The Doctor On Call

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

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

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.

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.

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.

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

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!