Clemence

Yesterday was a very special day.  I had the privilege of writing “Sortie” on the carnet of Clemence.  She had spent 7 months with us.  I told her we were going to write on the wall above her bed, “Le lit honoraire de Clemence”, “The honorary bed of Clemence”.

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Clemence and I in front of her home for the last 7 months.

I wrote about her a few months ago, as one of two patients with incredible wills to live.

To refresh your memory, she came to us in June following a cesarian section the previous December.  She looked like someone from a concentration camp,  nothing but skin and bones, with a strange mass in her abdomen and a small amount of pus coming from her incision.

In short whoever did her c-section (the baby died), had left  a lap sponge in her, and had somehow lacerated her colon.  I did my best to avoid doing an ostomy, but after her anastomosis fell apart several times I was forced to give her a diverting ostomy.

Thanks to fast work by the staff at Loma Linda and AHI we were able to get enough ostomy bags to keep her covered.  And ever so slowly she gained weight and got stronger.

I put off the operation to put her back together again for as long as I could, partly out of fear and partly out of wanting to give her as much time as possible to heal.  But finally in December, just after we got back, I bit the bullet and took her back to the Bloc.  I have been in these situations before and often there is so much scar tissue inside, it is like someone poured a quart of crazy glue and all the intestines are stuck together in a shapeless mass.

A lot of prayers went up for her and I that morning, from all around the world, and God answered those prayers. The scar tissue was minimal and I was able to get her ostomy closed without tension.  Now she just had to heal.

On rounds the fourth day Patrice was happy to inform me that she  had pooped for the first time.  And so we slowly advanced her diet.  I kept waiting for the green liquid to start coming out of her wound, but it never did.  She had very little pain, she ate well, she walked, she smiled.  She even came to church with us a few times.

Yesterday Patrice told me her family wanted to take her home.  And truth is she just needs a bit more time for her superficial wounds to heal, but she can do that at home.  So I went to her bedside and wrote those words I never thought I would write, and sent her home.

As those of you who have been to third and fourth world countries (yes there are fourth world countries, they aren’t even in the “developing” category yet) know the need that constantly surrounds you is so great as to be overwhelming.  And so often there is nothing you can do to help except pray, or give out some tylenol or advil.  And people die here, a lot, and often as a Western physician I know they didn’t have to die or suffer so much.  In another place they could have been treated.  So you learn to cling to the Clemences, and exult in every victory, no matter how tiny.

There is a story I have come to cherish here, because it is so apropos.

A mature 50 something man was walking along a beach after a big storm had come through.  He noticed that the storm had washed thousands of star fish up on the beach, stranding them on the sand where they would soon perish.

He came upon a young boy picking  up starfish and throwing them back in the ocean, one at a time.  In the wisdom and cynism that comes with adulthood, he stopped the boy and asked, “Son, what are you doing that for?  There are thousands and thousands of star fish on this beach, you can’t begin to make a difference by throwing a few back.”

The boy reached down and picked up another starfish and tossed it back into the surf.  He then turned to the man and said, “Mister, you are right, but I made a difference for that one.”

In the two years we have spent here in Tchad, we have not made the slightest, tiniest dent in the suffering just in and around Moundou, but we made a difference for that one.

Scott Gardner

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COURAGE

This was written last August, just not posted, during the height of rainy season, hence the reference to cold, wet concrete. This time of year it is cold dry concrete.

I once heard it said that courage was not the absence of fear, but the willingness to fight on despite the fear.
On morning rounds earlier this week in the Salle de Reveil (ICU/ER/PACU), the night nurse, Service, presented a new malade. The 30 something man was lying on his side on the guerney. Anal pain was the symptom, fistula was the diagnosis. I took a look and feel of his peri-anal skin (doctors are allowed to do that without getting jail time as long a nurse is present, nurses can do it without a doctor being present, go figure), and there was no fistula, in fact it looked fairly normal. But the skin next to the anus was just a bit shiny and very tender, so my working diagnosis was abscess. So after doing my mega workup, x-rays, CT scans, blood work, etc I wrote out his operative form. (Actually my “work-up” consisted of my right brain asking my left brain if I really thought it was an abscess. My left brain said yes, so we all agreed he needed surgery)

By the time I got him to the OR the next day there was already pus draining out. It was nice to have my diagnosis confirmed before making an incision. It was an abscess worth draining, and although he didn’t have a fistula when I first saw him, he probably is going to develop one. We got him cleaned out and cleaned up, rinsed out, put a drain in and transferred him to the Salle de Reveil. The next morning the OR crew rinsed out his wound again and then he disappeared. Actually in the midst of everything that happens during the day I kind of, well, forgot about him.
This morning I was leaving the men’s ward and Patrice our hospital nurse stopped me.

“Docteur, the patient whose back you opened can’t pee, he needs a suprapubic catheter.”

“Oh yeah,” I said, “Service told me about him this morning, he tried to place the catheter and couldn’t. Don’t worry, I will get one in, I have the “special” catheters.”

Patrice led me into what will one day be our pediatric ward, but now serves as our SNF (Skilled Nursing Facility, or depending on how you look at it, Severely Neglected Facility), it is our overflow space where non-acute patients who are here just for dressings stay. This morning Severely Neglected Facility was more appropriate as it was raining, and the roof leaks. Actually there seem to be more leaks than roof, so the bare concrete floor was covered with water with little walkways of dry ground around the puddles. Since we are currently full to overflowing there were a lot of people lying on wet cloth on wet concrete in the dark of the room. Today was one of the 5 days a year we don’t see the sun. It rained all day, and it was cold. In the room it was probably 70 degrees. People had on coats and sweaters and were still cold.

Patrice took me over to a tall man lying on a pretty dark green cloth.

“This man,” he said, “You opened his back two days ago, and now he can’t pee.”

Opened his back? I hadn’t done any back surgery. I could not for the life of me remember who this guy was. Patrice showed me his carnet, but I didn’t have my headlight. I could tell the carnet was blue, but that was it, so I took it over to the door and looked through it. I found my handwriting, which I of course couldn’t read, but I did recognize “abscess”. Oh yea, the guy with the big peri-rectal abscess. And that is why he can’t pee. Due to the infection his prostate and whole perineum are swollen, yea he needs a catheter, and I should be able to use the “special” catheter from America and get it in no problem.

So I took his carnet back to the office and wrote out the order for the catheter and urine bag. 5000 francs ($8), which includes my putting it in. I had one of the nursing students take it back to patient so his family could pay for the catheter and then I could put it in. Now if any of you have ever had urinary retention (you couldn’t pee), you know how miserable it is. So I figured he had a pretty good motivation to get his family to pay, if they could. I went about my business and forgot about him again until our social worker called me into my office.
“Docteur”, she began, “the family of Grace (really is his name) brought me his carnet, and this.”

She handed me the carnet and two coins, two 500 franc coins (about $1.50, or 1.25 euros). That was all they had. I thought about the widow’s mite in Jesus’ day. I took the coins, sighed and said, OK, I will take care of the rest, we will get it done.
Shortly after that Appo called me into the OR and we started a 3 hour femur nail of an old, partially healed femur fracture. When I got back to my office I found Grace’s carnet still sitting on my desk, with the two coins inside. I tried not to think about him lying on the cold wet cement, with a huge wound around his anus and a very very full bladder. When I was ready to start my afternoon consults I gave the carnet to Yankamadji, my afternoon nurse, and asked her to go fetch him and bring him to the office so I could get his catheter in. I kept his two coins and took a 5000 franc bill to the cashier and paid for his catheter and my work.

Soon enough Yankamadji came back wheeling Grace into my office on an ambulance guerney (I am guessing it is an extra because I saw one in the ambulance this morning). He looked miserable. He could hardly talk, he could barely stand. He didn’t want to lie on his back because his butt hurt, but I couldn’t put a catheter in with him on his stomach. We compromised, he laid half on his side and half on his back.

He had an IV catheter in his bladder already (that is what they do here for an emergency suprapubic catheter, and it works as you would expect, not well). I pulled it out. He was covered in urine from overflow incontinence, his bladder was almost to his belly button, he stunk, no he reeked, and all he could do was say “Seigneur” (lord), over and over.

I went about my business getting ready to place the catheter. I chose the perfect size “special” catheter (actually, just a coudé tip) and started to put it in. It hurt, and when I got the catheter to his prostate it really hurt. He snapped his fingers, he called on Jesus, he waved his arms, he said “Mon Papa” (my father) over and over. But he didn’t push my hand away. I tried really hard, but I could not get that catheter to pass through his prostate, it was just too swollen. I have learned to just concentrate on what I am doing, and not think about the suffering involved on the other end, otherwise I would never be able to do what I do, but still, I couldn’t help but admire his courage as he let me keep trying.

After what I felt was a reasonable amount of time and effort I gave up and pulled out the catheter and prepared to put in a real suprapubic catheter. Thanks to the warehouse team at AHI I have several SP kits, so I could put one in percutaneously. I wasn’t sure how much French he spoke, so I just told him he needed the SP catheter and I numbed up the skin and muscle (he has no fat). I got the catheter in and his bladder started to drain. I then numbed up more skin and stitched the catheter in place.

I thought again about his courage. This guy probably had never been cared for by a white doctor. I didn’t really tell him much about what I was going to do, except that he knew we were trying to get his bladder emptied. It would have done no good to try to explain it, he has no context with which to understand any explanation I could give. He also was not really listening, he was so focused on his full bladder, and sore butt. In fact this was only the fourth time I had really interacted with him, and each time he was so miserable there really was no communication. Since I first met him I had poked on his sore butt, cut it open and then invaded his penis with a tube and finally poked his bladder with a ginormous needle. Would you trust me? I don’t think I would. But he let me do what I needed to do.

After I got done I went to my desk and started to write out the note on his carnet. It was just the two of us now, the nurse had gone for some dry cloth for him to put on. His bladder was almost empty, and for the first time in a couple of days he started to feel human. And he started to talk to me, in French.

“Papa, je vous remercie.” (Papa, thank you.)

“Ça va?”, I asked.

“Oui, ça va,” he responded with a relieved look on his face.

(Are you better, I asked, and he responded, yes much better. Really, it is all in the voice inflection.)
And then he said something that brought tears to my eyes.

“Que Dieu vous benisse,” he said. (God bless you).

After all the pain I had inflicted on him, God bless you.

I reached in to my desk drawer pulled out two worn 500 franc coins and walked over to him. I put them in his hand and said, “Grace these are yours, you keep them. God bless you too.”

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