Will To Live, Part I

We are still stuck in the US, in Tennessee actually, as we await word from the General Conference as to whether they will let us return to Moundou or not. We had a window of 4 days without any appointments and so decided to make the most of it and headed to the Smokies for a few days of just the two of us. It has been really nice, small, private cabin in the woods, long walks in the
National Park, sleeping in…

Bekki in front of our cabin.  (just kidding, actually an old cabin in the NP)

Bekki in front of our cabin. (just kidding, actually an old cabin in the NP)

Shortly after arriving however, we headed out for a walk on the road leading to our cabin. Bekki headed out first and I was right behind her. However, as I was trying to get out the door she was rather hurriedly coming back in. It took a few seconds to realize the source of her haste. Just outside our front door, not 15 feet away were bear cubs raiding the garbage can, which is inexplicably not well contained. Momma bear was not far behind and as we found out was rather protective of her 3 cubs. They finally ambled off and we commenced our walk. I carried a big stick, and reassured Bekki that I was not worried, I did not have to outrun the bear, only had to outrun her.

Our little bear friends

Our little bear friends

So we returned to our cabin in fine shape. Now it must be told that our cabin is at the end of a 100 foot long lane, and who should be between us and the cabin. Yep, Momma and the three bears. We made rather quick acquaintance with our neighbors at the head of the lane. They kindly drove us the 100 feet to the cabin door after the bears once again ambled off. Bekki promptly moved the refrigerator in front of the door for the night.

I wrote the following (it is Part I of a 2 part series) in Abidjan. I am hopeful we can take a full box of supplies back with us when we return.

WILL TO LIVE PART I

As a physician I have always been amazed at how powerful our mind is. The control our mind has over our bodies is incredible. It is emphasized by the well known “Placebo Effect”, but is also demonstrated by our “will to live”. It is that inner desire to stay alive that allows some people to stay alive well beyond their normal physiologic capabilities. It is also the lack of said will to live that causes people to die we before their time, without direct suicide or euthanasia.

Shortly after arriving in Tchad, James Appel told me that if you tell a Tchadien he or she is going to die, they will die, just like you said, sooner rather than later. I once had an older man, probably in his sixties (really old here) who had hepatitis. He came in with fairly vague nondescript symptoms, some abdominal pain, fatigue, and jaundice. I checked his gallbladder, no stones, and reconfirmed the hepatitis. With the jaundice it seemed clear that his hepatitis was active. We treated his malaria and typhoid and he just didn’t get better. Finally after 2-3 weeks he was demanded an explanation. I first talked with his son who is a nurse, and then with him, surrounded by his family. I explained that his hepatitis was active and there was nothing I could do to reverse that and that most likely he was going to die from this. All I could do was treat the symptoms. I had in mind that he would slowly dwindle away over the next several weeks. His vital signs were strong and other than feeling weak, no particularly alarming symptoms.

That was about 5 in the afternoon in the Salle de Reveil. Shortly after I went home for supper. I had to come back about 7 pm, two hours later to get something from my office which is just off the Salle de Reveil. I noticed his bed was empty, so I assumed the nurses had transferred him back to the general ward. The next morning on rounds he wasn’t in the ward so I asked the nurse where he was.

“He died last night, Docteur” she said, “About 6 pm, an hour after you talked with him.”

I was stunned. I said he was going to die, but I didn’t mean right this minute. Needless to say I try to be careful what I tell people around here.

This summer I have witnessed an extraordinary will to live in two patients, and I would like to share their stories with you.

CLEMENCE

Clemence, as she improved and got stronger.

Clemence, as she improved and got stronger.

Clemence came to us just a couple days after we got back from furlough. She had had a cesarean section in December to remove a late term fetal mortality. An all too often occurrence here. Since then (it is now late June), Clemence just didn’t feel well. Vague abdominal pain, a little nausea, fevers, and loss of appetite, followed by significant weight loss. On exam she had a small opening on the left abdomen over a firm area that had a small amount of pus draining from it. The center of her c-section wound was also slightly open with a drop of pus on the skin.

I took her to surgery confident it was just a superficial post op infection we could get drained and cleaned up with minimal muss and fuss. She was very thin, but then so are most of our patients so I gave that little thought.
At surgery I found a superficial abscess cavity, but no explanation for it. After draining that, I looked at the wound, also expecting a superficial infection. I probed the wound with my finger, going deeper and deeper until finally I realized I was in her abdomen. OK, so it is not superficial, probably just an infection around the uterus. I opened up her abdomen big enough to get my hand in there and started feeling around. Actually it seemed pretty clean, not much infection to be found. But something was nagging at me, I couldn’t account for the swelling on the left side of her abdomen, it had not disappeared when I drained the abscess. So I kept working my hand over and over toward the left. Finally I found it, something that shouldn’t be there, so I pulled and tugged until a lap sponge came out. She had had this lap sponge in her abdomen for 6 months. No wonder she didn’t feel well. But as I looked at the sponge my stomach flip-flopped. It looked like stool (poop) on the sponge. Maybe it is just from old old infection, I vainly hoped, but as I explored further, it was clear there was more wrong than just a retained sponge.

I extended the incision again until I was able to see the problem. A good sized hole was in her left colon and the small intestine had tried to cover up the hole and so the two had grown together. I ended up having to remove parts of the large and small intestine and suture them back together. I checked for leaks before closing and then closed her up, hoping and praying she would heal the anastomoses. I knew I should put in a diverting ostomy, but ostomy care is so difficult here, I just dreaded that thought.

Clemence did well for about 8-10 days. One morning on rounds I took off her dressing to be greeted by pus from her incision. I didn’t even fiddle with it, she went straight to the OR where I found her small intestine anastomosis breaking down. I put a tube in it, in an attempt to create a controlled fistula. It didn’t work. Over the next three weeks there were several more operations as I did everything I could to avoid an ostomy.

During this time Clemence barely ate or drank. We kept her alive with IV fluids. She got thinner and thinner, until she was literally skin and bones. I left her abdomen open. Now it is not uncommon for me to leave the skin open, but I left her abdomen open so we could dress it and get the accumulating pus cleaned out. We usually gave her some sedation for the dressing changes, but she would still cry out during them. But never once did she try to fight us as we took her to the OR and started the dressing change. She just layed there and suffered day after day as we fought infection and nonhealing intestines. Every day when I came in I expected her bed to be empty. I just did not see how she could survive, or want to survive. I expected her to come down with malaria, but she never did. She would try to smile when I told her good morning on rounds. She refused to give up, and so we kept working with her, day after day.

Finally the day came when I ran out of options and I was forced to do a diverting ileostomy. It was a little over a month from her original operation. Up to this point the colon had not leaked, but now as I carefully inspected it, I found that the sutures were starting to deteriorate, and after a month there had been absolutely not one bit of healing at the tissue level. I re-did that anastomosis and made a makeshift loop ileostomy, wondering how I was ever going to close it.

Now as you are no doubt aware, an ostomy requires an appliance or bag to go over it to collect the product the body produces. One of the reasons I had put off the ostomy is that when I looked for the box of supplies I could not find them, anywhere. But the week before I did the ileostomy on Clemence the box of supplies showed up in my office. I had loaned them to another hospital in April and they finally returned them. I had totally forgotten about it, but God had not.

Any of you who have dealt with stomas, either your own, a family members or as a nurse, know that, especially with an ileostomy it is important to get and maintain a good seal around the stoma. Otherwise the bag leaks and the skin breaks down. It is always hard to achieve that, especially with someone really fat or someone really thin (read concentration camp emaciated). So we had every bit of difficulty I expected and over the last month have blown through our ostomy supplies. (Those of you who are into the gross pictures can find a picture of her wound and ostomy on the Surgical Pictures page.)

Diana told me when we were down to the last appliance. We don’t have a volunteer coming for two months. I didn’t have a clue what to do for this poor woman with the incredible will to live, who had proven that she deserves every possible chance.

Fortunately for Clemence I married an incredibly smart, resourceful, stubborn and pushy woman. The conversation went something like this.

“Scott, I just realized the team from AHI in California are going to meet us in Abidjan, Ivory Coast next week.”

“Yea, so what”

“Scott, they can bring ostomy supplies with them and we can bring them back to Tchad with us.”

“Rebecca,” I said in my usual patient, sunny, optimistic voice, “There is no cotton-picking way. First I am sure they are already full with things they need for the conference. Second they are no doubt already crazy busy trying to get last minute things done. They will not have the time to get supplies together, do not bother them.”

Now my wife has read Paul’s counsel to women on obeying their husbands, she just doesn’t very often buy into it.

As I write this I am sitting in our apartment in Abidjan next to a suitcase full of ostomy supplies brought over to the Global Health Conference by the team from Loma Linda. They busted their butts, along with everything else they had to do, to get supplies together for one little malnourished woman deep in the heart of Africa. A woman who just won’t give up.

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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MY BIRTHDAY

I hate my birthday. For one thing at my age it means I am a year older. It meant the same thing when I was younger, but then it was cool and great to be a year older. Now it just means, well I’m getting older. But really the biggest reason I have come to hate my birthday is that it is one of the two days of the year that will “Live in Infamy” in the American psyche. The other day is December 7. Now even those of you who don’t know me well can guess what my birthday is, yea, 9-11. September 11, now a national day of mourning. It is kind of hard to get worked up about your birthday when the entire country is remembering a horrid, dreadful, cowardly act of infamy.

So it was that nine days ago, on my birthday, I was not in a particularly good humor. Work that day didn’t help things much. The entire government was on strike, including the central pharmacy where we buy most of our medications, so we still were not able to restock on badly needed antibiotics. Then just the usual petty annoyances of trying to diagnose and treat patients without either proper diagnostics or medications. That and just the general misery that we are constantly surrounded by, the man with the necrotizing fasciitis (flesh-eating bacteria) on his neck and chest from his dental cavity, the old man in the coma, the patients without limbs and on and on. Most days I can push it aside and just get the work done, but that day it just kind of enveloped me.

When I started surgery it didn’t get better. I had a pediatric hernia to do, the surgery pack had no small delicate instruments in it, so I was trying to find and remove the hernia sac with adult sized forceps. The rest of the surgeries were more of the same, surgical packs with three pairs of needle drivers and no scissors, other packs with three pairs of scissors and no needle drivers. It seemed like the anesthesia didn’t work right on most of the cases, so there was a lot of moaning (both me and the patient), and movement during the operations. It really wasn’t significantly different than any other day, It is just that on this day the irritation was more acute.

And so it was that my thoughts turned sour, “God get me out of here.” Really how can I be expected to practice any kind of medicine, to do surgery, in this environment. I was surrounded by a lot of negative energy, much of which I was creating myself. The wishes of “Joyeux Anniversaire” (Happy Birthday), instead of brightening my mood only made it more dark. I made it through the day and that evening Bekki had planned a nice little birthday celebration. A couple of missionary friends came over and we had a nice dinner together followed by an evening of singing and fellowship as we welcomed the Sabbath together. I have to admit my spirits were lifted, my thoughts of wanting to quit and go home were washed away and when we went to bed that night all was well.

Sabbath morning September 12 our world was turned upside down. Top of the list of e-mails that had come in during the night was another travel advisory from the US State Department STEP program. Now we get these every 2-4 weeks, and they have not changed much in the last 2 years. In fact according to those in Tchad longer than us, they haven’t changed much in 10 years. This warning though started with, “It is recommended that all US citizens leave the country of Tchad as soon as is feasible.” What? Why? What happened? Bekki got on BBC and Al-Jezeera looking for news, nothing. I soon got a call from the missionaries in Bere, as we all were trying to make sense of what was going on and what we needed to do. Olen woke up John Thomas in the General Conference (GC) in Washington DC and the crisis management team there was activated. I went over to the hospital and talked with David my administrator, nothing, all was peaceful and quiet in Tchad.

At 9 am the five of us ex-pats met in our living room. We shared the e-mail with our volunteers. The only thing clear at that point was that Danny had to go home. I couldn’t take the responsibility of keeping a student missionary in Tchad with that kind of advisory. What was to happen to the rest of us was really up to the GC. In Bere they were going through the same process, with the same angst.

The e-mail from the State Department put us in a real pickle. It gave no reason for the sudden evacuation recommendation, and from what we could tell all was Tchad was internally peaceful. Did the State Department know something no one else knew? Was this our window of opportunity to leave (akin to the Chirstians in Jerusalem in AD 70)? If we waited till something did happen would it be too late? Decisions had to be made quickly without adequate information. Sometime early Sabbath afternoon we received word that the GC had decided to take us all out of Tchad.
The next 72 hours are a blur in my memory, a blur of e-mails going back and forth across the Atlantic, where are we going, when, how? The GC was making sure everyone was accounted for and taken of, we were trying to make sure everyone was taken care of as well. We packed, not knowing if or when we were coming back. So everything was sorted into the 200 pounds we could take with us on the plane and then the things that were boxed up to be shipped out later if we couldn’t go back, and finally everything else that would just be left. We got everything done with two hours to spare. The last box was taped shut and the last suitcase closed at 3 am Tuesday morning and we left the compound for the bus station at 5 am.

The rumors, this may be hard to believe, but rumors were everywhere and all over the map. The whole thing was an error and the State Department was going to issue a retraction. The State Department sticks by its recommendation and is not going to issue a retraction. This is all overkill, there is no good reason to leave. This is real, you need to get out now. The president of the country has cancer and is in a coma and dying. The president of the country has left the country. The president is in fine health and no problems.

Amidst all the confusion, all the rumors there was one thing that was crystal clear, on thing that was real, tangible. It was the tears, the looks of shock and horror when our staff found out we were being told we had to leave. I have never seen David so somber as when he realized the weight of the center would be on his shoulders alone. Not only that, the future of the center suddenly became uncertain. Solange came to our house to say good-bye to Diana, she thought Diana was the only one leaving. When she found out we all were leaving she covered her mouth turned and ran. She wouldn’t talk, wouldn’t even look at us. We were betraying them.

The Staff and Students at CCAM, Monday, September 14, 2015

The Staff and Students at CCAM, Monday, September 14, 2015

Solange is in between Bekki and I.

Solange is in between Bekki and I.

Monday afternoon at 3:30 we had a staff meeting in our front yard. By then everyone knew we were leaving, but were not necessarily why. One advantage of all the rumors that were floating around is that I felt at liberty to choose the one I liked best and stick with it. Telling my staff that I had no idea if or when we were coming back, or what the future of the center looked like really did not seem like a good idea, so I went with the rumor that the recommendation was an error and that it would slowly be retracted over the next couple of weeks. Therefore I was able to confidently and with a clear conscience reassure our employees that we intended to be back in 3-4 weeks, and all would be good. It made what would otherwise have been a horrific staff meeting, into one that at least held out a ray of hope.
Bekki with Francis, the young man we are sending to the Adventist University in Cameroon.

Bekki with Francis, the young man we are sending to the Adventist University in Cameroon.

Tuesday morning the five of us went to the bus station and had the least eventful trip to N’djamena we have had in months. We found a capitol city with no signs of disruption, no stress, it was quiet, calm and peaceful (at least as quiet, calm and peaceful as it ever is). Wednesday morning I woke up feeling like I had been hit by a truck, headache, and fever. Bekki immediately started me on anti-malarial medication. Thursday we flew out of Tchad. Friday afternoon Jon and Lindsay met us at the Chattanooga airport with an enormous group hug. It was hard to leave, it was good to be with our kids.

At this point our future is uncertain, despite my assurances to my staff. I am still an employee and to some degree have to do what my bosses tell me to do. Will the GC let us go back, if so, when? We don’t know.
But I do know one thing. Last Friday I was so frustrated and wanted to just go home. Sabbath God said, “OK, Scott, this is what you wanted, you have your ticket out, you can go home, in fact I am taking the choice away from you.” I had the next 72 hours to see the effect my leaving had on my staff. I had time to really think about all the people who wouldn’t be helped, who would continue to suffer, because we were gone, or even worse if the center closed. I had time to reflect on my petty selfishness and my perpetual pity parties. And I realized, I am not ready to leave, our work is not done here. Yea, OK I will go home for a bit. Lindsay’s birthday is tomorrow and so it will be nice to be with her to celebrate. But I don’t want to stay here. I want to go home.

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

TWO BOYS REVISITED

About a month ago I wrote about two boys. Both boys had open fractures of their lower legs. One boy’s family had refused amputation of a badly infected leg with dead bone, and had taken him home. The other little boy we had treated with wound care and a little external fixation device. I would like to give you the rest of their stories.

Yassine was the little 10 year old who had broken his leg in a moto accident. It was two weeks before he came to our center and by then the bone was dead and infected. We made a vain attempt to save the leg with external fixation, but it was clearly not working so I finally recommended amputation. His family refused and took him home, where we figured the infection would spread and probably take his young life.

About two weeks later his carnet showed up on my desk. I asked the nurses why he was here, because often patients will come back thinking I will have changed my mind and so will now do what they want me to do. It is always a battle because they won’t take no for an answer. So as I called for Yassine I mentally braced myself for the expected battle. And, of course, since I was prepared it didn’t happen. The family had apparently decided they would not be able to miraculously fix the little guys leg and so they meekly agreed to the amputation.

Yassine just before his first operation, you can see what is under the dressing in the Surgery Pictures Page

Yassine just before his first operation, you can see what is under the dressing in the Surgery Pictures Page

I warned them that it would take two operations and that I was not sure I would be able to save his knee. I feared the infection had spread up into his thigh. I was again pleasantly surprised in the OR when I found that his infection was limited to the lower leg and although I had to make the first amputation a little high I felt like we could save the knee. The reason for the two surgeries is that if I tried to close the wound with the first amputation it would just get infected. About a week later when his wound was clean and without pus I was able to revise and close the amputation. He has done well. He has a functional knee and is able to walk with crutches and someday should be able to use a prosthesis. Praise God!

Yassine after his amputation

Yassine after his amputation

Koudma was the little 3 year old referred from Bere with an open fracture of his own. Because of the advance warning by the team from Bere we were able to assemble a pediatric sized external fixateur. I had never done it before on such a little one, but figured the principles should be the same and I just needed to avoid the growth plates on the bones. So we got his wound cleaned up and fixed in position and then I tried to get some soft tissue over the fracture site. He is the cutest little guy, and we got to enjoy him for about 6 or 7 weeks. I did not want to send him back to the village with an open wound and with the ex-fix as I figured he would get the wound infected and I would never see my ex-fix again.

Koudma sitting in his wheelchair, with those legs crossed.

Koudma sitting in his wheelchair, with those legs crossed.

Koudma and his little brother playing with Myriam a french nursing student who spent 5 weeks with us.

Koudma and his little brother playing with Myriam a french nursing student who spent 5 weeks with us.

So I had plenty of time to teach him how to high five and low five, but I didn’t get to the fist bump or bro hug. Anyway, from day one he would be on his bed with his broken leg with the ex-fix crossed over the other leg, just laying there taking in the world. He was one of our brave little ones, he never cried during dressing changes unless it really hurt. He didn’t cry when he saw us enter the ward, unlike most of our pediatric patients.

The day finally came, about 10 days ago when his wound was finally healed and I carefully removed the bars from the ex-fix. Now I will admit I didn’t put the leg through a lot of contortions or put a lot of stress on it, but with the pressure I used it didn’t move. We were able to remove the screws and let him start walking carefully on it. The bone seems pretty solid, and very clean, no pus, no cellulitis, no infection.

Koudma taking his first steps after removal of the ex-fix.

Koudma taking his first steps after removal of the ex-fix.

God is good, by His grace both boys will recover and do fine. Thank you to all of you for your support, prayers and encouragement.

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