Pregnant and Trapped

She came from a health center after 2 days of malaria treatment. She was six months pregnant. On arrival at our facility she rapidly delivered a dead fetus. Then she began to hemorrhage. Her eyes were yellow from jaundice and she was anemic from malaria. We rushed her to the OR and examined to verify there were no lacerations requiring repair. We packed her uterus with compresses to tamponade the bleeding and gave medications to contract the uterus. No success. The bleeding soaked through the compresses. Her heart rate was high and blood pressure too low to measure with the machine. We did not have enough of her blood type in our refrigerator. I decided to do a hysterectomy to stop the bleeding. 

She was oozing blood from every surface upon entering the abdomen. The blood was not clotting. An ominous sign indicating a person has lost the ability to form blood clots and stop bleeding from even small abrasions. Took the uterus out. Her blood pressure did not rise over 60/30, causing dreaded acidosis. We did not have any more blood to give her. Her heart stopped, restarted with epinephrine, stopped again and did not restart. 

Megan was also six months pregnant at that time. I spray our house with insecticide almost weekly and Megan only leaves the house in daylight. One evening at dusk a lady came wanting to sell bananas. Megan stepped out for 2 minutes and when she came back in she had a mosquito bite. Eleven days later she developed fevers, chills, fatigue, and headaches. At the same time she began having painful, frequent contractions. Malaria parasites concentrate in the placenta and can instigate preterm labor. My mind sees the jaundiced lady dying in front of me in spite of my best efforts. 

Megan started Malarone for malaria. She continued having painful contractions. Then after 3 days the contractions began to improve. The fevers and chills resolved and she began to feel better. Yay, we can hang in there until we leave to give birth in the US. She still has contractions at times. They improve when she lays down or rests. Frustrating for a type A personality.  

I finish a case and sit down to write my operative report. A text from Megan reads, “Our flight on June 24 was cancelled.” COVID 19 has kept the airport in Chad closed, but certainly it will open some flights soon? The flight was rescheduled for July 6. 

We search for other backup options. What other countries surround Chad? The part of Nigeria bordering Chad is home of the Boko Haram and even most Nigerians won’t go there. Niger is not friendly. The part of Libya bordering Chad is hostile. It would be unwise to cross the border to Sudan as a white person. Central African Republic is unstable. Cameroon is the best option for a land escape from Chad in spite of being in a civil war between the English-speaking and French-speaking people of Cameroon. However, the border is closed with military guards due to coronavirus. The Cameroonian embassy refuses to give visas until Chad officially opens its borders.  I have patients who can sneak across the border on motorcycles via back roads, however me trying to do that with Megan and Adelie might get us shot or in jail. 

The US embassy had a repatriation flight in early April, and has communicated that no further flights are being planned.  We suspect that the embassy staff have also left, since we have been told the embassy is essentially closed. If the baby was born here, we would be unable to leave for a while since it would require a consular record of birth abroad and a new passport, which according to the website, are unavailable at this time.

Work has been busy here. A man came with a necrotizing infection of his neck and chest that turned his tissue into pieces of grey dead matter that would almost knock you over from the smell. My assistant had to take frequent breaks to keep from fainting while I performed the debridement. I thought the patient would die. The infection tracked under the sternum toward the mediastinum on the right. I placed a chest tube on the right, but no pus came out. I told him to prepare to die and pray to live. He lived. He required several debridements as new pockets of infection turned up further lateral on his neck and inferior on his chest. His dressing changes take a long time, but today there is no longer any infection!

Another man presented with an abdomen full of stool from an intestinal perforation after he fell from a mango tree. He was also near death, but pulled through. I closed his ileostomy today. I was going on to another case when a boy came with low blood pressure, tachycardia, fever and severe abdominal pain after having fallen from a camel a couple days ago. He is one of the nomadic Fulani who roam far from civilization.

I perform a laparotomy and evacuate lots of blood. He has a hematoma in the back of his upper left abdomen (zone II). It does not seem to be actively expanding. Not too much blood oozing from around it. Hopefully it does not re-bleed. His 3 family members tried to give blood for him, but they all tested positive for Hepatitis C. They somehow found one unit for him and we gave him an additional one unit from our precious stash. He’s improving. 

I’m sitting down to write my operative note and see this text from Megan: “Our July 6 flight was cancelled and Air France plans to not schedule any flights the rest of the summer.”  

We strive to provide the best care possible with our limited resources here and continue to improve. Patients travel hundreds of miles and bypass numerous other hospitals to receive higher quality care here at Bere Adventist Hospital. However, this is still not where I want to risk my wife giving birth. Things could go great and it would be no problem. Things could be complicated. When will this COVID-19 insanity end for Africa? 

The baby inside of Megan is happily trying to do triathlons already. The baby kicks, runs, and swims. The fetus is now at the gestational age where it could likely survive if born here in Chad where there is no NICU. 

Adelie is healthy. She is finishing a course of quinine for a bout of malaria she got in spite of Malarone prophylaxis. We’re grateful she has taken her horribly bitter pills like a champion. She likes to go running with me in the morning. She points out cows and says, “Moo.” She chases goats. We are grateful for health ourselves and the ability to help many people here attain it.    

What were we thinking coming here?

(Written on January 1, 2020)

He came with severe abdominal pain for 5 days. He was distended, tender, and covered with numerous sets of cuts—neat little rows of three parallel skin cuts in each set—marking the efforts of an enthusiastic witchdoctor. We opened the abdomen and found black bowel. A congenital hole in his small bowel mesentery had allowed both a section of his sigmoid colon and terminal ileum to become strangulated. We excised the putrid-smelling bowel. I experienced the joy of beautiful hand-sewn bowel anastomoses. 

Two weeks ago we flew to N’Djamena, Chad’s capital, loaded our 7 suitcases onto a bus, and rode 12 bumpy hours to our new home in Bere, Chad. Our kind friends in the dental clinic there had purchased food for us. They also arranged our taxi who brought us to get SIM cards, use the restrooms in their house, and helped us get loaded onto the bus. We felt spoiled. It was an incessantly bumpy ride. Adélie had more than enough traveling that day, but she got out at a bus stop and enjoyed making friends with the local kids who were eating dried grasshoppers. 

We arrived in Bere to find a welcome sign drawn on our wall, a cozy-looking fireplace fashioned with construction paper, and stockings with our names on them. Olen and Danae Netteburg have really gone out of their way to help make this transition easier for us. Also, Staci cleaned our house, Keith and Tammy cleaned and cut our yard for us. The student volunteers made the artwork for the sign and cinnamon rolls for us. We feel so welcomed.

The last 2 weeks have been a blur. There is a list of patients waiting for surgery. To accommodate them we work often into the night and never stop for lunch. There are rounds with the one nurse in charge of all 20-40 surgical patients. Communicating with the patients typically involves communicating in French to someone who then translates to whatever other language the patient speaks. Then there is the stream of patients filing into the pre-op area for consultation. 

I am adjusting to the system here. There is a single OR. The team of OR staff consists 2 people--a local nurse that has learned to perform spinal anesthesia, give Ketamine, and rarely halothane/isoflurane with a bag mask. The second OR staff member is a local nurse who washes and autoclaves instruments, preps patients for surgery, and assists when needed. There is no scrub tech and I dream of having one as soon as I can make it happen. We put the sharps on one corner of the instrument stand and grab all the instruments ourselves. Often the spinal either doesn’t work, or wears off quickly. The patient starts straining and pushing all the intestines in our way during a critical part of the operation such as closing the peritoneum on a giant sliding inguinal hernia. It is quite frustrating and I hope to never complain about anesthesia in the US as we are so spoiled there. 

One notable case was when we were securing a prolapsing uterus to the sacrum with rectus fascia. Exposing the sacrum without good retractors is enough of a challenge, but then the patient started pushing all her viscera out at us making it impossible to safely place sutures without risking damage to the unforgiving iliac veins. In spite of the inadequate anesthesia, the patient’s blood pressure was intermittently 60/30 mmHg due to the anesthesia. We stopped and called our ER doc who can do anything. Olen came and further titrated the bag-mask halothane. The patient stopped expelling her abdominal contents at us and her blood pressure normalized. Olen has countless responsibilities, so it is not feasible to tie him up on the OR routinely. Olen and Danae have sent nurses to nurse-anesthesia school so if they come back we may have better anesthesia in a couple years. 

I use electrocautery when operating by myself, but Danae uses only a scalpel blade. Most of the instrument trays don’t even have a scalpel handle so we just grab scalpel blade with 2 fingers and cut. 

Danae is an OB-GYN who has been the only surgeon here for much of the last 9 years. She has tremendous experience and I’m grateful for the chance to learn from her. She has handled the volume of patients--1400 operations/year—primarily single handedly. I estimate she has performed about 3,000 inguinal hernia repairs, more than many general surgeons. She is teaching me OB-GYN and everything else that is so different here. 

I’m learning to perform prostatectomies. They involve opening the bladder followed by distasteful blunt finger dissection. It’s bloody. Not my style. An elderly man had a prostatectomy shortly before we arrived. He had the bladder fall apart because the family unthinkingly occluded the urinary catheter while tying it to the bed. It was like that all night. No nurse noticed. He had a string of complications related to that and eventually died.  

Nurses are supposed to take q4 hrs vitals for the first day post-op, but it is often a struggle to make that happen. There are many discouraging things. Nurses are supposed to arrive fresh for their 8 hour shifts, but at times they have been working in the rice fields to make more money and then sleep on their shift. They are also stretched quite thin with all their patients. Families feed the patients, purchase the meds and IV fluids in the pharmacy, and do most of the basic care. Last week we found that medications were not given even though a nurse signed stating that they were administered. We made an announcement and this week it seems medications are actually being given. I am working to get them to record urine output. There are so many challenges it can be quite discouraging, but we have a nursing school and are helping to raise the quality of care through education. 

Then there is my friend with the big smile. His bowel anastomoses obviously healed well. He is eating and walking around. I broke into tears today when I explained to him how much he encouraged me. He is a human being snatched from imminent death. That makes it all worth it.