monks on the beach at Hua Hin

Out of Biharamulo

On 8/14/08 we victoriously left Biharamulo having completed our  6 week stay and lived to talk about it. Of course leaving Biharamulo may have been victorious but no one said it would be easy. And of course  I would be the last one to  forget George Bushes epic blunder of declaring "Mission Accomplished" too soon. We had lined up the hospital ambulance, a toyota land criuser, to give us a ride to Mwanza.  From there we would eventually get a flight to Addis Ababba and then on to Paris. But as word got out around the hospital grounds of a trip to the big city the ambulance filled up rapidly. By the morning of our departure we had one dying patient ,who was in a coma. One severely burned and disfigured teenager. Two strangers, one hospital doctor, the driver, Barbara and myself. Of course the dying comatose patient was loaded into the back ON his hospital mattress. Add  luggage and 5 boxes of Disani water bottles I was bound and determined to recycle in Mwanza and we had a classic African  road trip.....too many people for one vehicle.

The story picks up with  8 people, one mattress, luggage and boxes  in a land cruiser ambulance pulling into in Mwanza. We have just crossed the Kagera region. The temperature inside the ambulance was above 100 degrees all day. It's been 5 hours of eating, breathing and being coated with red Tanzanian dust. I can't see my hair but Barbara's hair is now red. The African man I do not know  who never got a seat and never spoke a word now has red hair. We have just dropped the patient( still alive ..barely) at Bigondo Medical Center and are headed for our favorite hotel in Mwanza..... 

   We pull into LaCairo Hotel. Hot, dusty, filthy and stinky. The place never looked so good. We are back and this is our portal to the 1^st world. LaCairo is on a dirt road in Mwanza. But once you enter thru the gate it’s all paved and tiled and pretty clean. Its really a transition zone from the jungle, to a 3^rd world city, to TV ,the internet and food and civilization. We turn into the courtyard  and I’m sure we are  looking pretty funky  to the hotel staff ,even by Tanzanian standards. 1st of all we are in an ambulance , not a daily occurance I hope.. 2^nd we are covered with red dust. 3rd we  really stink. The back of the amulance  still smells like the patient. He peed and sweated and I think threw up. But worst of all is the fish. I think the driver bought some fish at the Lake Victoria  Ferry. Its more complicated then that.  At  the market when you buy fish , you buy fish,  that doesn’t mean you get a bag. That doesn’t mean the fish are wrapped. You get the fish. So on top of my expedition bag which is squished in the back of the truck, and covered in red dust are 4 dead, desiccating, smelly, ugly looking Lake Victoria  fish. The bell guy comes out to get the bags. I try to warn him but he is not responding to English.   He opens the back of the ambulance and the 5 boxes of empty Dizani bottles fall out onto the ground. What doesn’t fall out but engulfs the bell guy is a giant cloud of red kagera dust that smells like dead fish and dying human. It’s a hot ugly scene. Barara has gone inside to check in. She no fool, there’s air conditioning in there.

  I  am trying to get the bell guy not to bring the bags inside the hotel. I want them washed off before they are carries into the lobby. He carries them in anyway. Things are getting uglier. The local hang around guys on the street are getting all excited and watching the stinky ambulance unload it’s cargo. I’m sure they are saying how many people are in that  thing anyway?  Its about then that Barbara comes out walks up to me and says they don’t have any reservations in our names and they don’t have any rooms in the hotel.  How could this be ?  I got a e mail reply to my reservtion request. I march into the cool, clean  lobby  and  walk up to the desk. Sling my filthy dusty knapsack onto the counter ( it gets the effect I want) and whip out the apple computer. I  want to show them my email letter of confirmation.  BUT….no internet available!! Arrgghh!  We are suddenly powerless, no evidence of reservations.  Of course it is always at time like this when suddenly no one speaks English. They do not want to deal with an irate filthy mazugu so its really quite easy. The hotel staff, as if by some invisible signal,  switches to Swahili only. Its also at times like this when I have to remind myself…it’s the 3^rd world, it’s the 3^rd world, it’s the 3^rd world. Never count on there being electricity or internet or English when you need it.

   OK, Babs is still in control. She is  moving on , letting it go. She has asked the front desk girls to see if theres room at Talapia, the white peoples hotel across town. The women calls and actually books us a room!!  I'm having a visible melt down but Barbara and the desk lady seem to be having a nice time. I think they are going to have tea together! I feel like Rambo.! Is this a girl to girl thing or is this  just a "we don’t want any Mazugos especially stinky, mazugo around our hotel"?? I never could do the Rambo thing anyway. We march out to the ambulance leaving a little bit of our dusty, aromatic  selves in the LaCairo lobby.  The journey continues...

The Shifting Sands

Mashoka risking his life
  On Aug.16th we left Mwanza and spent 3 days travelling through the Serengeti. Maybe the biggest national park in the world, it is just... huge, which is what "serengeti" means in Masai, (the local tribe and language.) That 3 day adventure is a book in itself and a photographers dream come true. 

   After 2 days we took a side trip in our land cruiser to an area south of the Serengeti, near Olduvi Gorge called "the shifting sands". First written about by Mary Leakey in 1959 it is a sacred place to the Masai that I suspect they don't care to commercialize.  Barbara, the geologist, knew about this place and it had been on our list of "must see" places from the beginning.  And since she has the biggest  collection of sands from all around the world in new england,(stored in our house!), there was no avoiding this trip. We "off roaded" it through flat desert  with   wind blowing sand and reducing visibility till came to the site. Our Serengeti guide Mashoka had picked up a local Tanzanian geologist for the ride. On the way, in a mixture of English and Swahili, we got the story.  For some mysterious reason this  BLACK sand dune has been travelling across tan, red sand desert for as long as anyone can remember.  It is pushed along by the continuous east to west wind that blows there....mysteriously.  What's odd is that the black sand stays together and hasn't been mixed up with all the other tan colored sand over all these years. It travels about 15 meters /year in a straight east to west line. Mashoka  says the Masai think the shifting sands are spirits of the dead that hold themselves together  and the dune needs to be treated with respect. " Don't walk on the dune and don't take any sand". Disturbing the dead is bad ju-ju.

   We get to the site and it does have a  sort of  has a Indiana Jones feel to it. It's desolate, windy, sand blown and you just want to look down wind.  Its like the sun never really shines there.  There in front of us in a cloud of  red, tan blowing sand is a  parked black stealth fighter that looks like it just came in from Iraq. But its really the mysterious" shifting sands". It's flat black, shaped like a crescent, maybe 10 meters high and 30 meters long. I want to take pictures but I'm worried about my camera. We all sorta spread out and walk around , it is a spookey place. I remember that  last night I did see Barbara stuffing a few plastic bags in her back pack. Now she's disappearing into the sand cloud and walking around to the other side of the dune. 

   Its true, there is no mixing going on. The black sand is moving. the tan sand is moving but they are not mixing. I definitely have the spooks for this place.  The local geologist says the shifting sands are magnitite and have magnetic properties thus the particles stay together. Yeah, but THAT TOGETHER is  really odd and why is it so windy here? I have read too many Harry Potter books.

    I look around, Mashoka is walking on the dune!  Now, that is just asking for bad ju, ju!! The local geologist is shaking his head. Barbara is walking back to our side of the dune, she's all excited, its like she just saw GOD.  She and the geologist babble on about rocks.  I take a few pictures, yell at Mishoka  to get off the dune. He comes over and says "...Don't worry, is safe. I am not Masai". Exactly.

   Its time to get out of the sand storm, we pile back into the truck. On the way back  to Oldavai Barbara and the geologist  continue to "rock on" in the back seat. Mashoka throws in a few phrases in Swahili and I'm in the front seat bouncing around thinking about those plastic bags.

Did she steal some of the mysterious shifting sands? I decide it doesn't matter what I know, its what the spirits know that counts.

.

I

Biharamulo and Suburbs

Rush Hour
What is that?
There are Kids Everywhere
Bihar's Back Streets
The Dept. Store

Bringing Water Home Barbara Fitting In
Staying Cool At Lunch Time

My first night on call...in Africa

WARNING PARENTAL GUIDANCE SUGGESTED. THIS IS A PG 13 STORY. I had been in the hospital for 4 days now and was slowly learning the ropes. I knew where the bathrooms were, where the "operating theaters" were and I was making good progress on people's names. I still didn't know where the cafeteria was but that is another story in itself.

It was winter Fri. afternoon in July and I made sure everyone who was on call the weekend knew to call me if they had something interesting, needed help or just anything. This was all volunteered by me. I was a volunteer after all. But I did want to see how the system worked on weekends, what went on, and also I wanted everyone to know that I was "into it".....which I definitely was.

Dr Akim Tampale was on the weekend. She had struck me as a pretty serious women from the get go. This was no piece of cake 9 to 5 bank job she was into. Her schedule is heavy. The hospital doctors are on night call for a week at a time. The doesn't mean you have the days off. Your there just like everybody else during the day, then you go home if its quiet but you're responsible for everything that goes on at night....it's all yours. And just like a 4th of July fireworks display your week ends with a grand finale....the weekend. If you weren't tired by Friday you you will be dead by Monday morning when your friends rescue you. This creates great teamwork. You really do love your colleagues, especially on a Monday morning.

Technology advances in odd and erratic ways throughout the world. Communication at Biharamulo Hospital is almost exclusively by cell phone. Everyone has one..everyone including me. This is a big advancement from MMC in Portland, Me. where we are still in the" beeper age".....so primative. Having left my cell phone # everywhere and given it to Dr Tampale I went home Fri. afternoon to begin our first weekend in Biharamulo.

I woke up about 5:00AM with that inner smile you have when you know you got a full nights sleep with no interuptions. Its like you dodged a bullet, no phone calls, lucked out again, hopefully Tampale had a quiet night too. I closed my eyes and the phone rang not 5 mins. later. It was Tampale, she was in the "minor operating theater with a bad accident ...come quickly.."

I was out of bed, out of the mosquito netting , dressed and walking to the hospital in the pitch dark in a flash.

I walked into the "minor theater" which serves as a procedure room and just about anything else room and all the lights were on and every one was home. On the stretcher was an 18 yo male covered with blood and dirt. One of the anesthetist was putting in a perih IV, nurses were getting bandages and Tampale had his right foot in her hands. Well almost. The only that stopped her from walking away with his foot was the remnants of his achilles tendon. He was awake and still breathing but had lost a lot of blood and was still bleeding actively. After a quick good morning Tampale tells me in English the kid is from a clinic maybe an hour away, MVA (motor vehicle accident), blood is on the way, we need to stabilize and splint. I feel the kids skin, he's cold, trembling, and not saying anything despite her moving his degloved, almost auto amputated compound fractured leg. He's in shock and about to stop breathing. I ask the anesthetist if I can put a central line in to help and he intubate the patient. He looks at me and keeps trying to get a IV in the kids arm. Does he understand English? I ask Tampale do we have a CVP (central IV line thats big and feeds fluid right into your heart) tray or kit? She tells me we don't do that here. !!!! OK, I have to remember where I am and try not to piss off too many in my first week.

The anesthetist has scored with a 16 G IV, if we get one more 14 G or 16 G IV we might have a chance. Tampale is checking the BP. It's 80. The nurse yells the 1st unit of blood is here. I lookup, its a huge bag of blood . I ask Tampale what is that and she says "its whole blood" I keep asking myself "where am I??". In this situation whole blood is a blessing. By now this kid is at risk to have coagulation problems and the whole blood is full of clotting factors..its a gift.

I talk with Tampale on the side. We are in big trouble. We need to go to the Operating Theater(OR) now. There's at least one arterial bleeder in his calf, possibly three, and he's running on empty. We need to forget washing his wounds and try to save his life. We need to stop the hemorrhage and amputate his leg.....which he's already done...mostly.

I put a tourneget on his right thigh and Tampale tells everybody in Swahili we are going to the major theater.

Before we wheel out to the OR we have another "learning moment" The kid is covered with blood and dirt and gravel. His whole body is road rashed with little pebbles in his skin. It's as if he was run over 3 times and dragged thru a gravel pit. He can't go into the OR with his clothes on and nobody seems to know how to get his pants off around his fractures. I keep asking someone, anyone, for a big pair of scissors. Finally a heavy pair of shears appears and I cut off all his clothes. I can't fixate on this but shouldn't this be done when you first arrive at the hospital? We will talk about this on Monday.

OK, we are in the OR and the changes just keeps on coming! This is going to be a real experience. The anesthetist has 2 good periph. IV's to pump blood and fluid into the patient. He has anesthetized the patient with Ketamine. and still has not intubated him. When I tell him he needs to be intubated Tampale starts a running dialogue in Swahili that turns into an argument. Both of the patients lower extremities have been scrubbed up to his umbilcus.

Its a good thing the OR faces east and has BIG windows because the lighting is not great. Not to worry, the sun is coming up just in time!

Tampale has disappeared. Phone call? Probably change her scrubs. Even with the tourniguet

the bleeding continues. I finish drapping the patient and wrapping his dangling leg in a sterile towel, and am looking at the back table where the all the instruments are. Speaking to the nurse, the tech, the anesthetist or anyone who cares to listen to my English. " Do we have a bovie?...you know electical cautery? I'll need a sucker (suction) and the saw and a rongeur ( bone cutting instrument) I'm getting a lot of blank looks from masked faces. The anesthetist says "lets go". I realize the back table is looking pretty bare and lacking everything I just asked for. OK, so I didn't really need an electric saw to amputate this leg but a bovie, a bovie!! thats pretty mandatory. The tech. hand me the knife. First I want to stop the bleeding by finding that artery or arteries that are out of control. But before that I ask for a big pair of scissors. Two snipes and we are through the achilles tendon and skin remnant and we can hand off his distal leg wrapped in the sterile towel. Somehow that just seems to make things neater. The leg stump is a real mess of exposed and twisted tibia and muscle and tendon. There's no real obvious pulsating squirting bleeder, every thing is just oozing everywhere. There is no cautery so I place hemostats on the biggest bleeders but this is wasting time. The best way to deal with this is start the incision and find the popliteal artery ( the main artery to the lower leg), control that, and take care of the hemorrhage. I start a long tangential incision that starts just below that bump thats 2 fingers below the lower part of your knee cap. The cut goes posteriorly and distally down the leg so you create a long flap that will later be rolled up to create a nice meaty stump, all below his knee. The purpose being to create a solid foundation for a prosthesis. I think, will this kid ever REALLY get a prosthesis so he can walk?? Well, first he's got to get through today.

Tamplale is backand scrubbed in. She is across from me and looks OK but flat. I tell what I was thinking. She's OK with that. In surgery there is a lot of protocol, culture, ownership and just simple "surgical manners" One cardinal rule is you don't ever steal a case from anyone else. I think this is universal...even in Tanzania. I ask her what side of the table she wants to be on (ownership is almost always a right side of the table thing). I tell her its her case and she can take over now. She wants me to continue. We cut through a lot of muscle with the knife which creates more bleeding. We place hemostats on bleeders as we go. I cut into a good sized artery. The field fills with blood.That may sound bad but its actually god. Now we know where we are. We control the arterial bleeding with a hemostat and follow the artery back up the leg and whamo! There it is ! The popliteal artery. If we can control this we will stop the hemorrhage. The rest is simple....well sort of.
After a few more minutes we have controlled bleeding, exposed the tibia( the big bone in the lower leg) and the fibula (the little bone) and we are ready to cut thru them both and create a stump below his knee. This part of the operation takes about a minute, if you have an electric saw...which we don't. It could take 5 minutes if we had a gigley saw...which we don't. It took more then 10 minutes with the amputation knife they handed me. I 'm starting to get the impression now that the real reason I'm here is to grunt through this part. The amputation knife is sharper then a butter knife but duller then the history channel at midnight. After 10 minutes of sawing and 2 pounds of sweat I'm drenched and the rest of the patients leg is off the table. We fold up the flap we have made and it looks like it might be an OK closure. Best of all the patient will live.
I'm relieved and have stopped sweating, Tampale is happy, her night call is over. The patient is stable and not bleeding. Even the anesthetist is happy. We get back to our regular broken English conversation with mixed in Swahili and I promise myself a big breakfast....if I can just find that cafeteria.

Every Picture Tells a Story....

Don't it.......