A Day at the Market & A Day with the Artisans

A Day at the Market

Well, it finally happened. The water ran dry today. Had to start the generator to pump water up to the gravity feed tanks. I'd gotten so used to reliable water since getting here less than a week ago, that I'd forgotten that going WITHOUT running water is the norm in these kinds of places. The nice thing about water here is that it's fresh well water. Now, there are actually 2 water tables in this area. There's one above bedrock, then one below. The hospital and the residential housing in the area all get it from below bedrock, so that all the contamination from run off doesn't risk their water supply (sweet!). I've not had to use the water purifier I brought, or boil water, or anything. Really shortens the tedious time spent during the day to overcome the inconveniences of remote living.

One of the first things I did today was go through the huge blue shipping container (like what you see sitting on the back of train cars stacked two high) looking for goodies I figured I might find amongst all the donated junk. I wasn't disappointed... 2 colonoscopes, 1 light source (do they actually work?), anesthesia masks, circuits (for building a draw over anesthesia system. Hey, what's this? No vaporizer?!), surgical instruments (I brought a sharpener), vaccuum extracter (for when the bun doesn't want to pop out of the oven after it's done). Looks like this stuff's been sitting in here under the 130 degree summer sun, for a couple seasons (turned out later, it had been about 12 seasons actually). They even had a machine for drilling wells in there. No one here knew how to use it, and we couldn't find any instructions anywhere either. What a waste.

After I got sick of sorting through unlabeled boxes, Suzanne and I went to market to get lemons, bananas (yes, they have no bananas), soap, and cloth for her custom sewn dresses she plans to have made (spent about 15.5 US$ for 10 yards, the taylor will cost about 15$ as well). In the process, we learned how to say "Thank you" in Tchadian Arabic from the fabric salesman who spoke a bit of English. We also learned that buying airtime for your cell phone occurs two ways. One way (the one I assumed we'd find) is to purchase a paper card that has an amount of talk time on it along with a purchase code, entered into the phone and dialed. This programs the minutes onto the phone. I've done this before. It's quick and familiar. The OTHER way is a guy will call your phone, programming it with extra talk time in the process. This of course necessitates you KNOWING your OWN PHONE NUMBER. Which I didn't. I mean, I've never called ME in Chad Africa. I just got here. Why would I need to call me in Chad Africa?! It just makes no sense. So, no minutes for you! (Imagine the "Soup Nazi" from Seinfeld.)

When we got back from the market, James and Jeremy had been working on the hospital vehicle (which hadn't been running very well since someone drove it through muddy water that was a little too deep during rainy season). At this point, the battery was dead, and the starter was questionable. I had recharged the battery the night before, but we still ended up having to push start the vehicle. We knew that it wouldn't make the 8 hour "road" trip to N'Djamena scheduled for the next day... you would never be able to roll start it out of the mud after getting stuck 8 inches deep like we did on the way here.

In the evening, we watched some people play soccer as the sun went down in the background. One of the most memorable sights I have so far on this trip is seeing a goalie who played while hobbling on one crutch. He was quite good, actually. I couldn't tell if it was illegal for him to use his crutch to stop a goal. Maybe people would just accuse him of using it as a crutch. I dunno. Something to think about.

After it got dark, I built the charcoal fire while the ladies got the food ready. Now, have you ever felt like you've been helped enough? One of the guys there felt I was using too LITTLE gasoline to start the charcoal aflame. I disagreed, and had purposely placed the one liter bottle holding the gasoline away from the hole that held the charcoal so that I could focus on fanning the flames with a fan through the channel cut in the concrete and stone that lead to the fire pit portion of the "stove." My "helper" proceeded to add some fuel to the fire and re-light the charcoal after putting down the bottle of gas. Flames promptly shot up to nearly the ceiling, cutting off easy access to the bottle of gasoline he'd just placed on the other side of the charcoal pit. I put aside my anger and tried to quickly think how I was going to get that bottle out of the way, or put out the fire. I grabbed the biggest pot I could find, covered the flames, and quickly reached across to grab the hot plastic bottle to move it to the other side of the cooking area. I didn't say anything... I'd been helped enough.

At some point that afternoon, I noticed that my shoes were missing. VERY distressing. I'd bought them specifically for Africa, and put orthotics in them. I had started wearing a cheap pair of flip flops a bought in the market and left my lace-up shoes in the foyer (where the cooking "stove" area is) so I could come and go more quickly, swap out on the fly when entering the OR, and be more cooler in general because my feet were bear (I also spared myself from washing socks). I swear, these people with steal anything from anybody at anytime for any reason!! Drives me nuts. James and Sarah politely turned down my gift of heirloom vegetable seeds stating that they don't garden here... people steal all your stuff before you get a chance to eat it.

To finish my day, I spent 3 hours trying to get the sink and shower to drain properly. I knew that teflon tape and epoxy putty would come in handy :) Silicon caulking would've been the best answer, but you use what you happen to have eh? Before it was over, Jeremy and I had pulled out 3 small rat sized clumps of gooey hair and mud from the P trap under the sink. This allowed the plunger we used on the shower drain to be much more effective (both of the 2 drain to the same pipe system) and afford the luxury of taking a shower without standing ankle deep in each other's soapy water run-off.

Things you don't want to hear in the mission field: "I give (pronounced gee-ve) you 3 pigs (pronounced pee-gs) and a cow to marry your cousin!"


A Day with the Artisans

The fan batteries died somewhere in the middle of the night, and I didn't even notice. That means it's getting cooler at night. Yeah!

Well, the sink seems to have only a minimal leak, so score one for for the expatriates! We'll have to see how long it lasts, and wether or not it requires further attention. I hope not... I've got so much else to do here besides plumbing.

After breakfast we started the OR schedule. We began with a simple hernia repair. Nice, since I could do a spinal and not have to deal with the ketamine side-effects for a change. James is pretty quick with a hernia repair, so I could use lidocaine instead of the small, precious supply of bupivicaine which we would reserve for a longer cases. James does use mesh to repair the many hernias people have here, but the mesh is actually a small piece of a 10$ mosquito net, sterilized of course. It's a much more affordable way of creating a tension free closure, and it's flexible enough to ease handling during placement. As for the anesthesia, I did what I could, with James' translating, to teach the French speaking OR nurse some anesthesia knowledge that could be used after I leave. This trip, we'll keep it simple and limited to regional and ketamine anesthesia.

The next case was a hysterectomy which James said would take longer, so I used bupivicaine. Part way through though, she started complaining of pain and REALLY started to become uncooperative. But, after a syringe full of valium, a touch of fentanyl & midazolam (I'm not sure it's wise to describe how/why I actually had access to those, but, I did have some here), a slug of ketamine, an ampule of promethazine, another of chlorpromazine, and another syringe full of ketamine squirted up into her IV fluid bottle... and Viola!! It went so much better after all that!

I can't remember the next case. I mean, it's not like we keep an anesthetic record or anything. Part of it was that Suzanne interjected a memorable bit of non-medical nomenclature into the operating room conversation. See, what happened was, as we were getting the IV started, administering pre-operative antibiotics, and rolling through the double doors with the patient... James had just finished releasing the sutures on a testicular hernia repair he'd done on a man a few days before. It was a quick deal... done in the foyer, after he unabashedly dropped his drawers and sat down on a stool while James sits down and snip-snip... that was it, done deal. Pant's back up and away he went. So then Suzanne grabs James' stool to bring it into the OR (filled with no one but guys) and without stopping to think if she should be using her INNER voice bluntly announces, "I'm not sitting on that thing after he's had his nut sack all over it!" The sudden silence and frozen forms of the men in the room as they all turned to look at who had just said that was accentuated by the stop action suspension in what otherwise would've been a flurry of activity as we got the case off and running. I think it was the surgeon who broke the silence by offering the observation, "Normally, we refer to it as the scrotum." Still, we couldn't help bust up laughing.

The last case was a woman with a huge fungating tumor on the bottom of her foot that smelled like it had been there for months. Turned out, it had been. James had actually seen her about 3 months ago, taken off a small tumor from her foot and referred her to her local health clinic for dressing changes. We did a mid-foot amputation under lidocaine spinal. And we doubted that she had actually gone for any dressing changes, otherwise she would have been referred back to us for removal of this huge mass preventing her from walking. Oh, and one more thing... she was HIV positive, so when Suzanne caught a bit of blood on her arm and wigged out, it took me a bit of time to calm her down and assure her she wasn't going to die from it and it wouldn't go through her skin. That's Karma. It's what happens when you don't use your INNER voice for certain thoughts.

After that, Suzanne went to break the stress the way any woman on the planet would... go shopping.

I brought out some of the donated instruments for James that I found in the shipping container sitting in front of the guest house. The container had been sitting there for 3 years, by the way. He was very pleasantly surprised by some of what I had found in there for him and the operating room. We're going to have a little bit of Christmas when both of us have a chance to go through it together. It's funny though... most of what is sent over is absolute crap. I mean it. It's the exact same story I told of when I was in all those hospitals in Zambia and Malawi... tons of medical garbage is sent over in the name of "charitable donations." James has a different term for it... "Junk for Jesus." It's like people in the west, at some point in time, find themselves using undesirable instruments/materials while they operate and then have some kind of wicked epiphany and realize that they want to give to Christ's cause the very things they themselves refuse to use. It's kind of like the Life cereal commercial, just with two people in the OR commiserating...
"I don't want to use this needle driver/pair of scissors! They're awful."
"Yeah, they are!"
"Hey, wait a minute... I know! Let's give them to Jesus!"
"Great idea!!"
"Yeah, He'll use ANYTHING!"
"Put these in a box labeled "Donation for Africa."
"I bet we get a tax write off for it too, eh?"
"Yeah, we do. You know, we should do this more often!"

I hate those guys. They've turned Africa into a medical garbage dumping ground, and I'm the one having to wade through it all to sort out what's even remotely any good to use. But this time, I came prepared. I brought a sharpening tool, and those crappy scissors are now nicely sharpened and ready for the charcoal fired autoclave sterilization process tomorrow :) Or tonight. I'm not sure when they actually do it. It seems a bit hot for it right now in the afternoon... it's about 103 F.

I actually saw a few patients in the ER/outpatient clinic. Can you believe it?! Me, an anesthesiologist seeing patients! I know, I know. Weird. Anyway, the last guy had diabetes (just as weird, for Africa) and as James gave him his final instructions, I got a chance to visually evaluate this patient. He was an Arab with a long goatee extending out from under the lower wrap of his turban, wearing longsleeves and pants, (remember, it's over 100 degrees) covered halfway to his knees with a winter parka with fur trim (picture Spies Like Us, minus the Siberian setting). He and his buddy turn to head out the door after the perfunctory ritual goodbyes and handshakes and Asalam Alekahs ( or something like that ). He shakes my hand too, and discouraged because I haven't understood a word he or anyone else has said, I do my best to wish him well, wave good-bye and flatly suggest, "Better bundle up, it's kinda cold out there. Maybe consider adding some mittens to go with your parka... I dunno, it's up to you I suppose. Just a thought. Anyway, see ya!" Of course, not speaking English, he didn't get it. As for me, I cracked myself up, along with every English speaker within earshot.

Things you don't want to hear in the mission field: "No, the nearest place you can buy toilet paper is back in NDjamena. You may have to use your left hand."