Sunday, September 18, 2011

# 58 Prayer request

I ask that you to pray for this girl. And if you know of any other way to help her, please pass this along.

Female 15 yo
Kalme, Tchad

Her problems started February 2011. She came to the hospital with dry cough for two days. She has rales anteriorly on the right. She was treated with amoxicillin, ibuprofen and fansidar.

In March, she came with right-sided intercostal pain and cough. She was treated with erythromycin, ibuprofen, tylenol, salbutamol and fansidar.

In April, she came with foot pain for two days. She was treated with ibuprofen, cloxacillin, fansidar and tylenol.

In May, she came with epigastric pain, anorexia, insomnia, cough and joint pain. We have a lot of patients. I can’t see every patient personally, so the nurses often treat and discharge patients without me ever knowing they exist. This time, the nurses asked me to see her. I heard a heart murmur. We found some parasitic ankylostomes in her stool and I noted mitral regurgitation, a huge left atrium and evidence of pulmonary hypertension on my ultrasound.

I put her on vitamin B (a cheap and safe medicine, just in case she had Beri-Beri), quinine, fansidar, mebendazole, praziquantel and told her to come back.

When she came back she was vomiting, had chest pain, hypotension (80/50), dyspnea/tachypnea and tachycardia. She had bilateral leg edema. I treated her with diethylcarbamazepine, ivermectin, metronidazole (she had giardia lamblia), quinine, IV fluids and phenergan (she was vomiting a lot). I also ordered an ASO titer, which was positive. I started her on penicillin. She couldn’t sleep because she couldn’t breathe, her heart was beating out of her chest, she was sweating and she couldn’t stop vomiting.

After a few weeks of treatment, she got a little better.

I diagnosed her with rheumatic heart disease, mitral stenosis and mitral insufficiency. Her heart valve was shot and she needed it replaced.

In June, Danae and I left for annual leave in America. Celestine was sent to N’Djamena to see a cardiologist. She saw Dr Ganone Tedang, who sent her to Dr Madjirangar Natirngar, educated in Senegal and the only cardiologist in Tchad. (+235 66 54 89 or +235 95 24 51 36, Boite Postale 5093, N’Djamena, Tchad, or

He did an ultrasound personally and gave the same diagnoses.

Blood tests today showed:
Hemoglobin: 12.66 g/dL
Blood group: AB+
Hepatitis B: Negative
Hepatitis C: Negative
HIV: Negative
Creatinine: 3.57 mg/dL.

Just today I discovered the Creatinine and noted that the cardiologist put her on Captopril. I will stop her Captopril, have her drink lots and repeat the Creatinine on Monday.

Since the sickness started, she’s lost 4.4 pounds.


Vital Signs:
38 kg.
153 cm.
O2 96% at rest.
Pulse 98 at rest.
Respiratory Rate 28 at rest.
Pulse 129 with minimal exertion.
Respirator Rate 52 with minimal exertion.
Temperature 37 Celsius.

Clinical Exam:
Lungs: Scant rales.
Cardiac: 4/6 blowing systolic murmur loudest at the apex, radiating to the back.
Abd: Trace hepatomegaly.
Extremities: No edema.
The rest: Normal.

EKG: Not possible here.
X-ray: Not possible here.

Does anybody have a method beside prayer to help her get a new heart valve?

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Olen Zain: +235 62 16 04 93
Danae Zain: +235 62 17 04 80
Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad
Volunteers Welcome!!!

Feminin 15
Kalme, Tchad

Ses problemes ont commence en Fevrier 2011. Elle est venue a l'hopital avec toux seche pendant deux jours et rales anterieur droite. Elle etait traitee avec amoxicillin, ibuprofen et fansidar.

En Mars, elle est venue avec douleur intercostale droite et toux. Elle etait traitee avec erythromycine, ibuprofen, paracetamol, salbutamol et fansidar.

En Avril, elle est venue avec douleur au pied pendant deux jours. Elle etait traitee avec ibuprofen, cloxacillin, fansidar et paracetamol.

En Mai, elle est venue avec douleur epigastrique, anorexie, insomnie, toux et douleur articulaire. Nous avons trop des patients. Je ne peut pas voir personallement chaque patient. Mais cette fois ci, mes infirmiers ont demande que je vois cette patiente. J'ai ecoute un murmur du coeur. J'ai fait des examens (positif pour ankylostomes) et une echographie. Pendant l'echographie, j'ai trouve retrecissement mitral, cardiomegalie, evidence de l'hypertension pulmonaire et une oriate gauche tres grande. J'ai traite avec B Complex (Beri-beri), quinine, fansidar, mebendazole, praziquantel et demande un rendez vous.

En Mai encore, elle est revenue avec vomissement, thoracalgie, hypotension (80/50), dyspnee/tachypnee (frequence respiratoire ecrit a 128, mais je pense c'etait 28) et tachycardie (102). Elle a eu l'oedeme des membres inferieurs. On a traite avec diethylcarbamazapine, ivermectin, metronidazole (positif pour giardia), quinine, liquide intravenouse et phenergan (elle a vomit). J'ai fait ASLO et elle etait positive. J'ai commence penicillin. Elle n'a pas pu dormir parce que les respirations. Elle a transpire beaucoup. Elle a vomit beaucoup.

Apres quelque semaines des traitements, elle va un peu mieux.

Je suis parti en conges en Juin et elle etait envoyee a N'Djamena pour voir un cardiologue. Elle a vu Dr Ganone Tedang qui l'a envoye a Dr Madjirangar Natirngar, Diplome a L'Universite Cheikh Anta DIOP de Dakar Mobile +235 66 54 68 89 ou +235 95 24 51 36, Boite Postale 5093, N'Djamena, Tchad,, Il est le seul cardiologue au Tchad. Il a donne les memes diagnostiques de retrecissement mitral et fievre rheumatique. (Je ne connais pas les mots en Francais, mais le cardiologue a fait une echographie lui meme et il a ecrit aussi 'maladie mitrale, fuite mitrale 3/4, gradient max 29mmHg, gradient moy 19mmHg, surface de l'OG 68 cm2, dilatation de l'OG, dilatation de VD. Au total: Stenose mitrale rheumatisme et Insufficiance mitrale. CAT: Plasthie mitrale.)

THb 12.66 g/dL
Groupage AB Rh+
HBs Negative
HCV Negative
HIV Negative

Je viens decouvrir que le cardiologue a donne Aspirine, Atenolol, Captopril et Fer acide folique. Et aujourd'hui elle a fait Creatinine, qui etait 3.57 mg/dL. Je vais arreter Captopril, elle va boire beaucoup de l'eau et on va repeter l'examen Lundi.

Depuis que la maladie a commence, elle a perdu deux kilo.


Signes vitales:
Elle pese 38 kg.
Taille de 153 cm.
O2 96% quand elle est en repos.
Pls 98 quand elle est en repos.
FR 28 quand elle est en repos.
Pls 129 quand elle fait l'exercise minimale.
FR 52 quand elle fait l'exercise minimale.
Temp 37.

Examen Clinique:
Pulmones: Un peu des rales.
Coeur: Murmur 4/6 a l'apex, irradiante au dos ('blowing' en Anglais).
Abd: Souffle, Hepatomegalie minimale, Pas de splenomegalie.
Extremities: Pas d'oedeme.
Le reste: Normal.

EKG imprenable ici.
Radio imprenable aussi.

Mais plasthie mitrale est impossible au Tchad. Nous voudrions sauver sa vie.


PS Merci beaucoup pour cette aide. Si vous avez des questions, s'il vous plait, posez les.

Friday, September 9, 2011

#57 You Gotta be Kidding

I’m surprised my hands aren’t shaking. I cut clean from pubis to sternum, looping around the belly button. I should not be doing this. I cut down through the layer of fat to the muscle. I’m a little off-center, so I rip the muscle up to find center. Then I just keep on going down. Not really how you’re supposed to do it. It risks nicking bowel on your way in through the peritoneum. But I don’t have time. I married Danae so she could do this and not me.

‘Baby, just go. Don’t worry about it. I’ll be fine. What’s the worst that could happen?’ That’s what I told Danae exactly 32 hours earlier. She wanted to go to Moundou with the Parkers. She wanted to do a little shopping and to get out of the house and away from the hospital. She was going to leave at 6am and come back in the evening. Moundou’s only a couple hours away. I was so supportive that I even woke up early and helped her pack a day bag.

‘I think I’ve got an ectopic,’ was what I texted her.

She texted back that she was stuck in the mud. They had driven off the road in the rain and were now trying to get the car back on the road.

‘Should I come back?’

‘No, don’t worry. I’ve still got Samedi here.’ Samedi’s been here like 34 years and has been doing surgery for most of those.

‘Blood pressure’s 70/40. Anemic.’ That was my text a couple hours later.

‘Tire flat. Spare no good.’ That was the text she sent back.

After distributer issues and needing to drain off all the oil (to get the water out), they finally made the two hour trip to Moundou... in about twelve. They decided to spend the night there.

‘Really, Samedi? I think we should take her back. Well, no. I don’t see a for-sure ectopic, but I also don’t see anything in the uterus but her pregnancy test is positive. Her belly is tender and she’s anemic. Well, yes. Her blood pressure did come up to 130/80. Yes, she does have a lot of vaginal bleeding, which is more common in miscarriage than ectopic. I suppose we could do a dilation and curettage.’

Samedi wants to wait. He think with a good blood pressure she’s getting better and will complete her miscarriage without curettage. He doesn’t think it’s an ectopic.

I take Samedi with me to see a patient on the surgery wards. He’s old and he came in for a hernia repair. However, since he arrived he’s started spiking fevers, his belly has become distended and tender, he’s vomiting and he’s stopped pooping and farting. His colon looks really edematous on ultrasound. But his lab tests show Giardia and worms and malaria. He’s getting treated for all that and not getting better. I’m pretty sure he’s got dead bowel. Samedi swears he’s seen this a million times and they just get better with antibiotics.

The next morning at 6am, Samedi goes to N’Djamena. No Danae and no Samedi.

The nurse comes to get me at 8am. A woman just came in. She’s been laboring at home with her first baby since the night before. I wheel over the ultrasound. Baby’s still got a heartbeat. No meconium. Smallest pelvis in the history of pregnant ladies. No way that baby’s coming vaginally. Well, I suppose we’ll let her labor until Danae gets here or until the baby’s heartbeat drops. If mom goes hypotensive, if baby goes bradycardic, come and get me and I’ll do a C-section.

No way those words came out of my mouth. Did I really say I’d do a C-section? I married an obstetrician. There is no good reason in the universe for me to do a C-section.

On surgery rounds, the old guy’s even sicker. He’s obtunded now.

So I have what I believe to be an ectopic, necrotic bowel, arrested labor and no surgeon. Awesome.

I bounce back and forth all day between checking up on my presumed ectopic (who’s got a blood pressure of 130/80, has received two units for her anemia and who’s vaginal bleeding has stopped) and the lady who needs a C-section.

About 1pm, I do another vaginal exam. I can see baby hair, but now the baby’s pooping himself. Meconium everywhere.

I tell the nurse to take her to the OR and set her up for a C-section. Are you kidding me? No way I just said that.

On the way to the OR I glance at the presumed ectopic. Hmm. She doesn’t look so hot. Get her to my office.

I put the probe back on her belly and it’s now full of blood. She just ruptured her ectopic.

Ok, change of plans. Hold that C-section and get this girl in the OR now.

In the OR, her IV’s gone. They finally get a second one and start her third unit of blood. She’s barely breathing at this point. A second IV with a liter of Ringer’s are going. A foley’s in. I’m bagging the patient, since she’s only taking agonal breaths on her own. We even flip on the oxygen concentrator. We can’t get a blood pressure, but the finger oxygen monitor tells me her heart rate is in the 130s and her sat is in the 90s. That’ll do.

I teach Ndilbe how to bag. I tell Abel that this patient doesn’t need anything more than a shot of IM Phenergan for anesthesia. I get Salomon to scrub in with me. Salomon gives a quick prayer. I check the finger monitor again. Heart rate still 130s. Sat 99%. Fourth and fifth units of blood are up. Another Ringer’s is up.

I’m surprised my hands aren’t shaking. I cut clean from pubis to sternum, looping around the belly button. I should not be doing this. I cut down through the layer of fat to the muscle. I’m a little off-center, so I rip the muscle up to find center. Then I just keep on going down. Not really how you’re supposed to do it. It risks nicking bowel on your way in through the peritoneum. But I don’t have time. I married Danae so she could do this and not me.

As soon as I enter the peritoneum, blood is everywhere. Soaked through the surgical drape and my gown and my scrubs and my boxers in seconds. We aspirate out two liters of blood in addition to the pool that I’m standing in. My shoes, everything is covered. I’ve never seen so much blood.

I quickly cut the peritoneum north and south. I hope the bladder got out of the way. I finally aspirate all the blood I can so I can see the ectopic on top of the uterus. I identify all the blood vessels and the Fallopian tubes. I clamp, clamp and cut the bad tube and tie it off. I bluntly dissect the ectopic off the uterus. It looks like it’s matted to the colon too, so I clamp, clamp, tie and repeat a million times. Eventually, there is no blood and no bleeding and no more ectopic left. We irrigate and I close peritoneum/muscle/fascia together in a couple layers. I look at her finger monitor. Pulse 90, sat 90%. It had been as low as 83% when Ndilbe stopped bagging, but now it’s back up.

I scrub out to let Abel (who also scrubbed in when her realized that she was too sick to need anesthesia. I open the fridge. Blood bank only has two bags left and it’s not her type. She’s still pale. She still has no blood pressure.

Abel puts in the last skin suture. I listen for breathing. She’s not taking any spontaneous breaths. How can she have such a good pulse and oxygen sat and be completely unresponsive? Her blood pressure should at least be findable if she’s perfusing that finger monitor.

And then... she loses it. The finger monitor doesn’t pick up anymore. I already had the ultrasound set up in the room and it takes me five seconds to put the probe on the chest. No heartbeat. Simeon and Danae just got into the room from Moundou. Simeon hasn’t even changed into scrubs, but he immediately starts chest compressions. We draw up epinephrine and atropine. I start instructing the nurses to breath, do compressions, give epi and atropine while I dust off the defibrillator and plug it in. I have no clue if she’s in vtach or vfib, but it’s probably her best shot.

She gets three shocks, three atropines and three epinephrines. I’m in no-man’s-land Tchad. What am I doing?

I call in the husband and let him hold his wife’s hand in between the shocks. She had never been pregnant before. In the end, she finally was pregnant. And that was what killed her.

Great. So I correctly performed an ectopic pregnancy surgery on my own. And lost the patient anyway. Most cases that you carry with you in your mind have many ‘if only’s.’ This case has just one. If only I had taken her to the OR earlier.

Before we even get the corpse out of the OR, we bring in the woman who’s been laboring for two days now. We get her on a bed and roll her over to look at the wall (so we can do important medical things, as far as she’s concerned) while they carry out the body of the last patient. You really don’t want to see a dead previously pregnant lady being carried out of the OR when you know you’re the next pregnant lady to go in.

Danae starts the C-section while a nurse grabs me to see a new patient who just came into the ER. Young woman with abdominal pain, vomiting and diarrhea. Cachectic. I palpate a suprapubic mass.

‘Uh, is she pregnant?’

‘No. She had her period within the last month.’

‘Take her to my office.’

By now I’ve got the ultrasound back in the office. I put the probe on the mass. Not only is she pregnant, she’s over 17 weeks pregnant. And the baby is dead. Her blood pressure’s 70/40. I get an IV in her and start a liter of Ringer’s.

I go to the OR to discuss this one with Danae. Danae’s just about to pull out the baby. Danae can’t the baby out. The head is stuck in the pelvis. I put my hand under the surgical drape and into the vagina. I push on the head for all I’m worth. Danae can just barely get her fingers under mine and pull out the baby.

I put the baby girl on the table. She’s hiccuping (or gasping), but not taking in any air. I put one end of a tube into her nose and down into her lungs. I pull it out slowly while sucking on the other end of the tube. Meconium comes out into the trap. After a while, no more comes out. I start breathing for the baby. We get an oxygen monitor on her foot. Oxygen is 80%, pulse 150. With a little help, the oxygen easily comes up to 99%. I stop breathing for her, and it falls to 51%. I breathe for her and it immediately skyrockets again. I show the nurse how to breathe for the girl and I grab a syringe and sugar water. I inject the sugar water in her veins. So many babies here are born hypoglycemic from protracted labor and a malaria-infested mother. This baby fit both criteria.

After three hours, the baby girl will barely take a few halting breaths.

We take her to her mother. We put her skin on her mother’s skin. We put her mother’s hand over the baby. We explain that we don’t expect the baby to survive the night unless she starts breathing better.

We are called to see the old man with necrotic bowel. We tell the family that he needs surgery tonight. They refuse and take him out of the hospital.

We see the woman with the dead baby inside and write orders for her for the night.

We get home about 9pm. I can’t even remember the last time I ate.

The C-section baby dies about 3am.

The other woman delivers her already-dead baby at the same time.

Dead woman of an ectopic. Dead baby after C-section. Dead baby before birth. Guy taken out of hospital certainly dead by now.


What am I doing? Are we helping anybody?

Dear God, give me a sense of purpose and of Your light in this place that can often feel so dark and lonesome and depressing. Help me to understand why all the suffering happens here. And although I live in the midst of all this suffering, please protect me and my family from suffering.

olen and danae

Olen phone: +235 62 16 04 93
Danae phone: +235 62 17 04 80

Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad

Volunteers Welcome!!!

Monday, September 5, 2011

#56 The Will of God

When we got back, I learned that my pharmacist was sick. She had been sick with severe malaria. She was hospitalized, given IV quinine, then taken home and given a second week of quinine. Just for good measure, she was given a course of Ceftriaxone too.

My opinion was asked for. ‘Bring her to the hospital.’

Finally, several days later, she was brought in. She was so tired. Barely had the energy to answer my questions. And usually, she was quick to smile and chat. In fact, talk about energetic, because we only have two pharmacists, and we’re a 24-hour pharmacy, she slept at the hospital every other night. And I never heard her complain about it.

She wasn’t without problems, though. Her husband was estranged and up in the capital, N’Djamena, a six-hour drive away.

Looking at her then, I knew something wasn’t adding up. I asked her a lengthy review of symptoms. Seemed like she was experiencing more respiratory problems than would be expected with malaria; dry cough, shortness of breath, difficulty exerting herself, etc. But she was running a fever and she was exhausted and had vomiting and diarrhea, which all go with classic malaria.

I hospitalized her, put her back on IV quinine, treated all the parasites I could think of with mebendazole, praziquantel, ivermectin and diethylcarbamazepine and gave her some IV fluids. I also gave her a slip for the lab to get tested for HIV the next day.

That night she had a fever, which would become a recurring theme. Despite treating her with Tylenol, Motrin and Aspirin, the fever persisted. As did all the other symptoms.

The next day I got her results back. Positive for HIV. Confirmatory test also positive.

The hospital ambulance took her to Kelo the following day for a CD4 count. 24. She must have had HIV for some time now. We couldn’t check her viral load, but I’m sure it was astronomical. Her HIV was a bullet train an inch from the cliff. Nothing short of a miracle could save her now. This was full-blown AIDS.

When she got back the next day from a trip to Moundou with her x-ray, it was pretty clear that she had PCP pneumonia, an AIDS-defining illness. All her symptoms fit.

By now she was on quinine, doxycycline (actually erythromycin, since doxy made her puke), Ceftriaxone and a veterinarian’s dose of Bactrim. She was still spiking fevers daily, despite all her antibiotics and all her antipyretics.

A week later, she had a nasogastric tube in her nose so we could crush up her pills, dissolve them and get them into her stomach, a Foley so she wouldn’t be incontinent all over the floor, an IV in her arm for steroid injections, family and friends surrounding her around the clock and a vacant look in her eyes. She was working much too hard to breathe. Her blood pressure wasn’t enough. Her pulse was weak. And from the oxygen sensor I put on her finger, I knew she wasn’t getting enough oxygen to her brain to think. She was gone. Her heart was still beating, barely, but the Dina I had known a week before was gone.

For days, everywhere I’d been, I’d heard the staff talking about Dina. About how we were just waiting for the will of God to take its course, whether it be healing her or letting her die. The will of God. That’s what our chaplain tells mothers and fathers when their two-year-old dies. It was the will of God. Really? How is it the will of God that a beautiful young person, with so much kindness and goodness left to give, should die?

We’re in a region where Islam has rubbed off considerably on animist and Christian alike, for better or for worse. The passive mentality, the Calvinistic bent, that all things are controlled by God and furthermore, that all things have already been divinely dictated and must occur as such, leads to a sense of, ‘Why do anything? We can’t change the outcome. God will either save or not, regardless of what I do.’ God already has created the final result, which we cannot alter. This leads to a lackadaisical workforce. Why bother to give the medicine? It won’t change what God wants to happen. Why rush to operate? God already has decided if the patient will live or die, no matter how soon we take out his appendix.

I kneel over her body as she lay on the floor. I pick up her cold and sweaty hand in both of mine. And I pray silently for her. And for her family. And for her friends. And for the community. And for my other patients. And for my own children. How easy would it be for something to happen to my own children? Dear God, why have I brought my family here? Why is there so much suffering here? How is this fair? How is this right? I can’t improve anything here.

At this point, I’m not really sure how to finish this private prayer of mine. I’m pretty sure God gets the gist of it, so a simple ‘Amen’ will suffice. I open my eyes. I’m looking at Dina’s dress. It says on it, ‘Eli, eli. Lama Sabbachthani?’ ‘My God, my God. Why have You forsaken Me?’ Uttered by Christ on the cross and now poetically imprinted on a dying AIDS patient’s garment. God, what are You trying to tell me?

Then I see the other side of her dress. ‘Father, into Thine hands I commend my Spirit.’

She died at 5AM. The nurse didn’t come and tell me. The wailing started and I knew.

In the afternoon, we went to her house. Following the sound of the drums, we arrived to find her open casket under the mango tree. While the drums beat rhythmically, the women wailed and mourned and danced, as if giving themselves to a supernatural realm that would make them move and cry in rhythm with the forces of life and death, good and evil.

Father, I don’t want to wait until I’m on death’s door. I commend my spirit into Thine hands today. And tomorrow. And the next day. And the day after that. And...

Olen phone: +235 62 16 04 93
Danae phone: +235 62 17 04 80

Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad

Volunteers Welcome!!!