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#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

Shanksteps #155

There was hushed sounds in front of the OR doors.  I turned on my headlamp.  A group of about 15 people are huddled around a gurney.  On the gurney is a 30 year old man, speaking in a hoarse voice.  At each word blood bubbles from the side of his neck.  He is conscious and responding appropriately.  Blood also bubbles from his nose and mouth.  A pool of blood is under the head of the gurney. His blood pressure is low and this pulse high.  He is from a village about a half hour away by motorcycle.  He had a stab wound entering the left lateral neck and exiting the right anterior neck.  So the medical students and I took him to the operating room.

He was bleeding more after being moved.  I opened his neck along the midline, low near his sternum.  Dissected down to the trachea, and made a window into the trachea.  A large tracheostomy tube was inserted and sewn in place.  He was now breathing better, but still bleeding when we let up pressure on his neck.  Along his left sternoclidomastoid (SCM) we opened the skin.  I dissected down to the internal jugular vein and noted that it was nearly transected.  His blood pressure was quite low by now and we waited for him to get more fluid so that his pressure came up.  We also were waiting for Kanas (the lab tech) to come in and do a groupage sanguine (blood typing).  The vagus nerve was dissected from the vein leaving it towards the carotid artery.  We controlled the bleeding and then explored the area.  It seemed that the knife had traversed the thyroid cartilage and exited the other side of his neck.  I could not identify any other injuries so I left a drain in his neck, closed the SCM, and closed the area that I had opened leaving the stab wound open.

Three days after the surgery he was looking much better.  The facial swelling that had been present after surgery had subsided and I let him start to drink water.  The day was busy.  I made rounds on the surgical/maternity ward with about 20 patients.  Then saw about 10 patients in clinic, treating their pneumonia, typhoid, malaria, rash, skin infection…  I then started the ventral hernia repair.  While in this surgery, the nurse came to tell me that Matakon (the man who had been stabbed in the neck) had liquid coming from his neck.  I tried to determine, by his description, if it was pus, water, or what kind of fluid.  I was unclear after discussing it.  So after the surgery I went back to see him again.  I asked Matakon if the water he drank came out his neck, he said yes.  So I ask him to demonstrate.  He took a big gulp of water, and out the left side of his neck gushed the water he swallowed! I returned to clinic sad for this man.  I saw another 6 patients that were waiting and headed home that evening.  I tried to look up neck wound in the ENT book and Trauma books that I had and all they said for esophageal perforation was repair it and put a  muscle flap in between esophagus and trachea.

The next day we took him back to the operating room.  I reopened his neck, identifying the vagus and recurrent laryngeal nerves.  Going next to the carotid artery and the trachea and behind to the esophagus.  After quite some time of tedious dissection I found the hole in his esophagus.  I closed the hole, then placed a sternohyoid muscle onto the repair.  Next we placed a gastrostomy tube (stomach feeding tube) into the abdomen.

He is now 4 days after that surgery.  We are often doing his tracheostomy care as the nurses are getting used to it.  Fortunately this one has an inner canula.  This can be taken out and cleaned then reentered to its position.  We are feeding him via the G-tube.  With many days of IV fluids and antibiotics and surgeries his bill has become huge, around $380.  The one who stabbed him in the neck is in jail, his older brother!  Please help him by praying for his recovery and healing of his extensive injuries.  Greg

#136a Shanksteps- followup
I sit here at 2AM unable to sleep.  I was called into the hospital to see Baldina as they said he had a low blood pressure.  On the way in I hear the wailing.  He has died.  I go through all we have done on him, all for naught.  He tried to kill himself and then there was hope, now he is dead.  He succeeded.  I hope his last few days were ones he used to ask forgiveness of his family and God, otherwise there is NO HOPE.
At the same time they call me to see another elderly woman who is unconscious.  I had admitted her this morning with epigastric pain and what I suspect is typhoid or malaria.  Tests have no been done yet.  I check her glucose and find it 41.  We start replacing her sugar with the IV but within 5 minutes she is gone also.  Too much death!
I sit here hoping for the day when Jesus will come back to get us all.  Rev 21:4 says: “and He will wipe away every tear from their eyes; and there shall no longer be any death; there shall no longer be any mourning, or crying, or pain; for these things have passed away.”
One day, when Christ comes, we will not have pain, sorrow, or death.  I pray that day come soon.  I’m tired of all the death and sorrow of this planet.
Greg

136b
Audrey here.  After Greg came home (and wrote the above follow-up) we prayed for the families of those who had just died. We reflected on the day, and prayed for sleep to come for us.  Two hours later I was called back in because Baldina’s wife was convulsing.  Apparently she hadn’t slept for about 5 days and had been crying hard for the past 2 hours. If finally took it’s toll on her. I gave her something to calm her and allow her a long sleep.  I too was unable to sleep after returning home. I reflected on the day.  Earlier that day, three children had died almost immediately upon arriving to the ER.  They were brought in about 4 days too late (which unfortunately is not unusual).  Five deaths within 12 hours.  Too much!
The following day was Friday. We had a lot of patients to see, both in clinic and in the hospital. After seeing them all and finally getting ready to go home, I started hearing someone crying outside the window of the ER. I looked outside and heard more wailing coming from the Adult Ward.  I ran over to find out what had happened.  The nurse said that Sali, an old man that had come in that morning with pneumonia, was taking his last breath. The family was wailing even before he was dead.  I examined him as he breathed his last.  I helped the family get his things together and return unused medication. As I was leaving the ward, another nurse asked if I had gotten all of Tize’s things together. I asked what had happened to Tize.  She said that was the man who died and his family was wailing.  He was a young man, around 36, who came in with abdominal pain but was getting better as of about two hours before.   Two deaths within five minutes of each other.  Two hours earlier, ne
ither looked like that day would be his last.  That brings the death count to seven within 24 hours.  Too much death and illness!!!  Greg and I finished up work (which at that point felt like it was never going to end) and walked home in a daze.  We got on the motorcycle and drove into the mountains to clear our heads.
Please pray for the families of these seven patients. Please pray for the emotional state of our workers who have had to deal with all of these deaths in addition to working overtime and covering for co-workers who are sick. Please pray for us to be able to hang in despite the grief, guilt, frustration, and fatigue.  Only God is able to sustain us during times like these. – Audrey

#130 Shanksteps (Shanks steps of Faith)

Today was Sabbath.  I was able to “sleep in” till 6:30 when they called.  Actually I woke up at 6.  My body used to one time won’t let me really sleep in.  I go in to see Nafissa.  The woman who I talked about in #128.  I had seen her during the night when she went unconscious after getting up to use the bathroom.  I found out she was hypoglycemic with a glucose of 16 (normal >70)  Now I find her conscious but breathing very rapidly and seemed to be doing worse.  Her bleeding had stopped a few days ago, her nasal bleeding also.  There was no more diarrhea.  She was still anemic and had received 1.5 liters of blood since she came to the hospital, I believe a record for someone here.  All three family members that were here, were willing to give.  Her lungs sounded like she had pulmonary edema, her body puffy, as it has been for the past few days.  The nurse had put her on oxygen until the power went out again.  It flickered back on, so we restarted it.  She was breathing bett
er with it.  The nurse gave her medications and I went off to see other patients.
There was a question about a child with a hematocrit of 10% who they were not finding blood for and was unconscious, a woman who had a seizure at home and was now combative, and a 2 year old that had just arrived with anemia and a fever of 105.5  These were the beginning.   I saw them and headed home for a bite to eat and planned on going to church.
After preparing, I left to go to church, only to be stopped by the guard, Allah-Hokki, telling me that they needed me at the hospital again.
I placed my Bible on the ER table and started examining a woman with severe epigastric pain.  I saw a few on the wards that the nurse had questions about and did a lumbar puncture for meningitis on a 2 year old.  I walked back to church just as everyone was leaving.
The afternoon I admitted a couple more.  About 4PM I decided to go for a motorcycle ride.  Audrey had a migraine so she stayed at home.
I ride out of the village.  All is green as it is the rainy season.  Millet stalks 9 feet high sway in the breeze.  Bugs hit me in the face.  Large cumulus clouds hang in the sky.  I ride past three little boys, each pushing a bicycle tire with a stick.  Little kids are sitting in the dirt pouring it on their legs.  Mangy dogs, with flees and ribs showing, give me a sideways glance as they make sure they are out of the way.  Men sit in groups under trees playing cards or speaking the latest gossip.  I pass some women carrying wood on their heads, headed for home.  Near the government protected forest, I see little thatch roofed shelters along the road with boys, a man, or woman sitting outside them.  I stop beside one to ask why they sit there where no one is and where there is no village.  The boys tell me that they are protecting their crops, across the road, from the baboons.  They say the baboons especially like corn.  I go on up through a shallow river bed and on to the
mountain with red dirt.  I figure I have been gone long enough and need to get back to see if the hospital needs me.  I am refreshed once again.  I ride back past all the same things.  Many people are in the same places.  Life is slow and purposeful.
I stop my motorcycle outside the “urgence’ (ER) and immediately I hear wailing.  It is coming from maternity.  Nafissa!  I cringe and walk to inside.  Jonas confirms it was her.  Also another 10 year old boy we had been treating for an arm infection, who has been getting better for the past week; went out side to use the latrine and he died as he walked.  Crying could be heard from the adult ward as the woman with seizures and meningitis died.  I go back to see the man who was breathing hard and we had put on oxygen.  The power had just been cut off again for the third time today and he was breathing his last.  No time to get my little generator out for the oxygen machine.  Four deaths within an hour.  We have sensed a spirit of death here before, and have had much prayer asking God to remove it.  We ask God to guard the physical and spiritual entrances to the hospital with His guardian angels.  Please pray with us that the devils power at the hospital be overthrown by Gods
power, and that whatever is allowing the devil freedom to work here be made null.  Pray that my life and in the workers lives are put in harmony with Gods will that His power can be manifest through us and that we reflect His love to these people.  We appreciate your prayers and letters.  In His Service, Greg

#122 Shanksteps

The nurse called me and said it was urgent.  Audrey is sick with malaria.  Quinine is making her very dizzy and nauseous.  I said goodnight to her and headed to the hospital.  A 20 year old male lay on the examination bed in the ER with a large pool of vomit next to him.  A cloth wrapped around his middle.  The nurses informed me that he had been stabbed in the abdomen by his brother.  They had fought after getting drunk on millet wine and sniffing glue.  This was the second time he has been here
for being stabbed by a family member.  The last time was last August before I returned from my time of recuperation in the US.  He had had a huge gash on his left upper lip extending back to his jaw.  He had run away without paying the hospital bill a few days later.  Now he was back again expecting to be treated.  The nurses knew him, because apparently he is a known thief in the market.  He hits people with a stick and runs away with whatever they had.  Has been in prison numerous times, but is
always let go very soon thereafter.  So I’m thinking what I should do with him.  He needs an operation, I need to ensure payment to the hospital, and he is stable.  So I tell him and his brother that he has two choices: 1: go to another hospital (nearest one is 1.5 hours by motorcycle) 2: come back with the $100 for surgery.  I then told them to send for me if they came with money, and walked away.  The brother went to consult with the family.  He came back with 5000CFA ($10).  The nurse played along
with my pressure on them and said he could not call me if he didn’t come up with the rest.  They (as everyone says, whether rich or poor) said they had no money.  He went away and came back with 4000CFA.
WWJD (What would Jesus Do) is all over America on bracelets, cups, hats, shirts.  In my opinion Jesus was forceful when he felt it was necessary to make a spiritual point.  So my actions were not the same.  I was making a point but not a spiritual one.  I feel responsible to make this hospital function as well as I know how to do.  I am not trained to direct a hospital but need to do it in this location.  So at times I’m very outwardly hard with patients and families.  All, whether wealthy or not,
claim to be poor and want reduced cost, or free meds or care.  Some of you have chosen to give money specifically to help the poor.  For me to determine who is really unable to pay is difficult. They are usually the ones that end up staying here a month or two after they are all better, waiting for the family to help pay their bill.  Often the nurses know who has ability to pay and who doesn’t.  This helps me decide who to help financially and who not to.  So WWJD.  Jesus would touch and heal this
man, in spite of what he deserved.  He had come wanting help and Jesus would have healed him.  As of yet my faith is still growing for being able to pray for healing but God has given me the ability to help the healing process with surgery. So that’s what I did.
He lay on the operating table, groaning.  Something poked out of the stab hole in his upper abdomen.  The table was at knee height because the hydraulics quit working and I need still to take it apart some evening and see why it’s leaking oil on the floor.  So it cannot rise to a normal level for surgery.  So we hoist up the heavy table with our arm strength and prop things underneath to get it to a decent height.  We prep and drape him.  He is put to sleep with Ketamine and Diazepam.  I open his
upper abdomen and then explore.  I find his stomach has been pierced, the colonic mesentery cut, and strangely enough a small bowl tumor.  All else looks normal.  I repair both sides of his stomach with silk sutures.  Surprisingly his colon is not pierced.  I evaluate the small bowl tumor which is smooth and firm.  Since I have no way of evaluating this later if I leave it I decided to take it out too.  I repair the remaining hole and we are done at 2AM.  We clean the OR and head home to sleep for
a few hours.  I am at peace within that I did what was right for him.
“God, help me love people as you do.  Help me to see this man as a lost, and try to win him for your kingdom.  Change my heart that I will want the best for my fellow man in all circumstances.  Fill me with your peace to continue the task you have put before me.”  Greg

Shanksteps #121
She sat down on the bench in my office and grinned, or at least did that motion with her lips.  Something was in front of her teeth.  She was three and her father had brought her in from a far village to be seen.  About five months earlier she had developed a toothache and then a hole started under her right mandible and draining pus from the hole.  The father was away for a few months with some work and her mother was afraid to come in without his permission.  He returned from his 4 month trip and
after a few weeks brought her in.
I look into her mouth and see what appears to be bone in front of her front teeth.  It appears to be coming from the left side and somewhat mobile.  She is calm and so I decide to wait and evaluate it in the OR under anesthesia.  I suspect it is osteomyelitis.  She has a 0.5cm hole under her mandible with foul smelling saliva draining from it.
In the operating room I peer into her mouth and see her mandible exposed with one tooth remaining in the section from the angle of her mandible to nearly where the incisors would have been.   She is asleep with Ketamine and I tug on the bone.  It comes out easily and I have half her mandible in my gloved hand.  God created our bodies incredibly!  Her bone had become infected; her body had pushed up the necrotic bone through the gums and healed behind it.  So she is still draining saliva from the
hole, but no more foul smell.  What I think she needs is a free graft fibula implant to the area! This would give tissue and structure to her mandible and face.  This is apparently done by transferring artery and vein to the carotid and jugular (sounds microscopic).  I suppose this is usually done with anticoagulants that I do not have.
Again, as often, I do not have the expertise, materials, tests needed for this situation.  God help me know what to do!
I was recently showing pictures to the visiting PA students from the south, that are doing a rotation with us.  I am amazed again at the number of peculiar and advanced diseases that we treat here.  We are usually beyond or way out on some tangent to what we were trained to do.  We pray often for guidance when tests and our knowledge are lacking for the patient before us.
Please continue to pray for wisdom, perseverance, ingenuity, and more love for the people we serve.  In His Service, Greg

117 Shanksteps

It is feast or famine, as far as surgery goes.  I may go days or even a week and not do a surgery, then there may be so much I cannot do it all.  That is what Monday was for us.  Sunday we saw  about 34 in clinic and made rounds in the hospital on about another 40.  Some are on “autopilot” with healing wounds or other static things.  Others very complex, like patients in diabetic ketoacidosis and recurrent ascites with no known cause.  I started the day knowing that I was going to do a real long surgery.  There is a woman who had urinary obstruction after surgery for which I was going to do a definitive operation.  I was either doing an ileoconduit or a bladder suspension with extension to adapt the ureter to it.

Before we made rounds I met with Audrey to pray that the day would go according to Gods plan.  As I went to leave my office a man who I had seen the day before, came running in dripping.  I have been seeing him nearly every two weeks and draining 15 liters (4 gallons) of ascites off him.  The day before as I was seeing 34 clinic patients I told him to come back tomorrow to do the drainage that I was too busy that day.  I also reiterated again that if at any time his umbilical hernia started leaking that he should come back immediately.  So in he comes with his umbilicus (belly button) spouting like a fountain.  His umbilicus had indeed ruptured.  I sent him on to the operating room and followed the trail after him.  I put a clamp on his umbilicus to stop the flow so to not get the entry to the OR all wet…  We opened him up to fix his hernia.  There was a fleshy mass on his gallbladder and a small one on the left lobe of his liver.  I couldn’t find anything else so I suspect this is the cause of his ascites. (still undiagnosed)  He needs a biopsy, but then he didn’t even want to do the surgery for fear of the cost.  I just told him there was no other option!  During the surgery, Djoudge, the cleaner, came in to tell us that a woman was in labor.  I asked him to call Audrey to check her out, since there was no nurse free to see her.  Audrey came in a few minutes later saying that she was concerned about uterine rupture and that she needed a caesarean section.  I the man’s abdomen in the most water-tight fashion possible.

Immediately we were called to see a woman who was having difficulty with labor and had a possible uterine rupture.  After checking her out, Audrey and I decided it was best to do a caesarean section for fetal distress and imminent rupture.  So Aud joined me for her c-section for speeds sake.  We delivered a crying baby boy of about 9 lbs.  We decided to do the long surgery directly after.  I went to finish rounds, Audrey to see some patients in the clinic before starting.  The nurses would have to take care of the rest.

Nguizaye had been operated on before for extensive uterine bleeding and had been transfused a number of times.  At the time of her hysterectomy everything was stuck to the back of the uterus which was much enlarged.  After extensive adhesiolysis and much difficulty in the pelvis from all the adhesions, a total hysterectomy was performed.  She came out of the surgery well but with bloody urine.  Over the next 24 hours she made essentially no urine in spite of being rapidly replaced with fluids.  The day after the first surgery, I reoperated on her and was unable to identify the area of ureter entrapment.  I put in some makeshift stents as a temporizing measure while I decided what to do definitively.  The stents became infected and she was not doing well.  So this was the day for a definitive repair.  Having asked many colleagues their opinions (and only one responding) we started.

Entering the abdomen, was already difficult.  Adhesions everywhere.  Then omentum stuck down to the previous operation site and the area of previous adhesions.  With much difficulty and tedious work we dissected out the ureters.  This took about four hours.  I decided we did not have the room sufficient to use a bladder mobilization to reinstitute urine flow.  So it would be an ileoconduit.  About this time another woman was having difficulty with labor so Audrey set up for a C-section in the other operating room.  We changed around nurses to cover both rooms well.  Fortunately the student missionaries are up to speed and a real help in the OR now.  Soon I hear yelling and movement in the other room.  Audrey comes back in a few minutes with a crying baby in hand.  She delivered without the C-section.  So she would rejoin me again.  I resected a piece of ileum to make the conduit between the ureters and the ostomy.  Reconnected the intestine and then started the anastomosis.  Baya (the ER nurse on call) came panting into the room.  “A man has been stabbed and is bleeding profusely from his abdomen. “  As I have one patient open on the table with no one else who can do this I tell him to have them hold pressure and that they MUST go on to Mokolo.  People do not want to go to  Mokolo but it was necessary.  So I continued my surgery.  It was tedious and deep.  The woman had lost much weight, but unlike most here, she still had a bit of fat, making the surgery deeper and more difficult.  We finished the surgery at 10PM, ten hours after the start.  Back cramps, headaches, and extreme tiredness made it difficult to write all the notes of what had taken place.  We made it home after seeing some in the ER, about 11:30PM, massaged each other’s back knots and went to bed.  She is still very sick, electrolyte abnormalities, delirium, malnutrition, and three anastomosis; enough to make any surgeon worried.  Then put on top of that the absence of an ICU and monitoring.  If she makes it, it is only because of Gods direct intervention. I pray for her before going to bed, as I wake up and many times throughout the day.  Please keep her in your prayers also.  In His Service, Greg

I am constantly amazed by the interest the rest of the world has in our elections.  I was awakened by a text message at 5AM with a worker telling me that Obama had won the elections.  Over the past few weeks we have heard comment that “we” are prejudiced because we haven’t had an african american president.  Now that we have one the word around Koza is that he is thier “brother” because he’s Kenyan.  i then heard it was  his mother.  But some figure it will make their chances of goning to the US
easier if not helping Cameroon more than the US does at this point.  As you probably know, we live in an area with about 100,000 people in the surrounding area and mountains.  Word travels around as if it were only 100.  Word of mouth gets any interesting idea or news out to all very quickly.  Whereas things like when vaccinations or other health related things dont seem to make it out at all.  

We are in the season of bad malaria and much anemia.  We do blood transfusions almost daily.  And have had a number of children die from malaria and its effects.   There are about 65 patients in the hospital.  Pediatrics is entirely full and Adults has much overflow from Peds.   We have seen our first case of meningitis this year.  we have had two die recently from Snake bites.  Another is in house and has had extensive debredement of her leg and is still quite sick.  Please keep her in your prayers.

I am starting a Fund for those patients with Snake bites.  Currently we purchase antivenum for 14000-15000CFA ($28-$30) and we sell it for 14000CFA.  Most people need many vials(5+) and we try to minimize the number to one to three, to not increase the cost for the patients.  Many patients refuse any further after 2 vials as the cost is so hight for them.  I am starting a fund for those of you who would like to help specifically for the snake bite patients.  I would like to give them the antivenum
for a huge reduction so that I feel free to give them as much as I need without thinking about the cost.  So if you would like to participate in this specific area please mark your donation as “Snake Bite Fund”  we use all donations in the way designated.  If there is no designation we have been using the funds mostly for purchasing medications in bulk in Yaounde, to reduce our costs of purchasing meds.

Another long term goal of mine is to reduce the cost of treatment to all patients who come to the hospital.  We are trying to get the agreement with the government so that we benefit from the funds normally given to a district hospital.  This is turning out to being a long process, mostly due to the stalling of the local health district doctor.  If you can think of any other LONG TERM solution I would be happy to know about it.  I want a solution that will last even after I leave or after the donations
dry up.  I would appreciate any input you may have in this regard.

In the mean time we have prices similar to other hospitals in our region but more than the local dispensaries (health clinics).  Most hospitals care for people only as they have money to start treatment, we treat and ask for money at the same time.  some are unable to pay anything for a while and they stay “prisoner” of the hospital till they pay or run away when no one is watching.  wE have about 40 unpaid bills that we are still trying to collect from.  Both systems, ours and the other hospitals,
have difficulties.

Keep us in your prayers as we continue to try to show Christs love in this spiritual battleground.  In His Service, Greg