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?

The Agony of a Medical Intern

Koven Cottage. It’s a chilled Saturday evening. The Karen skies are calm and azure. Tall indigenous trees give this place a rather scenic look. It seems so distant from the concrete jungle that is Nairobi, yet it is barely an hour’s drive from city center. I get into this compound and a sign of Mbwa kali greets me at the gate, stirring a little fear in me. I have an innate fear of fierce dogs like Bruno and Pablo, those dogs that bite flesh like cannibals. My dog is called Sibuor and that’s how we end the story of dogs.  The place is beautiful. An old rugged house stands in the middle of the compound and chairs are scattered outside. The look is rustic with art all around. What the human body cant say in words, it expresses profoundly in art.

Good vibes only
The scene
Mbwa kali

Beyond the stethoscope was holding an event for doctors, dentists, and pharmacists. If you didn’t know,  Beyond the stethoscope is a safe space for medical practitioners, dentists, and pharmacists where we learn soft skills that medical school never taught us. Talk of investments, taxes, tech, and everything that we need to catch up with. Opportunities available in both clinical and non-clinical areas are also shared on the platform.

A bright smile welcomes me to this place. It is Dr. Amakove. Amakove Wala – the founder and CEO of Wanderlust Diaries and Beyond The Stethoscope.  We are here to talk as doctors. You know those fireside chats that you wished you had while growing up, those are the chats we went to have. We went to validate our existence, to remind each other that we can never be more human than we already are.

We go into medicine without ever getting into terms with the fact that medicine has its unique set of challenges that only we doctors can solve. Nobody told us of the toxic work environment that awaited us upon graduation. While there are a handful of people committed to making the profession better, there are those that move in the opposite direction. They are the ones that hold us back. They are the ones who are sinking this ship.

The issue of Internships for doctors arose. Internship remains a fundamental part of our training. Unfortunately, it’s from here that we learn the worst traits that will haunt us for eternity. Training doesn’t have to be arduous and uninspiring as it stands in most internship centers. A 2015 Kenyan study highlighted lack of adequate supervision, inadequate social support, lack of mentorship, and inadequate clinical resources as the major challenges that the Kenyan medical intern grapples with. There seems to be no intent to tackle these problems. We will not be able to deal with the consequences.

Meet Dr. Joy. Joy is not her real name. She just finished her internship a few months ago. She interned somewhere in Kiambu.

“How was it like to be on call  Daktari?” I ask, staring blankly at her beautiful face. She painted her lips red and had a white top and blue jeans that fitted nicely. She belonged to the red carpet!

“It was hell, doc. We did long hours as junior doctors with poor working conditions, something that I don’t wish for even my worst enemies. We had only two beds in our call room. At any given time there were four interns on call, so we literally had to share the beds.”

“What if you were the only girl on call that night?” I ask with an air of shyness.

“It didn’t matter, you just had to find a way around with sleep.’ It was evident that the system was failing to take care of its own.

“What was your worst call?”

“It was on a Sunday. There was a road carnage along Thika Road that had claimed so many lives. The survivors were brought to our hospital for care. I had very sick patients some of whom required emergency surgeries. I decided to contact my seniors to see how we can go about this. I had more than ten injured patients. The second on-call picked his phone and said he is not coming. The consultant was unreachable. That night I  lost a boy that could have been saved. I don’t remember the rest. I mean, I don’t want to remember…” she smiled graciously, her eyes rolling sharply away from my gaze. She had been through it all. The worst possible night that you would ever get right after campus. No guidance. No nothing. It’s just you and your inexperienced guts. All these happen despite the fact that research consistently shows that poor communication among health professionals may lead to life-threatening complications.

“How was your relationship with your consultants?”

“Some of my consultants were so good, they taught me well. Then there are those that you never forget of course, because of the agony they put you through. I once forgot to add one more patient to the theatre list, the surgeon told me in a condenscending manner that the only thing I can’t forget is to do my nails. I remember it was his fault that the theatre list was not made in time. He submitted the name last after everyone else had been included.  I didn’t like those vibes, you know, when you are all bubbly and then someone shuts you up with those statements, your day is totally ruined.”

People have not yet streamed and so we still have some more time to talk.

We are joined by Dr. Juliana. Again, not her real name.

The wind drifts slowly in our direction carrying along with it the aroma of smoked pork ribs that is slow cooking at the smoker. The smell of the food stimulated my appetite centers making my mouth drip with saliva.

“Wassup Doc!” Joy and I muttered. The beauty of medicine is that sometimes you can get away with not knowing your colleague’s name. You just say Duck. Hi Duck.

Dr. Juliana is tall, so tall that my head literally rests on her shoulder when we stand side to side. She is fair-skinned and bubbly.  She came with a glass of water in one hand and her bag in the other. “Hey peeps, let me take my drugs, and then we can chill…” She says excitedly. As she was trying to close her bag, a packet of drugs fell to the ground. She could not easily bend to pick the drugs because the other hand had a glass of water. So I bent to pick the drugs for her. Fludac was the name on the packet. Fludac is a drug used in the treatment of depression.

“What is your internship experience doc?” Joy asks.

” Internship has been the most alienating and isolating period of my life. There is this culture where interns are seen as inanimate objects to get things done without any objection. There is constant pressure, unsupportive seniors, outrageous call hours, and sleep deprivation. Generally, there is no compassion or any form of emotional intelligence when dealing with interns. Everybody yells, ‘Where is the intern?’ instead of , ‘How is the intern?'”

She recounted her harrowing experience tears welling up her eyes.

“How do you cope Daktari?”  I asked her.

Silence.

“Well, I have learnt to be my own advocate. It is crystal clear that nobody gives a damn about interns. So whenever I feel like the center cannot hold, I take a break much to the chagrin of my seniors; which really doesnt move me because I know none of those *** will do more than contribute a measley 2k for my funeral when the work finally kills me. And my epitaph wont read ‘The best intern.'” Her voice is becoming heavy. I lean in to listen to more of what she has to say.

“The mistreatment of interns is often sanitized by statements like, ‘Its just one year, jikaze, umalize na uende. 365 days of agony and abuse hiding under the veil of learning. When you come out at the other end, you are a survivor and now you have the power to perpetuate the never ending cycle of violence, vehemence and abuse. This should not be the norm. A profession tasked with restoring health could contain so much sickness. Tragic.”

She tells us how she tried changing internship centers several times and failed at every attempt. There is a guy in the council who always wanted money from her. He kept her going round and round without anything ever materializing. That has always been the story with the council. There are people there who take advantage of the desperate situation that interns find themselves in. You must pay them to have you sorted. Unfortunate. We shall revisit.

Our chatting is suddenly brought to a stop when a sonorous voice welcomes us for the sumptuous lunch that followed. There was food and pomp and glory. There was no milk or honey, yet this was paradise.

Yummy!

Doctors, we must come to the round table and initiate difficult conversations of change. We must stand up for the profession. Again, we cant approach the problem by saying that there are a few other good people. The culture we have created is that of competition and intimidation. We young doctors are left to wander in murky and muddy waters, with no maps and no guides.

The bonfire

By any means, we are not complaining. We still want to follow the dreams we read in Gifted Hands. Growth, mentorship, and supportive environments are all we ask for.  If you can not give these then at least, do no harm. That is our cri de couer.

Laughter, the missing prescription

Photo credits: Instagram

Disclaimer: The name herein has been changed. I have just used herein in a sentence! Law school- express.

I will never tire of saying how nature is the most unfair referee. She will bet against you, with odds of up to ten. Be damn! Ten f*cking odds, all against you! Tragedy is a frequent visitor to some of us more than others. It is not uncommon to lose your job and child simultaneously. Nature doesn’t give a shit that you wake up every day and pray. She bids carelessly. In dangerous Casinos of the universe. John was on the losing end. Nature 7-0 John, 5 minutes added time.


I would meet John again in ward 4, the male orthopedic ward. He had broken his bones again, barely three months after we had discharged him. In the previous admission, we put a total of 5 implants in an operation that lasted 7 hours. One implant went to the left thigh, another one to the right knee, the remaining three ended up in his right forearm. And by the way, implants are metals used to fix bones.

Orthopedics is a rather chilled rotation. All you need is an X-ray and an implant, then they are good to go. John had none of those at that time. So he was on the long waiting list for theatre later that week. I was rotating in medicine. I had been called by ortho to go and adjust some insulin dose of some old gentleman in the acute room. That is when I met John again. “Daktari, habari gani? Nilivunjika tena kwa accident,” he said smiling warmly. “Pole kwa maumivu,” I felt sorry for him. He was a man loved by misery.

I loved John. He was street smart. I felt like he was my doppelganger, only that he is a full-time street man, and I left the streets at halftime. He is playing not to lose; I am playing to win. He had developed an ingenious way of making money in his last admission. He sold marijuana to the patients he was sharing the ward with. You could see a patient with severe pain go out behind the ward, comes back, laughs a lot, and lulls himself to sleep. Patients in my ward slept like they didn’t have fractured bones. My consultant sometimes checked my treatment sheet to confirm that I was not overdosing patients on painkillers.


The people in his cube were very fond of me, as was I. I remember a day when they all covered their faces with blankets. All of them, including those with significant fractures. When I got to the cube and called out one of them, they all burst out laughing. You know that game that kids play where they cover their heads when an adult sees them. That one. Another laughter emanated from behind the ward. “Hahaha!’ the laughter got louder and louder and louder. John never laughed haha like everyone else. He laughed ‘kithikithi,’ sticking his tongue out, raising his eyebrows, and moving his shoulder up and down quickly. The way you do when you laugh with your friends. He had given a bolus dose of his drug. The secret drug that was not in the treatment sheet.


As John waits to be operated on, I look forward to the happiness he brought into the wards. I long for the laughter that punctuated his stay with us. I miss ortho. There was never a dull day till we discharged him. John, the doctor with the other prescription, reminded me of the simplicity of our existence. It is always the moment that counts. Carpe momentum!

Letting go…

A melanocytic nevus.

I have never had to use the doctor’s room in my ward. Mostly because I never get time to sit down. I am constantly on my toes reviewing a patient or following up with surgery to review their patients who were erroneously admitted to our ward. Ward 3, Female Medical. It’s always tricky dealing with surgery, you all know. They are never commital.

I got into the doctor’s room. Jane, not her real name, was already seated. I had asked her to go in before me as I was finishing a bedside chest tube insertion. She was plump. The kind of plump that is motherly. The kind that you don’t body shame. Probably this was from the many children she had born and bred. She looked exactly like my mother except that she was brown with a conspicuous black dot that stood on her left cheek like a square peg on a round hole. If you zoomed closely, probably you would see some hair coming off the black thing. It’s called a melanocytic nevus. I love the grandeur of Latin. I later learned from our talk that she is an accountant; she didn’t tell me where, but probably with KPMG or Deloitte or one of those monster companies that rake in billions as annual profits.

The atmosphere is tense. Tense and grim. Jane tells me that Juliet is her sister. Juliet is not her real name. Sister from the same womb and balls. The sister you are born and grow with. The one you play hide and seek with. Jane is the big sister. Their mother went to be with the Lord when they were young. The father died of cancer soon after. “Cancer of the throat,” she said. Since then, she has assumed the role of a mother and a father to her little siblings. Being a hard-working woman, she was able to put them through school. She struggled a little, but her siblings went all the way through to the university. She talked like a proud parent, except her eyes were heavy with tears.

“Daktari, I have spent 5 million on my sister’s treatment. She has had countless surgeries. I am tired. I don’t know what else I can do.” Really, there was nothing else she could do or could have done differently. Her sister had been admitted to our unit with an infection. An infection only because the white cells were elevated. Sometimes an elevated white cell count doesn’t mean anything, really. She had lung cancer. Stage IV. With spread to the brain. Now she was mute. The only thing that bore semblance to living was how she closed her eyes when flies landed on them, a primitive brainstem reflex. She was only thirty-seven. Her body was failing her. She had bought a home, and a nice small car like all serious thirty-seven-year-olds do as they anticipate the beginning of life at forty. In her wisdom or lack of, nature was misordering her death. Why not the ninety-two-year-old with stroke in ward 4? In life, you never ask why not. Life has no Fairplay. It beats you when you are at the heart of the game. She had coughed up blood until she could cough no more. The cancer cells had probably depressed the brain’s cough centers. Mortality was imminent. I wonder what people see when they are about to die. Folks, Is it white light that people see? Is it blinding or calming?

A wall separated us from the agony of Juliet.

“You have done your best; there is nothing more you can do. We can’t do much either,” I say to Jane, feeling a little embarrassed. Is that not what we all do to our loved ones? We treat them all the way to death. As a doctor, we must always do something. In her sister’s case, I would probably put her on a short course of antibiotics and call the cancer team to come ‘poison’ her with chemo or radio. I resisted the temptation. It was time for a drug holiday.

The silence that ensued between us was uncomfortably dense. Jane’s tears rolled down her cheeks and then over the black thing to the table that was between us. I got a chance to scan the room again as a means to escape her gaze. The room was disorganized. Unused tubes, catheters, and drugs littered the floor. I sat on a creaky chair close to the door. She occupied the bench on the opposite side. One side of the bench was supported by a carton holding fluids. It was a clear depiction of the appalling state of our public health system. This was the place I was meant to be holding family conferences. I thank God I never had to do it there.

“What do I do, Doc? ” she now burst into a loud cry. She was talking to me like a friend. I realized that because of how she turned her head in a way that people don’t do in a doctor’s office. I felt so sorry for her in those moments. ” Perhaps, you should let go,” I said. I thought she would jerk and stop crying and look at me suddenly. She did not. I don’t know whether I was brutal, but I tried to the best of my ability to let her know the truth. Life was on its way out; it was just a matter of time. Hope is bad. It fuels rage.

I don’t know how long we sat in there, but we agreed that Juliet would not undergo any chemo or radio when we came out. That she would go home with her and watch her die in their home, in a warm blanket, with the aroma of roasted coffee and caring hearts. Jane said that together with her family, they would sing her Christmas carols in the dead of night and early in the morning. She took comfort knowing that even if her sister was not talking, she could see. Do you ever wonder how it is to live in silence? Maybe we should be grateful for the functional state we enjoy. Maybe life is one big pyramid scheme, and you never know when it will crumble.

This holiday season should remind us of how and when to let go. Letting go opens many possibilities; it gives us a chance to die at home with dignity, away from tubes, catheters, fluids, and an overworked medical intern. It also reminds us that the cure of a disease does not have to be more grievous than its endurance. Merry Christmas!