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."
Tuesday, November 25, 2008
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.
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."
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?"
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?"
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