CRIPPLE

From James:

My life as a cripple began insignificantly enough.

As far as I can tell, it started with digging that latrine last Sunday
morning.  I must have accidently hit the inside of my right ankle with the
pickax.  Whatever the cause, by Sunday night it was swollen and painful.  By
Monday morning, I could barely walk and it was red and angry.  I tried to go
to work, hobbled around on lightning rounds before I couldn't take the pain.

At the same time, I was hit with the worst attack of Malaria since the first
time I got it in 2004.  By the time I hobbled home my muscles were twitching
so badly and my teeth chattering so hard you'd of thought I was in the midst
of a Danish blizzard instead of 110 degree sub-saharan Africa.

I slammed down 8 anti-malarial combo pills straight in from China and
huddled under the blankets desperately trying to fight off the cold.

Did I mention my ankle was killing me?

After a day or two, the malaria was better, but as of last night, I hadn't
walked in a week.

I'd been hoping there wouldn't be any surgical emergencies as you can
imagine.  Despite two symphysiotomies performed resting my bum leg on a
stool on wheels in order to bring in two floppy, but eventually revivable
newborns, things had been relatively calm.

Until last night...

After a leisurely Saturday lounging around with my foot elevated to control
the edema listening to David Asherick talk about living in the End of Time,
I found myself strangely drawn to the window around 5pm that evening.  I
picked up my crutches (hand made in Chad and borrowed from a bed-ridden
patient) and limped over to the screen door facing the fence between us and
the Emergency Room.

It was hard to see because of the two screens and the distance between me
and the action, but I saw a group of people gathering hurredly.  A couple of
push carts moved back and forth.  Two people were carrying a stretcher.

I was not surprised to see one of the Intern nurses, Aimée, coming up the
path a few minutes later.

"There's a situation," she blurted out, gasping for breath.  "There's been a
fight at the market.  They've brought in a bunch of victims.  One woman's
dead.  A man has a huge knife wound to his neck.  This other woman is all
beat up around the head and unconscious.  There's a baby that's been
wounded..."

"Ok, ok, I'll be right there."

I pull on some scrubs as quickly as a cripple can and somehow cram my
swollen foot into my crocs and hobble over.  Crutches over moist, sandy soil
is not easy.

I pull aside the curtain to the ER and see groups of people huddled around
bloody clothes with arms and legs sticking out everywhere.  Some are on
beds, some on the ground.  Sarah looks up.

"I think this one is the most critical.  She's pregnant too.  We can't get
the baby's heart beat.  She has a huge wound on her head."

In the midst of a bloody pile I see a slender, young Arab girl with a
bulging middle sticking out of a brightly colored dress made even more
bright by her life's fluid spilled all over it.  Her face is irrecognizably
swollen, contorted and bloodied.  One eye is completely swollen shut and her
long, tight braids are matted with the dark, drying human liquid.

Jason tells me one pupil doesn't react well.  I don't bother to confirm.

Samedi and Abel have arrived.  Simeon is there shortly.  Ansley, Kristin,
Emily and Jacob are also there.

I start shouting out orders.

"Get IV's started on everyone.

"I want one liter of Ringers running full speed.

"Give them all 2 grams of Ampicilline.

"Where's Stephan?  Stephan, get a carton of those 1 L Ringers that just came
yesterday.

"Is there a pharmacist?  Where's Pierre?"

Andre has arrived and speaks up.

"I'll call him and get him right in," he says already punching in numbers on
his cell phone.

"That guy there is probably the second sickest," Sarah shouts across the
room as she attaches IV tubing to the arm of the first woman.

A young man is staring at me calmly.  His once white pants are now tie dyed
in his own color of red wine.  A bundle of gauze has been taped under his
right jaw on his neck.

I pull it off and see a 10cm laceration cut neatly from right under his chin
to under his ear.  It's about 5 cm deep and oozing a lot of blood until I
push the compresses back in the gaping wound.  It doesn't appear he got his
jugular or carotid though.  And he's breathing fine.

"Nathaneal, come and push on this as hard as you can...right there in the
center of the wound.  Don't let go."

IVs are running and nurses are frantically mixing up and administering
Ampicillin.

"Jacob, you and Jason...et Abel aussi...go get the gurney from
surgery...ABEL...LE BRANCARD...AU BLOC!"  I yell at Abel since he's almost
deaf, but one of our hardest workers and head nurse in surgery.

"Jacob, never mind, Jason and Abel can get the gurney, here take my keys and
bring me the ultrasound from my office."

I briefly look at the other two women who are beat up and bruised but
otherwise look ok.  One is pregnant and I quickly do an ultrasound
confirming the fetus is doing well.

Justine walks in with the baby who's mom had been killed, strapped to her
back.

"She's not injured at all luckily, we just thought so at first because she
was covered with blood."

"C'est bon!" I quip and head off to the OR.

In the OR, the lights aren't on so I hobble into the battery room/solar
panel master control room and flip on the switch giving us solar power to
light up the OR.

People scrambling around.  IVs going up and flowing in.  Needles, seringes,
gauze, scalpels, instruments, suture, gloves, scissors, razors, shaved
braids, and blood, blood everywhere.

After Abel finishes taking off a life's worth of braided African hair in a
few minutes time, Samedi gets going suturing up the huge upside down V
shaped gash in her scalp.  She starts to moan, she had been unconscious we
thought.

"Simeon, get her some Ketamine and Diazepam and put her under."

Meanwhile, there's a baby with anemia that no one has been able to find an
IV on all day.  They'd brought him to me at the house and I had tried
putting a needle into the bone marrow of his tibia, but I didn't have the
right needle and the others just kept bending.  It was about this time that
I was called for the mass casualty.  Now, the baby is before me again.

"Jacob, give the baby a milliliter of Ketamine IM and strap him into the
Papoose."

As Samedi starts suturing up the head wound, I slice into the baby's ankle
and dissect down to the saphenous vein.  I find it and slide in an IV
catheter.  We hook up the blood, see it's running in and I suture the wound
closed around the IV.

They've now brought in the young man with the neck wound.

"Kristin, you and Ansley take this baby off to peds.  Simeon, you and
Jackson (Jason) move the man onto this gurney."

"If it wasn't for Allah, I'd be dead."  The young man stares at me
earnestly, speaking in Chadian Arabic.

"Alhamdullilah!"  I reply and he nods and closes his eyes as he starts
softly repeating Koranic verses.

I stay seated on my stool as Simeon puts him under anesthesia with the usual
meds.

A couple sutures to bring the muscles together after washing it out well and
a few loose skin stitches and I'm done.

"ABEL...PANSEMENT!"  I point to the gauze bucket and to the man's neck.
Abel and I have our own sign language between us.  He nods and dives right
in.

Meanwhile Emily has brought the ultrasound in to the OR and I do a quick
ultrasound on the woman that Samedi has just finished stitching up her
scalp.  Her fetus is also doing well and at 32 weeks should survive even if
the mom dies if we can do a C-section quick enough.

I grab my crutches and swing outside.  Sarah is coming from the OR.

"They've just brought in another guy...a Nangjere man.  The sous-prefet's
truck is out looking for other victims.  This one doesn't look too bad."

He's got some cuts on his hand and a stab wound to the shoulder blade that
isn't deep.  I leave it for Samedi and hobble home with the volunteers.

After a game of Settlers of Catan our second game is quickly interrupted
with the arrival of more victims.

This time there're people scattered all over.  Camouflaged gendarmes armed
with AK47s and Kalishnikovs are unloading people from the truck.  I just
head straight to the OR and tell them to bring the worst one's in.

Samedi is just finishing up with the man I'd left him.

"James, I just heard the story of how it all started.  It started with this
guy..."

Apparently, the man was out in his field and saw some cows eating his rice.
He challenged the herdsman, an Arab nomad.  The nomad started to pull out
his bow and arrow so the Nangjere man rushed him and grappled with him.  The
Arab pulled out his knife and the Nangjere grabbed the blade with his hand
(hence the cuts).  He quickly let go and the Arab stabbed him in the back.
The man fainted and the Arab fled.  The women watching assumed the Nangjere
man was dead and ran to the market screaming bloody murder.  When their
relatives heard that their "brother" was dead, they attacked a group of Arab
women just leaving the market.  Hence our first wave of casualties.  Now
both sides were on the prowl and apparently a group of Nangjere had headed
to the Arab village going from door to door dragging women and children out
and the Arab men were organizing their reprisals.  There weren't enough
gendarmes to control it so they were just picking up bodies and wounded.

Samedi finished and wheeled the man outside.  At some point later on, he
wisely dissappeared.

Now, they bring in a wiry Arab with the face of Kobe Bryant who has a huge
slash across his right lower chest.  It's about 25 cm long and all the way
down to the ribs God gave him to protect his liver and lung.  The other Arab
is a wizened middle aged man with cuts all over.  His main complaint is
they've taken out his left eye but closer examination reveals a 10cm slash
across his cheek and a left eye swollen shut.  Small laceration cover his
body and arms.  An open dislocation of a finger I quickly "pop" back in.  He
also has a stab wound to his leg which has broken his tibia.

I put the tibia back in place, wash out the wound well, slosh some Betadine
of a gauze and place it over the wound.

"Jacob, hold that tight.  Jackson, keep pulling on his leg and hold it in
this position.  ABEL...PLATRE...PPPPLLLLLAAAATTTRRREEE!"  He doesn't
understand so I point him to the wound which he holds pressure to.

"Jacob, go get all the stuff for a cast.  Just like we did last Saturday
night:  webroll, tubing, plaster, a basin of water, scissors"

"Simeon, Diazepam and Ketamine for this guy too."  I point to the man with
the chest wound.

"Ashadu Allah illaha ilalallah, wa ashadu ana Muhammador rasullallah."  He
starts to repeat over and over his Muslim creed until he drifts off.

But he doesn't go quietly.  He starts to have a reaction to the Ketamine and
tenses all up not wanting to breath.

"Sarah, get me some Chlorpromazine."  She can't find it.

"Someone get me some from the Pharmacy."

"There is none."  replies Samedi.  "I needed some last night and we're all
out."

Just then Sarah comes out of the inside OR, "I found one ampoule."

The man finally calms down and I do a running subcutaneous suture to bring
the muscles and fascia back together and then some loose interrupteds to
bring the skin partly together, still allowing it to drain since it's
contaminated.

"ABEL...PANSEMENT!" and I turn back to put the cast on the other Arab's leg
while Samedi finishes suturing up all the lacerations.

Meanwhile, Kristin and Ansely and Augustin (who's just joined us) are
working on another man just brought into the room on a stretcher.

"His intestine is sticking out his side and he's got a ton of cuts."

"Start an IV with Ringers.  Simeon, Ampicilline 2g, Gentamycin 4 ampoules,
Flagyl 2 bottles!  Augustin, urinary catheter.  Abel, nasogastric tube!"

I turn back to the fracture and Jacob has already wrapped it well.  I wet
the plaster and quickly wind it around the leg while Jason holds it in
position.

"Hold it there until it's dry."

I turn to the guy on the floor.  They've got all the antibiotics and tubes
in and an IV is running well.

"Simeon, start the generator.  Let's move him into the operating room."

A few minutes later I hop in on one foot having just scrubbed my hands and
arms.  I dry off and Abel puts on my gowns and gloves.  The room is lit just
by the two overhead OR lights focused on the betadined abdomen.  Jacob slips
me my stool and I position myself on the right side of the patient.  We
drape him and then Augustin prays.

I open him up from his sternum to his belly button and dark blood surges
out.  I suck it up and start exploring.  There's no major gusher anywhere.
In fact, I don't see any injury.  The liver is fine.  There is no stool in
the abdomen.  The stomach and intestines are undamaged.  I pull out the
omentum which is what had come out his side and cut off the contaminated
part, tying off the vessels.  As I can now examine the spleen as well I'm
surprised to see no damage to that either.  Where's the blood coming from?

Finally, I get Abel to give me a good look at the wound and I see air and
blood spurting into the abdomen with each breath.  Of course, it's coming
from his lung through the punctured diaphragm.

That would also explain his poor oxygen saturation.  Duh!

I suture up the diaphragmatic tear.  Suck out as much blood as possible.
Re-examine the spleen since I can't believe the knife left a 3cm laceration
in the diaphragm right over the spleen without touching it, but the spleen
is clean.  I leave in a drain and close up.

Then I poke in a chest tube, hear the welcome rush of released air and a
smattering of blood, hook him up to the water-seal/suction apparatus, suture
up the large gash on his arm, the three small gashes on his back, and
finally come to the left buttock.

Jacob and Abel hold him as we roll him on his right side.  The wound is 15cm
long and 10cm deep and bloody.  I use a huge needle to bring the deep
muscles together and then sew the fascia shut.  I leave the skin loosely
approximated and Abel and Simeon dress all the wounds.

It's a half hour after midnight when I get home.  The truck drives up again
an hour later but since no one comes to get me I fall back asleep.  At six
o-clock, my haggard, yet still beautiful wife shakes me awake.

"Well, they brought in a bunch more Arab women but they all only have minor
injuries so I didn't wake you.  They also brought in three more bodies.  "Do
you want to continue antibiotics or anything else on that guy you operated
on?"

Oh yeah, post-op orders would be nice.  Sarah smilingly holds out an OR
order sheet that I quickly fill out.

She comes back at 8am showing me her lab slip.

"Yeah, not only was that the craziest night shift I've ever done, but I had
malaria the whole time!"

An hour later, I limp over to the hospital on my crutches to see the
patients.  Everyone is doing well.  All the women are awake, and while in
pain and swollen all over are able to sit up and take some water.  The neck
and chest wound men are also awake and praising Allah.  The man with the
punctured lung is also stable but not too awake yet.

Just then, a huge group of robed and turbaned Arabs flows in accompanied by
a bunch of soldiers with machine guns.  They go through and out the back
gate to the morgue.  I continue to the ER to see the other patients who'd
arrived after I'd gone back to bed.

I've just started and Djibrine, the nurse in charge of supervising our
district's health centers comes in.

"The governor and the sous-prefet want to see all the wounded."

I find them in the wards packed in with Arabs and gendarmes.  I send most of
them out with the full support of the sous-prefet except for a couple of
guards for the governor and the rest of his team.  I show them around as
they take town everyone's name and injuries and put them either on the
Nangjere or Arab list.

I finally make it home at noon and my ankle has ballooned.

I think I might always be a cripple.