N'Djamena in black and white...

I'm still in Chad, but N'Djamena feels already like a different world. When I arrived in Chad, my flight came in at 10pm and I had a bus to Moundou at 6am. I didn't get to see any of the city.

On Friday, after rounds, after saying goodbye to my patients, giving some instructions to the nurses about specific patients, and telling one of my patients that if nobody came to do his evening dressing change, his job was to scream at the top of his lungs until someone came, I went to find myself a minibus to N'Djamena. The buses here don't leave at specific times, they leave when they're full... and it seems not many people wanted to go to N'Djamena on Friday, because I was sitting in the bus for 2 hours before we started to move. They also said it'd take 6, maximum 7hrs... Well, it took more than 8... So I was in that bus for a total of 10hrs... 

In the middle of the journey, they make a stop in a city called Bongor, so people can eat, go to the bathroom, whatever. I decided to get off the bus and get some food. This was already 3pm and I had not eaten yet. So I got a whole grilled chicken and a baguette. Granted, the chickens here are a lot smaller than elsewhere (no hormones!!) but I still devoured an entire chicken by myself, with my hands, while sitting in a bus, somewhere in Africa. 

Anyway... I eventually made it to N'Djamena at 8pm, and Kristin, my German couchsurfing host and friend picked me up and immediately took me to a concert at the French Institute. It was fun. There were a lot of white people there, and I realized that I hadn't seen that many white people in almost 2 months! In Moundou, at least for the last month, I've been the only white person... It was a little weird to see so many again. I met another German guy who is married to a woman from cameroon, and he mentioned they were going to a museum on Saturday and invited me along.

So the next day we took off to look for this museum, lost in a village, somewhere in the outskirts of N'Djamena. We finally found it, and were treated to a private tour to look at utensils, vases, shoes and clothing dug out by a French archeologist. They represent a little bit of the Sao people, rumored to be giant warriorrs of up to 4 meters, who could "kill an elephant and carry it home on their backs". Well... probably not, but legends are fun... :)

After that, I went to CLAC, a community center where Kristin and Emery organize cultural activities for the kids. They had a show planned for the end of summer vacation, and it was awesome. From babies to teenagers, they were all there, singing, dancing, laughing, having a grand ol' time. And man alive, they can dance!! They have an incredible control of their bodies, and seem to have joints and muscles I didn't know could move... :)

Then it started to pour, and rained monsoon style for a while. We were trapped for a while, but left when it let out a bit, because we had a barbecue to get to...

The barbecue was organized by ex-pats that work for a construction company, and live in a very nice complex with a pool. There was a lot of really good food, a fussball table, and a bunch of white people... I keep bringing this up because I got so used to seeing only black people with their big smiles worthy of colgate adds, that it's weird to see a lot of white people together. 

Anyway, we ate, talked and played fussball until the rain finally stopped and everybody jumped in the pool. It was more like a giant bathtub, it was really warm and just wonderful. I was the second person in, and the last to come out. We went home at 2am, after a really full day. I was tired...but...

Got home and couldn't stop thinking about my patients and how they're doing... Couldn't wrap my head around the fact that I had just been to a party in a nice complex, with a ton of food, and they probably spent more money than most people here make in a lifetime. 

I feel I'm in limbo, caught between two worlds... A world of stress and indescribable pain and suffering, but where I am needed, appreciated, and can do something to improve people's lives every day. And a completely different world where nobody dies, and nobody goes hungry. Where life is easy, and there are things like fussball tables and pools. But where I end up crying in the pool when I think about the girl that died last week and I did nothing. 

I knew Africa would be hard, and amazing, and that it would change me. I think going back into the world next week will be the real culture-shock, and readapting will be a challenge. Luckily, I get to spend some time roaming around the mountains of Nepal... I have a feeling those mountains will hear a lot of stories, prayers, and tears... 

Daily joys and struggles...

Well folks, since my phone is kaputt, I actually don't have any way to post pictures anymore. Sure, I could walk around with my iPad and take pictures that way, but that's hardly convenient. It doesn't fit in the pocket of my scrubs... 

So I thought I'd post about some of the joys and struggles I go through every day... 

I don't speak Arabic, only French. A lot of my patients only speak Arabic... so when I'm trying to tell them something, I can either find a translator or we can use sign language and try to understand each other. This usually ends in good laughs. 

This morning, one of my patients, who has a giant road rash wound on her thigh, which we had to remove the dead skin and leave it raw, was trying to tell me something when I came to do her dressing change. I couldn't understand her. She kept saying something like "beshé, beshé..." and I kept looking at her blankly while unwrapping her bandage. Suddently, she grabbed my arm and very gently caressed it. And then the light went on in my head. I have to scrub down her raw flesh to remove the layer of pus. She was saying "be gentle..." I understood. Unfortunately, I can't be gentle... I have to scrub it until it's clean... 

Well, this afternoon, with the same lady, I was doing physical therapy, and showing her with my body what I needed her to do with hers. This resulted in a few hilarious situations in which half the ward (who was watching) laughed with us. She's doing very well, and when her road rash is healed, she'll walk out of here with full range of motion on both legs! 

Another patient has a baby son, an adorable little boy of about 6 months. He was in his dad's lap when I went to do PT. I simply picked him up and he started giving me the most adorable belly laughs! Told his dad what to do, and just kept playing with the baby... :) I asked his name, and dad told me it was "Donné par Dieu" which means "given by God." I thought it was a very appropriate name...

Yet another patient has kidney stones. Very painful. He keeps asking if there's anything we can do to make it stop. There isn't. I told him this afternoon that the pain of passing kidney stones is comparable to the pain of childbirth, and asked him how many kids he had. He laughed and said: "so every time my wives* had a baby, this is what they felt? Now I understand why they screamed!" (*yes, he said wives...)

And then a last little story: when I was on my PT rounds, one of my patients didn't want to get up, she was tired. I joked that she had been in bed all day, why was she tired? Her answer cut through my heart: "I haven't eaten all day... there's no more money..." I hadn't expected that. She had an actual, legitimate reason why she did not want to get up. Why she was tired. 

I went back to my room, got some money and silently put it into her hand... Her eyes said it all. 

--//--

I've been here for over a month. The sounds, sights and smells have become familiar. It's become a routine. I start my day with rounds and dressing changes. Then I go to the OR and check what's going on: hernias, hydroceles, prostatectomies, broken bones. Then I have lunch. Then I do PT. Then I do evening dressing changes, make sure everyone is taking their antibiotics and drinking enough water. Then I have dinner, shower and hit the bed... 

But I forget that they don't have the same luxuries I do. A lot of them don't have enough money for antibiotics *and* food. Or sterile gauze. Sometimes I'm reminded... and I am shocked that I take so many things for granted, and complain about silly, stupid things. So I do what I can. I buy antibiotics, or gauze. I give them money for food. I pray. I talk to them and explain what and why we do this or that. I try to make them laugh and ease their pain. I try to help any way I can... 

I just hope it's enough...

Death...

I mentioned in an earlier post that I had seen a man die for the first time in my life here. And honestly, as terrible as it was, I dealt with it fairly well. I didn't know his name. He was elderly. The first time I saw him, he had already collapsed and was being carried to the bed where he immediately died. 

Today was different. 

This was a beautiful young woman of about 18. She had had an operation here on Wednesday. I knew her name. I had talked to her and held her hand during dressing changes. I had checked on her when I did the dressing changes in the evening.

And today, just like that, she stopped breathing. I was a few beds away doing dressing changes when I heard the wail and saw the family start to cry. Her younger sister being carried away by the brother of another patient. The mother covering her feet, then her arms, then her face. Someone brought a guerney, and the men transfered the wrapped up body. 

It didn't take more than 5 minutes between the first wail, and the body being wheeled away, leaving behind just an empty bed.

Through it all, I watched as if in a trance. I couldn't move. I felt completely powerless. I wanted to do something, but what? I wanted to scream that we couldn't just let her die like that. No! We had to fight! Do something! 

I can't shake the feeling that in a different hospital, in a different country, with better equipment and facilities, she wouldn't have died. That was a senseless, unnecessary death, and I watched it happen and did nothing. 

There was nothing I could do. No defibrilator, no respirator, barely any drugs. 

I felt outraged and numb at the same time... I pushed it all down. I still had dressing changes to do... there were other patients who required my attention... I would have to deal with my feelings later. 

Malaria and dead phones...

It started Thursday... After Physical therapy in the afternoon, I just felt tired. I went back to my room and literally passed out. Woke up 2hrs later, a bit confused and wondering what time it was. Got up, did the night dressing changes and went straight back to bed, didn't even eat. 

I should have known... 

Woke up the next morning and noticed I had slept with my sleeping bag. This is Chad. Lowest temperature is like 30 Celsius (or like 80F). My sleeping bag is for below freezing temperatures (I'm going to Nepal after this). Something was clearly wrong... 

But I still got up and pulled on my scrubs. I made it as far as the living room (50ft away) when it felt like my head exploded and I just collapsed on a chair. 

There was no doubt. I had malaria... 

So whenever I felt able, I pulled myself together to go back to my room and swallow 3 more malarone pills (I had already taken my morning prophylaxis dose). Promptly collapsed again, and didn't move for the rest of the day.

When it rains, it pours, so my phone choose this particular moment to refuse to charge. It still worked perfectly, it would just not charge! So when the battery died, I would have no way of communicating with the outside world. No news of ebola. No way to tell my mother I'm still alive. No blog. Nothing. 

There was nothing I could do, so I just remained in bed and watched the battery drain... 

Today (saturday) I feel slightly better. Even managed to eat a bit... After that, I felt I had a little more strength, so I braved the malaise to go find someone who could tell me if I could get a sim card for my iPad, and get me connected again. 

Clearly, that worked, and I can now still blog and email, just no more phone calls, txt messages or whatsapp... Oh well... It's better than nothing, and my new and overpriced iPhone 5s (which I paid full price for, 3 days before it got reduced due to release of iPhone 6) will arrive in 10 days, along with Dr. Scott. 

I'll survive until then... 

Sucess!!

A lot of my non-medical friends are complaining about the graphic nature of my pictures... so for today I have a different kind of post: 

Meet Ali- a kid of about 16:

He came to us several weeks ago with a femur fracture. He was in traction for a bit, then Dr. Scott did a perfect sign-nail repair. 

Ali speaks only arabic, and only understands a few words of French. The first time I met him, it was to start him on physical therapy after the surgery. His cousin was translating for me, and when I said we were going to do some exercises, his answer was a cathegoric "no way!" 

He clearly didn't know me very well... 

Of course, I didn't take no for an answer, and over the course of another couple of weeks, we exercised every day, and improved the range of motion of his knee, which at first was only about 30 degrees. 

He did NOT get infected, his wound healed nicely, and he was discharged. 

Today he came for his weekly check-up, still using crutches. 

That's his current range of motion. He's pretty good at exercising on his own, and I have no doubt he will continue doing it and regain the few degrees still missing...

So today, I had the pleasure of pronouncing him completely healthy and telling him he had no need to come back to the hospital, or to use his crutches again. 

I admit, it was weird actually saying to him "get up and walk!" 

But he did. A little wobbly at first, but gaining confidence with each stride. 

SUCCESS EXISTS!!! And it tastes good! 

:) 

Irene

For those of you who follow my blog, you have read about Irene before, even seen pictures of her giant wound, in the place where her right leg used to be. 

Irene was my first challenge. When I arrived in Chad, she still had her leg, but it was so infected, she was getting septic. The day after my arrival, she had an above-knee amputation. She still had a pocket of pus tracking even further up her thigh, so every morning, my job was to literally stick my entire index finger all the way up that pocket of pus, dig around in it, clean it out, irrigate, and dress the wound. With absolutely no anaesthetic. You can imagine the amount of pain that caused her. You can imagine how hard it was for me to do it, hearing her saying the then unfamiliar words that sound like "Ma cuilliao".* I didn't know what they meant, but I could guess... 

Day 1 post-op:

Every day, I would start the day with her dressing change... and I could see the progress: 

You can still see the layer of subcutaneous fat, but granulating tissue is starting to form. 

Here you can't see the fat layer anymore, and the wound is just starting to fold in the middle. Notice that the pocket of pus on the left is still there...

This was the first time she ever smiled at me, the first time we got her up and walking (already 3 weeks ago). 

This was the wound last week, already much smaller, and the pocket had no pus in it and was only about 3-4cm deep. 

This was Irene and I yesterday, when we were out practicing with her new crutches. 

Today, she is getting her leg sutured shut. The wound is clean, and small enough that we can join the skin on both sides. 

It is incredible, the healing power of the human body, and the resilience and strength of the human race. It is exactly 1 month since her amputation. She will be going home soon. 

I will miss her, but I'm glad she is healthy and even happy, as you can see from the big smile above. 

She might forget me. I will certainly never forget her. 

Right before closing...

Closed!!!! 

It's a happy day for me. And for her. :) 

*"Ma Cuillao" is an expression of extreme suffering in Ngambaye, there is no exact translation. I have become quite familiar with those words... 

A weekend away...

Hey everyone,

Sorry I didn't post anything last week, but things were just a bit crazy, I wasn't sleeping well and just felt exhausted and overwhelmed. 

A few weeks ago, I had met two people, James and Casilda, who work in a refugee camp in the south of Chad, for citizens from the Central African Republic (CAR) who have been deplaced by the war. They had invited me to come visit, and last weekend, I finally did. 

You might be thinking that going to a UNHCR refugee camp is probably not the best way to decompress, but it was actually great. 

There's no electricity there, only the big NGOs and a few restaurants have generators, so there's very little light pollution. The sky at night is incredible... 

The children are not afraid of white people (they probably weren't told that we come to take them and drink their blood) so they all smile and come shake hands. 

The food at the market is pretty darn good, and the meat is from a cow/sheep/goat who roamed the fields freely, was alive that morning and was immediately put on the fire after slaughter, so it's as healthy as it gets... 

I went for long walks by the river to watch the sunset--

I met handicapped refugees who got parts so they could fix their tricycles (no wheelchairs here)- 

That's Paulin, his legs are completely atrophied, but he gets around great on his tricycle, even going about 40km to the nearest city and back!

That's a beautiful African mama, also handicapped, holding her adorable baby...

James taking a fixed tricycle for a test drive...

It was an intense weekend, but very relaxing. I met people from several NGOs, people whose job is actually improving the lives of the refugees. I got into great discussions about how to organize health campaigns and teach the people what they should do if a child gets sick (**immediately bring them to the hospital and not wait 3 days until they're almost dead**). 

I also watched a Muslim funeral, for the father of one of the refugees who is a friend of James. He probably had a massive stroke, from what I gathered about how it happened.

Then we were invited for a genuine feast by another refugee, a man who was an architect, had worked and traveled to several African countries, had 2 houses and his own business in Bangui (capital of CAR) but was persecuted and almost killed for speaking against the government. Today he's a refugee living in a camp, with almost nothing. He still honored us with a 3-course meal of salad  fried plantanes, fried potatos, lamb in a delicious sauce, and watermelon for desert. 

That's Rodrigue on the right, with his sister-in-law, another refugee and James.

That's me holding Rodrigue's adorable baby...! 

All in all, it was a great weekend. Of course, coming back to the hospital, I had a horrible pain in my stomach, wondering what awful things had happened in my absence. Luckily, everything was ok, everyone was still alive, and **all** of the patients were happy to see me, wanted to shake my hand, said they missed me and were happy to see me back. 

It's hard to be here, but it's also good to be back where I know I can make a difference. It's good to know I'm appreciated and missed. And I like the fact that everybody knows my name and smiles big when they see me... it's kinda like being home...

The thing about Malaria...

A couple of days ago, when I went in the evening to do the dressing changes of the two patients who are on twice a day dressings (one who is improving, one who is not), I saw two little babies in our "ICU" brought in with Malaria. 

Again, one had a hemoglobin of 2g/dl and the other 5g/dl (at that age, normal values are 11g/dl - 14g/dl).

The malaria parasites (mostly P. Falciparum in these parts) invade and destroy erythrocytes (red blood cells) causing anemia. 

The hemoglobin in the red blood cells is what carries oxygen in our blood. Without it, you can have all the oxygen in the world available, you're still going to slowly suffocate because there's not enough hemoglobin in your blood to carry oxygen to your cells. 

Hence why we immediately check hb levels and give blood transfusions, along with drugs to kill the parasites in the blood, and the hypnozoites which are maturing in the liver cells waiting to be released into the blood stream. 

Malaria, if diagnosed and treated early enough, is curable and you should feel well again in about 3 days. 

Here, these kids come in when they're already so sick, they're barely alive. The percentage of parasites in their blood is so high, it takes a while for the drugs to help. The transfusions improve oxygen transport, but don't fix the underlining cause. 

The drugs and the parasites damage the liver, and once they get jaundiced (sign of liver failure), there's little we can do. We have to stop the drugs, and then the parasites in the blood can once again roam free, worsening the anemia until the child is dead. 

That's what happened to one of the babies who came in Wednesday night. He was still alive last night, and I actually thought he was going to make it (when they come in that sick, they usually die in the first 24hrs)... but he was no longer there this morning. 

I broke my rule and asked what happened, and the night nurse said he got jaundiced, they stopped the quinine and the family took him home to die. 

In comparison, this is Chrystelle: 

She's the little girl I mentioned in this blog post: http://livinglifewithoutfear.blogspot.com/2014/08/the-day-i-did-everything-i-shouldn.html?m=1

For a few days after that, she would hide from me, because she knew I was the cause of her getting pocked full of holes so we could finally get her meds, fluids and blood. But it doesn't matter. She's back to her smiling, adorable self, went home with her mama, and even accepted a kiss on the cheek from me. Her parents always have a big smile on their faces when they see me. 

I might not be able to control the infection that is rampant in some of my fracture patients. 

I might not be able to save all the little babies that come in already half dead and unconscious from advanced malaria. 

But I will take heart in the story of Chrystelle. She might have been one of those who came in too late to be saved, if I hadn't stepped in. 

She'll probably not remember me after I leave. I, on the other hand, will never forget her... 

A day of firsts...

**WARNING** Graphic pictures, not for the faint of heart!!!

Today, in the middle of rounds, they bring a man in carrying him in a very awkward position, sort of vertical... When they passed by where I was standing, his eyes were rolling backwards and he seemed to have no muscle tone. Apparently he had fainted when he went to the bathroom... They put him on the bed as I finished the bandages on another patient. I immediately went over there, and the Samedi, our Chadian doctor had just stopped looking for a pulse. He was gone. I grabbed his wrist, nothing. Looked for his carotid pulse, nothing. He was still warm. 

The daughter let out a scream, almost fainted herself, and walked out crying, accompanied by another family member. The wife stayed there, wailing and touching him, and covering him, and touching his face... 

It was heart wrenching... 

It was the first time I actually saw someone die. Not even my own family members, (my dad!), I had not seen them after they were dead. 

I have seen dead bodies, cadavers in Anatomy Lab, but it is **really** not the same thing. They're cold, bloodless, and feel like rubber. It's hard to think of them as humans.

He was warm. It's hot here, so he was a little sweaty. He had come in for a hydrocele and had seemingly nothing else wrong with him... 

There are no autopsies here. He just died. I'll never know why. Maybe he had a stroke, or a pulmonary embolism... who knows...

People here seem to have coagulopathies, either they clot all the time, or they bleed and bleed and bleed. Probably a product of their poor diet... 

They also have cancer. Giant cancers. They let it go on for too long, and usually come in when they have giant fungating masses that smell awful and look even worse... 

That's supposed to be a knee. There's nothing that can be done, except amputate above the knee, but at this point, it's certain that it's in his lymph nodes and has spread to who knows where. There are no CT scans or MRIs here. He's going to die. We just don't know how soon. 

The surgery was gruesome. I had only seen a big toe amputation (diabetic foot) and the last part of an arm amputation, but I was scrubbed in and holding his leg from beginning to end. 

Separate the muscle from the bone 25cm below the hip joint, pull back the flesh to expose the bone, bring on the electric saw...

Those are my hands holding his stump.

Did I mention he was moving? He had a spinal block and ketamine, but apparently it was not blocking his motor functions. Thankfully, it *was* blocking his pain receptors, so he couldn't feel a thing.

It was the saddest surgery I've ever seen... 

I had to leave and go make myself some coffee... It was a really rough morning. 

In the afternoon, there was a hernia repair, no complications, a simple operation... So I scrubbed in as the first assist! 

That was awesome. I had my fingers inside this lady and pushed her intestines back into place. It made me realize that in the OR, when you're focused on what you're doing, you forget everything else. For a little while, I forgot about the man who died, and the other man who lost his leg... 

I guess I understand why some surgeons say the OR is their sanctuary... I think it might be mine too...