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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

The second day of the Christian wedding;

It was supposed to start at 11AM, and it was announced to be there at 10:30. We arrived at 11 supposing everyone to be later. We were about the 10th person to arrive. The church ceremony was in the outside tin-roofed structure. It holds more people and isn’t as hot. People slowly filtered in to the “hangar”. We were the guests of honor since we are good friends with both sides of the family and had come the farthest. We were seated on the groom’s side in the second row. Slowly people came. At the beginning, a bible boy and flower girl came down the isle. The flower girl was spreading little hole punches of white and pink paper, as the flowers. She ceremoniously spread them all over the red carpet that went up the middle between the white plastic lawn chairs that had been moved from the previous site to here. There are a defined number of these in town, so any event requires borrowing them from the school, mayors office, sous prefet… to get enough to have a large crowd sit down in one place.

After these entered then teenaged boys and girls danced their way in, on the red carpet down the center. The music was a classical march on the speakers. A small step forward with the left foot. Shake the right foot out in front of you. Boy and girl face each other, the girl bows, she rises then twirls facing away. Grasps hands with the boy behind her, and does a few right foot pumps in the air about a foot off the ground. Then twirl back to him, and grasp hands again and make an arch with their arms. Then forward one step and REPEAT…. Till they have arrived at their designated seat along the isle. They all join hands across the isle and make an arch that the bride walks through with her one bridesmaid. She arrives in a small red Toyota four-door car. It has been decorated with pink toilet paper ribbons and toilet paper flowers. All stand. She slowly walks down the isle underneath the arch of arms, to a tune by Enya, tripping over her long white gown periodically. Arriving at the front of the arch her groom meets her. Everyone sits down. The bride and groom are sitting on chairs facing each other in the front. They have been decorated with a shiny white cloth and some toilet paper flowers. A row of balloons crosses the front of the stage, and a gust of wind rips it off at one corner, making a trail of balloons fall to the side. There is an audible gasp, but all continues as planned. The maid of honor and best man are on chairs directly behind the groom and bride.

The service continues with music by several choirs, some visiting from Maroua, about three hours away, where the bride is going to her last year of high-school, very uncommon for a local girl to make it through high school. Here there are about 100 that graduate each year. About two are girls, and usually one if from the south, as her parents are here as teachers, or government officials. The choirs end their songs, and the pastor has a short sermonette about love and working out differences and being faithful to each other for the rest of their lives. They each say rehearsed vows. Rings are exchanged as a symbol of their unity. And they march out to the car decorated in toilet paper.

They head out to the reception that is to follow by invitation. Food and drinks for MANY people. We are seated under the circular tin roof with all the important people and the married couple and their close family. Food consists of chicken, beef, goat meat, plain noodles, salad with dressing, popcorn, a green bitter vegetable, fried plantains, boiled taro root, fried sweet potatoes. All eat till they are full. When the foods done, everyone leaves. The family looks tired. Audrey, Sarah and I get on the small motorcycle and we head home. G

He lay crying on the emergency room table, grabbing his lower abdomen. He got up and slowly walked outside, all bent over. Nearing a tree he lifted his gandara and tried to pee. Nothing! With a grimace on his face he walked back in. He had come to the hospital a couple weeks ago. He had taken the antibiotics and felt better for a little while. Yesterday he couldn’t pee, so he went to a hospital in Mokolo and they put in a urine catheter. After his bladder was empty he felt pain and the need to pee but nothing was coming out the tube so he asked for it to be removed. He went home that evening and couldn’t pee all night. Then he came to “our” hospital.

The nurse tried to place a urine catheter, but it wouldn’t go in. I walked back into the room as the old man is yelling, grunting and deep breathing, trying to tolerate the placement of a catheter that was trying to enter the prostate that is to tight to even let urine through.

So I get on sterile gloves and give him a hand. More yelling ensues. I get it partially in, but not enough to get urine. As I pull it out it tugs significantly and he jumps and yells some more. The curtains the we put up have been removed between patient beds in the emergency room, so the 13 year old girl who has pneumonia and is breathing at a rate of 50/min, looks on at the commotion. Neither he nor she seems to be bothered by the indecency of the situation. I call for the nurse to bring me a smaller catheter. The pharmacy doesn’t have one. Dr. Roger, a Congolese doc that is covering for a while, walks in and says he thinks there are smaller ones. No one can seem to find them. I take off my gloves and check out the stock. Fortunately for the patient, we find some and it goes in much easier with only short yelling and grunting. We send his family off to the pharmacy to purchase all the materials for a prostatectomy.

I take a look at the 13-year-old girl. She came in that morning after 4 days of not breathing well. She is thin, in the first stages of puberty, and breathing fast and deep with a LOT of effort. She had been started on penicillin. Her bed is in a sitting position, and she was leaning forward to try to get in more air. The oxygen concentrator was giving her 2L of oxygen. I ask for the oxygen saturation monitor, and they tell me both have been broken. I ask for one of the nurse’s motos and go home and get a finger monitor that my anesthetist in OR, gave me to come over with. I head back and check her oxygen, its 77%. I listen to her lungs and there are crackles all over, with quite a bit of wheezing. Let’s see, what antibiotics do we have right now? Amoxicillin, Ampiciillin, Chloramphenacol, Cipro oral, and metronidazole, penicillin. What bacteria are possible here? What’s common here? I’ve forgotten what I used to think when here! I start her on Ampi and Chloramphenacol, thinking it will cover Strep, Staph, and H. flu. (common bacteria in the US). In the US I would intubate her, here I just hope she keeps breathing.

The family returns, having paid the materials for the prostatectomy. I’m surprised, but then remember that they had been home preparing to come back for surgery, when they heard that I was coming. I head off with Audrey to go home and change cloths to attend the wedding of Avava and Valantine that we came for.

After the wedding I head to the operating room with Dr. Solomon (The other Congolese doc that’s covering here). They have done one prostatectomy and the patient didn’t do well, so they have been telling the old men with urininary problems to come back in Dec, when I arrived.

Ketamine, Valium and Atropine are given and the old man is off to sleep, making the funny faces people make when hallucinating on Ketamine. We open the pack of sterile equipment and find they are out of gowns and have put yellow, infectious gowns in the packs. These are a thin, see-through, material that is NOT sterile. We open other packs till we find the one with cloth gowns. We put these on and I have to say something to the other Doctor about sterility as he grabs his gloves with his bare hands and pulls them onto his gown. We change the gloves and continue.

I press the blade against the dark skin, and it fillets open showing the white and yellow inner layers. It’s been a while since I’ve operated on dark thick skin. Essentially no fat is there. I divide the fascia and open the space above the bladder. I fill the bladder with saline, and then open it. My finger examines a huge nodular prostate at the apex. Cancer? I crack the prostate anteriorly with finger pressure. The other doc feels the same area. I realize that my thin gloves must have a microscopic hole, as my index finger is wet under the glove. I double glove. I attempt to shell out the prostate unsuccessfully. I think about a different approach, and decide that it’s not wise under my current circumstances. I have opened the prostate enough that he should be able to pee again, but the prostate will stay. We close the bladder, fascia, and skin, leaving a glove piece as a drain. Wish I had brought in the drains someone gave me before coming! I always worry about part of the glove tearing off inside as I try to pull it out a few days later. As we are closing the irrigation starts filling in the wound. The catheter must be blocked. I irrigate it and a large clot comes out. I reinforce with the assisting nurse that is giving Ketamine that this is the reason we need to be vigilant of the irrigation. He assures me that they are. (even though it is truly the family that does the irrigation and empties the urine sac).

I return to see the 13-year-old girl in the emergency room. She says she’s breathing better, but looks about the same. Her oxygen saturation is better after increasing the amount, but she is still breathing very fast.

I head home to prepare for the evening party of the married couple for close friends and family. That night I pray for all our patients, but specifically the old man and the young girl. “God protect them from poor care, dirty surroundings, and their disease. Thanks.” G