A TALE OF TWO BOYS

In my years of practice as a general surgeon in the United States I saw my share of patients and families who made decisions and had dearly held beliefs based on superstition, misinformation, just plain bad information, and old wives tales (if you expose cancer to the air it grows faster was the most common one, and I know some of you are thinking, “Wait a minute, that is not true?” No it is not.). But like everything else I have experienced living here in Tchad, I have never experienced the superstition, wives tales, and closely held beliefs in the concentration and the intensity that I have here. There are lots of sociologic and anthropologic reasons for this, but it doesn’t change the fact that every day I witness another bad decision, based on faulty premises and/or bad logic, which has predictably bad outcomes.

After my volunteers have seen any number of heart wrenching cases of badly infected or dead limbs from accidents that happened weeks before, or cancers so advanced we can do nothing more than prescribe pain pills and hope they die soon, they all, to a man (or woman) ask me, “Why do they wait so long? Can’t they see there is a problem and that they need to get help?”

Well the answer is, “Yes, they can see it.” But I refer you to paragraph one. With the additional information that although getting emergency health care is free, getting to it is not. So with the superstitions, the misinformation, the poorly trained health care workers (doing the best they know how), the old wives tales, the urban legends and the transportation factor all built in, it is not wonder it takes days or weeks to get to appropriate care. And with that in mind, I bring you “A Tale of Two Boys,”

KOUMDA

“Maman, Maman”, three year old Koumda screamed at the top of his lungs from somewhere under the pile of bricks, “Maman, la maison est tombé, et ça fait très mal, Maman, aide moi.” (“Mama, the house fell on me and it hurts really bad, help me Mama.”)

It is rainy season, and a consequence of not having the money to afford kiln dried bricks is that you have to use sun dried bricks to build your house. In Tchad bricks are made in exactly (and I mean exactly) the same way the children of Israel made bricks for the Egyptians 3,400 years ago. Sun dried bricks are cheaper, but they tend to disintegrate in the rainy season. So, during the second or third rainy season walls start to collapse, sometimes suddenly, sometimes hurting people. Little Koumda was in the wrong place at the wrong time and the wall fell on him breaking his leg just above the ankle.

His parents quickly took him to the nearest health center, staffed by a nurse, who assessed him and made the correct diagnosis, open fracture of the left tibia and fibula. He (or she) then did what they are trained to do with all open wounds, he carefully closed the wound, making sure all the dirt and brick pieces were kept inside where they couldn’t get out and attack anyone else. The fracture was stabilized with a Chinese splint.
This was on a Tuesday, by Friday Koumda predictably was draining pus from his nicely closed but poorly stabilized open fracture wound. His parents took him to our sister hospital, Bere Adventist Hospital, where Dr. Olen Netteburg (a great guy and my nephew) opened the wound, cleaned it out, started him on antibiotics and called me. His surgeon (also his father-in-law) was on furlough in the US, so not available. Olen was able to convince the family to come to our surgical center in Moundou to try to save Koumda’s leg.

About three days later, Koumda and family showed up on our doorstep. Thanks to the care he got at Bere, the leg didn’t look too bad, although it still had pus coming out and definitely needed good stabilization. It wasn’t clear if the bone was still alive, but it wasn’t clearly dead, so we felt like it was worth it to try to save the little guys leg.

Because Olen had given me a heads up I had been able to search through our supplies and find material small enough to put an external fixation device on him. We took him to the OR and we prayed, cleaned up the wound, and we prayed, cut away the dead and infected tissue, and we prayed, got the bone reduced, and we prayed, put the ex-fix on him to keep it reduced and then tried to cover the fracture with tissue to help it heal, and then we prayed.
The first thing Koumda did after surgery was to prop his newly reduced and ex-fixed leg on his other knee. I thought, “OK, it must not hurt too bad, this hopefully is good.” He then promptly broke down the flap I had tried to make and the bone and fracture were again exposed. Pus continued to come out of the wound, but not a lot, and each day it seemed better.

Koudma with the  little pediatric ex-fix on his leg.

Koudma with the little pediatric ex-fix on his leg.

Today when I made rounds, Koumda and I worked some more on his high and low fives, and then I changed his dressing. The donor site for the flap is healed, the bone is now completely covered with healthy red tissue, with no pus. He has no pain, he still likes to cross his fixed leg over his other knee, and he is cute as can be. Koumda should, by the grace of God, do just fine, his fracture doesn’t involve his growth plate, and so he should grow normally.

YASSINE

Ten year old Yassine was riding on a moto, which is how most people get around here. I don’t know who he was with, but there was an accident and Yassine fell off. For some reason it is the left tibia and fibula that are most often fractured in moto accidents, and Yassine is no exception. Like Koumda he suffered an open fracture of both the tibia and fibula. Like Koumda, his family took him to the nearest health center where his leg was carefully assessed and then just as carefully sewn up, making sure all the dirt, leaves, rocks and oil were kept inside.
In a few days, surprise, surprise, pus was pouring out of his wound, and then it completely broke down. Unlike Koumda, Yassine’s family kept him at home for two weeks before they finally came to us. He arrived when I was in N’djamena and when I got back and took him to the OR and took off his dressing my heart sank. The fracture was not too bad, it was a clean break, but the bone of the distal end toward his foot was completely stripped of tissue. The wound was dirty, full of pus and dead and dying tissue. I had told the family we would try to save the leg and the bone wasn’t absolutely dead yet, so we prayed, we debrided dead tissue, we prayed, we reduced the fracture, we prayed, we got the ex-fix on, prayed, and I tried to get some healthy tissue to cover the bone with, and then we dressed the wound and prayed.

I warned the family that it was in God’s hands and that we had done all we could. When I made rounds today and touched under his knee to lift up his leg so we could take off the bandage he screamed. I thought I could feel a bit of crepitance (feels like Rice Krispies under the skin), which is a sign of a very bad infection. When I got his dressing off my heart sank for the second time. The flaps had all completely broken down, the wound was full of pus, and the bone was completely exposed. There was no doubt that this attempt had completely failed. In fact it was to the point that he needed that leg off sooner rather than later or he was going to be septic and die. The family is Arab so Patrice, our hospital nurse explained to the family in Tchadien Arabic that the bone was dead, the wound was very badly infected and to save his life we needed to amputate the leg. When his mother heard this she ran screaming from the ward. We explained to them that we would use funds from the US, from Restore a Child, to pay for the operation, as they had already paid some for the first operation. The response was the same we always get, “We must hold a family council and then we will decide and tell you.”

This afternoon Patrice found me and told me the family had met. One of the big brothers told the family that he (the big brother) was all powerful and he would get the leg healed and Yassine would again walk normally. So the family refused the amputation. We took off the ex-fix as it is now useless and dressed his wound one last time and sent him home.

Hopefully they will take him to another hospital and will get a second opinion that he needs an amputation. But as is usually the case, the family will search until they find someone who will promise to heal his leg, and will care for him with poultices, rabbit fur and only God knows what else until Yassine becomes septic and dies.
Why does God answer some prayers and not others? That I will not know until heaven. But I suspect it has a lot to do with our free will, and with our superstitions, deeply held beliefs, and prejudices.
As he was being loaded into a car to leave, one of my nurses came into my office. She was so angry she was trembling.

“Doctor”, she said, “The little boy you operated on, the one with the infected leg who needs an amputation, his family is taking him home. Do you know that? He is going to die if they take him home, he doesn’t have to die.”

“Deborah”, I said, “I know, and I am angry too, but I cannot stop them, it is always their choice.”

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 as well as the videos she has made of 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 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.

We welcome volunteers.

-Scott Gardner

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THIS OLD MAN

There is an old pre-school song, “This Old Man”. It goes like this for those of you who don’t remember:

“This old man he played one, he played knick-knack on his thumb….
This old man he play two, he played knick-knack on his shoe….”

And so on up to ten.

I have a new verse to add, “This old man he played last, he played knick-knack on his cast….”

He hobbled into my office 2 days ago. An old man who had broken his leg just above his ankle eight days before. Amazingly it was a closed fracture, there wasn’t a lot of swelling, at least not now, and his x-ray didn’t look too bad. Except that it was too low to get a nail in. At first I thought about plating it, and even filled out the operation form, but then when I examined him, I thought, “This guy will do fine with a cast. We can reduce the fracture fairly well, cast him and it will heal OK. He won’t win any races but he will have his leg, without infection and he will be able to walk.”

I showed his son the x-ray and explained to him what I wanted to do and why, and also pointed out it would be a lot less expensive. His son agreed and then explained it to his father in Ngombaye. He agreed, this was great, everyone agreed, me, the family the patient. It was a moment to be savored.

That afternoon McKennan Cook (our med student from LLU) and I put a long leg cast on him. It looked great, ankle was in alignment, all was right with the world. I told his son we would keep him overnight, and in the morning when the cast had cured and hardened we would teach him to walk with crutches and send him home. Great plan.

In the morning we saw him in the Salle de Reveil, and felt his cast. It was still wet, and the back part was mush. That was weird. It was Tchadien casting plaster, but still this was not how it usually is. So we watched it throughout the day yesterday. It never really set up in the back, but it did in the front. Last night I told McKennan we would have to redo it this morning if it didn’t set up during the night.

This morning we came in to find the cast starting to disintegrate, and we found a very annoyed nurse who complained that she couldn’t keep the malade (patient) in bed during the night. He kept getting out and crawling all over the floor. That explained the cast falling apart.

So this morning McKennan and I redid the cast, adding 5 more rolls of plaster. This time it set up quickly and the cast was already hard by the time we left. Since it is Sabbath I only see emergency cases, but when I got called over to see a 12 year old with a fresh femur fracture, I saw my old man, sitting up on his bed with his cast hanging over, propped up on the side bar of the bed. I checked him out and he had already managed to make the back of his once hard cast mush again.

He told the nurse he wanted to go home, and she told me once he gets home he is going to rip the cast off. I believe it, because when I left he was standing on his cast, which will be destroyed by morning. Long ago when I was a baby doctor I learned never to argue with a patient who didn’t want me to care for them anymore. If they wanted a referral to Portland, Seattle or Spokane I was always happy to do it for them. Here when a family or patient want to go home, or refuse a treatment I let them go. I don’t argue or try to convince them otherwise. I simply give them my advice, and why, they can take it or leave it. Same thing with this old guy. If he is going to destroy my cast, I would rather have him do it at home where I can’t see it then here, where I have to watch.

I left really annoyed, he was destroying my hard work. I was happy I hadn’t operated on him and tried to plate the fracture or use an external fixation, only God knows what he would have done with that. But I was still annoyed. I told McKennan what had happened to all his work (he was the official leg holder and reduction holder), and then I realized or thought about why.

The older people here in Tchad have no frame of reference for casts, or surgeries for internal or external fixations. The only frame of reference they have is the traditional healer, with leaves, rabbit fur, cutting and bleeding, and Chinese splints. All this Western stuff is scary to them. The cast is heavy it is hot and uncomfortable, it restricts movement (at least for a bit, until he destroyed it), it is ugly. There is no way to convince him that this cast is going to help his leg heal. “How?”, he would ask. How is this ugly white thing on my whole leg going to make my ankle better? Good question, it just is. As we loved to tell Jon and Lindsay, “Because it will, that is just the way it is.”

But it takes faith to believe that it will, it takes faith to believe that putting up with this misery for 6 weeks will result in a miracle. And how can I expect him to have faith in someone who doesn’t look like him, who is younger, who is clearly not from around here, and who can’t even speak properly. Have to admit, I wouldn’t have much faith in me either.

All that being said, this old man who played last, who played knick-knack on his cast, is going to end up a cripple, with a deformed ankle at best, and never be able to walk well again, if at all. Just because he didn’t have faith in someone who wasn’t like him, someone different, who had different methods, different ideas, despite his efforts to explain all that to the old guy.

And then I thought, wait, this sounds familiar. Haven’t I heard of Someone who wasn’t from here, Who came with different new ideas, Who spoke different words than we had heard, Who came with a different way.

“Just have faith,” He said, “Believe what I am telling you even if you don’t understand it all, and you can live forever.” Hmmm….

“This old man, he played last, he played knick-knack on his soul…and he lost it.”

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 as well as the videos she has made of 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 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.

We welcome volunteers.

-Scott Gardner

System Fail

He died about 7 pm last evening. I don’t even remember his name, just another poor Tchadien. I do remember seeing him walk in though. He was brought in by pickup and walked in the back door, slowly, hunched over, holding his stomach. The other person brought in with him had a broken elbow and dislocated shoulder, from another accident, he had blood on bandage so he got seen first.
This young man, I will call him Mahamat, which has about an 80% of being right. Mahamat was in a fight, I was told, and he got stabbed in his left butt cheek. Typically not a lethal blow, but he was holding his abdomen and on exam had peritonitis. It was a pretty easy call, he needed an operation, today. In cases like this I write on their operative form, “Cas d’urgence”, which means it is an emergency and we can set up an engagement or payment plan. Frankly most of our non muslim patients don’t have 150,000 francs in their back pocket, ready to pay for their surgery. So paying for the surgery was not a problem.
We got started on his operation about 5:30 or 6. After the spinal anesthesia we turned Mahamat over and I stuck a finger in the stab wound, trying to figure out where it went, and to see if maybe he perforated the rectum. No stool, but lots of thin watery bloody fluid. I figured the knife must have gotten his bladder. We turned him back over and opened up his abdomen. Lots of bloody fluid there too, and sure enough a knife sized hole in the top of his bladder.
I got that closed but then it occurred to me that this didn’t make sense, how did the tip of the knife put a hole there in his bladder? That and the fact that red watery fluid kept welling up tipped me to the fact that there probably was another hole in the bottom of the bladder. So we opened up the dome of the bladder and sure enough, there it was in the bottom, another hole, the entrance hole in fact. We closed that hole and the dome of the bladder leaving a catheter in place. Checked the small bowel and reassured ourselves that somehow he had missed the rectum.
He still seemed to be bleeding from deep in the pelvis, but not a lot, so I closed the peritoneum and left a drain in the stab wound in his butt. I was worried about the left ureter as the hole was right where it should be, but figured he would drain urine out the drain tube if it was divided.
In the morning, his last morning, Mahamat looked OK, relatively stable, and not a lot of drainage out the drain tube, but lots of non-bloody urine out the catheter. Our lab was now open so we checked a hemoglobin on him. 5.8 (normal is 12-15). Very very low. That explained his tachycardia, and why when he sat up he nearly passed out. I ordered a unit of blood on him about 11 am.
Mahamat was in the Salle de Reveil, our ICU/ER/PACU, so I walked past him all day. He just laid there with a glazed over look in his eyes, really not moving or saying much. His abdomen was soft and not tender except around the incision, and it wasn’t distended. I couldn’t see any signs that he was still bleeding or that he was leaking urine. But I noticed the distinct lack of blood hanging from his IV pole, all day, no blood. I mentioned it to the nurses several times, asking about the transfusion. The only answer I got was we had no blood his type in the fridge, and he had only one person with him, his father, and he couldn’t donate blood.
About 5:30 in the evening his mother came from the village and we got word that they would like to donate blood now. I asked our lab tech if she would stay late to do the type and cross. She called me into my office and told me that we didn’t have the reagents to check the Rh factor, the + or – part of a blood type. Kind of important. Give the wrong one and people can die. She took a moto taxi over to the central hospital to find the reagent, and was successful, she brought some back with her. Mahamat died while she was trying to get the blood from his parents. It was about 7 pm.
We have patients die here all the time, most of them are almost dead when they get here. This death though is the most glaring example of a huge fail in the medical system as found here at the Centre Chirurgicale Adventiste de Moundou. In the US it would be listed as a preventable death at the trauma morbidity and mortality conference. It might even make the news, “Young neglected man dies while waiting for over 24 hours for a blood transfusion.”
Frankly, they would be correct. Mahamat died of neglect, he died because of negligence, he died because of terrible medical care. He died because our blood bank had one bag of blood in it. He died because he had only one person with him, and that person didn’t want to give blood. He died because we ran out of the necessary reagents to do a cross match. He died because the doctor here practices veterinary medicine. I patch them up and ship them out to wards where they either get better or they die. I make rounds there only on weekends, so our two nurses provide the medical care in the wards. I am too busy counting money, checking receipts, fetching betadine and bleach and gloves for the staff, figuring out why the power is out for the 4th time today, and why we have no water now, and taking care of the bleeding accident victim that just came in to have time to worry about someone I operated on yesterday.
But as any good quality control person will tell you, it is only bad if you didn’t learn from what happened and change the system. And they would be correct. But reality in Tchad is that there will be no review, no mortality conference, no root cause analysis, and nothing will change. His death will not make a difference in how things are done, or be a stepping stone for quality improvement. As long as third world hospitals in backwater places like Tchad are understaffed without adequate resources, including human and material resources many more like Mahamat will die of neglect, waiting on a gurney for care that won’t come before it is too late.
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 as well as the videos she has made of 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 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.

We welcome volunteers.

-Scott Gardner