Wednesday, March 16, 2011

#31 Immunity

I know I should know this guy from somewhere. I vaguely recognize his face. And he sure acts like he knows me. (Of course, being one of only a couple American doctors in Tchad gives everybody the impression they know you.) I have only a couple more seconds to place his face before he walks up to me.

I fail.

‘Remember, I said I’d bring my daughter to see you?’

‘No. Who are you? Who’s your daughter?’

‘I’m the guy from Lai. We met last week at the meetings. My daughter was the one operated on in Kelo. The neck? The abscess? You don’t remember?’

‘Of course, I remember,’ I lie. I don’t remember him. I met a lot of important people last week at the meetings in Lai. (I don’t particularly like important people.) I don’t remember the story about his daughter. ‘Has she been seen by the nurses?’

‘She was already seen yesterday. She’s outside the OR. She’s ready for her surgery. They’ll be taking her back any minute now.’

‘Great. I hope my wife has the opportunity to do the procedure. She’ll be in good hands.’ I hope I’m not the one who saw her yesterday. I’ve forgotten her already.

About thirty minutes later, while walking by the OR, I see a woman sitting with a big mass on her neck. ‘Must be her,’ I think to myself. She looks ok.

Another hour later, I’m in the office holding my stomach. I know I should be doing ultrasounds. There’s a ton of carnets and bulletins sitting in front of me staring at me, paper-proof that patients have already paid for my services and are waiting on the other side of the door. If I don’t do them, that will just be more work at the end of the day for Danae to do. A good husband doesn’t leave a load of pelvic pain patients for his pregnant wife at the end of the day. I know I should stand up, grab a carnet, walk over to the door, swing it wide and call out the first name. Oh, and do it with a cheery, Christian, missionary smile. And I know as soon as I do, a dozen more people will ask me if they can go next. I sit. I turn around. I turn on the ultrasound. ‘The machine will take a while to turn on anyway. I’ll just sit here a bit longer,’ I think.

I try to sip some water. Then I try not to vomit. Same routine for the last four days. It started with muscle aches, joint aches, back pain, headache and vertigo. By the end of the first day I had nausea and diarrhea... and a negative malaria test. The next day my diarrhea turned bloody. I learned some things though. #1) If you’re about to get a bout of some random diarrheal illness, do not under any circumstances wolf down a load of fiery-hot salsa the night before. You will regret it every time. #2) It’s humanly impossible to swallow two grams of Flagyl at once. You’ll vomit every time.

By now I’ve completed three days of injections to treat malaria, plus a one-time dose of several Fansidar pills. I’ve taken my two grams of Flagyl at once (in four separate swallows) without vomiting. I think I feel worse. I thought I was better earlier in the day. Maybe I’m just overdoing it. It’s 105 outside, at least. Oh, and everywhere here is outside. Our house is usually hotter than it is outside. Our hospital has only screen windows, no air conditioners (save for the OR). I’ve still rounded every day. Oh, and this morning the scale said 159, a weight I haven’t seen since 2002. Two weeks ago, when our container arrived (and the scale with it), I weighed 172. This morning, I thought it was wrong. Then I confirmed it on a hospital scale. I remember weighing 197. I have an excuse to be weak.

Guilt gets the best of me and I stand up to call in the first patient. My phone rings. It’s Danae.

‘There’s a woman not breathing well in the OR.’


We’ve learned to be brief on the phone, since we’re literally charged by the second.

I walk to the OR. I don’t have the strength to run, plus, the longer I worked in an ER, the less likely I was to run anywhere. Running just makes everybody around you, including the patient, nervous.

I push open the door. The first thing I smell is pus. The first thing I see is the oxygen saturation monitor. It tells me that only 74% of her red blood cells are actually carrying oxygen. The squiggly line looks normal, meaning that it’s probably a true reading. 74% can’t last. Either she’ll get better or she’ll die. She won’t stay at 74% forever. I grab an ambu-bag and start breathing along with her, giving her supplemental... well, supplemental room air. Still no oxygen tanks at the hospital. Or oxygen in the country. I’ve heard we can get some medical-grade oxygen from our neighboring country, Cameroon.

Actually, I’m just suffocating her. Somehow, the pop-off valve on this thing is set at virtually nothing. All the air I squeeze is just shooting out the side. Finally I get that problem fixed and get some air into her lungs. Between forcing air into her lungs and giving her a good strong jaw thrust, she comes up into the 80s. That’s better.

I start to take a better assessment of the situation. Heart rate in the 140s, which isn’t an unreasonable response. Plus everybody here gets atropine with their ketamine, and I’m guessing that she got ketamine. I would have preferred they do this without ketamine. Why take an unstable airway and make it more unstable?

I look at her neck. Wow, that’s certainly not normal. She has several holes in her neck, possibly all surgical. One is packed already. Samedi is packing another. I tell him to stop. I rip out all the packing. ‘I don’t want any more pressure in the neck.’ Samedi agrees. Samedi is the kind that will always take a doctor’s orders. He might do something else after you leave, but if you’re there, he’ll support you. He’ll never tell other people that you’re wrong. He’ll never tell you that you’re wrong in public. He’ll only give his opinion in public when asked. And he’ll talk to you in private if he disagrees with you. Always calm. And I almost always want his opinion. He’s been around forever and knows the sicknesses and surgeries of Africa better than any other nurse.

Now that I have a moment to let it settle in, the smell is the first and strongest thing to settle in. That’s terrible. I’m still not wearing a mask. (I actually don’t have a chance to wear a mask throughout any of this. And most of it’s without gloves. My skin-intact hands can’t infect pus and gloves don’t stop needle sticks.)

A bit of the story comes out. She went to Kelo and had a neck abscess drained. She was coughing up pus and blood. She came to our hospital because it was worse. That was enough story for me. (I went into ER because of my short attention span. What?)

Her oxygen saturation starts dropping back into the 70s again. I run the options in my head. I could intubate her (put a tube into the mouth and direct it into her windpipe, thus giving me surefire access directly to her lungs), leaving a family member to squeeze the bag for who knows how long, leaving her to choke on an endotracheal tube for who knows how long and then hope and pray we can extubate her. I could perform a tracheostomy (put a tube through her skin and into her windpipe, totally as easy as it sounds). Infected skin and abnormal anatomy are contraindications (no-nos), but it’s also a contraindication to let a patient die.

Danae suggests an LMA. Laryngeal-mask airway. Pretty much the dummy’s intubation. Fool-proof. I go to the stock room, find an adult LMA amongst all the pediatric ones (this is a fat, but long neck) and return. I rip it open, grab a syringe and check the balloon. The ballon works great. They keep trying to hand me a laryngoscope. I keep refusing. Standing over her head, I take my left index finger and thumb and scissor open her mouth. With my right index finger, I smash the LMA into the roof of her mouth and push it back, getting well behind and below the tongue. I put up the balloon and the LMA lifts a bit, just like it’s supposed to. I bag. Air comes out her neck. Blood shoots up through her mouth. Her belly doesn’t rise. Her chest doesn’t rise. This is weird. I reposition several time, deflating and inflating the balloon. Nothing. It’s like I just can’t find good tissue to seal against.

I rip the LMA out of her mouth and we bag her up... to the 80s again.

I think of the options again. If I can get a trach through that nasty neck, maybe I can get below all of her problems and get right into the healthy part of her windpipe. Our volunteers just found a couple needle trach kits.

After fumbling through some pedi kits, I find an adult kit and go back to the OR. Sizing her up, this trach kit looks inadequate. As her sat falls back into the 70s, then 60s, I rip it open and make sure it’s compatible with our ambu-bag. As I’m familiarizing Danae with the kit and what order I’ll need things handed to me (needle, wire, knife, trach with dilator), I tell the nurse to Betadine the neck. He keeps asking questions. Where? With gauze? The wounds? I grab the bottle and squirt a health dose of betadine all over the neck. He takes the gauze in his hand and pushes the betadine around. It’s all a filthy, pussy, infected mess anyways, so whatever.

I feel for anatomy. The skin is all so hard and indurated. I can’t make out trachea, let alone thyroid cartilage and cricoid cartilage. With a pulse ox in the 60s, I put the syringe in her neck, half expecting pus to fill the syringe. I go straight down until I’ve buried the needle to the hub. I’d be in esophagus by now if this were a normal anatomy. I have no air coming back into my syringe. Maybe the pus has pushed her trachea laterally. I feel again. I’m guessing it’s still medial, but since I got nothing there, I try laterally, both directions. Nothing.

I grab the scalpel and cut straight down her neck. Great, I’ve got the only person in Tchad with centimeters of fat on their neck. Blunt dissection. This is unreal. How can I not even find trachea? I’ve heard of trouble finding thyroid cartilage and cricoid cartilage, but come on. This is ridiculous. From deep inside my incision, I start the same process with the needle. Center. Left. Right. Nowhere do I get any return of air into my syringe (meaning that I’m in the windpipe). I dissect bluntly again. I think I’ve found something. My fingers touch what feels like cartilaginous rings. I put the needle in again. No air. How can that not be trachea? I put my finger in again.

Oh my. How can that be? How can that be trachea? How can a trachea be that eroded? That’s not the front of the tracheal rings. That’s the back of them. The front is completely eroded.

I shove an endotracheal tube in. It’s too hard to bag. Too many gurgling noises. Too much blood and pus coming out of the neck. That must not be trachea. I don’t think of trying to suction before I pull out the tube.

I realize that the endotracheal tubes don’t have stylets. Danae goes to find something stiff. The nurse hands me a pediatric laryngoscope handle to match the Miller 3 blade. This would be a perfect set-up... if she was a four-year-old. They can’t find anything bigger. I lay the blade from her chin to her neck. It barely reaches. ‘There’s no way,’ I think. The saturation goes to the 50s. I can’t wait. I try to intubate with my pediatric set-up. I’m shocked that I can actually hook epiglottis and see cords. But I stand no chance at hooking this 6.5mm endotracheal tube into her short-chin anterior vocal cords without a stylet to stiffen up the floppy endotracheal tube. Her sat stops picking up. I had recently noticed that her pulse was irregular. He heart was ticked it wasn’t getting enough oxygen for too long. Danae returns just then with something that will work. I intubate her.

She’s impossibly hard to bag again, but I saw the tube go through the cords. I know I’m in. I ask for chest compressions. Danae starts. I think to ask for suction this time. Disconnecting the ambu-bag, blood and pus shoot out the end of the endotracheal tube and onto my face. I shrug my shoulder up and tilt down my face to wipe it off on my sleeve. We suction out a load of blood and pus that has filled her trachea and lungs. Maybe that’s why I couldn’t find air with my syringe. All that was in her trachea was blood clots.

She has good chest rise. The nurses confirm that she has bilateral breath sounds and no breath sounds over the stomach. I’m still bagging, but I ask Simeon to give a milligram of epinephrine. Later I ask for atropine. Abel relieves my pregnant, short wife from doing chest compressions. Suddenly the monitor picks up a heart rate of 130. I tell Abel to slow it down a bit. The oxygen sat eventually comes up to the 80s again. She gets a pulse. I tell them to keep doing compressions. Simeon bags for me and I tape the tube in place.

Time to reassess. She has a major neck abscess and loads of holes in her neck. Her tracheal cartilage and soft tissue is eroded. She’s intubated in a place without a ventilator and where the electricity goes off every night anyway. We’ve spent an LMA, a trach kit, an endotracheal tube, epinephrine and atropine. We don’t have unlimited resources.

Her sat starts a slow and steady decline. She’s still losing blood into her lungs. We won’t have electricity to suction her all night. She’s already on her third blood transfusion of precious type-O blood from our tiny fridge. Her sat now doesn’t pick up. We can’t find a pulse. We continue chest compressions.

I send for the family.

Her Dad and Mom come in. I remove all the staff from the patient, except the two bagging and doing chest compressions. I bring the parents to their daughter’s side.

‘You understand?’

‘Her Mom is a midwife and I, well, you know who I am. We understand.’

‘Simeon.’ He looks up. Our eyes meet. He understands. He stops chest compressions and ushers Ndilbe away so he’ll stop bagging. We get some stools for the parents.

We understand?!?!?! What does that mean?!?!?!

I don’t.

I don’t know who he is still.

And I don’t understand.

I don’t understand why there’s an entire underdeveloped (in reality, undeveloped) world who suffers like this when there’s an entirely differently world who doesn’t.

I don’t understand why God saw fit that I should be born into a life of luxury and that this girl should be born into a life of, well... a life cut short by asphyxia.

I don’t understand why this twenty-year-old daughter of a medical boss of some sort in the neighboring district, with a simple skin infection, develops an abscess, has inadequate surgery and follow-up care and then comes to die in my OR. I don’t understand why that twenty-year-old daughter in the developed world has access to antibiotics and gets better before she ever gets to the abscess stage.

I don’t understand how parents can accept with such grace the death of a fully-developed child, one they spent half of their lives raising, when I can’t imagine losing an unborn child of my own, whom I’ve never even seen.

I don’t understand why the mother of my eleven-month-old patient doesn’t have the twenty cents, the price of two mangos, to pay for two medications proven to decrease her son’s chance of recurrent malaria and recurrent hospitalizations.

I don’t understand why malaria still exists. If there was a single infectious disease responsible for a third of all ER visits in America for decades on end, there would be eradication. If there was a 600-bed hospital in America receiving 200 patients in the ER for decades due to a single infectious disease, there would be eradication. If there was a 600-bed hospital pronouncing over ten children dead every week due to a single infectious disease, there would be eradication.

And I don’t understand my own arrogance.

I don’t understand what makes me think that I can come to their village, live side-by-side with them, eat their food, drink their water, have my children play with their children, treat their sick and not suffer along with them.

I don’t understand what makes me think that I’m immune to their problems.

I don’t understand what makes me think that I’m immune to their sicknesses.

I don’t understand what makes me think that a 12.5% newborn mortality rate doesn’t apply to my family.

I don’t understand what makes me think that my children don’t have a 21% chance of dying before the age of five when theirs do.

I don’t understand what makes me think that my wife doesn’t have a 2% chance of dying every time she gets pregnant when theirs does.

Our closest missionary families have lost newborns and four-year-old children. What makes me think I can be immune from the suffering?

Can’t God offer me a little earthly immunity from suffering? I’m a missionary. Can’t it work this way?

You Might be in Tchad if...
A wet T-shirt contest means that you put on a soaking wet T-shirt and then see who can fall asleep under the fan before the shirt dries and you’re too hot to sleep again.

And for our ritual begging...

Danae is offering that the next person to send us a care package could include VeggieTales DVDs in English or French. People have just been asking what to send, so...

Oh, and if somebody wants to donate the money for a new air-conditioner... it would mean that our staff would stop asking EVERY volunteer who comes through to buy us a new air-conditioner. It would also mean that Danae wouldn’t need to operate pregnant, under a heavy canvas gown, in a 130-degree OR next month.

You will notice on our blog,, that we have a link for donations. This is through Adventist Health International’s website. Please keep in mind that AHI takes 10% of the donation for administrative costs. However, AHI also provides us with invaluable support, and we believe strongly in the mission of AHI. We feel that AHI is an organization worth supporting. And remember that your gift is 100% tax-deductible.
Olen Tigo: +235 98 07 46 28
Olen Zain: +235 62 16 04 93
Danae Tigo: +235 98 07 46 27
Danae Zain: +235 62 17 04 80
Olen et Danae Netteburg
Hopital Adventiste de Bere
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Kelo, Tchad
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