COVID hits Chad

Ricky was coughing and breathing hard. He was a small 12-year-old boy with grey fluid and pieces of necrotic tissue draining from holes on his leg. I took Ricky to the OR, explaining to the family that he may lose his leg. The infected tissue encased his tibia from just below the knee down to the mid shin. 

On the OR table his oxygen saturation was 60%.  He was coughing and taking each rapid breath with difficulty. We have no ventilators and not even oxygen. We performed the operation with only local anesthesia due to the risk that Ketamine would worsen his respiratory status. It was painful for both of us. I removed the infected tissue, and left the skin open to change the gauze dressings in the wound daily. He also developed other abscesses in other parts of his body the subsequent week. 

With antibiotics and excruciating dressing changes, the infections began to clear. We now had a segment of exposed bone needing tissue coverage. Dr. Bill Rhodes, a plastic surgeon with 25 years experience in Kenya, graciously mentored me via WhatsApp on performing a saphenous fasciocutaneous flap to cover the bone. He prayed for me too. I’m indebted to him.  Ricky’s leg is healing wonderfully now. 

We will likely never know if Ricky had COVID-19 and consequently became more susceptible to infections, or if his respiratory symptoms were simply from the bacterial infection with resultant sepsis. We have no tests for coronavirus in this part of the country. 

The capital has limited testing for COVID-19. Over 800 patients have tested positive so far. Close to 10% have died. Chad has 15 million people and only a handful of ventilators. There is no capacity to manage critically ill patients here, even if they were spread out over a 6-month period. In spite of this, the country has prohibited all transport and non-food commerce since March. For the many people who eat by what they have sold at the market that day, the economic consequences are devastating. Our patients tell us that in the nearby city of Kelo, there are children crying on the street in hunger. Hunger is a serious problem at baseline in Chad which shutting down the economy has only exacerbated. 

We have a nutrition center to help combat hunger. A potentially more challenging problem however, is how to treat the surgical diseases that cut short or handicap many people’s livelihoods.

The city of Kelo is the commerce center for our district. It is 2 hours away by motorcycle and located on the main route linking the capital from Moundou, second largest city. This whole district, including Kelo, at the moment has only 1 trained general surgeon. Our hospital serves a population of approximately 100,000 villagers in its local district which does not include Kelo. However, we are the primary surgical center for Kelo. In addition, patients regularly come to our hospital from all over the country and surrounding countries. 

A physician in the district hospital of Kelo sent a patient to me to re-open after he had performed a laparotomy that day. He did not feel comfortable managing an intestinal stricture. It was apparent that he had performed a lysis of adhesions and was concerned about a part of the bowel that had become narrow from the compression of an adhesive band. However, the band had been cut and the narrow area would now dilate to allow normal intestinal transit. I closed the patient, reassuring the family and the physician in Kelo that he should have normal intestinal function within a few days. The patient did great. 

Another patient arrived from Kelo because there was no one perform his surgery there that week. He had a distended, hard, abdomen. He had suffered from abdominal pain for 5 days. He took his last agonal breath as I entered the emergency room to see him. I screamed with emotion asking why he had not come earlier. They said, “It’s God’s will that he died.” From a throat tight from crying I said, “NO! It’s God’s will that he could receive life-saving surgery earlier.” 

Then there is Ricky, and many others like him who are alive and walking because they came to our hospital. We do not lack patients. They crowd outside the OR. When I leave to see patients on the ward, or to try to go home they call out to me. It is exhausting. In a couple years we will have enough surgeons to start a top knife surgical training program. This will begin to beat back the onslaught of suffering we face daily. There will be so many more boys like Ricky, smiling as they walk. 

(Written in May 2020)