Eid al-Adha

For those of you who may have missed it, last Monday, September 12 was one of two main Islamic holidays, Eid al-Adha, or Feast of the Sacrifice. You guessed it, it commemorates the willingness of Ibrahim to sacrifice his first born son Ishmael. It also marks the end of the annual Hajj to Mecca.

We live in a predominantly Muslim country (60%), so as soon as the Supreme Court in Saudi Arabia set the date officially as September 12, it became a national holiday. So Mobile Clinic was cancelled, but things were pretty much as usual at the hospital. A hospital, like Las Vegas, never sleeps you know, or takes vacation.

That being said it was pretty much an uneventful quiet day until about 4:30 in the afternoon. Mr. Fobbie came to my office as I was starting to pack things up to go home.

“Mr. Abu is going to Mamamah to attend to Mr. Augustine Conteh”, he told me.

“Oh, why is that? What happened?”

“He was on his way home and was in an accident.”

“Is it serious?”

“I think so, they took him to his house.”

I am a surgeon after all, and so I thought I should go along and check it out for myself, plus I figured it would be a morale booster for Mr. Conteh, who is our head nurse.

Mr. Abu and I quickly got together a few supplies, not having a clue what we would find. Afterwards I realized we left the BP cuff and IV supplies behind. Next time we will try to have an emergency kit prepared.

Pa Sanko, our intrepid driver, the man who has no fear, holding Augustine's older girl, Rachel.

Pa Sanko, our intrepid driver, the man who has no fear, holding Augustine’s older girl, Rachel.

We hopped in the van with Pa Sanko and Mr. Abu had prayer. We desperately needed that prayer. I have spent many hours in the van with Pa Sanko at the wheel. He is a pretty aggressive driver. This time it was the Indy 500 and we were making up for too much time lost in the pits. I buckled in tight, and tried to concentrate on my solitaire game and not count the times we passed one or two cars going our direction while being passed by cars going in the opposite direction. These guys have incredible depth perception, they miss each other by millimeters, or sometimes not.
The vambulance

The vambulance

20 minutes later (of the usual 30 minute trip) we pulled into Augustine’s front yard. Abu and I hopped out and followed the sounds of wailing to the little carport behind the house, where they had held the naming ceremony for Augustine’s baby girl, Sarah.

Mr. Conteh was laid out on the cement on a pink lacy sheet. He was surrounded by probably 50 friends and relatives, many of whom were wailing and wringing their hands. One woman was standing over him pointing to a mass protruding from his bare abdomen. At first I thought he was dead, but then I noticed he was breathing. We did a quick primary survey and found nothing imminently life threatening, other than all the noise and commotion. His pulse was full and strong and didn’t feel too fast. I breathed a sigh of relief as we began the secondary survey.
The mass in his abdomen turned out to be an old hernia, apparently this woman had not seen him before without his shirt, so she thought it was new. He was able to talk fairly normally and answer questions. They said his left leg was broken and it had a traditional splint in place. Abdomen was soft and non tender, chest was normal. Glasgow Coma Scale was 15.

OK, this is good. I really didn’t want my head nurse dying on me in front of all these people, actually I didn’t want him dying on me at all. But I did want him back at the hospital where we could watch him in case something did show up.

I suggested we get him moved to the van, so 5 guys got on the right side of the sheet leaving me and one other skinny Sierra Leonean for the left side. I had visions of this not going well, but it was still better than the Tchadien method of transport; 4 men, each one holding a different limb with the head flopping around loose. We got him in the van without incident and tried to reassure the weeping crowd that he was going to be alright. Unfortunately, it is a van, so he had to sit semi-upright on the seat so we could fit all of him inside.

As we headed out I told Sankoh that Augustine was OK and we could go a little slower. I have always been opposed to accidents involving rescue vehicles, especially if I am inside.

I was now able to talk with Augustine and find out what had happened. He had been on his moto and was turning left onto the road going to Mamamah and failed to see the other motorcycle trying to pass him on his left (very common practice). So the left side of his body took all the force.

As we drove along I reflected on all the people weeping and wailing as they gathered around Augustine as he lay there. I realized that they had seen this before and knew that he was badly injured and for all they knew he was going to die. Augustine is the one who has the good job, so he supports a large part of the family. Their future lay on that sheet. What would happen to them if he died, or was no longer able to work? So it was truly a cry of frightened desperate people who had no control over the situation or the future.

When we got to Waterloo his brother-in law, who had come with us, said he was hungry so we stopped at a favorite cafe and picked up some food. At that point Augustine still looked pretty good, but then he commented that he was tired. I was really hoping that it was all the excitement and the broken leg talking…

At the hospital he was loaded up on a gurney and quickly moved to the private room that had already been prepared for him. I found out later that while we were gone the whole staff had gathered together and prayed for Augustine and for our safety as well. God answers prayer is all I can say.

As we moved Augustine onto the bed I noticed his skin, previously dry and warm was now cool and clammy. Oh boy, direct left side hit, hard enough to break a leg. Hard enough to break a spleen, too? His pulse, once full, regular and slow was now fast and thready. While the staff got things together for starting an IV I got my ultrasound to do a quick scan of his abdomen. I really am not very experienced at these, and frankly not very good, but by God’s grace I quickly found his spleen and it looked pretty good. I didn’t like the black at the end of it though. I looked in the pelvis, a little black around the outside of the bladder. Then I looked at the left abdomen, black in the gutter, and I could see the bowels floating in a black sea. Black on normal mode ultrasound is liquid. In this case blood. Great.

My head nurse has a ruptured spleen. I have no night time OR, yet. I hope and pray he is not one of the few that don’t stop bleeding on their own. Mr. Abu got two IV’s going. I noted that we would need to be talking about the concept of “LARGE” bore IV’s for trauma. But the 22 gauges worked. 500 cc of fluid later he started to look around again and he quit sweating. After a liter he was talking normally and his skin started to warm up. Adequate blood pressure for brain perfusion has always been a favorite of mine.

Augustine feeling much better.

Augustine feeling much better.

I examined his leg and decided he just had a broken fibula, the little bone on the outside of the leg. The main bone, the tibia, was fine. I put a splint on it and then had prayer with him and told him I would be back in a couple hours to check on him.

At home I filled Bekki in and confessed my worries about what I was going to do if he didn’t stop bleeding like the book said he was supposed to. Patients have a nasty habit of not reading the books before coming into the hospital. We are not really set up yet to do surgery outside of regular hours. We are working on it, but it will take some time yet. So she called on her prayer team through e-mail and face book.

About 9:00 pm we went down the hospital and checked in on him. He looked pretty good, awake, alert, pulse good, abdomen soft, no pain except in the leg. I gave the nurses their final instructions and told them to call if he got sweaty again.

I have to confess I did not sleep well that night, waiting for my phone to ring. Praise God my phone stayed silent all night. I hurried down to the hospital early so I could check on him before worship, and was greatly relieved to see him holding court in his room very awake and alert and already busy disobeying doctor’s orders.

The big grin is because he had been eating against my orders.

The big grin is because he had been eating against my orders.

At worship that morning I noticed that Augustine was the scheduled speaker. I told him later that if he really didn’t want to do worship all he needed to do was talk with someone, having an accident was really not necessary. He got a good laugh out of that.

A very relieved Mrs. Conteh holding the baby Sarah, and a shy Rachel standing next to the bed.

A very relieved Mrs. Conteh holding the baby Sarah, and a shy Rachel standing next to the bed.

By Friday he was well enough to go home. Sunday morning at 6:30 my phone rang. Augustine called to thank me for taking good care of him, and to assure me that he was doing OK. I thanked him for calling, but have to confess that my thoughts were more of, “If you really want to thank me, don’t call me at 6:30 on Sunday morning:)”

Intercessory prayer works, it kept us alive during Sankoh’s mad dash to Mamamah, it stopped the bleeding in Augustine’s spleen, it helped us get the IV’s going in time. I cannot praise God enough that I was not faced with doing a splenectomy on him at 2 in the morning. We are not set up to deal with major trauma’s, but by God’s grace our head nurse will be back at work in early October.

It also showed me that we really do need an ambulance. Lights and siren would have been nice. A real ambulance gurney in the back of an ambulance that was already stocked with the supplies we needed would be nicer. As we grow, these kind of emergencies are going to be more common, we need to be ready to meet them. When we do the best we can with what we have, God makes up the difference. When we are just lazy and don’t plan ahead, and don’t work to remedy our deficiencies and ask God for help, it is presumption.

Despite the fact that Bekki did not serve mutton for supper that Monday night, it was an Eid al-Adha I won’t soon forget.

Paul checking Augustine's BP at his home today.

Paul checking Augustine’s BP at his home today.

Epilogue: We visited Augustine today as he lives just a couple hundred yards from our Mobile Clinic in Mamamah. He is doing well. Hemoglobin is stable, he is eating, no dizziness, minimal pain. We praise God for His mercies and healing. sg

A very happy Mr. Conteh on his bed at home, showing off his fancy cast-boot, and sitting up with no dizzyness.

A very happy Mr. Conteh on his bed at home, showing off his fancy cast-boot, and sitting up with no dizzyness.

For those of you who are 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, and now we are adding videos of Sierra Leone. Watch a real Ebola survivor tell his story. Watch our community health officer explain why the staff agreed to work in the Ebola Red Zone even after they lost 2 staff members to Ebola. 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. On the Projects and Donations pages you can find the projects we are working on and how to donate to the project that touches your heart. 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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Is A Human Life Worth $200?

I happened to glance out my office window yesterday to the front parking lot of the hospital. I watched bemusedly as a yellow cab pulled in, the front seat passenger got out and opened the right rear passenger door. My curiosity was piqued as I watched him pull out a young man by his arms. As if out of nowhere a crowd appeared and several pitched in to help carry the patient up the steps into the hospital.

It didn’t look good, but it also didn’t look surgical, I hoped. We had just cancelled my one case for the day because the young lady had eaten breakfast so I was looking forward to being able to get caught up on paperwork and other administrative stuff. Not long after I ventured out of my office and ran into Mr. James Abu, our CHO (Community Health Officer, basically a nurse practitioner).

“Doctor”, he said with his usual sly smile, “Doctor, I just admitted a patient with a bowel obstruction I would like you to see.”

“OK, no problem.” This is my usual response whether it is a problem or not, always hoping the lilt in my voice would put a smile on my otherwise sour face (those of you who know me will understand).

I asked if this was the young man they had just brought in. Sure enough it was. So much for being nonsurgical.

We went to the mens ward and found a young man, Sahr, in his early twenties laying on his side facing the wall. He had little ulcers on his right leg. I found out he had fallen from a mango tree some years back and has been paralyzed since.

The history was three days of abdominal pain, nausea and vomiting. Indeed, he looked like a bowel obstruction, distended abdomen, tight, tympanic (sounded like a drum when I tapped), no evidence of an incarcerated hernia and no peritonitis.

Here, our only non-invasive diagnostic is an ultrasound done by a rank amateur (me), so the only real decision is does this patient need an operation and if so, when? Well, he needed an operation, and since the crew was there and anesthesia was present, now was good.

As I walked back to the OR, Mr. Abu stopped me and said, “Doctor, his family has not paid anything yet. What should we do, who will pay the 1.5 million leones ($200) for the surgery?”
My response was simple, “He needs surgery and he needs it now, we will worry about the money later.”

I am done with not treating someone with a life threatening or emergency condition simply because they cannot pay. We will get what payment we can from them later. But as a hospital it is our creed to treat everyone regardless of ability to pay. God will either make up the difference, which so far He has, or we will go under. But I am going home if I have to turn someone out because they don’t have money.

Back to the story. In the OR, I was explaining the necessity of being careful when opening the abdomen on cases like this to the surgical team. Because the abdominal wall is stretched thin and the dilated bowel will be just underneath it is easy to slice into the intestine. (Most teaching of this nature is from personal experience, this was no different). This time though, as I gently opened the peritoneum there was a rush of odorless air. It was followed by thick yellow fluid, 5 liters of it. The surgery people among you know exactly where I am going with this. No bowel obstruction, but instead a 1 centimeter (1/2 inch) hole in the duodenum, just below the stomach. Diagnosis, perforated ulcer.

As I repaired the hole and cleaned him up, I marveled at how far God had brought us in such a short time. A month ago I would never have dreamed we would be ready to do a case like this, but with our new suction and cautery and OR Table and the reorganization of the OR, we were ready. The case went well, and I am happy to say that today he looked as good as anyone can look with an NG tube hanging out their nose. He has a long way to go, and many bad things can happen, but so far a life has been saved by God’s grace.

Sahr the morning after surgery.

Sahr the morning after surgery.

After surgery I met with the family and explained what we found and what we had done. I also shared with them that Sahr was still very ill and needed lots of prayer, and that God is the One that would need to heal him.

In worship this morning Mr. Abu shared the “rest of the story”. In the days since he became ill the family had taken him to traditional healers and other clinics and hospitals. Sahr had been treated with herbs and other local remedies, which I can attest to as I suctioned out a number of pieces of leaves from his abdomen. The family had spent all its money before coming to AHS. They had only enough to pay the 30,000 leones ($5) for the consultation.

Sahr and his nurse.

Sahr and his nurse.

If we had insisted on some payment yesterday before treatment they likely would have put him back in the taxi and driven off, and he would be dead today, instead of being on the mend. And we would never have had the opportunity to point them to Jesus as the Source of healing.

Will Sahr fully recover? Remains to be seen.

Will the family pay? Probably something, although not likely the entire amount.

Will it hurt us financially? Maybe.

Is a human life worth $200? Definitely.

For those of you who are 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. On the “Videos” page watch a real Ebola survivor, Dalton Kabia, tell his story. Watch our community health officer explain why the staff agreed to work in the Ebola Red Zone even after they lost 2 staff members to Ebola. 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. On the Projects and Donations pages you can find the projects we are working on and how to donate to the project that touches your heart. 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