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,”
“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.
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.
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