Tuesday, November 25, 2008

White Man Can't Jump

The Toyota van which was rumored to be our transportation back to the capital still was not functioning well. It was for that reason we had had to hire a truck to bring us here to Bere from Kelo when we had first arrived. Now, weeks later, after recharging the battery and having some work done on the distributor, it had yet to shed it's "unreliable" designation. The problem likely originated during a drive through a flooded road during this past rainy season. We suspected that water had gotten into one of the hoses of the engine, given the muddy residue in the space where the battery was bolted down. With just a few days before it was needed to return Suzanne and I to civilization, I was strangely calm and nonchalant about the whole prospect of being stranded in the Chadian desert. I'd been around long enough in these places and situations not to worry to much about it.

Next to the "garage" where the van was parked was a small concreted area and basketball goal post, complete with backboard and net (surprisingly). One day, while milling around next to this failing experiement in rural transportation and wondering if I should've booked an open return date, I let myself get sucked into a game of 2 on 2 basketball. I really didn't want to play. I mean, I hadn't actually dribbled a basketball this mellinium. I was short. My shoes had been stolen. My rubber sandals I had gotten at market were 2 sizes too big. I hadn't had surgery yet to remove the cyst on top of my left foot. But I got to be on James' team (who was about 6' 3"), and I figured that, after all, we'd get beat soon enough that my feet wouldn't have time to develop blisters as I ran around trying to pump and fake jump shots on the rough concrete. So, we began our quest to score 10 goals.

Being on the hospital grounds, the court was on the inside of a chain link fence. However, the main road was only about 20 feet away, and as 4 white guys began playing basketball, a small crowd pressed their faces into the fence to watch. It was like they'd never seen a game of basketball or something. Some of them even climbed part way up to see over the people standing in front of them. I wasn't sure if they wanted to see a game of basketball, or if they just really thought it was just a chance to see white people without shirts get hurt. I was told that the common belief amongst Africans is that white skin is really flimsy... doesn't hold up well, cuts easy for surgery, doesn't heal well. I mean, with the hair that's all stringy, straight and flops all around, white skin couldn't be all that durable. You know how it goes.

So without going into deep detail on the play by play, let me just tell you that this white man may not jump, but he's got a KILLER sky hook. See, when I was in grade school, I never could manage to shoot over the reach of anybody in my class. I had seen Wilt Chamberlain do his sky hook shot over anybody and everybody and thought I'd try the same. I got to the point where I could make the shot IF it was made from right at the 3 point line. Any closer and I'd usually shoot to high or hard, and any farther away I wouldn't come close enough.

Well, we came right down to the wire. James and I led by only 1 point, and we needed one more to win. Somehow, the shorter half of the team got possession of the ball, and I dribbled to the right side of the court, around to where I imagined the 3 point range was. Then, I took one step back away from the goal and pushed upwards into the air using the beginnings of a large blister under the large toe of my left foot. As my body rocketed a good 3-4 inches heavenward, my right leg instinctively bent at the knee, while my right arm and hand (entirely incapable of palming or even gripping the ball very well) described a scooping, yet graceful, arch in space as I lobbed the ball towards what would be the game winning goal. Time slowed. I could hear the ball pass through the air, propelled by the anticipation of at least a dozen small African children, each letting out little gasps from behind the fence as they squirmed to see whether or not this inconceivable shot was going... was... going, going... YESSSSS!!!! IT went IN!!!! Nothing but net! Sweet victory.

At least, that's how I remember it. Perhaps it looked more like the Karate Kid trying out Mr. Miagi's "Crane" technique for the first time. I don't know. Ask James, he saw it all. I don't know if he could believe what he had seen, but he did see it.

Oh, and speaking of keeping your eye on the ball...

There was a man who came in for surgery shortly thereafter. He had a collection of fluid around his testicle that was giving him a lot of trouble. So, I did a spinal, and James cut out the fluid collection, along with the large, swollen, slick and rather oblong testicle. As we moved the patient over onto the gurney to be rolled out to the hospital wards, I heard a thud followed by a kind of splat, bounce, bounce sound. Out of the corner of my eye I could see Abel, the OR scrub tech, briefly scamper around grouping at something on the floor. It quickly became clear that Abel had, uh... well, how shall I say this? Well, quite literally... he had dropped the ball. I suppose it was understandable. The size, shape and slick surface combined to make it very difficult to regain control of the ball after initialy losing possession. He finally got a grip, and holding it with both hands, slowly stood upright under the curious gaze of all us in the OR (including the patient, who'd been awake the whole time under spinal anesthesia). "Able, my man," I said, "you need to keep your eye on the ball."

Things you don't want to hear in the mission field: "If you lift up the passenger's seat, unbolt the engine cover, and hold down the flap mechanism of the carbeurator, the engine starts much more easily. Three cranks instead of twenty. You'll probably want to leave the cover off as you travel to N'Djamena so you can manipulate it as you drive, otherwise it may stall and who knows if you'll get it started again. It does make the inside of the van quite hot though."

Friday, November 21, 2008

Things That Bleed in the Night

Things That Bleed in the Night

The month-long trip was almost over, and I still hadn’t been woken up in the middle of the night for any emergencies. Until tonight, that is… at 4:30 AM.

I don’t remember much until I got to the hospital, which was only about 50 yards away from the guest house where I slept before being aroused by a hushed, anxious voice calling to me from the darkness outside my screened window. I was needed at the hospital right away.

As I staggered out the door, adjusting my headlight and rubbing my eyes, I wondered what it could be. Whatever it was, it was probably pretty bad. Emergencies in Africa usually are. I mean, you usually get killed or die before making it to medical care or else by some miracle, you actually survive and present with some horrendous problem that could easily be a case report in Western medical literature.

I picked up the pace and rushed over to where I could hear voices and met a few people scurrying into the labor room. As I came into the light, my gaze fell upon a woman who I immediately knew was in trouble. I can’t remember if I said it out loud or not, but all I could think was, “She doesn’t look so good.” Her eyes were partially rolled back in her head, she was gasping for air, weakly, infrequently, laying in a puddle of her own blood. Her skinny abdomen was grossly misshapen for what should’ve contained an average, round, 5-6 lb African fetus. James was standing at her side, shaking his head and muttering over and over, “This is a catastrophe, a catastrophe.”

As we struggled to get functional IV access re-established, the story unfolded. She had arrived about 4 hours earlier in troubled labor. James had been notified, but with such incomplete and poor information that he’d sent the staff back to the hospital to learn more. They returned with more information… 4 hours later. In the interim, IV Pitocin had been initiated, but unfortunately this had only worsened her condition… a bleeding, ruptured uterus. She had been bleeding to death the whole time.

The thought occurred to me that if we ended up coding this woman, there was no more epinephrine in the hospital. This was followed by the realization that this woman was no longer breathing, and we still hadn’t gotten an IV. James quickly started running the code, and chest compressions were started while I got an IV in her external jugular. We considered intubating, but with no oxygen to administer, I saw no advantage in intubating over a simple jaw thrust to maintain a patent airway in a skinny Arab.

We had the monitor from the OR, and her pulse ox was reading in sync with the chest compressions. We couldn’t measure a blood pressure and there were no EKG patches to check her heart rhythm. Oh, and no epinephrine… not exactly a textbook example of CPR. Meanwhile, the husband, standing just outside the window in the cover of darkness, was asking why the baby couldn’t just be cut out if there were problems.

After a few minutes, I got the distinct feeling we were attempting to resuscitate the dead. On one or two occasions I remember thinking, “We should stop this… it’s just futile.” But I bit my tongue. I could see James was dedicated to trying his best to pull this one out of the jaws of death, and I just couldn’t bring myself to oppose the effort.

We took her to the OR, transfused multiple units of blood, tied off her uterine arteries, and poured in 2 packets of Celox to stop the bleeding. In the whirl of activity James remembered that there were some epidural kit trays sitting in the next room in storage, where we could find 1 mg vials of epinephrine to compliment the atropine I had already tried after moving to the OR. We shocked her with a defibrillator, but were able to see little activity on the EKG. Nothing helped. Two and a half hours after starting the code, we stopped.

The child inside her broken body was hydrocephalic and had spina bifida. The large, alien like head would never have been able to pass through her pelvis, nor have lived long, if at all, after being born. It looked like the Devil had taken us for a 2 for 1 special this time. We carefully cleaned off her blood stained body, covering it with the long, gold-threaded, silk cloth covering she had worn when she arrived. It was time to give her back to her husband. I wondered if he would understand what had just happened.

He met us at the door, in the early morning light, as we lowered her cold body onto the ground. I watched as the realization of what he didn’t want to know swept across his creased countenance, replacing whatever measure of hope and joy that I can only imagine a husband and father brings to the birthday of his first child. For once, I was glad I couldn’t speak Arabic. With the Arab he knew, as best he could, James told the story of the man’s now dead wife and son. The man slowly sank to his knees, uncovering his wife’s face to see the truth for himself, cradling her face in his hands. The other Muslim men quickly came to his side, responding to his call for water, as he washed her face and closed her eyelids with his hands. He then covered he again, and began to quietly morn and chant, rocking back and forth while kneeling, surrounded and consoled by his Islamic brothers.

As James and I walked away, I asked him if he knew what the man was saying. “He’s saying, ‘There is no God but Allah, Allah be praised.’ How many Christians do you think would respond like that if this happened to them?” We both knew the answer without saying it.

Monday, November 17, 2008

Cat on a Hot Tin Roof

It was bound to happen. I mean, I was expecting it…eventually. Today we finally got a case that was going to be hard to do with the little supplies I had to work with. I just hadn’t spent much time thinking about what specifically I’d do for workarounds given I didn’t have inhaled anesthesia.

James called me into to look at an abdominal ultrasound he was performing on a man with complaints of right upper quadrant pain. It seemed obvious, even to an anesthesiologist, that the guy had some junk in his gallbladder, and probably needed it removed. Thing was, he was otherwise doing pretty well, and happened to be the chief of the area. You hate to do something for a VIP and things go wrong, you know? But, it seemed as though this guy’s time had come. So, that left me to figure out how best to do the anesthesia.

Ketamine and spinals was all I had, though after using nothing but for over 2 weeks, I had gotten used to it. On the other hand, we’d not had to operate this high in the abdomen yet, so a spinal would probably not reach high enough to cover the operative area. Then again, ketamine, while entirely adequate to keep the patient pain free and unaware of what was going on, would likely leave James a very difficult operation to perform, high up near the diaphragm, with no abdominal relaxation. What to do?

I chose an unorthodox approach. I planned to place a spinal anesthetic, then tilt the table to get it to rise higher in the abdomen than usual. It would be a bit of a trick, I’d have to watch out for hypotension and maybe a dangerously slow heart rate, but if it worked… it’d be just what the doctors ordered. The patient paid his bill (all services here are prepaid, even the pills you take), and we went to the OR to take care of business.

The spinal went in easily, and I put him at about 5 degrees head down for 10 minutes while the spinal medication set in. His blood pressure and heart rate seemed to be doing fine, so we started the case. He didn’t flinch at all as James cut him open and started moving in toward the liver and gallbladder. So far so good.

Well, it took a while, but he did indeed get hypotensive… to the tune of about 60/35. Gulp. OK, not a problem. I had some epinephrine set aside just for the occasion. I had jealously guarded it since my arrival because it was the only vial in the whole hospital. And I was about to need it.

I got the sense that things weren’t going to go as planned right after I cracked opened the vial. See, over there, most meds come in breakable glass ampoules. No big deal, many in the States do to. Just crack the top off the vial… I’ve done it hundreds of times. Well, this time was a DIFFERENT glass vial. This was a brittle, brown glass that shattered between my thumb and forefinger as I opened it, cutting my thumb and spilling out the precious fluid like perfume out of an alabaster box.

It’s hard to stay calm in a situation like this. I mean, how much worse could it get? And the fact that I was the one who had essentially wasted the very drug that was desperately needed only made things worse. I muttered under my breath as I looked at the crumbled glass in my hands, but noticed one larger piece of glass that had a *small* puddle of epinephrine still in it. Looked to be about 1/20 of what came in the vial. Well, I thought… it’s all I’ve got. And, it may just be enough. After all, I didn’t need the whole vial. At least, not just yet.

So I sucked it up and diluted it into a 10 ml syringe, all the while hoping I wasn’t inadvertently mixing in either tiny broken shards of glass or trace amounts of my own blood. The next blood pressure was enough to convince me that there was no error being measured… he truly was hypotensive, and he wasn’t responding quite the same to me as he was before (even though we didn’t speak the same language). It took a few doses, but I was able to get him back up closer to 100/60 mmHg.

By now, James was convinced his gallbladder was fine. This was good news for me. It meant that we’d finish quicker than I’d thought, and that the spinal would not likely wear off before we were on our way to the medical ward with this patient.

The odd thing though, was that as he was wondering how he could have thought things were so bad on the US, when in reality the anatomy was pretty much well fine, he noticed a dark spot that seemed out of place. It was a little past the stomach, on the small intestine. Closer inspection revealed a duodenal ulceration that was probably the source of his upper abdominal pain. AND… it perforated WHILE James was looking at it! We were stunned. We had operated for the wrong reasons, using an incision and anesthetic plan that would’ve been completely different had we actually known what we were in for. Yet, providentially, it worked out perfectly. Amazing. Just amazing.

I try to do other stuff to help out around the hospital when we aren’t actually operating. Today was the day I planned to solve one aspect of the water supply. See, there’s a water tank, mounted above the garage, that is fed from a 300 ft well. It’s a very important feature of the hospital’s operations. The water comes from below the bedrock, so there is no runoff contamination. It’s pure, no need to boil it or anything. The tank supply is used for nearly everything from scrubbing in for an operation operation, (important), to patient’s laundry and cooking (less important). It’d be nice if surface well water (only about 10 feet deep) were used for the later since cooking always entails boiling, and giardia on your clothes is really no big deal (especially since it’s going to get cooked in the sun as it dries on the clothes line anyway). But people would rather turn a spigot instead of draw from a well. So, we run out of tank water relatively often, and often it’s at an inconvenient time (time to scrub for surgery).

The problem is that you never know how much water is in the tank, and you don’t know if it’s time to turn off the generator before wasting fuel as the overflow valve lets excess water spill out of the tank after it’s been filled by the pump. So I designed a gauge for the tank… MacGyver style (modified from a similar design seen in season #1). I tied some fishing line to a plastic soda bottle with about 50 ml of water in it and floated it inside the water tank. I fed the free end out a small hole in the top of the tank, near the edge that faced the hospital, and covered the edge of the hole with scrap plastic and epoxy putty I’d brought from the States. This way, the heat and friction would not cut or melt the line. From there, I ran the line down the side of the tank, back up again, and down once more, weighting it down with small lead sinkers on the free end. I had cut off several of the plastic rings from which the IV fluid bottles hang to make a pulley system, again, sealed onto the side of the water tank with epoxy putty. The down, up, down arrangement of the line made it so that the middle third of the fishing line rose and fell with the bottle floating inside the water tank. And for the finishing touch, I used a piece of Duct tape acted as a marker, reflecting where the water level was inside the tank.

At least… that was the theory. See, when I actually climbed up on top of the garage to install this contraption, things got a little dicey. I took off my sandals (shoes were stolen, remember?) to make it up the round rung ladder that led up the side of the water tower. As I stepped off the ladder and onto the top edge of the water tower, my feet were scorched by the intense heat accumulated by the hot metal tank under the blistering Sahara sun. I instinctively lunged away from the edge, hopping around toward the middle of the tower, in case I lost my balance and fell over (at which point I fully expected to get 2nd degree burns on my hands and forearms). I quickly realized I was NOT going to be able to do this indefinitely. It must have looked like I was doing the Samba or something while dancing around on top of what felt like the trap door to hell itself. Then I had a another one of my brilliant ideas… I’d just sit down. I mean, I had scrubs on covering my legs, right?! I’d have a little insulation, a bit of a reprieve… just what the doctor ordered!

I quickly sat down and flopped my legs over the side of the tank… only to become acutely aware of the need to turn the other cheek. Buns burning, I maneuvered as best I could to relieve the somewhat diminished pain and heat coming off the top of the tank so recently felt on my feet. CLEARLY, I had made the right decision that morning to wear underwear instead of going commando (fortunately for me, I’d done laundry the day before). In the end (HA, funny!), that little extra bit of insulation saved me from developing what I imagined in the moment to be lifelong disfiguring scars all up my thighs and buttocks.

I somehow managed to “walk” my way over to the ladder without giving myself the wedgie of a lifetime, scamper down to the cool, shaded underside of the tank and put my sandals back on. I hobbled away with a stout resolve to return only AFTER the sun had set to complete my best laid plans (which, it turned out… worked perfectly).

Things you don't want to hear in the mission field: "Yes. It’s rice again."

Wednesday, November 12, 2008

Malaria Strikes

Now, about Suzanne's bet with James over the Milkyways ... she lost.

It started with headache and really bad muscle aches in her tricepts. The fatigue was a bit hard to figure out, since the lack of food combined with the heat makes one tired all the time anyway. But she was tired, that's for sure. Add a little nausea, and viola... you've probably got malaria. We didn't even bother to check her blood smear, we just started therapy. And since she wasn't vomiting yet, she didn't have to have me start an IV for her quinine. She could just take the pills. Those are combined here with doxycycline. You do have to keep eating though, which is no small deal since the quinine takes most of your appetite away. But if you don't, the quinine makes you hypoglycemic. It also make your ears ring a high, annoying pitch. Bad enough to make it hard to sleep at night sometimes, and difficult to hear a conversation under certain circumstances.

The first night she was miserable. She was restless, had fever alternating with chills, a bit of nausea ... just felt awful all over. Fortunately, I'd made her start medication earlier that day (over dosed her a bit with the doxy, as a means of revenge on the malaria parasites), and the next day she was feeling much better. On the up side, after a week of quinine, 3 weeks of situps and just as long eating only 2 meals a day... she's lost 2 inches around her waist and now fits loosely into her "skinny jeans."

As for me, I continue to be well... not even a case of traveler's diarrhea (though I admit that the cigarette smoke in Paris first, and then N'Djamena, gave me sinusitis). I've gotten a few mosquito bites, but I take my low dose doxycycline prophylaxis faithfully and I'm on my cumulative 14th week of life in Africa still malaria free.

We continue to be busy in the operating room... usually 2-4 cases per weekday. Today brought in an unusually good smelling Arab woman with an equally unusual problem. As best as we can tell, she'd been unable to get pregnant by her relatively older husband (recall, the average life expectancy in Tchad is 41). She'd been allegedly pregnant recently, but had lost the child, and had been unable to get pregnant again since. We prepared her for exam and probable D&C. It QUICKLY became apparent that she was NOT going to let 4 strangers, all men, uncover her to get ready for the proceedure. Of course, unless she was buck naked in a certain specific and strategic area, there was nothing we would be able to do for her. She thrashed around a bit, enough to to make us feel like we were forcing her against her will (even though she'd already agreed to the procedure), and we gave up for the moment, not sure what to do or say (in Arabic, which none of us spoke) So, I figured it was time for a little better living through chemistry. After 15 mg of Valium, not only did she not care she was dressed down as Allah originally made her, she was no longer going to remember the 4 men she was with instead of her husband.

Turned out that her cervix was about as uptight as she was, and it took James a good 20 minutes of dilation before we convinced ourselves that she was no longer impregnable. We rolled her out of the OR and were promptly met by her devout husband as he covered her from head to toe. James, in his limited Arab, explained that, "The door of the house of the child (This is literally the phrase translated as uterus) was shut. I opened it. May Allah give you many children." He looked very relieved. Later, when he passed me on the path he paused to speak with me and taught me the typical Islamic greeting "salaam aleikum," (Peace be with you) and it's customary response, "aleikum asalaam," (And peace be with you).

After settling into the guest house later that day, I was summoned by one of the student missionaries who ran to get me. I was told that a baby had been admitted with severe malaria, but that they couldn't get an IV to rehydrate and start quinine. So, I quickly went to the peds ward to see what I could do. The two of us found the child, now lifeless on the ground outside the entrance to the peds wing, her mother weeping bitterly over her form as the father covered the tiny body with a drape. I learned she had been brought in 20 minutes ago, and had to wonder, yet again, why it is that people wait until the last possible minute to take action. The more important it is to do something, the longer it is they wait to actually do it. I circled around the ward to see if there was anything else I could do before heading back home. When I walked past the doorway again, the family was gone. A little wrist bracelet, so common on the children here, remained on the dirty concrete where they had been. I stooped to pick it up, and stood, looking for the parents. I never saw them again, and have kept the bracelet as a reminder to not put off the important things in life.

Not long afterwards, I got another call for a similar problem. Same story, though this time the parents had come sooner in the course of the disease. Everybody had tried to get an IV on this kid, and had blown all the best veins (I thought that only happened in the US!) I tried a few places where I imagined veins to be, until I was convinced they were all mirages. I gave up... and went to get a 20 gauge IV to start a femoral line. No sterile prep, no drape, no lidocaine, no nothing except gloves (which the parents had to buy), and IV catheter on a syringe, and some alcohol sprayed on the skin. I knew if I hit the femoral artery instead of the vein, the 13 red blood cells left in this kid would end up flowing out on the bed (the lowest hemaglobin I've seen here is 2.3). I said a prayer, and then slipped it right in. I stitched the IV onto the leg, covered it with a tegaderm and made sure the quinine was ordered and the blood transfusion was dripping. As I turned to go, I wondered how long the parents would keep the think working (nursing care is largely provided by family members, since THE nurse has to cover the whole ward).

I didn't have to wait long. I got called back that night because the IV wasn't working. I went to take a look. The dressing I had so carefully places was partially pulled back, and a fly was crawling on the bloody joint where the IV joins the catheter. "Nice," I thought. There was dried blood and feeding flies on the tape I'd used earlier to secure the line to the leg and prevent any unnecessary tension on the catheter/tubing junction. I do this on purpose because they have no screw-on Leur lock connections here... everything is slip tip, making it exceptionally easy for IV sets to come apart. This is by design, as there are no such things as 3-way stop cocks which would otherwise allow IV injections to be made without any disconnecting of the IV drip set tubing. To uninitiated eyes, the filth and lack of care and cleanliness is simply revolting. It's just that patients, no... people survive, and rarely thrive, in this dirty world. Or, they do not live at all.

I took of the tegaderm dressing, pulled the catheter back a bit, got it running again, redressed it, and went back home to go to bed. I was glad to see that in the morning, the blood transfusion had been completed, and there was enough fluid in those little veins so that another IV could be started... since my femoral line had infiltrated (or something), and then removed.

Things you don't want to hear in the mission field: "Say... what's your blood type?"

Tuesday, October 28, 2008

Back to Market & Advice for Newbies

Back to Market

My feet were swollen and hurting. Not surprising after spending over a week going barefoot and standing on concrete floors sans Ecco shoes avec orthotics (l REALLY hate thieves). Despite this, Suzanne insisted that I go with her to market so she wouldn't have to go alone. So, I did.

We're learning more where things are. We found a guy who has a refrigerator (of which there are only 2 in the whole town that we know of) and sells powdered milk. His name is Mahatmet Samir. He also has these UNbelievable seasame seed snacks from Egypt. Then, around the corner are the bakers stall, with open, mud brick ovens. Good stuff. While there, there was a guy from the next stall who tried desperately to sell me some really dirty, ugly roots of some kind. He's the only guy I've seen smoking here, ever. Anyway, I didn't entirely understand his French, and he clearly didn't understand my saying I didn't need any roots, thank you (turns out you should never simply say "No." because it's offensive to reject someone's goods... so I've learned to say "I don't need any, thank you.") I had just finished a cold drink in an aluminum can from the Mahatmet's fridge, so I told him in quick plain English (which of course, he didn't understand in the least), "I tell ya what, buddy... I'm gonna just give you this can so you can use it as an ashtray, would you like that?" "Oui," he said. So I handed him the can and tried to take his hand, holding his cigarette, and tap his long ash into the hole I was just drinking through. He didn't get it. Everyone else around him seemed to though, as they laughed.

From there, after paying about 65 cents for 3 small round loaves of bread, we cut through a few buildings/shacks where the taylors can be seen running the foot powered circa 1890 Singer sewing machines. They'd been conspicuously absent for the past few days and we learned that was because as a group, they refuse to pay the market place tax. The Police had been looking for them, so they'd been hiding. We stopped by and talked with the Arab cloth salesman that sold Suzanne her cloth for her dress (and sells AMAZING tea). Using some Enlish, some French, and a bit of Arab, I told him I had cloth and wanted a traditional pair of clothes made by an Arab taylor, in a certain style... and a turban, not a cap. I was told to come back tomorrow in the afternoon for measurements, and that the turban would be available in one week.

The walk to and from market is always punctuated by voices calling out "Nasara!" as you pass by. It occured to the three of us Americans that if the situation were reversed, we could NEVER get away with what these people were doing to us. Imagaine... a couple of white Americans out somewhere just minding their own business in San Francisco or Atlanta when these two guys from Africa walk past. They don't really speak Enlish, they've just arrived and really only know a few words of English. One American thrusts his hand through the air as he repeatedly points at the Africans and calls out loudly for all to hear, "Blackie! Blackie!" That would never, EVER be tolerated. BUT... here in Africa, doing the reverse is perfectly OK. Call me "Honkey." How about "Cracker." "Nasara." Same thing.

Actually, they call Suzanne's skin color red. They paused a bit when asked about mine, and still called me white (I can't help it. I'm taking Doxycycline, and I'll get a monster sunburn if I try to tan.)

Things you don't want to hear in the mission field: "Hey Cobos! Are those your shoes that the goalkeeper is wearing?"

Advice for Newbies

Friendly mission tip #1: When packing important things to bring along, consider the Navy Seal slogan, "Two is one, and one is none."
Friendly mission tip #2: While in the WC, consider the water conservationist's motto, "If it's yellow, let it mellow. If it's brown, flush it down."
Friendly mission tip #3: As you shop at the market, recall that your thickly accented conversation starting with "How much does ... cost?", is quickly and universally interpreted as meaning, "I want to barter. I have much money to spend. I have no idea how much I should be paying for what you're selling me. Make an opening bid and you will enjoy yourself and make a killing while haggling over the price with me."
Friendly mission tip #4: When visiting the locals, DO NOT insult them by turning down their offer to drink some tea. EVEN though it's 95 degrees in the shade where you're sitting together, AND the tea is actually steaming.
Friendly mission tip #5: It's OK to shake hands with everybody, even though you don't know them, don't know what's been on their hands, don't know if they even know how to wash their hands, they pick their rotten teeth or pick their nose with more than one finger while they shake hands with you. Just wash your own hands before touching your face. And, if there's water that night at the house... take 3 showers.
Friendly mission tip #6: If you can actually see a stinger on the wasp as it flies by, DO NOT (I repeat) DO NOT take a swing at it with your bare hand. Use the fly swatter. It's probably next to the stove.
Friendly mission tip #7: When you feel something crawling in your pants, DO NOT smash it directly against your skin. Instead, grip it between two bunched up layers of clothing using your fingers... THEN smash it to death, letting its crunchy remnants fall harmlessly out your pant leg as you walk away as if nothing at all out of the ordinary has just transpired.
Friendly mission tip #8: Remember, every time you use toilet paper right now to blow your nose, brings you that many more little paper squares closer to having to use your left hand later on... in the end (so to speak).
Friendly mission tip #9: Hear me now and believe me later on, but when the soldier holding the Kalishnikov machine gun in his lap and riding in the back of the only functioning automobile within a 50 mile radius shakes his finger in the universally understood "No no" motion as you raise your digital camera in his general direction... DO NOT take his picture (while he's still looking).
Friendly mission tip #10: BEFORE cracking ANY eggs, check to see if it floats. An egg that sinks will likely taste good. If it floats, keep it in a secure location, preferably under lock and key, ready to be launched by hand or slingshot in case civil war breaks out. You will be on the winning side.

Things you don't want to hear in the mission field: "You know, the medical officers on night shift use that sink to pee in."

Step Into the Sun & What's Cookin', Doc?

Step Into the Sun

The previous 5 years that James has been here have largely been characterized by limited electricity. There is no "grid" here. There are 4 generators, 2 of which are broken beyond their numerous previous repairs. Of the other 2, one is running as I type so the fresh water tank can be filled and running water is restored to the hospital grounds (an every other day endeavor around here). I went with Abel (the nearly deaf surgical scrub tech) to start it, along with Jacob, a premed college student who is volunteering here. The generator looked to be circa 1920. Abel tried to explain to us, in French, how it had to be started, while Jacob and I tried to pretend like we understood what our role was about to be. There was an exceptionally large shaft sticking out of this thing to which Abel attached a hand crank, very much like what a Model T Ford automobile had. On top of the generator was a large slide/switch that he talked about and moved from side to side as he made a circular cranking motion with his other hand and arm while making put-put-put sounds with his lips. He hefted the crank around for a few seconds before getting tired and yelling something in French. Jacob tried throwing the switch and Abel stopped turning but nothing happened. He tried to explain again what we were supposed to do and we did it all over again. This time he yelled something I understood, "Cest bon!" "It's good," I said to Jacob, who slide the lever again as Abel stepped back out of the way and the motor slowly chugged to life.

James told me that that generator had been repaired by a pilot (who's gone gone) nearly every other day for the previous 2 months. It's a miracle the thing actually functions at all, and it's quite expensive to run the thing. The analysis I am doing will help them determine whether or not it would be in their best interest to purchase another 25 Kilowatt generator or double their solar panel array.

So, the solar panels are a very recent addition, done as a specific donation/project just a few months ago. This has allowed the night shift to have lights in the hospital, the OR to run electrocautery, overhead lights, an air conditioner (well, sort of... it's better than nothing!), suction, and patient monitors. The system also supplies a limited amount of electricity in the houses within the hospital compound. That's why I can charge/use my computer to type to you without pulling out my own 60 watt foldable panel (powerfilmsolar.com) that I brought in case I actually needed it to charge the battery pack. The computer links via Bluetooth to the Chinese iPhone clone, and from there, to the internet (~ kb/sec). The phone is charged via the USB port when the computer has power, or via the handheld panels (solio.com) I brought for the iPod and iPhone. Neither of my solar systems have been necessary yet (which is kinda nice, but makes you feel as if you carried extra weight for nothing).

I measured a maximum power output of 1.25 kilowatts at high noon, dropping to about 750 watts about 3 hours either side of that time of day. Cumulative power storage for a day is about 8.5 Kw. We hope to figure out the power draw of all the major appliances so they can figure out if they should get more panels, more batteries, or both. Or, even neither. It may be they are conserving energy for no reason. See, they have a battery bank of 24 2 volt batteries holding 900 Amperes. The charge controller prevents more than 50 % discharge, to maximize the battery life, which is supposed to be about 12-15 years (though the summer heat here probably will cut that in half, at least. They ought to just burry them). The panels, however, were quite dirty when I got here. I cleaned them off and got about 10% more power the next day. Also, they face a bit too far west, and are laying to far on their back. My next step will be to redirect them so that they will more closely approximate a 90 degree angle with the sun around the time of local solar noon (11:30 AM). That should give them a bit more power too. 10% may not sound like much, but consider that over a year's time... that's more than an extra month's supply of solar energy, for free.

In between measurements, we played Rook and went shopping at the market, where we found fresh Chai tea, sugar, limes, bananas, bread, and phone credits to send txt messages and link with the internet. Suzanne tolerated one drunk suiter to take his picture with her, but we agreed that next time I will be responsible for breaking up that scenario pronto. We passed the theater, which is a tiny area darkened by grass mats used as walls and French subtitled American films are shown on DVD players. I think they said the cost is like 25 cents US. Curiously, it's about the same cost of recharging a cell phone here... which is done by the phone company itself, actually. See, the phone company has to run a large generator to power it's tower, so it sells off the excess to people wanting to charge they cell phone (after all, they have no electricity at home).

We also got a chance to see a local metal worker working with what looked like iron or steel. I couldn't tell. He had two hand bellows that he would use to heat a small clump of red hot charcoal, then strike while it was hot in order to shape it into various tools (spear heads, knife blades). Rumor is, the Arabs make a much better, and more threatening sword... with a lot more style too.

Turned out the fish section of the market was in full swing today... and it stank to high heaven. It really wreaked. I mean, I've smelled some filthy, foul, filth in my life... but this had to be the mostest... worstest... badest.... THING, I have smelled in my entire life. (Did I mention it smelled bad?) I'm confident Allah himself was nauseated with the stench. Maybe it wasn't JUST fish. I readily admit the cumulative aromatic experience included healthy/unhealthy doses of animal excrement, feet, unwashed hair, arm pits, and other body parts that rub together when you walk. So you can imagine our dismay when we encountered two of the student missionaries from the hospital walking towards us munching on this oil-soaked, orange eel/fish-like thing we had fervently avoided. They claimed they had watched the things get deep fried in front of them, so that had to have killed anything that would've been dangerous, right? I just couldn't see the wisdom in such a course of action. Must have been a double-dog dare or something. Suzanne vowed on the spot to be vegetarian for the rest of her life. The cow (maybe goat?) carcass/pile of bones that was entirely covered with flies that we passed, laying on a table, the last trip to market certainly helped her make this decision.

After securing out valuables, we bid adieu to all the gawkers who'd never seen a white/tan person before... "Smell ya later!"

All the kids like to line up and point at you saying "Nassara!" It translates loosely to "whitey." There's an arabic variant which is more precise, meaning "Christian dog." I have yet to be called that one. And, when the occasional child repeatedly (5 times, minimum) asks, in a thick Tchadian accent, "Whass jyour naime?" I usually tell them, "Nassara... Monsieur Nassara to you."

When we arrived back at the hospital, Sarah had returned from N'Djamena with more toilet paper, assorted edibles, and fabric (sans turban) for my Tchadian outfit that James' Arab taylor is to sew for me before I leave for the states. It's a nice light blue color.

The water ran out just as I entered the bathroom this evening, so I went to bed without a shower, or washing the day's accumulation of oil and dirt off my face (no small amount), and without brushing my teeth or being able to flush the toilet. Just like all of God's other creatures out here on this nearly dessert plain, I suppose. Gross, I know. But honestly, life could be worse. In fact, it is in the next building over, about 100 yards away. It's a TB isolation ward. Then, there's the next building from there... pediatrics. One child has died there every day this past week, except for today. Only 4 remain. The next building over is the main ward... isolation there is for AIDS etc. I use the term isolation loosely, because in this latter case, the area is right next to the labor and delivery. It was there, just today, that I helped James as he used lidocaine to anesthetize the ligaments that join a woman's left and right pelvic bones in the front... then cut it in half to increase the diameter of the birth canal to deliver her baby before her contractions had enough time to rupture the recent C-section scar on her uterus. This way, she wouldn't bleed to death (as many other young mothers do). So, no... I didn't have running water, and I didn't have AC. Yes, I smelled bad and my teeth felt a bit fuzzy... but things could be worse.

In fact, I slept pretty good. Woke up the next morning to the sound of the generator and was taking a nice cool shower 10 minutes later... felt good to be alive :)

Things you don't want to hear in the mission field: "Oh, don't worry, the 5 second rule applies here too."

What's Cookin', Doc?

Normally, we have a cook. Now, it's not as nice as it sounds really. That's because the cook works M-F, and only makes one meal... after all, the entire nation is accustomed to eating once a day. I don't take that so well, as I personally will eat up to 6 times a day. So, this is harsh. Especially on the weekends. So today we were essentially out of food (except for eggs), and had to go to market to buy what we wanted, then return to cook it ourselves. I know, I know. Sounds easy. It's not. The process took approximately 2.5 hours... a huge chunk of time out of the middle of what otherwise could've been a much more productive day.

So you have to take a back pack to market, otherwise there's no way to carry all the little individual bags of purchased items from the various vendors you buy/barter from. Some will give you plastic bags, but they will likely tear open half way home, spilling your food on the foot path (likely on top of several little goat turds). So, don't count on them having bags to carry your treasures home in. You go to market on foot, since even if the hospital vehicles were working (and they're not), gasoline would be prohibitively expensive to justify the trip. It's about 15 minutes each way (if no one stops you to try to buy/marry your cousin). Once returning, one must decide if/how to clean your food before attempting to eat it. Bananas are easy... unwrap with one hand, eat with the other. Packaged food (like pasta) is also easy. Tomatoes and lemons are tricky. Trust me, if you saw the hands that sell me this food, you'd question wether or not it's safe to eat, ever. We decided to scramble the eggs today along with some fried potatoes, tomatoes and onions. Of course, this requires heat... which leads me to a description of the stove.

The "stove" is a concrete/block cookout looking area that's screened in on the front side of the guest house. There are 3 holes on the cooking surface, slightly larger than the average cooking pot, each with 2 short pieces of iron rebar intended to lay across the opening and support the pot without it preventing air from circulating from underneath, where the charcoal burns. Charcoal is loaded from the top, resting on 3-4 pieces of rebar built into the cement block in grill-like formation. This allows the ashes to be removed periodically, as well as provide a channel to fan the coals with extra air to make them burn hotter. That's the temperature control... you, your arm and a woven grass fan. As alluded to previously, the charcoal is easier to light if you use a little gas (emphasis on the LITTLE). If you use too much, flames shoot out the top and front of the stove, scorching your eyebrows and/or burning your knees. Now, after it lights and the explosive phase is passed, you have to kick in the fan action before it burns out and you have to decide if you're going to add more gasoline onto already hot coals (I recommend against this approach). Personally, I just fan like a madman with one hand and barehand in more charcoal as I think the growing fire will take it. At some point, the girls will say they're ready to put pots/pans on the stove, and the often futile attempts at temperature control begins.

Today, however, this period was interrupted by a pop and scream from the sink area, where the new Danish girl had been cracking eggs to add to our potato omlette mix. I looked around the corner to see what was the matter. Things looked fine. I walked over to her to see if she was as OK as she looked at first... and then it hit me. The smell. You know how I said that the fish market was the mostest... wrostest... badest... THING, I have ever smelled, in my entire life? Well, I spoke too soon.

The pop was the small gaseous explosion that occurred when she cracked the egg. The blue goo containing black speckles coating the countertop was physically overpowering. I'm talking level 5 DEFCON biohazard here! There is no question in my mind this small capsule of evil could have easily be used as a weapon of mass destruction. Before we were finished preparing lunch, we'd "found" 3 of these little jewels. The third one contained a fully developed chick. None of us will be able to eat eggs again without thinking of today.

After we had eaten, Henry and I poured boiling water down the bathroom sink's drain, and the shower drain, in hopes that it would dissolve the accumulated goo, hair, oil, dead skin, soap, dirt and muck of the past years that clearly was slowing the flow of waste water. It actually did help a bit. What I wouldn't give for one cup of Liquid Drano!

Once the dinner table was cleared, I turned it into a workbench and swapped out the sealed lead acid battery from the non-functioning ProPaq monitor, using the battery from the one good device the OR was using. It worked! Now all I need to do is figure out if the charge controller is out, or if the battery itself, if replaced, will solve the problem. James also suggested I try to get a second oxygen concentrator working, as a back up. I asked him how high a priority it was, and he shrugged. To be honest, in over 5 years he's never had anyone die because they didn't get extra oxygen. "It'd be nice to have though," he said.

Suzanne's had a bad headache and stomach ache. I hope it's not malaria. She hopes it's not malaria. James bet her all the Milkyway chocolate bars she brought him that it is. We'll see who's right, and who keeps the bet!

This evening we watched the sunset over the African plain while sitting on top of the water tower. Impressive. As an afterthought, we lifted the lid to see just how much water was left in the tank... about 1 inch! There've been so many volunteers here lately that the water tower has had to be filled every day, instead of every other day. We rushed home to fill one large cooking pot and an emesis basin with fresh water so that we could take bucket baths when the water ran out. Fortunately, I had enough water to get a shower. I hadn't had one in 2 days.

Things you don't want to hear in the mission field: "Dude, life is too short to need insurance. Besides, if you're sick enough to actually need medical evacuation, you're probably not going to make it out in time anyway!"

Thursday, October 23, 2008

A Horse is a Horse... of Course, of Course & Things That Go Bump in the Night.

A Horse is a Horse... of Course, of Course.

I had not come to the other side of the planet expecting to do veterinary medicine. But, you come expecting the unexpected.

Sarah, Jame's Danish wife and lead RN for the hospital, happens to love horses, and owns 2 of them here in Bere. One of them developed some kind of abcess just above the knee on the inside of his right rear leg, just above the knee. For whatever reason, the royal "we" decided I was the one who was going to lance the thing. I was assured that this was a "good horse," that would never kick me in the face as I stooped over with a sharp object to inflict pain without anesthesia during this medical endeavor. So, I found a #11 blade in the OR and off I went to meet Sarah and Suzanne in the brick stable where they were tying the front and rear left legs together. After saying a brief prayer and strategically placing my right shoulder against his flank, and my neck pushing against his hip, I felt down the leg with my hands until I found the abcess. The horse keeps trying to push his legs together, just like a 3 year old trying not to use the bathroom before making it inside the house before loosing control. Well, after jockying for position a minute or so, I was able to sink the blade to the hilt in the pocket of pus that popped out as soon as I stepped away from the danger zone. Hmph. That was easy.

Sarah was so grateful, that the next day, when the horse came back with a HUGE, gaping, bleeding wound on the extreme upper inner left rear leg... who did she turn to? Exactly. Me. Fortunately, I was given the anesthesia duty while her husband James was cajoled into doing the sewing. Once again, we raided the OR for some equipment, paid the pharmacy for 4 grams of ketamine, 40 mg of Valium (in retrospect, perhaps a bit much, but hey... it NEEDED to be enough to anesthetize a HORSE) and about 12 million units of penicillin. I've never started an IV on a horse, and I wasn't about to learn. I made Sarah give the shots IM (in the neck muscles). It took a while, but the horse did get drunk-ish, and 6 of us combined were able to tip the horse over onto the ground. Unfortunately, it fell operative side down, making James' job all the harder. We poured some dilute bleach over the wound to wash it out, still requiring 6 people to hold the horse down and tie the legs so James didn't suffer from 4 or 5 different kinds of facial fractures while sewing up the horse's ass. I got to irrigate and cut the sutures with the kitchen scissors (finally, a pair that actually cut!).

Now if you think people come out of ketamine anesthesia badly, you should see a horse do it. This thing wigged out! it was running in circles on it's side, scrapping off it's skin around the face/eye and knees on the one side. We stuffed a towel as best we could under the head to keep the damage to minimum, but he fought SO hard, it was nearly impossible to do a good job of it. Of course of course the horse the horse couldn't feel a things he was doing to himself, and wouldn't stop either. Eventually, enough of the meds wore off (after about 25 minutes of this fiasco) and the horse could actually stand up... sort of. Sheeze. I thought people were hard to deal with. Anyway, best we could guess, either a bull gored the thing from behind (unlikely, it's a fast running horse. I should know, I rode it.), a person threw a spear/knife while chasing it out of their garden/property, or it got spooked and back into an old, stiff, cut-off palm frond (those things are like gladiator weapons around here!).

Other than that, I did actually anesthetize a human today... an 11 year old girl while James fixed her cleft lip. She really needed it, and it was her best chance at a normal life and possible marriage. My problem... I couldn't intubate this kid. The mouth just wouldn't open after we gave her valium and ketamine (no inhaled anesthesia or muscle relaxants available here). I considered injecting epinephrine around the surgical site to decrease the bleeding I knew would run down into her airway, but James and I feared the tissue deformation would alter the appearance too much. So, I shot her IV bottle full of ketamine, set the drip rate by hand, put on sterile gloves and suctioned as much blood as I could to keep it from running down into her lungs during the case. All she had to breath was room air. Running to many things in the OR on the generator power has been known to blow the generator, so the O2 concentrator wasn't a reliable option when suction, overhead lights, pulse oximeter, blood pressure cuff, and (excuse for) air conditioner was running. So, it was a new kind of airway "management" for me. Before it was all said and done, she'd lost about 200 ml of blood in the suction canister and we'd pulled out 2 very large, long clots from her posterior nasopharynx. Fortunately, she coughed up some blood a few times, and that cleared out her airway almost as good as the suction. I dripped some dilute epinephrine into the wound from time to time, and we held pressure on occasion, and learned it's true... all bleeding stops. I left her laying on her side after surgery, after briefly considering holding her upside down by the ankles to see if I could drain out any extra blood. But, since her O2 saturation hadn't ever been less than 94% on room air, I didn't think it would matter much. So I let her alone to wake up later in the day.

We were supposed to operate on a 9 month old... but the parents refused to pay (James requires payment PRIOR to operating on ANYONE. It's a policy that works well).

I spent some time trying to repair a Welch Alyn ProPaq monitor today... to no avail. Maybe tomorrow. The new power supply I brought does take the local 220V, but the plug is US style. The OR has US style plugs, but they are all on a 110v circuit. So, that'll take some work. I think it's the old lead acid battery that's gone back and has broken the flow of electricity, even when it's plugged in with a good power source. I will attempt to re-wire it tomorrow. And, if it goes "kablooey" when I turn it on... oh well. It wasn't able to be used before I got my hands on it anyway :)

Suzanne gets her local garb tomorrow (she met the taylor for measurements 2 days ago) and will shop for my cloth as well. I'm going Ossama style... turban and all. Suzanne insists she's getting me a pair of gold aviator sunglasses to wear with the outfit. Oh, and get this. She's going to throw in a pair of all leather, Ali-Habbiib sandals with the thick strap that goes all the way around the big toe (this facilitates running from the local authorities). This could be fun. Imagine me landing in Omaha Nebraska all decked out like this and walking past security. HAA!

Things you don't want to hear in the mission field: "No way, it's WAY to long to be one of my hairs."

Things That Go Bump in the Night

As you might suspect, one of the reasons they call in the jungles of Africa is because of all the animals that live and move out, about and around here. Our encounters thus far have provided various levels of entertainment for me, and sheer terror for Suzanne. The first time was when a praying mantis landed on the broken screen between us. I made an offhand comment about it, knowing Suzanne wanted to avoid ALL contact with creeping insects. She surprised me by grabbing her camera and started snapping picts! Then, as she zoomed in on it, the thing turns it's head and looks right at her with it's alien head and googly eyes. It was THEN that she freaked out. If that wasn't enough to get her paranoid... the big bats that whooshed by us the next evening were just what the doctor ordered. I hadn't seen her stop cold in her tracks like that since we first arrived in N'Djamena and saw these 10 inch lizards scurrying up and down the outside walls of the room we stayed in before coming to Bere. Then, after we got to Bere and got settled into our new rooms, she was woken up by a scratching sensation under her bed. That would've been the mice or rats. She told me the next morning she was ALMOST came and woke me up at 3:30 AM to come into her room to kill whatever was living under the bed. And let's not forget the two large spiders that live under the pictures hanging over the dinner table and come out like clock work when we sit down to eat. She's gotten used to those. It's the wasp that she wigged out over this evening, flailing her arms wildly around her head, tripping and nearly collapsing on top of me and my laptop while I was studying French using Rosetta Stone. She really hates the insects here. In fact, nothing gives her more joy than to hear the bug zapper *snap* in the evening as we sit around using iTunes to play Name That 80's Tune after dinner.

Things you don't want to hear in the mission field over dinner: "You could think of them as large pieces of sand. But I wouldn't go so far as to say there are rocks in the rice. Beans though... those have rocks."

Things you don't want to hear in the mission field: "No, I'm not kidding. We're about out of charcoal."