Another message forwarded from James Appel in Chad.

Another message forwarded from James Appel in Chad.

For those interested see www.bereadventisthospital.blogspot.com/

—— Forwarded Message

From: James & Sarah Appel

Date: Mon, 2 Jan 2012 20:34:49 +0100

To:

Subject: Grief

I’m lying flat on my back on the veranda.  Dusk has settled.  The stars are

not out in force yet, but the half moon and it’s bright under star are

straight over head.  Among the dark tangled branches a few fruit bats flap

silently across the clearing, temporarily blocking out the moon.  Darkness

settles in as I feel a gnawing in my gut and the need to release my anguish.

But the tears won’t come.  My mind wanders to a million memories.  It’s only

Monday but Friday already seems a lifetime ago.

I’ve already started to feel the waves of grief mixed with a calm peace that

ebb and flow like the tides that Tchad has never seen.  A few incidents stick

out.

I’m in the tiny office off the waiting room with Sarah and Miriam.  Miriam is

half-way through her treatment.  She has just finished an hour of cooing,

flopping, half-crawling and wrapping herself in her IV tubing.  Now, she’s

sleeping, her legs hanging off the edge of the mattress face down and slightly

turned to the side away from the her left arm which is encased in tape, an

armboard and an elastic wrap to keep that precious IV access going.

I hear the sounds of French with an Arabic accent outside.

“I just want to see James and give him my condolences.”

“He’s at the house,” replies an unknown informant.

Through the broken slats and ragged curtain on the window I see a couple of

Muslim hats on top of well-known faces as they turn to head in the wrong

direction.  I take the route through the waiting room and from the door yell

out, catching the two men’s attention.

“AS SALAAM ALEKUM!” The two muslims turn and smiles light up their faces as

they give the traditional reply: “Wa alekum as salaam.”  One is a contractor

who remodeled the Bere Hospital ER and built some staff housing.  The other is

the local imam.

The Imam is dressed in a light blue robe with embroidery on the chest.  He has

a white, flat topped hat on his head and a checkered middle eastern scarf

around his neck.  One eye is blind and almost shut and a scraggly white beard

graces his chin as a smile crinkles up his lined face.

“This is the way of the world,” the imam continues in Arabic after we have

shook hands and exchanged the appropriate long greetings. “This is the way of

the world.  Only Allah knows why these things happen.  Only He knows.”

“Al hamdullilah,” I reply.

“My heart hurts with your heart,” the imam continues, first touching his chest

and then moving his hand out pointing at my chest.  “My heart grieves with

your heart.  Only Allah knows why.  May Allah be praised.”

“Mashallah,” I intone my head down as I shake and hold the Muslim leader’s

outstretched hand.

“Where’s Sarah?” the imam asks.

“Inside.  Come.”  We walk back together as both men offer me more words of

encouragement and condolences.  Inside, I check and find Sarah is sleeping.

“Don’t worry,” says the imam with a smile.  “Allah will give you more

children.  This is the world.  There is loss.  Allah gives and Allah takes

away.  Let’s pray.”

Both Muslims stand with their hands outstretched to receive Allah’s blessings

as the imam leads us in a prayer of praise and consecration.  When he has

finished we all bring our hands to our faces to accept the blessings from God.

That evening, my uncle, a Christian pastor calls me on the phone also offering

his encouragement and condolences.  He also ends with prayer.  During the

prayer I realize that this is a rare moment.  I have been blessed by both

Isaac and Ishmael.  For an instant, around a tragedy, the two brothers have

stopped fighting and helped the hurting.  I am moved to tears, which is quite

easy these days.

The next morning, Miriam’s 3 days of IV Quinine are finished.  She has no

fever and is back to her normal self.  We pack up the van in truly Tchadian

style with baggage to the ceiling, three American volunteers, one Tchadian

patient and his two family members (plus small child), one Tchadian nursing

student, one Tchadian cook, our two Tchadian adopted daughters (Yahdang et

Djongyahbo), Sarah, MIriam and I.  Before getting in, the three of us make a

final pilgrimage to the two graves under the red flowered tree.

Then we head out in an eery fog.  The whole country seems to be mourning with

us as a white haze drifts in and out of the dried grasses, half burned fields

and cracked clay.  Passing a lake, some massive rounded backs rise out of the

mist, nostrils flaring as a herd of cattle is driven by.  The chill lasts

until we are safely back in Moundou wondering what do we do now?

—— End of Forwarded Message

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#182 Shanksteps (lack of faith this AM)

#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

#175 Shanksteps

#175 Shanksteps

I first saw her in clinic.  Her nomadic, bright colored attire, hid her frame.  She said her stomach had been growing.  I asked how long, and the response was 10 years.  Hernia? Cancer? Baby? (the time frames I am given often do not apply to the current episode of things happening, but may be an accumulation of events that the patient relates together).  I examine her and fine a huge abdominal mass that seems to be little mobile, maybe 10X10X13 inches.  I did an ultrasound.  It appeared solid and cystic (little fluid pockets). Likely a cancer.

She took the “standard” bowel preparation the day before yesterday.  She took it all and had NO stool.  So she did it again yesterday with even more bisocodyl. Finally she had a lot of diarrhea and cleaned out.

She lies there with cachectic arms and legs, with a VERY protuberant abdomen.  Lying on the operating room table, she takes up a small portion of its 1.5 feet width.  She looks embarrassed as we uncover her to start the preparations for surgery. We administer Valium, atropine and Ketamine; prepare her abdomen with betadine, and lay on all the cloth drapes.  She has NO fat on her body.  So once I’ve cut through the skin I’m nearly inside.  Usually when I’m working on a belly this protuberant I’m apprehensive because I’m wondering if the baby is going to be OK.  Now I’m apprehensive because I don’t know exactly what I will find.  Where it will be coming from and if I’ll be able to take it out.  I see intestine stuck to the surface.  Huge vessels feed the mess.  I feel below it and don’t feel a free spot, neither on the sides and top.  So I slowly start freeing the intestines from its surface.  There is oozing everywhere.  We give her Vitamin K in hopes that she might be low in Vit K and that this would then help.  It doesn’t seem to.  I control the bleeding with some sutures.  We continue the slow work.  Freeing up here and there around the sides of it.  Now I’m behind the large intestine and behind the stomach.  The pancreas is in view, it’s rather stuck to the cancer.  I realize that all the large vessels that feed the intestines are within this cancer.  It is impossible to remove.  So we decide to close.  The nurse giving the anesthesia recommends that I call a family member into the operating room to see what we have found and to explain why we cant take it out.  I call in an uncle that is a person I recognize as having seen before.  The nurse puts a mask on him and a cap and he comes in the door.  The nurse stands behind him to assure that if he passes out he doesn’t hit the floor.  He takes it all in without emotion.  Thanks us for trying, and states it is God’s will.  Though I desperately disagree with the last statement,  I say thank you and he leaves.  We close up the abdomen and take her back to her room to wake up.  I instruct the nurse to get vital signs on her every hour for four hours, knowing it will only happen if he has nothing else to do. G

Shanksteps #174

An older woman sits in front of me in clinic, her husband on the chair beside her.  She says that something is coming out below when she walks, and has ever since she had her last baby a few years ago.  I examine her and find it’s her uterus coming out

Another young man is having rectal bleeding for the past few weeks.

A third had an accident on his motorcycle a couple days ago.  The huge swelling on the side of his face is improving.   He arrived unconscious and now is thinking clearly.  He says that one tooth doesn’t seem to be in place.  I examine him closely, and find that he has a mandibular (jaw bone) fracture right before his last molar.

These are the surgeries for today.  The older woman took her bowel prep which consisted of a bowel stimulant (Bisocodyl) and water. She is placed on the operating room table.  The preparations are made and I put on my cloth operating gown.  It’s cut real small for my long arms, and when it get’s wet with blood or other fluid, I’m wet with it too.  I help Dr. Solomon put his on, as I’m particular about sterility even though others don’t seem to see the necessity of all that I do.  This is probably the cleanest she’s been in 60 years of life.

I open her lower abdomen.  She has essentially no fat!  I open the skin down to fascia in one fell swoop.  Cautiously enter the fascia and peritoneum.  I search her pelvis for the uterus.  I grasp it between my fingers and pull it into the wound. It has been prolapsing so far that it comes up easily.  It turns out to be one of the easiest hysterectomies I’ve done.   I didn’t bring large enough suture to do hysterectomies so use a smaller than normal one.  For her tissues it turns out fine.

The next was the young man for a colonoscopy.  I finally find the colonoscope again and all the things that go with it. I look inside and find a very inflamed intestine.  Colitis.

The 30 year old guy with the mandibular fracture is next.  I take him to the OR but cannot find the materials I need. I need arch bars (metal bars for the teeth) and wire to attach them to his teeth.  I need to wire his mouth shut for two months to let things heal.  After opening a number of sterilized packs, I finally find the one that has the right equipment in it.  I wire the arch bars to his teeth then, the arch bars together.  I find that I cannot include his last tooth so the fracture is still loose.  At the end I realize I will still need to wire his bone itself together as I don’t have any metal plates to put on it.  I’ll wait till the swelling goes down then attempt to finish.

I return to the clinic to finish seeing the patients that have been waiting for hours.  See more malaria, typhoid, pneumonia, and another malnourished kid who is 2 and weights about 14 pounds.  I head home to a meal of millet paste and sauce (my actual favorite here).  G