Fit to Plead

Photo Credits: Instagram

There is a section in the Kenyan law that provides for persons accused of Capital offenses to be seen by a psychiatrist to assess their fitness to plead. That law protects psychiatric patients from being tried when not in a fully functional state. Patients with debilitating mental illnesses cannot plead in a court of law. Dear readers, this is one subject that has baffled me as a doctor. The mental acuity to stand a trial.


Maundu* would be referred to us from a nearby remand for a mental assessment. We had our forensic psychiatry clinic that day, and so our clients were those who had found themselves in conflict with the law. He had been charged with second-degree murder. The details, he says, are a little hazy. Still, he remembers finding a man, deep in pleasure with his wife at their matrimonial bed. He was hurt. The man escaped by a whisker, and consequently, his wife got a lethal stab in the chest to quell his gladiatorial anger. The knife must have found the heart because Maundu says, “It was all red, I know no amount of medical prowess that could repair such a wounded heart.”


Maundu was a jua kali artisan. He made jikos and metal boxes for form one students. He tells me how he was a happy man when he came back from work on that fateful day. Then when he got home, he found the living room in a bizarre state. The room was cluttered, with clothes strewn all over. A man knows his sitting room just like Dr. Mokaya knows the labor ward. His wife did not respond to his sweet nothings, and the door was wide ajar. The man had left his open shoes at the entrance, big open shoes.


His wife was moaning in ultimate pleasure when he stormed into their bedroom, breaking Maundu’s heart into small pieces. A fight ensued, and the estranged man clutched his clothes and fled. Then anger filled Maundu’s heart, and the next thing he went for was the kitchen knife, straight from a local grinder. “It was sharp; that’s all I remember,” he says with a trembling voice and teary eyes. He was well built with fat cheeks. The tears from his eyes flowed freely in the crevices that formed on his wrinkled face when he was crying.


“With pain and anger, I took her life,” He lets a sharp, wry cry that would have me look aside to avoid his gaze. It takes a man, to know a broken man. Moments change lives. He had lost it that night, and his life was about to drastically worsen. I imagined the day of the jury’s final verdict. The heavy voice of a drunk magistrate would burrow into his heart, tearing it into pieces.


His speech is coherent, and he does not seem like someone with a psychiatric problem. He is well-kempt with appropriate behaviour, befitting a dutiful citizen in any republic, anywhere in the world.


“Do you ever see or hear people or things that other people do not see or hear? ” I asked


“No; I just don’t know what happened that day,” he says.


“Do you use any substances of abuse?”


“No, I don’t. I only drink occasionally.”


Then he tells me of the beautiful times he shared with his wife, from the courtship years a decade ago, all to the events that led to her tragic demise.


“I met my wife when I was a young man; I loved her with all that I am.”


“And then what happened?”


“Anger descended on me, why did she decide to give herself to another man? I felt betrayed. When I picked up that knife, I found myself in the police cell. That is where I put into perspective what had happened.” He says, staring at two flies mating on the bench in front of us. The male fly was too brief. Maundu had made friends with the officer who brought him, and therefore, the officer immediately granted his wishes when he requested his hands be freed so that he scratched his back. I didn’t think he would jump at me with violence, and therefore I did not move an inch. Not a flinch.


My mental assessment did not reveal any signs of mental disease. Maundu talked normally, behaved normally, felt about the situation in the way that an average person would: His judgment was reasonable, and his memory was above average. “But, what about the grief and the remorse?” I asked myself as I was concluding my assessment. “Is he really fit to stand a trial with all the heaviness in his heart?” I didn’t know about this.
“Fit to plead,” my notes read.

*not his real name. The identifying clinical details and identifying information in this story have been changed to protect the identity of those involved.

It’s all a show!

Its storytelling time

In the extremes of my imaginations, I have imagined myself a full-time writer and a part-time doctor. I want to walk the world and search for my truths and those of others. Only by listening and telling stories do we ever get to deeply connect with others. It is by the conversations we stimulate, do we ever get to know the core of the people we interact with. Most importantly, I would love to follow stories of compassion, stories of grit and bravery, and sometimes stories of anger, angst, grief, and pain. For life, is an oscillation between emotions of happiness and sadness.

A few weeks ago a bunch of us became buddies. 5 friends. A young doctor that is me, is always the convener, young, no money, no anything, just ideas. Then there is a very happily married man, this one tells us the morality of our decision-making, every time we meet together. The guy we always go to when things are thick. We shall call him Sammy, he is 35. The third person is a single lady, a respected gynecologist at a thriving private practice in town, recently graduated with a master’s, she is 32.

The fourth is an Engineer from Kitale, he wins a lot of business county tenders that guy, Joseph is his name, a shrewd investor, 64 and not so happily married. He has lost it all and rebuilt from scratch.  He reminds us of how to pick up in life at our lowest.

Then there is a tiny college girl that found herself in our circle. Her name is Dorah, she is 23. She does some social media work for Sammy. That’s how I got to know her. Once in a while, we call her for a little office work here and there to help her get money through college. By the way, Sammy is an IT guy. As men in this clique, we held a WhatsApp crisis meeting and said there is no chewing anyone in the club and we were serious that we want to be proper friends. Folks, these are new friendships that I am building intentionally. I told them, we want to have candid conversations about life, but we mostly want to savor life. Most of it through telling our stories. For the stories that we cant tell, may we have the willingness to forgive ourselves and treat our failures, guilts, and shame with compassion.

Stay tuned at The Doctor On Call, and let’s see life from the perspective of 5 of my friends. Most entries will however remain the diary of a junior doctor, just some little dessert on top of the usual drama that is the life of a doctor.

That will form the foundation of The Doctor On Call, telling stories of the comedy that is life, from the perspective of my newly found friends and I. Immerse yourself and follow. It’s all a show!

Remembering my Cadaver

Human anatomy laboratory, UoN. Photo credits: Internet

Table 9 is directly in front of you when you enter the Human Anatomy Lab. One table, then table 9. I loved table 9 because I could easily peep when Prof Saidi (Rest in power) was coming, Saidi, or Dr. Beda. Table 9 also gave you another advantage; you got access to fresh air from the wide door and the air conditioner behind us. You needed the fresh air because you could easily choke under the heavy stench of formalin, a substance used to preserve dead bodies for us geeks to cut. Typically, formalin is pumped into the femoral artery, midway between where the torso gives way to the thighs. Then on the neck of the cadaver, you would find another cut with a hurried stitch on it; another route for formalin infusion. I guess you need copious amounts of the chemical to preserve the brain.

We were in group B, so we dissected on Wednesdays and Thursdays. People from group A thought they were God’s lastborns because they dissected on Mondays and Tuesdays with kina orthopedic and neurosurgery residents. And these residents took them for lunch; they had money, good cars, and big dreams of becoming surgeons. I remember once reading a golden name tag ‘Dr. Dave Mangar, Neurosurgery. ‘ Oh, how I admired that chap.

Even dental guys dissected with group A people. And folks, dental guys brag like hell. You would think those people breathe the ozone layer. Kwanza, if you go to their school, opposite Nairobi Hospital, you see some beautiful petite brunette babes in blue scrubs wiggling around. You know those babes that you don’t want to open your mouth in front of because you fear they might find the smell of your breath repulsive? Those are the babes you meet in dental school. For this reason, my dental problems are sorted by Dr. Naph Macharia, a fantastic dentist we went to school with. He now pokes teeth at VIP Dental Suite, Allamano Center, off Waiyaki Way. If you go there, pass my regards, tell him you know The Doctor On Call.

On Wednesdays, the dissection would begin at eleven, after Prof Nguu’s class of orbitals and Schrodinger. That is the most complex content I have ever had to master in the last decade. Nguu’s orbitals. We would begin our dissection by carrying our cadaver, lifting it on top of the table, and then removing the one on top and putting it down. The one on top was for group A. When you forgot and started dissecting their body, you would find it a little strange. You would feel that that is not your cadaver because you never forget your cadaver when you are in your first year. Our cadaver had a characteristic look that I couldn’t easily forget. His face dried on one side and his neck was stiff and inclined to the right. Probably the person who embalmed him didn’t care to return him to a neutral position. He had a dent on his forehead with a blue nylon stitch. His eyeballs sunk defiantly in their sockets, and his eyelids were half-mast. We named him Eugene. Me and Priyanka, now Dr. Priyanka. He was not as big as the corpse of table 13, who must have been a bodybuilder back then in life. You never missed a muscle on that man. Talk of a rare variation, he had it.

I was the chief dissector at our table. Sometimes I did separate the muscles nicely, but sometimes I inadvertently chopped them without any clear discernment. Mungai’s dissector is sometimes not so easy to follow, you know. It will give you instructions for going to Kisumu, and you would turn the other way and go to Muranga, then call Muranga Kisumu. Whenever muscles are separated nicely, like Innocent did when dissecting the leg, the human body becomes a work of art, a masterpiece. Check Gunther Von Hagen’s body worlds on YouTube if you think I am lying.

There was a guy in group B whose name eludes me. He was so artistic with his dissection that he defined the femoral triangle so well that us mortals were called to marvel at it. The arteries, veins, and nerves, perfectly outlined. I don’t know what became of the guy, and I never saw him again after the first year.

The late Prof Saidi would come a few minutes past five when the Chiromo clouds had started gathering above us and darkness slowly setting. He came adorned in a well-pressed designer suit and a well-fitting tie. Mostly a red tie. His relaxed demeanor was befitting of a proper professor. His hands were enormous, and I particularly loved how he moved them when he pointed at a structure.

“What is this?” He would ask.

“The superior colliculi, ” one of us would retort.

“And this?”

“The anterior perforating substance, “I would answer, feeling a little clever.

Then he said “Good!” and moved to the following table. He always ensured that he said ‘good’ in a way that made you feel you know anatomy. Oh, how he loved evolutionary anatomy, a subject that he preserved for Wambua, now Dr. Wambua. Wambua taught us with unparalleled enthusiasm, but he mostly talked about the hard things. You know a man is not entirely normal if he can have a ten-minute conversation about the periaqueductal grey. He now has a youtube channel where he teaches people human anatomy.

Dr. Beda would come slightly after Prof. He would tell us how we did not do so well in the Marathon CAT. We didn’t do well, yes, but Koki did well. Dr. Koki, by far, is the most brilliant human being alive after Elon Musk. That girl knew anatomy like the back of her hands. Who gets a 90 in anatomy? Collo and I were mostly in the 60s, on a bad day 54, and we were comfortable there. If we aimed any higher, we probably would have given up our long daily walks to Klabu, seducing Main Campus girls. Collo, an aspiring eye surgeon, now works as a doctor in Kisumu.

I would leave table 9 shortly before 8pm. Priyanka and Mursal would be the last to leave, and then they would ensure our Eugene is well covered with plastic wrapping to prevent him from drying up. That is when I would call back my mother on my way to Klabu.

We pray that the UoN post-graduate fees remain affordable because the ground is unsettling for us young doctors, stable jobs are hard to come by, governors are giving lousy contracts, locums are becoming fewer. I yearn to go back to table 9, Dr. Kiaye Oliver, Ear Nose, and Throat Surgery. Yes, ENT. Deal with it.

A torn Vena Cava

Graphics by Sheldon Kahiga

An abdominal scan showed that Syombua* had free fluid in her abdomen. She had been involved in a grizzly road accident that claimed the lives of two others. Syombua made it here just in time to create drama that had never been witnessed before in the many years of existence of our hospital. When you have been around in medicine for some time, you kind of know the kind of patients you need to treat with utmost urgency and those that you can buy some time. It is a survival trick that has kept me afloat as a medical intern. Syombua was to be treated as an emergency.

I informed the surgery resident of the ‘bad case’ we were about to have and went straight to the theatre. With emergency operations such as the one Syombua was scheduled for, you don’t want to be the one delaying the operation. Again as a junior doctor, if you lack some semblance of urgency in you, people might be tempted to think that you are not a good doctor.

“Skin incision time, 5pm, ” I said as I reached out to the diathermy on a tray across the patient. Getting into the abdomen was becoming a favorite habit of mine. The abdomen that whets my surgical appetite remains that of a 21-year-old petite lady with an ectopic pregnancy. If you are meticulous, you can operate on such an abdomen with textbook precision, word by word, step by step.

Syombua was undergoing an explorative laparotomy, an operation that involves ‘blindly’ going into the abdomen and dealing with problems you find in there. Such an operation becomes so unpredictable because everything you do will depend on what you find. The plot only thickens when you don’t find anything or when you find a problem bigger than your capacity to solve. Often times it is the latter that will haunt you the most.

A gush of clotted blood confirmed our entry into the abdomen. I peeped a little at the vital signs on the monitor a few inches close to the head of the patient and immediately knew we had no chance at life whatsoever. Yes, we could go look around and solve the problem, but evidently,  we could not make it in time for the return journey. As the clots were falling apart, the blood pressure was also dropping ruthlessly. 32/20 mmHg was the last reading my brain recorded. That was severely low blood pressure. The monitors were beeping endlessly, sending a few chills down the spines in theatre, including the one on the table. The last place you want someone dead is on the operating table. This is the nightmare of every surgeon. It is career-changing for a junior doctor.

The surgical resident had kept the consultant on call on the loop. He had even told him to get on his way just in case we got stuck along the way. I was the primary surgeon at the start of that operation but I ended up on the assistant’s side as the drama continued to unfold.

Having sensed that things were taking a turn for the worse, the resident instructed one of the nurses to call the big man and ask him how far away he was. The big man said he is on his way. That’s 45 minutes if he uses Southern bypass to get to the hospital.  Meanwhile, we needed to figure out what was happening in this abdomen.

The torrid stench of poop that emanated from the damaged intestines didn’t seem to bother us. The liver featured prominently on the right side of the abdomen. Of all the livers I had seen and touched, this one was unusually pale and mottled. It had no injuries, nonetheless. The spleen was equally intact. These two organs are notorious for bleeding in accident victims.  The intestines had multiple injuries, so severe but not severe enough to create that dam of blood that was staring coldly at us. “Doc, hebu tuangalie the retroperitoneum,” the resident said in our quest to find the bleeding culprit. As I pulled the intestines gently out of our way, some thick watery fecal matter jetted out from one of the loops, staining my mask before some settled into the abdomen to add to the mess. “F*ck! Get me another mask please!” I said with urgency, hurting under the smell of poop. The student on the call with us was gracious enough to be of help to me. I heaved with a sigh of relief and thanked the student countless times as I refocused on the operation.

The retroperitoneum is the space between the intestines and the back. It has large vessels in the body. An injury to this region can be very unforgiving. Bleeds are torrential, intestines are stubborn and visibility is oftentimes limited. This is the valley of the shadow of death, a playground only for the most experienced in the trade.

Syombua’s vena cava was torn, almost dividing into two.  It bled slowly but steadily, life ebbing away along with it, like a satisfied child slowly drifts to sleep at the sound of a lullaby. You should have seen the despair written on our faces when we saw this. Every time we tried to control the bleeding, it almost always came back to us with more zeal and rage, like the Victoria Falls on River Zambezi. The die was cast. Everybody around was not convinced that we could lose someone after trying that much.

The consultant arrived in theatre not so long after the phone call. He didn’t have his personal scrubs and so he looked funny in those single-use hospital scrubs.  “Daktari, wachana na matumbo kuja ufanye compressions!” He shouted looking to my side. I knew we had no chance at all, no matter what. I begrudgingly climbed onto the stool on the side of the bed and started the compressions. I positioned myself comfortably because I didn’t how long I would be standing there, clutching at the straws.

“Get me some intracardiac adrenaline!” The big man gave instructions. He meant that the adrenaline was to be injected directly into the heart to try to jumpstart it. I had never heard of such a move before. “Sir, we no longer give that according to current literature,” the anesthetist replied with some sternness we had never witnessed before in theatre. “Leta nijiwekee, ” the big man retorted, grabbing a syringe of adrenaline into his hands. He pushed me aside a little and then fixed a long needle onto the syringe and injected the heart. A pulseless electrical activity appeared a little on the ECG tracing and the whole line became straight. The tension between the surgeon and the anesthetist was piling and every time the surgeon talked, he avoided the eyes of the anesthetist. Basically, it had got to the point of kuvumiliana.

I was getting tired of the compressions. I asked one of the nurses to help me so that I could gather some more energy for this exercise in futility. Syombua continued to lie calmly on the table, unperturbed by our ambitions. Her pupils were fixed and dilated. The coldness of the theatre, as well as that of death, had slowly crept into her body. The consultant surgeon stood still behind our backs, still in disbelief that the worst had unfolded right before his eyes.

8pm. With fallen shoulders, we closed Syombua’s abdomen with the same dexterity we would have accorded her in life. And just like that, she crossed over to the other side. The theatre retreated back to silence. The hooting of matatu across the road was now becoming louder. The life around was moving as it would on an ordinary day.

“Patient arrested in theatre. Cause of death – Multiple organ failure due to massive blood loss,” my operation notes read.

* not her real name

Secrets

Photo credits: Instagram

I don’t know what Sophie (not her real name) wanted to tell her son that she had not said her whole life. She waved at me and asked me to see her on the day we talked about this. I went to her and checked that her wound was not bleeding and that she was alright. She was doing the first postoperative day after a guillotine amputation, an operation that involves cutting the limbs and leaving a raw stump. It is usually performed in severe contamination or infection. The stump is closed at a later date when the wound has formed healthy tissue. Sophie had a stump on her left leg that was not healing; the leg had been cut in a piecemeal manner that it was now getting to the torso. She kept getting infections every so often that we could not close her wound.

High blood sugars in Sophie’s blood prevented the wound from healing. When she called me that day, it was never about the wound. “Daktari, kama nitakufa wewe niambie, usinifiche,” she said, laughing with mockery. She only laughed because she wanted to sound polite. Otherwise, from her face, she meant every word of her statement. “Kuna kitu nataka kuambia kijana yangu kabla niwachane na dunia,” she added, her eyes welling with tears.

Sophie was happiest when she was with her son. You could see them talking, laughing, and embracing each other whenever they got the chance to meet. On a typical day, she kept to herself and had this sort of melancholia around her, constantly worrying me. I am pretty sure that she would have given up everything if only we could restore her back to health. How I wish we could afford to give her whatever she desired.

I did my ward rounds the whole of that week without anything suspicious ever drawing my attention to her. She ate and drank without any challenges, and she laughed loudly whenever her son came to see her. These brief moments of vulnerability brightened my days and reminded me of the beauty of medicine. Meanwhile,her stump was healing well.

On my last Saturday in the surgical department, I was alerted to the heartbreaking news that Sophie hadn’t made it through the previous night. She had developed sudden onset difficulty breathing and ended up in the ICU, where a scan revealed a large blood clot in her lungs. She had yet undergone another surgery to close the stump. There was no chance of recovery from the critical state in which she was. She hungered for air and passed on on a cold Saturday morning, with tubes all over her frail body and a heart with a big secret.

Sophie had asked to be warned of such an eventuality. How could we have known?