Wednesday, July 15, 2015

Independence & Storms

Some big storms can knock down some big branches. So I encourage my children to gain independence... And go at it with an ax. But don't worry, there was supervision. Brya, who was also chopping. Don't judge me for allowing a woman to chop up my tree. I'm just trying to keep the local workforce employed. 

Olen Netteburg

Missionarydoctors.blogspot.com

Danae.netteburg@gmail.com

Olen: +235 91 91 60 32
Danae: +235 90 19 30 38

Olen et Danae Netteburg
Hôpital Adventiste de Bere
Boîte Postale 52
Kelo, Tchad
Afrique

Volunteers Welcome!!!

LIONS AND TIGERS AND... Hippopotami?


So what do you do if you're telling the story of David killing bears? In a place with no bears? In a language with no word for bear? Where nobody's ever heard of or seen a picture of a bear?

Yup, that's right! Our David killed a hippopotamus to protect his flock!!!

Go Eric for thinking on your feet!!!

Monday, July 13, 2015

Inappropriate


I get tired of paying peoples medical bills. Particularly children. Well, thats not entirely true. I get tired of parents refusing to pay their kids bill. The kid is innocent. But Im still much more hard-hearted than Danae. I may be vomiting my guts out from malaria, but I still would rather round myself on pediatrics than let her do it. I cant afford otherwise. Danaes too soft. She always agrees to pay for every childs medical bills. Shes already paying too many medical bills on the maternity ward, despite most of the treatment there being free. It would be cheaper for her to stay home and not get paid than for her to work and pay everybodys bills.

In the last four+ years, Ive tried multiple methods of coercing parents to pay their bills. At first, I tried the optimist/pragmatic approach. You know if you buy these medicines, your kid will get better, right? And if you dont, hell die, right?It didnt work.

So I switched tactics. I tried the guilt tactic. What kind of father wont pay for his kids medical bills?That didnt work either.

I tried the financial approach too. You realize its a lot cheaper to pay for these medicines now than it is to pay for the kids funeral.That never convinced anybody, even though its true. And theyd find the money for the funeral.

I tried shaming. Dude, you have a super nice watch. You have a cell phone! Go leave it at the pharmacy as collateral. Once you pay off your bill, you can come pick it up. Or your bicycle. Or your cooking pot. Anything! Seriously? Your cooking pot is more valuable to you than your childs life!Even this didnt work, boggling as it may be.

I tried threatening. You know, kids are expensive. They dont come out of the vagina holding money in their hands. You need to feed them, pay for their medicines, pay for their school. They are expensive. If you cant afford to pay for the childs medicines, we give birth control away for free here! Male condoms, female condoms, pills, shots, intrauterine devices, implants, vasectomy, you name it! Free! Ill even pay tie your tubes! If you cant afford this childs medicines, he will die. Then youre just going to have another one! And guess what?!?!?! I can promise you that next child will be sick eventually too. And you wont buy the medicines for the next child either?!?!?!?! And they will die too!!! And some day, you will need to answer to God how you decided to have a bunch of kids that you refused to take care of, chose your cell phone and cooking pot over, and allowed to die, all because you couldnt pay $2.10 for intravenous quinine!!!I was always screaming by this point. Hence the exclamation marks. Remarkably, this had been my most effective technique.

But the other day I was rounding on pediatrics again. Once again, a very well-educated and well-dressed couple inform me they wont be able to pay for their babys medicines. $2.10. I remind them we gave them free medications the day before and we told them they would need to spend the day looking for money to buy todays medicines. I also remind them they are from Bere, so surely have plenty of friends, family and neighbors who will loan them $2.10 to pay for their kids treatment. The father starts a not-unfamiliar tirade about how I am an American and cant understand because Americans only have two or three children each, maybe four. Its easy to pay for only four children. I agree with him. Why do you keep having so many expensive children? Why not just stop at four and take good care of the four you have? He thinks about it for a while. Then decides he had better just stick to the party line. We dont have any money.

I know this tactic well. This is when parents enter the game of chicken. They lock you into a stare down. If the kid is just a little sick, this game can go on for days. If the kid is a lot sick, and they dont realize it, the kid can die. Or if the kid is a lot sick, and they do realize it, the parents figure its futile and a waste of money and no way will I cough up the money as the father, but if you want to pay for my kid as the visiting missionary I suppose I could be sufficiently gracious to allow you to do that. Usually, the parents will finally produce the money. Occasionally, rarely, I lose the game of chicken and I agree to pay. But Im not ok with the innocent child losing in this game. This is so frustrating. Taxing, even.

At this point, after seeing this child suffering and talking to these resourced parents, and after taking part in this ludicrous dance each day of the last four years, my soul sighs. Somewhere deep within, I feel my heart inhale deeply and then fall, letting it all out. I give up. I am no longer angry. I am barely even sad. I am simply tired, at the end of my rope and letting go.

So I turn to the mother.

Did I have sex with you?

The mothers jaw drops. Her eyes get wide. The husband takes a step back (which, I note, is better than a step forward). Even my nurse turns and looks at me.

The mother is quite certain she doesnt understand the French this crazy guy is speaking. Huh?

Did we sleep together?The neighboring kidsparents are overhearing this and are getting curious. Boy, imagine that! We may have quite the story to tell in the market about what the white missionary is doing in town!

No.

Youre sure?Im wading pretty far outside of what was taught at the three-week missionary training course we took. Although, admittedly, I did skip a lecture and the asking-the-national-if-youve-ever-had-sex-with-her topic may have been discussed in my absence. And Danae is a lousy note-taker.

We never slept together.

You are absolutely certain you and I have never had sex with each other? I mean, Im a heavy sleeper and Ive been known to sleepwalk. And every time I have malaria theres about three days Im completely out of it and dont remember a thing. Maybe we had sex and Im just forgetting it.

No. You never had sex with me.

I turn to the husband. Did I ever sleep with your wife?

No.

Theres no doubt in your mind?

You never slept with my wife.

Ok. Then that baby isnt mine.

The lights come on. The relief is evident. The husband smiles. The wife starts cracking up. All the eavesdropper in the room, and even in the next ward over, start laughing out loud.

So I never had the pleasure (presumably) of sleeping with your wife. This child will never work in my fields. And this child will never take care of me when I am old.

And then the coolest thing happens.

With a smile, the father of the baby shakes my hand, nods his head recognizing I just out-maneuvered him in his own game of chess, pulls a large bill from his pocket, and walks off to the pharmacy.

I feel my heart inhale again. I feel a smile on the corner of my lips. Respite for the soul can come in the strangest of circumstances.

(Ive used this same method now repeatedly. And astoundingly, it works every time. Everybody smiles and laughs and the father digs out some money to pay his bill.)

Restore a Child has given many significant donations via Adventist Health International to pay for bills on pediatrics. Its been a huge blessing. So now Danae can round on pediatrics again without emptying out our safe! But its always a challenge trying to determine who is truly needy and wont be able to pay their bill and who is playing the deadly game of chicken.


Olen Netteburg

Missionarydoctors.blogspot.com

Danae.netteburg@gmail.com

Olen: +235 91 91 60 32
Danae: +235 90 19 30 38

Olen et Danae Netteburg
Hôpital Adventiste de Bere
Boîte Postale 52
Kelo, Tchad
Afrique

Volunteers Welcome!!!

Hemotoxic


I hate snakes.  I hate snakes.  I hate snakes.  

I hate them even more after this story.  

We have some neurotoxic snakes.  Their venom attacks the nervous system.  There are other types of snakes here that are hemotoxic.  Meaning once you get bit, the venom binds to your bloods clot-making system, causing it to quit working properly and your blood can no longer coagulate and make clots and stop bleeding.  In our worst cases, our patients slowly ooze from their IV sites, from their ears, from their nose, from their gums, even from their eyes.  They cough up blood, they vomit blood, they poop blood and they almost always pee blood.  Slowly.  No big gushing fountains of blood.  Just mere oozes.  Oozes that never stop oozing.  And despite the slowness of the oozing, you eventually outstrip your bodys ability to make new blood.  Your marrow cant keep up with the slow oozing.  And you eventually hemorrhage to death, or bleed out.  

Scary, right?  Remember the Ebola epidemic?  Caused you to bleed out.  Same thing.  Only if you get bit by a snake you arent contagious like with Ebola.  

I once had a pregnant patient come in with a nose bleed after getting bit.  It stopped eventually and she did fine.  Ive had another pregnant patient come in after getting bit, lost her baby, delivered, stayed in a coma for a day or so, but eventually recovered. 

Ive had some real disasters this month.  This was one of them.  But somehow I had a bit of hope for the patient who came in last week.

She was a young village girl coming in with vaginal hemorrhaging at six months pregnant.  I mean, she was really pouring out blood, not oozing.  Vaginal bleeding, we know how to treat.  The only thing is she had been bitten by a snake four days prior with no antivenin (anti-snake-venom) given.  Andour hospital was out of antivenin.  Sigh.  

With uncooperative blood like this, its never a good idea to do a c-section.  Id rather get her delivered vaginally.  However, she was bleeding too much.  And we werent certain that her blood wouldnt coagulate, just speculating since we have no labs to test that here, except for cutting the patient and sitting around and watching to see how long it will take the blood to create an effective clot, if ever.    

So c-section here we come.  

Mom was completely alert and talking as we wheeled her into the OR.  I dont like to scare people, nor do I ask everyone if they know God before surgery, but this one just was a setup for disaster.  You see it over and over here.  You can see death has a higher possibility of occurring in this patient, but not in that one.  You think about it later and wonder if it would have changed their eternal outcome if you would have said something and told them it was easy, just accept grace, unmerited favor.  No point in wondering anymore. 

Like most of my patients, she didnt speak French.  I asked her through an OR nurse if she knew God.  She said she did, but seemed shy and not real clear with her response.  I told her it was never too late to decide you wanted to be on Gods side.  The thief on the cross decided right before his death. We prayed and started the c-section.

Cut through skin, fascia & uterus.  Got tiny little baby out.  Only about 1 pound.  Looked dead already, but had a heart beat.  Lived only a couple minutes.  

Closed uterus.  Uterus wouldnt contract well.  Put stitches around uterus to help it stay contracted.  Seemed to work.  

One problem.  Her muscle.  Her abdominal muscle would NOT stop bleeding.  And her uterus then started to bleed from the suture points.  A few more sutures put in.  Sutured up the muscle as best as I could.  Next her subcutaneous tissue (her fat) kept bleeding.  I kept suturing, closing off all of the tiny vessels that wanted to bleed out.  They were begging for a way to let her blood drain.  Skin sutured.  Done.  She wasnt hemorrhaging vaginally.  Her conjunctiva looked pink.  Sigh of relief.  

Five units of blood were given during her surgery.  She was blood type O positive and we only had six more units in the fridge of O+.  I put a very pressurized dressing on her lower abdomen and prayed for the best.  Sometimes thats about all you can do here.  

Two hours later Ndilbe told me she did not look well and looked really anemic again.  

Oh boy.  This wasnt going to end well.  I knew it.  Mason knew it.

But as a doctor, its hard to sit by and watch someone slowly ooze to death without trying everything you can do.  So we try.  We try despite our knowledge this is unlikely to work.  But you think theres a chance.  You give the patient that slim chance.  And then you leave the rest to God.  

We urgently brought her back to the operating room.  She was not the same young girl, alert and talking.  She was in a bad state.  Anemic and out of it.  

I reopened her and found a belly full of blood.  The abdominal wall muscles simply would NOT stop bleeding.  Now bleeding seemed to come from everywhere.  I wanted to try to block off all of the big vessels that might be causing her hemorrhage.  I did an emergent hysterectomy.  There was no more pelvic bleeding.  I ligated her bleeding abdominal muscles again.  I closed her again.  

We tried.  Mason poured more blood into her.  Yet five more units for a total of ten bags of blood.  When I finished the surgery, he held up his last unit of O+ blood, and we agreed reluctantly, hesitantly, somberly, that we couldnt give it to her.  We needed to leave something for the inevitable pediatric patient with a hemoglobin of 1 or 2 or maybe 3 who would certainly come in that night, like they do most nights this time of year.   We did everything, except give an eleventh bag of blood.  

She lived another eight hours.  And then she died.  She died of a snake bite.  One that we dont have the antivenin for.  And one that the family refused to go to Lai (18 km away) to get the available antivenin.  It costs 38 dollars there.  And we hadnt charged her anything for the care we gave her.  Honestly, it probably wouldnt have made a whole lot of difference.  It was already so late in the game.  

We wont know the real outcome, her eternal destiny, until Heaven.  Only God knows.  Until then, we keep trying.  

Tuesday, July 7, 2015

Chadian Ambulance

Congratulations. You are now a Chadian villager. You are happy
living a simple, rural life. You live in a small mud hut and provide
for your family with the simple crops that your field produces. You
sometimes sell chickens or goats in the market. You don’t have much
money. But you don’t need much money either.

You are a woman. You are a mother. You have cared for many children.
Each one is special to you. Your daughter gets married and is now
expecting. Her family will soon be expanding.

You get word that your daughter has been having seizures at home. You
don’t live in the same village as her, but you must get to her. The
roads are bad because the heavy rains have already started, but none
of that matters to you. You must get to her.

You find your daughter at her home in a coma. Her husband has not
taken her to the hospital even though she has been seizing for many
hours already. You know better. You know she needs help.

You don’t have transportation. You ask people around if they know
anyone who can get her to help. One young man knows someone else who
has a motorcycle.

The motorcycle arrives. Your daughter is not waking up. Her body is
floppy and difficult to position on the motorcycle. It doesn’t
matter. She must get to help. You position her behind the driver and
sit behind her so she doesn’t fall back. Her legs flop down on the
sides of the motorcycle. You prop her head up between you and the
driver. This must work. You must get help.

You arrive to the nearest health center. You carry your limp daughter
to the door only to find out they are sending you to the nearest
hospital.

Back on the motorcycle. Just as you are taking off she starts seizing
uncontrollably. It’s really scary. You think she is dying. Finally,
after what seems like an eternity, she stops seizing and goes limp
again.

Off again over the bumpy, mud-slicked roads. You hold tighter onto
the driver in front of you so your daughter will not slip from between
you. Her breathing is rough now.

You get to the hospital.

Only to find out they are referring you to the mission hospital 20 km
away still.

More bumps, more puddles. More seizing. Whatever it takes.

Finally you arrive at the mission hospital. It has been over 12 hours
your daughter has been seizing and not speaking. The people there
explain that your daughter is suffering from toxemia of pregnancy
(eclampsia) and that she needs a surgery to deliver her baby to make
the sickness go away.

You wait outside of the place where she is having surgery. You are so
tired, but you refuse to sleep. You have to stay awake to see your
daughter come out of the surgery place.

After a long time the doctor comes out and explains that your daughter
is very sick. The surgery went well, but unfortunately the baby was
too sick and has died.

Your daughter stays in a coma for the next 2 days. The staff tries to
reassure you that sometimes this happens and people can still survive.
You do what the staff ask, repositioning her, massaging her legs. You
keep a little hope left. You are so tired still. You have barely
slept in the past few days. You would do anything for your daughter.

The morning of the third day your daughter opens her eyes. Your
daughter, who you fought for, opens her eyes and talks. She asks for
water. Words cannot express the joy you feel. It was almost
hopeless, and then she recovered. And you are so thankful. You have
your daughter back.

This is a true story. In the past week, we had six seizing pregnant
patients come in. There’s not much going on in the hospital, as far
as elective cases, but the emergencies are keeping us busy somehow.
It’s hard to tell sometimes which sickness they have when they have
signs and symptoms of both eclampsia and cerebral malaria, so we treat
them both. You can’t really base your decisions solely on blood
pressure or fever or other tests.

So far none of the six have died. One walked home today. The patient
in this story has fully recovered. Two of our patients are still
seizing postoperatively. Our hospital has run out of magnesium, a
medicine to prevent seizures in this sickness. Luckily I found some
expired magnesium hidden in our office, but it is from 2013. It’s
probably less potent now. It’s also illegal to give expired
medications here now.


Many, many times I see this burn on a comatose patient’s leg. It’s called a Tchadian tattoo to those who have visited here. Even if you are not comatose, it’s easy to get burned. But when you are unconscious, your legs flop so easily on the sides of the motorcycle, it’s impossible to not get burned. The burn is the easy part to heal. Sometimes it’s not so easy to fix the underlying problem.

People use all types of ways to get their loved ones to the hospital. The least common method is by car. Other ways are moto (motorcycle), ox cart, donkey, pousse-pousse (a hand pushed cart with large wheels), and by foot.

Wednesday, July 1, 2015

Tchad bombings


More bombings in Ndj this morning. I'm not saying this to scare you all, bc we are far from the capital but doesn't make me want to leave the country either bc I have to go trough NDJ.
Here's what another missionary wrote/discovered about the situation, "the story is that the Tchadien police discovered a BH safehouse and raided it this morning. Those in the house blew themselves up which also killed 5 police officers. So it was not another attack except that the police attacked them. Still terrible but makes us feel better about it. "
Prayers appreciated!
This just after the bombings 2 wks ago. Hopefully things calm down before we are to go back to America in 3 wks (leaving via Ndj). Another reason why I don't like cities!

Tuesday, June 23, 2015

The Bomb

For those who haven't heard, N'Djamena just became a victim of international terrorism. Boko Haram, a terrorist organization based in Maiduguiri, Nigeria, crossed into Tchad last week and orchestrated twin suicide bombings, killing 29, wounding hundreds and striking fear into the hearts of many, causing them to seek out what could protect them, for some the Koran, for others the Bible, and for a great number, whatever spirits they feel can do them the most good. 

I want to thank you for your prayers. We covet them. I know there are many families and individuals who pray for us daily. 

The bombs went off in places we have been to dozens of times. My colleague, Dr Odeï, was scheduled to be there at that moment, applying for his passport. Due to a last-second cancellation, he wasn't there. Two other volunteers were driving away when the bombs exploded. They heard them and saw the smoke. 

This is real, but we remain optimistic. Optimistic security will now be at an all-time high. Optimistic Boko Haram will go back into its cowardly hiding. Optimistic Boko Haram will soon be annihilated. Optimistic God hasn't brought us this far not to have us finish the work He's set before us. Optimistic God will continue to protect us. Optimistic this will all not matter soon enough, and we will be on our way to a better home than even America can provide. 

Olen Netteburg

Missionarydoctors.blogspot.com

Danae.netteburg@gmail.com

Olen: +235 91 91 60 32
Danae: +235 90 19 30 38

Olen et Danae Netteburg
Hôpital Adventiste de Bere
Boîte Postale 52
Kelo, Tchad
Afrique

Volunteers Welcome!!!

Friday, June 19, 2015

Tchadian medical case of the day:

I rounded on medicine today since Odeï is out of town for a few days. Every day I follow his patients on the electronic medical records system and physically walk through the wards and ask Odeï and the nurse how the patients are doing.

So I knew already there was an elderly gentleman admitted for stroke nine days ago. They asked me what could be done when he arrived initially and I talked with them about blood pressure control and aspirin. Of course, the nearest CT is a day's drive away an out of people's budget, so we go with the 85% thrombotic rule and treat everybody with aspirin.

We had also discussed the benefits of a nasogastric tube and started him on feeds and switched him to oral medications a few days ago.

But today was the first day I discussed care at his bedside or examined him or talked with his family and I took the opportunity to delve a bit deeper to confirm his diagnosis.

I looked through the chart again and saw he had received quinine, ceftriaxone, flagyl, vitamins, parasite medications and just about everything else our pharmacy has to offer. And all tests were normal.

So I asked his wife, "Has he said anything?"

"No," she replied, but still smiling.

"Does he move?"

"No."

"Does he eat or drink or swallow?"

"No."

"Does he open his eyes?"

"Oh, yes! Just the day before yesterday he opened them. He's getting better!"

OK, great. So I have a vegetable whom the family believes to be improving and cares enough about for them to be feeding him via nasogastric tube 24/7. This means they won't be eager to take him home to die.

Then I noticed how skinny he was.

"Has he lost weight since coming to the hospital? Are we not putting enough into his nasogastric tube?"

"No, he's always been skinny like this."

"Oh. Um. OK. Does he normally walk around at home?"

"Oh my no. He just sorta scoots around on his bottom."

"Oh? For how long? A couple weeks?"

"For several months probably."

"Like since April?"

"Before then."

I figure I should speed this up. "2013?"

"No. He wasn't walking then either."

"OK. But he was talking and eating before he just recently got sick, right?"

"Oh yes! In fact, he was eating and talking and banging on the ground with his fists when he got sick."

"OK, so then... Wait. Did you just say he was banging on the ground with his fists when this started? Did it start suddenly or gradually?"

"Suddenly. I mean, one moment he was banging on the ground with his fists and quite literally the very next moment, he fell over on the ground."

"Uh. Weird. Was he singing and the ground was his drum?"

"No. I don't believe so."

"OK, was he seizing?"

"What's a seizure?"

"Never mind, was he trying to get your attention? Was he with it? Was he choking?"

"No, silly white guy. He was talking very clearly and loudly and banging on the ground right before he keeled over."

"OK. I need you to help me out. What EXACTLY was he saying the precise moment he fell over?"

"Well, he was in the process of putting a curse on his sister and her children saying they would all die, but he keeled over right at the end just before he could finish the curse."

And... Discuss. I skipped this lecture in residency at Baystate.

Olen Netteburg

Missionarydoctors.blogspot.com

Danae.netteburg@gmail.com

Olen: +235 91 91 60 32
Danae: +235 90 19 30 38

Olen et Danae Netteburg
Hôpital Adventiste de Bere
Boîte Postale 52
Kelo, Tchad
Afrique

Volunteers Welcome!!!

Sunday, June 14, 2015

Moving on up---MUST READ PREVIOUS BLOG for this to be complete

So how does Bere move past the huge amounts of money that has been stolen by hospital employees? (See previous blog.)


Fed up with all the stealing, we had started randomly asking patients where they had paid for their labs when we couldn’t find a receipt. One gentleman told me that he had paid outside of the lab (they are supposed to pay at the cashier’s office). The patient was all set to show me who he gave the money to, but the employee wasn’t at work that day. I was sure who it was, but two days later when I asked him to identify the accused, he could no longer be sure who it was. I’m sure someone else had gotten to him first, and told him to be quiet. And probably paid him to do so. Others we discovered and fired.


But we’re tired of all the interrogations and corruption. I didn’t come to Africa to practice criminal investigation. I came to practice medicine. But it seemed that so much of my day was taken up asking where the patient got this medicine, or where did he pay, or why weren’t the number of medicines correct with the receipt. It was getting old. Time after time this kept happening. We were firing people left and right for stealing.


So we decided to be proactive.


One way to do this is with our A-team!


Introducing Dr. Dirk Wunderlich and Zachri Jensen!


If you’ve ever visited Bere Adventist Hospital, you have seen our patient charting. You have seen our notes and orders scribbled down in the little patient medical book called a carnet (car-NAY).


But lo and behold, things have changed!


We now have an Electronic Medical Record system!!!


Dirk, a German neurosurgeon, came to Bere via providence. Looking for something to do with his vacation, he emailed a supporting mission of the Adventist church and said, well, if they respond, maybe I’ll go on a mission trip. If not, maybe I’ll take a week and go skiing!


Well, the organization forwarded the email to a friend, who forwarded it to Olen, and Olen replied to Dirk, all in the matter of a few minutes. Olen explained to him that there wouldn’t be any neurosurgery to do, but he’d be welcome to come anyway. Dirk, figuring he’d never hear back and would be free to go skiing, was surprised and figured he shouldn’t ignore providence. So he came!


When Dirk got here, he was… Well, he had the same reaction everybody has when they see our hospital for the first time. A reaction that can’t really be put into words. Overwhelming needs. He was also crazy enough to think he could implement an EMR in the bush of Africa. Olen told him he could do it if he was willing to foot the bill and do all the work. (Olen is generous like that.)


Dirk had already created a note-tracking EMR for hospitals in Germany and Australia. So he set to work writing code so the program could do everything else we needed it to.


Again by providence, Olen got a random email from a Walla Walla University student, Zachri Jensen, asking if there was still validity to an ancient request we had made for somebody to start a computer school. We told him no, but there’s this project to implement an EMR. He agreed to help.


Now here’s where providence turns into divine intervention…


In November, when Zachri arrived, most of my staff had never touched a computer. Including 100% of my pharmacists and cashiers. Literally! As in, they didn’t know what one felt like on their fingertips. Let alone find the on button. Including my 58-year-old charge nurse and lead consultant in the emergency room, our main intake for the entire hospital.


So when we say, ‘Our first lesson was “Here’s the on button,”’ that’s a lie. Our first lesson was, ‘This is how you open a laptop. Now here’s the on button. And now here are the keys you need to peck at to log in.’ Our first hour was spent logging in.


In December, we started twice-weekly hour-long lectures. In mid-January, Dirk arrived to work out some kinks. January 24 at 9pm, we went live. Think about that for a second. In less than two months, we went from a majority of employees never having caressed a computer… To having a functional EMR. This may seem daunting for an American nursing staff to all learn a new EMR at once. But my nursing staff was different…


On top of this, there was ZERO network installed when Zachri arrived. He had to set up a server, a router, a switch, six unidirectional antennas and five access points. In addition, he built into the network no less than six backups of our patient data, five updated continuously and the other updated hourly and saving the backups for a month. Oh, and he also translated the EMR from German/English into French.


On top of this, we went live during our highest patient volume period (well over 2000 new patients per month for the first three months in a 70-bed hospital with 23 nurses).


And 100% of my employees have bought in.


We use this EMR for registering patients and their demographic data, prescribing ultrasounds and lab testing, ordering surgeries and tracking the surgical schedule, ordering medications, tracking ALL income, receipt printing, tracking ALL stock, automatically generating medication and consumable purchase orders for the hospital to prevent our stock from running out, surgical reports, ultrasound reports, admission notes, progress notes, discharge summaries, staff list, track floor usage of consumables, track inpatient list by service, track individual prescriptions of our precious free medications, track individual intake by each cashier/pharmacist and many other things. In addition, the software is capable of doing payroll and data mining and a glut of other modules we haven’t implemented.


This also opens up huge avenues for research too with capabilities to search the medical records.


Our humble little bush hospital, in a region of a million people with no electrical grid or public running water, 42 kilometers from the nearest pavement, computer-illiterate… We have an electronic medical record, despite all my bets against it. Credit goes where it is due. A really hard-working staff, three genius programmers (Dirk, Zachri and Adrian) and a pretty amazing God.


We are convinced that stealing, like in the rest of the world, is like a cancer. We can’t completely stop it. But we can better control it. We are so thankful to Dr. Dirk and Zachri for setting up and continuing to work out the details of this system!


Bere will never be the same! We have moved on up!!!


(We should state that this system has actually helped us continue to catch thieves, although we won’t reveal our secrets and state how.)

Toileting Looting



Ok, so it’s time to catch up a bit. Haven’t really written much since December, so probably won’t go into too much detail. (Nah, just finished writing. It’s a lot of detail.)




First of all, a huge thank you to all the people who gave us money in December. We started the month in the hole. We were actually borrowing money from AHI-Global to do our AHI-Tchad specific stuff. But thanks to your incredible generosity, we came out of the hole and more, and we haven’t yet had to stop our activities, even six months on. So thank you very much for allowing us to do what we do. We hope our projects represent you adequately and make you proud to be a part of this, whether your involvement be financial, volunteering, praying, thinking good thoughts (for my heathen friends who don’t pray and don’t mind me calling them heathen) or even just reading our blog.




First thing I should tell you about is a few of the challenges we’ve faced since December…




We’ve been doing our best to clean house at the hospital, at least as far as staff go. Since December, we’ve fired several for being drunk at work, several for sleeping with colleagues or minors, several more for stealing, others for absences, others for falsifying documents… I could go on and on. It’s been extremely stressful and depressing work, but I’m optimistic that it’s leading us toward establishing a team that can be a great witness for our God.




What follows is a blog Danae wrote about one of these cases… (Olen’s notes in parentheses.)



Toilet Looting

I remember the day well. It was the 13th of January. I had a ton of cases waiting to be operated on. The OR had already prepped a hysterectomy for me. Dad is fully capable of doing a hysterectomy, but I really want to do them all myself since I’m preparing for my oral boards this year (you have to collect all of your cases for an entire year!). So when I yelled into the OR to have Dad just do the case, it was clear that something more important was going on.

(Back story: Back in October, after firing another pharmacist, my administrator Antoine made the decision to move to triplicate receipts from duplicate receipts. One receipt stays with the cashier, one receipt stays with the patient and one receipt stays where the service is rendered, be it consultation, operating room, ultrasound, lab, pharmacy, etc. Antoine ordered dozens of books of triplicate receipts, organized them into sequence numbered 1-24000 and put them into service. We started with receipt number 1 and had now progressed up to the 16000s. One day, we noticed a receipt in the 21000s, which seemed odd. Antoine checked his stack of receipt books and, sure enough, somebody had been pulling the receipt books off the bottom of the stack, without signing them out. And the three receipt books he had hidden in his file cabinet were gone too. There were eight receipt books missing in total.)

(So Zachri, a student missionary, and I looked through our surveillance video and discovered the cashier was switching out receipt books several times a day. It was clear as day. He’d see somebody come up with a surgical form, which looks different from all over forms and is a much more expensive bill than anything else, then close his window, pull out the naughty receipt book from under a pile of papers, switch the books, then open the window and work for a couple hours out of the fake receipt book, then close the window and switch back. He might do this twice in a day. At the end of the day, he’d smash a massive wad of $20 bills into his back pocket and walk out.)

(However, it was clear he wasn’t working alone. He didn’t have access to Antoine’s office. Furthermore, the receipts that were turned into us every morning from the previous day’s activities… and the false receipts were always missing. So either everybody was in on it… or my accountant was in on it. I didn’t want to believe that as my accountant had become one of my closest and most trusted friends. I even paid thousands of dollars out of my own pocket for months of lovenox injections when he got a DVT/PE. It hurt pretty bad. I was eager to have concrete proof one way or the other.)

(So at 9pm, I snuck into the hospital and slipped into the ultrasound room and locked the door behind me. By light of headlamp, I counted seven bogus receipts in the stack. Then I snuck into the operating room. With a surgical instrument and my headlamp I extracted two fake receipts from the locking box, to which I didn’t have a key. I then returned them to the box. I looked in both consult offices, pulled more receipts out with my surgical instruments and headlamp and discovered even more false receipts, numbered in the 21000s when all the real receipts were numbered in the 16000s. I had enough proof, so I went to bed and tried to sleep.)

(The next morning I went into the hospital and counted the 21000 receipts in the ultrasound office again. Still seven. I opened the door between the ultrasound office and my office and I sat in a chair. My accountant came in and took the receipts. All of them. I saw it with my own two eyes. I was 100% certain he took all the receipts, including the seven bad ones. And just to be certain, I had written down ALL the receipt numbers, good or bad, from the ultrasound stack.)

(I then went to Antoine and told him to detain my accountant when he arrived to deliver the previous day’s receipts in an envelope, as was his daily habit. An hour or so later, the administrator called me to say my accountant was there with the receipts.)

(I went into the room and asked my friend, the accountant, Are those ALL the receipts from yesterday? He replied in the affirmative. There aren’t ANY receipts missing? He said no. So I asked him to open the envelope and separate the receipts into those from the 16000s and those from the 21000s. He looked at me dumbfounded and claimed there were none from the 21000s. So I asked, Are you certain you are the ONLY person with a key to the receipt boxes and that you collected ALL the receipts this morning and ALL the receipts you collected are in that envelope? He insisted it was true. So I made him open the envelope and confirm there were no receipts from the 21000s, which he did. I asked him where he had put the receipts from the 21000s. Then my friend, who was a leader in our church, looked me in the eye and told me, ‘Doctor, before GOD, I know nothing about any receipts in the 21000s.’ I asked him to go home before he could invoke the name of God again, think, and come back in two hours.)

(At nearly the exact same time, Miki, another student missionary, called me. I had asked her to watch the live surveillance video feed and call me when the cashier closed the window, switched books, and opened the window again. She said it just happened. I walked in and found the receipt book in the 21000s. And under a pile of papers, the receipt book in the 16000s. I picked up the receipt books and didn’t say a word to him, but asked him to give me his key and go home and come back in two hours.)

(They came back and continued to deny it, ‘Before GOD!!!’, repeatedly. I never asked them to swear anything before God, they just kept saying it themselves. And of course, they’re tribesmen. After several hours of denying it, I took my accountant into his office, asked for his keys and told him he would be fired. At that moment, he broke down crying and admitted to it, saying the other guy, the cashier, had fooled him into doing it. His role was to get the receipt books and destroy all the bad receipts. He burned them, he said. The cashier was the one who swapped receipts books and controlled the money.)

(We went back into the committee meeting and he admitted to the others he had gotten the book from Antoine’s office and had burned the evidence. Then the cashier got mad my accountant had fessed up. They said it was the only receipt book they had stolen and they knew nothing of the other seven. The other seven were all later numerically, so it made sense they had just pulled off the bottom each time and this was not the first. But they swore it was the first. There were only three days’ worth of receipts in it, but in those three days, they had acquired $1000. Not a bad three-day haul for an institution doing less than $400,000 of business a year. Roughly 1/4 of hospital income was vanishing with these two guys. And since it was the accountant, we didn’t notice. We trusted him. But of course, it was only three days.)

(I was getting nowhere with these two guys trying to figure out how long they’d actually been doing it, as they were giving completely different stories, all stories being unbelievable. And they keep repeatedly insisting ‘Before GOD!!!’ that it was the truth, only to blatantly contradict, backtrack, or admit partially to lying later. This was now my fourth day out of five spent interrogating these guys. So I decided to call in back up…)

Olen had texted me that our 2 thieves in the administration and cashier’s office still weren’t telling the truth. I asked if I could have a go at it. Hey, it was worth a shot. And I was sooooooooo sick of employees stealing from our hospital.

Olen was stuck again in yet another administrative meeting. This time he was trying to get 2 thieves to admit to their crimes.

The cashier and the accountant were caught red handed. We had footage of cash going into the cashier’s pocket and footage of him switching the books. We also were able to confiscate the book that was in the cashier’s office. Unfortunately it was only 3 days old. In 3 days, the total money stolen was over $1000! The other missing books, however, were nowhere to be found.

All of this and we were somehow still functioning!

So now it was my turn.

Olen allowed me to talk to the accountant, who still wasn’t talking or telling the truth.

Since Olen and I had started watching Suits, a TV show about lawyers, I felt like I could be one of them too. There is no real justice system here, so if you don’t get to the truth yourself, you never really get to it. That’s one of the frustrating things about living here. You can’t just give the job to someone else. It won’t happen.

The accountant and I went into a room by ourselves. We had a long talk about how we’ve known each other for a year now. It was he who had caught our previous administrator in stealing. We talked about how Olen and I had personally paid for his medication for his DVT that became a PE when he had been sick last March and April. He was our friend, and even if he did do something unimaginable like stealing loads of money, we would forgive him.

He finally accepted that he had stolen money, told me the amount (less than $1000 total), I called Olen in, and we all prayed together.

Well he told a few tidbits of truth. But one of those tidbits helped seal his fate. He told me that there were 5 receipt books total (also a lie) and that 3 nights before he had thrown them in his toilet.

Now this isn’t just any old toilet. There aren’t flushing toilets outside of our compound in Bere.

It’s a pit toilet.

Very dark. Very smelly. Very deep. Very……

Gross.

I told Olen my new found information, who was of course STILL in the same meeting. He texted me, “Get me those receipt books!” He was still working on getting more information out of the second accused, who wasn’t admitting to a whole lot yet.

Now….Who was going to help me?

Of course, our outstanding SM, Zachri!

So, Zachri and I set out to find the old receipt books in the disgusting, maggot filled toilet. We brought 1 pair of work gloves, 1 rope, 1 metal hook thing, 1 flashlight, 1 long stick, and a few other things we imagined we would need.

Zachri and I arrived at the correct toilet a few hundred yards away from the hospital compound. The accused was renting a room, so it wasn’t actually HIS toilet. There were a few little kids scampering around us wondering what we were doing going into their toilet room. I tried to explain that I dropped something in there and really needed it. I just kept smiling and tried to look like I knew what I was doing.

Chadian toilets are pretty simple. It’s a 10 foot by 5 foot enclosed mud brick wall with a cement floor. In the center is a small hole that you aim for when you do your business. (And no, Tchadian aim is no better than Kindergartner aim.) Zachri and I pressed our faces against the nasty floor and tried our best to aim the flashlight without dropping it. You could see down 20 feet or so to a mucky mess of crawling maggots. Vomit in my mouth a little bit. Flashbacks to our volunteer losing her headlamp in the latrine. Flashback to another volunteer falling IN the latrine when the cement floor gave way.

It was a long ways down. The flashlight wasn’t that bright. But there in the corner…..

We could see the receipt books! We’ve got to get those! But how? We tried several attempts of stabbing them with my parents’ fruit picker. No luck. It was so deep, and the books were loaded with pee and poop secretions. They were so heavy.

Olen texted again. “Having any luck?” We were running out of time. He was tired of stalling. “Get it now, or forget about it”.

We’ve got to break the toilet, I thought. I texted Olen my awesome plan.

It was a no-go unless I could find the owner of the house before I did it.

Olen texted Zachri and laid the pressure on. “Come on Zachri, you’re an engineer!” (Mechanical engineering major at Walla Walla University.)

I had a new plan. I decided to run home to get some cloth. We would tie a few pieces of rope on to the corners of the cloth, then push the books over on the cloth and cinch it up just like the removal of a large ovary in laparoscopy. It was sure to work!

I ran home to get my needed supplies.

Out of breath, I ran back to the crime scene toilet. Zachri had one book up near the hole already! He had managed to use the hook to get under it and balance it while pulling it up. Not wanting it to fall, I grabbed it and pulled it to safety (yes, with my bare hands). Then I almost vomited again in my mouth. (I can’t believe I actually make babies with this woman.)

One by one we pulled 3 more up. You could see that there were more in there though.

I put the work gloves on and wrapped the 4 books in a pillow case. I ran to the hospital and pushed my way into the meeting with the two accused, where both were still very far from telling the truth.

“This is what we’ve found so far. There is more where these came from. ARE YOU GOING TO FORCE ME TO CONTINUE TO DIG IN A TOILET BECAUSE YOU REFUSE TO TELL THE TRUTH? OR ARE YOU GOING TO START TELLING THE TRUTH?!” I yelled while still out of breath from running.

Everyone could see and smell the evidence.

I like to think that our digging in the toilet helped our case. In reality, it was God protecting our hospital, because it was a complete miracle that our hospital is still a float. We just like to imagine what our hospital could be without the HUGE amounts of stealing that we keep finding!

The stealing had been going on since our new accountant came last January. Huge amounts of money that we can only estimate. With the help of the toilet books, we could see that it had been going on for longer than 3 months. The cashier finally admitted to his fault, but the accountant has yet to return to Bere.

(In an interesting turn of events, the receipt books from the toilet told a story. Once we cleaned the crap and maggots off them, we could see the numbering was completely different. These weren’t the triplicate receipts! These were from the old duplicate receipt books! So this had been going on since well before October. And there were more than eight receipt books involved. The one receipt book was only half-filled and had over $1000 stolen. As best as we can tell, the stealing started March 2014 and continued for ten months.)

(As more and more information came in, we discovered our accountant, who only ever admitted to less than $1000 while his colleague admitted his own part in the take was over $12,000 at a minimum, was sending nearly $1000/week up to persons unknown in N’Djamena. As a further investigation, we pulled out all surgery forms from October to December and found $12,000 of missing bills ONLY from surgery and ONLY from three months. Extrapolated over all the ten months and including the other services of consultation, pharmacy, lab, ultrasound, etc… who knows what their take was.)

(I’ve also sadly learned the game of fake receipt books is pervasive in the country. Even income tax payments aren’t exempt.)

(This case is still not resolved in any sense, least of which spiritually. My friend the accountant threatened to kill himself the day I handed him a letter from my hospital committee asking him to repay his debt he had stolen. He told me he would kill himself and it would be my fault. I refused responsibility and informed him that innocent men don’t do that. Plus, five family members of his heard him say it, so it’s their responsibility to make sure he doesn’t do anything stupid. Supposedly, he drank acid that night. But after a quick trip to the hospital, he was released without injury. Nobody saw him drink acid.)

(At any rate, please pray for both of them. My heart breaks for the cashier and even more so for my friend the accountant, whom I’ve been extremely careful not to name. He really is a dear soul to me. But if he cannot ever come to admit to what is clear to all, I fear what becomes of him. Once we allow pride to enter into our lives to such an extent that we start lying, then become consumed with fear of being found out, things just continue to spiral downward. Pray he can come clean, be honest, make amends, and then move on with his life, not allowing this to define him as a thief, but allowing it to define him as a man who made a mistake, lost his way, and then repented and ran back to his Father’s arms.)

(As Danae wrote, it’s God protecting His hospital at this point, because I’m sure not doing a decent job of it. Besides this, we have my ex-administrator who stole well over $36,000, but we’re only holding him to $36,000, none of which he’s repaid yet. We are repaying a social security debt of greater than $36,000, about half of which has been repaid. We spent over $40,000 on medications and lab supplies we gave away for free. Nurses and lab workers are taking fees directly from patients and not having them pay at the cashier. I fired all government workers so we are responsible for 100% of our employees’ salaries. And somehow we’re still afloat.) 

Aren't you glad blogs don't include smells!!!!


Ps. If you visit, bring your own pillow cases. You never know….we don’t throw away anything here!

Olen Netteburg

Missionarydoctors.blogspot.com

Danae.netteburg@gmail.com

Olen: +235 91 91 60 32
Danae: +235 90 19 30 38

Olen et Danae Netteburg
Hôpital Adventiste de Bere
Boîte Postale 52
Kelo, Tchad
Afrique

Volunteers Welcome!!!

Thursday, May 28, 2015

May 27, 2015

I haven’t written a blog in a long time. So much to write. So little time. So many excuses.

But today I received a letter. And I can’t really ignore it until I tell you about it. But I don’t really even have commentary to give. Much. I’ve been here for four and a half years. And I still get surprised.

Anyway, this letter is from the court system asking for my witness in a judicial case.

I will give you my best and most honest and most literal translation of the bad French (although there are parts that are difficult to understand due to the lack of French by the author). And I will leave the commentary to you. Remember, this is a case in a legal regional court in a country in 2015. I’m doing my best to not pass judgement. Honestly, I’m not sure what I would do differently if I were the President of the Tribunal of Lai.

Note: I will translate ‘Village Chief’ for ‘Chef du Canton’. A canton is actually quite large, comprised of dozens of villages. So the Chef du Canton, although a traditional (and typically genealogically-anointed) figure, still bears massive political clout over the nominated government authorities sent to an area.

I will also translate ‘Marabout’ as ‘Witch Doctor’. A marabout is an individual with zero formal schooling who learns his craft in a secret apprenticeship. A marabout cures illness with the sacrifice of animals to various individuals and creating traditional potions and inflicting various wounds. (Example: I had a patient with an empyema, pus in his chest cavity outside of his lung. Before the patient came to the hospital where I placed a chest tube and drained the pus, the patient had gone to the Marabout, who sacrificed a chicken and then scratched him on the chest with the deceased chicken’s foot, thus combating the spell his mother-in-law had placed on him which was causing his chest pain. He also had to drink a potion created with the deceased chickens most spiritually important parts.) These potions can bring large blessings as well. The less respectable marabouts will use their powers to cast spells on people. Then they run the risk of becoming sorcerers. Sorcerers and marabout will often engage each other to do the other’s dirty work, either in collaboration or at odds, doing and undoing spells, ensuring the other stays in business.

Marabout is not to be confused with Tchoukou. A Tchoukou is an individual who passes out modern medication (which are legally controlled and protected), however, does so with zero formal schooling and zero legal authority. As such, a Tchoukou is illegal, practicing without the authority to use controlled substances, like Tylenol. A Marabout is legal, not using controlled substances.

So if you have appendicitis and a spare chicken, go to the Marabout. If you have a headache and want a pill, any pill, go to the Tchoukou.

First Page


From the Regional Tribunal

To the Medical Director of Bere Adventist Hospital

We have the honor to come and ask you to diagnose Patient R, who was treated at your hospital. And for an equitable judicial decision.

We are counting on your collaboration.

26 May 2015

President of the Tribunal in Lai,

M


Second Page…

25/05/15

Complaint by Mr N, subsistence farmer living in Village G, Canton T, against Mrs L, housewife living in Village K Canton T in the care of Mr M, for reclamation of the health of his child after poisoning. The accused does not acknowledge the facts.

Next Section…

From the Military Brigade

25 May 2015

The Adjunct-Chief, C, Commander of the Brigade of Research of Bere, Officer of the Judicial Police, Auxiliary of the Attorney General of the Republic for the Tribunal of Great Instance in Lai

To the President of the Tribunal of Great Instance in Lai

I have the honor to willingly transmit to you the presently cited complaint for competent analysis.

The Commander of the Brigade

X


This next section is the actual formal complaint itself, written by the father of my patient.

23.05-015

I have the honor to come very respectfully before your lofty personality to address this complaint against one named: L, housewife in Village C.

I bring prejudice against her for a very serious affair which is against us. It’s an affair we didn’t even know about. It’s a miracle of God. When my child was sick, we believed it to be a sickness from God. We brought our child to different hospitals, three times to Hospital X and three times also to Bere Adventist Hospital. It was the third time in Bere when the child was operated on. During the operation, they did not detect any sickness. We were obligated to bring him home. Suddenly, the child died. It was during this death that he came back to life just as suddenly as he had died. He automatically denounced the name of the accused, that it was she who killed him. He insisted we take him to her. This was in a big crowd. This is a verified fact. This is not merely an accusation or hearsay. As we said before, it was a miracle of God. We were obligated to bring Madame L. It was a dialogue between her and the child. The child asked her, “What did I do to you at my age that you want to kill me? Please forgive me.” She refused. We were obligated to call the pastors to bless the child in the presence of this sorceress. We believed the affair was finished. We continued without problems. But to our great surprise, she called us before the village chief to say we accused her of being a sorceress. Once judgement was rendered by the village chief, she declared she wanted to take an oath. But the village chief didn’t want that. The question was posed if we should take her to the witch doctor. The village chief delegated one of his advocates to accompany us. Once there, the witch doctor declared the sorceress guilty, that it was in fact this sorceress who was the origin of the death of the child. The witch doctor commanded the sorceress to give the antidote to the child and declared that would heal him. But the sorceress said she didn’t know which antidote to give. The witch doctor himself made a decision and said, “I will give you an antidote, which you will give; if it is not you who poisoned the boy, he will not vomit. If it’s you, he will vomit.” The sorceress then gave the boy this medication before the village chief. The boy vomited, even in public. The medication was finished. Everybody told the sorceress to go get another medication, but she didn’t want to. Now there is a relapse. Everybody says there’s a piece of wood she introduced.

We didn’t do everything, but we don’t have the faculties. We don’t have cold steel nor any other weapon to combat this very sad phenomenon. Afterward, the sorcerers went somewhere to glorify themselves. We don’t know where they went, but they go home unhurt.

Therefore, we don’t have the ability, such as your superior authority as officer of the judicial police, to take the matter into our hands, to discern the good from the evil of this affair.

Waiting for a favorable continuation, Sir the Commander of the Brigade, I present the expression of my most distinguished sentiments.

The interested,

N

And the final page…

From the Village Chief of T to

The Commander of the Military Brigade of Bere

I have the honor to transmit the complaint of Mr N from the village of G, Canton T against the named Mrs L from village K, Canton T

Motive: Poisoning by fetish (sorcery).

Mr N has filed a complaint against Mrs L, who poisoned his child at the age of twelve (12) years. This woman, L, has been declared a fetisher by the seer of Village A. Having been declared guilty, the conciliation recommends Madame L to give her antidotes to the sick to recover his health, but she didn’t want to. As this is an affair which will lead to certain death, I transmit the case to you.

For the competence of Sir the Commander of the Brigade of Research of Bere.

Done in Canton T, the 22/05/2015

The Village Chief,

K

Note: The brothers of Madame L have declared that if this affair is taken to the justice, she will not do anything for her brothers, so they leave the matter in your hands.

So witch doctor is better than sorcerer and seer is better than fetisher, I guess.

I’m sorry. I just can’t muster any commentary on this. So sad. What am I doing here? Please pray God somehow gets Himself glorified in all this, cuz I sure don’t know how to do it.


Olen Netteburg

Missionarydoctors.blogspot.com

Danae.netteburg@gmail.com

Olen: +235 91 91 60 32
Danae: +235 90 19 30 38

Olen et Danae Netteburg
Hôpital Adventiste de Bere
Boîte Postale 52
Kelo, Tchad
Afrique

Volunteers Welcome!!!