Wednesday, December 10, 2014


It’s nice to have short-term volunteers to remind us of how unique our careers are.

We just got a group of two anesthesia students and one anesthesia professor. All of them have worked years in ICUs before going into anesthesia. And all of them got to see a case they’ve never seen before.

I was in the OR chatting with these fine people when Sabine came and got me from pediatrics. She told me a kid swallowed of bottle of chemicals used for growing cotton.

I’d seen this before and knew what to expect. I called to the anesthesia students and asked if they wanted a shot at saving a life. They eagerly responded in the affirmative, so off we went to pediatrics.

In pediatrics I found a classic organophosphate poisoning. A boy about ten years old. And he was wet. Just imagine every possible way to lose fluids, he was doing exactly that. The most dangerous part was the froth coming out of his mouth.

These kids die when the fluid in their lungs overwhelms them. This kid had lots of fluid in his lungs. I could hear it from ten feet away as I walked up.

I sent somebody off to get atropine and explained to the anesthesia students that the treatment was essentially atropine until the lungs are no longer wet.

Atropine is a ‘code’ drug, meaning, it’s a drug that’s given in a code, or when a patient’s heart stops. In fact, when a patient’s heart stops, atropine may be the first medicine you give in your attempts to restart the heart. So it’s considered pretty potent. We give 1mg IV for a newly-stopped heart. Or maybe 0.5mg IV for a heart that’s fixin’ to stop and is very slow, but hasn’t stopped yet.

Well, we gave this kid 5mg IV bolus to start. This is a higher-than-recommended dose, but he was quite clearly on his way out, so we went for broke. His lungs started drying ever so slightly, but he was still quite wet. So we repeated it. I didn’t measure his heart rate, but judging by the amount of atropine he got, it was probably well over 200 beats/minute.

Next we gave him glycopyrrolate to dry him out. The anesthetists had just brought a bunch over with them, so they gave a couple doses.

He was actually drying out nicely, so I left for a meeting and left them in charge, essentially to give a couple milligrams of atropine whenever his lungs got wet.

I returned about four hours later to some bad news.

The boy had been sent home to die.

Organophosphate poisonings usually happen inhaling stuff or getting stuff on your skin. This kid had swallowed a whole bunch of it for reasons unknown. By the shear volume in his body and calculating roughly how long we’d need to treat him… It was decided his odds of survival were very low anyway and we would risk using the entire hospital supply of atropine to treat him. As it was, he received 21mg of atropine. That’s 21 pushes of medicine usually reserved for restarting a stopped heart. Or preventing a heart from stopping. Or preventing a child from having too many airway secretions during surgery under ketamine anesthesia.

And so our visitors had another first. First time they sent a ten-year-old home to die, when there was still the possibility of fighting longer and continuing to give atropine in a likely futile attempt to save his life, but possibly at a huge expense of resource which could be spent on other patients.

That’s a really tough first. I know, because I still remember those firsts quite vividly. I remember all the newborns we gave up on, knowing neither the family nor the hospital could afford the resources to really go all out 100% saving lives, particularly when we are already quite certain of the outcome. It’s rare the Tchadian father willing to spend every last dime to fight for the life of his child if it’s unlikely the child will survive. It’s difficult to allocate limited hospital resources to likely futile cases.

But we are taught to provide the highest level of care at all times. We are taught death is the worst possible outcome. So our urge is to always fight.

Tchadians have us beat in some ways. Although they may often accept death too easily, when I’d rather see them fight to save life, they always accept death gracefully. There aren’t many things I would describe as graceful in this culture, but they know life, spirit, soul, what have you… They know there are some things which transcend mere breath.

And that realization, for most of us, even if we say it intellectually… To not just say it but believe it and live as though we believed it… It’s another first.

olen and danae

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

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


  1. Just wanted to wish you all a Merry Christmas! You are in my prayers and thoughts regularly.

    Steve DeWitt

  2. May God bless you for the sacrifice you're making, and the way you represent the Great Physician. You have hard choices to make when dealing with limited resources. I will pray that the Lord gives you the wisdom of Solomon. You would enjoy reading "Jesus, M.D." - a great book by a fellow missionary doctor to Africa.