A Plea

Warning: The following blog post contains graphic pictures that may be disturbing to some, and is likely to cause tears, and is also an unashamed plea for money.

One of the things they taught us in medical school and residency was to be somewhat disimpassioned. Don’t get too caught up with your patients, don’t get too personal, don’t empathize too much. I know that sounds heartless, but to do our job effectively, especially in surgery, we can’t identify too closely with our patients. If we did we would never be able to do our job. If we thought too much about the suffering of our patients it could easily get overwhelming and one loses ones objectivity, and then judgment is sacrificed and finally good patient care. That is why we are not supposed to treat family and close friends. That, and because they ALWAYS have the worst complications.

Here in Tchad it would be really easy to get overwhelmed by the suffering we see around us everyday, all day. It isn’t that there isn’t suffering in the developed world, or really wild bizarre pathology, it’s just that it isn’t normal to see it every day, all day. For instance today I had a lady with a huge, I mean huge, breast cancer, the whole lateral aspect of her breast is one big fungating, ulcerated mass. There is no way to get flaps to cover the defect if it is removed, she has an abdominal mass as well, probably a metastasis, and of course lymph nodes under her arm as well. Her hemoglobin is four. I can not remove this mass with killing her because she will bleed to death on the table. Friday I did a upper leg amputation for a young man who, a month ago, was in an accident and broke the end of his thigh bone (femur). The end of the bone came out through the skin behind his knee, taking with it the nerves and major blood supply to his lower leg and foot. So he has foot drop now. He also had 2 inches of dried rotten femur sticking out of the back of his knee, and a small opening on the front of his leg that literally squirted a fountain of pus 2 inches high each time we moved his leg. Thankfully I was able to convince his father that the leg was not worth saving, so we did an amputation and left the leg open.

One evening last week the nurse comes to my door just as we were sitting down to dinner.

“Docteur, a patient is here with a dental abscess he has had for the last two weeks. He is in a lot of pain.”

“Ok, I will come after dinner.”

He had been sick for two weeks, how urgent could this be? So after a nice leisurely dinner I strolled over to the hospital. “OK, Rafine, where is the malade (read “patient”)?

“Oh, he died 5 minutes after I came to get you.”

HE DIED? What kind of dental abscess is that? Not one I want for sure. And this is just the last few days, pretty much every day has its own little surprise in store for me. Oh, I forgot about the guy with the hernia with quite literally half of his small intestine in his scrotum, been that way for a long time. And although this was the largest one so far, the hernias here are ginormous. I can’t imagine having that volleyball between my legs all the time. (For those pictures, visit the surgical pictures page, if you dare, followed by a deep guttural Vincent Price type laugh.)

But twice since I have been here I have been pushed to the edge. Two times I had to blink back the tears and try really hard not to think too much about what it is like for these patients. Both times were for little kids with Burkitt’s Lymphoma. I included pictures so you can share my pain and more importantly their pain. But I have to tell you, pictures do not come close to doing this disease justice. It is horrifically dreadful.

A little girl, horribly disfigured, she just cried and cried all day and night she was so miserable.

A little girl, horribly disfigured, she just cried and cried all day and night she was so miserable.

Burkitt’s Lymphoma is a type of lymphoma (cancer of the lymph system) that is endemic in high malaria areas. It manifests itself usually as a swelling in the face, and if untreated can cause gross malformation of the face and jaw and swelling around the eye. There can also be abdominal tumors. Usually these are in preschool age kids, little ones who can’t understand what is happening to them. They have a hard time eating and drinking because their jaws and mouth don’t work right. They can’t see out of one or both eyes, they constantly drool, they cry, the swelling is uncomfortable at best, painful at worst. They are sickening to look at, partly because of the grotesque deformity, and mostly because the suffering hits you right in the mouth.

I just treated this little guy for the first time this last week.  He too was just miserable.  He has a large abdominal mass and ascites as well, his chances at cure are not as good.

I just treated this little guy for the first time this last week. He too was just miserable. He has a large abdominal mass and ascites as well, his chances at cure are not as good.

But, and this is a big but, it is amazingly treatable, with single agent chemotherapy. Cyclophosphamide works wonders in these kids. It cures over half of them. They get a dose every three weeks until the tumor is clinically gone, then one final dose. The first kid I treated came back for his second dose. He looked normal. The next two, were the two worst ones I have seen. They haven’t come back yet, and they may not, they may not survive, or maybe their parents don’t have the money to pay for treatment, who knows. But it is their only hope, and only help.
Same little guy, side view.  The dark skin hides a lot of the deformity, but it is there.

Same little guy, side view. The dark skin hides a lot of the deformity, but it is there.

Now for big but number two. There is no cyclophosphamide in Tchad. In fact as far as I know, there are only two places in Tchad that kids can get treatment for Burkitts, Bere and Moundou, the two Adventist hospitals. And we have it only because we purchase it in the US and we or our volunteers bring it with us. The stuff, as you can imagine, is not cheap, over $100USD a gram. We usually treat the kids with between one and two grams depending on their weight. Since the medication is donated, we can’t charge for it, which is just as well since no one could afford it anyway.

I have one gram of cyclophosphamide left, Bekki is going to try to get more while she is in the US and bring it back with her. If your heart has been touched and you want to help financially please send your tax deductible contribution to The Clarkston SDA Church, PO Box 548, Asotin, WA 99402. Put on your check that it is for the Africa Mission Fund, for Burkitts Kids. And if you send me an e-mail, or a comment on the blog site that you have donated for a Burkitts Kid, I will do my best to send you a before and after picture of a kid you helped save. Thank you on behalf of all our Burkitts Kids.

For those of you new to our blog please look around at the other pages, the “About” page tells a bit of who we are and our background, the “Definitions” page explains some terms that are used that some of you may not be familiar with, such as GC or AHI. The “Timeline” gives an idea of where we will be throughout the year, and the “Video” page has a video Bekki made of Koza Hospital, where we initially were to be. Soon there will be a new video about Moundou. There is also the Surgical Pictures Page, but be forewarned, it has some very graphic pictures, so if you don’t like blood and guts, stay away from that page. You will also find links to other missionary blogs such as Olen and Danae Netteburg, Jaime and Tammy Parker and others. Finally, if you like our blog and want to receive each new post directly to your e-mail, please sign up with your e-mail in the subscribe box. It doesn’t cost anything, there is no commitment, it just makes it easier to follow us. For our Francophone friends there is a French translation of our blog that you can find at http://gardnersenafrique.wordpress.com.

We welcome volunteers.

-Scott Gardner

Advertisements

Worship

Morning worship under the veranda.

Morning worship under the veranda.

It has been a couple of weeks since I have written, and for that I am sorry, the plan is to write something every week. But I have been wanting to write about worship here in Tchad for some time.

We have a custom, which is typical at most mission hospitals I think, of starting each day with worship. All the staff that worked the night before and the staff coming on for the day, including our nursing students, as well as some patients and patient families, gather together under the veranda for morning prayer. We start with prayer and then one of the staff members or sometimes a family member of a patient, or even one of our nursing students will give the morning devotional.

I came over here with the silly notion that I would probably be asked to preach, teach the Sabbath School lesson, you know impart my Biblical knowledge and wisdom to these people we have come to serve. Well, it turns out they don’t need that. In fact they do quite well without me, which is good because I couldn’t keep up the French that well anyway.

The devotionals are pretty good from what I can tell, well developed thoughts from the Bible, with just the right amount of humor mixed in. Then we have prayer requests, always remembering to pray for the patients, the staff and the families. Often the prayer requests are quite touching as family members ask for special prayer for their loved one who is scheduled for surgery, or is ill in the hospital. It helps remind me that as stoic as these people seem, they really have feelings inside, they just keep it buried most of the time.

After prayer we do the handshake thing. This is an African custom that is done everywhere in West Africa that I have been, OK Cameroon and Tchad. Anyway the first person starts around the circle and shakes everyone’s hand, then the second person follows and so on, so everyone shakes everyone’s hand. It is actually one of my favorite parts. It is a way to personally greet everyone in the group, and say good morning. We do it after church, basically after any gathering. Shaking hands is really big here. It means you have a good relationship.

"THe Handshake" after worship

“THe Handshake” after worship

Church is pretty standard. The good news is that the dress is casual. I cannot wear a tie and jacket here. Not unless they want to take me out in the ambulance. Speaking of the ambulance, we routinely have 15 people that we take to Sabbath School and Church. It is a real blessing to have the room. Sabbath School lesson study first, there are two classes, one in French, one in Gumbai (the main local language). After awhile I get brain fatigue and have a hard time following. But there is a lively discussion, just like at Clarkston. The African Adventists tend to be pretty conservative, but they seem pretty knowledgeable about their Bibles. One thing that is cool is when there are breaks in the action, someone will just start singing, and then everyone will join in. A friend of ours gave us a church hymnal in French so we can sing along a little better. But it is just the words.

Worship in the Moundou SDA Church

Worship in the Moundou SDA Church

A word about the choir, they are a pretty lively bunch. Every song, and there are usually at least three during the service, is choreographed. They sway with the music and dance with their feet. It is pretty cool to watch. They have a drum/guitar combo (see the picture) and homemade maracas that keeps the beat for them. My favorite choir member though, is a little 6 year old girl. She is a choir member in training. She is always on the front row, and is always 180 degrees out of phase with everyone else. When everyone moves their feet left, she goes right, and so on. She is so cute.

The Moundou Church Choir, with our choir member-in-training in the white dress.

The Moundou Church Choir, with our choir member-in-training in the white dress.

The pastor speaks pretty good English, and he is on our hospital board, so we have gotten to talk together quite a bit. We talk in French until I get bogged down then he tells me what he said in English. It works.

Our stringed drum

Our stringed drum

???????????????????????????????Worship is the same and yet different everywhere we go. I find worshipping with my Tchadian brothers and sisters to be a huge blessing, and there is much I can learn from them. Enjoy the pictures.

For those of you new to our blog please look around at the other pages, the “About” page tells a bit of who we are and our background, the “Definitions” page explains some terms that are used that some of you may not be familiar with, such as GC or AHI. The “Timeline” gives an idea of where we will be throughout the year, and the “Video” page has a video Bekki made of Koza Hospital, where we initially were to be. Soon there will be a new video about Moundou. There is also the Surgical Pictures Page, but be forewarned, it has some very graphic pictures, so if you don’t like blood and guts, stay away from that page. You will also find links to other missionary blogs such as Olen and Danae Netteburg, Jaime and Tammy Parker and others. Finally, if you like our blog and want to receive each new post directly to your e-mail, please sign up with your e-mail in the subscribe box. It doesn’t cost anything, there is no commitment, it just makes it easier to follow us. For our Francophone friends there is a French translation of our blog that you can find at http://gardnersenafrique.wordpress.com.

We welcome volunteers.

-Scott Gardner

Sabbath

It is Sabbath evening here. Bekki and I have just returned from our pre sundown walk. We wait until it cools down a bit then head out for 45 minutes or so down the streets around the Surgery Center. Today we walked on the newly paved road that runs along the river. The last two weeks have been a whirlwind of paving. There are all sorts of paved streets here now. Hopefully, it will relieve some of the congestion on the main road, which previously was the only paved one.

It has been quite a Sabbath, not exactly how I would have scripted it, but I don’t write the script for my life anyway. Yesterday we instituted some changes intended to make this more like a surgery center rather than a General Hospital. One was that we aren’t doing consults on Sabbath anymore. Very few , of the consults are emergencies, so it was usually just like any other day, except I try to remain scarce. So now from Friday mid-afternoon until Sunday morning we are closed for consults. So when I got home around 2 yesterday, I thought great, 36 hours of peace.

An hour later, tap-tap, “Docteur”. “Yes, Carlos, what is it?” It was moto accident, wow, something new, Not, with an open tib-fib fracture (lower leg), wow, something else new, Not. But this had just happened, like this afternoon, Wow, that really is something new. Most of the open fractures show up 5 days after the accident with the wounds tightly sutured shut, so all the debris and dirt will stay in the wound, and now pus is starting to pour out of the bone. But this time, a fresh open tib-fib fracture, woo-hoo! Turns out he had gone to the regional hospital first (they are a kilometer away) and they had sent him right over. This is great, they are not holding on to the patients for a few days, however, next step is to get them to take the x-ray while he is there. So we sent him back for the x-ray, sure enough, a nice, not too badly comminuted mid shaft tib-fib fracture. I looked at the wound, just a couple of small puncture holes, so not too dirty. This is a perfect case for an intra-medullary nail, and it is still relatively early, should be able to get everything in order to start the case right after supper.

Shortly after 7 pm we had prayer and I made the skin incision. The accident had done pretty much all the dissecting for me, I didn’t even have to clean off the bone ends too much. We irrigated everything out, no dirt, sand, money or other items in the wound, and prepared to put in the nail. Pretty much everything after that went wrong. At one point the nail was stuck, I could not get it to go in any further and we could not get it out. I had visions of sending this guy home with 2 inches of a tibial rod sticking up out of his knee. Finally after a couple of hours we had the nail screwed in place, and his leg was at length with good rotation and alignment. Whew, another case done by the grace of God. We had just let the tourniquet down, and there was the usual muscle bleeding, which stops pretty quickly, but its not stopping, and it is a lot of blood, and it just keeps coming. Finally after another 30 minutes I find this little vein branch way back under and between the tibia and fibula, where it had torn off during the accident, got it tied off, and miraculously the bleeding stops. Praise God again.

On my way out the door I stop by to see a 15 year girl with abdominal pain who had come in around 4 pm, she is the cousin of one of our nurses. After some fluids she is resting comfortably. Not having CT scans for these mystery abdominal pains is a pain. About the only reliable piece of history is how long it has been hurting for. When I ask where it hurts, I always get this look like how stupid are you, Docteur?, it hurts everywhere. Physical exam is also incredibly unreliable, I have had patients with a soft benign abdomen that was full of pus, and others with frank peritonitis on exam who ended up with a negative laparotomy. So for those who present with abdominal pain that need hospitalization, I check a hemoglobin, malaria test, typhoid test, and urine dip test. That pretty much uses up my lab resources. Most of them are dehydrated so I give them Ringers Lactate, start the malaria and typhoid meds as needed, and watch them overnight. If they are really septic I take them to the OR after resuscitation, but that hasn’t happened yet. Most of the time the pain is a combination of malaria, typhoid and dehydration and by morning they are much better. If not they get a laparotomy that day.

My 15 year old had malaria, but by this morning she still had peritoneal signs on exam, so I got things going to do a laparotomy on her this afternoon after church. The only other thing I knew was that she had a 5 cm ovarian cyst on ultrasound, but I didn’t think that should cause the peritonitis.

We had a full ambulance going to church, 15 was the count I believe, and since the OR crew was in the ambulance with us, we all just headed over to the OR together when we got home. Bekki stayed home and made lunch. When I opened her up I found pus, but no foul odor, so I looked around, no perforated ulcer, no holes in the bowel. The appendix was inflamed but didn’t look gangrenous, and then this big cyst in the right ovary. After taking out her appendix I aspirated the cyst, pure pus. Apparently an ovarian abscess that had partially ruptured and caused all the pelvic mess. Her left ovary and tube were fine, so I took out the abscessed right ovary, cleaned her up and got her closed. So much for my 36 hours of peace and quiet.

But it was all very satisfying anyway, one less floppy leg, one less purulent abdomen in the world after this Sabbath. And OK, I will be honest, it is not all bad to spend the hottest part of the day in the OR in the air conditioning.

Furthermore, Thursday morning I terminated OB at the Surgery Center (notice it is a Surgery Center, not a General Hospital, not a Maternity Center), and since half the nurses know less about OB than I do (a very disturbing thought), and since I can hardly keep up with the surgery cases, let alone having to do the after hours c-sections for the regional hospital, I told the staff that I was not doing OB. I don’t think it was a very popular decision, but here is the deal folks, you can do OB, or you can have a surgeon, or you can convince James to come back, but I am not doing OB. My stress level plummeted. The next morning, as I expected, our mid-wife (who has not been working as a mid-wife) quit. That forced the other major change I wanted to make. We no longer have the staff to run a 24/7 ER. So now we have set consultation hours, and no consultations on Sabbath or at night. So much for easing into the job and not making any rapid changes.

So as we are serenaded by our beloved Imam, we wish you all a very blessed Sabbath.

For those of you new to our blog please look around at the other pages, the “About” page tells a bit of who we are and our background, the “Definitions” page explains some terms that are used that some of you may not be familiar with, such as GC or AHI. The “Timeline” gives an idea of where we will be throughout the year, and the “Video” page has a video Bekki made of Koza Hospital, where we initially were to be. Soon there will be a new video about Moundou. There is also the Surgical Pictures Page, but be forewarned, it has some very graphic pictures, so if you don’t like blood and guts, stay away from that page. You will also find links to other missionary blogs such as Olen and Danae Netteburg, Jaime and Tammy Parker and others. Finally, if you like our blog and want to receive each new post directly to your e-mail, please sign up with your e-mail in the subscribe box. It doesn’t cost anything, there is no commitment, it just makes it easier to follow us. For our Francophone friends there is a French translation of our blog that you can find at http://gardnersenafrique.wordpress.com.

We welcome volunteers.

-Scott Gardner