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…
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.
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.
CLEMENCEClemence 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.