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Another message forwarded from James Appel in Chad.

For those interested see www.bereadventisthospital.blogspot.com/

—— Forwarded Message

From: James & Sarah Appel

Date: Mon, 2 Jan 2012 20:34:49 +0100

To:

Subject: Grief

I’m lying flat on my back on the veranda.  Dusk has settled.  The stars are

not out in force yet, but the half moon and it’s bright under star are

straight over head.  Among the dark tangled branches a few fruit bats flap

silently across the clearing, temporarily blocking out the moon.  Darkness

settles in as I feel a gnawing in my gut and the need to release my anguish.

But the tears won’t come.  My mind wanders to a million memories.  It’s only

Monday but Friday already seems a lifetime ago.

I’ve already started to feel the waves of grief mixed with a calm peace that

ebb and flow like the tides that Tchad has never seen.  A few incidents stick

out.

I’m in the tiny office off the waiting room with Sarah and Miriam.  Miriam is

half-way through her treatment.  She has just finished an hour of cooing,

flopping, half-crawling and wrapping herself in her IV tubing.  Now, she’s

sleeping, her legs hanging off the edge of the mattress face down and slightly

turned to the side away from the her left arm which is encased in tape, an

armboard and an elastic wrap to keep that precious IV access going.

I hear the sounds of French with an Arabic accent outside.

“I just want to see James and give him my condolences.”

“He’s at the house,” replies an unknown informant.

Through the broken slats and ragged curtain on the window I see a couple of

Muslim hats on top of well-known faces as they turn to head in the wrong

direction.  I take the route through the waiting room and from the door yell

out, catching the two men’s attention.

“AS SALAAM ALEKUM!” The two muslims turn and smiles light up their faces as

they give the traditional reply: “Wa alekum as salaam.”  One is a contractor

who remodeled the Bere Hospital ER and built some staff housing.  The other is

the local imam.

The Imam is dressed in a light blue robe with embroidery on the chest.  He has

a white, flat topped hat on his head and a checkered middle eastern scarf

around his neck.  One eye is blind and almost shut and a scraggly white beard

graces his chin as a smile crinkles up his lined face.

“This is the way of the world,” the imam continues in Arabic after we have

shook hands and exchanged the appropriate long greetings. “This is the way of

the world.  Only Allah knows why these things happen.  Only He knows.”

“Al hamdullilah,” I reply.

“My heart hurts with your heart,” the imam continues, first touching his chest

and then moving his hand out pointing at my chest.  ”My heart grieves with

your heart.  Only Allah knows why.  May Allah be praised.”

“Mashallah,” I intone my head down as I shake and hold the Muslim leader’s

outstretched hand.

“Where’s Sarah?” the imam asks.

“Inside.  Come.”  We walk back together as both men offer me more words of

encouragement and condolences.  Inside, I check and find Sarah is sleeping.

“Don’t worry,” says the imam with a smile.  ”Allah will give you more

children.  This is the world.  There is loss.  Allah gives and Allah takes

away.  Let’s pray.”

Both Muslims stand with their hands outstretched to receive Allah’s blessings

as the imam leads us in a prayer of praise and consecration.  When he has

finished we all bring our hands to our faces to accept the blessings from God.

That evening, my uncle, a Christian pastor calls me on the phone also offering

his encouragement and condolences.  He also ends with prayer.  During the

prayer I realize that this is a rare moment.  I have been blessed by both

Isaac and Ishmael.  For an instant, around a tragedy, the two brothers have

stopped fighting and helped the hurting.  I am moved to tears, which is quite

easy these days.

The next morning, Miriam’s 3 days of IV Quinine are finished.  She has no

fever and is back to her normal self.  We pack up the van in truly Tchadian

style with baggage to the ceiling, three American volunteers, one Tchadian

patient and his two family members (plus small child), one Tchadian nursing

student, one Tchadian cook, our two Tchadian adopted daughters (Yahdang et

Djongyahbo), Sarah, MIriam and I.  Before getting in, the three of us make a

final pilgrimage to the two graves under the red flowered tree.

Then we head out in an eery fog.  The whole country seems to be mourning with

us as a white haze drifts in and out of the dried grasses, half burned fields

and cracked clay.  Passing a lake, some massive rounded backs rise out of the

mist, nostrils flaring as a herd of cattle is driven by.  The chill lasts

until we are safely back in Moundou wondering what do we do now?

—— End of Forwarded Message

#182 Shanksteps (lack of faith this AM)

It’s 4AM and Audrey and I can’t sleep anymore.   We have been up every hour or two throughout the night.  The time change from Koza, Cameroon to Oregon is enough to be difficult.  I get a message late last night from one of my best friends and didn’t read it last night as I was asleep early.  So as we decide to get up, because we can’t sleep anymore, I read his message. I immediately feel mad at God, combined with a deep sorrow for our missionary friends I have just left behind in Chad.  Please read the following just sent from James and Sarah Appel, missionaries in Chad these past 8 years.

The moon has gone down.  I walk in the dark with only the stars and the promises of yore to light my way.  I make my way past the silent benches that all day held crowds singing in French and Nangjere as the drums pounded out their mournful beat.  My body is as limp as the pillow I carry. Every last tear has been wrung from my eyes.  I make my quiet pilgrimage to the site of my greatest sorrow.  I enter the room that holds so many memories.  As I open the rickety lock I remember locking that same door from inside as I cared for two little African babies struggling for their lives while outside men fought to end each others.  The faint odor of bat guano greets my nostrils and makes me think of the time the winged mammal hit the fan and landed on the face of the baby fighting for breathe in the clutches of an asthma attack. I shine my light on the IV slowly dripping into the arm of my sweet little daughter, Miriam, as she tosses and turns in a fitful slumber.  Sarah lies by her side in the mosquito net softly comforting her one remaining child.  It seems like an eternity already since the morning when two babies wiggled and squirmed and flipped and grinned and giggled and squealed together in that same tent.

Sarah woke me up less than 24 hours ago. “The twins are really active and I’m having a hard time.  Can you come over?”  I arrived to see Adam staring at me with a silly grin right before flipping off the mattress between it and the net and letting off a howl of frustration.

“You should have seen them.  They both woke up, looked across the mat, grinned and tried desperately to crawl to each other,” said Sarah.

We’d arrived in Bere the day before. Thursday night, Adam had a fever of 104.  We were in N’Djamena and I bought a rapid malaria test.  It was negative.  I wasn’t convinced.  I opened a capsule of Artemesia, poured it on his mashed sweet potatoes and fed him despite his obvious preference for medicine-less food.  The next morning, I fed him another dose and we loaded up the scalded dog and were on our way to Bere by 6:30am.  By 2:30pm, both Adam and Miriam had been diagnosed with Falciparum malaria and started on IV Quinine.  Through the night, they each got two of the every 8 hour doses.

I start Miriam’s next IV perfusion and turn to Adam.  I let 150 mL of 10% glucose solution run from the IV bottle into the pediatric reservoir on his IV tubing.  The tubing has special air traps to avoid any accidental entry of air into Adam’s veins.  I pull out 0.5mL to flush his IV and then carefully measur 90mg (0.3mL) of quinine and inject it into the top of the reservoir of 150mL.  I open up the IV, see that it was running well and slow it down to a drip.

I turn to look at Miriam and talk to Sarah.

“Is that a seizure?”  Sarah interrupts our conversation and we turn to look at Adam.  He’s not breathing.  We start CPR.  I run and get some 50% glucose solution, afraid of low blood sugar.  I text Olen who is there in minutes.  Still no breathing.  Olen confirms a heartbeat, slow and irregular, but there.  Olen gets a bag valve mask and starts breathing for him while I do chest compressions and Sarah continues to give glucose. Anatole arrives and checks the blood sugar.  It’s high from all the glucose we’ve been giving him.  We try Adrenaline in ever increasing doses.  His heartbeat never picks up.  Every once in a while he grimaces, groans, struggles for a couple breathes, giving us hope.  We work on him for over an hour.  His heartbeat disappears.  His pupils are fixed and dilated.  I’m praying desperately for a miracle.  We stop.

Deja vu.

How many years ago did the same thing happen to my friend Gary and his little boy Caleb?

It’s 8:00 am and my life has suddenly changed for the worse.  Sarah and I hold Adam’s still warm body.  I desperately kiss his neck, my tears know no bounds.  My cries echo across the campus to join the thousands of others I’ve heard over the years in this corner of Africa.  Will I never again see his tongue half hanging out of his silly grin?  Will he never again wrap his legs around my arms, brining my fingers to his mouth as he softly coos?  Will he never again thrash his arms in legs while staring at me with a look of pride and joy?  Will he never again take up the airplane position looking around for confirmation of his abilities?  Not in this life.

A day long ritual of African mourning begins as the news spreads like wildfire through the village.  People come to offer their condolences.  Miriam becomes agitated with all the visitors.  I wrap Adam’s body in my green and black checked Arabic head scarf and carry him over to the house where friends have arranged to let the mourners come in and visit.  All day long the songs sung in rhythmic Nangjere drift in as people make their way to where I am sitting on a thin Nigerian mattress.  So many people, so much collective pain and loss. Salomon comes in and hugs me. A flood of tears bursts forth as I remember him holding Adam so many times as we ate together in Moundou, enjoying one of his famous sauces.  Frederic kneels down and holds my hand long and hard in an undulating shake of sympathy.  Just last year I was at his house as he held his son who had just died.  The mother of the boy across the street who fell down a well and died crouches and holds my hand as we share tears of sorrow and she offers words of comfort and hope.

The steady stream of people brings me a steady stream of tears as I shake and hold the black calloused hands of so many people who’s lives have been filled with loss.  The strength of the grip and the power of the muscular arms of both men and women combined with their roughened feet tell a thousand tales of woe.  Their is no awkwardness.  They’ve done this before a thousand times.  Tears come from faces I’ve never seen before.  But we now have a common bond of tragedy.  The only ones who seem uncomfortable are some of the westerners, but their warm embraces make up for the lack of familiarity with death.

Gary and Wendy fly in from Zakouma just in time for the English portion of the day long wake.  Hymns of hope sung gently and powerfully by the many musicians in our group of Nasaras warm my soul as Sarah holds Adam’s now cold and stiffening body.

“When the trumpet of the Lord shall sound and time shall be no more…when the roll is called up yonder I’ll be there.” The rollicking song brings bursts of tears from Gary, Wendy, Sarah and I as we remember Caleb’s favorite song and the other little foreigner buried in Bere what seems like ages ago.  Now it’s time for last good byes. Sarah and I bring Adam’s long little body into the house and place it gently in the casket made by Jamie just this morning.  I kiss his cold brow one last time and we put on the lid.

The pathfinders are outside to carry the body to the grave site.  Under a little tree in front of our old house in Bere lies a volcanic stone with a little plaque that says “Dinah Bindesboll Appel”.  Next to it is a deep, rectangular hole waiting for our second child to return to the African dust.  Noel gives a stirring eulogy reminding us of the day when God will say “Viens” to both death and the devil and both will be done away with forever.  Then God will turn to Sarah and James and say, “Here’s Adam.” And to Gary and Wendy, “Here’s Caleb.”  And the innocents will be restored to their rightful place.

But for now, we miss him terribly…

RIP Adam David Bindesboll Appel, June 25-December 31, 2011

I don’t have any explanation, just sorrow, and thoughts of Job’s story in the Bible about profound loss unexplained.  I call James and Sarah with not much to say.  We love them and feel profound pain at their loss.  God come save us from this terrible world soon. G

#175 Shanksteps

I first saw her in clinic.  Her nomadic, bright colored attire, hid her frame.  She said her stomach had been growing.  I asked how long, and the response was 10 years.  Hernia? Cancer? Baby? (the time frames I am given often do not apply to the current episode of things happening, but may be an accumulation of events that the patient relates together).  I examine her and fine a huge abdominal mass that seems to be little mobile, maybe 10X10X13 inches.  I did an ultrasound.  It appeared solid and cystic (little fluid pockets). Likely a cancer.

She took the “standard” bowel preparation the day before yesterday.  She took it all and had NO stool.  So she did it again yesterday with even more bisocodyl. Finally she had a lot of diarrhea and cleaned out.

She lies there with cachectic arms and legs, with a VERY protuberant abdomen.  Lying on the operating room table, she takes up a small portion of its 1.5 feet width.  She looks embarrassed as we uncover her to start the preparations for surgery. We administer Valium, atropine and Ketamine; prepare her abdomen with betadine, and lay on all the cloth drapes.  She has NO fat on her body.  So once I’ve cut through the skin I’m nearly inside.  Usually when I’m working on a belly this protuberant I’m apprehensive because I’m wondering if the baby is going to be OK.  Now I’m apprehensive because I don’t know exactly what I will find.  Where it will be coming from and if I’ll be able to take it out.  I see intestine stuck to the surface.  Huge vessels feed the mess.  I feel below it and don’t feel a free spot, neither on the sides and top.  So I slowly start freeing the intestines from its surface.  There is oozing everywhere.  We give her Vitamin K in hopes that she might be low in Vit K and that this would then help.  It doesn’t seem to.  I control the bleeding with some sutures.  We continue the slow work.  Freeing up here and there around the sides of it.  Now I’m behind the large intestine and behind the stomach.  The pancreas is in view, it’s rather stuck to the cancer.  I realize that all the large vessels that feed the intestines are within this cancer.  It is impossible to remove.  So we decide to close.  The nurse giving the anesthesia recommends that I call a family member into the operating room to see what we have found and to explain why we cant take it out.  I call in an uncle that is a person I recognize as having seen before.  The nurse puts a mask on him and a cap and he comes in the door.  The nurse stands behind him to assure that if he passes out he doesn’t hit the floor.  He takes it all in without emotion.  Thanks us for trying, and states it is God’s will.  Though I desperately disagree with the last statement,  I say thank you and he leaves.  We close up the abdomen and take her back to her room to wake up.  I instruct the nurse to get vital signs on her every hour for four hours, knowing it will only happen if he has nothing else to do. G

An older woman sits in front of me in clinic, her husband on the chair beside her.  She says that something is coming out below when she walks, and has ever since she had her last baby a few years ago.  I examine her and find it’s her uterus coming out

Another young man is having rectal bleeding for the past few weeks.

A third had an accident on his motorcycle a couple days ago.  The huge swelling on the side of his face is improving.   He arrived unconscious and now is thinking clearly.  He says that one tooth doesn’t seem to be in place.  I examine him closely, and find that he has a mandibular (jaw bone) fracture right before his last molar.

These are the surgeries for today.  The older woman took her bowel prep which consisted of a bowel stimulant (Bisocodyl) and water. She is placed on the operating room table.  The preparations are made and I put on my cloth operating gown.  It’s cut real small for my long arms, and when it get’s wet with blood or other fluid, I’m wet with it too.  I help Dr. Solomon put his on, as I’m particular about sterility even though others don’t seem to see the necessity of all that I do.  This is probably the cleanest she’s been in 60 years of life.

I open her lower abdomen.  She has essentially no fat!  I open the skin down to fascia in one fell swoop.  Cautiously enter the fascia and peritoneum.  I search her pelvis for the uterus.  I grasp it between my fingers and pull it into the wound. It has been prolapsing so far that it comes up easily.  It turns out to be one of the easiest hysterectomies I’ve done.   I didn’t bring large enough suture to do hysterectomies so use a smaller than normal one.  For her tissues it turns out fine.

The next was the young man for a colonoscopy.  I finally find the colonoscope again and all the things that go with it. I look inside and find a very inflamed intestine.  Colitis.

The 30 year old guy with the mandibular fracture is next.  I take him to the OR but cannot find the materials I need. I need arch bars (metal bars for the teeth) and wire to attach them to his teeth.  I need to wire his mouth shut for two months to let things heal.  After opening a number of sterilized packs, I finally find the one that has the right equipment in it.  I wire the arch bars to his teeth then, the arch bars together.  I find that I cannot include his last tooth so the fracture is still loose.  At the end I realize I will still need to wire his bone itself together as I don’t have any metal plates to put on it.  I’ll wait till the swelling goes down then attempt to finish.

I return to the clinic to finish seeing the patients that have been waiting for hours.  See more malaria, typhoid, pneumonia, and another malnourished kid who is 2 and weights about 14 pounds.  I head home to a meal of millet paste and sauce (my actual favorite here).  G

It is Saturday, Christmas Eve, and I was at church. I’m called out in the middle of it to see a patient that was in a moto accident. One of the health center workers was riding at a “slow speed” and hit a rock and fell over. He lay in the dirty suture and dressing change room moaning. I asked Bouba, the nurse to find a stethoscope. I had forgotten mine in the US. He ran to the ER and came back with one. The man complained of his shoulder only. I listened to his lungs checking for a pneumothroax that could kill him, and they sounded normal. So I examined the rest of him. I only found a broken clavicle. I put him in a figure-8 dressing to help put this in place. I checked on a couple others lab results then headed back to church. Right at the end of church they called me again.

There were three that had been on a moto. Two men and a teen girl. The girl had a fractured wrist, one man had a fractured wrist and a hematoma on his head. The third man had a fractured wrist, broken femur (upper leg bone) and a ankle fracture. They were laying in their hospital beds moaning. After checking each one out I asked whether they wanted to be treated here or by the traditional bone setter. Two wanted to leave and the one with multiple fractures wanted to be treated here. I have always had to fight with them before, so I knew what was coming. I decided since they were adults they could choose badly for themselves, and besides, though I have shamed many people in the past for not doing what the doctor ( me) wanted, they still wouldn’t let me do it. So when these decided to not do it, I wasn’t surprised. It ended up after the x-rays that even the lawan (the local low level chief of a certain area of the village) with three fractures, he decided not to do it either. So I left and went home.

We prepared a special evening meal. In the late afternoon our friends from Chad arrived on a surprise visit. And the power went out. So we filled up every available pot, jug, and glass with water before it ran out in the water tower. We had a wonderful candlelit meal. It consisted of home made everything; gluten, beef stew, stuffing, green beans, salad, potatoes with margarine, rice. Later we opened the few gifts we had brought for our guests and the student missionary here, while sitting in front of our decorated tree branch that we cut from a tree. Decorated with toilet paper streamers, paper figures, and cutouts from a magazine. We had a great time. We think we appreciate a simple Christmas, as theses have been our favorite. G

I sit against the operating room wall holding a small baby in my lap. He is wrapped in a dirty blue towel that has amniotic fluid and meconium all over it. He had come out of the cesearean section that I just performed with a big cry and apparently breathing well at the beginning. I was doing a surgery on a woman with a small pelvis that had been in labor for three days before making it to the hospital in the evening. I had done the same girls previous surgery a couple years ago. She says that her girl is still living. She wanted to have her tubes tied after this surgery. Her husband agreed. As we finished up the surgery, Yaouke was suctioning the baby, Dr. Solomon and I were closing the uterus, and abdomen. Yaouke said the baby wasn’t breathing well. At the end I checked the baby. If a black baby can be blue this one was, or at least his lips were! I put oxygen on him. He had small grunting sounds. I sat there against the operating room wall will the nurses cleaned the room. As I sit there I cradle this new life in my arms. I try to wipe meconium off my finger by wiping it on a “clean” area of the towel. I place the oxygen monitor on the baby’s finger. The whole hand fits inside, but eventually I get a reading. When the baby wiggles around and the oxygen comes off his nose, his saturation drops to 77% (normal >92). He desperately needs the oxygen. The next thought that runs through my mind is how long should I sit here holding the baby. As we have been back here it is easy to fall back into my previous roll and concerns. Again, how long will I sit here taking care of this baby. It’s a little different this time because I only have to have enough energy for two more weeks, not a year. So I sit there longer. After about an hour there seems to be no change and everyone is done with their cleaning and other tasks and ready to head home, 10PM.

I take the baby to the nurses sleeping room, office. I set up the oxygen concentrator, monitor, and voltage converter to keep all running. The nurse finds a padded foot of the bed to move into place on the floor. I place the baby on it and tape the monitor to his foot that is moving constantly. It seems to pick up his vessels and oxygen concentration. Tape the oxygen cannula to his face and cover him with all the cloth the family was able to come up with. A couple small pieces. I watch the pile on the floor move a few minutes and everything seems to be working.

I check on the 17 year old girl that had a bad motorcycle accident. She arrived unconscious and on palpating her head I felt she had a depressed skull fracture. I had rushed her to surgery yesterday afternoon. I explored her scalp. There was a large hemotoma (blood collection), but no apparent skull fracture. I closed up my incision. I talk to the family who is sleeping on the mats beside her bed. They say she has not moved or done anything since surgery. I uncover her from the large blanket that is on her and she feels hot. She’s about the age of Sarah, and I worry about her, knowing I can do nothing more. We get a glass thermometer and check her temperature, its equivalent to 104.5 deg F. Is she having malaria, or a central (brain) fever? Well I can treat malaria and not the other, so I treat malaria, and give her IV asparin to help bring down her fever. IV asparin is the only med here to give for fevers.

I check on the small pile of fabric in the nurses room. It’s still moving with the baby boy inside. The oxygen numbers seem OK, so I head out to the ER, on the way home. There I am stopped by a nurse who just brought a pale baby to the the ER from the pediatric ward for oxygen. A hematocrit (blood count) has been ordered since 2PM but not done. I ask them to call the lab tech and get it. Then to verify the blood of the mother who is present to give it to her baby. They are instructed to call me if there is no match as I am O+ and can give to most people. I head home.

…

I am thanking God! HE protected the child through the night and the kid had breast fed a couple times before I saw him. Mom is complaining of pain, but then again why not, I forgot to write our strongest pain medicine, Ibuprophen! The mom is laying in her bed on her back. She is covered by panye (colorful cloth) from the waist down, the top bear with the baby attached to her right breast. She is smiling because her baby is alive. This one moment makes my hours last night worth ALL of it!

It was Sunday, market day in Koza. I awake with diarrhea at 4AM. I cant sleep after this. Have diarrhea a few more times by 7:30 when I head in to the hospital for morning worship and signout.

Sunday means that hundreds of people are in the market and extra people are in the hospital too. Dr. Roger and I saw about 24 outpatients. One had a huge abdominal tumor that was a little mobile, and we will attempt surgery, another had a muscular tumor in her upper tricep that appeared separate from the important vessels on ultrasound, a 5 month old child with Pertusses (whooping cough, that normally children, even here, are vaccinated against), a child with Beri Beri and malnutrition, and another malnourished, dehydrated and with malaria, and the rest were pneumonia, malaria, typhoid and dysentery. Also saw one of the workers boys who had a huge leg abscess. It had begun with ankle swelling, then the leg swelled and they drained out pus at the ankle and mid calf. I looked at the leg and after giving the kid Ketamine to help him sleep, I felt his joint. At the opening I can feel the ankle joint exposed. I filleted open the leg from about mid calf down, exposing the musculature below. Drained a lot of pus, and packed it. Saw a few patients in clinic again. Then by 4PM made it home for lunch. G

I went to bed last night with my belly all distended. I felt like diarrhea was coming but it wasn’t happening. Finally about 10PM I drifted off after flopping around in bed. The night before there must have been a mosquito under our net as Audrey and I had bites in the morning. I fall asleep with the buzzing sound, not knowing whether they are outside or inside the net. About midnight I wake up with abdominal cramping and go quickly to the bathroom…diarrhea. I fall back asleep and wake up at 4AM as I turn over and my belly makes a huge gurgling sound. I cant fall back to sleep. Guess the time change is still affecting me after a few days here. I go to the bathroom and squirt some more. Guess I’ll stay up now and write you all. I am tired but can’t seem to go back to sleep.

Yesterday was a special Sabbath day. We had the usual church service. A Sabbath school, followed by a church service. That consisted of choir groups singing and a sermon. This was a special Sabbath because it was a baptism day. Outlying churches walked many miles to come to the communal church today and bring their candidates for baptism. They slowly showed up during the whole service. At the end of the service, the fundamentals of following Christ and wanting to be a part of this church were read, with the candidates verbally agreeing after each statement with a “halaow”. The service ended and a water immersion baptism ensued. Each was given a white robe over the cloths they wanted to keep on. The baptismal water is a concrete structure built into the ground outside. It is filled with water. They enter four at a time with the pastor and elders performing the baptism, four at a time. It took a while for about 120 people to be baptized.

Many people greeted us after all was finished. Each stated they were happy to see us shaking our hands, asking how our families were, how our parents were, how our siblings are. We in turn asked the same questions of them. Nearly each stated their desire for us to come back.

In the evening we ate some spaghetti with home made sauce and as I went to bed early, I felt bloated all over my abdomen. Suspecting diarrhea would be coming, I went to bed. I lay there tossing and turning, thinking about my patients, and finally convinced myself that I am not in charge here and was able to fall asleep. It’s easy to fall back into the same thoughts and feelings as before. G