ON THE ROAD AGAIN

16 September 2013

Early Saturday, I find myself driving my Vanagon up and down the rolling hills
just northeast of Moundou.  Everything has transformed itself from desert brown
to jungle green.  Patches of red earth show out between the lush tropical
vegetation.  The air is cool.  The sky is blue and dotted with puffy white
clouds.

As if I didn't have enough work already, I'm off to seek and heal that which was
wounded.

Yesterday, I came out of surgery and found David talking on the phone.

"When was the accident?  She has a broken femur?"  My ears pick up.

"David, who is that?"

"Abbas..." he whispers.

"Let me talk to him."  David passes me the phone.

"Abbas, it's Dr. James, someone broke their leg?"

"Yeah, it's my niece," Abbas voice replies on the other end. "She was in a
motorcycle accident last night.  She and two other women were walking along the
road and some guy came and knocked them into a ditch."

"It's the femur?"

"Yes."

Contrary to my usual cautious, take-it-safe attitude I reply spontaneously,
"I'll come get her tomorrow with my van.  She needs to be operated on."

"That's what I told them too, but they've already called the traditional bone
setter and he's set it.  But I'll talk to them.  You should come."

The next morning, I grab my passport, a little money and two jugs of water.  I
open the gate, drive the Vanagon out onto the road and come back to close the
gate when I see David on the verandah of my house.

"Bon jour!" I greet him.

"Salut! Where are you going?"

"Off to Abbas' village like we talked about yesterday."

"But Abbas called me this morning to say that the village elders decided they
wanted to wait a couple weeks and see how the traditional method works."

"David, when were you going to tell me?  What if I'd left earlier like I
planned?  Never mind..." I go drive the Vanagon back inside and shut the gate.
I go shake David's hand and we have a little small talk.  In the back of my
mind, though, I'm starting to regret not going.  I was kind of excited about
getting out to the bush again and see a new village.

"David, I think I'm going to go anyway.  No matter what the case, talking to the
village elders, trying to persuade them, seeing Abbas' village, it'll be an
enriching experience for me."


I get back in the Vanagon, attach the two wires off the ignition, hold in the
button for the glow plugs for 20 seconds and then touch the loose wire to the
two connected wires and the diesel engine roars to life.  What can I say, the
Vanagon has become Tchadian!

So I find myself on the road from Moundou to Kelo.  Abbas told me the village
was 31 km past Kelo on the road to Bongor.  He said when I get to Batchoro I
should call him.  I note the mileage as I leave Kelo and calculate that about 20
miles should equal 31 km.  I'm at 165 so at 185 I should about be there.  I
don't see any signs for Batchoro but when I get to Gang I'm at 185 miles so I
call Abbas up.

"Salut! I'm at Gang..." I inform him.

"What?! You've gone to far, turn around and I'll go wait for you at the side of
the road."

I do a three point turn on the narrow main highway of Tchad and head back.
Within a mile or two I see Abbas waving by a straw mat covered rude shelter by a
sign saying Teleou. I pull off the road next to the shelter and sign, lock the
doors and greet Abbas.

  

"Ça c'est le village," Abbas points to the sign. "We have to walk through water
to get there." He points to his pants rolled up to his knees and his sandals in
his hands.  I follow suit and soon we are wading up to mid-calf along what used
to be a road.  After a few hundred feet we hit dry ground again and Abbas points
to a rudimentary brick structure half built up to the tops of the windows over
to the right behind the school.

"That's the clinic the village is building with their own resources.  There's no
medical care for over 20 miles in any direction."

We continue through small paths around huts, millet fields, pigs, cows,
chickens, goats, kids and winding fences until we come to a few chairs and
benches arranged under a mango tree.  Some of the elders are already there and
we go around shaking hands.  Most don't speak French, only Marba.  Abbas motions
that we should go on a little further.


"Let's go see the patient," he says leading me into a courtyard and through a
cloth hanging over the door of a hut where 5 women scurry out of the way,
grabbing their millet paste and sauce as they go.  A young teenage girl lies on
a mat on a dirt floor with bricks stacked around what must be the fractured leg
as it it wrapped in an Ace Wrap and other bandages.  It looks to be straight and
out to length.  She has a urinary catheter draining into a dish.

"Who put in the foley?" I ask Abbas.

"The local nurse."

"Did the bone break the skin?"

"No."

"Ok, let's go talk."  We duck back outside and return to under the mango tree
where the meeting will take place.  Many more elders have gathered.  They motion
me to a seat next to a younger guy who will act as my interpreter.

We sit around in silence for awhile. It seems they are waiting for me to speak.
I start explaining the complications that can arise from lying too long in one
position and the advantages of being operated and having a metal rod stuck in
the femur so she can start mobilizing the day after surgery.

The man who seems to be the chief elder breaks in.  He talks a lot about how
happy and honored they are to have me come, blah, blah, blah.  Then he talks
about having a lot of confidence in their bone setter and they'd like to see how
it works for 2-3 weeks before trying something else.

"Yes, I saw that he is very competent.  The bone is aligned and the leg is out
to length.  It could heal like that.  However, the muscles of the thigh are very
strong and will likely pull it out of position. In any case, she'll suffer a lot
having to lie there without moving for several months..."

The arguments and debate go on like this in a calm, respectful manner for awhile
until I finally make a breakthrough.

"You know how in the past you had to mill your rice by hand?  Wasn't it nice
when people brought machines to run the rice mills?  Didn't you suffer before?
Wasn't that development good?  Didn't it relieve a lot of suffering even though
the result was the same?  That's the same way with this new method of treating
fractures, it relieves a lot of suffering."  I hear chuckles and see a lot of
nods and smiles around the circle.  They then get up and go off to discuss among
themselves.

"Doctor," my translator leans over to speak to me directly. "The real problem is
finances. All their rice from last year is gone, and the harvest is still a
month or so away. They don't have anything to pay for it.  They're afraid it
will be very expensive since your surgery center is private."

Now I understand.  "C'est vrai, we are private, but we are also non-profit and
our prices are very low so that even the poor can afford them.  But I understand
it's a difficult time in the village, we'll find a solution."

When the elders come back I address them directly. "I know it's a difficult
time.  Here's what I propose: I'll pay for the surgery and then after the
harvest, I'll come back and you can find a way to repay me."

Everyone is then very happy and things get moving.  An ox cart is brought pulled
by two bulls.  The girl is brought out by 6 men carrying her gently and placing
her on a sheet in the ox cart.  They go off and we follow on foot.  I take a
brief tour of the "clinic" and then we meet them at the Vanagon.  She is soon
loaded in and we head back to Moundou.  Abbas accompanies me as well as two
family members who will stay with the girl post-op.



The surgery is done that afternoon without too many complications.  The distal
fixating screw is a little frustrating, causing some non-missionary like words
to escape my lips.  Other than that, all is routine until Dr. Roger bursts into
the OR as I'm starting to close up.

"This young girl just came in," he exclaims breathlessly, speaking rapidly as is
his custom. "She swallowed some unknown object and no can't breath."

"Are you sure she swallowed it? Sounds like she may have got it in her airway.
Go listen for stridor."

Roger comes back shortly.  "She has stridor."

"Ok, I'm almost done, I'll be right there."  I finish quickly and go see a 8 or
9 year-old in respiratory distress, agitated, with nostrils flaring and
whistling sounds coming from her throat.  We hurry her back to the OR where I
inject her with Ketamine in her thigh.  Soon she is out.  I finally find a
laryngoscope that works and insert it into her mouth.  I pull the tongue left
and see the epiglottis.  I lift up and into view comes a green plastic circular
object with spikes along the rim sitting right on top of her vocal cords.  I
reach in and grasp it with some forceps and pull it out.  It's the middle
section of a plastic flower with a centimeter or two of stem that had gone into
her trachea.  Needless to say she's breathing better now.



I go show the family and then head home for a much needed nap.

NECROTIZING

26 September 2013

I'm just sickened. I'm wracking my brain trying to see why I didn't see it
sooner.  Hindsight is 20/20. Yesterday, Dr. Roger comes up to me after staff
worship.

"You should come see bed 11. Last night at nine, they called me and he had a
wound that erupted in his groin."

"Bed 11?"

"You know, the man with the double fracture, tibia and femur..."

We walk the short distance to the men's ward and enter the dimly lit room.  Just
to my right is a man I recognize well.  Three days ago, Saturday, I operated on
him for a floating knee where the distal femur and the proximal tibia were just
shattered.  Sunday, he was doing well.  Monday, he was groggy, but the nurses
said he'd had so much pain the night before they'd injected him with a
tranquilizer and a narcotic.  I assumed it was just that.  He was arousable and
his vital signs were normal.  His femur fracture was an open fracture that had
been sutured at the government hospital three days before coming to us.  At
surgery, the wound was very traumatic, but didn't look infected like many that
I've seen.  The wound looked good on Monday, though there was some
serosanguinous drainage on the dressings.  There was no odor.  Tuesday, I let
Dr. Roger do rounds while I operated.

Today, he looks like death warmed over.  His breathing is shallow, his eyes are
closed, his skin is sallow and he's lying in a pool of foul smelling maroon
liquid.  I pull back the sheet and his groin is covered with gauze soaked in
brown liquid and around the edges is poking out peeling, necrotic tissue.  The
side of his leg is also weeping with skin sloughing off over dark, dead looking
flesh: necrotizing fasciitis.

"Go get the gurney, quick!" I call to Appolinaire who has accompanied us. 
"Roger, how did it look yesterday?"

"The wound was clean with only some clear, reddish discharge.  No odor. The only
thing I noticed was some swelling of his upper thigh but I thought it was just
from the trauma and surgery.  Then, they called me last night and I saw this
nasty wound in his groin so I dressed it..."

"You should've called me last night..."

We rush him to the OR.  Anesthesia is not necessary as the man is in a coma. 
His blood pressure is really low, but curiously, his heartbeat is normal.  We
get him on oxygen, open his airway with an oral cannula, find two large bore
IV's, start pumping him full of isotonic fluids, inject him with powerful
antibiotics and grab the amputation kit.  I don't bother scrubbing, just put on
sterile gown and gloves.  I grab the scalpel, but then hesitate as I'm not sure
exactly where to start.  Finally, I just begin slicing down through dead skin at
mid thigh, identifying and clamping off the large vessels as I find them
(although many are already thrombosed).  When I get down to bone I just pull out
the IM nail with the knee and the lower leg attached.  I'm really glad now that
I didn't put in the fixating screws in the distal part of the rod.  Then I peel
back the muscles as far as I can and try to cut through the femur with an
extremely dull, hacksaw-looking bone saw.  I toss the piece into the trash and
then start attacking necrotic tissues.

I start with cutting away dead skin.  I get all the way up the back of his leg
to the top of his hip bone before I hit bleeding skin edges.  Then around the
front into his groin I remove his scrotum and half the skin of his penis before
moving up to his pubis where I finally hit live tissue.  I clamp and cut off his
left testicle.  I remove the skin of his anterior thigh.  The only  good skin is
a small patch on his posterior thigh.  I then start cutting off the green
colored fascia and olive, pussy muscle until I find red, bleeding tissue.

Meanwhile, the anesthesia team keeps pouring in IV fluids.  I place a foley
catheter and get some dark colored urine out.  I dip some lap sponges in
antiseptic liquid (diluted cresyl) and drape the raw stump before wrapping it in
gauze.  It takes another half hour of reanimation before he's stable enough to
take out to post-op recovery.

If he makes it, it'll be a miracle.  Meanwhile, I'm left thinking of all the
things I could've done differently to recognize it sooner before it led to this
catastrophe.

Looks like another sleepless night...

CATASTROPHE

10 October 2013

I'm deep in the belly when the catastrophe starts.  I've already started
dissecting the descending colon off the grossly enlarged and inflamed left
kidney when suddenly I can't see anything.  The man's stomach comes popping out
of the abdominal wound and his abs tense up so that all the rest of the
intestines and the enlarged spleen block off any view I used to have of the
diseased kidney.  The man is retching and dry heaving.

"Can't see or do anything here, can't you give him something?" I shout at
Patrice, our nurse doing anesthesia.  Thus starts a long, labored process of me
trying to hold in guts on one end while trying to verbally direct anesthesia on
the other.  Finally, I have to break scrub and tend to the man as his oxygen
saturation has plummeted.

His jaw is rigid and his whole body tense and he's refusing to breathe.  This is
why Ketamine isn't used often in the developed world.  Alcoholics just don't do
well on it.  We're pounding him with Valium, Thorazine, Promethazine, Ketamine,
trying to get his body to relax so he'll take a breath.  But now he has vomit
spilling out of his oral airway and nose.

"Suction!" I scream as I try in vain to tilt his head back and open his mouth
against his strong muscular contractions.  Finally, I get a suction tip into his
mouth and aspirate the yellow, bilious liquid out.  I can barely get in a
laryngoscope but fortunately it's enough as I see the vocal cords wide open.  I
slip in an ET tube and start bagging.  His sats finally come up to decent, but
not ideal as yellow froth bubbles up in the tube.  I suction out the tube  and
lungs but it keeps coming.  He's aspirated and this is not good.

And I still have an open belly and most of a difficult surgery ahead of me.  I
scrub back in.  The abdomen is still rigid.  Finally, after 5 doses of Valium,
one each of Thorazine and Promethazine and two bottles of Ketamine, things are
relaxed enough to operate but his sats are still not good and I'm afraid he'll
die on the table.  There is lots of oozing in the operating field so I decide
that careful dissection just won't do in this situation.  I reach in my hand and
peel off the kidney all around it's lateral and posterior aspects and pop it up
into the wound.  I pack the kidney bed and put three clamps across the pedicle
where I know the major vessels and ureter are.  I cut out the kidney and toss it
onto the mayo stand.  I stick tie the pedicles, irrigate the abdomen, place a
drain and close up.

As I scrub out to check on the anesthesia part, the man is now completely
relaxed and his sats are normal.  He has a bag of blood running and has used up
over 10L of Ringer's Lactate. We wait about 30 minutes until he starts to make
some movements with his mouth.  I take out the NG tube and then extubate him.
He does fairly well on just oxygen so we take him out to post-op recovery.

There, the woman with the thyroid mass who is intubated now needs the oxygen so
we are forced to switch back and forth between the two patients since we have
only one oxygen concentrator.  When one patient's sats go down we give them
oxygen for a few minutes until it comes up and by then the other's sats are
dropping so we switch.

The next day, Roger comes to see me about a patient who has an intestinal
obstruction that was hospitalized yesterday.  The man is gaunt with a swollen,
air filled tender belly.  I go see Juliette who hospitalized him with Malaria
and constipation yesterday.   He hasn't had a stool or gas in 10 days.  When I
ask her why she didn't tell me about this patient she says it is because I was
so busy with the complicated case yesterday and then she forgot to tell me
afterwards.



They have no money and are obviously poor so we just take him to the OR bloc
even though he hasn't paid. When I open the peritoneum, gas and a foul odor
escapes.  THere is over 3 liters of putrid pus in the abdomen.  His cecum is
necrotic with a hole oozing brown, gritty stool.  The appendix is normal.  I
dissect out the cecum, ascending colon and terminal ileum and remove them.  I
then reattach the ileum to the rest of the ascending colon, wash out the abdomen
with liters and liters of tap water, place three drains and close up.

Fortunately, his anesthesia went without any catastrophes.

24 HOUR

06 November 2013

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

"Doc, the general hospital has referred another patient with anemia.  They say
they've tried to find the IV but can't so they sent him to us."

This is starting to get to be a chronic story: the huge government hospital
which is supposed to be Southern Tchad's regional referral hospital, is now
regularly referring us patients not only for surgery, but for blood transfusions
and complicated obstetrics as well.  Just two days ago they referred a woman
with a hemoglobin of 1.6 g/dL who had been bleeding at home for two weeks after
a home delivery.  It was midnight when I started two large bore IV's to get
blood running and her blood came out like water with a little red food coloring.
Not only was she alive, but talking and with bulging veins...

"How old is he?" I ask Josephine.

"Three."

"Ok, I'll be right there." I pull on scrubs, grab my flashlight, walk across the
lawn and through the gate to the hospital.  I veer left instead of going to the
clinic and open up the storage container.  Inside, my flashlight helps me find a
pediatric central line kit among the piles of surgical and orthopedic supplies.
I walk over to the recovery room where a young girl is lying panting on a
gurney, her eyes closed and sweat beading her forehead.  I take her back to the
OR, give her a shot of Ketamine and feel her bounding femoral pulse.  I prep
with Betadine and open the central line kit.  I put on sterile gloves, place the
drape, prepare the guidewire, fit the introducer needle to a syringe and palpate
the femoral artery again with my left forefinger.  I go just medially and after
about 5 slow insertions and withdrawals of the needle, I hit a gush of dark
blood.  I hold the needle firmly in my left hand and gingerly take off the
syringe.  Blood trickles out as I pass the guidewire into the vein.  I nick the
skin with a scalpel and pass a 9cm 24G catheter over the guidewire before
pulling it out and attaching the blood transfusion.

Josephine bursts into the OR and starts rummaging through the bundles of suture
kits and dressing change instruments.

"What's going on?" I ask.

"The second woman in labor...she's breech and about to deliver!"

I quickly put on a sterile dressing, take off my gloves and hurry down the hall
to the tiny labor and delivery room just off the recovery room. A large woman is
lying down, legs bent up with a scrotum and anus poking out of the birth canal.

"Don't push, Madame!" I shout as I hurriedly put on some simple gloves.
"Josephine, do you have the instruments and the bulb suction?"

"Yes, it's right here!"

"Ok, Madame, go ahead and push with the next contraction..." I don't need to
tell her twice.  As the scrotum and butt cheeks advance out I slip a finger
around the thigh and pull the top leg out.  THen I twist the body around so the
back leg is now on top and pull that one out too.  Putting the tiny feet between
the fingers of my right hand I pull until the body is out to the armpits.  Then
I deliver the anterior arm, swinging it down over the chest.  I twist the baby
around so the undelivered arm is now on top and slide that one down and out too.
I put my left index finger in the baby's mouth to flex the head and pull the
baby out in a slippery burst of meconium stained amniotic fluid.  I suction out
the mouth as the baby gasps but doesn't cry.  I clamp and cut the cord and take
the baby to the resuscitation table where I  vigorously rub and slap until the
baby is screaming.

"Josephine, go get some oxytocin and give her an IM shot..."

"Doc," interrupts Josephine. "Better take a look...I think there might be
twins..."

Sure, enough, the woman looks as if she hasn't delivered anything.  I examine
her again and find a bulging amniotic sac next to  the first boy's clamped
umbilical cord.  I break the bag of water in a gush of bloody fluid and feel the
next baby's head. She doesn't have contractions, so we start an oxytocin drip
and once the contractions start I give her the green light.

"Come on, Madame, time to get this baby out."  I expect it to take some time
since the baby's head is so high up inside and maybe things aren't completely
dilated since the first baby came out breech.  But with one massive heave and
grunt the baby almost flies out in a splurt.  Another boy who is also quickly
dried, suctioned, slapped and made to cry a heartening scream at the new world.

I turn my attention to the other woman in labor.  She's been there all day.  Her
bag of water broke at 9AM and she's had good, solid contractions but no cervical
change.  She had a previous c-section 8 years ago and hasn't been pregnant since
(rare in Africa.)  I decide she's had a fair trial of labor and another
c-section is indicated.  I call in Abel and Daniel who soon have her prepped and
ready.  The spinal I gave isn't working so I have Daniel prepare a little
Ketamine and when I'm poised with the knife and we've prayed I give him the go
ahead.  In about 30 seconds, the woman is out and I slash down to the uterus and
peel back the bladder from the lower uterine segment which is quite thin.  I
enter the uterus and expand the incision laterally and superiorly.  The baby
comes out fairly easily but once we've clamped and cut the cord and handed him
off to Daniel and once I've pulled out the placenta I see geysers of blood
gushing out of both sides of the wound where it has extended into some serious
artery action.

I clamp them all off with ring clamps and suture the uterus closed.  There is a
small bleeder in the middle that I snag with a figure of 8 suture using 0
Chromic.  Then I notice another oozer on the left and when I try to suture that
it just oozes more.  THen I notice the whole side of the uterus is swollen with
blood clots just under the surface.  I have to tie several figure of 8's all the
way up and down until the bleeding actually stops. Then I close her up and go to
check on the three new babies.  The twins have already breast fed and another
patient has just arrived.

A nurse from the Refugee Camp in Goré on the Central African Republic border was
in a motorcycle accident at 7pm and had an open tibia fracture.  It was washed
out and splinted and he was given antibiotics and got one of the UNHCR Land
Cruisers to bring him to us, over 50 miles away. It's now about midnight, so I
give him some IV fluids and Valium and set him up for surgery at 7:30AM.

6:00AM comes way to soon and I'm up, eat oatmeal and go up to the hospital. I
give a short worship for the staff and patients about Jesus healing Peter's
mother and then go do rounds.  The hospital is packed to overflowing.  It seems
like every other bed is filled with a child getting a blood transfusion for
severe anemia secondary to Malaria.  Most of the other beds are orthopedic
patients recovering from surgery or healing chronic wounds.

I put in an IM rod into the Refugee Camp nurse's tibia, take out a large uterus
with a molar pregnancy, do a hernia repair with mosquito net, perform a D&C,
pull a tooth, do about 10 ultrasounds, see patients with HTN and Diabetes,
prepare a man with hydrocele for surgery, hospitalize a 9 year old with
recurrent urinary infection, treat a middle aged man with hypertensive heart
failure, eat lunch with my family, treat some more patients with Malaria,
Typhoid Fever, Dysmenorrhea, infertility, first trimester bleeding, completed
miscarriage, chronic knee pain, tell about 10 people to go on a whole food plant
based diet, pray with some patients and am about to get ready to go home when a
man gets carried in from the general hospital.

He'd been sitting there for 3 days getting a few shots now and then with an open
tibia fracture.  Finally, the chauffeur who hit him and is responsible for
paying his medical care decided to bring him to us since they weren't doing
anything for him.  He pays for a third of it so we start preparing the patient
while the driver goes to the market to find the rest of the  $135 dollar
surgery.

So much for basketball today, I think, as I glance up at the clock which reads
4:15pm.  We take the young man back to the OR and place the IM rod through a
crushed distal tibia fracture. Finally, I'm able to go home to see my kids.  As
I walk through the door I yell out, "Miriam?! Hey you!"


My 2 year old daughter with the wild, curly blond hair pulled back in two
haphazard pony tails, looks up, squeals and then starts dancing up and down over
some wooden bear pieces on the ground while laughing hysterically.  I plop onto
the couch and start laughing with her as she looks at me with a goofy grin and
then runs off around the corner with her tongue wagging back and forth babbling
in her best imitation of a turkey's gobble.

KIDS

10 November 2013

I don't know why I wake up crying, it seems to be my habit of late. But then
again, it's not that surprising as everyday I'm seeing such suffering and death.
I feel sorry for Andrew, our family practice resident.  He hasn't seen much
death before and he's taking it hard.  But then again, when did I stop taking it
so hard? Or maybe I just bury it quick and it comes back out in the early
morning tears.

Two days ago, there was the two year old with malaria.  She'd been sick for a
long time and finally came in to the general hospital where they found she had
severe anemia.  They didn't have the reagents to do a blood transfusion so they
sent her to us.  We gave her blood and three days of IV quinine. The nurse came
to get me at night.

"She's not breathing well."  I knew that already.  I'd seen her earlier. We'd
given her antibiotics, glucose, quinine, blood.  I couldn't think of anything
else to do. Besides, her liver was very enlarged: the worst prognostic sign in
malaria. The next day, Andrew saw her on rounds and was worried, as well he
should have been. He did even more.  Put her on oxygen, gave her a little bolus
of IV fluids and stronger antibiotics.  She died shortly thereafter.  He came
back to the house. He'd been crying.  I was trying to recover from the week long
marathon of trying to save lives accompanied by a sore throat, diarrhea,
headache and fever.  Andrew then went back to comfort the family until they took
the body away.

Then today came. Another baby with malaria and not doing well.  Andrew sat and
bagged him and gave him oxygen and monitored him and gave him steroids then
heard crackles in his lungs and gave him a diuretic with no response.  His
kidneys and lungs and liver were failing.  He somehow hung on for hours...and
then died right after a four year old with: surprise, surprise...malaria. And
then one thinks of the fact that developed countries have eradicated malaria
using DDT and then jumped on the political bandwagon to ban it for the rest of
the world that continues to suffer and die from it at extraordinary levels.  I
really don't care if it does wipe out some bird species (it doesn't, by the
way.)

We all need a break.  After Miriam and Noah wake up from their afternoon nap we
go out for a walk to the river.  Sarah has Noah in the Baby Bjorn, securely
hanging in front of her as happy as can be.  Miriam has her pink Tinkerbell
swimsuit on with an aqua Swedish sun dress on over it.  She's riding on my
shoulders singing away. Andrew and Rodney plod along besides us in shorts.  We
cross the main road to many a curious stare of passing motorcyclists.  Just
across the street some young military guys are sitting on the leaning,
half-broken down wall surrounding the Armée Nationale Tchadienne (ANT in
French!) barracks.  They yell out greetings and wave.

Around the corner we hear the silence from the city power plant as Moundou
remains without power for some unknown reason. Crossing another main, almost
deserted road, we arrive in the swampy fields next to the river where the brick
making men are hard at work, sweaty, shirtless bodies glistening in the
afternoon sun as they tramp out mud, collect straw and slap the mixture into
their crude brick forms.

We finally find a way through the maze of bricks to the river.  There is a
solitary tree on a small hill with piles of sand and gravel around being sold to
push cart workers carrying it to some construction site.  We descend the small
slope into a tiny little bay of calm water next to the swiftly flowing, shallow,
wide Logone River.  The Logone is one of Chad's two main perennial rivers
joining together at the capital, N'Djamena, before emptying into the astonishing
Lake Chad which has no outlet to the ocean yet stays fresh and not salty like
the Dead Sea or the Great Salt Lake.


The water is amazingly cold.  Miriam at first is afraid but then wades out
slowly to me with a silly grin on her face.  She soon wants to go back to Mommy
and Noah who are leaning against a sand pile.



 

Andrew and I wade out into the swift current and then swim across to a sand bar,
barely making the end of it as the current rapidly takes us down river.  We then
walk back up the sand bar past where we put in so we can make it back to our
cove.  There is nothing on the sandbar but a few driftwood pieces and some
chicken hawks and pigeons.  A few dugout canoes ply the waters checking their
fishing nets. We swim back.  Miriam is ready for some more play time in the cove
and giggles and laughs as she jumps up and down on me and spins around crazily.



I crash on the couch at home and almost fall asleep before getting up to make
supper.  We are just watching a Jesus Culture video, about to sit down to eat,
when Josephine comes knocking on the door.

"There's a little boy who was just hit by a motorcycle.  He's unconscious with a
large wound on his head."

"I'm coming right over." I pull scrubs over my shorts and t-shirt and jog over
to the hospital.  A five-year-old is lying on the bed covered in sand stuck to
the blood on his head. He is agitated and left side is twitching in a focal
seizure.  His right temple has a 5 cm laceration.  There doesn't appear to be
any skull fracture and his pupils are equally round and reactive to light.
Remadji is just starting an IV when a couple of Chinese show up at the door.
One man is crying holding his deformed right arm and the girl is speaking French
with a Chinese accent.

"This man is serious.  He hurt his arm playing basketball. It's come out."

I usher them in to a bed and feel his shoulder which has an anterior
dislocation.  I go to the OR, get 5mL of Ketamine and give it to him in his left
deltoid.  Then I go back to the boy who has the IV now and is getting diazepam
for his seizure.  His breathing sounds labored so I open his airway by putting
an OR gown under his shoulders and check his O2 sats.  They're 78% so I rush to
the OR and bring back our one O2 concentrator.  Quickly the sats go up to
98-100%.  The father speaks to me in Arabic.

"Look at his leg, is it broken?"

"Which one?" I ask back in Arabic.

"The left one, there."  I check it and it's fine.  But when I check the right
one it is obviously a mid-shaft femur fracture.

"That one's ok, but this one is broken."  I have the father hold the leg out to
length while I get an ace wrap and tie the two ankles together to temporarily
keep the leg from shortening. "If he comes out of his coma, we can fix the leg,"
I inform the dad.

Meanwhile the Chinese basketball player is out.  The man with him doesn't speak
French so I try English.

"Hold his arm under the pit," I show him what I mean and he understands.  I put
traction on the arm and after a few minutes I feel the humeral head pop back
into joint.  I check it and there is no more deformity and full range of motion
of the joint.  I recheck the boy and his pupils are still reactive and he's not
seizing and his O2 sats are normal.  I go home and watch "Capitalism: A Love
Story" with Andrew.  Then I go back to check on the boy.  He is still agitated
but more awake, not seizing, normal pupils and doesn't need oxygen anymore.  I
go back home and crash.

EPILOGUE

20 October 2014

You might be interested in listening to this conference presentation by both doctors who served recently in Liberia...inspiring and informative.

http://www.lluglobal.com/site/c.msKRL6PNLrF/b.8707879/k.C18B/Global_Healthcare_Conference.htm

Wait, hurry up I'm not patient yet...

Tout le monde,

As I sit here finishing off my nutritious, delicious evening meal of Southwestern barbecue goulash with Paul I think back to one word to describe N'Djaména (besides Sodom, Gomorrah, Babylon, frustrating, filthy, dangerous, corrupt, etc) it's BUREAUCRATIC. (Actually the goulash is just corn, old rice and burnt lentils...hence the "Southwestern" flavor).

So I'm in N'Djaména. I'm waiting as usual. All I want is some fabric to have some extra surgical gowns and drapes made. I've come to the "Grand Marché" (Great Market) where one can buy everything from dried beans to pharmaceuticals to door locks to plastic pitchers to dried flowers for making "Jus d'Osais" to axes to radios to turbans to cloth to shoes to...I've come here to the fabric section and they've run off somewhere. A boy passes wearing the long flowing Muslim robes with a small bowl balanced perfectly on his head. I'm sitting with Bichara who has his legs crossed contemplating the passersby. He orders a glass of red tea from a turbaned vendor and then buys one for me as well. As I try to balance to glass in my hand without burning myself with the tea-heated-glass a pair of Arab women with brightly colored wraps and shawls pass by giggling in Arabic which Bichara translates as "So, Nasara [whitie], you drink tea, too?" Hee-hee-hee. Several Arabs across the street start the ritual washing for prayer. The prayer mats are rolled out and taking a small plastic pitcher they carefully wash first the hands and forearms then the face and lastly the feet and ankles moving them onto the mat when finished. All is done with a fluidity and grace that comes from doing this five times a day for the last who knows how many years. It is a communal event as an old man will be joined by a merchant who'll be joined by a passing youth. They will stand together facing east. They will bow together. They will pray together...shoulder by shoulder. Finally, the man comes back with the thick green cloth I've been looking for and we move on...

I'm just trying to make photocopies. The place said only 30 Francs per copie so I couldn't pass it up. I sit on thinly covered pole chairs...not comfortable. The generator has been fired up for me. I'm trying to copy 200 "Dossiers" or medical charts so we can document things at the hospital. That took forever yesterday with me finally coming back this morning only to find it still not done. I then gave them a Nangdjere (Béré's local language) song book so we can turn our church service into a local language speaking church rather than a foreign French/whitey church. I gave it to them at 8am and it's 10am and still not done. So I wait...at least they call me by name now...Oh, here comes Bonaparte...what's he doing here? He just seems to be everywhere. He's going to help us lay the foundation for the staff housing we'll be building in June with the help of a group from the states...he seems to show up everywhere...I greet him and continue waiting...

I'm in the bureau of the State Police. I came here yesterday to have a paper signed authorizing Paul to film us in Béré. It was already signed by two other offices. This is the last signature. I was told to come back at 0930AM today...then noon. It's now 2pm. The office is sparse with three desks. Behind one works the secretary, a wiry man with a little gray and purposeful movements who is always coming and going, bringing and taking papers...I'm not sure if he really does anything with them. It's hot but a little breeze comes in the doorway right where I'm sitting next to a large woman reading the Bible in French. She's in Genesis and says she's going to read through it all when I ask her if it's interesting what she's reading. The other desk has another large woman behind it reading some other book. I make small talk. They don't seem to mind their reading being interrupted. The man comes back and says he can't find my paper amongst the visa requests. I say that's because it's a request for authorization to film. He says "Oh that shouldn't have taken any time at all...I thought it was a visa request." He comes back in two minutes with the paper signed and puts the all important "cachet" on it and I'm outta there...

Ah yeah, the omnipotent "cachet" or rubber stamp. One cannot survive here in Tchad without it. I'm just beginning to discover it's secret powers. Paul and I went to register him with the National Security Office. He filled out a small form and we wait. Then the guy starts to ask me some questions. He seems suspicious. What is he doing here? Where will he stay? Who's responsible? Give me the address. I write down my name and the PO box of the hospital. He still has a scowl of disapproval on his face. Then, thinking quickly I reach for my secret weapon. To the untrained eye it is simply a piece of wood with some carved rubber pasted on the end. To the one who has wisdom...it is power. I place the rubber stamp in the ink and stamp it down forcefully on the paper in purple ink. The man's face lights up. He smiles approvingly and shows me a stack of similar papers all with a variety of stamped ink. He returns in 1.5 minutes with the document approved having placed his own stamp in Paul's passport...he is now legally in Tchad!

I go later to the Central Referral Hospital for the country. I'm dressed in cargo pants, a t-shirt and tennis with uncombed scraggly hair. I say I'm the Medical Director of the Béré Hospital...for some reason the guard says he doesn't believe me...where are my credentials. I start to panic. I don't have any. They've all believed me before because I'm white. I need to see the director of Women's Health there. Then, I remember my secret weapon. I pull out my "cachet" and present it reverently to the guard. He nods knowingly for me to enter. Once again, rescued by the power of the "cachet"!

It's so good to be back in Béré. The first day back I released 13 people from the hospital. They were all complaining about having no space and patients sleeping on the floor but there were patients who hadn't been seen in almost a week and had been ready to leave for several days. Saturday, I cleaned house some more. Unfortunately, the baby I'd operated on just before leaving for N'Djaména had died. The boy with the skull injury though was awake and eating. He won't see out of his right eye though and he has lid lag. I casted his tibia/fibula fracture and sent him to another hospital for an xray. Things were smoothing out...until the "Sunday of Pregnancies from Hell"...

I rounded and did clinic while Dr. Claver did a C-section. No big deal. Then about midday three women came in to labor at once. One was tiny with a huge baby that then didn't progress. I did a symphysiotomy so her pelvis would open up and she still took forever to deliver and required an episiotomie as well. Then the baby wasn't breathing and was floppy. We mouth to mouth suctioned with a tube and I took a bag-valve-mask and tried breathing. THe heartbeat was slow. Sarah was listening and air wasn't going in. I adjusted and finally air started going in. The baby was limp and blue. Then the heartbeat picked up. Then the baby opened it's eyes with a look like a deer in headlights and coughed a few times. Some of the ever-present onlookers murmered "its a miracle." I had to agree. The baby is still alive today. I then went and had supper and was talking with Sarah outside in the early evening when the "Gard" came to tell me about a woman who'd just arrived with the baby's arm sticking out. Things were looking up though because the baby kept waving it's hand to let us know he was still hanging in there! At 9pm I was called to see her. At 1030pm we'd finished mopping up the mess from the c-section and the woman was already in recovery with a healthy baby girl. I really prayed for that one though because first of all the baby just didn't want to come out of the uterus and secondly I nicked the uterine artery with a suture needle and it bled like stink. I just pressed on it with gauze and tried to calm my panic. I asked for a suture hoping my voice wouldn't crack and was able to control it without much blood loss. Whewwww...I then returned to see the last woman in labor who had also not progressed despite adequate contractions. The woman and baby were big, but the pelvis was small...time for another symphysiotomie. After the procedure she pushed twice and the baby was screaming almost before it hit the mattress and the cord was clamped. By then it was midnight and I didn't even want to deal with the woman who'd just come in with a retained placenta after a home delivery. Fortunately, I didn't have to since I didn't find out about it till the next day! Oh, yeah, today, the next day. I woman comes in by oxcart from one of the outlying health clinics for a breech presentation (butt first instead of head). Another C-section, which fortunately went smoothly with another screaming, healthy kid.

Today, the men from Lai came who'd offered to give us another estimate on a wall to enclose the hospital. The pigs just keep getting more numerous and fearless and the hospital is a zoo. I spoke with the Architect of the government project that we have partnered with as well as the engineer in charge of the implementation. They had planned to give us $60,000 for a wall but not until the second phase which would be at some unknown time after the first phase which will start in September and include a new operating block. I felt we couldn't wait and had seen a beautiful fence around the Catholic school here made of 3 feet of brick with a cement and rebar header imbedded with another 3 feet of heavy chain link fencing on top. It was strong, durable, funcitional and yet open and not prison or concentration-camp like since you could see through and know what was happening inside. And, most importantly it was much cheaper. So these 2 guys from Lai gave me an estimate today of $26,000. Still way too expensive but I think we can negotiate as the Catholic Sisters got a much better deal. I think if we had $18-20,000 we could enclose the hospital, keep out the animals and extra people, keep in the patients, start to really clean things up and provide a hospitable environment as well as move forward with other projects such as providing mattresses and mosquito nets. Without a wall those things just walk away. Then, the government has said they will use the $60,000 to build us a new hospital ward which we also desperately need. I think it could really work out for the best if we can somehow raise the money for the wall.

Your encouraging letters mean more than I can say to each personally. They keep me going knowing I'm not alone out here but that there are people all over the world praying for us here at the little lost hospital of Béré.

I'm finally a real missionary!

March 5, 2004



Salut a tout le monde,

I finally feel like a real missionary. Yesterday, I awoke not feeling the greatest. Sarah and I had just had an important talk concerning trust where we were learning a little to trust each other by sharing some personal things. Unfortunately, that went late. So I attributed my tiredness and soreness to that. Also, it has been very hot here, over 100 F. That must be why I've been sweating so much the past few days. Anyway, at morning report, the "Garde" (Jean Bende) reported on several cases where he had done treatments we'd discussed many times before as inadequate. Then, he talked about a Pediatric case that should have been hospitalized that was sent home. Then, another case that he put on "observation" because, as he said, only the "Médecin" (moi) can hospitalize. That was the last straw. I exploded. I tore him apart. I told him that they've been hospitalizing patients for years without me. I asked the charge nurse how many patients he had personally hospitalized the day before. He said "three." I continued until he spoke up very hurt and said he could tell I was displeased with his work and he'd worked virtually without sleep and if I wanted he would just go back to the District and not work at the hospital any more. I told him he was tired, he should leave and rest and we'd talk later.

That afternoon I did a mastectomy (removal of a breast) on a man (!) with a mass there. During the surgery all my muscles began to ache. I began to have a stomach ache. My head began to kill me. I had a strange premonition I was about to become a true missionary. I finished the surgery and went straight to the lab and had them do the "gout d'espece". Sure enough, it was positive. I finally had Malaria. I was kind of excited even though it meant I'd lost the bet with Sarah and owed her my last bar of dark Swiss chocolate. I got some Fansidar and Quinine from the Pharmacy and headed home to rest. I felt like...well I better not use that word...let me see, oh yes, I can say "awful". But let me tell you...the sleep was sweet. Aside from not being able to hear well and the worsening of my pounding headache (both side effects of Quinine) I felt great. It was the first time in a long time I got a prolonged sleep. The next morning I felt wonderful (but still couldn't hear well...it's like having partial earplugs in).

I also had to to reflect.

At morning report we had worship and then I got up and apologized to Jean Bende. He reported that he too had thought about it a lot and felt like the Devil was trying hard to divide us and he didn't know what to do so he was very glad to accept my apology. Today was the most relaxed day I've had with the best interactions among the staff that I've seen. It was like everyone let out a long sigh that lasted all day long...

To top it off we got our autoclave working just by a little trial and error to figure out the two different knobs! Now we can actually operate with sterile instruments, gowns and drapes.

As for the Malaria...what's the big deal really...:)

Don't worry...

Everyone,

I've got some letters from people who are worried about me...don't worry. I'm trying simply to be real and honest. To say that things are always rosy, exciting and rewarding here would be a lie. But just because I share them doesn't mean that there is any less joy, happiness or fulfillment in being here. I could have shared the same feelings probably from any point in my life. We live in a world that is full of doubts, fears, rejection, disappointment and disillusionment. That is what living in this world is...no matter where we are. But that doesn't mean that God doesn't also fill up each day with visions and reminders of how things are supposed to be. It doesn't mean that I am not satisfied to the core. It doesn't mean that I'm not at peace. Au contraire, I can say that not a day goes by that I don't humbly thank God for bringing me here. I also have not lost my respect for the highest levels of medical care just because I jokingly describe what we have to do sometimes here in order to save lives. We would love to have all the equipment, all the clean and sterile conditions, all the availability of specialized services and specialists, etc to practice medicine at the high standard that I have been well trained to do. But I have had to sacrifice a little professionally as well. While I try to inspire and little by little improve the standard of care here, most of the time I find myself doing things that I know is below the standard I am used to and would love to incorporate here. We slowly work towards that objective but in the meantime we do our best and God does intervene...that doesn't mean I practice below the standards available to me here just thinking "Oh God will help." I work hard and with joy to bring the highest standard of care possible here knowing that it will still be lower than the standard I am used to but that I always hold that higher standard up in my mind as guiding light.

If you would prefer I not share my struggles as well as my successes I can limit my stories to the miracles and write only when I am on top of the world so that everyone can be at ease. However, I would prefer to paint a realistic picture without making anyone too anxious...never for a moment has the thought of leaving or not wanting to be here entered my head. As far as fatigue is concerned, this is nothing compared to what I have endured the last 5 years of my life in the clinical years of medical school and residency. Yet even during those five years I can look back with nothing but joy and satisfaction and thanks for what I experienced. Here I have never gone a night without sleep and most nights I get at least 6 hours. And when I am up I feel it is for a good reason, not like residency or medical school when sometimes I was up just because that was part of the process or initiation or "we had to do it so, so do you" attitude that is found in medical education. When one is up knowing he's saving a life not just writing in some chart or standing by observing on feels satisfied and one is less fatigued. Also I've never slept more at peace in my entire life. When I lie down I go directly to sleep whereas for most of my life up till now I've always brewed on things before falling asleep.

The bottom line is, please, keep praying for us but know that I am not only surviving fine but have really never been more satisfied in my life...I'm just sharing bits and pieces and sometimes the bits will be the doubts and fears that can come and sometimes the pieces will be the tremendous successes, surprises and satisfaction that also come each and every day.

I have learned the secret, when in plenty or in want...I can do all things through Him who gives me strength (Phil. 4)

I must speak...

I am weak. As I lie here on the first carpet I've felt in two months with a welcome fan whirring overhead to chase the suffocating heat away; as I lie here without the ever-present dust suffocating and making it hard to breath; as I lie here having eaten more than I should for consecutive meals for the first time in a long time; as I lie here having chosen to lie here over going to church; as I lie here I have time to truly think and reflect for an extended period of time and I am afraid. An uncontrollable fear descends on me. I think of where I am and I want to be elsewhere. I think of what I have done, not done and what I face and I know I cannot face it alone. As you have heard so many tales of excitement, adventure, sorrow and joy you may have been tempted to think that somehow you couldn't do that. Let me tell you that's exactly what I think: I can't do that. I know that everything in my nature rebels against what I am doing, where I am doing it and why I am doing it. But when I do it, somehow the strength is there and everyday in some unexpected way there is joy as well.

I think of the young man who consistently approaches me about work. He is about 18 years old, married with a couple of kids. He wants to be my gardiner. I say we would like a garden but without a fence or wall the goats and pigs will make short work of it, come back to me when we have a fence or wall. He keeps coming back anyway..."just to make a social visit." He brings tomatoes and lettuce from his own garden...they are impressive. He comes one time when I'm with Bichara, the chauffeur, with the smell of alcohol on him. After he's gone Bichara, a strong Muslim, shrugs in disgust at anyone who drinks or smokes. Later, he approaches me after a long day of work and says that he has not eaten in 5 days. Everyone asks what kind of man he is to have taken a wife when he can't provide. He has looked for work. There is none. Isn't there some work he can do for me. I say that the only need I have is for laundry. I've already given the work to Bruno. He says that he'd approached me first to ask about doing laundry or gardening. That is possible. I acknowledge that with my poor French I may not have understood that from him. He says Bruno has other work already. It's true. Dr. Claver pays him $40/month to clean, guard, cook for him. I pay Bruno $1/week to do my laundry once a week. This guy offers to do it for 50 cents. He's desperate. He asks me to have pity on him. He's been coming to the Adventist church he says. Shouldn't Christians help other Christians. I acknowledge that. Inside I feel he only comes to church because he thinks it will help his cause. But I don't want to judge. I say that I will talk to Bruno and see if he's willing to give it up. He's not. That night I happen to come to the hospital and he's in the ER with his wife who has a cut over her left eye. He says she fell. Both the catholic nun who's with me and I think its because he hit her. When I see him next he gets me at a busy time. I'm annoyed. It seems like no way out and I'm tired of being bothered. I tell him so. I haven't seen him since.

Did I do the right thing? Maybe he is a drunk. Maybe he beats his wife. Maybe he comes to church just to get some work (he hasn't been back since.) So logically I did the right thing. Then I read about Jesus and think what he would've done and this guy is exactly who Jesus welcomed, hung out with, healed, and served. If I start helping people everyone will start to crowd around thinking the rich white man is the answer. It will never end if I start. Then I read that Jesus also was bothered. When he started healing people crowded around and never would let him have a moments peace. Even when he tried to have some quiet time with his disciples they found him. What did Jesus do? He had pity on them. What did this guy ask of me? To have pity on him.

These are the difficult things I am faced with all the time. It's not just the medical work or administration or finances that is challenging. It is the myth that the white man is always rich and a source of gifts, hand outs, money and work. I want to break that tradition. I want them to recognize me as someone who has come to work with them side by side as their equal not as just some magician or philanthropist. How do I do that and yet still not ignore their cries for help when I CAN help them? Where do I draw the line? These are not easy questions...the expectations are high...the myth is deeply rooted...

I'm in N'djaména now and I see the hopeless position many feel because of the corruption of the government. A man's car breaks down in front of the president's mansion at night. He gets out to look under the hood and is shot down. The president hands out lists of people he doesn't want around and bounty hunters collect $100 a head for their deaths. A neighbor of Jabel, Jared and Caleb happens to walk onto a street that has been shut down so the president can drive through. She is beaten within an inch of her life. He has been in power for 14 years as a "democratically elected" president and is not about to step down. The US supports him because of the oil deal recently struck. Two days ago I went to the bank. To get there we were redirected down small dirt lanes packed with people who had to find another way around the main road whick was being cleared off for the president. Shops along the route had to close down. People had to evacuate. We got to the bank finally with the last few blocks on foot. We finish and walk out only to be gestured back in by a soldier in camo bearing an AK47 saying go inside it's dangerous out here. We go inside just as about 10 brand new SUVs, Humvees, and Jeeps bearing soldiers and large machine guns go flying by at about 90-100 mph through the soldier-lined, empty streets. The people starve and beg and are helpless as the illiterate relatives and tribe members of the president live in luxury.

And yet, still life goes on at Béré. A woman very pregnant with twins comes in with a kidney infection. She gets up one evening to use the restroom and discovers a small foot sticking out below. She tells Felix who runs to tell me. We get things ready for an emergency ceasarian. Someone runs to borrow the small generator from UNICEF while we go ahead and get started. It's pitch black but fortunately I have my trusty head lamp. Sarah assists me...very well except for the brief moment when she almost faints due to the diarrhea she's had caused by Amebiasis...but she stands strong and finishes! As I open the uterus I realize how nice it would be to have suction as a hugh gush of amniotic fluid rushes out to join all the blood already in the operating field. I reach in the bloody puddle and find the first baby. I pull the leg out of the vagina and into the uterus and then do a breech extraction. She is fine. I then break the other bag of water. Also a breech presentation who I deliver with a little more difficulty. He is fine too. I then try and see what's going on down in the uterus with all that fluid and blood. Somehow God helps me to sew it together so that the bleeding stops and we finish the surgery. All three are in fine shape. As I'm about to close the skin the generator shows up and roars to life...thanks.

I get called another day for a strange case. A young man about 17 or 18 years old had been hospitalized here in December after being stabbed in the upper right chest and treated with a drainage bag for blood in the chest around the lung. Now he has right upper abdominal pain, a large tender liver, a rapid strong pulse and veins on his right abdomen, chest and neck that are bulging. I think this has to be something different as the chest wound was so long ago and looks healed. I did a quick but not complete exam, gave him IV fluids, hospitalized him and went home. I saw him the next day and the right side of his face was swollen up and when listening to his heart I noticed it was really displaced to the left and had a massive heart murmur that sounded like mitral regurgitation. THen I thought maybe he had heart failure from Rheumatic Heart disease or something else. Fortunately, God will help even sometimes stupid and blind physicians to make the right diagnosis so that they can actually help their patients. I listened to his lungs and found that their were no lung sounds over his right chest and it was dull when I percussed it with my fingers. I had the family buy a syringe and needle and stuck it into is chest withdrawing brownish liquid. The lab told me it was almost all white blood cells indicating infection. Since we have no chest tubes for tube thoracostomies here I found a piece of rubber tubing about the right size (large) and cut small holes in the sides. Having heard one of our Thoracic Surgeons in Ventura talk about how unnecessary it is to have a sterile tube ("spit on it before you insert it") I took him to surgery, gave him Ketamine, sliced a hole over a rib, and poked a clamp over the rib and through the muscles into the chest cavity. Immediately, the coffee-colored fluid shot out across the room under a lot of pressure. I put in the tube and then slowly took off about 3-4 liters of that fluid and saw his heart return to normal, the swelling in his face go down, and his engorged veins flatten out. Not having the appropriate equipment for putting the tube to suction or water seal I tried to rig something but ended up having to just stick the end in a huge jar of water so fluid and air could escape but air couldn't get back in. He's doing fine now.

Dr. Claver is back so that gives me some breathing room to be here in N'DJaména to get the materials needed to repair the generator, buy medicinces and get stuff for the lab. We had just finished our last blood-typing reagents to save two kids who came in with severe anemia from Malaria. The materials I bought yesterday is the first use I have made of the funds donated by you to the hospital through AHI. Now, we can continue to do life saving blood transfusions for patients like these kids with malaria and the woman who had the retained placenta and needed three units of blood during her emergency hysterectomy and who went home in good health but would've gone home in a coffin without the transfusion. Also, now we can test the blood for Hepatitis B and C (as well as HIV which we were already able to do thanks to a national AIDS prevention program) before transfusion. We can also now check the hemoglobin to see how anemic patients are rather than relying on how pale their conjunctiva are to decide if they should be transfused. I purchased pregnancy tests as well so we can diagnose pregnancy earlier rather than waiting till its obvious. We also got test tubes and other materials needed for the lab to help us with diagnosing parasites and other infections. The lab is key as it is our only adjunct to history and physical right now for diagnosis. Also, a well-running lab will help generate money for the hospital.

We should also soon be able to sign the contracts for the staff and get them the salaries they deserve for the work they do based on local pay scales (nothing by Western standards).

The Rhythm of Africa...

The drum beats pound loud and long into the night. It is the rhythm of the plain. The rhythm of Tchad. The rhythm of Africa. The young dance in tune around the drums and small fires their twisting bodies keeping perfect timing and allowing a temporary joy in an otherwise desperate life. The rhythm flows through all here. The generator giving me power and light pounds out its cadence. It is everywhere. The turbans flowing, the robes churning up and down on the pedals keep its rhythm.

The pattering of chickens feet. The bleating of goats. The crowing of roosters. The buzzing of flies. The hum of mosquitoes. The crying of Sarah's cat when left indoors. All the animal kingdom keeps time with the rhythm of this place.

The rumbling of intestinal sounds. The fast paced breathing of the severe malaria or chronic tuberculosis patient. The pounding heart of the dehydrated infant. The short grunting squeals of the 5 month old in the midst of a seizure due to meningitis. The sucking of the premature twin now breastfeeding well having survived against all odds. The popping of fluid filled lungs of a child about to succumb to severe Falciparum malaria. My own stomach demanding its own rhythmic ritual of purging as I call for the car to stop just as we're about to leave N'Djaména. The fish/sesame seed balls come up in the rhythm of vomiting as my body tries to adjust to the rhythm here. Fortunately, it only happens 8-10 times more over the next hour or so and then my body has found contentment in the local cadence. All sickness, death, healing and life marches in tune with the pounding out of this rhythm flowing in and through all here.

The lilting chant of Lazare, the maintenance man, singing hymns in N'Djeré with a rhythm unrecognizable to the western mind but in harmony with all things Tchadian. The rise and fall of Tchadian Arabic shouted and bartered in the open air markets where one can buy anything and everything to the harsh cries from the Mosque and the Koran is taught to the people. The washing of feet, hands and head systematically with a small plastic pot on the side of any road or in front of any shop prior to the hour of prayer. A hundred or a thousand forms rising and bowing and touching the forehead to the ground facing Mecca five times a day. The erect, proud stride of the turbaned Tchadian with robes flowing as he goes about his business. The beat runs through all.

You can try to fight it...it doesn't work. Show up at seven as promised...but that is Western rhythm...move on...do what you can and come back...then come back again...work with the rhythm. All we can do is take the rhythm that is here but sing our own song to it...try and find a song pleasing to God that at the same time doesn't disrupt the fundamental heart of Tchad, that doesn't interrupt the soul, the rhythm of Africa. I believe that rhythm has been placed here by God...just some of the popular songs that have been sung to it haven't been His...now its time to find what songs he really meant for this beat here at the Hospital, here in Béré, in Tchad, in Africa. The beat goes on and on and on...boom batta boom boom battata boom...