Thursday, December 19, 2019

Wednesday, December 11, 2019

Moving a Cavewoman

‘Did cavemen ever had to deal with this?' I wonder to myself.

I’m currently packing the fifth suitcase, and I know there are many more yet to go. Tomorrow, we will drive all these suitcases up to Silver Spring and drop them off at Dad’s house for some of our very dearest friends, Blair and Brenda (or Brair and Blenda if the kids get mixed up), to bring to the airport in a month when we leave. We aren’t completely certain we will be able to fit all our dozen suitcases, dozen carryons and family of six into Dad’s minivan and tiny Audi, along with Dad and Donna.

‘This is totally a stereotypical situation,’ I think in my head. The man struggling to keep his wife happy, moving a half dozen suitcases and hat boxes comically into a hotel room for one night, tripping, stumbling, dropping things, but still madly in love. It all seems very much to warrant a black and white silent film à la Laurel and Hardy.

The reality is much less entertaining, the expansive master bedroom of our family lake house, cluttered to the brim, with me cramming one more T-shirt into a suitcase and then bouncing on top of it cartoonishly to compress things just enough to get the zipper shut, tangs holding on for dear life, scale registering 52 pounds, which we have scientifically determined to be the actual limit of the written 50-pound checked baggage limit.

If it conjures a black and white film in my mind, how hard is it for me to imagine this in Victorian England? Elizabethan England? Not too hard. What about Joseph rolling his eyes as he loads yet another bundle on Small Donkey? Yep, I get it, man. Or Abram asking Sarah, ‘Dear, do we really need another tent? Yes, Dear. Ok, whatever you need. Of course.’ Abraham, Brother, I feel your pain. I’ll bet you five bucks Noah’s wife was trying to sneak in a third elephant behind his back. I can even see Adam grimace as Eve hollers at him, ‘Make sure you pack my spare fig leaves, Honey!’

My mind’s eye enjoys the image of a man with a strong chin, leopard skin and unibrow looking entirely defeated as his wife convinces him they absolutely MUST pack a third club or else risk being eaten by a wooly mammoth should the first two clubs break. (And yes, I know wooly mammoths aren’t voracious human-eaters, but my mind’s eye tends to wander.)

Yet at the same time, I marvel that my beautiful wife was able to pack for the both of us for a week on a cruise in personal items. No, not carryons. Personal items. As in, the hand bag that fits under the seat in front of you. We are quite fortunate her bikinis are skimpy. Or there was that clothing-optional beach we got lost at on Saint Martin.

And then on our next trip, the van will be overflowing with camping gear (it’s not like we can carry it all on our backs, although she will try!). Or a long weekend in Tennessee with four full suitcases. It’s bafflingly unpredictable.

As it turns out, however, packing that fifth suitcase was just the beginning…

Every year when we return home, Danae tries to buy Amazon. Not a prime membership. Like, the entire warehouse. All the warehouses. I suspect a genetic compulsion. If you time the market with our vacations in America, I’m betting Amazon stock goes up while we’re stateside. She’s personally responsible for destroying square miles of forest merely in Amazon boxes. In addition, she got a lot of donations this vacation for her pet projects. So to all of you who gave so generously… I hate you. You make my life miserable.

Ok, so that might be a bit of an overstatement. And actually, she would have spent her own money to buy stuff anyway. So, I guess I love you. Thank you.

Danae bought THOUSANDS of baby T-shirts to give to newborns at our hospital. She bought hundreds of T-shirts for the staff of all the AHI-Tchad hospitals. (All these T-shirts were transported from Dallas/Oklahoma in our minivan, along with six people and their personal belongings, and nine boxes of medical equipment.) She bought MP3 players with solar panels so people can listen to the Bible in villages without electricity (which is all of them). She bought picture Bibles she had designed specifically for her, with versus she had copied from Bibles in a half dozen surrounding tribal languages. (Which we picked up in Tennessee and drove back in a full van.) She purchased her own invented ‘Grief Kit’ material for families who lose babies/children.

Do you know how many suitcases it takes to pack over a thousand T-shirts? I do! Too many. It takes too many suitcases to pack over a thousand T-shirts, if you want a scientifically precise answer. And all those picture Bibles? The over 200 pounds worth of picture Bibles? Oh, I haven’t even mentioned yet all the donated medical equipment from Mission Regan or all the scrubs people donated.

‘But, Urg. The third club is for us. Shouldn’t we pack another club to give to the people we’re going to visit? What would Jesus do?’ (I believe all cavemen were named ‘Urg’. And Urg had Jesus.) ‘But Noah, can’t I squeeze in twenty more sheep? You know, as sacrifices to God. Are you saying it isn’t a good cause? You don’t love Jesus?’ (They knew He was coming, right?) ‘Joseph, why don’t we just buy Big Donkey to help Small Donkey? Then we can take EVERYTHING! I mean, don’t you want the best for our Son. He’s God after all. Don’t you love Fetus Jesus?’

Yup, our wives have their noble reasons. Grrr.

So final tally:
12 suitcases travel with us.
12 carryons with us.
8 suitcases sent to my friend, Ricky, who’s arriving next week.
4 suitcases left with a friend, Bekka, who’s coming in January.
3 suitcases left with Dad, who’s coming with Donna in January.

27 suitcases. And 12 carryons. And over $12,000 spent on noble causes. (None of those noble causes were excess baggage, emotional or otherwise.)

‘cuz… well… my wife loves people. And Jesus. I know, totally annoying, right?

(I didn’t even tell you about landing at 3am in N’Djamena and loading 12 suitcases and 12 carryons into/onto a Corolla, then onto a bus, then onto/into a LandCruiser, stopping to pick up the suitcases that fell off and into the mud, and finally get them into our living room, where the suitcases vomited their contents all across our house.)

(In case you’re reading this, Dear, I love you 😘.)

PUSH!!!

And now PUSH!

Celestine had come to our hospital in labor.  Her twin babies were both breech, but this wasn’t her first baby.  With a little patience (always for breeches), she delivered vaginally with the help of some lifesaving maneuvers to deliver the nuchal arms they both ended up having.  The first baby had to be resuscitated for about ten minutes, but finally let out a good cry.  Both babies are doing well now and are already one week old.  

Every day we provide obstetrical care for the surrounding villages.  We receive many referrals from the neighboring cities of Lai and Kelo for prolonged labor.  Often times from Pala as well (a four hour drive in dry season).  I’ve had ruptured uteri travel the bumpy roads all the way from Pala.  I have about 20 ruptured uteri every year, almost always unscarred uteri, and always from prolonged labor.  

The country of Chad was named the worst country to be a woman in 2019.  In 2018 it had the world’s worst maternal mortality rate.  I know we are making a difference here, but hopefully not worsening these rates.  Just kidding.  I know we are making a positive difference in individual lives.  But sometimes it feels like a drop of water in an ocean.

Our hospital delivers about 1200 babies a year.  We have one obstetrician and two family practice physicians, each with a year of obstetrical fellowship.  We have one local midwife with her masters, and five or six nurses who function as midwives.  Our nurses do all of the normal deliveries, and call the doctors when there is a problem.  

Every Tuesday and Thursday are our prenatal care visit days.  Usually once a month women walk from all around (yes WALK) just to get checked out while they are pregnant.  Prevention goes a LONG ways.  They also know that when they deliver at our hospital, they will get a free baby Bere Adventist Hospital T-shirt and random other baby clothes or blanket/hats.  This has been going on for years, and they will ask for it!  These are women who do not get a fancy baby shower, so it might be the only new thing they will get for their baby.  It’s so fun to give to them!

There are three main causes of maternal deaths here in Chad.  Hemorrhage/Anemia.  Preeclampsia/Eclampsia.  Malaria.  With good prenatal care, the risks of these causes of deaths can be assessed and often death can be prevented.  

Most deliveries in Chad are home deliveries.  The problem is that many of these home deliveries have never had a good prenatal visit, let alone ever had an ultrasound.  Malpresentation goes undiagnosed.  Multiples go undiagnosed.  Often at the expense of the baby, and sometimes the mom as well.  And many of these home deliveries are grand multiparous patients.  So their uterus does not want to contract, and they bleed.  Sometimes to death.  

So many times surrounding places that provide ‘prenatal care’ have never done a blood pressure on a patient.  Thus, the patient arrives completely comatose after their eclamptic seizures at 8 or 9 months of pregnancy.   

Malaria affects everyone here, but it hits hardest on the pregnant mothers and babies.  Malaria also causes anemia, further compounding the hemorrhaging problem of delivering at home.  

All of our nursing students rotate through labor and delivery, but it’s time to graduate some midwives!  We’re going to make it official and open up our midwifery training program.  

To all of my midwife friends who would love to teach a course….come on over.  It will likely be a 4th year to our three-year nursing program that we already have going.  But we need to develop our own curriculum and make things official.  French friends with curriculums already in place would be very welcome! 


So come on people.  Help us PUSH some babies out!  And push some midwives into training.    

Push, don’t PUSH!

Push, Don’t push

Okay, I’m a gynecologist.  I’m supposed to get people to push, right?  Well, that works in the obstetrical land.  Push the baby out.  Push yourself down here on the bed so I can examine you.  Lots of pushing in the OB world.  

But in the surgical world pushing is bad.  For an abdominal surgery, we want a nice soft abdomen.  No pushing involved.  Pushing makes it hard to see.  Pushing makes it hard to poke your needle into tissue and then tie off a vessel to stop the bleeding.  Pushing makes the bowel get in the way.  

Why do I have so much pushing in my abdominal surgeries?  All of my cases are done with spinal anesthesia by my nurse.  He learned how to do anesthesia from others, but was not formally trained.  He does not know how to intubate.  Spinal anesthesia works great when it works.  But sometimes the medicine doesn’t work here, even with a perfect stick.  Sometimes then you have to give ketamine, AKA God’s gift to the developing world.  

Needless to say, I often times don’t have a soft abdomen to operate on.  But you know what?  I do the case anyways.  Because that’s what we do here, we push on even when it’s hard.  Visiting doctors don’t like it.  I don’t like it either, but I’m just used to it.  If a case gets too difficult with the patient pushing, I make the nurses call Olen just in case the ketamine gets a little too deep, so he can secure an airway.  So I try not to complain to much during surgery about pushing, because then I just have to worry about the patient’s airway (as Olen is often home with the kids lately).  

We recently had a visiting CRNA for our Smile Train.  She mentioned that we need a training program here and I absolutely agree!  I think we should start one RIGHT NOW!  All I need is a dozen or so CRNAs or Anesthesiologists to come for one month (or less) per year.  You’ll help us set up our curriculum, and voilà….We’ll be on the right track!  


We certainly have the surgical volume!  

Sunday, July 14, 2019

Work Note

Sheer terror.  That is the only thing I can think of that describes the situation we were in.

Our new doctor Sarah had called me at 1am. Hey Danae, can you please come and help me for a uterine rupture?

Ok, Ill be right there.

So rare in America, uterine ruptures happen here in Chad all the time. Women labor for a long time at home. By the time they get to our hospital, their babies are dead. Surprisingly, they usually arent hemorrhaging badly. The baby typically is compressing the big vessels of the uterus, so the women somehow survive. We cut into the abdomen and repair or take out the uterus.  Its my bread and butter here, or so it seems.

But this is far from that situation. This was something worse.

I walk to the Operating Room (OR) to meet Sarah there. There is a woman on the table already, but Sarah comes racing around the corner with the gurney and another patient. I quickly realize that she was managing multiple patients at one time. She had a patient on the table awaiting Cesarean-section for failure to progress in her labor, but she hadnt gotten to her yet.

The patient on the gurney is the true emergency. I look around at whos going to help us. Five saucer-eyed nursing students stare back at me, clueless as to how bad the situation is.

They somehow switch patients to put the hemorrhaging woman on the OR table. Even doing this is a challenging task for our inexperienced team working tonight.

Has Philippe been called?” I ask.

No.

Sarah calls Philippe. I call Philippe. We need Philippe. We need anesthesia. We need a 16 gauge IV. In fact, we need two. Actually, we probably need three. All we have is a tiny catheter unable to drip fluid into our patient fast enough. Its never going to work.

I quickly assess the situation. The patient has a postpartum hemorrhage. Sarah told me a little of the history. The patient was induced, but then required a vacuum delivery, essentially pulling the baby out with a suction cup on the babys head, a very common and safe procedure. Sadly, but unrelated, the baby had died during labor prior to delivery. Sarah said shed felt inside after the delivery and could tell the patient had a ruptured uterus. She had hemorrhaged out like a bathtub faucet. I try to compress the uterus from below, but it isnt helpful.

Instinct sets in.

Must stop bleeding.

Foley please. Call the other nurses from the other services. We need a good IV! Call Staci to come help. We have nobody here to do anesthesia. Staci can give anesthesia.” Still nothing better for an IV.

A few more nurses show up from the other services. One clearly had been sleeping, rubbing his eyes. Its a major no-no, but I tell myself to address that later.

So many nursing students threatens my sterility, which Im usually absolutely rigid about, but at this point sterility doesnt matter.  I quickly scrub the patients abdomen in 30 seconds. Sarah and I do a half scrub.

Any moment, Philippe should walk through that door and place a good IV, and well be all set. I just have to stop the bleeding right now.

No Philippe, but Staci shows up.

The patient starts making gasping sounds.

I cut into her abdomen with zero anesthetic. She barely flinches. (Not a good sign.) I grab the uterus at its base, stopping the flow of blood into it, and thereby stopping the flow of blood out of it and out of her. Thats all I can do for now. Shes so close to death. It doesnt matter if I do a hysterectomy or not now. Ive stopped the bleeding with my hand, but if we cant get a better IV, we will lose her. I cant do it all at once. I just squeeze.

She has no blood pressure, no response, no sign of life. She needs epinephrine, the pharmaceutical equivalent to a horse hoof to the heart. We give some epi through the barely-functional IV.

Philippe shows up. He tries to get a better IV.  

But its all simply too late. Im trying to run the code, directing traffic to give chest compressions and breathe for the patient and give IV medications. I pass the uterus to Sarah to squeeze while I start chest compressions. Too late. All too late.

Give atropine IV. Give more epi.

Epi. Atropine.

Just keep pumping. She cant die. She labored at our hospital. Sheour patient.

My hands and arms grow tired. The sweat is dripping down my face. Thinking what else to do. We discuss placing a central line, an IV placed closer to the heart, but nobody is really comfortable doing that. I should have told Staci to do one. I should have tried one. Philippe can always get a line. But its too late.

We started CPR minutes after Philippe arrived, but she had already bled too much, too quickly, for too long. She needed blood. She needed blood fast.

After a long time, while shes still being coded, I go out to talk to the family. Her husband is there. I ask how many children they have. Three. I tell them how bad the situation is.

I go back inside. Its too late. Weve coded her for over an hour. We called it. Shes dead.

I give the news to the family.

We wheel her out to the pre-op room and switch patients. The next patient has to be done too. For moral support, I wait in the room as Sarah and Staci perform a C-section on the next patient.

Then I go outside to be with the family of the woman who died. The mother of the patient had been in the maternity ward and hadnt been told her daughter was actively dying. Now, shes actively grieving.

Its 5 am. Were all beat. We debrief some and then go home to sleep a couple of hours. Sheer exhaustion. Thats what happens after a stressful situation. Sheer depression.

The next day at work, I find out the patient had been waiting for a month at the hospital so she could have a safe delivery.  The baby died in labor, and the mother died after a vacuum delivery from a postpartum hemorrhage. A month living at the hospital to ensure she didnt die in labor at home. And she dies here instead.

Deeper depression sets in. We failed. I failed. After a month of being safe.

But theres still work to be done. Still need to round and see all the hospitalized patients. Operations on normal cases. Lots of consults. Sarah had gone home to get some rest because I told her she should take the day off. But shes too depressed to be at home, so she came back to work in the afternoon to help us with the consults. Shes amazing and smart and strong.

She presents a patient to me that had a fistula, an opening between her bladder and her vagina. The patient had lost her medical booklet, but Sarah had copied the operative note I had written in the computer three years earlier. She had been my patient. She had had a large 5 cm vesico-vaginal fistula that I had repaired, including a left ureter anastomosis to her bladder.

This next week is a fistula week at our hospital, but I hadnt made any announcements on the radio yet when this woman came in. So I was surprised that she was here to be operated on again. I was depressed already and now this woman came back who wasnt fixed by my major surgery on her.

She didnt speak any French, only Lele, a language far from Béré with only 26,000 native speakers, none of whom work at my hospital. I bring her into the OR so I can do a proper exam on her with good light. She doesnt smell like urine. Theres no urine leaking from her vagina, and theres none on her clothes. Maybe, just maybe, we misunderstood. I find a nursing student who speaks a neighboring language similar to hers, and we piece it together.

She isnt leaking urine. Shes been dry since I did two surgeries on her back in 2015. I told her to not work until her visit with me. Well, now three years on, shes back for her visit. She hasnt done any major work for three years. She was too nervous about the fistula breaking open. On her exam, everything feels soft and her urethra appears normal. She is cured.

She explains shes been arguing with her husband about whether she should be working or not and came back today to ask if she should. Should she start carrying things on her head and working in the fields this year?

Three years. Three years and she chose today to come back and ask this simple question! With tears in my eyes, I tell her today had been an extremely awful day, and I believe God had sent her for this very moment to tell me she had been cured. He had spoken to her heart so she could encourage me.

I ask her where she lives. She tells me she lives well past Kelo, a town 26 miles away. She got to Kelo and didnt have any more money to continue her journey, so she walked the 26 miles to our hospital just to ask if she should start working again three years after she was healed.

Right then and there, I give her money for her transport back. Actually I stole money from my amazing volunteer nurse, Sonam, so she could ride back to her home, plus a little extra. Which reminds me, I still need to pay Sonam back.

Saturday, June 15, 2019

The Farmer and the Cowman

“Oh, the Farmer and the Cowman should be friends...”

I don’t remember exactly how the whole song goes, but Rogers and Hammerstein knew about Tchad when they wrote Oklahoma!.

« Docteur, venez à l’hôpital. Il y’a guerre à Delbian et mon malade saigne trop ! »

10pm. Well, at least I still hadn’t gone to sleep. Might as well go see who’s bleeding in the ED. At this hour, in hot season... patients can deal with me in basketball shorts and a scrub top and flip flops. Whatevs. 

First bed, a 30-something very muscular man. Why won’t he greet me? Oh, the nurse didn’t notice the giant goose egg on his forehead. His eyes are meandering in different directions, each going in a direction irrespective of how the other tracks. Like a chameleon, I muse to myself. Pupils symmetric and reactive, so at least he has that going for him. ABCs solid. Well, kind of. That B part. Somebody get me a stethoscope. 

A nursing student brings me the disposable kind that hangs in contact precaution patient rooms in America, but remain our stalwarts here. Auscultation seems bit reduced left base. Percusses a bit dull left base. Tympanitic left apex. Heart fine. No respiratory distress. 

His chest has a hole just north of where his heart should be. It’s sutured up. Pretty solid suture job actually, for the health center. And another small hole just parasternal. Lower abdomen has another hole. Right hand has a massive slice across the base of the palm, sutured up. Pretty gaping spaces between a lousy suture job, and filled with dirt and filth. 

« David, qu’est-ce qui est passé ? »

And then I learn the story. This tribe was having their “Initiation” outside their village, 18km of horrible dirt road from here. Initiation is when the young men who want to know the secret spiritual ways of the ancestors are taken at a certain age outside the village for a few days to weeks where the older men teach the secrets of the ancient good and evil spirits. This is only for a select few and it is CIA-level secretive stuff where leaking of information is paramount to treason and punishable by death. To divulge would be to make public the secret curses and blessing of the witch doctors and put them out of business. 

During said initiation, the nomads came through, driving their cattle. Driving cattle across Tchad, as in the musical “Oklahoma”, comes at the expense of cattle trampling crops. When you’ve spent most of the year tilling and planting and weeding and watering and whatever else it is the Farmer does, and then all your efforts are squashed by a five-minute passage of a herd, and you are faced with the desperation of the prospect of traversing an entire year with no income and no food... you become unhappy. 

Conversely, when you are a Cowman and your entire livelihood depends on your cattle eating and moving from grazing pasture to grazing pasture and then to wherever they will be sold, and there are no roads, you must drive your cattle where they go, and that will invariably be crossing farmland at some point. And when you have a history of constantly being unwanted and shooed and impeded from living your ancient way of life... your fuse gets short. 

Well... somebody’s fuse got short. I’m not certain how it happened, but nomads interrupted the holy initiation and offense was taken. To counter the affront of the offended, the nomads bore their weapons and let fly. 

Wait, wait, wait. These are arrow holes?

« Oui. »

Are the arrowheads still inside?

Blank stare. Patient can’t answer us. Well... let’s assume they aren’t there. 

Ok, so two arrows to the chest, one arrow to the belly, a machete to the hand and something blunt to the head. Exhale. 

I go get the ultrasound to check for hemo/pneumothorax. It’s dead. Plug it in to charge. What? More patients? Ok. 

Next bed, elderly woman moaning. Nothing seems too amiss except her arms. Left arm, slice across forearm. Patient highly non-compliant with exam and I don’t feel like doing this tonight. Ring/pinky don’t move. Oh sheesh. Oh what? She broke that arm years ago and those don’t move? Ok. Moving on... other fingers seem to move. Sutures filthy and poorly done. Right arm. Horror. Practically circumferential slice around forearm. Base of palm sliced up badly. Hand crunches and patient screams anytime I touch it or move it. Yeah, something is broken in there. Stitches on forearm are intolerable. So I don’t tolerate them. Scissors. Cut. That’s better. Oh great. Isolated radius fracture just proximal to midshaft? Not common. And terrible to deal with. 

What? More patients? Grrr...

Next patient, old lady. Also histrionic. Well, if a lady with a big unsutured lac on her forehead and a slice from elbow to tuft of index finger down to bone for the length of it can possibly be considered histrionic. Those sutures are even dirtier. Take ‘em out. 

Fourth? Why not? 30-something man with two holes to the chest, huge lac on the forehead sutured and a hair less filthy, and a hole on the butt, also relatively unfilthy and sutured. I think I should start measuring filthiness of sutured wounds on a zero to ten scale. He seems stable enough. Good lung/heart sounds. 

I’m tired. I slept like two hours last night. 

« David ! Tu es où ? »

Ok, David, first dude, let’s pop out the stitches on his chest. See those bubbles coming out? He has a pneumothorax. Keep that open. If he starts breathing poorly, send a nursing student to my house and plunge a finger in that hole to open it up. Check his pupils hourly. If one blows, maybe we will drill a hole in his head. His belly is soft. I’m not opening him tonight. Not if he doesn’t wake up. Soak him in bleach. Especially that dirty hand lac all sutured up. I’m too lazy to redo it, we’re too far out from his injury to redo it, and the suture job is bad enough any pus he makes will immediately leak out the gaping holes in the suture line. 

Old lady #1... soak her arms in bleach. Left arm is also a bad enough suture job we will see pus if it forms. Right arm... just pack it open. Fasting after midnight... so like, now... and we will exfix her radius in the morning. Stitches on that hand really need to come out too if you don’t mind. Too dirty. And translate for her she will very possibly lose her entire right forearm. What? Her son just died? He was the first one killed? How many died? Five?!?!?! Ok, and tell her I’m sorry for being a jerk to her for not cooperating with my exam. 

Old lady #2... translate to her she will likely lose that index finger in an effort to save her hand. People adapt incredibly well to finger amputations. She will be fine. We can do a Rae. And that huge forehead will now just need to be secondary intention too. Sorry. Keep her NPO after midnight too. Just in case we decide to take the finger. But we can probably wait a day or two before we decide. There’s a small chance she can keep it. Oh, and soak that arm in bleach and wash her forehead too. 

Last patient... yeah whatever. I’m tired. He’s fine. Just give him the bleach bath. 

Tetanus for all. And give them as much ceftriaxone as their bloodstreams can handle. 

A quick shower and I’m asleep. For an hour. 

« Oui, David. C’est quoi ? »

« Le malade continue à saigner beaucoup ! »

« Qui ? Le même homme ? Il n’a pas saigné quand j’étais là. Juste un peu avec l’air. »

« Oui, lui même. »

« Ça va aller. Bonne nuit. » I’m too tired to care. 

3am next phone call. 

« Il faut venir. Il saigne trop. »

« J’arrive. »

Back up at the hospital. He’s fine. He’s bleeding, but not that much. I’m not gonna try to stop the bleeding, because the hole he’s bleeding from is what’s preventing his pneumo. Actually, he’s not bleeding. That’s all old stuff. And no more air is coming out. Gimme that stethoscope. Ummm... so his heart sounds are on the right side of his chest. They weren’t before. I go and get the now-charged ultrasound. Yup. That heart is on the right and there’s a lot of blood and air in there. Go to the OR. Get a chest tube, a scalpel, a suture on a straight needle and a curved clamp. 

Bedside. Geez, this guy has more muscles in his pec than I have in my body. I hope he doesn’t wake up. He’s gonna hurt me. Betadine scrub the clamp. Betadine the skin. Stab. Tunnel. Clamp. Puncture. Rip. Insert. Wow. Glad I wore flip flops. They don’t hold as much blood as shoes. I probably should have done this hours ago. That’s like liters of blood. It just keeps coming. Suture it in with the straight needle because it’s easier than getting pickups and needle holder. No suction. No impregnated gauze. Just unclamp it if he gets into trouble. Clamp the tube. Ultrasound again and confirm heart is back where it belongs now on the left side of his chest. Hemoglobin 13. Now 12 hours out from his trauma. No way that’s a real hemoglobin with this much blood. I’ve never had a tension hemothorax before. And no way I’m gonna crack a chest here at 4am for a 12-hour-old penetrating chest trauma with blood. It all looks dark red. He will be... ummm... fine. Yeah. Let’s go with that. He will be fine. Get a hemoglobin in two hours again please. Off to bed. 

The next morning, they are all fine-ish. Danae wants me to do the exfix. I assure her she’s every bit as good as I am. She does it with me in the room for moral support. I drill the pins in. We make do with oversized steinman pins cut in two. Very very very not ideal. And plaster to hold the pins in place. There’s a lot of traction on these radial fractures to rotate the bone all wonky, but it’s better than internal fixation here where everything gets infected and everything is too open for a cast. Danae rocks it. 

I go to visit the other patients. There’s a guy there in military fatigues to protect them. Drunk as a skunk. My guard doesn’t want to kick him out, so I take the military by the hand to the gate, hand him back his billy club and wish him well with a strong shove in the back, ignoring his vehement denials of his intoxication. Close the gate behind him. Kids aged 10, 7, 5 and 3 have been home solo for hours now. Time to go home and see what they’ve burned down. 

#anotherdayintchad

Update: X-ray confirmed danae got the radius perfectly aligned. And Danae saved the finger of the other lady. Everybody ended up doing well and going home with all body parts intact.