BY JAMES E. APPEL

I walk through the gate. My Tchadian robes swish gently as I stride forward purposefully. Its Saturday. The sun is newly up, and I have a purpose. I want to round quickly on the hospitalized patients and make it to church. But that wont happen today. God has other plans. My mind wanders back . . . of all the remote places in the world, how did I end up in Br? In Tchad? In Africa?

I was sitting in my cousins den in Collegedale, Tennessee, staring at a computer screen. I felt my heart quicken. They needed physicians desperately for the family practice residency at the Adventist Hospital in Ile-Ife, Nigeria. Was this what I was looking for? Was this the answer to my question God, where should I go, what should I do? I wrote back, little realizing I was releasing a chain of events that would quickly lead me to Nigeria and eventually to Tchad.

I approach the clinic. There is a mother sitting outside on a broken metal chair with a splintered wood seat and no back. An infant is in her arms. Coming out of his scalp is an IV. Attached to the IV is a tube filled with blood. The blood runs from a bag hanging by a coat hanger to the bars on the charge nurses office window. There is a metal tray on another chair. On the tray is a bloody IV catheter needle. Next to it is a wad of cotton, an empty IV tubing bag, and a roll of tape.

I turn the corner and enter the ER (emergency room). Dimanche fills me in. Malaria. Severe anemia. Took 40 sticks to find the vein. Had to use the scalp. Our third in 24 hours. Yesterday two died. Same disease. One died in front of Anatoles eyes as he frantically searched for the vein. Would this ones fate be the same?

I remember the first time I saw Dimanche and Anatol . . .

After writing back to the Ile-Ife Hospital, I was called one evening by Dr. Richard Hart, chancellor of Loma Linda University and president of Adventist Health International (AHI). He asked if I could make it out that week to meet with him and Monita Burtch from the Central African Union. It was there I first heard about Br, a small Adventist hospital in the middle of one of the poorest countries in the world, which had been without a Seventh-day Adventist physician (and often without any doctor) for more than 10 years. It was tiny, poor, and undeveloped, and in the middle of becoming part of a national project to develop a health-care system in a country without one. I was intrigued. I was ready to sign up that same day. They told me to think about it, and suggested that I visit Ife and Br before making a decision. So I did . . .

Id just traveled five days from Nigeria (where Id completed a residency rotation) by plane, taxi, minibus, motorcycle, and canoe to the tiny Br Adventist Hospital. I then had only about five hours to see the place that might one day be my home before racing back to NDjamena, the capital of Tchad, to catch my plane to return to the United States. It was in those five hours that I briefly met Dimanche in the midwifes office and Anatole in the lab.

I grab my stethoscope and make rounds. Before I finish, Martin comes to tell me there is another case. I hurry back as fast as one can when wearing a dress (Arabic robe). There in the shadows of the unlit ER is another baby struggling. I quickly examine him. Heartbeat 180. Conjunctiva white. Palms pale. Respiration labored. Limp. Tired. Eyes shut. This one cant be long for this world. Jacob and Anatole are there already. As they prepare to type and cross-match the child for a blood transfusion another baby arrives.

I recognize the mother. She is dressed in brightly colored cloth wrapped around her body and head in Arabic fashion. She has henna stains on her hands, and the scent of incense and savory oils. She has just had two children hospitalized here. Shes pregnant again. In her arms is a 3-year-old with coffee-colored skin, huge brown eyes, and a white-and-black-bead necklace just at her throat. She is tired and breathing fast. I take her pulse. 160. Her eyelids are colorless as well. Quick decision. I tell them to stop with the other child and type and cross-match this one first. She is more likely to survive.

Having signed up for the deferred mission appointee program while in medical school at Loma Linda, I knew Id be spending six years somewhere in the developing world . . . but Br? Id never even heard of Tchad, much less Br. Br is not even on most maps of Tchad. To find it, one has to have a decent map of Tchad that will at least show Klo and Lai. Then, about halfway in between, one can imagine a small village of mud-brick, thatched-roof huts. My major fear about coming to Br was, How will I survive? I worried mostly about food and water and isolationthose have turned out to be the least of my worries.

The first kid matches blood with both mom and dad. O+. The second child matches with mom, O+, but moms pregnant and dad hasnt arrived yet. Anatole has meanwhile started an IV with quinine on the Arab girl while Martin has started the quinine on the first. Anatole then draws the blood from the dad for the sickest baby while we wait for the papa of the Arab child to arrive. The transfusion is started. The kid is still alive, and soon starts to breathe easier as the life flows back into him through the blood.

Meanwhile, the little girls father arrives. I recognize him immediately. He was the one who was stabbed right outside my office, leaving drops of his blood all along the hallway. During the fight Id been in the ER with a kid seizing from malaria and an infant twitching with tetanus. That was three months ago. Hard to believe. Wed operated on the man twice, and hed been in the hospital almost two weeks recovering. He looks great. Jacob draws his blood. Its a match, and the girl
gets her essential life-giving red fluid pumping into her veins.

I often ask myself what Im doing in a town of 60,000 people, without plumbing, electricity, paved roads, sewers, clean water, or telephones; where people still live by plowing fields with plows and oxen or by hand, and plant rice, millet, and corn by hand. I wonder what I was thinking to make me agree to come to work in a district hospital covering an area of 140,000 inhabitants as the only doctor. I must be crazy to work in a hospital with leaky roofs, falling-down ceilings, electricity by generators only at night for a few hours and during emergencies, no mattresses, broken windows and doors, cracked paint, bats in the rafters, mice and bugs in the walls, no toilets, no x-ray or other imaging, minimal lab facilities, tuberculosis patients coughing all over everyone because theres no isolation ward; and with pigs, chickens, and goats running around (until we built a fence . . . now only the ducks get in occasionally). What was I thinking!

I go finish rounds. The baby with the scalp IV has finished his transfusion and looks better. As Im walking back past the ER, Anatole says I need to look at the little girl. Shes seizing he says. I go look at her. Her skin is scalding. Temperature 104.9 F. She is shivering uncontrollably as we try to cool her down with water and fanning. She just has the chills, not seizures. I speed up the blood transfusion, as her heart rate is still fast.

Martin comes to tell me the other boy isnt doing well. He is lying on the plastic of the exam table with his blood slowly dripping in. Just a few milliliters left. Hes exhausted. I notice hes breathing slowly with a few sighs. I place my stethoscope to his heart and hear it start to slow downtoo much even as I listen. I rub his back and pinch his feet. His heartbeat picks up as he cries in pain and the adrenaline kicks in. I yell or Jacob to bring the respirateur (bag-valve-mask for artificial respiration). I continue to stimulate the kid every time the heart slows down. Jacob arrives with an aspirateur for sucking out mucus from newborns mouths. I yell Respirateur, and he bumbles off to get it. Im afraid it wont arrive in time. After what seems an eternity, Jacob arrives, and I start to try to breathe for the baby.

A hospital without oxygen. Can you imagine? We do surgery without real anesthetics (we use ketamine, which puts the person in a dissociative state in which theyre awake but nobodys home), or breathing tubes (intubation). I find myself, as a family doctor, having to perform, at times, major surgery, as Im the most qualified person here (only two other hospital personnel have their high school diplomas, and we have no registered nurses . . . everyone is either a nurses aide or apprenticed into nursing on the spot). And our conditions for surgery are a far cry from what Im used to . . . but we have yet to have a single wound infection.

He fights the artificial breaths. Every time I try to breathe he cries and struggles. He almost loses his IV. Ive changed it from blood to a quinine drip. I listen to his lungs. Filled with fluid. Overload from the transfusion.

I call for Martin to inject Lasix to clear his lungs. He does. I continue to bag and stimulate as the heartbeat drops off every time I stop, but responds nicely to his own adrenaline surge. Minutes go by.
He hasnt urinated. I double the dose of medicine. Bag. Rub the back. Keep the IV from being torn out. Try to keep my stethoscope balanced on his chest so I can monitor his heart rate and see if any air is going into his lungs.

He still hasnt urinated. I feel his bladder. Full. I push. Urine squirts out. An hour has gone by. I stop bagging and watch. He seems to be breathing O.K. His heart rate is fine . . . no, its dropping off again. I restart. Another half hour goes by. Finally, his lungs are clear. The quinine is starting to kill the malaria. The blood has refurbished his worn-out circulation. He breathes on his own. His heartbeat stays up. Its 3:00 p.m. I head home.

Home . . . always hard for me to define. I moved around often as a child, since my father was an Adventist minister. I had a hard time figuring out what God wanted me to do with my life. In college I took some nursing, some psychology, some education, some premed, and some theology, ending up with a B.A. in Theology along with the premed requirements, and was accepted to medical school at Loma Linda University. There, I found myself liking everything some, but nothing so completely that Id want to do it the rest of my life. So I chose the general path of family medicine.

Moving around, changing a lot, having to be adaptable, meeting new people all the time, learning foreign languages, and my residency at Ventura County Medical CenterI look back on all that now as God preparing me for Br, where anything and everything is possible and you never know what to expect, except that it will be different than you thought, and the only surprise is if everything goes as planned.

A few weeks later I find myself staring at another kid getting a blood transfusion. This time, however, its a little different. More personal. Cest mon sang qui coule dans ses veines, I remark to the nurses. Neither the father nor the mother matched the babys B+ type. So I offered to part with a little of my own blood. Lona jabbed a huge needle in the big vein right where my elbow bends, and before I knew it 150 milliliters of a dark-red liquid was hanging in a bag ready to give life to a tiny, unknown African child. As I watch the blood flow, I feel ambivalence. The moment is mystical, yet mundane. I really dont know how to describe my feelings as I watch the blood slowly drip down the IV tubing.

The blood of the martyrs is the seed of the gospel, said one of the early Christians. Its one thing to run around giving blood transfusions to save lives, even if its your own blood. Its another thing to have that blood slowly beaten, whipped, twisted, and pried out of you against your will.

In one large Asian country today people are literally giving their blood for the sake of their belief in Jesus. Brother Yun describes one such experience: As they drove throughout the day on the bumpy roads, my handcuffs cut into my wrists so that blood splattered everywhere, covering the walls of the van. The handcuffs cut so deep that my wrist bones were exposed. I was in such agony I could hardly breathe. I was about to fall unconscious because of the pain and loss of blood.

Those who think that perhaps thats an isolated case probably dont know any of the 250 million Christians worldwide who are suffering persecution today. Dear friends, do not be surprised at the painful trial you are suffering, as though something strange were happening to you (1 Peter 4:12, NIV).

I gave my blood voluntarily this time. What about shedding it unwillingly for something or Someone I believe in? The question haunts me. Honestly, Im afraid. Yet in some bizarre way, there really is powr, powr, wonder-working powr in the blood . . .

James E. Appel, M.D., is the physician at the Br Health Center in the Republic of Tchad, Africa.