Post Exposure Prophylaxis

I wanted to hate that guy. I would have loved to hate that guy. How do you just bump into a consultation room without being called? You know it is unethical, it is lack of courtesy. He looked like the one who knew little about etiquette. I later realized that he was called Omondi (not his real name), Omondi from Homabay. Had he arrived a minute or so earlier, he would have found us examining the breast of a fairly young lady that came in with a lump in the right breast and was very worried. Luckily for her, we had finished the examination and she was dressing up.

Omondi  waited patiently outside till we finished with the lady. Then he got in without waiting for his name to be called. Did we throw courtesy to the jackals? Fortunately, he was next in line. He was a well built man, approximately six feet tall and dark in color. I don’t want to comment on whether he was handsome or not, I just want to tell his story. One thing that I was sure of, Omondi was not sick.

His card was marked very urgent, so we decided to deal with it with the urgency it deserved. I was to have my clinical exams very soon, so the doctor asked me to take the history and present it in a coherent way so that I build my confidence.

“So, what brings you to hospital today?”

”Daktari, you know people like us, we are old men..mmmhhh..“

“ Tell me what brings you to hospital,” I interjected sensing that Omondi was trying to veer off from what I wanted him to tell me. He was not as old as he was trying to insinuate. He was in his mid forties, very energetic and full of life. He leaned forward, I too leaned forward. After reassurance, he decided to hit the point.

“ Daktari, mine is a case of burst condom, I have come for Post exposure prophylaxis, Please give me a prescription. “ I admired his honesty. He looked embarrassed, miserable and so sinful after saying those words. I wanted to remind him that no sin is beyond redemption but time was not on our side, we had so many patients on our list that day. The doctor in charge was so pissed off with the whole idea of a burst condom. What angered him most was that a case like this had to be dealt with at Accident and Emergency, with red color code meaning very urgent. Omondi must have charmed the nurse at the triage. The doctor had no choice but to do the prescription which he did so quickly for that matter, just to have the man leave as quickly as possible. “Next time you go to the outpatient for a similar problem,” he said to Omondi  amidst the many thank yous that Omondi sang. I have never heard that many thank yous from a man.

 

The Wailing Spree

Wailing is one of the ways we Africans express our grief. Whenever I hear a wail at the Casualty, the message is always clear, someone has passed on. The wails however vary from community to community. Let me say with the deepest conviction that Luhya wails are the loudest and the most interesting. I can defend this in a court of law by the way. One time you would think they are laughing, another time they would roll on the ground and cry with mouths wide open but no tears and no signs of tears ever coming out of their eyes. We will get back to this wailing in a short while.

It was one of those Fridays at the casualty. The casualty was busier than usual. You know Friday is that day of the week that doctors dread the most.  A serious case will come just when you are about to leave to go unwind. Often times you would hear the doctors cursing why they got into medicine whenever such situations arise. Some would even try so hard to have the patient fall in the next shift but only after stabilizing them and removing them out of danger.

The Nairobi County Police Land-cruiser halted with a massive screech at the casualty entrance. The screech was so sharp that I felt it in my teeth. Out came two police men who seemingly had no single minute to waste, probably they were in a hurry to get back to the road to collect their dues. I know of a police officer who keeps on foregoing ranks to remain on the road as a traffic police. Damn it! Of what use is a rank when one can earn twice as much standing by the road side?

The policemen had brought in a man who was severely injured and needed immediate medical attention. The man was unconscious. He was drenched in sweat, blood, alcohol, sewage and anything that can run on a drunkard lying on the streets. This combination gave a torrid stench that would be part of us till our shift ends. Poor us!

We took the guy to resuscitation room B and  started him on intravenous drips, put him on oxygen and drew some blood for our investigations. The policemen left without any notice and so the patient was ours, we were the relatives and the care providers. This happens more often than not. after all this is a public hospital for heaven’s sake.

Just then, a wail emanated from outside. It was the typical wail I had mentioned before. It was very loud, so it had to be a Luhya wail. It rose to a deafening crescendo and then silence, only to emerge again at another corner of the casualty. It was a feminine wail but a strong one. It was an afternoon, most probably obusuma was doing the magic, adding strength to the wail. Hungry luhyas wail for a short time by the way, and a hungry wail too can be recognized. It is often sharp and sometimes cut in the middle of wailing. It is like when you want to say Oliver, then you say Oli.. and then hunger bites you so hard that you stop it at that. Mid way.

When another relative joined the wailing, the casualty went into a mess. It was like a wailing spree yet only two people were wailing. In those moments of frenzy, our patient woke up, and remember he could not wake up before to give us a history. Actually the police had thought he was going to die in the next few minutes and was  brought into the hospital to die. To me this was like a resurrection. He managed to open his mouth and asked, “Wameenda?…”

 

 

 

Vows Renewed

If I ever become a physician, then it will always be because of Professor Bhatt. Whenever I want to tell a story of passion, he always comes to mind. He represents an ideal physician, the typical physician that Hippocrates had in mind when he wrote the oath of our profession. He is one of the oldest in his department. One would expect him to be tired after years of practice but that is not the case, he walks upright, his teeth are intact and he is still as vibrant as he ever was. The wine gets better with age, the professor becomes classic with the passing of the years.

Professor Bhatt is of Indian descent. He claims Kenya is home. He understands Swahili very well and speaks it way better than any mswahili that I know. He understands kikuyu too and even luo. Often times he would say Jaduong abirochwadi matek in a weird accent to mean he will cane you hard. You know when you speak luo with an Indian accent, it does not sound as sweet, actually one would think he speaks one of the native Indian languages.

When you find professor in your clinical exams you are screwed. But you are even more disadvantaged if you find the other professor from my village, Prof CFO. Let me start with the professor from my village who having left the village, sunk deeply into medicine and nothing else but medicine. He knows the hydrazine ring of isoniazid, a drug used in TB treatment, and he expects you to know it too, too bad for a clinical exam, right? Then if you think that is hard,try this, do you know the circum-oval proteins of the eggs of Schistosoma? Well, I also don’t know. Professor Bhatt will approach the situation on the extreme end of the spectrum. He believes common things occur commonly. When a spotted animal crosses your path as you are walking, it is more likely to be a cat than a cheetah. this is entirely true but that is where he catches you, he will ask a simple question and expects you to list your answers in order of how common they occur. And that alone will shift you off your balance.

Ward 8D is always the place to be. Professor Bhatt brings along the enthusiasm of a young man and the wisdom of an old man. This sets him apart from the rest of the consultants. I always stand right next to him during the ward round for two reasons. The first one is obvious, I always want to get the best out of his ward rounds without missing a thing. The second reason is to hold the professor when he is about to fall, some of the answers we give to his questions almost always make him fall, so I hold him.

The patients love him in equal measure. Some of the patients would not go home until the professor discharges them by himself. In the rounds, the patients look up to him with great admiration. They see a man who practices medicine as if it were a craft, they see an artist and his art. He would greet the patients and ask them how they have been and how they are doing. The patients would always warm up with a smile and say all is well even if they were in great pain. The terminally ill patients in our ward are kept alive by Professor’s smile and nobility. If there is nothing else to look up to in life, they always look up to Prof’s rounds.

The nurses too bear witness that Professor’s passion borders on obsession. He works with everybody and collectively, patients get the best of care. He always emphasizes on clinical acumen as the most important tool for a doctor in resource malnourished areas such as our setting. Under professor’s leadership, everyone feels obliged to do what is right and to play their part in patient care.

Professor Bhatt has made me love medicine. He has reminded me that medicine is an enduring art passed from generation to generation with utmost fidelity. Above all he has brought to my attention that curing is not always the main aim of medicine, healing is. This is someone who has beheld the ‘gods’ of medicine and the ‘gods’ have found a way of loving him back. So tonight I renew my vows with medicine…’ I swear by Apolo…to be true to you, to love and cherish you always…’

We All Bleed the Same

“Get blood samples for blood gas analysis,” the doctor was loud and clear. I quickly put on a pair of gloves, took a needle, a syringe and a swab and went to the patient’s bedside. The patient was a lady in her mid fifties, though she looked quite old for her age.She wore a veil that signified her faith, she was a woman who belonged only to her husband.Every part of her body was covered and successfully, every predator was kept away. She was a Muslim.It was evident from how her husband showered and chanted praises to Allah and she responded faintly, “Amina”, gathering all the strength she could amass.

She had been brought in by an ambulance a few minutes ago. Immediately she came, I made a spot diagnosis of her condition, she was in diabetic coma, a medical emergency. We quickly wheeled her to Resuscitation Room B to perform our rituals. These are the times my adrenaline levels shoot high above the roof. I relinquish emergencies. These are the moments when I am pushed to the wall to think on my feet. At such moments, Harrison’s Textbook of Internal Medicine becomes clear in my mind, the current guidelines appear vividly at the back of my mind. I can literally read every sentence and follow them without missing even a full stop. Sadly, these moments are as short lived as the emergencies themselves. How I wish I had such moments in the examination room.

Her husband wore a face of despair that scared me. He gave us the medical history of his wife amidst the sobs that occassionally took the better of him. He looked at his wife and bent down to kiss her forehead making me a little bit uncomfortable. Had it not been for the gas mask that covered the lady’s mouth and nose, this man would have opened a scene that is not common in such a setting. I took her hand, swabbed and determinedly looked for a vein. The lady was morbidly obese. Looking for a vein was like looking for a needle in a stack of hay, not during the day but in the dark of the night. We had to find a vein none the less. We needed to run IV fluids and collect samples for investigation in the shortest time possible.

“Every minute counts young doc, “the doctor we were working with uttered trying to maintain his calm as much as possible. Deep down, I knew he was getting impatient.

“Go for the femoral artery, feel the pulse and draw blood from the point of maximum pulse, “he added. His voice was deep carrying with it the gravity of the whole matter. He had taught me how to do quite a number of things. He expected the best therefore from me.

This was a tall order for me. I had done it before but the situation before me was a tricky one. I felt a barrier between me and the patient. I knew I had to unveil her to access the ever accessible femoral artery. Other times I would do it without hesitation but today was not one of those days. The unwritten rules restrained me from doing what I knew should be done. Then I remembered that I am in the ministry of healing. Mine is to alleviate pain and suffering. There is no way I could let her deteriorate lest I bring more troubles. I had to do it.

‘I know you fear, but just do it, ‘the husband reassured me. He had read the fear in my eyes. He was not ready to lose his wife because of barriers that are created by men. I let him do the unveiling himself. He was gentle with the way he handled his wife and that motivated me. In no time, her thighs were exposed before me. I wasted no time, I went straight for the pulse and then with the needle and syringe, I drew bright red blood. This was obviously arterial blood. It was not different from the tens I had drawn during my Internal Medicine rotation.

In those moments, I felt a sense of oneness with her. Despite the religious barrier, we were all men. This new revelation only confirmed to me that all men are created equal. We all bleed the same. That is the stark reality of life.

 

 

 

Ritual Knife

I remember that cold December morning with a lot of nostalgia. My father rose very early at the crow of the first cock. I saw him through the window of my room that was slightly obscured by the dew that covered the panes. He stood at a strategic point in our homestead to ensure that my brother and I didn’t leave. He knew I dreaded this moment. The moment when my blood would be shed to the ground to show solidarity with those who went ahead of us. I had no choice but to submit to the dark forces that had conspired against me.

A black pick-up halted at our gate a few hours later. It was an old Datsun that had covered several miles on the sands of time and I knew for sure that the time had come for us to go. We climbed at the back together with my brother and met a number of other boys in our age group that were sentenced to the same fate as ours. Others by their parents, others by their own will. My father waved as the pick-up fled. I never wanted him to see my face because I was not happy with this.

I wish there was a way in which I could get to the circumcision parlor without using this pick-up. This pick up was known in the entire village to be the initiates’ pick up. Some boys saw it on the way and literally took to their heels leaving us bursting in laughter. We threw them insults that they were not brave enough to face the knife. We even told them never to play with us. This succeeded in distracting me from the impending danger. We passed a few girls on the way. They carried buckets on their heads and without support, the buckets stood steadily on their heads only sometimes swaying slightly at the swinging of their hips. As we passed, they recognized the pick-up and shouted, “Udhi nyange!” this meant we were going for circumcision. It was shouted in a mocking way that I felt embarrassed.

One by one we got into the improvised theatre in a local primary school classroom. We were to get in one at a time because the surgeons were only two against twenty or so boys. Those who went before me came out strong. I admired their courage. I went in. I removed my clothes and submitted myself to them. I felt like I was offering my body as a living sacrifice. The first injection of local anesthesia went deep into the base of my manhood. It was so painful that I protested loudly. In fact I almost kicked one of the surgeons but he moved out of the way of my legs and the legs went into the air. My man felt heavy for the first time, so heavy that if I were to stand, he would have brought me down. At stitching time, the effect of the anesthetic drug was slowly abating and the pain was incredible. I am glad it came to an end fifteen minutes later. Those were the longest fifteen minutes of my life.

Going back home was trouble. People now knew that we had faced the knife but that was none of my problems. The road leading to my village is a loose marram road with a lot of rocks and stones along the way. We sat behind the driver with my brother. The Datsun was a double cab by the way. Whenever it hit a stone, I would literally stand holding my man gently to avoid the impact caused by the rugged terrain. Sometimes I just did not anticipate bumps and the impact would be crazy. My brother was silent all this while, occasionally he would show his teeth when he could not contain the pain. The boy next to him was moaning. You would think it was a lady doing so under intense pleasure from her lover. Oh my! That day I found myself in a pack of cowards, did I show courage myself? No. Why? I don’t know.

Healing was as horrendous as the procedure itself. I had to sit in a particular way or sleep in a particular way to ensure that there was peace between me and this guy of mine. Passing water was hell on earth. I had to wait for several minutes for the water to flow and endure the pain it caused. Afterwards I would gently sink in my bed with a towel around my waist. Mourning. My brother was recovering uneventfully. Once in a while he would shout in the night when the stiches held a piece of cotton and was pulling his flesh as he tried to pull it out. He shouted like a movie star who was destroying his greatest enemy. I laughed. Two days later I suffered the same fate when my towel held the stitch at the upper part of my manhood. I tried to pull gently but the pain was too much. I took a blade, cut the string attached and I was relieved but part of the string remained attached to the stitch. It was supposed to stay there, till the stitches fall off.

Now I took you through all that because last Friday, I was the surgeon passing the rite to a young boy from the street family. It was an experience that reminded me of my very own day. The difference was, this small guy was brave and he came in panting. He was escaping from his colleagues who wanted to circumcise him in the streets using a broken glass as the scalpel and alcohol as the disinfectant. I agreed with Somerset Maugham when he said,

 “For men and women are not only themselves; they are also the region in which they are born, the city apartment or farm in which they learnt to walk, the games they played as children, the old wives tales they overheard, the food they ate, the schools they attended, the sports they followed, the poets they read, and the God they believed in. It’s all in these things that have made them what they are, and these are the things that you can’t come to know by hearsay.

Everything basically went like mine. He was lucky he found a good nurse who gave him a few clothes to carry on with his life in the streets. This was a young man who was a son to none and a brother to many. Life had not prepared him for the dark alleys and cold nights but he seemed to be getting along quite well.

He dressed up in a hurry. I think he was rushing to show his friends that he had successfully become a man. I forgot to tell him that the local anesthesia would soon wear out. He moved out quickly and true to my word he started feeling pain just as he was exiting the door. I used this slow down moment to ask him to come for dressing on the third day.

In Wonder

It has been three years since I joined medical school. I have learnt a lot about the human body. This has made me appreciate art for what it is. For art is art. It is an expression of the ingenuity of the human mind. I have known people who have left everything else to pursue art for the sake of it. When everything else has ceased to matter, art matters.

The human body stands at the center of all creations. The creator looks upon his art and marvels at multiple complexities that have merged into intergrated simplicity. It is intricately woven piece by piece into a masterpiece. Many are the times I have gotten lost in the labyrinth of the human body as I traverse various regions.I have studied it in awe. It could not have happened by chance! The human body was designed by a true designer.

Men have built structures that have amazed them since the beginning of time. Some of these structures have been branded wonders of the world. Talk of the Great Pyramid of Egypt, standing proudly in the middle of Sahara Desert, it has defied the cruelty of the desert and has stood for millenia but still it doesnt surpass the wonder that the human body comes with.The hanging Gardens of Babylon also stood displaying their color in the desert many years ago but the wonder never came close to that of a human brain.even a super computer controlling activities in space can not come close to a human brain! Yet these are just but two of those wonders.

We are entering another age of even more wonder. The quest for knowledge and understanding has brought us back to the cell, the basic unit of life. The human genome has been sequenced. We are understanding diseases better by understanding the cellular language and the cellular way of doing things. It takes me back to the time in history when the missionaries came to Africa, they had to learn the African language to facilitate the spread of the gospel. We have invaded the cell. learning its language is not an option because we are not leaving anytime soon. The cell must give us its secrets that it has kept away from us.

This constant wonder helps me understand the body even in sickness. Disease deranges the human body. Sometimes the derangement goes to the extreme. Sometimes the body says enough is enough. At such times life returns to its Giver. I have heard before that God  pours life into death and death into life without a spill and this is entirely true. I know I will continue in wonder. I may get lost but I will still wonder. I choose to wonder because very soon I will not wonder. So I wonder.

 

 

 

The path of most resistance

27th July 2013 fell on a Saturday. It was a landmark Saturday for me. It brought to an end the bliss that had briefly come into my life. Never before had I felt that grave. I looked again into the eyes of my beloved girlfriend and I knew she was truly going, I could do nothing to bring her back. I questioned life, I questioned my God, “God, why did you let my love for this lady grow so strong when it was never going to last?” she too was looking into my eyes daring me to say the parting words that would end everything. My heart, my fragile heart, was bound to break. I could imagine the left ventricle in pieces, the heart valves ripped apart and the sinoatrial node racing. I wonder how it would sound in a stethoscope. Could it sound like the mid diastolic rumbling of mitral stenosis or the radiating murmur of mitral regurgitation? Perhaps the pulse would even collapse. The collapsing pulse of a broken heart.

It was a few minutes to 4pm. I waited for the clock to struck 4 so that I could break loose. I was breathing fast, the minutes had elapsed quickly and the time had now come. I remembered the preacher’s sentiments “…a time to be born and a time to die…a time to love and a time to hate…’ Was this a time to hate? How could I hate the very person that I had given my heart? Then I encouraged myself that a lot would become available if I let go. “You can go,” I said to her trembling but composed. This was a path of most resistance. It looked like the Spanish soap operas, Alejandro breaking up with Isabella. But this was real, I parting ways with my sweetheart. She took a U-turn and then it was over. ‘Free at last! Free at last!’ but did I really become free?

Three years have elapsed since that day. Exactly three years. A lot has happened in my life. Looking at Akula (not his real name) I can’t help but identify with him. We admitted Akula for attempted suicide. He had taken poison to part ways with this world full of struggles. He was lucky his mum came in time to rush him to the hospital. A stitch in time saves nine. He had been relieved of the poison from a peripheral facility and was referred for further management and psychiatric consult. I quickly took his history. He had lost the girl he had dated for six years to an old man whose only advantage was money. Coupled with a few problems from work, he had so much stress. So much seemed hopeless to him that life was no longer worth living.

I quickly wrote a lab request for liver and kidney function tests as the doctor we were with summarized his report and clinical findings. I was relieved when the tests came back normal. However he was admitted still and a suicide note given to the nurse in charge. These people need close monitoring. One attempted suicide could always lead to another. The mother was happy that the son had not gone so soon and so were we.

Later when he was regaining his normal profile, I asked him to narrate to me the experience of a poison in the belly. “ Hiyo kitu ilinipeleka mbio, “ he said as we both laughed. He meant that the poison had raced with him. He had so much to say. He told me that love is a strange thing. He himself has not understood it in his twenty eight years of life. He has heard of princes leaving kingdoms for the sake of love. When he told me the story of Taj Mahal in India, I knew he had so much knowledge around this thing called love. He took me to Shakespeare’s classics and I sank in. He was willing to do anything he could to prove his love for his girlfriend. What he got in return was betrayal and bitterness.Woe unto those that break the promise of love. None the less, when you find yourself in such a mess, never take the path of most resistance. Remember that you have another story to tell. The story of courage. The story of a better tomorrow.