Mission: Implausible

White Man Can't Jump

2008-11-25T17:26:00.001-08:00

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."

Things That Bleed in the Night

2008-11-21T10:17:00.000-08:00

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.

Cat on a Hot Tin Roof

2008-11-17T10:16:00.000-08:00

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."

Malaria Strikes

2008-11-12T13:07:00.001-08:00

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?"

Back to Market & Advice for Newbies

2008-10-28T12:19:00.000-07:00

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?

2008-10-28T12:16:00.000-07:00

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!"

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

2008-10-23T11:42:00.000-07:00

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."

A Day at the Market & A Day with the Artisans

2008-10-23T11:36:00.000-07:00

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."

Rise n Shine & A Day at the River

2008-10-19T05:08:00.000-07:00

The next day Suzanne got up and ate porridge for breakfast. It was made of peanut butter, rice/rice milk and a touch of lime. It was quite good actually. I, on the other hand, had a glass of water and suddenly felt the desire to eat nothing else and go directly back to bed. That is, until they called for help to do anesthesia on an exploratory laporatomy for a large abdominal mass, combined with a hernia and hydrocele... so I got up anyway and skipped breakfast to go to work. It turned out that he had an obvious intrahepatic tumor (cancer in his liver) that likely had spread from somewhere else (who knew where), and might even already be studding his spleen (James could feel it with his hand). Bummer. The ultra sound done earlier hadn't seemed to be that bad, but now it was apparent that we were facing a bigger challenge than we had thought.

The tumor involved the entire left lobe of the liver, and a bleeding stink of a mess awaited us should James elect to attempt a partial liver resection (something usually only done by a liver transplant surgeon, and an anesthesiologist equipped with double central lines, 2 dozen units of blood and clotting factors, and pressurized infusion devices to overcome the blood loss as it occurs). We checked a hemaglobin. It was 7.0, the lowest you usually let a patient go before transfusing (and we handn't even begun to cut yet!). After talking with the family, the decision was made to close him up and let him have whatever quality of life he had left instead of risking him bleeding to death as we attempted to cut out this liver tumor. Unfortunately, I had hammered him with enough Ketamine to last several hours, so it would be awhile before he actually woke up to talk with his family.

Suzanne and I did some inventory of the anesthesia equipment and drugs as a way to start building a model by which a hospital wide system could be then implemented. Right now, there are 2 answers to the question of how much of any kind of drug or supply the hospital has. One is, "We have that." The other is, "We don't have any of that." For example, the other day administration was told by some of the workers, "We are having to fill the generator with fuel today, which completely empties our reserve tank." So you see, there is no mechanism by which to tell WHEN to order more of WHAT, and no one tracks the supplies that they use up to do anything. So, imagine discovering that you are out of something at the exact time that you need it most. This, my friends, is Africa!

We went to market to find me some flip-flops to walk around in so that I can get out of my closed shoes and socks... it's much cooler, and easier to change into your surgery pair of shoes quickly. So, we went to Bere market for the first time... alone. We spoke just a little French, and a few words of TChadian Arabic. We were so proud of ourselves and our little purchase. We'll try more advanced stuff next visit.

We've learned from the others who've been here long-term that the best way to stay cleaner and cooler is to shower off (without bothering to use soap... save that for when you REALLY mean business) every chance you get. You also have to watch out for little wounds on your hands and feet (since they get used a lot) because they can easily get infected with bizzare bacteria. And antibiotics can be hard to come by at times, so prevention is MUCH better than trying to get some cure. Which brings me to another point. If you have any weird allergies (ie. Suzanne who broke out on her arms), cortisone, tiger balm has no effect. :-(

Another things that has dawned on us is that cooking has to be done on an as-needed basis continually because there is no refrigeration. Thus, if you want to eat something other than fruit, bread/peanut butter... you're going to have to cook it (without electric stoves), and that assumes that you don't have to go out and buy it (you thought ahead enough to not need to go back to market). Cooking here is done over charcoal stoves that are either wire cone frames that sit on the ground, or stone/brick ovens that have a hole in them that the charcoal is loaded into and fired for the pot that goes on top. And this is NOT the charcoal you've seen in the states... it's charcoal made from trees, not fuel soaked briquettes. And let me tell you... they burn HOT! We realized during the last communal cooking spree (hosted on our 3 stone stoves and 2 wire charcoal burners) that one nice benefit of having concrete floors is that when you spill the hot coals all over the place... the house won't burn down.

Things you don't want to hear in the mission field: "It's not that bad really, except for those first 2 days. I've already had malaria TWICE since I got here!"

A Day at the River

The first Sabbath. Everyone slept in and woke up around 7:30 am. With the exception of nature's alarm RIGHT below our window, Mr. Speckles (aka. rooster). After a quick cold shower and breakfast that consisted of left over porridge, bananas, and bread......off to church we go! We showed up at 8:30 am at church located outside the compound (I should quickly add that when we say "compound," this should in no way be taken to represent anything like David Koresh lived in). It turns out that the first few hours or so are singing sermons. The songs all in French, the tunes memorized (there is no piano) and we were the only white people so far, other than a few college students. There were, however, a few drums, and Franklin was unceremoniously handed a mini tamborine that he had to learn how to play on the fly. It was difficult to follow much of anything, since the service was done in French and translated into the local dialect. The seats were 2 X 12 boards served as pews without backs or seat cushions. This made it harder to fall asleep in the sweltering heat.

After eating lunch, we went off the the river for a swim. This was to be a 2 mile walk/ride on horse back (Sarah, James' wife, has 2 horses... one of which Franklin did that lance/drainage job on earlier). Well, for those of you who followed the last trip, you already know that if you are told here that something is 2 miles away, or will take 1 hour to walk to... what that REALLY means is that it's closer to 3-4 miles, and will take nearly 2 hours to get there. This was the case again today. Franklin thought it'd be nice to ride for a while, but the horse wanted to gallop so much it was hard work keeping him from running out of control. The stirrups also dug into his legs, and to be honest, flip flops are not the best for riding horseback.

BUT... we will say it was kind of cool to swim in an African river. You know, always wondering if piranhas or something are going to start eating you (even though, honestly, you know piranhas are only in S America. Just the other side of the world). The current was quite strong, and it took a while for a smaller group to swim to the other side and jump out a tree overhanging the river. Climbing it was half the fun, and then after hitting the water you could just relax and let yourself get swept downstream and back across to the other bank with the others.

The hike back took until after dark. No small thing in a land with NO signs or directions available (why, oh WHY didn't I bring my GPS?!). Fortunately, the ONLY cell phone tower for hundreds of miles around is near the hospital, and after it's dark, and if you're close enough, you can see it in the distance and just walk towards it to find your way home at night. The whole trip left us with several blisters on our feet, and questions as to why we didn't bring any moleskin from Walgreen's, and why Franklin had settled for that european sized 43 set of flipflops instead of looking harder for some 41's.

Our futile attempts at connecting to the internet for email and blogging drained what little energy we had left. We listened to the shortwave radio for some glimpse into what's going on outside our small, remote world (didn't learn much), and then went on to bed. It's been cooler at night here in the south compared with N'djamena. It's actually comfortable from about 3-4 AM until 7:30 AM. Then, you might as well get up because it's going to get hot and sweaty soon anyway.

Things you don't want to hear in the mission field on rounds: "That guy doesn't look so good."

Saleem Maliiko!!

2008-10-19T05:07:00.000-07:00

Hi!! Bonjour!! Saleem Maliiko!!

Well how do I (Suzanne) send you emails. Franklin bought a sweet GSM Chinese "iPhone" and we are able to get a SIM card for both internet AND texting AND to call home. So, maybe you will get a text from me or a phonecall :-) dunno if you can text me back though. We flew into N'djamena at around 9:15-ish on Sunday. That was AFTER a suitcase was abondoned, and the following occurred...

We arrived with about 1.5 hours to board the plane. We stopped at the great big display board to see which desk we should check in at, and what gate we'd be board to load onto the plane. We'll our check in was in zone 9, and we were standing in zone 2, so we turned right and started rolling towards zone 9. Immediately, 2 police men/women and 3 French machine gunners stopped us and pressed us and the crowed back about 5 feet, blocking our way towards zone 9. Finally the police chick told us in English about a suitcase that was left unattended 20 meters away (you could look over at it) was a suspected bomb and that they were securing the terminal. OK, I thought... do what you gotta do, right? As we waited at the secured zone, looking at this blue tote bag, we decided it was time to beg the guy at zone 2 to check us onto our flight, but he refused (snooty little Frenchman). He did reassure us that if we were still roped off from zone 9 in another 30 minutes, when they would close the checkin for the flight, he'd take us in. Then, we were hearded out of the terminal as the loudspeaker announced the problem and informed us that all flights were now cancelled! Sweet. Goodbye Chad trip!

We stood outside for about 30 minutes, police cars with the sirens all over the place, while the bomb squad went in to take care of business. We assume they put the thing in a box and blew it to Allah, because the explosion was quite loud (even though the ground didn't shake). Within 5 minutes it was business as usual. We were into the terminal walking past a lady sweeping up some charred paper off the floor, with people sipping wine in a nearby cafe off to the side. Go figure. We made it onto the plane with only 3 minutes to spare, and after grabbing the last copy of the English newspaper with the headline "World Markets Crashing" with figures showing 20-24% losses from London, Tokyo, New York and Germany. Looked like it was going to be a good time to drop off the face of the earth for a while.

So on the flight to N'djamena I sat next to this oil tycoon who informed me he was a chain smoker. Approximately 7 cigarettes in one hour. "I'm addicted (pronoune ad-deeee'cted)". So to compensate he decided that getting drunk would be the most logical option to ease the jitters. He kept ordering wine bottle after wine bottle and even ordered me wine bottle after wine bottle. During that time, he managed to not only get hammered BUT to spill red wine all over his trousers. Followed up by what I assume some profanities in French that I have yet to learn. Upon landing we get off the plane on the runway and this bus drives us about 20 yards to the luggage claim/airport. We could have walked that distance. Did i mention its very dark?? Yeah, no city lights (Franklin - Actually, there were, Suzanne just didn't notice them. We later learned that only 5 years ago there really were NO lights in N'djamena). We walk into the airport to go through customs and there are bugs EVERYWHERE! Not a good sign. So the guys in customs didn't speak English (or Engrish, for that matter), we were the last in line, and just stamped our passports and pantomimed that we needed to register with the police within 3 days. Fine. OK, off to get luggage. We met our peeps that were there to pick us up, and apparently there was another person named "Maria" that was supposed to be on the flight. After waiting for several minutes, we decided Maria wasn't even on the plane and continued the journey to our port of call, which was the SIL institute (where we slept that night). Turns out Maria actually was on the plane and somehow was diverted to another room to so called register. (It also turned out that someone felt sorry for this 18 year old white girl that they gave here a nice hotel room overnight, for free.)

We finally were able to rendevous with her at the market in N'djamena. The market let alone the streets AND the so called 'bus' ride are not for people with a weak stomach. The heat, the filth, the poverty was a real eye opening experience. You don't know or can't even conceive what poverty and filth is until you have been to a major city in Africa. Or Tchad.......or what the Chadian Arabic would call Tachaad. I have been picking up a lot of French (doing Rosetta Stone as well) along with a lot of Chadian Arabic. You have to speak the language if you want to make it here.

We had quite an adventure in the capital and quite an adventure on the travel south to Bere. When we reached the first destination of Kelo to rent a 4x4 (because the roads were flooded) a fight broke out. Africans will jump in and carry your luggage and want you to pay them. This was the case with us this time. I have it all on film to show when I return. I am writing you from cellphone-bluetooth-macbook remember?? Uable to post pictures/video yet. We managed to pile luggage for all the volunteers in the back of the truck bed, cram 7 people in the cab of the truck, and 5 people on top of the luggage, clinging on for dear life in the back... true african style. Away we went to Bere on rutted roads and absolute wilderness and wild country. It reminded me of the pictures i would see of remote Africa in National Geographic. We managed to get stuck one time. We crossed a river on a homemade barge that they use ropes to pull across. FINALLY we are at the hospital......14 hours later. So far Franklin is getting over his illness, 4 volunteers have beginning symptoms of malaria. I am ok so far. I feel rather nauseous at night and fatigued. So I have been extra cautious. But all in all.... I really really like Bere. With a nice comfortable matress cot, my mosquito net, I quickly fell asleep. Which was much needed.

First day on the job. The hospital is supposedly "quiet" right now because of a dispute that broke out between some Arabs and the locals that resulted in 5 dead and 14 wounded (stab wounds). All which showed up at the hospital. Most were women, children and a few men. The fight started when an Arab cow wandered into the rice field of a local, a stabbing ensued, followed quickly by revenge over the "dead brother" who fell when stabbed in the field. Later, after everyone else was wounded or dead, he revived. True story. Oh, and did I mention the law? Doesnt exist. Things should be very very busy again by next week though.

I saw a patient that had AIDS who was misdiagnosed at another hospital for Polio. He was so thin and deathly looking. Picture Auschwitz and take it to another level. Then I assisted with a girl who was 14 years old who has AIDS, gastroenteritis, meningitis, malaria and something else. She is very bad off. I was able to help in the Operating room of a patient who had a premature baby the previous night but there was still after birth left inside her. She went into shock and the doctor had to perform a D&C to remove the remaining placenta. The heat in the OR was so intense the sweat was literally pouring off our arms and backs. Towards the end, they switched on the AC (which has to be used carefully or else too much current is drawn and burns out the generator). Afterwards I had to 'milk' her breast down into a cup (because her family wouldn't do it) and feed her premature baby the milk by spoon. All the while the patient was wheezing-breathing loud and basically clinging on to what life she has left. We don't expect her to make it through the night. (She died before nightfall.) Which means the baby won't make it either. I also took another baby outside in the sun because the mother had been stabbed during the fight and couldnt move.....the baby has jaundice. So sunlight 1 time every hour for 15 minutes. No patients and much of the staff only speak french, local language or chadian arabic. My French has increased leaps and bounds in the last few days, along with Arabic.

There was one other case (Suzanne didn't see this one) of a wiry, skinny guy who was... well, just not right. He was wild-eyed, wouldn't hold still, wouldn't sit down, wouldn't talk, and was ALOT stronger than he looked. We tried to lay him down to do an exam and he nearly bench pressed James with one arm (James is about 6' 3") while fighting off another hospital worker with the other arm. James called for the chaplin, who had a special prayer service with him, suspecting he was possessed (let's just say they've seen this kind of thing before, and the chaplin has had to deal with it a number of times). He was seated and in his right mind next time we came through... no other interventions needed. (The chaplin has his own story, we'll try to tell you about it sometime... prior to his conversion, he was a successful, Russian-trained, Islamic terrorist.)

Some other cases were malaria, some were poorly healed fractures that the doctor rebroke the femur, set the leg with pins so the leg could grow to normal size.....other cases included????? It's all a blur now. OH YES! I also helped Lin with the doctor's horse that had an unopened abcess. He stabbed it with a blade and nothing but puss.

The highlight? I was offered a job of being the director of projects for Tchad and Sudan. But that would mean I would have to move to Africa. Right.

Tomorrow's agenda is to do rounds in the morning, do inventory and establish ledgers for accounting. Then order all the medicine for the whole next year. And try to eat something with substance. Today was bread for breakfast, beans and rice for lunch, the locally made peanut butter on bread with a side of sliced tomatoes. All the sweating and moving around I do....must have Big Mac!! I have to run in scrubs or a skirt because your not supposed to show your knees here. SHORTS (not long skirts!).....hello women of Tchad....liberate yourselves!

Time for bed for a shower (cold) and try to sleep off the long day of hard work. Very fatigued and feeling a little sick. Sometime tomorrow I hope to slip away to the local market and have a dress made for about 7 dollars and practice my Arabic. Or French.

"Je veux acheter du robe" Or!! "Nidoor nachri angumaaji (roob)"

OK, until next time, we leave you with a new blog feature we'll be ending with from time to time... Things you don't want to hear in the mission field: "I'll help you wash dishes right after I finish going to the bathroom."

Flom Palis Wiff Ruv - The Asian connection.

2008-10-14T12:56:00.000-07:00

(From Paris With Love)

Arriving in Paris from different points of origin, Suzanne and I had to rendez-vous at the hostel before seeing some sights in the afternoon. We had spoken by phone one last time the day of our departure to confirm our directions to the hostel and our emergency plan to meet up in case we couldn't find the place. Fortunately, we didn't need to execute aforementioned plan. However, it did take me about 3 hours to reach the hostel, and Suzanne 4. This was due to a combination of factors, the most important ones being the fact that neither of us had sleep very much for the past day, neither of us was very enthusiastic about dragging 100 lbs of luggage each through the Paris Metro, up and down stairs and corresponding underground walkways between train lines. I spent my time waiting for Suzanne by wondering the surrounding streets trying to not look too American, too sleep deprived, or too much like a staggaring drunkard who enviously eyed all the baked goodies in every other window store front, drooling as I stared, and wondering when my travel partner would arrive so we could celebrate with a huge lunch before hitting the town.

Finally we got settled into the hostel after a confused discussion with a foreign born Fre-nglish speaking host, who odiferous fragrance filled the room, justifying the idea that the French originate the finest perfumes on earth. He directed us downwind, and downstairs to store our luggage in what looked like a dungeon until after 4 PM when the rooms opened for check in. I nearly fell down the stairs with my 3 bags, and after steading myself on the damp stone/tile steps promptly had a near miss on the low hung archway ceiling that lead around to the left into the crypt below. I hesitantly crept forward as I worked my way through the catacombs, certain that I would see an Iron Maiden or Rack in the room with the luggage. All I found was a sump pump.

Upstairs on the ground floor (not the first floor... that's what we'd call the 2nd floor), we had a concrete box (i.e. "room") with 2 Asian girls staying in the "loft" (a cement cage joined with ours via small spiral staircase in the corner... next to the other cramped corner with small shower and tiny toilet (complete with part of the seat cut off so the lid could actually be put down and not catch on the wall). Clearly, the Asians had yet to master how to keep the shower water from flooding the 3.5 tiles of floor space in the "bathroom," and running out the opening under the doorway and out into our room. But, at least we HAD a shower and toilet. All they had was a sink upstairs.

We went to the Louvre as our first stop, and enjoyed an audio tour of ancient Greece, Rome and Mesopotamia. We saw the Mona Lisa and some of the most important works of art in all of western history. This assumes, of course, you can find them. Now we did actually ask for directions from the Frenchman standing around doing nothing (maybe, just waiting for a reason to go on strike... and do more of nothing) for this one exibit which they claimed was in London. "Oh contrair, mon frer!" I thought. "I've been there, and I've been here... and I can assure you it's HERE!" I thanked them (in French, to be polite) as I bid them aduie, leaving them alone with their prim and proper snickers directed in our general direction. We later found it by accident, without the help of the French.

The architecture of the Louvre itself is something to see. It used to be the home of the French Kings, though for one of them who grew up there, Louis the XIV, it was a bit overkill. So, he built Versailles, about 10 miles away from Paris to get away from it all out in the country.

Upon returning to the hostel, we discovered a whole flock of Asians inhabiting the dining/socializing area... oh, and ONE english speaking guy who showed us how to log into the wireless network set up in the bar across the street so we could send email. There was an expensive email kisok machine there in the hostel lobby, buy why pay for something you can get for free, mon frer? Though limited to 20 minutes, it was an effective mode of communication... which is all we wanted other than a REALLY good night's sleep. In the room, not surprisingly, the floor was flooded again. Dang Asians! Well, turned out the 2 girls in the loft had been swapped out for a pair of Aryan giants (seriously, the cute one was really tall!). Well, at least I could talk with these people.

One drawback of this room we quickly discovered was the fact that EVERYONE on the first floor had to come by ours on the way to theirs. It also was just across the hall from the eating/socializing area. Now, why should that matter? Well, if you're from Asia, and visiting Paris, and it's 1 o'clock in the morning, it actually 7 AM where your brain lives (and lives quite loudly, evidently). So, why not just chatter away making sounds like silverware falling down the stairs to the luggage hold so that everyone from 2 Metro stops around can enjoy your own frivolity? I mean, it makes perfect sense... if you DON'T think about it. Naturally, I ALWAYS travel with earplugs and eyeshades so I was prepared! And fortunately, Suzanne had kept those very supplies from the AirFrance flight that had brought her from San Francisco. So, we were able to largely block out the rude world around us, and dream of ways we could return the favor to these people when we got up the next morning!

The next morning we went out to eat and found very simple fare... a bagette sans/avec butter and/or jam, hot milk/chocolate. Period. Yes, period. "Dude!" I thought, "I forgot all about the dearth of breakfast food on the "continent" (hence the term continental breakfast.") We finished up and promptly left to find a shop open this early that would sell something reminiscent of what I would call breakfast, totally forgetting our vow of revenge toward the Asian chatter boxes.

After filling our bellies with some finer French cuisine we spent the entire day at Versailles. It took 40 minutes to get there by train and 10 minutes to purchase a Paris Museum pass from a snooty tourist office worker. With the pass, we were wisked in VIP style without having to wait with the hoi-poloi who had been told "Let them eat cake." This is where we failed to learn out lesson about not asking for directions, yet again. We were tired, it was the end of another day, we hadn't gotten as high quality sleep as we had hopped for with our new German roommates... we were really tired of walking (though, at least we weren't carrying 100 lbs of luggage each) and we just broke down and against our better judgement, asked (in French). All we wanted to know was where the "sortie" was (i.e. the exit). The French gardner politely referred us to the other side of the garden, where he was certain an exit would let us out toward the road leading back to the kings chambers. 10 minutes later, with no cheese at the end of the maze, we found a locked gate in that general direction. We wondered another 15 before getting out of that area and heading back to the mansion. From there, it was back to the train, and a 30 minute nap on the way to the Eiffel Tower. We ate crepes at a delightful cafe on Rue Cler, got our second wind, and headed to the Arc de Triumph. We climbed to the top and were able to see the light show that is now done at the top of every hour for 10 minutes, lighting up the tower in blue, white sparkles, and the gold stars of the EU.

The next morning saw us embarc on a tour of Orsay Museum via Concord (where they chopped people's heads off in the public square), and the Champs de Elyssee (where the Tour de France bike race ends). We broke for lunch to do some people watching and enjoy some more fine cuisine. While waiting, it was hard not to notice how beautiful the French women are (Suzanne agrees). In fact, the REALLY hot ones have really ugly little dogs. I personally believe it is a trick they use on purpose to accentuate the own beauty. In any case, all I can say is Vive la France! Vive la difference! There was even this one lady, must have been about 55 years old, peddled by on her lunch break from work wearing gold stillettos, fish net panty hose, and matching, short cut, gold leather jacket!

After finishing the most exquisite French Vanilla ice cream I have ever had, we went to see the "Thinker," and "The Kiss," sculptures by Rodin. Then we went on to Napolean's tomb and WW I & II museums. Afterwards, we were hungry again and found another cafe on Rue Cler. Dinner was great, and the snooty lady whose large black dog blocking the waitress's pathway created quite the scene, providing more than adequate entertainment for the evening. The one word I recognized that the waitress said after this woman left was, "Halleluja!" My sentiments exactly. And with that, we went back to noisy-land for an attempt at some sleep.

Prior to going to bed, I tried to check email with my Mac out in the eating area. As I struggled to hack into the system across the street, a sexy accent asked me if I spoke French. At the moment I looked up to see who it was, I cannot tell you how much I wanted to say "Oui." at that moment. You see, the young woman (who switched into an even MORE sexy accent in English) turned out to have competed in the Miss Switzerland pagent before working/traveleing on a cruse ship for the past 5 months. She wanted to charge up her Mac, but didn't have the correct plug adapter for France. I assured her I had what she needed, and came back from my room with my own cord and power adapter. We spent the next 2 hours traveling the world together through photos we'd each taken over the past year, exchanged email, and decided to meet for breakfast.

Off I went to bed. I should mention though that just before going to bed, I had been approached by the Curry Infused Indian desk worker and asked if, as a favor, I would let a little Chinese girl (who had just arrived without a reservation at 10:30 PM) sleep in my bed with 3 girls in that room so that she wouldn't have to share with 2 guys upstairs in the only other vacant bed. I reluctantly agreed... for one night. Well, when I went upstairs to knock on the door, the guys wouldn't answer or let me in! I came back down and tried to talk to Indian Air De-freshner but could NOT for the life of me convince him I was unable to get into the room (there is only one key for each room. Don't ask me why). Finally, he gave me his master electronic key, which I stomped upstairs with after knocking I don't know how many times before resorting to this. After deftly swiping it and whooshing the door open I found a Spainard, gape mouthed, wondering how on earth his room had been invaded by someone he was NOT expecting. I looked straight at him and asked, "Why wouldn't you OPEN THE DOOR!" He answered with a non-sequitor.

Shortly thereafter, a Chinaman came in who wreecked of rotten Manderine, or socks. I couldn't quite tell, and frankly at this time of the night, I could've cared less... and frankly, as a doctor, I've smelled worse. I settled in on the bottom bunk, the Chinaman up top, and the snoring Spainard off to the other side of the room. For the next 4 hours I could hear and feel the Chinaman shift and toss and turn and he robbed me of my sleep (not that I could hear or see anything). Unbeknownst to me, one floor down, Suzanne was having the SAME experience with the Chinese girl! In retrospect, it is clear that those birds of a feather really should've been flocked together.

Swiss Miss met me for breakfast as I drank hot chocolate and chatted. Ah, the joys of having a beautiful and intelligent, well traveled woman for company. It doesn't get any better than this.

For sights, we saw St. Chapelle, Notre Dame, the Crypt below it, the Pantheon, Trocadero and Eiffel Tower. On the way to the last stop, where we purchased some more vanilla "glasse" to fuel out final evening's activities in Paris, we spotted an balding elderly man with Coke-bottle glasses, seated crossed-leg, smoking like a petite chimney, wearing a blue pin-stripped suit, brown shoes and screaming bleach-white socks. The fashion faux pas was shocking, even to an American like me! His arrogance seemed to suggest, "I am SO French, I can get away with this and STILL look good!" Oh contrair, mon frer. Further on down, as we licked the dripping ice cream we spotted some Arabs dressed in black suits... ALL with brown leather shoes. It was like we were looking at a pack of Doberman Pincers. I was waiting for the voice of Robin Masters from Magnum PI to call out, "Lads! Chase!" After taking a seat under the shaddow of the Tower, we did some more fashion policing (deeply frowning on the Yak's Yak Yellow stocking one woman was parading around in). We cought this one lady in line to climb the tower wearing Rhinestone studded jeans with triangles opening up the side of her legs, followed closely by another lady wearing black stockings with the same style effects. By all apearances, the older lady was the mother of the younger, who also had a todler following her. Enter into the scene an old gypsie appearing lady who seemed to be trying to talk to the younger of the two fashion foibles. It suddenly dawned on us that this was no gypsie working the crowd, but rather Great gram-grams for the 3 generations of Russians we'd been clandestinely peering at the past few minutes. Shocking, but true.

NOTE: Email here creates a great oral vaccuum. We will try our best to make more posts, but can promise nothing. It may be that we'll post everthing after returning stateside :( We appologize to all our loving, loyal fans! We will attempt to open another blogsite, and direct you to it at that time from this blog. Thanks! FVC II

Soap gets in my eyes...

2008-07-27T14:48:00.000-07:00

I know, I know... it's been forever since I updated the blog. So, your patience pays off today! Hurah! On with our story:

The next day was spent doing some research on the internet and crunching numbers for financial decision making. What we needed was a reliable supply of anesthetic gases, vaporizers to administer them, oxygen concentrators to suppliment the air people would breath through the vaporizers, as well as replacement parts for the whole breathing system. After all, this is Africa... things break routinely. The connection to the net was so slow though, that it was hard to learn or accomplish much of anything.

I met with the accountant and business manager to discuss oxygen, halothane and concentrator costs. To sum it all up, an oxygen concentrator costs about 700 US$ and can provide 5 liters per minute of oxygen continuously. That same supply of oxygen would cost about 2 US$ per hour. Thus, one concentrator would pay for itself after 350 hours of use (excluding the cost of electricity, which in Zambia, at least, was about 2 cents per hour). in 2007, the hospital's O2 usage cost 19,333 US$, and much of this was probably wasted when staff failed to turn off the tank after the oxygen supply was no longer needed for a particular patient. That annual dollar amount would buy 27 oxygen concentrators, each of which would last 5-10 years if properly maintained.

Now, assuming that electricity is about the same cost here as in Zambia, you could purchase 3 concentrators for 2,100 US$ and run them for 12 hours per day, 365 days per year for 263 US$ worth of electricity, do it for 5 years, and the total cost would still only be 3,414 US$. Therefore, 5 years of oxygen at a cost of 3,414 US$ versus 5 years of cylinder oxygen at last years actual cost of 19,333 US$, would amount to a savings of about 96,000 US$. In others terms, in order to turn an investment of 3,414 US$ into 93,251 US$ (for a total of 96,000 US$), one would have to find an investment that gave a return of 2,700%. I am unaware of ANY opportunity that would yield such returns consistently. Other than changing practice from purchasing compressed, tank oxygen to oxygen concentrators.

Further, a savings of some 93,000 US$ would pay the present day salary of 2 anesthetists for 27.5 years, along with an extra month's salary as a yearly bonus (ignoring yearly inflation).

That weekend at church I met Ted Powers, a 4th year medical student from Loma Linda. He matched there to do anesthesia, though he had interviewed in Nebraska while I was on staff there last year. I never met him when he came to Nebraska, so it is as improbably as it is amazing that we should end up sitting next to each other on the other side of the world.

That night, along with Dr. Mataya, Ted and I went for supper to Dr. Terrie Taylor's house. She's a friend of Mataya's and just happens to be one of the world's leading experts on malaria. She comes from Michigan to Blantyre, Malawi every January through June. She has medical students and research assistants join her regularly, of which 3 were with her this evening. We had a wonderful time eating and talking together all evening. And of course, in keeping with the British tradition, there was even time for tea afterwards.

The next day I tested 3 oxygen concentrators that I found locked in a storage closet. Guess what? They all worked! Well, at least they all put out some gas from the machine that I assume is oxygen. I suppose I could've tried to burn it, or set up some explosive experiment. But I settled on just breathing the stuff and seeing if it raised my O2 saturation measured by the one functioning pusle oximeter in the OR. Maybe I'll try to blow up something next time. I'll check my chemistry books back in the states after I get back, then be prepared for more "kitchen chemistry" type fun when I return to the 3rd world. Now, I should tell you that one of the grounding pins on the power cord is broken, and another missing the air filters, but they do WORK. This was after I'd already asked if the hospital had any concentrators and was told, "We only have two, and one of them is broken." It was also after I had asked to be SHOWN the concentrators... and was taken down a side hall and pointed to an empty oxygen tank. Definitely NOT helpful. In fact, it was somewhere around this time that I had decided that I had been "helped" enough, and that I was going to do whatever needed to be done without asking for prior permission or opinions, as well as believe whatever I thought was likely true about a situation because asking for clarification would only bring a fresh supply of lies, or at the very least obvuscate the truth I was trying so hard to elucidate.

My next trip into the shower was less than amusing. To me, that is. You'll probably get a kick out of it, though. And, I'm not posting any pictures, so if you're a woman, or if there are small children around, please, feel free to continue reading my blog posts. It'll be OK. Really.

As you know, losing water here is pretty routine. In fact, I can't remember a day during my whole trip where I didn't lose either the power or water supply, or both at the same time. However, this time there was a bit of a caveat to the whole ordeal. This time, I was all soaped up, in a shower with no curtain, when only the cold water ran out (I presume I was still getting hot water out of the small reserve tank). The scalding I received was enough to test my Christianity. I rinsed my hands and eyes the best I could, then carefully made the dripping wet and naked trek to the kitchen. This is where I found the 25 liter reserve water jug and a cereal bowl to finish what is locally referred to as a "bucket bath." These 2 fixtures remained in my bathroom until the day I left the country, once again illustrating that one can never have enough backups in place.

After finishing most of the final rinse cycle, I tried to mix in a little of the hot water, which promptly also ran out. So, I toweled off and got dressed as I heard the sound of rushing water filling the pipes again (which is easy if you just leave the spigots open). So, I figured, "Might as well at least get my face washed with hot water." I splashed it on, soaped up... and of course heard the pipes run dry once again. "I just can't win here!," I thought. "About how far away is that bowel and bucket, and can I get to it without opening my eyes?"

And as for washing my clothes, well... I got back a load from the hospital cleaning department and was shocked to see that nothing was missing. What good fortune! It was only the second proper laundering my clothes had gotten in over a month. The rest of the time they had been washed by hand with a bar of soap, in the shower, sometimes on me, and then rinsed and dripped dry on a line.

So cleaning yourself and your clothes... hard. Getting said self and clothes dirty? Easy. Take for instance the storage garage, where the hospital had well over 150 cardboard boxes of varying sized and shapes dumped in a pile and containing "donations" of medical supplies/equipment from the merciful, kind and thoughtful US of A. (Don't even get me started on the utterly useless JUNK that is dumped on Africa in the name of good will! I mean, how many cardiopulmonary bypasses do you think we do here anyway?! Hint: NONE!!) So, I get in there and try to sort it all out... for 3 days. I was covered with dirt, dust and God only knows which microbes, hoping all the while I wasn't breathing hanta virus through the mask I was trying to wear while trapsing around areas that were obvious living quarters for cockroaches, bats and various other non-flying rodents. But hey, I wanted an adventure, right? At least at the end of it all we had a list of 60 numbered boxes arranged in order that had descriptions listed in an excel spreadsheet that could be searched and sorted according to contents. Christmas all over again. :)

After cleaning up I checked my email. I got a response from UNICEF regarding my inquiry into a supply of affordable O2 concentrators they claimed to supply the poor and needy of the world. It was surprisingly unhelpful. I'll never ask them for help again. I might not even offer any to THEM, actually. Sheeeez.

That night I got ready for bed without water, and wrote in my travel log by right hand, while holding a flashlight in the left.

BAH Continued

2008-05-04T09:42:00.000-07:00

And now, back to our story!

When we last saw our hero, he was in Blantyre, Malawi where he continues to stamp out disease, and save lives (though, not all the time).

The first full day that I spent at the hospital, the business administrator started taking me around around to give me a tour of the facility. As we walked down the hall to the double doors that entered into the operating rooms, a doorway to my right burst open and the medical director grabbed my arm saying, "Come quickly Dr. Cobos we have an emergency!!"

Dr. Verona is a pediatrician, and she and the two anesthetists were struggling to save a preterm baby who had JUST been born at 33 weeks gestational age (no prenatal care, mom had had vaginal bleeding for the past month, ruptured her membranes yesterday. It was her 4th child). The parents were waiting down the hall to hear of the outcome. I saw the child had a club left foot, and was beginning to have that ominous gray dusky appearance the newborn black children have when they don't get enough oxygen. This, despite the fact that the child was intubated and being ventilated with 100% oxygen. There was no blood pressure cuff. There was no EKG machine. There was no pulse oximeter that we could get to function on those tee-tiny fingers. Of course, even if it had worked it's not like we could have given any more oxygen. My immediate guess was that this child was going to live about 10 more minutes, at best. I listened to the heart and chest with a stethoscope. The heart rate was aproximately 100, and the lungs were not being ventilated very well. This did not surprise me, since the child's lungs were not designed to even function until after at least another month's develpment in utero. If we saved the child, there was no ventilator which could be used for respiratory support.

We decided to continue resuscitative efforts for approximately 30 minutes, after which time we all agreed that further efforts were futile. We stopped, and I drew down the little eyelids for the last time, never having had the chance for light or vision to spark her imagination. Dr. Verona went to explain to the parents what had just happened. I stayed behind.

Later that day, I was able to e-mail my family and friends back home to let them know I was still alive and that my malaria test was negative. It was not my time to die. It had been someone else's.

It had been some time since I had actually had to stand right there and watch someone die. It's hard to explain clearly what all goes through your mind during the experience. And of course, it is different when it's a young child as opposed to an old person, full of years. In the case of the latter, there is consolation in the belief (be it grounded in truth or not) that the dead or dying one had a fulfilling life which is successfully coming to a close. In the case of the former, one is haunted by the fact that this life was barely opened, and an uneasy wonder that had you but acted smarter or sooner an entire world of difference would have been made, and a life full of dreams achieved. These are, as it were, the skeletons in my medical career's closet. Thankfully, they are few and far between. But is it important to acknowledge their presence, if only to crack the door open just wide enough to accept one more silent, small, skeleton.

The next day, much of my time was spent modifying the draw-over vaporizer system they were using. They were using too much cylinder oxygen, and the modifications would allow for them to save money by using less, making up the difference with room air. I have been surprised how much repair work I have needed to do. I've actually spent more time as a repair technician than an anesthesiologist.

The next case was done under spinal rather than general anesthesia. I watched in shock and awe as the anesthetist performed the sterile prep without wearing a mask. Then, he proceeded to place a nonsterile lidocaine jelly on the skin in an attempt to numb it. This was promptly wiped off, as if it could have taken effect in five seconds. Why lidocaine was not injected directly into the skin I have no idea. Before I had a chance to voice my concerns over what I was watching, the announcement was made in English that we were about to pause for a prayer. Given what I had just seen, I felt this was an appropriate intervention, so I just stay quiet.

Things got a little bit busy during the day and I was asked to do minor surgery alone to facilitate completion of the surgical schedule. I removed five Norplant rods from a lady's upper arm, using lidocaine with epinephrine, a scalpel, scissors, forceps, and closed her up with two stitches. I still got a it! I can still cut and sew!

We operated for much of the next day also. I had been scavenging for parts and supplies throughout the OR and nearby storage room, but had not found much useful equipment. The Drager anesthesia machine had three large locked drawers in it, but of course no one had a key to open them. I wonder if anything worthwhile was inside. I pushed the machine away from the wall and looked at the back. There was an opening behind the top drawer which was just large enough for my arm to fit through to reach in behind the drawers. Though the top drawer would open, it would not come out completely (thus, exposing the contents of the drawer beneith). However, there WAS just enough space for me to fit my hand down to the second drawer's locking lever arm. It was held in place with a flathead screw, which was just begging to make friends with my Swiss Army knife. So, with a flashlight strapped my head, the second, and then the third drawer, were opened African style (i.e. they were broken into).

My hope had been that the drawer would hold the power cord for the oxygen/halothane analyzer, or at least a spare set of cables for the EKG machine or pulse ox. All I found were some US 110v power cords, precordial stethoscope heads, paper clips, and some laryngoscope blades that fit none of the handles we had. Well, it was worth a try.

By the end of the day the power cord for the gas analyzer was found by one of the anesthetists. This allowed me to test the oxygen concentrator's performance and evaluate the modifications I had made in their draw over anesthesia system. It was only then that I knew they would be able to save tank oxygen, use the oxygen concentrator instead, and save money without compromising patient safety.

They also brought me the cable for the EKG machine which they said wasn't working. The reason was now obvious. The cable appeared to be 30 to 40 years old, with cracked, broken off plastic insulation around each of the leads. The leads had been forming short cicuits, and after I wrapped each cable (what was left of them) with cellophane tape the EKG machine worked fine. :)

Two pulse oximeters were not functioning, and the rumor was that all they needed were batteries. ("Why do they need batteries? They run off the outlet in the wall! Whatever.") The surgeon brought me one battery which he said was supposed to work in them, but that no one knew how to install it. If I could figure it out, I would save the hospital money that was the equivalent of one month's salary for a nurse. Nobody could bring meat tools that were helpful, so I was thankful my Swiss Army knife at all the screws I needed to undo. The inside of the pulse-ox appeared free of physical damage, with only two wires (one red, one black) dangling free. ("Ah, so there's a break in the power circuit. No wonder it "needs" a battery. I wonder if a dead battery would work?") Obviously, this is where the battery was supposed to go. I looked at the battery and quickly saw that the wire connections were designed to fit a different battery. The wires had connectors with two small holes, whereas the battery had connectors that were flat, flush to the plastic housing, with one hole screwed in the middle. Now what? I looked around the room and began to hear the theme from MacGyver playing in my head.

I went back to the Drager machine I had just Africanized and looked in the bottom drawer. I wondered if maybe I could rig a connection using the power cables I had just seen. But, that would require a soldering iron, which they told me they didn't have. So much for that idea. Well, I thought... who says you actually need to solder the thing? I grabbed a couple of the paper clips out of the drawer. These were small and round, I thought. Just what I needed for the wire connectors. I bent the other half of the paperclip flat to match the shape of the battery's connectors. Then, since I didn't have duct tape, I used the cellophane tape left over from the EKG cable repair job to hold the home-made paperclip jumper cables tight against the flat metal posts of the battery. I screwed the whole thing back together again, cliped the pulse ox on the finger of one of the anesthetists, and turned on the power. Viola! The most rewarding thing I'd done in weeks!

Not a bad day's work. It ended with two functional EKG machines, one additional pulse ox, and one gas analyzer. None of which were working before I arrived. People at the hospital thought it was like Christmas!

In the afternoon I went to the maintenance building, where I had been told donated supplies from the US had been stored. The room was steaming hot, filthy, dusty dirty, with stacked cardboard boxes up to my shoulders, all unlabeled, some with cockroaches, others chewed by rats/mice, and filled with donated equipment and supplies (obviously, some no longer sterile). Amongst other things that I found within a few hours were an EKG machine, a new manual suction device (great for when there is no electricity), Ambu bags, carbon dioxide sample lines for the gas analyzer, one-way respiratory valves, tons of masks, airways, and ET tubes, small adult and adolescent blood pressure cuffs, and a brand-new laryngoscope with replacement light bulbs. They were sitting on a gold mine, and they weren't even using it! It reminded me of the stories I heard about rice and other food being donated to starving Africa, only to be left to rot on the docks where the shipments arrived. There is such a lack of organization and lack of personal responsibility that multiple people become the weakest link in a failing supply chain meant to provide equipment and supplies for those in need.

I spent one hour trying to connect to the Internet that night. Eventually the power went out, and the hospital's emergency generator kicked in a little while later. I still couldn't get connected. I decided to walk home and go to bed. The guest house where I was staying with only a one to two minute walk away. It was quite dark outside the hospital, where no generators were running to provide power. Halfway to the apartment the power surged back on and a large cluster of sparks flew from a transformer atop a nearby telephone pole, lighting up the night.

First Findings of BAH Anesthesia

2008-04-17T04:52:00.000-07:00

I was pleased to find 2 functioning anesthesia systems. One continuous flow system (a Japanese machine: Acoma complete with non-functioning ventilator, and one year old soda lime), and the second system, a draw over set-up with a... with uh... well what do you know!? A good-‘ol OMV (Oxford Miniature Vaporizer)! How very quaint ☺

I couldn’t believe it! I’d seen drawings of them in books, but here was the real deal! And *I* was going to get to use it! But then, suddenly, I recognized a group of letters, printed all caps on the top of the dial, next to the word “Halothane.” They struck terror in my little American heart... PENLON.

Say it isn’t so! I hung my head for a few moments, there in the darkness of the humid OR, all alone, and sighed out loud. You see, back in the states, about 2 years ago, our department made the mistake of purchasing 5 new anesthesia machines made by Penlon to replace some of our older Drager machines. We started having serious problems right away... like the ventilator stopping for no reason in the middle of a case, the CO2 absorbant container leaking like it had more holes than Swiss cheese, complete re-breathing of all CO2, etc. We had a “wall of shame” in the faculty office with modified Far Side cartoons that poked fun at the Penlons and our experience with them. It was like I’d come to the ends of the earth, and yet I STILL couldn’t escape this British company’s freaky-fickle equipment. I thought, “Well, the thing looks like it’s a good 50 years old. If it’s lasted this long, maybe it’ll make it another week or so and I can get outta' here without any repeat offences.”

Room 2 was their minor sugery room, and the graveyard for donated equipment. There was a Drager 2A and a Drager AVE (I've never heard of that model). Both had seen better days, and those days were before I was born. I was told that neither worked. And even if they did, I knew that they’d need high flow, compressed oxygen to make them work. Still, it’d be nice to have at least one machine in the hospital that had a ventilator, and could serve as a back up should the Acoma fail (which was likely at some point, given its age and working condition. The Penlon, as much as I hated to admit it, was nearly fool proof and maintenance free. It had only one working part (excluding the screw cap that came off to fill the vaporizer), required no electricity, and could be operated using only room air. A mission hospital’s dream machine, really. At least it would be as long as they LEAVE the OR, and THEN use ether to dissolve the thymol residue that tends to build up as the halothane is vaporized. What I didn't want to hear later was that they opened up a can of ether RIGHT IN THE OR where electricity was flowing through a varied array of frayed wires and cables. If they can remember to take that precaution, then the hospital won’t literally be blown to kingdom come as the ether (a very explosive chemical) drifts down to the sockets, power strips and cables at floor level.

Here at Blantyre Adventist Hospital there are 2 anesthetists. They typically run one OR at a time, and either tag team doing the cases, or more often than not, help each other do the same case. It actually does take 2 anesthetists to do 1 case... one to start doing anesthesia, the other to trouble shoot all the problems that arise while the other one keeps trying to care for the patient. They do not intubate here, and there is no ventilator, so one person has to hold the mask while the patient breathes on their own. So, examples I’ve seen of second person anesthesia responsibilities are: setting up suction after a patient has already vomited, getting drugs drawn up to inject for the treatment of low blood pressure, getting the pulse oximeter to keep work, putting on the blood pressure cuff after induction of anesthesia with halothane... and cycling it once or twice, filling up the halothane because it’s almost gone, adjusting the ceiling lights for the sugeon (no sterile handles for them to do it themselves), going off somewhere to find an oral airway. No, I'm not kidding.

The anesthetist I helped out today barehanded the Tylenol suppository into this kid’s butt, THEN put on gloves to hold the mask again for continuing anesthesia. Good grief. What am I supposed to say to that? Don’t some things go without saying?! I just shook my head and wondered if I really could help this guy learn.

Off to Blantyre

2008-04-17T04:45:00.000-07:00

I was able to fall back to sleep as it cooled down in the wee hours of the morning, even though I had to lay awake and wonder wether or not I was coming down with malaria. I had been taking my pills faithfully since arriving in Africa, but I had been bitten about 8 times. Seems like I swell up and itch a whole lot more when the mosquitos over here bite me.

The next morning while I was relaxing on the lake shore, an ebony carver met me to sell me some of his wares. I had seen ebony only once or twice in my life, so it took some convincing before I believed he had ebony and not just wood that had been colored by Kiwi shoe polish (a well known trick used in Africa). A little sanding and scraping with my Swiss Army knife convinced me it was for real… along with a consult from some locals. I traded my sandals and some US$ for several good sized blocks that I will carve on my own back in the states.

I got to visit with Iqbal and his family again, exchanging ideas and experiences on all kinds of things. One thing I remember them telling me is that their DVDs have 16 movies per disk! I don’t understand how they could pack that much onto one disk. However, it would stand to reason that if it is truly possible, it is probably something that was designed and engineered by the same Africans that put 26 people in a 16 person mini-bus.

It was about this time that I got a chance to shower and shave for the first time in days. The mosquitos the night before were bad enough that I had sprayed my whole body with 30% DEET, even though I was under a net. They had gotten underneith the net the night before because I had let one edge rest over top of my suitcase, rather than flat on the floor, or tucking it in under the mattress.

The final day arrived for us to be at Lake Malawi. We said good-bye to Iqbal and all his family, inviting them to come stay with us some day. The drive to Blantyre was, as usual, over the three hour prediction, and was yet another bladder testing experience. As we neared the city, past president Bakili Muluzi past us in his motorcade. He’s starting his campaing for next year’s election, and is running for his UDF party’s primary election, in 2 days (not that anyone else is running for the UDF). This guy’s an average corrupt politician, of whom I may tell you some more later. For now, let’s just say I was ammused to see how little armed guards and private security was with him on the roads.

After settling into my guest flat at Blantyre Adventist Hospital, I relaxed and did some reading. I felt a bit dizzy, kinda funny, and fatigued. That night I woke up in a hot sweat, and decided to get checked for malaria the next morning… after all, I was at a hospital, how hard could it be? And, it had been 3 days since the last time I woke up like this. Seemed like it could be P. vivax (a type of parasite that is the cause of malaria), since the best I could remember was that P. falciparum was a every 4th day fever/chills. If I had it, I just hoped the cure wasn’t worse than the disease.

All's well

2008-04-04T04:03:00.000-07:00

Hi all,
Just a quick note to say I'm fine. Internet access in Malawi has not been as good as I was told it would be. I will try to post again, after typing things out in a Word file, for a quick cut and paste job.

Bye for now!!

Lusaka to Salima

2008-04-01T03:18:00.000-07:00

We got up the next day at about 0430 to make it to the bus station by 0500, for the 0600 bus. You can reserve a ticket the night before (which we did), but you cannot purchase a ticket early. I’m told it confuses them. Their system of selling tickets is out of a carbon copy notebook. There are no computers anywhere at the bus station. In fact, the Juldon bus company’s “office” is a press-board shack with a tin roof. The dimensions are roughly 4 feet wide, 7 feet high, and 8 feet deep. I couldn’t tell how the guy got in there. We bought our tickets and pressed through the crowd of advertisers to squeeze towards the bus. See, as soon as you drive into Lusaka bus station, you are inundated by people shouting the praise of their bus company, and desperately urging you to buy a ticket from them, and not their wicked competitors. The first time I came here, it nearly frightened me... now that I understand what’s going on, it’s tolerable.

8 hours later we arrived at Chipata. The Mwami hospital mini-van that was SUPPOSED to meet us was no where to be seen. Was I surprised? Nooooooooooooo! Jim called on the cell phone. No answer (no surprise). He sent a text, no reply (no surprise). 1 hour later we hired a taxi to drive us there. How long will this take,” I asked. Of course, I already knew how long. I had ridden the road before. I was just curious to see how badly the driver would lie, or how badly he would estimate the travel time. “20 minutes.” Hmph. Just what I suspected. Off by 100%.
We got to Mwami 45 minutes later.

Once we arrived I checked in on how the new machine was doing. The anesthetist told me it was doing just fine, even the halothane leak had stopped. I suspect that the thymol preservative had plugged the hole as small amounts of halothane leaked out over the past 2 weeks. However, a huge leak had developed in the old Drager 2A. I took a look, confirmed what I had been told, and quickly realized that there were no tools to disassemble the thing and try to repair it. They’d have to use the 50 year old Boyle’s machine as their back up, like they did before the glostavent arrived.

I went to bed, again, face down. It was hard to sleep without the fan I had become accustomed to during my time in both Lusaka and Yuka. I couldn’t tell if it was me I smelled, or just memories of the people I’d spent the past 2 days with on the bus.

The next morning, the Ang and Peduche families (Philipinos, both) and I loaded into the Toyota 4 wheelers to drive to lake Malawi (WE left on time, and bought fuel legally! Where’s the fun in that?

It took about 25 minutes to enter/exit Malawi/Zambia. The guy on the Malawi side recognized me and said, “Hello Mr. Cobos!” I hadn’t even given him my passport yet. (It pays to have friends in high places!)

After getting to Lilongwe, we stopped at 4 or 5 stores to buy stuff for the weekend. Most of the businesses are owned by Indians or Mid-easterners. A large procession was passing through the main street, mostly in purple. I had forgotten it was Good Friday (purple being the symbolic color of repentance, used generously in Catholic festivals).

We arrived at an estate on the shore of lake Malawi, near the city of Salima. Our hosts are a wealthy Muslim family who happen to live back in Chipata, Zambia and have been patients of Mwami. They invited the doctors to join them for the long holiday weekend at this retreat, which they themselves hadn’t stayed at for over a year. We stayed in 2 guest duplexes (3 other Philipino families joined us), next to their own main, large, house. Local workers cleaned for us, and it reminded me of Africa’s old slave age.

The first thing you notice about ANY building that Islam has anything to do with in all of Africa is... it’s clean. And in Africa, that stands out like a sore thumb. A beautiful, magnetic, sanitary sore thumb. I love it. Ah, to be clean :)

Iqbal’s family came to Zambia nearly 100 years ago, as negotiators between the Zambians and the English. Now, they’re traders, and run a farm with 500+ employees. They dismiss dishonest workers on the first offence (stealing is a major problem, and they claim they could write a book over 1000 pages long describing all the methods the Zambians have stolen from them).

The electricity went out, as usual. It was hot, and I couldn’t sleep in the heat. Eating a big Philipino dinner hadn’t helped either. I woke up in a sweat about 2 AM.

Living in & Leaving Yuka

2008-03-30T06:16:00.000-07:00

And now, back to our story...

Live in Yuka is one of severe isolation. They struggle to get people to work here for that reason alone. The doctor here is on bond with the government, and had no choice but to come. On the other hand, he grew up in western Zambia, so it's not so bad for him. The other doctor, an Argintinian, is on medical leave having a hernia repaired. He gave it to himself after lifting an engine without asking for assistance.

Futher complicating things is payment of salaries. See, there is no bank here. In fact there's no bank in Kalabo either. The nearest bank is back in Mongu, and that's going to take 1/2 a months salary to pay for gas to ride to the bank. So, if you choose to do this, you lose 1/2 your salary just taking your salary to the bank! "Why not just get a safe at the hospital?" I asked. Becuase no one trusts any ONE person to be in charge of keeping the safe, well, SAFE. Petty theft is nearly the norm out here, even among some of the hospital workers. It's largely, in my opinion, why places like this can't grow or flourish. The solution for now is that the accountant takes everone's money on ONE boat ride at the end of the month and puts all of it into the bank, returning with records for each person who made a deposit.

I spent one afternoon trying to clean out their O2 concentrator. It was about 2000 hours overdue for maintenance, and I didn't have any replacement filters for this thing (made in Colorado, USA, c.a. 1980). We did actually get to do surgery on that guy I mentioned in the previous post... the volvulous (torsion of the bowel). Here's how it went down.

After the doctor's meeting finished, we went over to the Kalabo district hospital, and went into the OR. I found a state of the art, new, Japanese anesthesia machine (with O2, CO2, and anesthesia agent analyzer), 2 new portable vital sign monitors, and an oxygen concentrator! Too bad there was no compressed air, oxygen or halothane that's required to actually USE such a system. In fact, there is no anesthetist at this hospital. And no muscle relaxants to use on this guy's massively swollen, bigger than 40 weeks pregnant abdomen. Sheeze. This was going to be fun.

So, I used what I had. I gave him the African triumverate of: 5 mg of diazepam (Valium), 600 micrograms of atropine (to counter the drooling-like-a-dog side effect of the...) ketamine! No intubation, LMA or mask, no inhaled anesthesia, no local anesthesia, no morphine. Just a nasal canula, an IV and the aforementioned drugs. I used what I had, and I had to use it well.

The bowel lunged out of the incision and looked to be about the size of my upper thigh. 4 hours and 2 GRAMS of ketamine later, we rolled him out to the medical ward minus most of his large bowel (there is no such things as a post anesthesia care unit here). I hoped they would check vitals on this guy, though he'd done quite well for me during surgery. (We heard that the next day he was doing well.)

So after a total of 3 days in Yuka, we awoke at 0530 to go to the dock and take the boat to Mongu, and catch the 9 AM bus to Lusaka. Of course, since we weren't the only ones going from the hospital to Mongu, we had to wait on them to arrive on African time (meaning anywhere from 45-90 minutes late). We loaded onto the little boat as it began to rain and pushed off into the river.

The boat wouldn't start. After a dozen or so attempts, it did fire up. Which kinda surprised me, since this wasn't the nice boat we came on. It was the hospital's boat, which had the gearbox drop out of the bottom of it a month or so ago and had been under repairs. Repairs had been delayed since the fishermen who retrieved the hunk of metal from the bottom of the river held it for ransom to the tune of 3 million Kwatcha. This had recently been negotiated down to a more reasonable price, and then the boat "fixed." Yeah, fixed. Fixed like a cat taken to the vet.

So we're idling up to speed, leaving 45 minutes behine schedule, and the pilot announces that we have too much weight on board. We go back and spend 15 more minutes to the dock and put 2 people and their luggage off (which was smart since we didn't have enough life vests for all of us anyway), and restarting the engine... again, and again, and again.

We arrived at Mongu 30 minutes after the bus was to leave. In reality, this is usually enough time to get on the bus before it leaves. However, we had to wait for a taxi to drive by, flag it down and get to the bus station. And, that took time. After getting to the bus station at 9:45 , we saw a lovely, huge, yellow bus idling and pointing in the direction of Lusaka. You can imagine the combination of comic disdain I felt when they told us that yes, that was the bus to Lusaka, and it would be leaving at 2200 hours. Lovely.

We had to take a mini-bus (16 passengers) that was scheduled to leave at 11 AM and headed TOWARDS Lusaka. We'd transfer at some other place to take another bus that was SUPPOSED to be crossing paths with us SOMETIME between 1400 and 1500 hours. It was the best we could get, and Jim and I HAD to be in Lusaka that night to catch the 6 AM bus to Chipata the next morning, so we could then leave the day after that for lake Malawi. So, I layed down on the concrete porch and rested my head on my backpack, pulled my hat over my eyes and chilled until the minibus showed up.

We loaded up around 10:45. I saw an albino load up, and tried not to stare. It had been years since I'd seen an African albino... the white skin, almost yellow hair... pink eyes. Then there was another passenger... a boy, about 5 years old climbed in too. It didn't seem as though he was with anyone. His face appeared as though it had been melted in fire, the sink now hardened like previously dripping candlewax, about a quarter inch lower than youd expect the facial features to be. He had no read ability to express emotion anymore. He sat behind me, as we faced the front. I wondered if he looked at me, like I looked at him.

Of course, we left late again, and we ended up driving around town to find fuel. We found some, but not legally. See, there is no gas out here. Or at least none left. What I saw the driver siphoning out, by mout from a used 10 gallon corn oil jug, and flow out a cut garden hose and through a rag/filter before filling the fuel tank, was actually Namibian gas brought over the boarder and sold on the black market. Without this fuel, Mongu has no transportation system.

We FINALLY got off TOWARDS Lusaka. With 21 people in a 16 person mini-van. What I wouldn't have paid for a small privat plane at that moment. Dude, these poeple smelled like phys-ed left over from last month!

About 3 hours later the driver pointed out the front window and said, "There's your bus." It was aobut 1/3 of a mile ahead of us, driving on the same road, belching diesel fumes out the tail pipe, looking all the world like the one I had seen on MacGyver 25 years ago that he had to repair before escaping from Mexico. Well, I thought, at least a bus in that bad of shape shouldn't be too hard to catch up with.

We did catch it, and after paying the extra 1.50$US bribe to have my bags underneith the bus instead of carry-on, we settled in for another 7 hours to Lusaka. I couldn't complain. I had an isle seat, and had brought enough kwatcha this time for a packaged snack (shipped over from China probably 6-12 months ago), fresh water, and some left over to pay for a couple first class pee-breaks (worth every penny when compared with the cleanliness of the free versions).

Total costs for the day were about 15$US per person.

I slept face d0wn again that night, my butt was so sore.

From Blantyre, With Love

2008-03-26T08:14:00.000-07:00

And now, back to our story.

OK, so... Yuka mission is right near Kalabo (8 Km), if you can find that on a map. We arrived there after traveling 8 hrs. by bus from Lusaka, after leaving there 45 min late. Now, I have figured out the reason they leave late (this is the 3rd time I've taken what they call a "timed" bus, and they didn't leave on time). They charge you extra for taking luggage along that has to be loaded underneith. The guy who takes your money charges you more than the bus company actually expects from him at the end of the day. So, at the beginning of the day, he and his buddies divy up the extra cash amongst their theiving little selves before turning in the cash and receipts for the bus that is leaving right then. Bingo. Free money for them.

We rode through a big game park about 4 hours into the ride. I saw a lone, large male elephant, a cluster of zebra butts sticking out of the bush, a lot of impala, 2 grey monkey, and some large birds. Sorry, no picts (we were driving kind of fast).

Speaking of driving... I've been trying to learn the rules here. You know, they use the wrong side and everything, and honk all the time. Actually, they don't always drive on the left side of the road because there are SO MANY pot holes, that if the ride would be smoother, you always swerve and weave and curve to get the cleanest path possible. This is one reason why being a driver is actually a career here. I'm not kidding. It takes skill, man. All this while dodging farm animals being hearded over the road (goats, cows), small children left unattended (or more likely, orphaned by HIV) on the side of the road, a soccer match gone astray, bicycles and pedestrians going in both directions, merchants looking to sell their wares (who knows how) to cars speeding past, and the generally unattentive bystander. To effectively dodge these continual annoyances, one must use the car's horn. There is a code I've elucidate that goes a little something like this:

1 short toot = I see you, and see that you see me coming. Get out of the way, I'm coming.
2 short toots = I see you, and see that you DON'T see me coming. Get out of the way, I'm coming.
3 short toots = I see all of you, and see that some of you can see me coming, but some can't or don't seem to care. Get out of the way, I'm coming through where all of you are.
1 long toot = I see you didn't respond to my last toot/toots. You annoy me, now get out of my way! I'm coming through.
1 long toot, 1-3 short toots, followed by 1 more long toot = I see you see me, I don't think you're deaf, and your being rebellious. Now, get the hell out of my way! I'm coming through anyway, and I'm not slowing down for you (though if there are big pot holes, I may have to slow down inspite of your pig-headedness).

At least, that's what I think it all means. I asked if you had to get an international drivers license to drive here and was told "no." I thought it might be hard to learn all the rules of the road, but in retrospect it's quite easy here, compared to the US. Here, all you have to know or do is... honk all the time, and don't hit anything or anybody. Then, it's all good.

Well, we got to Mongu after about 8 hours and took a taxi to the "harbor." Actually, we took 2. See, we'd come with 13 boxes of medicines and supplies (the government hadn't supplied Yuka with any meds for about 2 months), so it took a bit of extra car space. At the harbor, I made my one monitary splurge for the whole trip: round trip speed boat for the 3 of us and our stuff... 600$ US. Why, you may ask? Here's why...

The rainy season leaves only one road open to Yuka from Mongu/Lusaka. It is about 350 Km and takes over one day to drive. There is also 2 other boat options... the slow boat (aka the banana boat), which might as well be to China. It's travel time varies from 8-24 hours, depending on the weather and skill of the pilot (one person told me they got lost in the rain, at night, and had to sleep until morning and then find their way after it was light). So, this is how it went in Mongu... Taxi from the bus station to the harbor: 10$. Cookies and water from the local "market:" 2$. Price for riding on a 80 hp Mercury outboard powered "speedboat:" 600$. Not having to sit on my but for another 8-24 hours while swatting mosquitoes, trying to stay dry, and not letting my hands fall into the water with the crockodiles (no kidding, really): PRICELESS!

Yuka translates to "Someplace to rest." No kidding. And did I ever need it!

When we got to the "harbor" in Kalabo in the twilight and transfered ourselves and 13 boxes into to 2 ORVs. I grabbed Dr. Suingini's 12 fish, hanging on a stringer, and climbed into the back of a barely running jeep/ambulance that was donated from Mwami (probably because it didn't work). I had to hold the back door shut with the hand not holding the fish by pulling on a rope. Fortunately, someone thought "Hmmmm... that doesn't look to safe, even if it is only for 8 Km." Frankly, I didn't care at that point. Anyway, I climbed back out, went to the other car, and they tied the door shut behind me after I got out.

We arrived to no electricity (BTW, I've yet to spend one day in Africa where I didn't have electricity for some part of the day, or something didn't work), lit some candles, and ate supper with the Valenciano family (She's a physician, he's the maintenence chief). Then, Ed and I went to our half of the duplex that serves as the guest house.

Elmita is in the other half, she's the 4th year Argentinian med student who's been here 7 months in a row (one more to go). She's seen 2 amputations following snake bites and said that they killed 5 cobras the first month or so she was there, and she met one on the path to the TB ward a few days ago. It was raised up on it's tail to a hight of about 3 feet, hood spread out, and about a yard in front of her. A photo I saw of one Mr. Valenciano had clubbed and held out at arms length above his head gave me my only glimpse of a snake during my 3 days at Yuka. It was about 7 feet long, and as big around as my forearm! They later noticed the snake wasn't actually dead (it's easy to laugh when you weren't the one holding on to it at the time!) The cobras like eggs, and when rainy season comes, they flee up out of the flood plain to higher ground. If you happen to raise chickens, they know, and they come to your place to eat. It's simple actually. Very predictable (and enough to make me vegetarian).

Back in my half of the duplex, I did have a mosquito net already hanging over the bed I was to sleep on. Which was fortunate, because the silicone glue I had brought with me to install the hooks on the ceiling for hanging my own jumbo-sized, safari-grade, ultra fine mesh net... solidified in the tube (I also could've used it to seal the leak in the vaporizor back at Mwami. Rats.)

I went to the bathroom to wash up. The toilet seat was cracked, and pinched when you sat on it (I shouldn't complain... at least this one HAD a seat). The tub had no shower curtain, and no shower head. The sink had one out of two spiggots working (YES!!!!). It did leak onto the floor a bit (a least I hoped that's where the water came from. The other option was the toilet).

Spiders crawled on the walls. I small frog jumped on my head while I dozed on the sofa one time. A cought an unrecognizable insect crawling up and over my right shoulder, and on another occation (on the boat ride back), one crawled off my lifevest onto my face when I turned to look back up river.

I woke up with a few mosquito bites. Which means the net wasn't treated with Permethrine. The mosquitos will bit you through the net if you lie to close and touch it during the night.

Seet dreams and sleep tight, America.

Quick Update from Kalabo, Zambia

2008-03-17T08:30:00.000-07:00

Hi all,

This has to be quick, and I´ll try to do a more complete update later this week...

Arrived yesterday at Yuka Mission Hospital near Kalabo, in the western provice. From Lusaka, it was a 8 hour bus trip, followed by 2 hours in boat on a tributary of the Zambezi river. For most of the past week I was at the Lusaka Adventist Eye Hospital, where they actually do more than just eyeballs, turns out. They´re pretty well off there so I didn´t do much work there, just a financial analysis to see if we ought to upgrade their equipment, and how long it would take for it to be worth their while financially for having done so.

Here in Yuka, it´s an entirely different story. They have an anesthesia machine, a Boyle´s model, with serial number 1605. The thing was in a closet, and no one knew how to use it. There is no circuit, and no anesthesia gases. I might not have even recognize the vaporizers, except they were labeled with big letters... ETHER and HALOTHANE. They were like nothing I´ve ever seen. They belong in a museum! In fact, I may try to bring them home just to have as my own personal peices, come to think of it.

Well, at the moment, I´m using a wireless connection at the Liuwa Plain National Park Headquarters (legally, I might add). I and a doctor from Yuka, along with a 4th year med. student from Rio Plata, Argentina, are waiting to hear from the medical director of Yuka who had told us to meet him here in town at the district hospital for an emergent operation for a patient who came in a few hours ago to Yuka. The patient, as best I can tell, is septic (38.7 ºC), and has a belly tighter than a drum head due to abdominal perferation (they didn´t take X-rays, and they had to retrive the one, manual, mercury, BP kit from the nurses station so I could measure vitals myself). I checked and was glad to see that at least he had an IV in place. Too bad it was only a 20 g, and was dripping quite slowly. I opened it up wide and asked if it was his first bag of saline, then realized as I spoke the words he should be happy he´s getting any fluids at all. Back at Mwami, they don´t give IV fluids to any but the hypotensive or C-section patients. It´s just not available, and very expensive.

The OR there at Yuka is under repairs, since it started raining in after the roof collapsed a few days ago. The bats love to fly in under the roof of the hospital buildings, pee and poop all night long for years and years until the ceiling rots and caves in. Such is life, eh?

Outside, no snake citings yet :) I did, however (mom, you´ll love this story), meet the red fire ants they have here last night. Fortunately for me, and my scarred for life psyche, there were only 2. But, they both bit me at once, just like the old days, on my legs after I inadvertantly walked too slowly past them. I´ll try to get a pict of these beggers... they travel in hords here, HUGE groups of them. I saw them this morning, traveling about 10 to 12 ants wide, both going and coming in a trail that flatened out the sand. You CANNOT stop and look at them long. They DO notice you, and the DO come after you. I´m having flash-backs just writing about it.

*Dream-like sequence here*
I was about 4 years old, playing in the front yard in Savannah, GA. I didn´t know it, but I was standing on a fire-ant hill, and suddenly, after climbing both of my legs up to my crotch, one of them gave the signal to bite, and so they did... all at once. After that, all I can remember is excruciating pain and being stripped naked faster than a trauma in the ER so I could be washed off.
*End PTSD recollection here*

Back in the present, we´ve been notified that the doctor who asked us to come for surgery here in Kalabo is in a meeting. I asked if the Kalabo hospital could deal with the surgery without us... I mean, they have a hospital with a functional OR, doctors, maybe even a nurse of two on duty, what the big deal? They said the Kalabo doctors are in the same meeting! Trouble is, the power in this region goes out every day at 7 PM until 9 AM the next morning. So, if you want to operate WITH electricity, they´ve only got 1 more hour to go. I also learned that while Kalabo District Hospital does have a new anesthesia machine, there is no one there who actually knows how to use it. :) How convenient.

My guess is this guy isn´t going to get a surgery until tomorrow. And that´s if he lives.

First Report

2008-03-11T09:12:00.000-07:00

Hi all!

Sorry it's taken a while to get connected, but hey, I was in the middle of nowhere you know?

Here's what's happened so far...

I went to London to meet with the manufacturer of an anesthesia machine designed specifically for difficult environments (read: the 3rd world). I was unable to visit and train on the machine because I wasn't there on a Teusday, but they sent me a training DVD to my bed and breakfast near Heathrow. So, for several days I re-visited the British Museum (the Rosetta Stone, and the best of ancient Persia, Greece, Rome, India, and Europe), the National Gallery (Van Gough, Monet etc), and took in a Baroque string concert at St. Martin's in the Field, and an organ recital at Westminster's Abbey. Also spent a half day reading at the National Library on halothane and ether anesthesia (that book was an original from c.a. 1850 by Dr. Morton... the one credited with "discovering" ether anesthesia). They also have there Dr. Harvey's book on human circulation, which he published at the age of 36 (I turrn 36 on April 6th). Oh, and Gutenburg's Bible, parts of Da Vinci's notebooks, the Magna Carta, and Galaleo's first published book (yes, they are the originals)... John Lenon's handwritten lyrics for "Hard Day's Night," written on the back of his son's 1st B'day card.

You gotta love London!

Ok, so from there I flew 13.5 hours to Lilongwe, Malawi via Johannesburg, South Africa... after sitting on the runway in London for 1 hour, nearly missing my transfer in JoBerg, and showing up in Malawi sans (def: French for "without") luggage. I was transported another 3 hours by car over what was referred to as a "road" to Mwami Adventist Mission Hospital near Chipata, Zambia, with the assurance that *maybe* my bag would be on the next plane from JoBerg (which would arrive 2 days later). I was greatly relieved (literally) to finish the journey 3 countries, 2 days, and 1 liter of water later. :)

The guest house I was in had 3 medical students on rotation from University Teaching Hospital in Lusaka (the capital of Zambia). They couldn't get enough of discussion on US politics. My room had a mosquito net, fortunately. My own net was in my bag, presumably in JoBerg, along with my DEET and Permethrine repellants, malaria pills, soap, tools and equipment for the OR. Oh yeah... and all my clothes. I did have my video camera though (But, I have no way of transferring images to the blog site, sorry!)

The machine ordered from the UK had arrived just before me, and we set it up right away. I also inspected the ORs and met with the 2 anesthesia providers (approximately equivalent to CRNAs... they trained 2 years in Tanzania, after prior medical experience). They had a Forreger with copper kettle vaporizer and a Boyle's type machine (fiited with halathane and Ether vaporziers). Their main machine was a Drager 2a, plugged into a rigged transformer to get 110v from the local 220v electricity, and hooked to an H class O2 cylinder, flowing 4-7 liters/minute of fresh gas (O2). The halothane is free, from the government, but one O2 tank costs the equivalent of 1/2 a nurse's monthly salary. They have no CO2 absorbent, so then must run high flows. The EKG machine broke last month. They have THREE Masimo Rad7 pulse oximeter machines (YES!!! ) and one crummy Nelcore pulse Ox. They have suction, but don't hook it up much (no yankaur tips). Everyone gets Atropine pre-op, so there's not a lot of slobber. They ran out of Succynylcholine, so they just use a mask for ventilating for the whole case. I showed them how to intubate under deep halothane anesthesia without muscle relaxant, but they were too scarred to do it without me after I left.

The new machine worked well, except the vaporzer leaked out ~20% of the halothane in stock over the weekend. Chewing gum quickly dissolved in halothane, so that solution was not even attempted. I had silicone glue in my suitcase, but that was still lost (I had planned to use it to mount my mosquiot net to the ceiling. Instead, I had to suspent the one that was provided from the light in the center of the room, and the other edges from the curtains haging in front of the unscreened windows). I tried using a metal foil wrapper from a scalpel blade, but the adhesive from the tape I placed on top of it quickly dissolved in a bit of halothane that still leaked out. I then tried a junk screw I found that just fit in the round plastic peice that was where the leak occurred. I could hear the theme from MacGyver in my mind as the leak stopped :) (My swiss army knife was still in JoBerg).

They now no longer need any O2 becuase the new machine has an O2 concentrator that can make 7-8 liters/min of O2 and costs about 15 cents per hour to run. When the electricity fails (and it usually does nearly every day), room air is autoatically pulled into the draw-over vaporizer. I made them shut off the concentrator and use room air only while monitoring the pulse-ox. I never saw O2 sats lower than 97 on room air. They will no longer need to buy O2 for the ORs, and it they can get a way to compress the O2 generated there the hospital, they might never need to buy it again... might even sell it to other facilities, and the machine end up paying for itself. Sweet :)

Yes, much of what you think of Africa is true. Yes, it's dirty, hot, and humid. Even in the ORs. Yes, they re-use EVERYTHING. Yes, I saw hemaglobin of 2.9 in a lady with TB and HIV... that was after transfusing 2 units of blood the prior day (they believe she is having a reaction to the ARVs (anti-retro-virals)). Yes, I went without underwear for a week, and wore scrubs. Yes, I did borrow some soap and shampoo, but deoderant is a luxury (at least, based on my own personal olfactory survey of the locals). Yes, I eat mostly the same things every day... often with my own bare *right* hand. Yes, they seem to be facinated by my hair. Yes, one little girl ran away terrified of me and refused to come to her mother's side and say hello. Yes, I bribed the Police with 30$ US after they stopped us once at a checkpoint and told the driver he could either leave his car or his license because we were not carrying red triangles to put on the road in case we broke down (actually, a real possibility)... and yes, he smiled big and let us go. (DEET, 6$. Diesel fuel, 8$/gallon. Freedom from corrupt Police... priceless.) As we drove away I wondered if it was morally wrong to *give* a bribe, or just *take* a bribe. What do you think? Write me! fvcobos@gmail.com

But there is much about it you probably don't understand, the sum of which could fill several books and form a doctoral thesis. For example, you simply cannot understand severe racism until you see it African style. Ever heard of Ruwanda? Remember the Hutu's and Tutsis? Say no more.

The African acapela singing at church is... well, indescribable. I got some of it recorded on video, and will get more as an MP3. I had forgotten how good it sounded (I had been in Kenya 9 years ago and couldn't believe my ears).

I have my one bag now from Lilongwe (The guy at the airport baggage asked me if I was studying Judo... I was wearing scrubs), and am in Lusaka, the capital, for 4 days spread across 2 hospitals. From here we go by Landcruser for 8 hours, then 3 hours by boat on the Zambezi River to Yuka Hospital. It is said to be a place where hyenas, lions and cobras can be found. I won't be looking.

That's it for now. Hasta la Bye-bye.

FVC II