ANOTHER OVERFULL DAY IN PIBOR BEGINS WITH OUR VISIT TO THE PIBOR CHURCH WHERE WE ARE INTRODUCED BY THE FIRST MURLE TO HAVE EVER VISITED AMERICA, AND BEHIND US SITS AN ELDER IN THE COMMUNITY CHURCH WHO IS THE FIRST PERSON TO HAVE EVER BEEN OPERATED IN PIBOR, WITH A THOUSAND PEOPLE WHO HAD BEEN TREATED IN OUR CLINIC UNDER THE TREES, AS THE SUNDAY SCHOOL DOES THEIR STYLIZED DANCE SONG AND WE ADJOURN TO A BURGEONING CLINIC UNDER THE TREES TO RETURN TO OPERATE ON STILL BIGGER CASES UNDER FLAWLESS SPINAL ANESTHESIA BEFORE EVENING UNDER A FULL MOON
FEBRUARY 20, 2011
We had another full day of outpatient in the “clinic under a tree” and concluded with an afternoon of our “OR in our sleeping quarters.” We had a start with the visit to the church, as we were dressed down to do our clinic duties in the hot sun. We came in to sit in the church at the back of the packed mud earthen church but they would not hear of that. We were invited in typical African fashion to the front of the church and sat at the platform next to the choir and the elders and the pastor at the fore. Overhead were what looked like leftover New Year’s Eve celebration party favors, including tinsel wreathes and a few glittering wall hangings. We sat near Pastor David who had come to visit me in Clinic yesterday getting treatment for his eyes. But today he was sporting a black suit and tie as the local Pastor. Since Rev Oruzu was the overall Bishop of the area, he was the one to do the introductions especially since he was the first Murle ever to visit America, and he pointed out that the whole area was Christian which started with the American missionaries on the station on the other side of the river. I had attended that beautiful site for a mission station, with the “hospital” in ruins and the old outpatient clinic being used as a small church for those people who cannot get across the river to PiBor during the rainy seasons. The magnificent mission home, is roofless, and has smoky fires of the cooking that many of the women had clustered around to do as we were walking through. It had looked like a warm and welcoming home high up on the bluff overlooking the Lily River, where Sandy Bixel was born. Her father was the doctor after whom the mission station is now named—in ruins. Sandy Bixel is the wife of the engineer who had asked me pointed questions about what I was doing in trying to take over PCC Sudan before he was convinced that I am not a big organization that funds me generously to claim other people’s effort s and that I was genuinely trying to help the people of this field and then get myself worked out of this job. Sandy Bixel and her husband are now members of the PCC Sudan board, and whose dearest wish is to see the hospital their father had built re-built. That was much of the theme of today’s session in church interrupted often by applause, as a potential pair of rival Dinka were there to say they were brothers trying to help them. I said that in heaven there would be no Murle and there would be no Dinka and there would be no Americans but we would all be brothers and sisters and we might try to get started in this here in this church right now. We pointed out that I had been here last year when the chiefs and commissioner pledged non-violence and as a condition of that they might have their health care redeveloped—and here was a pledge on that delivered through the leadership of Rev. Oruzu, and Ajak and Jacob who would see that the materials we had promised to redevelop their hospital were delivered along with the patients we said we would care for in Werkok in an exchange that would bring back to them the supplies that Ajak and Jacob here present would be guaranteeing for them.
They applauded my speech and that of Ajak and then we were excused to go on to our clinic responsibilities. We drove up for the “quick hour of seeing follow-up patients: to see more than were present yesterday. It is likely that it will continue to swell even more, as there is no more sustainable demand that free health care at the point of servicing and these people have all realized that their neighbors have been treated and came home with medicines and a few with promises of operations. They all seem to know about the successful operation on the elder of the church who sat at the front with a fresh hernia operation after having spent the night with us and having been guided out into the wind of the Waymool and the spattering of the unusual rain on the roof. He had a full liter of IV fluid, but we were all sucking down fluids including the abundant water we had pumped and U/V sterilized, and still no one here has had any bowel or bladder action. We are putting out liters of fluid from our skins.
I could not get the teams to get into gear. Our own members would get up abandoning their station and that would shut down everything. If they got together and talk as if they were in a coffee Klotz, two stations would shut down and others would come over to see what they were talking about. All this leisure is in the face of five hundred patients waiting in the sun and more coming each moment. They would never get out of this clinic by dark quite apart from the fact that we had scheduled three bigger OR cases back at SALT. But that did not seem to bother any of the team who were poking along and did not even get started until after an hour into the morning and then would re-see those patients I had already seen and resolved. The maddening part of this is I had to drag a sea anchor since my “translator” had little grasp of the language but much less of medicine. He would hand me the paper to ask me to fill out all the diagnosis and treatment even the patient’s name which would be unintelligible to me. I made the mistake of asking him what this sounded like and he could not recognize malaria or STD’s and PID after thirty consecutive cases of it. Now spell that M A L A R I A. Every time, every patient. Repeating every diagnosis and prescription in detail four or six times over for each since I refused to write down the Rx and run the clinic—“Where will I be tomorrow and where will you be and how much better off for my visit if you do not begin to recognize and manage these problems?
I got over a hundred patients run through and Zach and Josh stayed at their stations calling over to see if I could consult. But that meant the others would have over a hundred people sitting at their table in the rotating shade of the neme tree knowing full well they are getting “short”. If we do not see them today, it is unlikely they will be seen. And they were looking to add surgical cases when it was unlikely we would ever close down the clinic to get to those much bigger cases we had already booked. It did not seem to matter to those without a sense of time or urgency, or to the fellow who was still puzzled about why I did not just take over and write all scripts myself as he would ask five times running on the twentieth patient to receive the exact same therapy to spell Cotrimoxazole—and ask it to be repeated. So, I scratched him off my list of those in whom I will invest any time trying to have them take over when I am gone when they cannot handle it when I am here. Several others were helpful and we are taking Elijah back with us and training him up further in sterile technique. We saw two or three patients brought in acutely ill, and, of course, like all persons at the roadside traffic accident, all rushed over to gawk and get in the way, stopping all other treatments going on for all other patients. Then, each one has to start all over from zero again.
It was maddening to get them to get into an efficient care system, and even worse to try to patiently repeat for at least the thirtieth time the treatment of STD PID’s on perhaps the sixth time for each including the spelling and dosage. Every patient once seen would recircle back into the queue to be re-seen, largely on the basis that they had a prescription but did not want to wait at the Pharmacy window for it to be filled since they could clearly see we had drug kits hanging from the wall behind us so why didn’t they just take them? It is hard to explain that those are saved for CAR and being cannibalized here as a last resort. SO our clinic was a high volume and largely a supreme test of patience in someone who is trying to indigenize the skills here which in some instances seem to be set on again becoming dependent as a colony of something we will be running as once had happened before all the wars that overran the country.
A woman was brought in to see me and laid down on the ground before me, but it is not possible to see someone in extremis with fifty people crushing around, and all the progress that had been made on those we had been treating in line was disrupted. So, there seems no sense of the value of time except that they do not want to be left behind—but they are fully convinced that they will be the LAST patient seen. After we are packed up and at the truck, I can never convince people to LEAVE and not hang around and kibbutz as still other patients come on the run to greet and meet and to say, “yes, but it is my brother with this little problem”—the major operation that might be needed in the next minutes while you are awaiting at the truck.
One woman was to have an epigastric hernia repaired, so we got her and the baby on her back to the truck. She announced that she was going to go to another relative and drop off the baby and that was her cue to exit stage right, never to reappear. We had a fellow with ganglion cysts on his wrist, so we got him to come along, and the big case of the day was the woman with the large ventral hernia with her transverse colon stuck outside her abdominal wall in it. I could only partially reduce it. We brought her back and had a quick Power bar lunch and a liter of water and started in.
We freed up the large external sac with the transverse colon in it, and excised the sac and did a “pants over vest” two-layer closure of the abdominal wall defect. It was Zack’s turn to do the spinal anesthesia and it also turned out to be a near perfect spinal. SO, we did it efficiently and then had Josh in his Afghani turban close out—the first time in his life he did the closure of anything. He networked on the ganglion cyst as we searched for the woman whose epigastric hernia had been very symptomatic and was very eager to have it repaired until it came time to get into the truck and come along with us. We still had a full afternoon of operating without her, so we got the operating as well as the clinic underway well this weekend without any lapse of promise on our side. So, it seems that the PiBor as well as the MCH experience has turned out even better than anticipated in advance, with all promises fulfilled and an entering into a sustainable and enduring support system likely to result, if they can continue to keep the peace.
We will gather in the full moon evening and discuss the “After Action Report” of this PiBor status but it seems we are going back to one final overflowing clinic tomorrow morning with the departure at about twelve thirty to start up the next phase in CAR. The packet of whistles is now distributed to the chiefs through Rev Oruzu, and they are the ones now saying “Mission To Heal Accomplished!”