MABINTY

The RAC Mobile Clinic Team, Sanko, Paul, Kadiatu, Mr. Abu, and Shawn Hannah, KCMA PA Student

The Restore a Child Mobile Clinic team heads out from the Adventists Health System-Sierra Leone, Waterloo Hospital each Tuesday and Wednesday, taking medicines to children in villages with no access to health care. The following story is told in the words of James Abu, our beloved CHO (Community Health Officer) and head of our mobile clinic program.

Mr. James B. Abu, CHO, Director of the Mobile Clinic Program.

This child, Mabinty Kanu, age 3, was seen during one of our mobile clinic sessions in a village called Masentigie. According to the mother, the child had been having a fever on and off for one week, which became continuous over the last two days before we were there. In addition, she was coughing and vomiting after every meal. Her abdomen was distended and she was obviously seriously anemic. She was so helpless that she could not stand without support.

Mabinty Kanu, sitting on her mother’s lap with an IV hanging from a Mango Tree.

I asked the mother, “Why have you kept this child at home until now?”

The mother’s reply was, “I had no money to take her to the hospital. To get even what we eat is a problem. I have been giving her some native treatment, but it does not help.”

I asked about the father and she told me he ahs separated from her and does not even visit to know how Mabinty is doing.

Mabinty was quickly examined by another PA student from Kettering, Olivia Kwiatkowski, and given emergency treatment with IV fluids and antibiotics. A motorbike was hired and she was transported to the Adventist Health System—Waterloo Hospital, where Mabinty was admitted and laboratory investigation confirmed the severe malaria and anemia. Treatment that had begun in the field was continued and she was transfused with whole blood.

Mabinty on the road to recovery, sitting up on her hospital bed.

By God’s grace she responded well to treatment and 2 days later she was discharged to home with oral medication. The mother was so happy and was crying as they left, saying, “Thank you for saving my child’s life. I pray that God will continue to bless you.”

Ready to go home!! Praise God!!

We shall be making a follow-up visit on her after one week to see how she is doing. But she would not be alive today with the Restore a Child Mobile Clinic Program.

James B. Abu, Community Health Officer
Restore a Child Mobile Clinic Supervisor

Truly this child would not be alive today if it were not for the mobile clinic program. And the mobile clinic program only functions because of donations given through Restore a Child and our other faithful supporters. Thank you and God bless each of you.

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

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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

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

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

SYLVAIN

« Oooh-Ohh!! Ça fait mal, ça fait très mal !! » Sylvain screamed in pain as he lay on the soccer pitch holding his left leg.

Sylvain is a normal 11 year old boy, in the third grade, the third of 6 children. His family is very poor, although he is lucky enough to still have both parents. They live in the village of Bembaida which is 117 km (70 miles) from Moundou. Sylvain’s family are farmers, and their little field only produces 2-3 sacs of grain a year. Now granted each sac weighs at least 100 kg (220 pounds), but for the whole year that is not a lot.

As I noted, Sylvain is a normal boy, and like all little and big boys here in Tchad, he loves to play football (soccer). On this particular day last September he was playing with his friends. It is not clear what happened, but he fell to the ground screaming in pain. He had broken his left femur (the main bone between hip and knee).

Now in every village you will find a traditional healer. A man or woman who has learned how to use natural products to heal the various maladies Tchadiens come down with. These traditional healers are also the local orthopedists. They set and splint broken bones, and often do a pretty good job, as long as there is no wound. If it is an open fracture, the standard of care is to go to the local health center where the nurse will carefully and beautifully sew up the wound, making sure that all the grass, dirt, mud, and seeds are kept in the wound so they can’t get out of the wound and cause problems. Seriously, last week a lady came in with a nasty cut on the top of her foot. It had been sewn up at the regional hospital. The nurses had carefully cleansed the skin with betadine before closing the wound. We took her back to the OR and under spinal anesthesia opened up the wound. We found a bunch of what looked like hard little larvae. I asked her what was in the truck she had been riding on. It was full of millet, which is a grain. The Central Hospital staff had carefully closed her wound leaving enough millet seeds in her foot to grown a small garden.

A well padded splint

A well padded splint

A bark splint

A bark splint

So back to Sylvain, his family called the local traditional healer who came four times and manipulated the fracture to get it set correctly, massage it, and do who knows what else. After the fourth attempt he admitted that this case was beyond his ability. Now that is a pretty impressive admission, as usually they just keep treating and accepting money until the patient gets better, dies, or the family fires them.
A mud plaster splint

A mud plaster splint

When you don't have string or rope, strips of bark and branches will do.

When you don’t have string or rope, strips of bark and branches will do.

Well the next step was to call the local “voyants traditionelles”. These are the “clairvoyants”, the witch doctors of the village. These individuals are also an important staple of each village. And everyone, Christian, Muslim, animist, all seek them out if all else fails. Well the local clairvoyants came and examined Sylvain. Their diagnosis was that one of the local sorcerers had trapped Sylvain’s soul and was holding it under a special Spirit Tree in the bush. Now these sorcerers, or evil clairvoyants are also a staple in the villages, and are used, again, by Christians, Muslims and animists (the traditional religion). If you have an enemy, or someone offends you, seek one out and they will, for a fee, cast a spell on the person, or somehow cause some evil to befall them. You may laugh, but it is real and it is true. And the spells work, people are killed or badly injured or fall terribly ill because of these spells. And it is not just a psychological thing. Bad things happen that shouldn’t when the cursed individual doesn’t even know he is cursed until after the fact.

So Sylvain’s soul was trapped by a sorcerer under a spirit tree. Not a good diagnosis, but it obviously explained the reason the traditional healer failed. Immediately after that Sylvain’s leg began putrefy. It became more painful, swollen and started to smell as the muscle began to die.

By now it was the end of October and Sylvain was dying. Fortunately for him, his parents were not about to give up, and they called the only person they thought could help, a friend in Moundou. On October 29 Jean-Paul went to the village and picked Sylvain up and brought him to our Center. He was, by this time, a very sick little boy. His hemoglobin was 3 (normal 12-15). He was given 4 units of blood and had his leg amputated, which by now was dead.
Sylvain spent over 6 weeks with us as he healed. Despite the fact that he lost his leg above his knee, he kept his life. We were able to share with him and his family the story of Jesus. And Bekki was able to arrange with our local Handicap Center for Sylvain to receive a new artificial leg.

Sylvain

Sylvain


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

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”.

image

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

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