INTRODUCING JONATHAN PORTNEY

Dear Readers, I am sharing a blog post written by our newest long term volunteer, Jonathan Portney. “JP” comes to us from Loma Linda University, having just graduated with his Public Health degree, with an emphasis in international public health. He, like all our long term volunteers, has taken on his responsibilities with gusto and enthusiasm, or as they would say here, lustfully. I appreciate his post as it shares his thoughts, feelings and reactions to life here in a poor hospital in Sierra Leone. If you want to see his other posts, check out jpinternationaltraveler.wordpress.com. Or you can see his posts on our Waterloo Adventist Hospital facebook page.

JP leading out in stretches at morning worship

It’s 8:00 AM on a Monday morning. Sounds of praise radiate from the chapel located near the front of the hospital where the staff of the Waterloo Hospital gathers every morning to partake in worship. Inside this common area is a nursing station and at any given time a patient can be ushered through the staff worship to the nursing station to receive patient care. This particular morning was emotional for me because a few nights before a child aged 2 years came into the hospital with what was perceived as an untreated case of Malaria. The child was gasping for air, you could hear the fluid gurgling in his lungs. Beneath him, on the bed, there was a pool of blood that he had peed — the child was unconscious. As orders are being shouted by the nurses around me, I do what I can to help “Give me the oxygen mask” one nurse shouts looking at me. I held my headlamp over the child so the nurses could see what they were doing, I had to do this because there was no electricity, this is a common problem at our hospital because the electrical power is hit or miss and we can only run our generators at certain times due to hospital finances. The light I had focused on the patient was shaking, and I began to feel nauseous, I could feel myself becoming very hot, and had to continuously tell myself to breathe so that I would not pass out. For some, experiencing death is a common occurrence. For me, this was my first time seeing anyone on the brink of death, laying right in front of me, and I wish I could say it would be the last. The nurses did everything they could, but it was to no avail, the child aged 2 years died. It was quiet in the room once the child was pronounced dead, some staff cried, and other staff members walked away to be alone because I’m sure we all felt that this should not happen to a child this young. However, here at Waterloo Hospital this is a reality and does happen on a regular basis. We are here trying to do everything we can with the limited education and supplies that we have. Could WE do more? Yes, should WE do more? Absolutely. Unfortunately, we have limited equipment and funds to reach this goal, and this is just a reality.

On Monday morning I decided to take a shortcut to the chapel room which passes by the connecting nursing station. Songs of praise are heard radiating from the building. I peer in the nursing station window and see a child around the same age, if not younger, peering out the window with Dr. Scott, our physician, leaning over the child checking her pulse. The child had a little pink beanie on its head with matching footies and blanket. The child was so young that it still had that baby smell which we all love. The child had her eyes open wide, and her mouth opened as if she were yawning. For a brief second, I smiled because the child almost looked scared, often children this age are afraid of Opotu people “white people” because the encounter is probably their first introduction to someone with white skin. As I entered the chapel, I decide to see the baby because it was so cute. I walk in the nursing station, the child has the same facial expression that I noticed before with eyes big and mouth open. The mother is standing at the door of the nursing station holding back tears, saying a soft prayer, the dad is standing at the nursing station bed next to Dr. Scott with a hopeless almost blank stare expressed across his face. I look at the child and notice she is not blinking. I think to myself, this surely isn’t going to be a repeat of the night before. After this thought passed, Dr. Scott pulls his stethoscope away from the child and looks at the father and says gently “I’m sorry, she is gone.” I crumbled emotionally along with the parents as they wrapped the baby in the blanket and carried her off.

Us missionaries often sit around the dinner table on Sabbath evenings envisioning what it would be like if we had more funding and resources. In Gods power, we hope they will come eventually, and we have faith that He is molding the hospital just as He sees fit. We have fully come to accept that we are powerless over our current situation. Every morning without fail we wake up with a smile on our face to greet the day, staff, and patients. If we come off as defeated, then the whole morale of the hospital would change. While I have a smile on my face, inside, I am pained. While praying, I question if it would be foolish of me to ask God for just one week where a patient doesn’t die from preventable causes. I continue to pray for this, but my prayers are a little different now. I’m asking for strength, not only for myself, but for the other missionaries, the patients who have lost loved ones, and of course my family. I feel like if I pray for no one to die, I’m trying to play God and I know that is not my role. My role is to let God use my hands, body, and mind, stay out of His way and put a smile on my face to make the lives of those around me better. For me, this prayer is manageable and keeps me waking up to greet the day with a positive attitude despite waking up almost every morning to screams from the courtyard from family members who have lost yet another loved one.

Jonathan C. Portney, MPH — Mobile Clinic Director

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OUR STRUGGLE IS NOT AGAINST FLESH AND BLOOD

Yesterday at the end of worship the entire staff stood up and held hands, making sure there was an unbroken circle, and we prayed for one of our own. Our lab technician, our Ebola survivor, was ill. He had been ill for a couple of weeks, and wasn’t responding normally to treatment. It could be because he kept going back to work too quickly, and wasn’t getting enough rest, or because he really never let us finish an adequate course of treatment, or maybe he has something else wrong that we can’t diagnose, or maybe it is a result of his Ebola history. There is some thought that Ebola survivors are relatively immune comprised. Whatever the reason, he just wasn’t getting better.

However, that is not why we were praying. We were having this special season of prayer because at 5 am that morning his family had shown up and taken him from the hospital against his will. The staff did not need to be told what this probably meant. When families come and forcibly remove someone from the hospital they typically are planning to revert to the default–take the patient to the natural healer. Every village, every community has at least one natural healer. These are not naturopaths as we understand them. No, these are witch doctors in every sense of the word. I actually had no idea how evil these men and women are until just recently.

The AHS family was upset because just three weeks ago we buried the Seventh-day Adventist wife of a prominent staff member whose family had taken over her medical care. The husband shared with me the story.

Josephine had been ill for several weeks. The labs tests were all normal, and there was nothing wrong on physical exam, except she didn’t feel “bright”, meaning she was weak and tired. Different medications were tried without much success. Now, it has to be said that this happens in the US as well. Patients have some unknown malady that doesn’t respond to treatment. Eventually they get better, most of the time, or something shows up to steer us in the correct direction. However, in Josephine’s case the family was not going to wait. So, they took her home. Her family is not Christian, although to be honest, it really would not have made much difference. I have observed that whether you are Muslim or Christian, when the going gets tough the vast majority of them will revert to their animist roots. And who do they turn to for medical help? The natural healers.

So, these guys were brought in. What I am about to tell you will sound made up,like something out of a horror novel, but it is not, I assure you it is real. First, they found some masses or lesions at various locations on her body. These were removed. Without surgery, without incisions or scars. Cutting, actual cutting with a knife, and blood letting is a very common treatment here. Many of my patients have multiple scars on their bodies as the result of natural treatments. But then they reached into her abdomen and pulled out the real source of the problem, a snake like creature, 8-9 inches long, with a discernable head and tail, that was moving. I have seen the picture of it. It was fortunately destroyed so it would not bother anyone else.

I asked if there was a scar. I was concerned these guys had made a hole in her intestine and not closed it and she had died from sepsis. I was informed that these natural healers have magic and the wound just closes over spontaneously and very quickly, leaving no trace of a wound.

Josephine seemed to recover some after her “natural” treatments. But then 4 Sabbaths ago her family called the husband saying that she was very ill. She was brought to the hospital and died a few hours later, at the age of 39.

Did she die because of the natural treatments or despite them? Did she have some unknown ailment that was to doom her no matter how she was treated? We will never know. But what I can assure you is that as soon as the natural healers became involved with all their magic and potions, God was pushed out. How can God answer the prayers of the church for healing when the devil is involved? Who is going to get the credit if He does work a miracle?

It was with those thoughts in mind that we prayed about our lab tech. I am sure most everyone in the room knew the stakes involved. It is extremely unlikely the family took him from the hospital to try to get him into one of the fancy expensive European hospitals in Freetown, or that they are going to airlift him to France for treatment.
He knew as well, what was in store for him, which is why he vehemently protested leaving the hospital. But individuals here have no say, it is the family, specifically the ranking member of the family who decides for everyone.

So we prayed, we prayed that somehow God would intervene and the family would allow him to come back to the hospital, allow us to continue treating him. We may not have much for diagnostics or treatment options, but we have something greater than that, we have the Great Physician. And in this war, that is worth more than all the soldiers, all the armaments, all the captains and all the kings.

Here, the evil, the darkness is so “in your face”, so blatant it is impossible to miss. But it is just as real in the “developed” world. We just call it by other names, or we rationalize it away with our smart scientific theories and ideas, but the evil is there.

I don’t know how this will end, but I know God will not force Himself where He is not wanted, so ultimately it is up to us, we choose which side we will be on. And that is a decision we all have to make, whether we live in Sierra Leone, Tchad, France, England, the US, or any other country in this world.

I am happy to report that we just received a message from our faithful lab tech wishing us a Happy Sabbath, and telling us that he is home and will not let anyone mislead him. Praise God, but, he will need all the power of heaven to stand against the will of his family.

“For our struggle is not against flesh and blood, but against the authorities, against the powers of this dark world and against the spiritual forces of evil in the heavenly realms.” Ephesians 6:12 NIV

For more frequent, up to the minute short updates please follow us on Instagram or on Facebook, we are Scott N Bekki Gardner.

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

Death In The OR

Yesterday morning Abba, my consultation nurse, called me into his office to see a young woman. Abscess from a cavity in one of her teeth was his working diagnosis. My nurses know that these are serious cases and need to be seen right away, so he had appropriately had me come in to see her, instead of just adding her to the stack of carnets (health-care booklets) on my desk. That would mean I would see her, oh, around 5 or 6 pm.

I agreed with his diagnosis, hard swelling around the neck, can’t open her mouth, in a lot of pain, been sick for a week. Yep pretty much a standard neck abscess from a cavity. It is truly amazing how much suffering can be caused from a very simple minor problem, not treated in a timely fashion. And as I have said before, it is not because Tchadiens are stupid, they are very smart. It is a matter of not knowing where to go to get help, and also not having the money to get there if you knew where help could be found.

I went back to my office, which is just next door to Abba’s, our doors are probably all of 5 feet apart, sat down and began writing out the orders, including her Operating Room sheet (fiche operatoire). We started her immediately on fluids and all the big gun antibiotics I had, and started preparing her for surgery, I wanted to get the pus out of her neck before the swelling blocked off her airway.

Three hours later we had her in the bloc (OR). She was given the usual ketamine/diazepam “anesthesia” that we use. We do cases like these 2 or 3, maybe even 4 or 5 times a month. Dental abscess, necrotizing fasciitis (flesh eating bacteria for the grocery store checkout magazine readers), fractured jaws, all these cases that prudent doctors uses general endotracheal anesthesia for. In other words, standard of care is to control the airway with a breathing tube. We control the airway by hoping the patient or family was truthful in telling us when they last ate, and by having a semi-functioning sucker handy if they seem to be vomiting or acting like they are aspirating. If things get really dicey we have an oxygen concentrator so we can give supplemental oxygen at 5 liters per minute. And we have the patient fully monitored, automatic blood pressure every 5 minutes, and continuous, mostly functioning pulse oximetry to monitor how well oxygenated the patient is. Then of course we stay observant to make sure the patient is breathing, although that can be lost sight of when we are busy trying to stop bleeding. I think you get the picture.

There is not one time I have headed into one of these cases without being scared spitless, wondering if this will be “The One”, “The Disaster”, that will end up in a blog. There are more things that can wrong, lethally wrong, than you can count, and there is precious little I can do if they do go wrong.

Things started out OK, Jeremie gave her enough meds to put her to sleep, her sats were good, she was breathing, we had prayer as we always do before each case, and then things started to fall apart. After prayer I opened her mouth and found pus, the abscess had obviously eroded into her mouth and drained there. We suctioned her out. I identified the most likely spot to open up her neck and found a pocket of pus. I put my finger in and broke into a much larger pocket, that covered most of her neck and under her chin. I could feel the mandible (jaw bone), the muscles, the salivary glands, but not a lot of pus came out, certainly not as much as I expected, and certainly not enough to remotely fill the cavity. She had obviously drained a lot of it into her mouth.

About that time the beep from the sat monitor started to drop. Unfortunately to compound things she was one of the rare large (read fat) Tchadiens. So her neck was short and fat, and very swollen. I immediately did a chin lift/jaw thrust which was quite easy because her neck was open so I could just hook my finger around the chin part of her jaw bone. That usually does the trick, as most commonly the problem is just a bit of airway obstruction due to a relaxed tongue and jaw. And it worked, sats started to climb. All the way to 85%. It should have gone to 99%. By now we had her on oxygen, we got an oral airway in, and a nasal trumpet. She was breathing, moving her chest, moving air in and out.

Then her sats started to drop again. Then they went back up, but not as high, then they dropped, and up. We gave steroids, kept up the jaw thrust, made sure the oxygen concentrator was actually working. She started to wake up and cough, so we sat her up, and tried to help her cough. Got the sat monitor working again. With her sitting up and coughing we got a good consistent reading of 99% for…not long.

My med student asked, “Is she breathing still?”

No as a matter of fact she wasn’t. We laid her back down. No pulse either. Started CPR, threw our whole ACLS pharmacy at her, adrenaline, made sure her airway was open, it was. Once she coded I tried to intubate her. The light was weak, the whole posterior pharynx was swollen and there was only one place the tube was going to go, into her esophagus.

I had been watching for the last 15 minutes as we had tried to avert this. I had seen her oxygen saturation keep going up and down, but never going as high as it had been. Mostly around 50-70%. I had watched her pulse rise, 120, 140, 150. I knew that once she arrested it would be over. I figured she had to have aspirated, probably was all the pus that wasn’t in her abscess cavity. What else would make her be hypoxic with an open airway?

We did the CPR anyway, my nurses were frantic, they found the bag valve mask and tried ventilating her. I learned that they had not a clue how to do chest compressions, and not a clue how to bag someone. That was probably the best thing that happened, because I have two western nurses and a western medical student, all who speak French who are going to do CPR and first aid training on Monday morning for our students and staff.

I finally stopped them, her pupils were fixed and dilated, even if by some miracle we pulled her back she would at best be brain damaged if not brain dead. I tried my best to break the news to her mother gently. I thought she might have a clue that things had not gone well when I brought her into my office with another nurse. But it didn’t work, she was not prepared when I got to the part about, “she died”. We tried to be as caring and compassionate as possible, but what can you say? No one, not even in Africa expect that their loved one will die in the OR, on the table. They were fine when they went in, what do you mean they are dead? Diana took the family and the body home in the ambulance, it was the least we could do.

Many of you who are reading this are medical people, doctors, nurses, physical therapists, and so on. I know what you are thinking, especially the surgeons and anesthesiologists, and OR and recovery room nurses, “What the h…l are you doing? Where is the code cart? What do you mean you are going to do CPR training on Monday, why haven’t you done it before? Why didn’t you intubate and secure the airway before you started?”

And you are exactly right, those are the questions, the right questions. I have sat on quality assurance, peer review committees for years in the US. If a case like this came to that committee, I would lose privileges faster than the time it takes to read this sentence. If you really want the answers to those questions I invite you to come and work with us for a while, I think you will find the answers you are looking for.

This young woman died because the quality of care didn’t come anywhere close to the standard of care found in most of the rest of the world, not even in much of Africa. But the sad reality is that as bad as it is, we have the best reputation for quality of care in the city. And it is a deserved reputation. When I look back at how far we have come in the last 2 years I am so proud of my staff. They are the best healthcare team in Tchad. Unfortunately that is not as much a commendation for us as much as it a glimpse of the reality of life and death in a country so far
behind most of the rest of the world we can’t see the taillights anymore.

It’s sad really, but I wasn’t surprised she died, I was surprised that in 24 months she was the first one.

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

System Fail

He died about 7 pm last evening. I don’t even remember his name, just another poor Tchadien. I do remember seeing him walk in though. He was brought in by pickup and walked in the back door, slowly, hunched over, holding his stomach. The other person brought in with him had a broken elbow and dislocated shoulder, from another accident, he had blood on bandage so he got seen first.
This young man, I will call him Mahamat, which has about an 80% of being right. Mahamat was in a fight, I was told, and he got stabbed in his left butt cheek. Typically not a lethal blow, but he was holding his abdomen and on exam had peritonitis. It was a pretty easy call, he needed an operation, today. In cases like this I write on their operative form, “Cas d’urgence”, which means it is an emergency and we can set up an engagement or payment plan. Frankly most of our non muslim patients don’t have 150,000 francs in their back pocket, ready to pay for their surgery. So paying for the surgery was not a problem.
We got started on his operation about 5:30 or 6. After the spinal anesthesia we turned Mahamat over and I stuck a finger in the stab wound, trying to figure out where it went, and to see if maybe he perforated the rectum. No stool, but lots of thin watery bloody fluid. I figured the knife must have gotten his bladder. We turned him back over and opened up his abdomen. Lots of bloody fluid there too, and sure enough a knife sized hole in the top of his bladder.
I got that closed but then it occurred to me that this didn’t make sense, how did the tip of the knife put a hole there in his bladder? That and the fact that red watery fluid kept welling up tipped me to the fact that there probably was another hole in the bottom of the bladder. So we opened up the dome of the bladder and sure enough, there it was in the bottom, another hole, the entrance hole in fact. We closed that hole and the dome of the bladder leaving a catheter in place. Checked the small bowel and reassured ourselves that somehow he had missed the rectum.
He still seemed to be bleeding from deep in the pelvis, but not a lot, so I closed the peritoneum and left a drain in the stab wound in his butt. I was worried about the left ureter as the hole was right where it should be, but figured he would drain urine out the drain tube if it was divided.
In the morning, his last morning, Mahamat looked OK, relatively stable, and not a lot of drainage out the drain tube, but lots of non-bloody urine out the catheter. Our lab was now open so we checked a hemoglobin on him. 5.8 (normal is 12-15). Very very low. That explained his tachycardia, and why when he sat up he nearly passed out. I ordered a unit of blood on him about 11 am.
Mahamat was in the Salle de Reveil, our ICU/ER/PACU, so I walked past him all day. He just laid there with a glazed over look in his eyes, really not moving or saying much. His abdomen was soft and not tender except around the incision, and it wasn’t distended. I couldn’t see any signs that he was still bleeding or that he was leaking urine. But I noticed the distinct lack of blood hanging from his IV pole, all day, no blood. I mentioned it to the nurses several times, asking about the transfusion. The only answer I got was we had no blood his type in the fridge, and he had only one person with him, his father, and he couldn’t donate blood.
About 5:30 in the evening his mother came from the village and we got word that they would like to donate blood now. I asked our lab tech if she would stay late to do the type and cross. She called me into my office and told me that we didn’t have the reagents to check the Rh factor, the + or – part of a blood type. Kind of important. Give the wrong one and people can die. She took a moto taxi over to the central hospital to find the reagent, and was successful, she brought some back with her. Mahamat died while she was trying to get the blood from his parents. It was about 7 pm.
We have patients die here all the time, most of them are almost dead when they get here. This death though is the most glaring example of a huge fail in the medical system as found here at the Centre Chirurgicale Adventiste de Moundou. In the US it would be listed as a preventable death at the trauma morbidity and mortality conference. It might even make the news, “Young neglected man dies while waiting for over 24 hours for a blood transfusion.”
Frankly, they would be correct. Mahamat died of neglect, he died because of negligence, he died because of terrible medical care. He died because our blood bank had one bag of blood in it. He died because he had only one person with him, and that person didn’t want to give blood. He died because we ran out of the necessary reagents to do a cross match. He died because the doctor here practices veterinary medicine. I patch them up and ship them out to wards where they either get better or they die. I make rounds there only on weekends, so our two nurses provide the medical care in the wards. I am too busy counting money, checking receipts, fetching betadine and bleach and gloves for the staff, figuring out why the power is out for the 4th time today, and why we have no water now, and taking care of the bleeding accident victim that just came in to have time to worry about someone I operated on yesterday.
But as any good quality control person will tell you, it is only bad if you didn’t learn from what happened and change the system. And they would be correct. But reality in Tchad is that there will be no review, no mortality conference, no root cause analysis, and nothing will change. His death will not make a difference in how things are done, or be a stepping stone for quality improvement. As long as third world hospitals in backwater places like Tchad are understaffed without adequate resources, including human and material resources many more like Mahamat will die of neglect, waiting on a gurney for care that won’t come before it is too late.
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

The Baby II

« Docteur, ce n’est pas nécessaire d’allumer la groupe. La bébé est parti. »

It is 4:20 am here. Josué came to the door at 4 to ask me to turn on the generator because the hospital was out of power, and the little baby was still alive but needing oxygen. Without power the oxygen concentrator doesn’t work very well. I went to turn on the generator but the tank was empty, the gas cans were empty. The barrel of diesel fuel was full, but the hand pump to fill the gas cans was locked up in Isaac’s maintenance office, at least that is where I assume it is.

So I went to get our little generator. It had only a little fuel in it. As I was putting gas in it, Josué came back and told me, « Docteur, ce n’est pas nécessaire d’allumer la groupe. La bébé est parti. », “Doctor, don’t bother, the baby died, we don’t need the electricity anymore.”

Just thought you might want to know the end of the story we started last night. This little baby died because the parents waited, out of ignorance and poverty, for too long before bringing her in. Even just a few days ago we could have easily treated and cured her. This little baby died because we don’t have the personnel, the medications, the resources necessary to take care of a little one that is so very ill. This little baby died because we didn’t do our job and make sure fuel was available to run the generator when necessary.

Hug and kiss your kids tonight, and thank God that you and they, by some weird quirk of fate, were born where these kind of tragedies happen only very rarely, not everyday.

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

 

The Baby

The following is a fairly accurate translation of a conversation between a nurse and doctor in a small surgical hospital somewhere in West Africa.

“Docteur, what can we do for the little baby who is here?”

“What baby?” I asked the nurse.

“The little baby just outside your office who came in this afternoon. She has a very high fever, and is having convulsions. Her oxygen saturation was 36% (normal 95-100%) when she came in. Now that she is on oxygen it is 96%. I have given her quinine, ampicillin, ceftriaxone, and Tylenol, so her temperature has come down a bit, but she is still not breathing well and…well what can we do?”

(A word of explanation, in the evening and nights we have no lab, so no way of doing diagnostic tests, and even if we did our tests are so limited and of such poor quality that it doesn’t really matter the results, everyone gets treated the same. Quinine for malaria, ceftriaxone for typhoid, ampicillin if you are a kid, IV fluids and sugar. Most people get better)

“Did you check her hemoglobin?” (These kids are almost always anemic.)

“No, no one has the key for the laboratory, and the lab tech is gone for the day.”

“Well, it really doesn’t matter anyway, we can’t do anything about it, if the hemoglobin is low. We have no blood, because the refrigerator that holds our blood bank is not working, so all the blood is clotted in the bags.  Also because we have no refrigerator we do not have ice to cool her with.  How long has she been sick?”

“Two weeks. Oh yes, and her pulse rate is high, over 200. What can we do?” Josué repeated plaintively.

“You can give her 250 cc of lactated ringers. And we could give her 50% dextrose, since most of these kids are hypoglycemic, but oh yea, we don’t have any of that either.”

“But docteur, the family is out of money, they have no money to buy any more medications.”

“We could send her over to the Regional Hospital, treatment for emergency care is free there.”

“In her condition, she won’t survive the trip.”

“Josué, you are right, besides they won’t do anything more than we are doing, and likely they don’t have blood either as they often send babies and kids to us for transfusions. Give her whatever she needs and give me the bill, I will deal with it.”

Josué left my office to do what he could, I walked home. It’s been a while since we had a baby like this. But never again would be too soon. This perfect little girl, 8 months old, struggling to breathe, fighting for her life. She is going to lose, tonight or tomorrow. Even if we had all the right stuff, when they look like this, they all die.

Even still my thoughts are tortured. Should I call in Solange our lab tech? Maybe she could find someone with the same blood type and give the baby fresh blood. The problem is our other lab tech is on vacation this month, so Solange has to work every day. Do I call her in now and wear her out with a lot of work on a hopeless case, or save my call for a case where she can really make a difference. The chances of finding someone tonight, with the right type blood and no AIDS, hepatitis or syphilis, are pretty low.

We have been dealing with the refrigerator for a month now. Isaac gets it running and it breaks down again. He is going to look at it tomorrow, again. Problem is Isaac is an optimist, and he can fix just about anything. But I need it fixed to last, not work for 3 days and then break down again. I probably just need to buy a new one. But I feel like I have replaced just about everything here in the year I have been here. Oh, yea, it is not just a feeling, I have done that. Everything here breaks. Anything electrical from the US doesn’t stand a chance. If anyone tells you 50 hertz doesn’t matter, don’t believe them. 60 hertz electrical motors do not like 50 hertz power supplies. They will run, but not happily and not for long. But the stuff you buy here is mostly made in China, apparently in the factories with little quality control, so they don’t last too long either, and they are very expensive.

We are out of a number of commonly used medications. Why, you ask? Because, our supplier, the government pharmacy here, is out of them. Why are they out of these meds you ask? Because their supplier, the central pharmacy in the capital is out of the meds, or maybe they are in a warehouse somewhere and haven’t been unpacked yet, or maybe someone took them and sold them all, who knows? So why not just import meds from say, Kenya, you ask? Because that is against the law and is forbidden, because their meds are better quality, cheaper, and more available, hence competition. And why you ask is this important? Because we make a large part of our money on selling medications, and when I have to send people to outside pharmacies to buy medications it cuts into our income, which is barely adequate as it is. Also the outside pharmacies are way more expensive than we are.

Speaking of medications, today I reviewed the inventory of meds from our pharmacist. We prescribe a lot of Cipro, and I noticed we had 4000 tablets of Cipro in stock, set to expire the end of April, 2015. And in Africa using expired meds is a huge no no. They are very very sensitive to that, the general belief is that we dump our expired meds on them so they just get second rate stuff. I thought we had just bought a lot of Cipro. A trip to the pharmacy confirmed just that, we bought 5000 tablets the first of March. The Central pharmacy sold us 5000 tablets of Cipro set to expire in less than two months. Thanks a lot.

So I am trying to run a little hospital here, and make it self-supporting (that is the goal anyway, admirable, but ridiculous) with unreliable power, unreliable water, limited medication, limited lab support, limited radiology, limited staff, equipment that is constantly breaking down, patients with no money to pay for their supplies, doctors with limited training and experience (at least at first) in what they are expected to do…etc, etc, etc. And then I sit back and realize I have described life at every mission hospital I know of, Bere, Batouri, Koza, here.

Most of the time I can just ignore it, or bury the feelings it brings. Not tonight. As I looked Josué in the eyes and saw the pleading look, “docteur help us,” and I had to tell him over and over, there isn’t anything else I or you or anyone can do, all the anger, frustration and pain found its way to the surface, and I have to deal with it.

Tomorrow, I will be better. The little girl will probably be gone, out of sight, out of mind you know, and I will hide those negative feelings back down deep where they belong. I will face another day of unknown challenges, hoping that God will show me the right directions to go, the right decisions to make.

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

 

Ousman and Ali

I heard a car behind me and turned around to look. I was greeted by the sight of a white Toyota Hilux (the most common vehicle in Moundou) disgorging a number of Arabic men. They were tugging on something in the back seat, and pretty soon the form of a young boy, 11 or 12 years old, was drug out, and hauled by his four limbs, without any spinal precautions, across the sand to our back door. I finished up the consult I was doing and gave the nurse a few minute to do his assessment, then I went out into the Salle de Reveil (our ICU, recovery room, ER combo pack) and asked the nurse what had happened. “It was an accident, Doctor.” I nodded in agreement, thinking to myself, “I am never going to learn, am I?” Ask a stupid question…So I found out it was a moto accident and that he had been unconscious since the accident, which had just happened a short time before.

I quickly looked him over, he was breathing fine, lungs were a little junky, but good breath sounds, no obvious fractures, tummy soft, not distended, pulse and blood pressure were OK, and no evidence of head injury, except a little swelling around his left eye. In fact, not a mark on him. Then I opened his eyes, uh oh, right pupil was already fixed and dilated, the left one was a little smaller but didn’t react to light either. I had already decided we aren’t doing craniotomies here, so I won’t be tempted to use precious resources in a losing cause (God can work a miracle without my help), and anyway without a CT scan I had no idea what was going on in his head, I just knew it was really bad.

So I gave my well-rehearsed speech to the family that we would do what we could, but that without a miracle from God he was going to die. Throughout the evening he developed problems handling his secretions, so we set up suction and showed the family how to suction him. His oxygen saturations decreased, so the nurses started oxygen, but he continued to slowly deteriorate as his brain predictably swelled.

The next morning after worship I went into the Salle de Reveil and noticed he was still there, but he seemed to be breathing easier, much less noise. I went over to him and touched his forehead, it was warm, but as I watched, his chest didn’t move. I felt for his pulse and couldn’t find it. Abba, our consultation nurse, came over and listened to his chest and quietly shook his head. Ousman had just died. The family members that were at his bedside still didn’t realize he was gone. We gently explained that the inevitable had happened, and as we had expected he hadn’t survived his injury.

Ali was across the room from Ousman, just a few feet away, he had come in the day before with a broken femur, also from a motorcycle accident. He said something to me in Arabic and motioned me aside. He had been there all night watching as the nurses had cared for Ousman, so I thought he was upset about having to see this little boy die. I wished I had a curtain I could draw so he wouldn’t have to watch, but there was nothing I could to protect him from this sight.

I am always amazed at the perfunctory way a family goes about caring for the body. His catheter and IV were removed and within minutes the body was on the back porch waiting for the Toyota Hilux to come back for him. All this was done in total silence, with stone faces, totally devoid of emotion. As I usually do at times like this, I retreated to my office and closed the door. I needed a few minutes to just sit, and mentally prepare myself for rounds. I keep my windows open so I have fresh air in my office, and I heard a sound outside. I turned my head and saw Ousman’s father squatted down facing the wall, body wracked with sobs as he mourned the loss of his son. It was the most private place he had to give in to his grief.

Later that afternoon we took Ali back to the OR to fix his broken femur. The case went well, it was a nice transverse fracture, there weren’t multiple fragments so we were able to get a good reduction and fixation with an intramedullary nail. And thanks to the techniques I learned from Dr. Orie Kaltenbaugh, the blood was minimal as well. Toward the end of the operation, Daniel gave him some ketamine in addition to the spinal, so he had the usual moaning and verbalizations people get with the ketamine. We give them valium too, so they don’t remember it. Anyway, he kept saying Ousman, Ousman, Ousman, over and over. I looked at the nurses and that was when I found out that Ali was Ousman’s older brother, and he had been driving the moto that had the accident that killed his little brother. The look, the words in Arabic, and the agitation of the morning now made sense, and my heart broke as I finished closing his physical wounds, knowing I couldn’t heal his heart.

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, Jaime and Tammy Parker 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. For our Francophone friends there is a French translation of our blog that you can find at http://gardnersenafrique.wordpress.com.

We welcome volunteers.

-Scott Gardner