By James E. Appel ’00
Today I’ve only scheduled a few easy cases. I’ve been working too many busy Fridays lately. Unfortunately, as happens so frequently in Chad, things start off wrong. My car is in the shop. I have to take the quad to work. Surprisingly, it starts right up. With Miriam on the back and Noah on the front, we head off through the dry blustery wind of an early Sahel morning. The dust gives the sun an eerie deep red color. I drop the kids off at school and continue to the hospital. My eyes tear up in the wind and dust despite my sunglasses.
I drive through the hospital gate, pull into the shade of a Neem tree, and head off to surgery. We start with a difficult case. It’s a 9-year-old girl we have to bring back to the OR. Kalbassou had operated on her femur fracture a few months ago, placing two small Rush rods in the marrow cavity.
The fracture was healing nicely until two weeks ago. Unfortunately, at the insistence of the mother, I removed the nails. This is something I almost never do, especially before complete healing of the bone. To make it worse, whatever I wrote as an explanation in her portable medical record is lost. A couple days after I removed the rods, her femur broke again. I’d scheduled her for repeat surgery this past Wednesday, but she didn’t show up.
Now she’s on the table and under Ketamine. I try a closed reduction. It seems to work. However, when I try to introduce a new IM nail, it won’t go into the distal fragment. I have to open the fracture. There I discover a lot of scar tissue between the bones — a non-union! I clean out the scar tissue, freshen up the ends, and then easily pass the nail. In the end I think the result will be better. Sometimes things happen for mysterious reasons!
The next case is a 3-year-old with a hydrocele. I’m not completely sure of the diagnosis, so I make an inguinal incision. Sure enough, he has a hernia as well as a hydrocele. I repair both.
As my assistant closes up, I go to the next room. There I find a middle-aged man with a year-old proximal femur fracture. It turns into a nightmare. When I open up the site, I can’t identify any normal anatomy. Slowly but surely, by using high intensity electrocautery along with a hammer and chisel, I start to get down to normal anatomy. Finally, I’m able to put the femur back into a somewhat normal position. I stabilize the fracture with a large SIGN nail.
I’m exhausted, and time is rapidly flying by. I’ll have to pick up the kids soon. I have an infected SIGN nail to remove in a child and a hydrocelectomy to do. I have the anesthetist put the kid to sleep. He’d been operated here years ago. Last year, when we tried to remove the nail, it slid further into the canal. Now, months later, he has come back with pain in the tibia and probably an infection.
I open the patellar tendon and identify the hole where the nail went in. I push in the locking pin. Fortunately, I’m able to screw it into the nail blindly and extract it! As I unglove, the scrub nurse tells me there are two new cases: a strangulated hernia as well as a child with a supracondylar fracture.
I let my two assistants do the hydrocelectomy. I walk out to the quad. I plan to come back to finish the last cases after lunch.
The quad won’t start. Nothing even lights up. The battery can’t be dead! I have the gatekeeper give me a push start. After three failed attempts, the quad starts. I go to pick up Miriam and Noah from school. The quad dies at the school. Fortunately, there are plenty of school children around to give me a good push start.
Miriam, Noah, and I have beans and rice with guacamole for lunch. Sarah and Isak are at the airport to pick up an orthopedist arriving today from the U.S.A.
After lunch, Noah and the neighbor kids give me such a good push that the quad starts up on the first try.
Back at the hospital, I’m called into labor and delivery to see a tiny girl trying to deliver her fourth child. The head is huge and stuck. I put in a urine catheter, inject a local anesthetic over the pubis, cut through the pelvic cartilage, and the baby comes out in less than a minute. A fat baby boy, he screams his head off before I can even get him all the way delivered. I suture up the wound and head back to the OR.
Kalbassou has done the strangulated hernia, and the others are finishing up the hydrocele. One of the nurse consultants is there with an X-ray of a 19-year-old with a five-day-old femur fracture.
“Yes, we can do her,” I tell the consultant. “We shouldn’t make her wait the whole weekend.”
I make a midline incision over the elbow of the 6-year-old with the supracondylar fracture. I cut through the tendon and muscle to expose the fracture. I put in two lateral pins, close up the wound, and cast the arm.
The 19-year-old with the femur fracture has huge legs. The whole case is a wrestling match with my two assistants and me giving it all we’ve got. I sweat until I’m dripping despite the two A/C units on at full blast. Finally, we get a good reduction and fixation with a SIGN nail.
It’s getting to be close to sundown. Without electricity on the quad to power the headlights, I need to get home before dark. The two gatekeepers give me another push start. With the wind in my face, I race home across the desert with the sun setting in the dusty African sky.