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.