix of all our endotracheal tubes. I select one I think will work. I test the cuff with a 10cc syringe of air while Abel pulls out the laryngoscopes. In my hurry I forget to prepare suction or put in a stylet. I check the laryngoscope and the light works. Abel injects 2mL of ketamine and I insert the blade in the patients mouth. The light isn't working. I pull it out tap it a little, take the blade off and put it back on the laryngoscope handle. It works again. I put the instrument back in his mouth and lift up the tongue. I briefly see the vocal cords before a mass of saliva obscures my view. I call for suction and try to put in the breathing tube anyway. It bends down away from the vocal cords. I reach behind me and quickly leaf through a drawer in the anesthesia cart to find a stylet for the tube. I put it in and bend it into a distal hook to help me put the tube into the trachea. I try again and this time am successful. I put on a bag to the tube after blowing up the cuff and start to breathe for our dying patient. His saturation comes up to 85%. I give the bagging over to Samuel and go scrub. Samedi and Abel have already prepped and draped the abdomen. I'm sure that with release of the abdominal tension, Gaouna's breathing will improve.

I take the large scalpel and am quickly in the abdomen as a surge of dark red, slimy fluid surges out. We quickly suction out over 3 liters of fluid. The intestines look injected and angry but don't seem to be gangrenous. I start to explore and soon discover the real problem. As I cut up the abdominal wall to expose more of the contents a purplish, lumpy, alien-looking mass pops out of the right upper quadrant. Gaouna has end-stage liver cancer. Inside I'm furious. As I quickly try to close up the useless operation, many thoughts whirl through my head. How could the family deceive us? Of course, Gaouna's been sick for months if not years. Without CAT scans and other diagnostic equipment we base so much of our diagnosis on history and physical exam. This surgery could've been avoided. Now in all likelihood he'll die before making it out of surgery. How could God have let me make such a big mistake costing so much money for Gaouna's family and so much time and personnel resources for the hospital?

I've never closed up a surgery quicker. I take over from Samuel and take the bag off the breathing tube. Gaouna's sats go down to 57% but stabilize as he starts breathing on his own. I just want to get him out of here alive. I take out the ET tube and we transfer Gaouna to the gurney and wheel him out to the wards. I explain to the one family member who's there but it's not the same one who gave me false information.

An hour later, Pierre comes to inform me that Gaouna has "rendu l'ame" (given up his spirit). I'm not surprised. By this time, I've had more time to reflect. What if we wouldn't have operated? Gaouna may have lived several more days or even weeks. But he would've suffered. We have no real good pain medication. In hospital, we can give some pentazocine which is OK but not great. As far as pills, we only have Ibuprofen and Paracetamol (a medication like Tylenol). Instead of a slow, painful death, but operating on him we let him slip away in a Ketamine coma without any suffering. Sure, the operation didn't save his life, it just saved him from a torturous death. So maybe it was the right decision after all.

James

Dancing

2009-10-05T13:00:00.000+01:00

Suddenly, Samedi jumps to his feet. He has just finished translating my story of the Samaritan woman who meets Jesus by the well. We are in front of a packed house. Daniel, a school teacher, has just gotten up to sing in his tribal language, Kera. The rhythm is catchy and many heads are bobbing. The drums are pounding and Samedi can't hold back any longer. His overweight, yet strong, body has lost it's flexibility as he stomps to the small group surrounding Daniel and raises his fist pumping into the air. He circles around with the inner foot pounding out the beat as his body weaves back and forth. Bruno jumps up. The smallest of Pierre's boys, he has stayed to same size since he was 13 and despite being almost 18, he still has that pre-teen look. His energetic body bounces up alongside Samedi his knees bobbing up and down and both arms raised. Doulgue slides in smoothly stepping fluidly in and out of the dancing circle. The beat intensifies. Lam is whipping the drum as if it was a delinquent child while Allah lifts up his chin staring to the sky as his little hands flap in a furious blur all over the surface of the goat skin drum head. Koumakoy sets his drum down and hauls his lanky, athletic body across the aisle to join the fray, his shoulders bobbing up and down as his bent arms are held in closed fists against his chest.

It started with me telling stories of a woman caught in adultery and brought before Jesus and that same woman washing Jesus' feet with her tears at a dinner party. The young people around me seemed shocked at a God that would love that much. I finally went around and reluctantly got all of them to admit that God loved them just as much. Then the festivities began. Pierre's second oldest daughter and three friends got things off to a slow start as the younger girls were embarrassed to dance and the older girl was embarrassed to be dancing by herself. Amos then kicked things off in Nangjere with a furious rendition of "Kukusebur ne Jesu Christi" as Tabitha rounded it up with a raised, twirling fist and a high pitched "Ayyyee yi yi yi yiiiiiiiiiii." A flat song in English with the guitar and several Chadians singing in bad Nigerina English was soon forgotten as the same group kicked up their heels and clapped their hands to a up beat French song accompanied by a tight, but simple guitar stacatto.

Doulgue jumps up and looks directly at me. "It's not only Nangjere that can sing Nangere songs. James, come here." Grinning from ear to ear and throughly loving the first truly spontaneous church service I've ever been a part of I stand up and walk over to him, my brightly colored matching pants and shirt swishing as I walk. It's a song about Peter walking on water and we belt it out at the top of our lungs as Amos and a couple others join us. I'm not much of a dancer but I find my head, shoulders, and legs unable to resist the pull of the rhythm. We finish strong to many hearty amens. Degaulle's daughter stands up in the back, her baby hanging from her breast and lets out a high pitched wail. Antoinette echos from the back row of the choir, keeping herself hidden shyly behind the kids in front, but she can't hide her smile as Tabitha finishes off the response with a piercing cry that can only be appreciated by those who have lived in an African village.

We go into the early afternoon, much later than usual as group after group gets up to sing. We have sung in English, French, Nangjere, Ngambai, and Kera. No one has understood everything, but everyone has been moved.

That afternoon finds me on the new bridge staring down into the muddy, swirling water below. A crowd has gathered and I can't back down. I step up on the railing and launch myself out. My outstretched arms smack the water hard 30 feet below as the current quickly sweeps me under the bridge. I swim over to the support posts and find an eddy in the center. I rest briefly before striking out for the shore and clambering up the stony bank. Back on the bridge, someone shouts out "Lapia." I turn and see Marty smiling in the midst of the crowd along the rail.

Marty has survived a hippo attack and tuberculosis and looks in perfect health.

I rush over and grab his hand with both of mine shaking it vigorously as I greet him in Nangjere.

I call Jamie and Tammy over.

"Hey, this is the guy in the documentary that was bitten by the hippo!"

Carson and Michelle come over. Tim and Melody join us as well. All the foreigners want to shake his hand. I tell the crowd that Marty is famous in the United States, that's why all the white folk want to greet him. Everyone laughs as a local man translates my French into Nangjere. As everyone gets there picture taken with Marty I think how ironic this is. Usually it's the foreigners who are the center of attention that everyone wants to stare at or greet. Now, it's a poor fisherman who just happens to have been bitten my a hippo right before a film student came to make a documentary of our hospital. The film won some awards and was shown all over in the Adventist Church in the US and Denmark. Because of that film, many people gave money to support the hospital allowing it to become one of the best in the country.

I walk back over to Marty and the man who translated before.

"Tell Marty that while getting bit by a hippo was a tragedy, that God used that experience to help the hospital to become what it is today thanks to the film that he was in. Despite all he suffered, God turned it around to help many more people who are suffering."

As the man translates, Marty looks at me with a warm smile out of his small, bearded face. He nods and shakes my hand before walking off down the bridge.

James

Moundou

2009-10-04T12:59:00.000+01:00

I think my hand is stuck. I've been sticking it up the pipe trying to clear out 30 years of junk in the drain but I couldn't get it up far enough. Now, I'd managed to twist and angle my arm just right but now I can't get it out. I almost panic, but I twist turn and finally, scraping the skin off my knuckles on the rough cement, my dirty hand pops out.

Jamie and I are in Moundou putting the plumbing in the new surgery center. Everything has had to be redone.

We go to the local Quincaillerie or hardware store. Everything that you thought you could never find in Chad is stacked from floor to ceiling in a dusty, brick warehouse. We spend hours hunting down all we need. A large Arab in a simple white Jallibiya and a well trimmed gray beard walks in. He is the owner, Mahamat.

"As-salaam alekum. Wa alekum as-salaam. Inta afe? Afe, taybin? Al hamdullilah. Mashallah." And the greetings are over. He walks behind the counter. We continue shopping. After early afternoon prayers, Mahamat returns.

"You...eat..." he starts in broken French and then switches over to Arabic. "We want to you to eat with us. What do you think?" He almost seems sure we'll refuse. He is pleasantly surprised by my profuse response.

"Shukran, shukran, it would be an honor, thank you."

He calls outside to the others and ushers us into a tiny side room under the overhead office built high in the corner of the warehouse. We are seated and a huge platter is slung on the table before us. Piles of fluffy rice fill one huge bowl. A cast iron pot from Nigeria holds the steaming goat meat sauce while a shallow bowl to the side is bursting with a fresh tomato and onion salad. Surprisingly, we are given spoons to eat with as generous portions are heaped into our bowls. Jamie, the vegetarian, digs right in ripping the goat meat off the bones. Our host comes in last and there are no more chairs. We try to rise and give him ours, but he insists. A special bowl of cumin flavored yogurt sauce is placed in front of him along with a plastic bag filled with fluffy flat bread the size of large crepes.

Mahamat wishes us "bon appetit" and grabs a pancake. He bunches the whole thing into his hand leaving the ragged edges pointing out with which he mops up some yogurt sauce and shoves the whole mess into his hand. When we are all finally able to resist his efforts to get us to eat more he reaches outside the door and pulls a plastic bottle of wild honey off the shelf. He dumps some more rice in a bowl and covers it with honey. He tells me to dip in and try. When I say I like it and go for more he shakes his head and pulls the bowl over to him. Then he motions to one of his workers to pour me some of my own. I can't figure out if he just really wants to eat it all himself or doesn't want to have too much direct contact with an infidel.

Mahamat rises and thanks us again. "The French are always too busy. The Chinese sometimes take a snack or something, but this is the first time I've eaten a meal with a client here in my shop. Vraiment, merci beaucoup. Merci, merci, merci." He continues to thank us. He is quite pleased and so are we to be so honored.

We return to the job site.

I'm in the new operating room. I grab the jackhammer with the drill attachment. I lean into it and as it engages a puff of cement dust bursts out of the floor until it turns red when it hits the compacted earth beneath the slab. I slip out the drill bit, put in the small chisel bit and feel the vibrations up my arm and shoulder as the chirping and cracking of cement fills the room.

That night I find myself sitting on a hard stool under the stars in front of Antoine's house. The moon is 3/4 and provides enough light to eat the tiny, twisted potato like tubers covered with cabbage and peanut sauce. Antoine seems discouraged. The junior high that he runs has a drop in enrollment. I try to encourage him. We have brought some building materials that are still piled in the shipping container. Once we finish with the clinic, we can maybe help him with a couple of new buildings. Also, I hope to get a volunteer to help teach English to give his school an edge over the competition. I tell him that God has a plan and won't abandon something He has started.

The ladder is a little unsteady as I get to the top rung. There was no attic hole left in the new ceiling but one angle at the corner of the roof has been left open. I think I can squeeze through. I reach my hands up and grab the truss. I pull up as my feet kick out in mid air. I get to my waist and my tiny butt almost gets stuck but I slither through. I hop from truss to truss dragging the loops of plumbing pipe that I punch through the holes down to the sterilization room and consulting rooms below. The sweat makes the cobwebs stick easier as I try not to fall through the fragile ceiling below.

We pull up the van outside a brightly painted wooden shelter. Their are cartoon images of fish, chicken and millet painted garishly on the corners. Inside a crowd is loosely seated around a selection of differently sized rickety tables and wobbly benches. There is a tiny one open right in the middle. Someone, maybe a waiter, quickly wipes off the plastic mat covering the wood with his bare hand leaving a mixture of spilled beer and salad juice on the surface. Jamie and I sit down and nod hello to those sitting at other tables just a few inches from ours. Most seem to have liter bottles of Gala beer in various stages of consumption. The two men dressed in suits next to us are dipping their hands into a common bowl of lettuce and tomatoes covering some kind of meat.

"What's good to eat here?" I ask one of the men.

"Mutton ribs and salad's what we're having, c'est tres bon!"

"Merci."

We order two servings from the overweight Tchadian woman in charge of the kitchen carved out of one corner of the room. The sounds of popping oil and the smells of wood fire smoke waft out from the clatter of cast iron pots and cooking utensils.

A man approaches selling watches and cheap sunglasses. In the far corner, a man is stretching a piece of cloth between his hands to show a woman how strong it is. Several other woman are looking on eagerly as they sip their beers. A large man who looks more Nigerian than Tchadian comes up behind me and holds out a package of medication over my shoulder and in front of my face. There is a picture of a smiling black man on a yellow and red backdrop with "Super King" emblazoned boldly across the front. In small letters underneath I see the generic name for what is known in other circles as Viagra. I turn to look at the man who raises his eyebrows and winks.

"Super King?"

"Non, merci, I'm deja un Super King," I joke with him as I shake my head.

Disappointed he moves on to greener pastures.

Our meal has arrived. The cook holds out the traditional plastic basin with a plastic pitcher and brown soap for hand washing. I rip off pieces of tender, savory flesh off the sheep ribs, topping it off with lettuce, tomato and onion drenched in a vinaigrette. A small pile of grilled yellow chilies adds some spice to the mix. I was it all down with some Top pineapple soda and then help Jamie finish off the last of his meat.

Sign

2009-08-14T14:52:00.001+01:00

It's 3;46 AM and I can't sleep. My eyes are bloodshot and heavy, my head pounds, but I can't sleep. Jet lag is at it again. As I huddle under the blankets to keep from freezing in the airconditioned hotel room in Richland, Washington it's hard to imagine that just a few sleepless days ago I was in the bush of the Sahel. A six hour bus ride from Bere to N'Djamena, a 5 hour overnight flight to Paris arriving at 6AM followed by 45 minutes to Amsterdam and a direct flight across Greenland and Canada to Seattle where I met Greg. We grab a rental car and head over the mountains covered with pines and firs into the central valley with it's rolling golden hills, small farming towns and fresh, cold cherries. Following a smaller river down we hit the Columbia River in the TriCities and we've arrived for the SIGN conference.

I get out of bed at about 4:30, strap on my running shoes and head out the door. The night is just beginning to turn a lighter shade of black but the well-lit streets need no natural light and guide me across the street, around the middle school with it's sprinklers caressing it's well manicured lawns, soccer and football fields, up a side street, off the road up a grassy slope and onto the riverside walking trail. The scent of sage, mountain misery, pine and fir wafts across the early morning breeze which would've surely chilled me if not for the vigorous sweat I've already worked up in my out of shape body. A grove of trees and dense shrubbery gives me only glimpses of the dark, alabaster surface of the river until I turn a corner and see an opening leading down a pebbly bank onto a small sandy beach. I stumble down and after some pushups squat on the sand to reflect.

Yesterday, I found myself surrounded by an international aura of languages swirling around me: Urdu, Hindi, Vietnamese, Slavic, Arabic, French, Spanish, and a wide variety of English from Nigeria, Cameroon, Tanzania, Kenya, India, Bangladesh, Mongolia, England and the wide variety of American accents. There is the slender Dr. Shah with his ample gray beard and thin, fierce face with a long pointed nose from Pakistan describing doing more than 1000 intramedullary nails for long bone fractures starting during the terrible earthquake in northern Pakistan and continuing on today in some of the most remote areas of the world. There is the dignified, dark skinned Dr. Faruque from Bangladesh speaking calmly out from under his mop of black hair and half smile. Dr. Shahab from Peshawar lectures us elegantly on bomb blast injuries, his portly figure fitting well in his classy suit framing a jolly face encompassed in a well trimmed white beard outlining his dark features. I find myself being guided through the machine shop where intramedullary rods, screws and instruments are made at a fraction of the competitors prices but with the same levels of quality control. I enter into a workshop where 20 artificial femurs and an equal number of tibias await our inexperienced hands.

I am led through the process by an orthopedist from Vietnam who explains how to attach the guiding frame to the rod and adjust it so the distal fixing screws will be able to be placed without intraoperative imagery. I am shown the technique of insertion with frequent side to side sweeps interspersed with gentle taps of the mallet. The whole process of guided drilling, finding the slot in the nail and inserting the screws is simple and elegant allowing most lower limb long bone fractures to be treated with the highest standard of care in the world without needing the normal high-tech equipment or even electricity! I go over the process many times in the next few days until I've mastered it. Of course, real bone covered with real flesh on a real person will be different but I'm confident I can do it...inshallah.

SIGN was started 10 years ago by Dr. Zirkle, an american orthopedist who has spent his life in developing countries with the idea of equality of fracture treatment around the world. By the end of 2008 SIGN had over 144 programs in 49 countries involving over 3000 surgeons who have performed over 36,000 operations. Now, Chad and the Bere Adventist Hospital will make it at least 50 countries. We have been given the instruments, our first set of 30 intramedullary nails, a cordless drill with sterile cover, training videos, wound suction treatment systems and the full support of the SIGN team...all on faith that we will raise the money to help cover the costs of this equipment.

Anyone interested in knowing more or donating to this program in the name of Bere Adventist Hospital can contact SIGN at www.sign-post.org.

James

Moonlight

2009-08-09T21:16:00.006+01:00

I could never have imagined that things would turn out they did.

As I stare out into the moonlight filtering through the flamboyant tree branches casting shifting shadows with every breath of wind, as I hear the soft shuffle and breathing of our sweat-flecked horses outside the stable, as I draw my gaze back to the pile of pineapple carvings in front of the cutting board and bring the ice-cold pineapple to my mouth and slowly savor crunching into the juicy morsel, as I think back over the past few days I find it incredible to think of how this afternoon ended...I can only call it an unexpected grace, a surprising joy, a metaphysical moment when all things good come together out of the midst of all things wrong.

As I gallop through the forest, grasping Pepper's mane as fiercely as I hold to the reins; as I stand up in the stirrups and hug my body to the horse's powerful neck; as the leaves slap my face and a branch rips through the skin of my shoulder; as the full moon lights up the sandy trail like a river of silver stretching lazily out before me through the dark shadows of the trees; as my sweat soaked shirt clings to my back; as I am surrounded by the silence of an African evening in the bush I find myself carried way beyond the horrors, sorrows and sufferings of the last few days.

I can hardly remember the strong features of the handsome Arab man staring steadfastly upward with a look of incomprehensible peace as he is lugged up the ramp to the operating room in a vinyl stretcher with wooden handles held firmly in the grips of a dozen turbaned comrades his mangled body wrapped in a blood soaked turban in stark contrast to the serenity of his gaze. I almost forget the hours of working on his bilateral open fibula and tibia fractures uncovered on his right by a flap of skin running from his heel and achilles tendon up his calf and across the top of his foot revealing the anatomy of the muscles, tendons, ligaments and bones as I can only barely remember from Anatomy lab in medical school. The almost can't bring up the vague memory of him calmly complaining of neck pain since he can't move or feel the rest of his body is a silent grace to him allowing us to work on his tattered limbs without anesthesia after framing his chiseled face in a cervical collar. I thought I'd never survive the emotional roller coaster of the myriads of swishing robed, turbaned men and brightly wrapped head scarved women that filed incessantly in and out, many of the men leaving with tears unashamedly rolling down their cheeks as I had to console them to leave all in Allah's hands as only He can know the day of our death and we should trust Him. The memories flood in of fighting my way through crowds and over colorful mats and rugs to try and do his complicated dressings after spending what seemed like ages of emotional energy trying to get the swarming family and friends to respect visiting hours and hospital policies. When his paralysis didn't get better after three days I was almost relieved when the nurse came to get me yesterday morning to say "Ca ne va pas" and I arrived in time to see his unconscious, but still dignified face take it's last shallow breaths and feel his heart beat in his neck slow down and become weak. He was bound for a long road of suffering in this environment as a quadriplegic and it was certainly God's mercy that laid him to sleep.

As I stand on the bank of the river, looking down on the swirling eddies of the brown, engorged river; as I see the sun slowly set behind the great branching trees of the African plain; as I turn around and see the full moon rising through a circle made by two rounded trees and a small hill; as I watch the slow transformation of the day into moonlit night; as I feel the wet of the river slowly drying on my body; as I watch Stefan desperately trying to capture the moment on film; as Eddie slowly makes his way upstream against the current; as I pull on my jeans over my moist swimming suit and prepare for the ride home; as untangle Pepper from the bush I've tied him to I am amazed at how quickly depression and overwhelming burnout can be replaced by wonder and marvel and ecstasy.

Can it be that only this morning I found myself deep in a belly under the ribs carefully cauterizing a gallstone filled gallbladder from the liver of an elderly, lighter-skinned Muslim man? Is it possible that yesterday I was about to throw up and finally gave in and started taking malaria treatment only to go out immediately and take out an ovarian tumor stuck to all the intestines, omentum and uterus? Is it possible that only two days ago I didn't think I'd make it through the morning much less the weak because of fatique I refused to believe was another bout of Plasmodium falciparum destroying my blood cells? Is it possible that only three days ago the hospital was full to overflowing while we spent all of a Sunday afternoon filling it up with sick babies needing blood transfusions and malaria treatment? Is it possible that only four days ago I spent all Saturday in the OR with two motorcycle accidents needing emergent orthopedic intervention? Is it possible considering how things later turned out?

I come back from work almost collapsing. It's been another day of neverending hospital rounds, complicated surgeries, ER patients, ultrasounds all pleasantly muffled with the ringing of Quinine in my ears. I feel a little nauseated and drink some cold water. I sit down and finish reading "Flying Doctor of the Philippines". I just want to sleep, but decide I better go out and feed the horses to keep my wife happy. The next thing I know I'm in the saddle trotting past the mud huts of Bere, around the pond, through the forest and onto the river road mounted on Pepper while Stefan rides Bob and Eddie rides Libby. Out into the open Stefan and Eddie cluck their horses into a gallop. I can feel Pepper tensing beneath me and I give him the releasing cry and squeeze and he quickly closes the gap and passes the others through a mud puddle as Bob goes left and Libby goes right around it. We're in the open now and I slow down. We arrive quickly at the river ride down the ridges gauged out by the rain leading to the cattle crossing and then climb up the hill next to it. A quick assessment confirms the possibilities and Eddie and I strip down and race off the cliff arms and legs flailing wildly before crashing into the swift moving current below. It's not enough for Eddie, so we find ourselves pulling our reluctant bodies up the bank using exposed tree roots before climbing up the tree as high as possible with still a path clear of branches to the rushing waters below. I crouch on two diverging limbs my hands in front as I propel myself through the gap, past the other branches below and into the welcoming arms of the cool, refreshing liquid beneath. I'm glad there are no crocs and lions in this part of Africa.

As Eddie and I climb up the bank for the last time after multiple jumps from different levels, Stefan's face is glowing. It's hard to believe just last night he was talking about maybe wanting to leave. Now all he says is, "the only thing that could make this better would be a little ice cream."

Later as I walk through the cool of the moonlit evening from my house to his carrying the plate of chilled fruit I think to myself, "well, cold pineapple could arguably be as good or better..."

Then the clapping comes again...it's Salomon...

"There's an old man peeing blood since this morning..."

And I'm off to the hospital as the moonlight leads the way.

INSHALLAH

2009-07-26T12:49:00.002+01:00

I find myself in an SUV with a group of Muslims roaring across the desert towards Eastern Chad and the crisis in Darfur. We pass Bedouin caravans heading north. Women in brightly colored body wraps and head scarves with huge gold nose rings frantically beat donkeys to get them to move off the road as we come cruising past. Robed, turbaned and bearded, the men lumber by swaying on the backs of heavily loaded camels, bounce along on horseback or plod along on foot chasing the goats and sheep. Most are armed with bows and arrows or spears or staffs. Tucked away in the robes is the ever present dagger and many probably have rifles hidden in their saddle bags.

Dead animals in various states of decomposition and drying litter the shoulders of the highway. Poor rainfall this year has lead to famine and the loss of cattle, donkeys, horses and other vital livestock. Occasionally the smell of a rotting carcass sneaks it's way in through the windows of our passing vehicles.

The African plain starts to be interrupted by wadis, rolling hills and piles of boulders. In the distance, jagged peaks and granite outcroppings break up the horizon. We enter into the central Chadian Sahel where rain has been more abundant and the grasslands are bright green and crops of millet are starting to push their way out of the soil as local farmers dig up the ground with small spades on the end of long poles. Women coming back from the fields carry water and rations in woven net bags suspended from poles slung across one shoulder. No one carries things balanced on top of their heads like they do in Bere in the South.

We stop by the side of the road for a picnic. Tea and Arabic coffee is poured from thermoses as we wait in the shade of a thorny desert scrub tree. A platter of grilled goat chunks and French baguettes is shared among our two groups of five.

We continue on with regular stops for tea, milk and ritual prayer. One stop for prayer finds us in the midst of a cluster of mountains and date palms. The prayer rugs are rolled out and the absolution's begun in front of a man slicing up a sheep into large portions to be roasted on a piece of tin roofing suspended over a wood fire.

We spend the night in Mongo at the World Food Program compound and are up before five for morning prayers, milk, tea and Chadian beignets. We arrive late in the afternoon at Abeche, Chad's fourth largest city.

As we enter the mud brick compound and seat ourselves on enormous mats, I experience for the first time what an Arabic greeting really is. A rhythmic, staccato exchange of words proceeds for at least five minutes with at least 20 "mashallah's", 15 "Al hamdullilah's" and countless other words asking about health for everybody, strength, improvement, etc. I soon join in and find it very satisfying. Hands are shook during most of the greeting, eyes look down and occasionally the hand is released to bring one's own hand into touch the chest over the heart before reaching out again to take the other's hand in greeting. To end the salutation, one releases the hand and slowly sits down on the mat letting one's "mashallah's" and "al hamdullilah's" slowly fade out.

Adding to the milk and tea we now have local coffee seasoned with cardamom and added to the meat and bread is "boule" (millet or corn paste) and some of the best sauces I've had in Chad: ground meat with lots of cumin and okra.

I then take a shower in a walled in corner with a poop hole and a step up for showering from a bucket. Just outside, in the other corner, about 20 small girls are learning to recite the Koran in Arabic. Their sweet voices blend together in a cacophony of different rhythms as none of them is in sync with the other. It is beautiful and cute. It feels good to splash water on me and wash the red dust out of my hair and off my face and arms.

The men stretch out and sleep together on the mats in the men's courtyard where the women don't dare to enter. Whenever a female family member has arrived she starts her greeting and then kneels down just outside the low wall of the courtyard while the male family member goes outside to greet her and kneels down beside her for the prolonged ritual greeting.

The morning starts with sunrise at 4:30am and prayer. I read some passages of scripture, we drink milk and eat beignets and head out to see the local authorities.

First stop is the governor. Our host, Mahamat Saleh Abakar, explains that he's invited us out to look at the possibility of opening a medical center in his village of Gnelme. The Governor doesn't seem to keen since there's a health center in the neighboring town of Abougoudam. However, when Mahamat Saleh explains that it will be more than a health center, more like a hospital, the Governor reluctantly gives his ok. On walking out with his "Directeur du Cabinet", we receive a much warmer reception. The lighter skinned man with obvious Arabic features dressed in an ample robe and white turban beams a smile and says that he is from Gnelme and will do everything to help us get the paperwork pushed through for the land and anything else we need.

We miss the Prefet and Sultan who are out of town so we head out of Abeche towards the sous-prefecture of Abougoudam to see the local sous-prefet, the chief political figure of the group of villages including Gnelme.

He welcomes us into his old, colonial thick walled mansion that unfortunately hasn't been maintained since independence in 1960. We sit down on mats and drink tea and local coffee along with sodas and some goat meat. Directly in front of us is a room stacked to the ceiling with cement, all that's left of a project to build the sous-prefet a new house. Apparently, the rest of the supplies where stolen by bandits and the builder assassinated.

We follow the sous-prefet out to the village where he shows us a flat, barren stretch of ground he wants to give us. It doesn't feel right. We move onto where Mahamat Saleh and his brother have drilled a well for the village so they can have water. It's down in the wadi, too low for construction and likely to be washed away by flash floods. Next to the pump are three dried out cattle carcasses...the water came a little too late for them. About 10 boys mounted bareback on horses have come to water their flocks. I point to a fairly close plateau next to a small mountain and say that's more what I'm interested in. They say it's in another county and so they can't help.

We seem at an impasse when a local man almost hidden by his enormous turban rattles off something quickly in Arabic. We hop back in the SUVs and head a little out of the village towards another village where we find a small hill crowned with huge boulders that is unfarmed. In all directions stretches the African plain broken up by wadis and scrub brush and mountains in the distance ringing us in on all sides. It's perfect. They are happy and agree to give us 10 hectares (almost 25 acres). The location will also allow us to build using local stones.

That evening, I speak with Yacoub Abdoulaye, Mahamat Saleh's cousin.

"What's the hospital in Abeche like? For example, how's the surgery service?"

"Well, let's put it this way, if 10 people are operated on, 5 will live, 5 will die. Plus, often people die in the hallways of the hospital without even being seen by a doctor or nurse because they have nothing."

That goes along with what I'd heard last week in N'Djamena from a German mid-wife working at an Orphanage in Abeche.

"A few weeks ago, during a single week, three women died during c-sections while still on the table. Most of our orphans are orphans because of their mothers dying in childbirth. It's not AIDS or the refugee crisis or the war...it's almost complete lack of health care during deliveries."

If you have money, you can get health care, it just might be a little sketchy. An old Arab man with a skull cap, white robe and a wizened face with years of smile wrinkles shows me his lab slip and prescription. He has malaria and a negative Typhoid test. He was prescribed Typhoid fever treatment anyway along with 5 other meds including quinine for malaria. The total was the equivalent of $50, more than a month's wage for most. To top it off, they hadn't even filled the prescription right as he showed me his malaria medication which was actually Chloroquine instead of the prescribed Quinine.

That night, a funeral next door allows all the local Imam wannabes to practice their oral recitation of the Koran...with a microphone and speakers. All night long until 6am the next morning we are alternately soothed by those who have the talent and annoyed by those who seem to be screeching like dying mules trying to sing the otherwise beautiful Arabic of the Koran. I sleep well anyway.

On the way back, Mahamat Saleh tells us a story:

A man gets up one morning to go to the market. He fishes his money out from under the mattress and sticks it in his pocket.

"I'm going to the market to buy a donkey" he says to his wife.

"Inshallah" she responds.

Halfway out the door he looks back at her. "Inshallah? If God wills it? What has God got to do with it? I've got my money in my pocket and there are plenty of donkeys at the market. I'm going to buy one. Keep your 'Inshallah' to yourself"

With that he slams the door and marches off. Halfway to the market, he is waylaid by bandits who tie him up and take his money. They leave him under a tree all day and when it's dark they release him and take off into the bush. The man makes his way slowly back to his house where he finds the door locked. He knocks on the door.

"Who's there?" His wife asks from inside.

"It's me. Open the door...inshallah!"

As I finally pull up into Bere after two straight days of traveling back from Abeche I'm reminded of the story. I pray silently that God will continue to open the doors for us to have a hospital there in Eastern Chad...INSHALLAH!

Snakebite

2009-06-30T11:42:00.000+01:00

The sound of a load diesel motor and the sudden appearance of headlights outside the fence sucks me quickly out of a deep sleep into the darkness of a moonless Chadian night. The truck stops in front of the hospital. I have a feeling I might as well get up already.

Sure enough, within minutes, the all-too-familiar knock, knock, knock on the sheet metal door confirms my suspicions.

"Oui?" I mumble as I roll out of bed trying not to disturb Sarah.

"It's me." Sounds out from through the screen door and across the porch into the bedroom. It sounds like the night nurse, Augustin. I pull on some shorts, grab my glasses and fumble through the dark of the living room which is lit eerily by a blue bug lamp.

"They've just brought in a Fulani boy with a snake bite."

I arrive at the door and take the blue carnet from Augustin's outstretched arm.

"He's agitated and his leg is swollen."

"How long has it been."

"About two hours. They're camped out over by Lai and he went to get some water or something and was bit on the foot."

"How did they find a car at this hour?"

"They ran to Lai and found someone."

"Ok, give him a vial of anti-venom in 500cc of Ringer's. Let it run in over 30 minutes. There's not much else really to do. Either it'll work or it won't...oh, give him some Diazepam to calm him down."

"Ok." And Augustin disappears into the night.

I walk inside and pour some water into a canning jar which serves as my guide to make sure I drink at least 5 liters of water a day. As I stare out into the shadows of the yard my thoughts wander to the boy.

Should I go up to the hospital? Would it make a difference? Won't he just probably die anyway?

Then I start to think, of the two forces in this world, good and evil, which would want me to go up to the hospital and which would recommend I go back to sleep. It's a no brainer, so I put on scrubs, grab my keys and head up to the ER.

On the way I send up a quick prayer. "Whatever happens, make sure You get the glory. If I can pray with them, give me the chance so they'll recognize You as the One who heals."

I arrive in the ER and pull back the green and yellow curtain. Writhing on the bed in agony, looking like death warmed over is a slender, wiry nomad boy with dreads, traditional scarring on his face, leather fetish bags around his neck, string bracelets on his wrists and wild colored pants blood stained on the right leg. His right ankle is covered with blood-soaked gauze and the entire leg is swollen and already blistering.

He is moaning and non-responsive with gingival bleeding thrashing his legs and arms around from time to time.

A shaven headed man in a dark gray pant-suit and traditional tattoos and the obligatory leather pouches around the neck is remarkable amongst his people for the lack of dreads and the presence of a cell phone on a string around his neck and sticking out of his shirt pocket. He stands at the head of the bed. Squatting all around the ER are more men and several women with the crazy dreads and black, charcoal based lined tattoos on the face, arms and chest. Plastic shoes are standard. Another family member stands in a corner, the bottom of his left foot pushed against his inner right thigh as he balances on one foot like a flamingo.

Augustin arrives with the IV and we hold the boy's left arm still while the IV perfusion gets running.

"Give him an ampoule of Pentazocine sub-cue since obviously the Diazepam isn't enough."

As Augustin leaves to get the Pentazocine I motion to the Fulani men and speak to them in my broken Arabic.

"We pray to Allah. Allah give him health. Allah only. Ok?"

Heads nod vigorously in agreement as arms outstretch in the Muslim prayer position.

"Rabbina Allah! Give this boy health. Give this boy life. In the name of Isa al-Masih, Amin!"

As the simple prayer finishes our hands move to our faces to take in Allah's blessing as murmurs of "Shukran" and "Alhamdullilah" whisper around the sleeping, snake-bit boy. The bald man points to the sky and pronounces solemnly, "Allah only gives health and life. Allah only."

Augustin arrives and gives the Pentazocine.

I go to the OR and get a 60cc syringe. I draw up 20cc of Ringers and combine it with the 10cc of anti-venom and give it slow IV push over 10 minutes. Within minutes of starting the anti-venom, the gingival bleeding stops and the ankle bleeding slows down.

The boy is asleep now, thanks to the meds. In fact, he's gurgling. I show the Fulani man with the bald head how to do a jaw thrust to open his airway and the boy starts breathing easier. I keep reminding him to keep the airway open as he keeps getting distracted. Finally, he buckles down and gets it.

I tell Augustin to get some IV Chlorpheniramine ready in case he has an allergic reaction. He comes back to say that the pharmacy is out.

Just then, I notice some welts showing up on the boys arms and abdomen. I rush to the OR and come back with Adrenaline and Benadryl. We give him the shots. It seems to stop spreading. His heart is racing but he's still knocked out.

I go back to the OR into the stock room and find the Hydrocortisone we'd just finally found last week at the pharmacy in Lai. Augustin adds 100mg to the perfusion.

I stay by the boy's side often placing my hand on his chest to feel his heart beat and see if he has a fever. He's breathing is slow and shallow and without the constant pressure of his Fulani uncle's hands thrusting his lower jaw forward he would drown in his own saliva.

What I wouldn't give for an old foot powered suction pump!

The bleeding has all but stopped and the hives aren't spreading and, maybe it's my imagination, but they seem to be receding a little.

The Fulani faces around me seem to relax a little. They sense that he might live.

"Alhamdullilah!" I say and point skyward, "Allah only!"

I go home.

The next morning, the boy starts to wake up. We find he has malaria, after 3 more days of malaria treatment, he is eating, sitting up, moving around and the swelling in his leg has started to go down.

I bid them farewell after thanking God again one more time for saving his life.

James

Horses

2009-06-26T19:35:00.001+01:00

It's a gray Saturday morning. 6:30 am and a cool breeze is blowing in a cloudy sky bringing out the deepness of the green starting to push up through the desert soil. The transformation of desert into lush grasslands has begun with the first rains. Stefan and I are going for a ride. Pepper and Bob are standing near the stables but Libby is nowhere to be found. I search the compound and finally find her standing under a tree staring blankly through the chain link fence across the soccer field into the horizon. I grab her halter. She resists briefly with her head pulled back before resigning herself to her fate.

I tie Bob up to the tree right outside the stables and grab the new, synthetic saddle someone just gave Sarah and cinch it up as tight as I can across Bob's ever increasing girth. He's getting so strong I'll use the bit today. I slide the beautifully worked leather and silver harness and bit into his mouth and squeeze it over his ears and attach it under his chin. I attach the saddle bags over Libby's rump and fill it with water bottles, and a French Bible and Nangere songbook. I place my left purpose into Bob's stirrup and swing up and into place.

We saunter up to the gate and out into the street. Most people are just waking up huddled around smoky leaf fires warming themselves up after a long "cold" night. Some are gathered around a pot of bouillie anticipating the temporary assuaging of the ever present hunger of the end of the dry season. We cross Bere and approach Bendele. Gary and Wendy's empty house stares at us from the left, it's gate locked with a padlock and it's windows barred. A heavy silence reigns.

A few meters up Noel's children wave and flash huge grins as they shout out the obligatory "lapia! James-uh! Stef-ahn!

Passing Noel's house takes us out of the village into the bush. The main road is packed with a steady procession of people on their way to market. Women in brightly colored wraps saunter along their arms swinging in rhyme keeping in balance on their heads the large basins filled with sweet potatoes, sugar, millet, rice, corn, bean leaves and other marketable items. An ox cart plods slowly by loaded with sacks of grain, a few young kids piled on top and one lazily sitting across the pulling bar with a stick in hand to swat the two long-horned cows into the right direction. More women pass, long piles of twisted sticks cut into six feet lengths, tied and bundled onto their heads. Old and young mix in a never ending procession heading for the biggest event of the week, the Bere market.

Further up, we enter a small village where some of the travelers have stopped under a mango tree gathering around a large pot of freshly prepared rice wine to fill their bellies for the exhausting trip to Bere on foot and to prepare themselves for the social scene and eventually a staggering stumble home, dead drunk. They wave wildly their faces lighting up with white, toothy grins as we pass and call out our greetings.

I've switched to Libbly now, as Stefan was having some troubles controlling her. We've been trotting for a while when an open stretch of road heading to Dabague opens up before us. I give a cluck and a kick with my heels and Libby is off on a fast gallop. She's our newest addition to the stables and like Pepper and Bob came to us at a good price thanks to her malnourishment. When Sarah walked her back from the Arab village where we bought her, she could barely do 5 kilometers at a slow walk. Now that she's put on some weight and become one of the friendliest horses around I want to see if she can run and if she's at all competitive.

I'm in front for a while before Bob catches up and barely passes us. Libby picks up speed a little but seems content to stay with Bob and not pass him. Alternately walking, trotting and galloping the 18 kilometers to Delbian pass quickly accompanied by a thousand "Lapias" and "As-salaam alekums".

We tie up Libby and Bob near some grass while a short man with a limp brings a bucket, fills it at the local water pump and gives the horses a much needed drink. We take off the saddle bags and saddles and hang them over mango tree branches out of the reach of curious little hands. I get to tell the story of David and Goliath to a group of kids where practically every other boy his carrying his own sling and sheep are grazing in the background. The story of a shepherd boy killing a giant with a stone and sling has never seemed more real.

I then am told by Noel that I'll be preaching so I pull out of my past the sermon I borrowed from the Pineapple Story guy about God loving impossibilities in using Gideon and 300 men to fight off an army of 135,000; Elijah taking on 400 prophets of Baal on a mountain and God burning up the wet wood, bull, stone and earth with fire from the sky; and Daniel's three friends being saved from a fiery furnace heated up seven times hotter.

In a surprising lack of African hospitality, Stefan and I are allowed to escape the usually obligatory millet paste and slime sauce meal and head back to Bere. Just outside of Dabegue, we come across three young boys bareback on tiny ponies herding cattle. As we trot past, one of them turns and starts running alongside heading towards the road. He wants to race! I cluck loudly and give a big kick to Libby's flanks and she almost shoots out from under me as she pushes to catch the pony. Within seconds we pull even and leave the surprisingly fast pony in the dust. Entering Dabegue we tear around puddles of water, under trees and around people scampering to get out of the way. I'd seen Stefan gunning Bob and was sure he'd catch us by now. I quickly over my shoulder and he's nowhere to be found. A commanding "whoa", a sharp pull on the reins and a lean back with all my force and Libby stops dead in her tracks.

Stefan finally catches up explaining that he lost his hat as Bob sprung forward to enter the race. We continue trotting and walking until we are about 5 kilometers from Bere.

"Let's race Bob and Libby. I want to really see what she can do. See that tree to the left just beyond that puddle? It'll be a walk up start. As soon as we enter the shadow of the tree, the race starts."

I feel my heart beat pick up as the tree approaches and we try to keep the horses even. It's a slow walk up. We're only a few feet away. The horses start to sense our excitement...and...we're there. Libby seems to have been expecting it as she rockets forward almost pulling my feet out of the stirrups. I'm holding on for dear life. We're ahead! I then see Bob cut around a little to the left where a side path goes around some bushes. He's picking up speed. At the same time I feel Libby fading, she's just not in shape and running out of energy. Bob leaves us way behind as we continue a slow gallop to the entrance to Bere and do a cool-down walk the rest of the way home.

As i finally pull myself out of the saddle, I can't believe how tired I am. I'm so wobbly I cna barely stay a foot. I'm covered with sweat and fine dust. The horses slurp up bucketfuls of water and then go for a roll as soon as their saddles are off. I take a quick shower and fall into a deep sleep before being awakened shortly by the nurse on duty.

"There's a woman with high blood pressure and seizures. She's seven months pregnant. The cervix is completely dilated."

I give some instructions and go back down to lay down, but then think better of it and get up, put on scrubs and head to the hospital.

The woman is thrashing around on the bed moaning and whining. The cervix is only at three centimeters. We start an oxytocin drip to give her better contractions and I go to see some other patients. The nurse runs to get me.

"She's having a crisis again!"

I enter the labor and delivery room. The husband is at the bed side and the woman is hysterical. It's not a seizure, though, and she quickly calms down when the husband leaves. I order some pain medication and then she has a grand mal seizure. We hurry her to the OR. Luckily Simeon is there and Samedi lives right next door. The woman is combative and agitated and difficult to get on the OR table. We tie her arms and legs down good, prep the abdomen, scrub and gown and drape.

We pray and Simeon gives one milliliter of Ketamine and I slice down to fascia, rip the fascia and muscles open, lift up a bladder flap, slice into the uterus, poke into the amniotic sac and squeeze out a full term baby boy who after a little rubbing and slapping starts to give a healthy cry. I suture up the uterus and skin and head home to finally rest.

James

Only God Knows

2009-06-23T12:45:00.002+01:00

I've just started rounds on surgery. The young girl operated on for perforated bowel secondary to Typhoid Fever is doing much better. She still has a drain in and we're doing dressing changes on the open wound on her skin incision but she's eating, drinking, walking, pooping and peeing so we are otherwise happy. Suddenly, Carson comes in and in his slow drawl tells me they need me to help find an IV on a kid...it's kind of urgent.

I walk through the open screen door, across the porch covered with convalescing patients and family members lying on colorful mats, across the well-swept courtyard and over to the sidewalk where a small crowd has gathered around a mother with a brightly colored head wrap holding a limp child sitting on a wooden chair facing away from me and towards the white coated nurse bent closely over the child trying to start an IV. It's the new nurse, Tchiptchang. Standing to the side, muscles bulging out of his scrubs, Abel holds a bottle of 5% glucose attached to an IV line waiting for the chance to attach it to a venous access.

I'm quickly filled in as I stride up.

"Really low blood sugar. Sick for a week. Treated at home with market meds and who knows what else. Just came in. Unconscious. We can't get an IV."

The kid's eyes are rolled back in his head. His hands and face are pale. His body is like a rag doll. I listen and he has a faint heart beat. He's barely breathing.

"Let's get him to the OR!"

We rush off around the corner and into the brightly lit OR prep room. We place the child on a gurney and I start doing chest compressions. Abel and Tchiptchang are trying to find a scalp vein. Carson is holding the IV which we have placed subcutaneously on his abdomen which is swelling up. He remains unconscious. I suggest they try and external jugular vein on his neck. Augustin arrives and tries as well. No success. I try a femoral vein on both sides while Abel and Carson take turns doing CPR. I fail on both sides.

The nurses keep trying on the scalp and neck. No luck. I call for another hemoglobin as I can't believe the first one is really 10. He looks too pale. His heart is still beating, though barely. We keep on CPR. He's about 2 1/2 years old. His mom stands in the background, a helpless and hopeless expression on her face. She's probably thinking of all the other small boys she's seen buried in her life and thinking about probably burying hers today.

I'm thinking back to the 4 year old I was just doing similar, unsuccessful, resuscitation efforts on last week. I'm about ready to stop. The hemoglobin comes back 8. We keep on CPR. The nurses keep trying to find an IV. I finally try the right femoral vein again.

I stretch out the skin on his inner thigh. I feel for a pulse but find nothing. I poke blindly with a 22G IV catheter attached to a syringe I aspirate from. I get some dark blood back. I can't really thread the catheter. I take out the needle. No blood. I slowly pull it back until the blood starts to ooze out. I call for the IV tubing and attach the 5% glucose solution and hold the IV to let it run in fast. We tape it down but someone has to hold it just so in order for it to work. Within 30 seconds, the boy's eyes open. A few seconds later he's looking around and starting to move his limbs. He has a strong heart beat and is breathing!

We give him some oral sugar water and show the mom how to keep giving him that all day long.

We let the glucose run in. The nurses finally find a real IV and we start treatment for malaria. Why do some make it and some don't? Only God knows.

James

Coffin

2009-06-12T09:16:00.004+01:00

When I first saw the coffin it was half-finished. Lying amidst a pile of saw dust, it was a crude little thing, but somehow appropriate. Hard, twisted redwood had somehow been fashioned into a 3 foot long box with bottom, back and sides just waiting for the front and top to be able to enclose a little boy's body.

As I walk up to the container where Jeremy and Jonathan are making the coffin, I am struck by the cold beauty of the surroundings. A steel blue sky with gray angry clouds releases a slight drizzle of rain onto the African plain watering the wet sand and scrub bushes. A smattering of mango and Shea butter trees break up the monotony of the flat expanse. A group of tired grave diggers rest against the trunk of a tree to the right. Straight ahead is the beginnings of Gary's airplane hangar with the two old 20 foot containers making up the end of the hangar. Around the half-open doors of one container is gathered a crowd of mostly children with a smattering of adults all peering intently at the two white men making a coffin.

The purr of a small Honda generator is broken intermittently by the harsh roar of a power saw and the shocking pounding of large nails into hard wood. A cool breeze tries to soften the atmosphere which is heavy with grief. I squeeze through the crowd just in time to help Jeremy and Jonathan lift up the coffin, measure around and make the final trimmings. The wood is so hard that holes have to be drilled before nailing or the nails will bend. We place the small head piece on and Jeremy hammers the nails home. The only thing left is to place a small boy, recently alive and well, into the interior and hammer it shut until resurrection day.

The Adventist Youth Society has arrived in their sharp olive and tan uniforms. Jeremy, Jonathan and a couple of local men pick up the heavy burial box and lug it over to Gary and Wendy's humble abode. They place the casket gently on a simple wooden bed on the porch and wait for the final step.

Cherise, Gary and Wendy's two and a half year old daughter, runs in with a smile proudly showing off the cartoonish horse and car that Sarah has drawn on the back of her hands with a green marker.

It's almost time. Neighbors and friends are gathering outside. The rain continues to sprinkle the event as lighting flashes occasionally in the background. Gary looks at me. We walk silently over to the coffin and pick it up. It's rough and twisted wood bites into my hands with the weight of it's import crushing me more than it's physical gravitational force.

Followed by Wendy and Cherise we enter the house, pass through the living room and into the bedroom to the left where Caleb awaits, cold and silent. He is peacefully lying on the floor next to the two mosquito net covered mattresses where he slept with his sister. A small, baby blanket covers most of his lifeless form. Gary and I gently set the coffin down next to him. Gary lifts him up while Wendy arranges the blanket and smoothes it out over his face. Gary picks him up gently in his arms, tears streaming from his red and swollen eyes.

"Let me hold him one more time." Wendy's voice is deep and broken as she hugs her first born son for the last time on this earth.

"Cherise, do you want to kiss Caleb one more time?"; Gary asks softly.

"Yeah, daddy..."; She approaches wiping away a stray strand of pure, blond hair from her cherubic face. She leans forward, lips puckered, and places a tiny kiss on the top of Caleb's pale head.

Gary covers Caleb up again and lays him in the coffin. He fits too well. This shouldn't be happening. I sob quietly, letting the tears flow freely.

We take the even heavier coffin out to the porch where Jeremy expertly pounds the last nails home with a devastating sound of finality. It's definitely time now.

The uniformed young people wait outside. Gary and I place the coffin on the shoulders of six young Chadian girls who will bear the honors.

"Left, left, left-right-left..."; The solemn march begins as we all fall in behind while the young people sing a mournfully echoing marching song about following Jesus no matter the cost. The procession winds out the gate, around the fence, past the water tower and out towards the airstrip.

Gary's plane stares silently, it's windows covered with a tarp as if even it is too grief-stricken to observe the final steps of the young boy who loved so much to greet his daddy's return from mission flights or climb all over the cockpit dreaming of the day when he too would fly.

We march across the deep red laterite surface of the airstrip, cross a sandy path, pass through some low scrub brush and arrive at the six foot deep hole that will be Caleb's resting site until the end of the world. A pile of sandy clay with two hand made ropes strung across it lays to the side of the grave. The coffin is marched around the hole and deposited carefully on top of the ropes and dirt pile. A crowd has gathered. The wind blows. The rain falls. The universe mourns.

The service starts with a couple of French hymns that have never had much meaning for me until now.

"Jusqu'a la mort, c'est notre cri de guerre, le libre cri d'un peuple rachete, jusqu'a la mort nous te serons fideles..."; (Even unto death, it's our battle cry, the free cry of a redeemed people, even unto death we will be faithful...) Even song off tune the deep feeling of those singing it penetrates to the bottom of my heart. We are free, we are at war, their are casulties, but we don't mourn as those who have no hope...we will stay faithful...my heart wants to believe it.

"Et mon coeur n'a rien a craindre, puisque tu me conduiras. Je te suivrai sans me plaindre en m'appuyant sur ton bras." (And my heart has nothing to fear, because You are guiding me. I will follow You without complaint, leaning on your arm). A cold chill runs down my spine as I feel the presence of God. He is present. He weeps with us at this tragedy. We have nothing to fear.

After I give opening prayer, Andre exhorts us with a little eulogy reminding us that death is a sleep, that our hope is in the resurrection when Jesus comes again to reunite all of us who have abandoned our rebellion against him. Caleb's suffering is over, it's those of us left on earth who suffer, but Jesus is coming soon to wipe every tear from our eyes and destroy our last enemy, death.

Then, Gary talks about how much Caleb loved to talk about Jesus and his second coming and then he had us sing together Caleb's favorite song in English:

"When the trumpet of the Lord shall sound, and time shall be no more...when the roll is called up yonder I'll be there!";

Unfortunately, as the local gravediggers go to lay the coffin in the tomb they realize they've made the hole too small. As they rush to and fro quickly to dig the grave larger, the chorale saves the day with a some traditional, echo and repeat style African songs. Finally, the modifications are made and the coffin is slowly lowered into it's final resting place with the help of the rough ropes.

As the dirt starts to be shoveled on top of the coffin, Cherise seems to realize a little what's going on. Her heart-breaking cries and tears tear us all apart. Gary crouches down gently beside her.

"What is Caleb doing right now?";

"Sleeping, daddy."

"And when will he wake up."

"Oh yeah, when Jesus comes." Her face lights up a little and she wipes her eyes as Wendy picks her up and holds her close.

As the crowd starts spontaneously singing in Nangjere, the grave-diggers expertly create the funeral mound. A handmade hoe, a stick and the end of a shovel pound and stir the earth into place as two other men shovel the earth in and continually pick up what has fallen to the sides. Then with some final pounding with the flats of the shovels a perfectly oval mound arises as only those who've seen much death and assisted many funerals could make it.

We then turn to follow the Advent Youth as they lead us back singing the same marching songs. Arriving at the house, we follow local custom by seating Gary, Wendy and Cherise in lounge chairs along with the other participants in the memorial service while the mourners pass one by one to greet. The women curtsy and bow while solemnly shaking hands, often with two hands or the second hand touching the forearm of the right hand as they shake as a sign of respect. The men shuffle and nod somberly as they hold the hands for a long time and silently let you know they feel your loss (and they all have lost children so it means something). One crippled man on crutches hobbles in and hugs both parents while tears stream down his cheeks.

Finally, the kids file in for their respectful shaking of hands as the adults take a seat on mats spread out behind the choral which has been singing French hymns without ceasing. Annie and some of the local women serve Kool-Aid. People quietly converse. Occasional sobs burst forth. Laughter is sometimes heard. Gary and Wendy are periodically called away by phone calls from well-wishers around the world.

Dusk approaches. Noel rises and calls an end to the wake with a prayer. They graciously don't insist on their custom of singing, dancing and drumming all night long. Instead, everyone files solemnly out shaking our hands one last time. About this time, Rich and Anne, our friends from N'Djamena arrive.

The sun sets on a day that started out as any other day and quickly tumbled into an early morning ER call, a desperate last ditch effort and the laying to rest of a four year old boy in a crude, twisted coffin, resting peacefully in the African bush through the rest of this world's turmoil until the end of the world and the beginning of the next when God will wipe every tear from our eyes and our last enemy death will die as we all are reunited with those we have lost.

James

Tragedy

2009-06-10T12:47:00.000+01:00

"Hurry to the ER! James! Run!" The familiar words come not in the usual African French but in the familiar English of our friends, Gary and Wendy Roberts as they whiz by the house on their motorcycle.

I'd just gotten up a little before 5:00am to write email when I heard the roar of the moto and the cries of the anguished parents.

I quickly pull on some scrubs and rush out the door where I run into Sarah who's just come to get me. She is just finishing up a night shift in the ER. It's about 6:00am.

The hospital is bathed with an early morning tranquility that would've been soothing on any other morning but this one.

I arrive at the ER and see Gary bent over his son, Caleb, giving him mouth to mouth as his pale, limp body wants to sink into the top of the desk he's lying on.

"He was still breathing as we were coming but he just stopped. He has no heart beat!"

I start giving chest compressions as I bark out orders to Sarah, Wendy, Koumabas, Hortance and Augustin who luckily happens to be there.

"Get some IV glucose and some IV tubing!"

"Someone look for an IV!"

"Call the lab for a hemoglobin and glucose check!"

"Get the pulse ox from the OR!"

As they rush off to find the material I look closer at Caleb. His body is flaccid, his face is pale and haggard, eyes closed, mouth half open, a mild gurgling coming out of his throat with each chest compression. He has no heart beat and his lungs sound filled with fluid. His belly is soft with an enlarged liver.

Gary takes over chest compressions as Hortance hands me the D5W attached to some IV tubing which I quickly insert under the skin of his stomach for a subcutaneous perfusion of glucose in case his blood sugar is low.

"Give him half an ampoule of IV furosemide IM.

Augustin is patiently searching for an IV on Caleb's small, white hands and arms. Sarah arrives with the pulse oximeter. We continue chest compressions. The O2 sat is 15%. I have Gary start rescue breathing again. The pulse ox stops working.

"Sarah, get some Adrenaline and Atropine from the OR!"

Still no IV.

"Koumabas, get me a blue IV catheter and a 5cc seringe!"

I keep doing compressions while Gary does two rescue breaths every 10 cardiac compressions.

Wendy has come back with an epi-pen and accidentally sticks her thumb with it instead of Caleb's leg.

Sarah gives Adrenaline and Atropine intramuscularly.

I listen and detect a faint, slow heart beat.

We continue CPR.

"Wendy, find me one of those small red, urine catheters in the OR so we can empty his bladder!"

Koumabas gives me the IV catheter with which I miraculously find his right femoral vein on the first try despite feeling no pulse and am able to thread the catheter in. I attach the IV glucose bottle and let it run in.

Meanwhile Mathieu has arrived and now has the results: hemoglobin a little low and blood sugar extremely low.

Wendy returns with the foley and Augustin drains Caleb's bladder. Calebs lungs are clearer. He still has a faint heartbeat.

"Sarah, inject the Adrenaline as rapidly as you can....now!" I quickly pump Caleb's heart has fast as I can with my external compressions to get the medicine to his heart.

"Sarah, take over chest compressions, I'm going to find some Magnesium in my office!"

The magnesium goes in the IV fluids and slowly trickles in.
Gary still does rescue breathing. Wendy offers to take over but Gary wants to keep going.

"Mathieu, can we do a Potassium?"

"Oui!"

I draw a milliliter of dark blood from Caleb's femoral vein and Mathieu hurries off to the lab.

CPR continues. We've been going for 40 minutes.

I listen to Caleb's chest. No heartbeat.

We continue CPR.

"Sarah, more atropine."

Gary speaks up after his 2 rescue breaths. "Should we stop?"

"Let's go just a little more."

Atropine is in. We continue CPR 5 more minutes.

I listen to Caleb's heart...

Nothing.

We stop.

Gary and Wendy collapse weeping into each others arms as sobs explode from within my chest. I grab Gary from the side my arm draped across his neck. Sarah is on the other side hugging Wendy.

Gary solemnly wraps up the still, little body.

"Do you want to use the van? We can drive you back home."

Gary turns to Wendy, "No, let's just put him between us on the motorcycle and go home."

"Anything we can do?"

"No, we just want some alone time. Then in the afternoon we'll have a service." The trudge out to the motorcycle, the quiet bundle in Gary's arms.

Tears streaming down my face I walk slowly back home thinking back to September 3, 2001 when I also found myself stopping CPR on someone I loved and sadly giving them up temporarily into God's hands. Just like then when I told my twin brother, "I know where you'll be...I just better make sure I'm there as well," I think the same thing about little Caleb and can't wait to see him again, maybe even by my brother David's side, when things are finally finished down here.

But, meanwhile, I'm back home sobbing like a baby. Sarah walks in and kneels down in front of me. We embrace and cry together. Outside, the wind is blowing, whipping up a storm. It starts to rain. God is crying too.

Message from: James Appel

2009-06-10T12:44:00.000+01:00

I feel a cold sweat creeping along the surface of my skin. A sensation of nausea rises to my throat. I desperately try to focus my eyes somewhere that will calm the waves of motion sickness but as the Cessna 172 lurges and plunges in the turbulence 7500 feet above the surface of a desert in a wall of dust and clouds there seems to be no escape.

"I think I might need one of those barf bags Sarah just brought you." I stoically mention to Gary.

"Here, you better start flying again, that often helps...gives you a little sense of control when it's turbulent."

I grab the controls and try to remember to make small adjustments back and forth and side to side as my gaze shifts rapidly between the horizon and the various instruments on the panel as I try to maintain altitude, direction, vertical speed, and bearings as the thermals rising from the hot sand below buffet us up and down and side to side.

My nausea slowly disappears.

An hour later we as we approach Bere I give the controls back to Gary for the landing. The two men in the back from the Chadian government who have come to evaluate our work at the hospital break the silence with a heartfelt "Dieu merci" as the plane touches down smoothly and taxis in to the waiting hospital van.

I greet Levi warmly and we pack up and head to the hospital.

What was starting to turn green with the early April rains has changed to a dreary brown.

"I guess I must have taken the rain with me to the US," I joke with Levi. "A week after arriving in Florida they had a two week long rain storm that ended their drought. Don't worry, though, I brought it back with me!"

We both laugh, but half hope it's true as people are already starting to talk about famine this year (although they do every year no matter how much rain we get.)

I get our visitors settled in the guest house and change into scrubs to take a quick tour of the hospitalized patients.

The arab man with the broken tibia and jaw is elated to see me and immediately asks to have the PVC pipe external fixator removed. The wiring on his jaw was taken off a few days ago and seems to be well healed. The leg looks good too, we'll have to send him to Moundou for an x-ray since ours has been broken for years.

Mathieu, our friend who spent a month collecting a seriously infected fracture with the local traditional bone setters before coming to us just in time to save his leg waves to me from across the room. I greet him and take a brief look at the wound which has closed up somewhat but is still quite deep into the gap left where we'd removed the infected bone.

All the other patients are new.

That evening I am woken up by a fierce wind followed by a scattered rain. The next few days we have several intense thunderstorms. The drought is over. It's good to be back.

Hellp

2009-03-21T02:47:00.002+01:00

I start rounds right across from labor and delivery. A long man operated on two days ago for hydrocele and hernia is sent home after being advised to quit drinking as his alcoholism became evident during his difficult Ketamine anesthesia. A pregnant woman who came in yesterday with a hemoglobin of 4.3 sits with a blood bag attached to her arm with the plasma still inside. She has got two 450ml bags of whole blood and needs more but no family members can be found. The baby with the ileostomy is sleeping comfortably beside her mother. The ostomy that herniated out last night is back in place and the midline incision appears to be healing well.  

The little girl in the old maintenance closet turned into isolation ward is sitting up half naked eating some porridge. Six days of Chloramphenicol with a single dose of Ceftriaxone have done wonders to transform her meningitis coma into a hope of full recovery.

  Moving past the nurses station and the chaplain's office I greet the Fulani nomad woman with a long, gunnysack sewn up wound across her chest into her armpit where her tumor filled breast and lymphnodes used to be. The deep cavity left by the removed lymphnodes has become infected and is being dressed with diluted bleach. She wants to go back to the bush where she can drink milk from her own cows. She just doesn't like the food available here in Bere. We finally convince her son to keep her here.

  Two men operated on yesterday for large inguinal scrotal hernias grace the next two beds. I order there IVs out and for them to get up and ambulate.

  Beside them is a woman who's life we barely saved three months ago. She had been in labor for 3 days and came in with a dead and decomposing baby stuck in her small pelvis. A symphysiotomy brought the baby out quickly but the gangrenous flesh had to be debrided several times and her vagina packed for weeks with diluted bleach soaked compresses and heavy doses of antibiotics. As a result, she developed an enormous vesico-vaginal fistula and a scarred down vaginal vault and cervix. Three days ago I attempted a vaginal repair with not much success. That evening I was awoken by a sense of God's presence and an idea to operated on her the next day which I did opening up her bladder from the abdominal side and inserting a ureteral catheter into her right ureter to drain the urine out the abdominal wall. Her left ureter appeared scarred down as the catheter wouldn't pass. I then closed up the defect from on top and left the a foley catheter in the urethra and the uretral catheter coming out her lower abdomen.   

Today there is clear urine out of the right ureteral catheter and bloody urine out of the bladder drain meaning that maybe her left ureter is working after all. More importantly, she has no vaginal leakage.  

An emaciated Arab lies across the way. I saw him at 4:30 this morning with almost no blood pressure and a raging fever. He responded to IV fluids and IV quinine. I suspect him of AIDS and add broad spectrum antibiotics. His HIV status is confirmed later and he dies in the early afternoon.  

Meanwhile I move on to the middle aged woman who had a hysterectomy yesterday for fibromas. She is well. Next to her is a woman who has had her knees permanently bent since the age of 12 due to burn contractures until January when Dr. Bond released her right leg. I released her left leg in February and the wounds are healing well and she can almost straighten both legs now.  

First bed on the left in the men's ward is a man with an abscess deep in his thigh to the side of his hip joint and back into his gluteus. The drain is still working and the swelling and pain have gone down. His neighbor is another hernia that is sent home. To the right is a man with gangrene of the scrotum debrided radically 6 days ago who got malaria and had a hemoglobin of 4.7 found yesterday who is still waiting for other family members to come since no one has the right blood type. His wound is much better and he is sitting up comfortably.

  Missing from their mosquito net covered beds are the two miracle burn kids who are almost healed without skin grafts. In fact, little Bai has become Sarah's little adopted kid and walks around with her squirting patients with syringes full of water and sitting in her lap for morning worship. The older girl is healing well but is depressed and doesn't want to get up.  

The young man who was stabbed clear through the front of his shin between his two leg bones into the back of his calf severing his large vein and puncturing his artery is doing better today. I thought he had an abscess so took him to the OR by myself only to find myself removing massive clumps of blood clot releasing a pent up surge of raging blood. Since it was coming from behind the tibia there was no way to compress it. I ran and pulled up a used suction tubing from a basin and quickly tied it around his leg above the knee to stop the bleeding before calling in help, opening up his calf, dissecting down to the vessels, suturing the hole in the artery and tying off both ends of the vein. He know complains of foot pain. I prescribe Ibuprofen and paracetamol.  

His neighbor is the man who came back a month after refusing surgery for an open tibia fracture with his leg completely infected, swollen, edematous and spilling out pus from a non-union broken bone. We had to radically remove the front of the tibia and pierce his tibia with four Steinmann pins attached to some PVC pipe to act as an external fixator. The wound still smells but is much better and fortunately the pus around the pins is starting to dry up.

I tell Simeon and Abel to prepare the woman for the hysterectomy, do the spinal anesthesia and call me. Meanwhile I round on a pediatric ward filled with Malaria kids, most of whom are recovering and can be sent home.

I do the fastest hysterectomy of my life and go out to do a couple of ultrasounds while the OR crew prepares the 4 year old boy with bladder stones. As I approach my office a well-dressed woman greets me with her cute little daughter. She's about 4 years old with a spotless, frilly baby blue dress and newly braided hair and a sweet smile as she profers me her hand in a shy greeting.

"Do you recognize her? You delivered her by c-section in 2004 when you first came here."

I don't remember, but smile and nod as I go into my office with warmth in my heart.

I finish the first ultrasound and Sarah peeps in the door.

"You better see this patient in the ER."

"You mean now, is it urgent?"

"Yes, this woman is crashing!"

I rush out across the campus under the mango trees to the ER.

A woman lies in an army stretcher barely breathing, swollen eyes shut and gurgling through a weak respiratroy effort. She is obviously pregnant.

"Augustin, Job, Prudence! Grab her and bring her directly to the OR!"

We dump her directly onto the OR table and I prepare to intubate her as Abel quickly finds an IV. She starts to bleed as I search for her swollen vocal cords and finally slip the ET tube through with help from Simeon's cricoid pressure. I call for another IV and a glucometer and hemoglobin measurement. Her body is burning up so we have Ringer's Lactate running wide open on her right arm and IV quinine on her left. Simeon has put in an NG tube releasing some nasty gastric contents which spill onto the floor from the open urine bag attached to the end. She starts to gurgle blood from her nose and mouth in frothy spurts. Simeon suctions. Her glucose comes back way low and we trade Ringers' for Dextrose.

I go get the ultrasound from my office and confirm a normal fetal heartbeat, cephalic presentation and 33 weeks estimated gestational age. Her blood pressure is initially normal but suddenly sky rockets and stays high. We do a urine dipstick which is highly positive for protein suggesting the diagnosis of pre-eclampsia. With her enlarged liver and uncontroallable bleeding I also suspect HELLP syndrome. The only thing is to deliver the baby.

A quick, uneventful c-section brings a small but well-developed boy into the world with great tone and grimace. I pass him off to Hortance and sew up the uterus, fascia and skin. The woman is still doing poorly with heart rate over 150/minute and high blood pressure and low O2 saturations. Blood is everywhere as she continues to spray bloody foam all over. I don't hear a cry from the baby but Hortance has said he was breathing. I go over to look and find him pale, limp, with no respiratory effort and a slow heartbeat. I am furious and try desperately to do CPR and bring him back but it's too late.

We leave the woman in the OR on a gurney where we can monitor and suction her. We get two bags of whole blood running hoping the platelets will help the bleeding. We operate on the 4 year old pulling out two marble sized stones out of him and closing him up uneventfully. The woman is still breathing but sating in the low 80's. The watery blood continues to well up out of her nostrils and gurgle out her oral airway that has replaced her ET tube since we don't have a ventilator.

A quick inguinal hernia on a woman is done quickly and finally we decide to just wheel the woman out to the wards since the family is getting anxious and people don't understand when someone dies in the OR; they tend to think you killed them.

Gasps of fear flutter up from the crowd of relatives gathered outside surgery as we wheel the blood specked woman and gurney out to the wards. We drop her in a bed, tell the husband to wipe up the blood as it spouts out of the mouth and nose, write orders for IV fluids and IV quinine and leave her in God's hands.

The bell tolls

2009-03-15T22:18:00.001+01:00

It's early Sunday morning and the drums are pounding. Deep, holding bass thumps with rhythic higher pitched hypnotizing beats wafting through the background. In a few minutes, a mournful call pierces the African pre-dawn calling the faithful to the first prayer of the day with a long, drawn out "Allahu akbar!" Finally, to complete the symphony, church bells start tolling across town as the dawn breaks. But the music is rudely interrupted by a harsh clanging on our sheet metal door that can only be pounded out by the bare knuckles of a nurse seeking a doctor.

"Yeah?!" I mumble.

"C'est moi, it's me, Augustin."

"I'm coming!"

I fumble for my shorts hanging over the foot of the bed and stumble out the door to the porch where I open the screen door and come face to face with our charge nurse bearing a flashlight and a small carnet which serves as our patients' portable medical records.

"I just received a young boy who has respiratory distress. His whole chest caves in and you can hear the noise of his breathing clear across campus."

As I hurriedly put on my scrubs and follow Augustin through the bushes, around Lazare's fire pit, under the mango trees, on top of the straw and horse poop, to the side of the container, and through the gate into the hospital compound I understand what he means as I can hear a high pitched rasping coming from the dimly lit emergency room door.

A young boy is slouched across his mother's lap as she balances on a stool holding him up under the arm pits as his lower chest literally caves in all the way to his spine while desperately trying to suck in oxygen as he lets out a stridorous breath. His eyes are bugging out and almost rolling back. I listen to his chest with my stethescope and hear practically nothing. I place it on his neck and hear loud stridor. I get him to open his mouth and where the back of his throat should be is a smooth, bulging mass.

I'm afraid I won't get him to the OR in time. I call Caroline to help me and pick up the child in my arms as I jog over to the OR, flip the padlock to the secret code, insert the key in the door and burst into the OR. Fortunately, this morning the batteries have held their charge through the night and we have light. However, I'm afraid the power will go out any minute so I send Augustin to wake up Steve to turn on the generator.

Meanwhile, I lay the child on the operating table and give him a shot of IM Ketamine while Caroline searches for an IV. Just then, power goes out but I hear the slowly increasing thump thump thump of the Lister engine starting up and in a few seconds I can turn on the overhead OR lights and we are back in business.

I dump the cardboard box of endotracheal tubes on the floor as I rifle through them searching for one small enough for my patient. I finally find a 6.0 uncuffed tube and grab the laryngoscope out of the bottom drawer of the anesthesia machine as I slip on gloves. Caroline now has the IV running and the boy is now under Ketamine anesthesia. I find a guide wire, put it in the ET tube, check the light on the laryngoscope, raise the bed and open the kid's mouth. There is no way I'm going to see the vocal cords, the entire back of the throat is swollen shut.

I toss the equipment aside, grab a 15 blade scalpel and a suture removal kit, slice vertically down the middle of the neck, find the space between the tracheal and cricoid cartilages and poke through into his wind pipe with a hemostat. I spread it open, suction out blood and shove in the ET tube. I then hook up a bag and give him some breaths. The chest rises and I see vapor in the tube. I check with a stethescope hear breath sounds only on the right. The tube's in too far. I pull it out slightly, confirm there's now bilateral breath sounds, suture the wound closed, suture the tube in place and continue bagging.

His oxygen saturation is now up to 92% from the initial 35% so I stop bagging and just let him breath through the tube. His sats hover around 84-88% which isn't great, but without a ventilator and labs to follow it's more dangerous to bag him then to let him breath on his own.

I then try to place a nasogastric tube so he can be fed past the obstruction in his throat. It won't pass the mass. I stick my finger in his mouth and try to shove the tube in through his nose while feeding it past the mass with my finger. Suddenly, pus gushes out his mouth. I've ruptured the peritonsillar abcess. I quickly suck out the foul smelling pus and am relieved that it was so easily taken care of.

We wheel him out to his room and give his family instructions.

Later that evening, I go to check on him and find his tube choked up with secretions. We have a suction with a trap that allows me to put one end down the ET tube and then by sucking on the other end pull out the gunk into a chamber between the two ends. Very high tech. He starts to breath easier. I tell Jason to check on him every hour and suction as needed.

The next morning, he is awake, but tired and breathing fairly easily through the tube. I have the family members sit him up, suction him one more time even though it's pretty clear and move on to the other hospitalized patients.

In less than 15 minutes, Annie comes running up to me.

"Stuff's coming out his trach, he's not breathing!"

I run back to his room, chase out the family members and see instantly his tube is clogged up with pus that's dripping out. As I grab the suction to clear his airway I see he's not breathing and his eyes are rolled back. He has no pulse. As I suction, Jacques starts chest compressions. When the airway is clear I attach the bag and start breathing for him.

We take him to the OR quickly. We attach our cardiac monitor. He finally gets a heartbeat back with a pulse but after a few minutes it slows down again until we do more chest compressions to bring it back. We try multiple doses of Atropine and Adrenaline. His oxygen saturation stays in the mid to upper 80's when we bag him. But he just doesn't want to come back. Finally, after 90 minutes we are forced to stop. We wrap him in a cloth and call in the family. The dad nods, he's been expecting it. He wraps the boy up in his arms, carries him out and the family mournfully walks out the gate.

The drum beats on. The call to prayer continues. The bell keeps on tolling.

Ostomy

2009-03-15T22:15:00.001+01:00

"Doctor, you need to see this baby." Samedi calls me to the ER. "She's only 7 days old, but she's never had a bowel movement."

I pull back the curtain and see the frightened mother holding her newborn baby in her arms. The infant's belly is markedly distended, but still somewhat soft. I listen and hear good bowel sounds. The mother says she breastfeeds well and goes on to prove it by feeding the baby right in front of me. I examine the perineum and the anus is present.

"Samedi, get me a glove and some lubricant."

He comes back in a few minutes, I slip the glove on my right hand, apply some goo and gently press my pinky into the tiny anus slowly dilating it until my finger can go all the way in. It's a blind rectal pouch as I suspected.

I inform the parents that their little girl will need surgery immediately and they agree.

Without x-ray, I'm forced to guess exactly the extent of the malformation of the colon. I'm hoping it's just the sigmoid (the last part of the large intestine). Sarah and Simeon tag team the anesthesia calculating the tiny doses of Atropine and Ketamine for it's small, 2.4 kg frame. We strap her into the "papoose" so she can't move, prep her distended abdomen with betadine, scrub and drape and before cutting, pray.

I decide to gamble that I can make a colostomy from the descending colon so I cut a small circle out of her skin to the left of her bellybutton, cut through the fascia and muscles and enter the peritoneal cavity. Small intestines burst out under pressure and I can't get them back in. I move to the center and make a midline incision releasing the pile of intestines to the outside air. I then bring back those that have gone out the side hole and explore inside. The colon hasn't formed (atresia) all the way from beginning to end. The whole thing looks like a long appendix running from cecum to rectum.

Everything is so tiny. I take a part of the ileum about 10 cm from where it joins the cecum and clamp the bowel with non-crushing clamps. I divide the intestine and slowly identify the miniscule vessels in the mesentary and clamp/cut/tie them. I then open up the distal end and suction out all the meconium resting there and suture it closed in two layers. I then pull out the proximal part through the side window, sew the wall to the strong fascia, evert the gooey mucosa and suture that to the skin. I then suck out all the stool from 9 months in mommy and 7 days in the real world and close up the midline incision after irrigating profusely.

I write post-op antibiotic and immediate breastfeeding orders and go home.

Except for a fever the next day found to be malaria and treated with blind rectal pouch quinine suppositories, she has a routine post-op course and is just waiting to have her sutures removed in a few days.

Lubambashi

2009-03-09T17:03:00.000+01:00

The plane has stopped. I thought we were going directly to Lubambashi but we suddenly find ourselves on the ground at another airport. Apparently it was planned since I see people getting up and climbing down the stairs that open up from the tail of the old 727 airplane. I was actually extremely cold during the flight so I decide to take a breath of Congolese air outside. A sharply dressed young Congolese man is standing at the foot of the stairs just under the middle engine. We strike up an easy conversation until he notices something dripping on his suit.

I think it is fuel at first, but on closer inspection, it turns out to be simply water. The man is very friendly and I explain that we are with Adventist Medical Aviation and are doing some research on maybe doing some medical work in Democratic Republic of Congo and in Congo Brazzaville.

At this point our attention is caught by a large mobile staircase being pushed past us to the right engine of the plane a few feet away. Some men scramble up to the engine and start taking off the bottom enclosure. As jet fuel starts to cascade out, the ground crew rushes around collecting plastic buckets to catch it in as a small lake starts to form and flow off the runway.

A man in a suit rambles up lugging an ancient, twisted metal tool chest that folds out from the middle into several trays carrying some large, simple tools. He selects a large screwdriver and climbs up the ladder to the now-exposed engine as a couple of blue-overall wearing maintenance guys scrape out the fuel left in the bottom of the casing.

The mechanic tinkers around and eventually manages to pull of what appears to be the fuel filter. He takes off the filter and examines the cover which appears to be missing a gasket. He shows it around to a few other people amidst the shaking of heads and then puts it right back on. He tightens it up well as the blue guys mop up the remaining jet fuel with rags. Meanwhile, more ground crew have sloshed the tarmac underneath the engine with buckets of sudsy water.

The engine cover goes back on and we are escorted back up the stairway into the plane. Miraculously, we take off and land again at Lobambashi without further incident.

A thin, lighter skinned man with a huge smile, blue ringed brown eyes and a warm handshake greets us at immigration along with a short, stocky dark man who speaks some decent English. We breeze through passport control and are taken to the Adventist Surgery and Gynecology Clinic in a Toyota Hilux Surf SUV. The Hilux Surfs are everywhere but unfortunately no boards or waves are to be seen anywhere.

Most of the vehicles in town have the steering wheel on the right side of the car even though they drive on the right since most of them are imported from British East Africa.

We arrive at the clinic and are told there is an emergency. They are just waiting for the surgeon, Dr. Delgado to arrive.

When I inform them I'd like to assist, they drag me up some steep winding stairs to the attic which serves as pharmacy and stock room. I'm given a pair of elastic waist band scrubs and slippers too small for my feet and I quickly change and enter the OR.

It is small and long with tile running from floor to ceiling. Xrays showing obvious bowel obstruction are illuminated on a viewer straight ahead over the operating table. On the table, covered in a hospital gown is a young, 14 year old girl with a nasogastric tube coming out of her nose attached to a bottle of 5% dextrose for gastric lavage.

At the foot of the table is a metal table covered with a dark green cloth covered with shiny instruments and presided over by the surgical assistant robed from head to foot in the same dark green. His white surgical gloves rapidly arrange the instruments guided by his barely visible eyes behind a blue mask and protective goggles.

At the head of the bed is a jolly, pudgy man in ill-fitting scrubs whose large smile can't be contained by that silly piece of paper trying to pose as a surgical mask. In answer to my inquiries he shows me his anesthesia setup.

The archaic monitor is black and green with erratic QRS complexes running together on the EKG lead making their form, rate and rhythm almost impossible to interpret. But that is child's play next to trying to read the systolic and diastolic blood pressure and heart rate which for some reason are projected as mirror images of themselves.

The anesthesia machine consists of a metal table with bars on the back. An oxygen extractor behind the machine runs a jerry-rigged tubing apparatus up to a canister attached to the bar. The inhaled anesthetic is put in the canister and regulated with a twisting knob that the anesthetist proudly says he made himself. He shows me the scoring marks on the knob that let him roughly know the concentration given.

Laid out in an orderly fashion on the table are 4 endo-tracheal tubes, a laryngoscope and three unmarked syringes containing, according to him, Valium/Atropine, Thiopental and Succinalcholine.

Just then, Dr. Delgado bursts into the room. An Argentinean of Peruvian descent, Delgado has been in DRC for over 20 years. He started at the Songa Adventist Hospital before moving to Lobambashi and opening this surgery and gynecology center. He is known all over the region as the best surgeon around, is personal friends with the governor, has performed over 12,000 major operations there and has trained countless young, Congolese physicians and medical students in the art of surgery.

But I was to learn all that later. For the moment, Delgado was focused on the task at hand.

"What's her story?" He asks the resident who called him in.

"She was sick since Friday, went into another clinic on Saturday, was given malaria treatment and sent off for a bunch of lab tests and x-rays. After three days, she was getting worse and the family brought her here. When we examined her, she had an acute abdomen with signs of obstruction. As soon as we told the family she needed an operation, they wanted to evacuate her to South Africa until we assured them you would come yourself and do the operation."

"Ok, well she obviously needs surgery, it's too bad they waited. I'll go scrub."

Soon the operation is under way. On entering the abdominal cavity, we find pus everywhere with the small intestines stuck together. It takes awhile to clean things up and separate out the intestines to find just what we suspected, a perforated appendicitis.

After the appendectomy, massive irrigation and placement of a drain, Delgado leaves the closure to the residents and he starts telling me about his latest project: a new surgery hospital on the outskirts of town.

The girl is extubated and wheeled off to post-op recovery in stable condition.

The next morning, Delgado is flying to South Africa himself so we meet him at 7:30 in the suburbs of Lobambashi. He has been given 100 hectares by the government where he's built himself a beautiful house and is almost finished with his new surgery hospital. A local Muslim business man from Lebanon has financed the project to the tune of over $1,000,000. The equipment and initial medications are a combination of donations from the AMALF (Adventist Medical Association of the French Language) and purchases from a Swiss company that refurbishes medical equipment.

There will be two full functional Ors, a minor procedure room, a post-op recovery room, an ICU, private rooms, and an outpatient center. Everything is beautifully tiled and the solid, hard wooden doors have been imported from South Africa. It will probably be the best surgery center in between Nairobi and Johannesburg.

Also, on the 100 hectares, Delgado is helping build a Conference Office for the local SDA mission and an Adventist Church.

That evening, I check up on our young patient and she is lying comfortably with no fever and only slight tachycardia. Her abdomen is still slightly swollen, but soft and I already hear a few bowel sounds. I talk with the father who is eternally grateful and tells me that his son has just returned from a visit to Orlando, Florida where my parents live and his daughter wants to go there for nursing school.

As he gives me a ride back to the Union offices where I'm staying, I offer to put him in contact with the SDA nursing school at Florida Hospital and he likes the idea and takes my email address. He insists we come eat at his restaurant the next day but unfortunately, we already have plans.

The last day before heading back to Kinchasa, I make my final rounds and find the girl in even better condition having already passed gas letting us know that bowel function is returning. I pray with the family one more time leaving her in God's hands.

Kinchasa-ball

2009-03-08T17:01:00.001+01:00

Kinchasa has a sort of sport found maybe no where else in the world. I don't know if anyone has actually named it, but it seems the rules are well known. I'll call it Kinchasa-ball and it's played out every day on the wharfs of the city where the ferry crosses to Brazzaville.

There is a walkway from the street to the pier that is enclosed by steel bars that serves as the playing field. The game starts as the ferry prepares for crossing. Somewhere out on the street, the visiting team starts it's preparations as the trucks arrive bearing all kinds of cheap, processed goods for the markets of Brazzaville. Hordes of "runners" gather. Yellow and blue vests are handed out. The players have the option of wearing them over their shoulders and backs, tying them around their necks, or wrapping them around their heads as turbans. Most wear pants cut off just below the knees, ragged t-shirts and flip-flops. The players come in all sizes and shapes, but all are wiry tough and most are quite buff.

Meanwhile, the home team gathers at the elbow where the walkway curves around through a gate, runs parallel to the river for 50 feet before making its final turn down the gangway to the rusted out ferry boat teeming with spectators. The home team consists of a couple of player-coaches and five or six large, uniformed port authorities. The one who appears to be the head coach is of average height, has a scowling face and wears Arabic robes. His piercing eyes glare out from behind small spectacles perched on his flat nose. The "assistant" coach is a huge man with a beer-belly and a large, pocked marked face with a smug grin permanently hovering ready to pounce.

Gary, Jeremy and I have stumbled upon first row seats just behind the home team where the passengers wait to cross over the Congo River into Brazzaville on speed boats.

The first member of the visiting team pads around the corner, his slippers flip-flopping across the cement in cadence to his labored breathing as he struggles under an enormous load of yellow soap bars balanced on his sweaty scalp. The home team is just warming up so they let the first one pass.

The second is not so lucky.

A smaller man, with a 8 foot wide plastic wrapped burden of cracker rolls perched on his head, jogs down the gauntlet towards the corner where the uniformed home team waits. Each of the port authorities carries a doubled up rope in his hand which he occasionally fondles with the other hand in eager anticipation of feeling it zing down on another human beings flesh.

As the man approaches, the head coach steps out and grasps the side of the opposing teams load. There is a brief struggle as the unfortunate man desperately tries to keep his precarious balance. Finally, he is forced to drop down his load next to the leering home team members. He argues briefly and half-heartedly as if it's the thing to do even though he knows it's hopeless. Meanwhile, the same scene is repeated over and over. Most get through the gauntlet, but randomly, someone will be pulled down using their top heavy loads as leverage against them.

The game continues as those who have been pulled aside run back to the street and come back shortly with something in their hands to pass on to the home team in the form of a "secret" handshake. However, they don't seem to take too many pains to make it secret and don't seem to be ashamed at all of the blatant bribery and corruption.

In fact, after a giant, hulk of a uniformed man on the home team pulls down a tiny man half his size carrying double his wait he lifts his massive head into a victorious grin as he air boxes like Rocky his fists pumping the air in jubilant victory.

The worst is still to come. The visiting team has recruited some new players. A line of 5 blind people walk slowly up each left hand placed on the shoulder of the man in front with a guide showing the way. In their right hands, they carry some small bundles of merchandise for which they will be paid a few cents allowing them to honestly earn a living playing Kinchasa-ball.

There is no mercy. The coach himself steps out with an evil grin and pushes them back. They stumble trying to keep their balance, sightless eyes rolling around in their lolling heads. Kinchasa-ball is not for the faint of heart.

Next is a man in a wheelchair. It is a tricycle that allows him to pedal the front wheel with his hands. The chair has been loaded with goods and he is perched on top pedaling furiously. Surely, he'll make it through the gauntlet! But no! Our brutish giant lumbers a few steps forward and places his beefy hand on the cripples chest as he sneers out his order to stop! He too must pay to get through.

After about half an hour of intense competition, the game winds down, the gates are shut and the ferry pulls out slowly from the dock. The home team gives each other satisfied smiles as they finger their fat pockets as the visiting team, slowly climbs back up the gangway, sweat dripping from their soaked shirts and glistening on their ripped, but tired bodies.

Congo

2009-02-27T03:56:00.003+01:00

The never-ending, impregnable jungle finally gives way to a twisting silver snake of the river. My first view of the Congo is not as earth-shattering as I expected, but it is thrilling none the less to be looking on that legendary waterway immortalized in so many writings feeding central Africa with its numerous tributaries and irresistible tug towards the ocean.

I am crammed tight in the left rear seat of a Cessna 172. Gary and Jeremy have flown me straight from Bere down to Moundou and across Central African Republic and over the Democratic Republic of Congo where I get my first glimpse of its mighty river. There is a water jug between my feet and provisions stacked to the ceiling next to me forcing me to curl up almost in the fetal position. My only relief is to turn from my right to my left side occasionally and immerse myself deep into an absorbing book…in this case, “Seabiscuit”.

We descend across the Congo River and into the tiny airport of Kisangani. The immigration officials look fierce and determined to shake down these foreigners for some “tea money” until Gary starts speaking to them in Swahili and explaining that he grew up in Eastern Zaire (as DRC was called then). We are then whisked through the formalities and taken into the Congo Frontline Mission compound by the Mosiers.

Over meals rich in pineapple, bananas and avocados—a feast for this fruit starved Chadian—we hear about their efforts to start a medical mission program to meet the scandalous medical needs of the outlying villages. For now, a simple canoe with an outboard motor and a local doc takes them a few miles outside of town to provide basic malaria, malnutrition and parasite treatments. As they come face to face with burn victims, people maimed for life through various accidents and the incredible infant mortality rates they realize that much more needs to be done.

As the stories unfold around me, I am taken back to the three and a half months I spent on the Amazon River working with the Luzeiro mission launch program back in 1994. I remember reading the stories of Leo Halliwell and his wife as they opened up the Amazon basin with their little medical launch and handfuls of quinine for malaria. As I mention this outloud, Keith walks over to the bookshelf and pulls off their story, “Light in the Jungle”, which I hadn’t read in 15 years.

I start reading that very night as deep longings I had buried inside over the years start to be awakened. The river is calling me.

The next day Gary and I go to help Keith and his dad try and negotiate with the Ministry of Public Works for the use of a bulldozer to clear the jungle from the land they want to build their school on. Things are rough for a while and negotiations tense until I mention that I am a doctor and we are interested in opening a medical river boat program.

Suddenly, the scowling Minister stands up and stretches out his hand with a big smile on his face.

“I’m a surgeon too. I’ve operated on everything. Welcome, colleague. If you ever need any papers or authorizations to get this project through to the right people, just bring it to me and I’ll accelerate it right through.”

We finish and head out the next morning for Brazzaville, Congo. There we happen to meet up with the president of the West Africa Division of the Adventist Church and the Secretary General of the General Conference as well as one of the under secretaries of the GC. As we are given the tour of the mission compound we come across a map of Congo.

There, again, the River jumps out at me.

Running all the way up the border between Congo and the Democratic Republic of Congo it then branches off into the interior of DRC. However, another major tributary continues up the border until it reaches Bangui, the capital of Central African Republic and then curves eastward across the border of CAR and DRC. Hundreds of smaller tributaries pour into the River from the Congo side making it possible to reach most of the abandoned little villages with a medical launch.

Sunday, I finally get to touch the Congo River. We have somehow managed to get all the stamps and pay all the fees to get in a boat crossing from Brazzaville to Kinchasa. Nowhere else in the world are two country capitols this close. As the motor starts up and we start weaving our way through the slalom course of grass and reed floaties scattered across the breadth of our course, I dip my hand into the cool water and lean back to smell the river air and absorb the majesty of its greatness.

We are given the tour of Kinchasa by the honorable Bahati, a member of the House of Representatives, and find ourselves at the Adventist mission station. Years ago, the church had built a hospital boat that never got off the ground thanks to the civil war and was finally sold for a pittance in 2003. We wanted to find out what happened to it. The president of themission escorts us up to his office and spreads out on his desk a wad of
pictures of the boat under construction and the all-but-finished product. It is almost exactly what I’d been imagining and looked remarkably similar to the boats I’d worked on in Brazil.

The next morning our Hewa Bora flight takes off from Kinchasa bound for Lubambashi as the early morning sun casts a warm glow across the River as it spreads out in a flood plane filled with islands above the falls downriver. It is beckoning…

Stuck

2009-02-15T05:00:00.001+01:00

I'm calmly chatting with Doug in the air-conditioned OR in Bere. We are just finishing up a routine hernia operation. The external oblique is closed and we are preparing to close the skin. Before starting the surgery, I'd passed by the charge nurses, Augustin, deep in conversation with the midwife, Hortence. I briefly caught the words "breech presentation". I almost stopped to ask what was going on, but ignoring that still small voice I continued on to surgery rationalizing to myself that it must just be a prenatal visit or something or they'd come and tell me for sure.

So Doug and I take our time on the iguinal hernia repair which I do with mosquito net mesh as usual. Suddenly, Hortence's head pops into the OR through the swinging doors.

"There's a woman...the legs and body're out...the head's stuck...been that way for awhile...we can't..."

"I'm coming! Doug, close up the skin." I cry as I strip off my surgical gown and bloody gloves and race out through two sets of swinging doors, a screen door, around the corner, under the veranda, through another screen door and right into the tiny delivery room where I see a floppy set of legs and arms with no head plopped on the delivery table between a woman's bloody spread legs. The room is packed with Augustin, Hortence, a mid-wife student, another nurse, Dr. Jacques, a family member and now myself.

I start to shout out orders.

"Augustin, get me the symphysiotomy kit!"

"Hortence, bring me some gloves."

"Prudence, I need a syringe and some lidocaine."

"Jacques, a 20 blade scalpel."

As everyone goes off running I slip my hand in and with a few futile tugs confirm that the baby's head, extended on it's neck, is stuck.

Everyone back in a matter of seconds. I slip on the gloves, draw up the lidocaine, open the instruments, inject quickly over the pubis, put the scalpel on the scalpel handle and speak directly to the woman.

"Don't move whatever you do if you want this to work! Augustin, Jacques, grab her legs and pull them up and out!"

I slice through the skin and cartilage and feel the pelvis pop open. The baby slithers out. I clamp and cut the cord. I whisk him off to the exam table. He has no heartbeat, tone, movement, cry, respiration, color, nothing. I try and clear out the gunk in his mouth and nose and do chest compressions for a couple minutes before silently covering him with a rag.

I turn my attentions to the mother. I start to examine the position of the placenta and notice two things at once.

First of all, her belly's still really big. Secondly, there's a bulging bag of water in her vagina. Twins!

I break the back of water and out pop's a full head of hair. Within seconds the second twin is delivered, pulling up his arms and legs, grimacing and screaming his little lungs out. He's alive!

Niger

2009-02-15T04:37:00.002+01:00

I am back in Africa but this welcome is far different than the one I'm used to. Sarah, Gary and I have just flown 8 hours across the desert from N'Djamena to Niamey, the capital of Niger. We cross dry grasslands, rocky outcroppings and fingers of the Sahara itching ever southward. Arriving over Niamey, we circle the Niger river and the new bridge being built by the Chinese before making a smooth landing at the airport. As we taxi up we see large men in black suits and dark glasses walking over to meet us. Dick, Kari, Scott and Mindi are huddled together with Bill and Barbara Kirker in front of the VIP welcome center. Are bags are taken over on carts and the men in black whisk us through immigration and customs and out the front where black mercedes and land cruisers wait with chauffeurs leaning casually against the front fenders.

  Hazard lights flashing we make our way through the city ignoring lights and stop signs as other cars pull over to the side to let us pass. We arrive at the President's guest house overlooking the Niger and the irrigated fields crowning its banks. A sumptuous, yet simple supper awaits us. Air conditioned rooms, white table cloths, sodas and cold water on the side and comfortable couches welcome us in style. Conversation flows easily as we are from time to time interrupted to meet more important people in dark suits.  

The next morning starts with a tour by Jason Brooks of the ADRA office and school where bright kids in sharp uniforms smile and shout out English phrases they have learned. The school is an impressive combination of underprivileged kids sponsored to go where they'd never have the opportunity to go otherwise, and rich kids who pay big to get a good education. All have become equals in their matching uniforms.

  Then we're off to see the big wigs starting with President Mamadou Tandja himself. Circling around the winding, well-guarded roads up the the governmental palace is a little surreal. We climp up the massive steps and enter through a metal detector into an inner courtyard with high ceilings, traditional carved horses on stands, pictures and maps on the walls and a 10 foot giraffe carved out of the twisted root system of a tree.  

We are finally ushered into the President's office where we are presented by Bill Kirker as the group possibly willing to take on the management of the Maine-Soroa Hospital, which just happens to be in the President's home town. I translate for Dick as he presents the President with a gift from Loma Linda University. The President is very gracious, poses for photos with us all at the end and decides on the spur of the moment to give Dick on of the carved horses in his lobby.

  Whirlwind tours with more Mercedes and Land Cruisers and flashing hazards take us through the turbaned Tuareg Minister of Health, the distinguished, glasses-on-the-nose Minister of Education, and the plump, take-no-prisoners US Ambassador.  

The next day we fly 800 km across the desert, east towards Chad with a quick stop at the only Christian hospital in Niger. A quick, chicken dinner probably providing the source of our later diarrheal illnesses and a too short crash on floor mattresses inspected by a mouse and many mosquitos and we take off again the next morning for the last 600 km to Maine-Soroa. Two flat tires and mostly good roads later and we are stopped at the side of the road in the middle of a desert with widely spaced scrub trees, and goats, sheep, donkeys, horses and camels wandering through.

  As we get out of the cars, a crowd gathers around as we are welcomed by the governor, the mayor, the prefect and a host of other dignitaries from the region who then escort us into town in front of the king's quarters, in front of the central mosque and next to the market. A crowd has gathered. Brightly decorated horses mounted by robed, spear-and-sword-toting cavaliers prance on the sidelines. School kids in uniforms wave and chant. Turbaned, shirtless boys twist and contort in front of drum-pounding musicians beating out a fast rhythm accompanied by a bulging cheeked flute player. We push through the crowds to where chairs and couches have been arranged. The toothless, ninety-year old king nods and shakes hands as his eyes bulge out from behind coke-bottom glasses.

Speeches are made, kids dance and sing and recite and shout poems and slogans, horse-men dress out and shake their weapons, traditional dancers move and shake, and Dick is crowned "Wokil". He is brought crosslegged onto a mat in front of the king while his side-kicks circle around dressing Dick in a traditional, blue robe with elaborate embroidery, a red, felt skull cap and crowned with a turban. The "Wokil" is the king's new ambassador to the world, and in the absence of the king, his word is law. The ceremonies ended we end up at Bill and Barbara's for a feast of goat with couscous cooked in it's belly.

  The next morning is another whirlwind tour of Barbara's Second Chance School for kids who have never been to school and are passed the country's maximum age (9 years old) for entering elementary school, the king's court, the Prefect's office, on to Diffa to see the governor and back to Mainé to check out the ancient air strip. Friday morning we finally get to see the hospital newly named the Kirker Hospital in honor of Bill and Barbara's efforts as first Peace Corps volunteers and then as the only doctor for years in this extreme eastern city of Niger founding a hospital where before there was none. Now, the hospital is being revived after years of neglect with some new hospital wards and the hope of a new management team, nursing school and maybe even specialty services to serve the underserved populations of Eastern Niger, Western Chad and Northern Nigeria.  

We all crash Friday evening and Saturday with staggered episodes of vomiting and diarrhea. Another feast of splayed roasted sheep and couscous goat on Saturday night with the hospital staff finishes off our stay in Niger. Sunday morning, Sarah, Dick, Kari and I head off in Bill's Land Cruiser across the desert, up north and around the top of Lake Chad. 13 hours of desert, many camels, much sand, a few Lake Chad thick-horned cows, one gazelle, one desert fox, a large bird whose name I forget, clusters of white brick mud huts with flat, horned corner roofs, one half-hour stuck in the sand barely getting out episode, one border crossing where we are the only car to have passed in two days and we arrive in Chad at Bol.

  I am welcomed back to my host country by a couple of moto taxi-men trying to scam us into believing that the airport is a long ways away and only they can show us. We ignore them and continue through the one road town to the hospital where the charge nurse who happens to be on duty informs us that Gary and the Bere Hospital chaplain, Noel, have just arrived and are over at the regional medical officers home.

  The regional medical officer is a friend of Noel's and he welcomes us with a big smile and a feast of macaroni and tomato goat sauce which we partake together on a mat on the floor with the tray of noodles in the middle. Everyone digs in with his own spoon and washes it down with bananas and cold water. The next day, we fly off with Gary over the vast expanse interconnected lakes which is what remains of the great Lake Chad. Massive herds of cattle wander in long lines like ants across the green fields watered by what is still one of Africa's largest lakes only to end abrubtly in the sands of the Sahel. After landing in Moundou and showing Dick and Kari the progress on our Surgery Center project there, we finally arrive back in Bere.

Breech

2008-12-18T21:53:00.000+01:00

I didn't realize it was urgent till I burst through the door into labor and delivery.

I knew the woman in labor had a fetus in the breech position with one foot wanting to come out first. I'd told the midwife to alert me when she was completely dilated so I could assist the delivery.

Sarah came and told me that the woman was about to deliver so I wandered back over to the hospital.

When I opened the door, I sized up the situation instantly and sprang into action.

I saw a woman lying on metal table with her legs spread apart and coming out of her was an abdomen with two legs attached, flopping down onto the bed. No arms or head was visible. My first thought was gloves but as I reached for the ones I'd washed and hung to dry earlier I realized they were still too moist to get on quickly so I dove in with my bare hands.

When the baby comes out feet first it's very important that she deliver quickly because if not the umbilical cord coming out of the abdomen will be compressed by the fetal head blocking off the blood circulation and its crucial supply of oxygen to the baby.

I had no time to lose since who knows how many minutes had flown by with the head stuck before I arrived.

I reached inside to try and free up the first arm. It wouldn't budge. I twisted the baby around so the other arm was on top. This time I was able to hook it with my index finger and drag it down and out. I turned the baby over again and freed up the other arm. Then I stuck my finger in the baby's mouth and pulled his chin down to his chest all the while pulling with my other hand firmly grasping the baby's feet between my fingers.

The head popped out and the baby flopped to the table. No tone. No cry. No breathing. Grayish blue color.

I quickly clamped and cut the cord and moved the limp mass over to the reanimation table. I started rapidly pressing the chest with one had while I quickly grabbed the bulb suction with the other and tried to clear his airway. He had a faint, slow heartbeat. For those of you who know, APGAR at one minute was one.

I kept doing chest compressions while the midwife dried, stimulated and sucked the gunk out of his nostrils.

After what seemed like hours, but was really minutes the heartbeat started to pick up. He grimaced a little and seemed like he wanted to cough.

We continued our efforts.

Slowly but surely he started to pink up and his heartrate became normal. Still pretty floppy and no breathing.

Don't stop now.

Finally, his legs and arms started to curl up. He was getting some muscle tone and his body was now pink.

At last, after I turned him over and gave him a good whack on the back he started screaming like a banshee.

Amazingly enough, APGAR at 5 minutes was nine! He was discharged home in good condition two days later.

Miracles

2008-12-17T21:44:00.001+01:00

Miracles start with small things and are often small themselves and go
unrecognized unless we have eyes to see and ears to hear.

I almost forgot to bring my pillow. Sarah held it out to me at the last
minute as I rushed out the door, hopped in the back of the van and took a
nap all the way to Kelo where we dropped off Andre and his adopted daughter.
They got on public transport for Lere while Levi and I went to the TEAM
mission station there in Kelo to find some Arabic new testaments. The rep
for the Gideons wasn't there but promised to meet me at noon at the Kelo
hospital.

I foolishly thought I'd be done in Moundou before then.

We arrive in Moundou and go directly to the construction site. Frederic,
the boss, isn't there. I call him and while waiting check out the progress.
The bricked up windows have been reopened letting in a ton of light. The
back two rooms have been converted into one large room with three huge
windows and a double door from the outside and a small door into the
hallway. This will be the operating room. The slab for the veranda has
been re poured, the trusses have been repaired, the roof replaced and the new
ceiling mostly done.

I go back outside and see Anatole, our head lab tech. Two days ago I received a message that his son had meningitis here in Moundou.

"Anatole, bonjour, ca va? I tried to call you but I couldn't get through."

"Yeah, my phone was stolen at the hospital."

"I wanted to contact you to have you bring your son back to Bere, how did you find me here?"

"I just happened to see the van drive by and followed it here."

Anatole then goes on to explain how his son was treated (or mal-treated) first at the health center with once a day IM Quinine and Penicilline and then referred to the only hospital here in Moundou, Chad's second largest city. No lab tests were done to confirm or deny meningitis or cerebral malaria but treatment was started. The antibiotic wasn't available and had to be purchased on the black market for 5 times the going price. Nurses came by once a day only for injections and once, the nurse came to give a shot with an empty seringe and didn't notice until Anatole pointed out he'd just injected air into his son's thigh! In a week at the hospital, he saw a doctor once. He finally decided last night to just take him home where at
least he himself could make sure the meds were given when they were supposed to!

Antoine, our church contact in Moundou shows up and we go to see the "Chef de Quartier" to find out about purchasing 1 or 2 of the empty lots next to our project. We bounce over the dirt streets of this industrial capital of Chad and turn down a small side street before pulling up in front of a brick wall.

Attached to the wall is a small lean two with low ceiling made of brick and tin roofing. I stoop through the narrow door into a dark room filled with old men. The dim light comes through cracks in the bricks and ceiling and through the door illuminating several low wood slat chairs and a rickety hand made coffee table with various documents spread across the top. The chief is a wizened man in his late 60's or 70's with short white curly hair, a traditional long pocketed shirt and trousers and a leg wrapped in an elastic bandage.

We are motioned to some of the low chairs, only a few inches off the ground. I find myself basically squatting with the slats digging into my bony butt. Antoine starts speaking in Ngambai. I catch a few words like "doctor" "hospital" "magistrate" etc. and after much dialogue Antoine gives me the resume that he knows the original owner of one lot and he'll ask who he sold it to so we can see if we can buy it and that the owner of the second property is an old magistrate who is too old and tired to build and has told the Chief to contact him if he finds a worthy buyer. He is very content that we're building a health institution in his neighborhood and will do all he can to help.

"It seems your sick," I speak to the chief in French, pointing to his leg. "Mind if I take a look?"

He motions for a young man outside who comes in and between the two of us we lift up and unwrap his leg revealing a bunch of crumbled up dry leaves wrapped around a single swollen ankle and foot in the traditional manner. The other leg isn't swollen at all so I suspect early elephantiasis and prescribe him medicines for filarial worms and tell him to elevate his leg at night.

Just then, the pudgy old man to his right starts hacking up a lung. He's been coughing for a while so I prescribe him two antibiotics and an inhaler to open up his airways.

They are very happy and the chief steps outside with us to wish us well and tell Antoine to check back tomorrow about the properties.

After a few other errands, we stop at one of this metropolis's two gas stations. A couple of Arabs are lounging on chairs between the three antique pumps in the sandy courtyard. They slowly rise up as we place our three gas cans open in front of them and unlock the gas tank. We place our airplane fuel filter in the opening as they "warm up" the pump. It slowly whirs into action and after a few minutes they start pumping. The gas spews out in spurts and little bursts of air spraying the gasoline into our tank. After 18 L (4 1/2 gallons) it stops running.

"Sorry, that's the last of it. We should have some more tomorrow!"

We drive off to the second and last gas station. As we pull up the two guys sitting out front just look at us when we ask if they have gas and shake their fingers "no".

We pick up Anatole and his son and lay him in the back, conviently there is a slightly used pillow waiting for him to rest his head on.

We arrive in Kelo without incident. The Post is closed. We go to the hospital. It's 2pm and Mathias, my contact for the Arab Bibles has gone home. We get his number from the nurse on night duty and he tells us to meet him at the Pili-Pili Hotel.

After picking him up and going back to the hospital to get the Bibles we return him directly to his house in the "suburbs". As we head back towards the main robe a tall, athletic man comes running after us in a green Arab robe barely covering his basketball shorts. He waves his hands and yells after us.

"You have a ton of packages at the Post Office. You need to pick them up tomorrow."

"We're heading back to Bere now and it's not easy to come. Can't you open up the office and let us take them with us now?"

"Ok. Ca va."

He hops in and we pick up 25 packages, most for the student missionaries but one from the AMALF in France containing 150 vials of Ceftriaxone, the exact medicine we need (and just ran out of) in order to treat Anatole's son's partially and poorly treated meningitis.

As I pray with Anatole later, after arriving in Bere I am convinced that God will heal his son since he went to some much effort in so many small ways to bring us in contact and get us the exact medicines we need. Seemingly insignificant details when seen alone, but miracles none the less.