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



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

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?"


"Does he eat or drink or swallow?"


"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



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

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……


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



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

Volunteers Welcome!!!