Searching for Achilles

“Hello? Doctor! Wake up!”

The rapping at my window is insistent as I sleepily turn over.

“Doctor! Do you hear me? Are you awake?”

What is going on? Is that Mary? She doesn’t usually bother me when I am resting. Is it time to eat? Does my cook have a question?

Groggily, I peel the sheet from my sticky body. I get up and wrap a sarong around myself. The heat is scorching in the afternoon. Especially now, in the rainy season, it is humid and uncomfortably hot. After making sure I am covered modestly, I open the door. Mary, the head of the Pramkese (pronounced Prom-kayzee) clinic, is standing by my window dressed in her nurses’ whites.

She looks relieved and hurries over to me. I step aside for her to enter my apartment and she starts to speak urgently.

“A boy has come to the clinic. His leg is cut, and I believe his Achilles tendon is severed. Will you come see him?”

“What?” I must have misheard. Am I still asleep and dreaming? I doubt it–I wouldn’t even dream this up. I am a family practitioner, not an orthopedist. Why would Mary think I know how to repair tendons?

“Doctor, wake up! Did you hear me? We have a twelve-year old boy with a CUT ACHILLES TENDON.” She enunciates clearly in case I didn’t understand. “He needs your help!”

I guess I did hear correctly. I rub my eyes.  I feel disoriented, but I try to wake up. I blearily agree to walk over to the clinic as soon as I get dressed.

I think about how interesting my life is as I look around for my work clothes. I find the light, short skirt and t-shirt I wore to the clinic this morning. I quickly slip them on before heading outside for the brief walk from the hospital compound to the health center.

The Medical Clinic at Pramkese, in Ghana, West Africa, is my home for the next two months. Pramkese has a population of four thousand and is 80 miles from Accra, the capital. It is a two and a half hour trip by car because of the poorly maintained dirt roads. Signs bearing a skull and crossbones and the words “Death Trap” point out the many dangerous stretches along the way. There is no electricity in the village and most of the buildings, including the clinic, do not have running water.

This is my second visit to Pramkese. My first trip was during my third year of family practice residency. Then I spent one month here on my “away rotation.” Now I have returned two years later, and I am once again having a grand adventure. Although I have traveled extensively around the world, Africa is unlike anything in my experience.

I am the first physician ever to work in the village. The clinic is run by the Ghanaian Ministry of Health and is staffed by nurses and run by Mary, who is a “medical assistant.” The medical assistant training is similar to that of a physician’s assistant in the USA, with the addition of business courses for managing finances. Most ailments are handled at the clinic, but complicated or life-threatening conditions are sent to St. Dominic’s Hospital, which is a half-hour taxi ride away.

When I arrived on my first visit, Mary gave me a handbook to read on treatment of common illnesses.

“Memorize this,” she told me.

I was somewhat indignant—after all, I was a Doctor! Then I skimmed through the book. I started to read more carefully as I realized that medicine in Africa was not the same as in the USA, and I did need to study and memorize the book. In Ghana, there are many infectious diseases that I only vaguely remember learning about in microbiology class. In fact, I should say I remember hearing about them–I am not sure I ever really learned them. Who really knows anything about yaws? But that’s only part of the challenge. Even for the entities I do know, the treatments are often different. For instance, in Ghana worm treatment is a standard part of a pediatric seizure evaluation. Worms are rare in America and of no relevance in seizures.

Also, there are no labs, x-rays or EKGs available and the clinic pharmacy stocks very few medications. When a patient comes in with a problem, one often has to guess what is going on and try to improvise a treatment. The lack of diagnostic studies forces a practitioner to use clinical judgment instead of relying on technology. This can be frustrating at times, but I kind of like it.

Now that I have returned to Pramkese, I often forget the unusual algorithms. When I do, Mary reminds me with a gently worded question. “And shall I dispense some mebendazole to treat for worms?” While I am always grateful for her input, I have found it to be a humbling experience.

The villagers have welcomed me with friendliness and interest. They are curious about my being Jewish, and openly question why I am unmarried and childless at thirty-two. I identify my home as “North America,” because so few people have heard of New Jersey, or even the United States.

The reception, while positive, is sometimes overwhelming for me. I am the only white person in the village, and I am not used to being such a spectacle. Many of the villagers, especially the children, have never even seen an “Obruni,” – a white person. Mothers point me out to their children when they see me walk by. The older children follow me down the street, and I feel like a modern day Pied Piper. Frequently, the smaller kids cry and run away. I find this odd, until someone explains that when Ghanaian children misbehave, they are told that “Obruni” is going to come and take them away. This has its roots in the days of British colonization and the slavery era. Understandably, whites are “boogeymen” to these children, and evoke great fear.

After a two-minute walk, I arrive at the clinic perspiring, both from the humidity and my nervousness about what I will find. A very thin adolescent boy in ratty shorts and a torn t-shirt is sitting on one of the benches next to a woman who appears to be his mother. They are sitting quietly, without speaking. Several women in brightly colored dresses are chatting on the benches nearby and others are lying down sleeping, covered with the multi-purpose outer cloths from their garments. Two young women are nursing toddlers and laughing while their older children play on the floor. This is common–the clinic is a gathering place, and people often stop by to visit or to wait for the afternoon rain to pass.

I look around for Mary, and one of the nurses points to the “procedure room” at the end of the hall.

Several people welcome me saying “Akwaaba,” as I stride down the straight corridor past the reception area, the exam room, and the two “inpatient” rooms. The procedure room is for suturing, bandaging, and splinting; it contains a flat table, a straight chair, and some cupboards. I enter to find Mary drawing up a tetanus shot. They are very good about giving tetanus shots here.

“Here I am. What happened?”

Mary launches into the story.

“The boy, Samuel, is very badly behaved. His mother told him to fetch water, and he refused. She tossed an old machete at him, as she told him again to go. The machete sliced his leg. His Achilles is cut.” The telling is very matter of fact.

“His—what? His mother cut his Achilles with a machete?” I am incredulous, trying to understand.

“Well, it was an accident. If he had gone for water as he was instructed…” Mary lets that dangle–the implication is clear.

I am stunned, both by what happened and by Mary’s easy acceptance. However, it is not the first time my perspective has been radically different from hers and I try to focus on the medical details.

“Are you sure the tendon is severed? Is it partially or completely cut?”

“I believe it is cut completely.”

“Well, I don’t know how to repair an Achilles. If you are right, he will need to go to the hospital to get it fixed.”

“Doctor?” A voice comes from the doorway. It is Sarah, one of the nurses, who lives in Pramkese. She knows the patient and his family well. “The mother is very poor, and the boy does not have a father. If you send him away, they will go home and put herbs on the leg to try to heal it. They will not go to the hospital, because there is no money to pay for the surgery. Do you think you could try to fix it?”

I am torn. I don’t want to try–I want to send this boy to the hospital, but I realize that what Sarah said is true. In Ghana, things are different. You have to pay before services are provided at the hospital and the cost is far more than most villagers can afford. I am not trained to do this procedure and I have never even seen an Achilles tendon repair. On the other hand, I certainly don’t want the boy to be crippled…he is only twelve. If I don’t help him, he will probably end up a beggar, unable to work.

I lean back, considering. When I worked in Alaska, an orthopedic consultant once suggested that I repair a lacerated hand extensor tendon myself, instead of shipping the patient to Anchorage for surgery.

“It will be retracted, and it is shiny and pearly white. If you find it, tack the two sides together, and splint it.” His words echo in my head as I ponder what to do.

“Okay, let’s start by taking a look at him, and see what the injury is.”

“Samuel. Come in.” Mary leaves the room to call the patient.

The barefoot boy rises from his seat next to his mother to walk toward the procedure room. His gait is stiff, but he doesn’t seem to be having too much trouble. I am briefly hopeful.

“Mary, I don’t think his Achilles is cut.” I’m not sure whether I am trying to convince Mary or myself. “He wouldn’t be able to walk so well if it were.”

Mary looks doubtful, but doesn’t bother to respond. She knows she is right.

Samuel approaches the exam table, and hoists himself up with painfully thin arms. His small size makes him look much younger than his age, which is common in Ghana because of poor nutrition. He remains stoically quiet and grits his teeth as his leg is jostled.

Mary speaks to the boy in Twi (pronounced Che-wee), the local tribal language. I assume she must be instructing him to lie down on the table, because he reclines onto his back. He turns over at Mary’s urging.

I pull my hair back into a ponytail to keep it out of my eyes as I lean over to look at the back of Samuel’s right leg. It is skinny, but at first glance in the poor light appears ok. There is no blood, just a one-inch horizontal laceration on the back of his calf about five inches from the heel. The wound edges are straight and well approximated. I start to relax, but then Samuel moves his foot, which causes the wound to gape. Now I have an unobstructed view of the tendon—the part of it that is still there.

My breath catches in my throat as my hopes fade. Mary is right. The distal aspect of the Achilles is clearly visible, and the proximal part is….gone. Nowhere in sight.

I realize that Mary and the nurses are watching me expectantly. What should I do? Should I try to repair it? How hard can it be? It is true that I don’t know how, but I have repaired many regular skin lacerations. Isn’t it the sort of the same thing? I guess I am better than nothing. Maybe.

“I’ll try it.” My voice sounds a little shaky to my ears, but no one else seems to notice.

Everyone seems pleased, and Mary goes to inform the boy’s mother.

I start to go through my mental checklist.

“Do we have any pain medication to give him?”

“No–we gave the last dose of codeine to the woman with the sickle cell crisis. Remember? But we do have lidocaine, and some ibuprofen he can take.”

Ibuprofen. This just keeps getting better and better. Not only am I going to try to perform this surgical repair that I don’t know how to do, but I don’t even have any pain medication for the patient!

The boy swallows his 800 mg. of ibuprofen without fuss. The nurses bustle about getting set up while we wait for the medicine to work. The boy has probably never taken any medicine at all, so maybe the ibuprofen will be more effective for him. Or maybe I am just hopeful.

I pull on my surgical gloves. That is the extent of my sterile precautions. I would like to do more, but there is no surgical scrub or disinfectant available. In Ghana, it is not even common to irrigate or soak wounds prior to repairing them. Because of this, there is a very high incidence of post-op wound infections. I have tried to encourage better technique, but except for Mary, the clinical staff is resistant. Many of them “just won’t” wear gloves, even when touching blood, despite the moderately high prevalence of AIDS. In fact, a common misconception among the public is that if a medical provider washes her hands before or after patient contact it means the clinician believes that the patient is dirty. Because of this, the patients are often offended if they observe this routine behavior. While I do try to be culturally sensitive, I am unable to forgo hand washing before and after each patient exam because of my discomfort touching anything with unwashed hands—especially with the diseases they have around here!

It is time to get started on Samuel’s leg. The ibuprofen should be working by now. The room is hot from the sun blazing through the blinds. While I appreciate the sunlight, it is making the room very hot and doesn’t even shed light on the surgical table. Sweat is dripping down my back and face, probably as much from my nerves as the heat and humidity. One of the nurses dabs my forehead and the back of my neck with a towel of questionable cleanliness. I am thankful that at least now sweat isn’t dripping into my eyes.

We position Samuel on the table, which is not adjustable. The location of the wound makes it awkward for me to work. I quickly numb the skin around the laceration. We don’t have any retractors, so I have to use clamps to lift the skin. I try to peer underneath to see if I can locate the proximal tendon. I can’t see a thing.

A crowd has gathered to watch the proceedings. Word of Samuel’s misfortune has spread. The concept of patient privacy does not exist in Ghana, and everyone knows everyone else’s business. I am used to this by now, but I could do without the chattering throng of observers. I don’t need an audience to watch me when I don’t know what I am doing.

I have never liked extending wounds, because I am always afraid that I will worsen a situation by cutting a nerve that was previously okay. However, it is obvious that I am not going to locate the proximal part of the tendon unless I have a bigger window. I open the laceration slightly, but still can’t get a good view. After several more short extensions, the laceration is big enough that I should be able to see. The nurse assisting me raises the clamps in an effort to help. Despite the sunlight in the room, it is impossible to illuminate the wound adequately. I spot my houseboy Kwajo in the watching crowd and send him to my apartment to get a flashlight.

He returns quickly, and hunches awkwardly at the end of the table to direct the beam of light into the wound. The nurse again dabs the perspiration off my forehead. I wish she would wipe my dripping back, but I am too embarrassed to ask her.

Now that I have light, I need to find this thing! The problem is that the wound is very far down on the calf, and the tendon is retracted all the way up. I am not sure what to do, so I decide just to go for it.

I steel myself, take a deep breath, and stick my hemostat into the laceration. Samuel grunts. The nurse standing near his head starts to berate him.

“Why are you yelling at him?”

“I am just telling him that he should have gone to get the water, and then he wouldn’t have this problem.”

Disbelieving, I return to the job at hand. Samuel rarely moves or makes any noise, but any signs of pain are met with more abuse. Finally, I can’t take it.

“I am sure he wishes he had gone to get the water, but now he can’t, so stop yelling at him!”

The nurses look at me, wondering what my problem is.

For two hours, I struggle to find the tendon.

“I don’t see it. I can’t find it.” I look at Mary hopelessly, discouraged. I feel terrible. It is bad enough to do this to this poor boy, but not even to be successful! I can’t stand to have it all be for naught.

“Doctor, why don’t you rest for a moment?”

“Good idea. I am sure Samuel could use a break.”

I sit back, exhausted, in the chair. Everything feels stiff–my neck and my back are kinked from the position I have been in. Samuel remains prone on the table. My brow is dabbed once again, and Kwajo holds a bottle of sterilized water to my lips. As I gulp from it thankfully, I feel like a doctor on TV, being catered to by her “staff.”  I smile briefly despite the tension I feel.

I realize everyone is watching me.

“I guess it is time to go back to work.”

I turn to Mary. “Can you ask him if he is ready?”

“He is ready,” is her grim reply. I notice she didn’t speak to Samuel.

“Could you just ask him please?”

A brief exchange in Twi ensues.

“He says he is ready to continue.”

As I take a deep breath to fortify myself, I notice Samuel doing the same. I lean over, peer into the wound and start again. Ten minutes later, I still haven’t even seen the tendon.

“I don’t know where it is. I can’t find it. I guess we should stop.” I talk to Mary over my shoulder, while I continue to gaze hopelessly into the wound. I idly poke the hemostat into Samuel’s leg one more time as I speak.

“You have done all you can, Doct..”

“WAIT! I see it!” I can hardly breathe, I am so excited.

Although I did have a brief glimpse of the tendon, it has disappeared again. However, now I am hot on the trail and that one sighting was enough to convince me not to give up.

The nurses had been chatting, but a hush falls. Everyone is alert, watching and waiting in case there is some way to help.

After a few more attempts, I pull down my hemostat, and, SUCCESS! There it is, glistening and shining in all its glory. At this moment, it is the most beautiful thing I have ever seen.

“I need a suture!”  I am afraid to look up to talk to Mary, afraid that if I take my eyes off it for a second, I will lose my grip on the tendon.

“What size would you like, Doctor?”

We aren’t ready? The suture material isn’t laid out? I can’t believe it!

“What is the strongest one we have?”

“Do you want absorbable suture, or permanent?”

I am momentarily stumped. I wish I had paid more attention in medical school to when you use what suture. It turns out that it doesn’t matter– the only strong suture we have is “0-Chromic,” which is absorbable. That’s what I’ll have to use.

This is no time to be fancy. Tightly gripping the hemostat in my left hand, I place a row of simple interrupted sutures. This brings the proximal tendon fairly close to the distal end. I don’t want to use an extra suture if I don’t need to, because Samuel will be charged per piece. However, the approximation just isn’t adequate, so I place a second, tighter row of stitches, adding as many as I can fit until it is better. NOW it can heal.

I am giddy with excitement. The heat and sitting with my head at such an awkward angle for hours have undoubtedly contributed to the feeling. I force myself to focus as I close the skin, and then sit back. I can hardly think straight, but the job isn’t done yet. I need to protect the repair.

“What can we use to splint his leg?”

Mary leaves the room to look for something appropriate, and my mind starts to race. What kind of splint do we need? I vaguely remember something about plantar flexion. Yes, it needs to stay flexed so there is no tension on the wound. The next question is for how long? I wish I had a phone to call someone and ask. But even if I had one, whom would I call? I don’t know any orthopedists. I guess, like the rest of this process, I will just have to wing it.

Mary returns with some pieces of wooden boards. I look at them dubiously.

“I have sent for the carpenters, and they will be here shortly.”

Carpenters?

Samuel is now sitting up, and while he looks somewhat pale and weak after his ordeal, he seems to have tolerated it as well as possible. I ask Kwasi, my other houseboy, to get him a drink of water while we wait for the carpenters to arrive. He grabs a scarred blue plastic mug, heads outside and scoops a cup of rainwater from the bucket.

Two boys in their early twenties enter and announce that they are the carpenters. I give them the boards Mary has provided, and pantomime how I want the splint to be angled. I am not sure it will work because the boards are only about three inches wide, but they are all we have.

The carpenters take the boards and go back to their shop to construct the splint. Samuel wobbles slightly where he is sitting. I think he is still in shock. Kwasi gives him more water to drink, and grabs his t-shirt to steady him so he doesn’t fall off the table.

After just a few minutes, the carpenters return with the splint. Unfortunately, Samuel’s foot is a bit wider than the board, and doesn’t fit well into the opening. The nurses are undeterred and push it into the splint anyway. A small piece of fabric is added to provide cushioning under the heel. I wish I had something better to use, but I don’t. We wrap some fabric around the foot and splint to hold it in place, give Samuel’s mother a dose of ibuprofen to take home, and help her load him onto her back for the long walk back into town.

I watch them head slowly down the clinic’s driveway. Samuel’s mother is tall, thin and strong from doing manual labor. Although Samuel is smaller than most boys his age in the United States, he is still heavy to be carried for any distance. The going on the uneven dirt road is slow and painful to watch.  A woman carrying a baby on her back and a thirty pound bag of rice on her head glances at the pair curiously as she passes them.

I am exhausted but exhilarated. I CANNOT BELIEVE I DID AN ACHILLES TENDON REPAIR!!! Everyone here is very matter of fact about the whole thing, but I feel like I could fly right now.

I notice that patients have gathered for the afternoon session. I try to come back down to earth as the nurses start checking them in. I smile as I watch a toddler settled onto the scale. She looks kind of nervous perched there. I am not sure if she is worried about the upcoming visit or trying not to fall off. Balancing on a bathroom scale on your butt is not easy. My grin widens as the nurse removes the patient’s tiny flip-flops so her weight will be accurate. I’m sure that the scale is not nearly that precise—the shoes weigh only a few ounces.

We continue on with the afternoon session, seeing a few sick patients and several who just wanted to be touched by “Obruni.” As we work through the routine patients, I think about Samuel. We have instructed his mother to bring him to the clinic in two days for a wound check. I am anxious to see how the injury will look at that time.

Samuel comes in for the scheduled appointments, which are uneventful. At the second visit, it becomes clear he will not be able to use the splint any longer because it has caused a two and a half inch blood blister on his heel. His foot is pretty much in the correct position at rest, so I agree to let him leave the splint off, rather than trying to fashion a different one. I remind him not to try to walk. The skin is intact and the sutures look ok. I don’t know what is going on under the skin, but hopefully the tendon is holding together and healing.

It occurs to me that Samuel’s mother has to carry him from the center of town to the clinic for each doctor’s visit, which is a long walk. I go to town frequently and it makes more sense and is easier for me to go to his home while I am already in the area. Mary and I decide to check on him on each trip into Pramkese.

Whenever we walk to town, many villagers along the way greet us. Children trail us, and people often ask for money, assuming I have money to spare. Men stop to be introduced, and after the introductions are over, they usually inform me that they are going to marry me. They don’t ask me, they just tell me. It is almost a form of greeting. “Hi, nice to meet you. I am going to marry you.” Polygamy is allowed, so they are undeterred by my pointing out that they are married. Infidelity, even among men with several wives, is rampant. This surprises me, as most Ghanaians consider themselves to be religious Christians and are regular churchgoers.

The other frequent comment is “how fat” I am. From the time I arrived in Ghana on my first trip, my weight has been cause for discussion. Being American, I was bewildered and ready to take offense at such rude remarks. However, I was assured time and again, that it is a “good thing” to be fat. It is beautiful and healthy, while being skinny is a sign of disease and/or poverty. One female patient actually requested that I prescribe steroids for her just so she could be “fat like me!” In Ghana, it is rude to comment on weight loss, as it is likely a sign that something is wrong. I did finally get used to this view by the end of my first trip to Ghana.  “Fat like you!” Are there any sweeter words?

I had forgotten about it until I was ready to return to Pramkese. I lost twenty pounds on the first trip, which caused the townspeople considerable consternation. However, I had regained the weight in the intervening two years. While packing the suitcases for my trip, it struck me that I was going to have to deal with the whole “fat” thing again, and I groaned mentally. I was not looking forward to it.

On my arrival in Pramkese, the chief of the village greeted me enthusiastically.

“You have grown more fat, and more lovely!”

So when a man by the side of the road sees me and yells “You are TOOOO fat!” I just nod, wave, and continue on my way. I know I have been paid the ultimate compliment.

Two weeks after the “accident,” I remove the sutures from the skin of Samuel’s leg. It appears to be well healed, but after having clamps on it for hours during the procedure, the integrity of the skin is in question. I am afraid to leave the sutures in any longer for fear of infection.

Two days later, as I come out of the exam room, there is a big ruckus in the waiting area. A bunch of women are shouting at someone and waving their arms. They are surrounding the object of their scorn, blocking him from my view. The crowd parts and I see Samuel sitting on the bench, looking ashamed. My heart drops.

“What happened?!”

Several people turn toward me and start to talk simultaneously. Mary holds up her hand, and everyone quiets.

“He has split open his leg again.”

“What? But…” I can’t fix it again. I just can’t. Anyway, should I? What do you do if the tendon splits a second time? I don’t know!

My mind races, but I remain outwardly calm.

“Let’s take a look at his leg.” My heart is pounding furiously.

The gathered crowd parts briefly to let me through, and immediately closes back so tightly that I feel the heat from their bodies as I kneel at Samuel’s feet. I crane to look over my shoulder at Mary who is standing behind me.

“How did it happen?”

“Apparently Samuel was hopping out to the public toilet, and he slipped. There is no toilet in his home, you know.”

I lift the leg up, and twist my neck to see the back of the calf. The crowd is quiet, waiting for the verdict.

“It’s okay.”

The relief of the observers is palpable, but selfishly I am almost as pleased for myself as I am for Samuel. I just couldn’t face trying to redo my work. The split skin provides a lovely view of the INTACT, reconstructed Achilles tendon.

“It’s okay,” I reiterate. “The skin is open because it was dead after hours with those clamps on, but the tendon is still together. If we close the skin, it should be fine.”

I stand up to go get some steri-strips. It’s lucky that I brought some with me. The skin won’t tolerate resuturing.

Once the steri-strips are in place, Samuel climbs onto his mother’s back, piggyback style. She sighs as she accepts her burden, and they set off back to town.

There are no further mishaps with the wound. Mary and I continue checking on Samuel every time we go into Pramkese. The leg heals well without signs of infection, probably thanks to the antibiotics I brought from the USA.

Two days before I am leaving to return to home, I decide that it is time to start Samuel walking. It has been almost four weeks since the “accident.” I don’t know how long is usual to wait after tendon repair but I am afraid Samuel may end up crippled if he waits too long. Intellectually, I know that it is unlikely that a twelve-year-old boy would end up with an ankle contracture from lack of use, but this is my first Achilles repair and I am nervous.

Mary and I start off on our customary path to Samuel’s house. We chat idly on the way, but I am distracted. What if it is too soon? What if the tendon splits open? I really hope this is the right thing to do.

On our arrival, Samuel’s mother greets us enthusiastically. We decline her offer of food or drink; I am too eager to see Samuel. He hops out to greet us, followed by an array of giggling neighborhood children.

He smiles broadly as he sees us. He has finally gotten over his shyness with me.

“Hello, Doctor!” He turns to Mary, and speaks quickly in Twi.

She translates. “Do I start to walk today?”

“Yes.” I nod to him. “Today is the day. Are you ready?”

Mary repeats my question in Twi. Samuel looks at me and nods vigorously.

“Okay. Let’s get started.”

We review that he will take just a few steps and stop if he feels any sharp pain. He is to walk slowly.

Samuel stands up and gingerly rests his heel on the ground for the first time in a month. He tentatively leans to the right, putting more weight on his leg. He turns to look over his shoulder at us. He grins and gives the “thumbs up” sign.

He carefully leans forward, stepping onto his left leg. His right leg comes off the ground before the ankle flexes. As the right foot comes back down, my pulse goes up. I hope that Achilles tendon is okay!

Samuel is walking but it looks odd. I am not sure exactly what is wrong. I stare at him curiously until I realize what it is. The ankle is very tight; he doesn’t dorsiflex it at all. The leg and foot remain at a ninety-degree angle.

“Mary, tell him to bend his knee when he walks.”

He thinks about that for a minute. He steps forward, stops for a second, then bends his knee in an odd bobbing fashion. As he takes his next tentative step, he turns to look at me for confirmation that he is doing it correctly. His gait is certainly strange, but maybe that is the best he can do right now. I nod encouragingly.

Samuel tries it again, walking in a wandering line, continuing with his peculiar bouncy step. His loose, torn grey shirt flaps in the slight breeze. I glance briefly at his mother, who is beaming. The gathered children start to clap excitedly. As I watch Samuel’s proud progress, I think my smile matches his. I am thrilled and satisfied. This time, I made a difference.