Huh? This started out as such a normal morning. I woke up and went to the hospital for morning worship. I told myself I’d come back right after worship for a shower and breakfast, since it had been a while since the last time soap had hit anything besides my hands, but I’m on a run of making it to worship and I don’t want to break my streak. There was only one employee there when I showed up, like 20 minutes late. The boss isn’t really setting a good example. But the boss is tired. Worship was cool, led by two women, which isn’t such a normal thing here.
After worship, I did a few random administration tasks with Fabiene, who helps me keep track of everything, then headed back home a couple hours later so Danae could come up to the hospital for a quick fistula surgery. On my way home, there were a million people at the fence separating the hospital and our house, which isn’t unusual, but is still annoying. I went over and scolded people for having nothing better to do than to watch my children breathe. Through the gate, I saw more people walking around our housing. They were my employees and others I didn’t know. I asked them what business they had at my housing. They replied none, they just came to watch what was going on at the Adventist church school next door to my house.
At this point, the kids come running up blurting out their disjointed bits of news. ‘They were holding sticks and throwing bricks and throwing rocks and banging on gates and…’ I couldn’t really follow what was going on, but our personal guard came up, looking the slightest bit out of sorts, which is always an encouraging expression for your personal guard to wear, like a guy with stomach cramps, unsure where the nearest bathroom is. He told me there were ‘manifestations’ at the school. People were on ‘strike’. Things were slowly being pieced together.
Up until then, I had heard rumors the government was slashing salaries in the public sector 55%, while raising income tax from 10.5% to 20%. But nobody had been paid for six months, so nobody was exactly sure. And so many rumors fly hither and thither, you never have any clue what’s actually true. All I knew is I had heard no news about minimum wage being decreased in the private sector, and we have been getting killed financially at the hospital.
The story goes that the price of oil has dropped internationally, and the quality of oil in Tchad isn’t great, not to mention the price of bribes and the expense of pumping it out of a landlocked country. So no more oil exports means trouble in Tchad, a country with a financial portfolio about as diverse as the list of ingredients in salt. Not to mention, being a socialist country, everybody’s dream is to be employed by the government. Once employed by the government, you have to be a whole ‘nother level of atrocious before anybody can ever fire you. Their union is amazing. So like 10% of the country is employed by the government, and the rest are hoping to become government employees. All sounds well and good until the government cow dies and everybody who was completely dependent on that milk starves. Capitalism is a bit of a vague notion. There’s very little privatized interests. And then when the union of government employees gets upset and decides to strike, since everybody works for the government, absolutely everybody goes on strike and nothing gets done.
The other real drag of having everybody employed by the government is that when the government coffers dry up, the entire country has no money. The government slashes government salaries, so there’s less income to purchase stuff from everybody else. We’ve certainly noticed this at the hospital as absolutely nobody has any money to pay their medical bills. We’ve been losing tons of money.
Anyway, the government employees aren’t taking their cuts in pay laying down, so they do what any employee in a former French colony would do, they go on strike. The strike started Tuesday and is schedule to go on until they get what they want. (And what they want is for the government to miraculously have income to pay them their salaries, so I'm not holding my breath.) The strike in the health sector is to treat only emergent cases and is only scheduled for a week. In the past, they have completely locked the hospital doors. Selfishly, I’m kinda hoping the strike continues so patients will come here! My employees are awesome and have never gone on strike. I believe we are the only hospital in the country that can say that. Even during war, when everybody else is closed, my employees still show up. They are dedicated.
The reason for the ruckus at our school is because young men got bored. The public school teachers are, of course, on strike, as happens at least once every year or two. So the public school students got sent home. However, instead of going home, they heard that our school was still open, and they didn’t find that to be acceptable, so they came to our school to insist our private church school be closed also. After throwing bricks at the school (and our housing gate), and at the church, and after ripping down all the temporary overflow classrooms we had built with donor money, and after damaging the walls of the school and the roof of the church, the police showed up and forced our school to close in a ‘strike of solidarity and support’.
What? So private schools where the teachers want to teach and the students want to learn get shut down by the police of the government? Hang on. The police, whom represent the government who is being striked (struck?) against, is forcing private enterprise to go along with the private syndicate union of public government employees in a strike against them. Huh?
Anyway, they disperse the crowd right before I walk on to the scene, and this is roughly the story as it is relayed to me by my guard, who now looks like he just got driving directions from Bugs Bunny on crack and needs a moment to process. I kinda feel the same way as Abel. I could use some coffee, but we’re good missionaries and only drink the stuff when we’re not writing blogs.
The kids and I explain the disturbance to the other expats and head back inside. Apparently kids were throwing bricks at Christian and Sabrina’s house while Sabrina was inside. Being as how they have a tin roof, it made quite a disturbing racket. Ok, the kids and I head over to inspect the roof. Seems ok. Back home, I start doing some cleaning and hear the voices start screaming and running past our wall again, back toward the school.
‘Daddy, is the mob back?’ Mob? Dude, you’re like eight years old. Don’t worry about a mob. Go play with sticks and dirt or something. Hmm… no, actually, don’t go outside for a while. ‘Why?’ Well, because the mob is back and I’d hate for you to get struck in the head by a brick. Dang. Mob.
I head out to our fence adjoining the school. Sure enough, kids and teachers are then pulling down the flag and throwing bricks about. (This is Tchad and everybody builds everything with mud bricks, usually unfired, which break really easily. So a brick or some morsel thereof is always within arm's reach.) Some bricks are hitting the school and the church and our compound, and some are probably hitting the kids milling about. Some of our church members and students and teachers are also around, just kinda hanging out on the perimeter observing. I start talking to the young men passing by and we start chatting about what’s going on and why. Then more and more young men come up as we discuss. And as we discuss, I create for them a better entertainment than throwing rocks, and they gradually forget about the school. In fact, they get frustrated with the knot on the flagpole and decide to leave it and start yelling at me.
There are some young ruffians who are clearly intelligent and we’re having a good conversation:
So why are you trashing this school?
‘Well, they were continuing to have class and we weren’t.’
Um, ok… like, so?
‘It’s not good! They will get ahead while we stay behind!’
So you don’t want them to get ahead?
‘It’s just not good for some people to get ahead.’
Ok, so why didn’t you register at this school?
‘It’s not a good school. They don’t teach good.’
Well, clearly from your French, you aren’t being taught well either. So if they’re not teaching well, then they don’t really pose a threat to you, right? So let them keep on not teaching well. If your teachers are so much better, you’ll easily catch up after the strike. Right?
‘It's just not good for some people to be ahead of us!!!’
Ok, let’s change topics… Do you want to work for the government some day?
‘Yes! Of course! Why not?’
Well, for one, they do things like not pay you. If you have your own private enterprise, then you aren’t a slave to the state at their mercy for everything. You could be your own king, master of your own domain, controller of your own destiny. You could be like Zelda or something.
‘No. Why would I want to do that? That’s work. I want to be a government employee.’
This was the more productive of the conversations I had. Then came the less-productive young men:
‘White man! You’re the cause of all this!’
Huh? Excuse me? What did I do?
‘You took all of our money!’
How, pray tell, did I do that?
‘I don’t know, but you took it!’
Who paid me?
‘The hospital!’ (They were using exclamation marks at the end of each sentence, you’ll just need to take my word on that.)
Dude, the hospital ain’t never given me a franc. You have no clue how many tens of thousands of my own dollars I’ve paid to the hospital.
You really should cool it on the exclamation points. The government has never paid me either. Patients have never paid me. Patients’ families have never paid me. Even the Adventist church in Tchad has never paid me. My church in America pays me. The hospital brought in a little over $300,000 last year, before any expenses. Even if I stole all of that and never paid a single expense, I’d make more money in America. I assure you I’m not here for money.
‘Well, then what are you doing here?! You must be here for the money! You do nothing but steal from us! All you do is bring us suffering! You’ve never done anything for us!’
Uh… huh? So… like when you’re sick and stuff… like, where do you go and who takes care of you?
‘You’re taking our money!’
Dude, you are clearly drunk.
‘Yeah, we tore down a lady’s bar and drank all the booze in the bar before we came!’
And your point is…
‘But it’s the white guy who drinks!’
Dude, you just told me you’re drunk.
‘Yeah, but nobody drinks more than the white guy! YOU’RE drunk!!!’
Uh, yeah, no. Sorry, no I’m not.
Then we got less productive. Then people started throwing bricks at me, going by on either side of my head, landing in the branches overhead, flashing their sticks, flashing their hammers. I just stood there. My employees tried to get me to move, but at least the kids weren’t throwing bricks at the school and church any more. Eventually, the kids saw I wasn’t going away and they got bored of me. But also bored of the school and church.
‘Hey! Let’s go throw stuff at the prefecture!’
I thought about going with them, but hung back to chat with the little kids hanging around. We found mutual boredom in each other and I headed back inside.
Soon enough, my kids couldn’t stay inside and curiosity drew them out, so I figured I should be responsible and join them, even if it drew me away from productivity. Outside, I saw the pastor and we got to chatting about the school, the church, evangelism, lots of stuff. The school principal came up and we kept trying to find ways to make lemonade out of out lemons. Or at least Crystal Light.
Suddenly the screaming came back full strength toward the hospital. I was told somebody had been shot and they were in the operating room. Danae hadn’t come back yet from her surgery, so I knew all four doctors were at the hospital, Danae and Rollin, along with our Argentinian surgeon Christian and our American FP/OB Sarah. Everything would be fine.
But internally, an emergency doctor is not fine when he knows somebody has been shot and he is not with them. This is my specialty, my job, this is what I do. I kept glancing furtively, well, ok, staring, longing for any sign at all that I should run up, torn between the desire for everything to be ok and the desire to be needed. I saw Sarah carrying a baby and called.
‘Sarah!’ Nothing. ‘Belensky!’ Nothing. ‘Dr Sarah Belensky!’ She didn’t hear me, even though I was walking toward her. She walked away. Oh, how that hurts an emergency doctor.
Lately, I really haven’t been helping out much in the hospital. Sarah picked up medicine and pediatrics so quickly, I’ve turned things over to her and I’ve been helping out more at home and continuing to fill the role of administrator, while trying to take some of her evening and night duties on pediatrics and medicine. Dolores has been packing up her house and hasn’t had time to watch our kids anymore. Don’t get me wrong, I love our kids and I like being with them. But a patient with a bullet hole is a pitching wedge away from me and… and I’m not helping. Any emergency doctor will start twitching at that point.
To busy myself, I take the kids and walk away from the hospital. At the far corner of the compound, the kids and I play a bit, but I continue to wrestle with my meager thoughts. ‘Will I feel more guilty if I leave the kids, 8, 6, 4 and 2, all alone, when they’re already a little stressed by the screaming mob that was here a couple minutes ago? Or will I feel more guilty if I leave a shot patient alone?’ No, that’s silly. She’s not alone. She's surrounded by four of the best doctors in the country.
Mercifully, I see a nurse walking toward me.
‘Kids, go to Nana’s house! I’m needed in the hospital!’ The nurse hasn’t even made it to me yet, but I’m walking toward her and past her. She doesn’t need to tell me anything. My right brain fist-bumps my left brain.
I walk into the operating room and they have no IV access. Christian is trying for a subclavian. They say she’s 13 years old, but she looks much smaller. The closest vein to where I’m standing is her femoral vein. She’s breathing agonally, she’s bleeding, she’s out of it. She needs surgery and we aren’t operating without a vein. Philippe has her on oxygen and she’s breathing, her sat is holding despite her lousy efforts. I decide that’s good enough for now. My fingers go to her groin and feel her pulse. Check.
‘Give me a 16.’
A normal IV is slapped into my hand and I slip it into her femoral vein. It may be a normal peripheral IV catheter, but we will use it like a central line. Think of it as a pediatric cordis. We have access. ‘Go prep for surgery.’ I plug the blood draining out of her IV with my ungloved thumb while somebody hooks up the IV fluids. Taped in place. Good to go. A second later, Christian nails his subclavian vein. It feels good to be surrounded by competent physicians, something I’ve been blessed with for the past seven years.
I hang blood and fluids and squeeze. She’s still maintaining her airway and breathing on her own. Philippe gives ketamine. Dunno if she even needed it, but whatever. She doesn’t drop her sat. She does well. We get her some antibiotics. The surgeons drape her and open. There’s a lot of blood. Everywhere. Gushing out. Too much.
‘Dear, put gloves on.’
Danae scrubs her arms while I open one of our precious disposable gowns. A third set of hands is imperative, despite the tiny size of this girl’s pelvis. For the next three to four hours, my best surgeons, whom I might be willing to put up against any in the world, they fight for this girl. She is shot through the abdominal wall, through the colon, through the small intestine, through the uterus, through the bladder, through the iliac vessels, seemingly through every other vessel in her abdomen, and out the pelvis. She is bleeding profusely.
The girl fights to live and my surgeons fight for her. Hysterectomy. Tie off iliacs. Open bladder and stop bleeding. Stop all the intestinal bleeds. Stop all the abdominal wall bleeds.
Her 16 gauge subclavian is wide open ringers the whole time. Her 16 gauge femoral is wide open blood the whole time. Seven bags of blood. At least that much in Ringers. I’ve certainly replaced her entire blood volume by now and then some.
Despite the hours of surgery, she never needed a repeat dose of ketamine. This is not good. All the bleeding arteries and veins have been tied off. All the holes have been closed. But she bleeds from everywhere.
Klappette Angeline is in DIC, Disseminated Intravascular Coagulation. Oh yeah, she has a name. I had an attending in medical school tell me that DIC really stands for ‘Death Is Coming’. He was not wrong.
We kept her in our prep room for hours as we did other surgeries and saw other patients. I never did get a chance to change out of the basketball shorts I had been wearing when the nurse came for me. It was a busy day I wasn’t even planning on going to the hospital. Hydrocele, hernia, hernia, anal fistula, curetage, hernia, hernia, hydrocele, clostridium abscess from collarbone to top of head, fourth degree tear, laparotomy, cervical cancer, a few other cancers and abscesses… all either to operate on or to be scheduled for surgery or to be consulted on and sent home.
On the one hand, it was an emergency doctor’s dream. I had two surgeons, an OB/gyn and an FP in the room with me. I just grabbed the stack of medical booklets, glanced at the chief complaint, called them in, handed them off to the proper consultant and then helped the consultant do the paper work. Yeah, and I saw a few myself too.
On the other hand, it was a total mess. In a room maybe 200 square feet, we had a guy laying on the floor awaiting his laparotomy (he ended up having a perforated gastric ulcer and probably would have died within hours had we waited), an elderly woman being stabbed in the face to drain her clostrium abscess, which stunk horribly, a woman having a miscarriage and awaiting her curetage, an endless parade of men dropping their drawers for us to see their hernias and hydroceles, everybody’s family members, a steady stream of women going to the dark back room to have a pelvic exam… and Klappette, lying on a stretcher off to the side of the room… bleeding… just oozing… everywhere. Out her bullet hole. Out her incision. Around her IV sites. And almost certainly inside. The floor under her bed is a pool. A deep pool. We could reopen her. But she’s in DIC. It won’t help. Her blood has no more clotting factors in it to stop the bleeding. She will just continue to ooze. We’ve explained it to the family.
We catch up with all the consults. I see a few ultrasounds with Bernard. I come back. And she’s on her way out. There’s just nothing to do. We let her go in peace.
So how does a 13-year-old girl come to be shot? I’m glad you asked.
She lives next door to the military camp in town. The rapscallions ran to the government offices and to the police. Then they figured they needed a purpose. Ok, so in Bere in rural Tandjile region, we’re going to have a strike that changes the government’s mind and magically gives them money. So the demands are to end the strike. Well, the government isn’t on strike. Government employees are. Ok, so the demands are to increase wages so the employees go back to work. Uh huh. ‘Cause our local authorities can do that. Ok, and the other demand is to free all the prisoners. Really? You want to free all the prisoners? Yes. Why? Well, ummm… Do you know any of the prisoners? No. Do you know why they’re in jail? No. So why do you want them freed? Well,… that’s what people on strike do, right?
Tensions mount. Things escalate. Stupid youth binged on booze throw stuff. Drunk and nervous military pull a trigger.
‘But it was just a blank!’ ‘But he shot straight up!’
Malarky. I’ve seen the entrance and exit wounds. This was not straight up. This was firing flat into a crowd. And caught a 13-year-old girl. These are the good guys with guns. This is senseless in the truest of definitions of the word. Senseless.
Klappette dies. She’s at rest. She feels no more pain. It’s horrific. Especially knowing she probably could have been saved by American medicine. Five doctors. All day. Can’t save her from one, 2-ounce bullet to the pelvis encouraged out of the muzzle of a gun by some liquid courage. All she did was come out of her house to see what the excitement was about and got caught up with the crowd.
She doesn’t. even. go. to. school.
This was not her fight. But she lost anyway.
We are broken. But we press on.
I head home back to my fatherly duties. My superheroes, dressed up in scrubs… they labor on.
(P.S. Please don’t worry for us. We will be fine. We found out later that as soon as they heard fighting had broken out, our two off-duty personal guards came running to our house. All three were here, spread out across our compound. One was even on vacation! They are good guys, but they were not needed. Really, they’re employed to keep people from knocking on our door 24/7, not for security. But you should pray for Tchad. No economy. People not getting paid. Government bankrupt. People on strike. People don’t have money for food. They don’t have money for medicines. Tchad is a tinderbox. We are one bad crop-year away from a match.)