Government should Honour Covid-19 Soldiers who Pay the Ultimate Price.

When I remember Dr Alushula, I remember two moments.

The first was in 2019 in Meru County during the Surgical Society of Kenya camp. On a Friday evening, we missed the turn into West Wind Hotel in Makutano and had to make a quick exit into a petrol station and plan a detour. I was driving him and two colleagues in my Fukushima wheelbarrow. I had completely been immersed in his juicy stories. After finding our way to the hotel, we sat down listening to his tidbits of wisdom. Wisdom honed in the crucible of years of practice. 

The following morning we would again run into each other in the operating rooms of Meru County Referral Hospital as he gave the journalists a brief of what surgeries were going on. When he got to my operating table, he left me with the journos and asked that I explain to them what procedure I was doing.  It was hydrocelectomy and I was just done with prepping the surgical site, just ready for the knife to meet the skin.

Zoom Meeting

The second instance was early this year in a zoom meeting. A colleague was presenting on the place of surgery in the COVID-19 era. After the presenter gave all the recommendations including hospitals having multiple surgical teams so that in case one team was exposed to the virus they would all abstain from work and self isolate, Dr Alushula asked the poignant question of the whole evening.

Which teams? What of places where there is only one surgeon for the entire hospital?

Last week Dr Alushula succumbed to COVID-19 related complications. It has been a difficult week for the Kenyan surgical fraternity as we come to terms with his demise.

He was such a respectful and mellow senior colleague. Every time he spoke, he would always quip, ‘SSK is Surgical Camps and Surgical Camps are SSK’. He believed in the central role of organised surgical camps as a way of giving back to the society. He never missed any of them. 

His death, coming in the heat of the so called second wave, has robbed the country of a selfless man. May his soul rest in peace. 

Ill Equipped Soldiers

This global pandemic, judging by the magnitude of disruption in social order and economy that it has caused nations, belongs up there with the world wars. And the health care workers are the soldiers we have sent to the frontline. Ill equipped and overwhelmed. The only commodity they carry in abundance is their spirit of selflessness. 

Every time our political leaders speak, they proclaim the national and county governments’ preparedness to tackle the pandemic. Yet just the other day medics in Nairobi had to go on strike demanding medical cover! 

A simple guarantee that if infected, the nation that you took care of will take care of you! Let us not mention the decibels of ‘lack of PPEs’ cries that we have heard since the virus landed in our country.

Given a chance, healthcare workers would  gladly work from home. But then ours is a profession that cannot render itself to that work place adjustment. Safe for a few. For most, especially for surgery, you have to be there physically. You have to clock in hours in proximate contact with a patient, removing a tumour, or a diseased appendix, or fixing a broken thigh bone. Saving a life. 

It is time for us to ask not what our healthcare workers can do to save us from this pandemic but what we can do to save them. During war, we celebrate and honour the soldiers who have taken the battle frontlines. We have 21 gun salutes for members of our disciplined forces who pay the ultimate price. 

What can we do for our COVID-19 frontline soldiers? What is their 21 gun salute when the Alushulas and other colleagues pay the ultimate price?

Is it time to offer them medical and last expenses cover?

We would like to see actions accompany the praises. Give us PPEs, give us medical cover. Give the healthcare workers a last expenses cover.

Yes, it has come to that! Healthcare workers are contracting COVID and some succumbing to it. It has become part of their job description. 

***An excerpt of this blog appears in the Healthy Nation of 26th November, 2020

ÎCHIARO CLEARANCE BEFORE ANAESTHESIA CLEARANCE

My friend and colleague Dr Bundi Karau opines that one day he will hopefully discover the gene that makes Africans so religious, denomination not withstanding. 

I hope that  his massive genomic project will also attack the issue of beliefs in Witch craft and curses. 

In the sub tribe of Meru where Bundi and I  hail from, curses and witch craft are held as strongly as gods and the devil. So much so that when I graduated as a doctor  nearly a decade back I had to address myself to that notion. 

Having read  the physiology of the nervous system and then dissected the anatomy of the brain and spinal cord, I could not wrap my head around witch craft. Studying psychiatry and psychology did not completely explain it. 

Happening during the uruûra season when everyone has depleted their food stores and is looking forward to the new season’s crop, it was a financial torment to get any of my folks or siblings travel the hundreds of kilometres to Eldoret for my graduation. I chose to graduate solo and carry my gown, hood and cap to the village.

We opted for a small mass during the second week of December to celebrate my graduation.

The priest may not have been fully briefed because he kept mentioning how I had cleared bachelors and masters degrees, and now I had brought home the PhD! 

Protocol did not grant me a chance to shout some corrections. May be it was a dream being verbalized. Or may be the short stopover at my friend’s in Nairobi which had me exposed to a mannerless Nairobi fly had given my face an old man’s look. Six years of non stop university education can make one age too. Trust me, I saw it! 


A summary of Medical School

Now, when the chance for the guest of honor to speak came, I decided to summarize what is entailed in medical school.

I narrated how the 6 years were  divided into 3 segments: 2 basic science years, 1 preclinical year and 3 clinical years.

I told them that during the first two years we had studied the normal structure and function of the healthy human body. That is where we had dissected every muscle and nerve. We had peeped into the bottom of the heart and sliced the brain open. Just to know how a human being is structured. 

For the preclinical year we had learnt how a diseased body looks like. And how the disease affects the body. For the practicals we would be found in the mortuary. Here we would spend afternoons splaying open the hearts of heart attack victims to study the wall thickness and contrast them with normal. We would sequentially move up or down the body depending on the unit we were covering.

Having known the healthy and the dead, we had then been ushered into the realm of the ailing. Here you may not have the luxury of cutting them open to demonstrate the disease. But with a scan and a lab test you can add documentary evidence to your mental picture. Those three clinical years culminated in the tall dark and lanky graduate who stood before them, I added. 

After nearly fifteen minutes of this ad lib recap of medical school punctuated with memorable personal experiences here and there, I surveyed my audience wondering whether they had understood everything or nothing at all. 

“In a nutshell, in those 6 years I have learnt that the only real witchcraft comes in the form of poisoned food,” I concluded. I think some of them clapped. 

I would have spoken about îchiaro

If wishes were horses, I would have spoken about curses. And another  belief called îchiaro. This is a firm belief that bad things will befall you if you wrong someone from a particular clan. I grew up knowing that there are certain clans with which our clan has such a relationship. Wronging someone from these clans means inviting calamity which can come in whichever form. 

I must confess that there are diseases that behave in such suspicious ways that even if there is scientific explanation, it is difficult to describe them to the laity. Such become fodder for these believes. 

One such condition is called foramen magnum syndrome. It arises from compression of the spinal cord as it exits the skull. The progression of loss of sensation follows a circular distribution that at first glance looks so suspicious.

I remember quipping to a fellow classmates back in the days, ‘there is no way you are convincing a relative that their patient has not been bewitched to develop this weird problem’. 

Now having resigned to surgery, I have not  been keen on foramen magnum.This is the forte of Dr Bundi and others. That does not mean weird-looking diseases are not in surgery.

Flesh eating disease

They come for example in the form a flesh eating disease called Fournier’s gangrene. It attacks the private parts, starting around the genitals and quickly creeping up the crotch to the Lower belly skin. Often times it can go as up as the collar bones. It may arise from an infection in the anus or the urethra. There is a detailed anatomy pattern that describes the spread of the disease.

Fournier’s gangrene is so weird and scary that supernatural powers could easily be invoked to explain its origin and progression. 

When patients turn to supernatural explanations, the curse and îchiaro come to play.

It was not any different when Mr BK,  a man in his sixties was brought to our unit with Fournier’s gangrene. 

At first look, my medical officer and I shouted ‘debridement’ in unison. He needed urgent surgical source-control before he could collapse into overwhelming infection. The damage is best assessed after surgery. And it scares the patients.

Usually the patient will get several trips to theatre, every time the surgeon removing the dirty tissue as an addendum to the tons of medication given to fight the bacteria responsible. 

Waiting for mwîchiaro

The return to theatre for BK was tricky because his blood level was low. We needed to put our heads together with the anaesthetist and make a hard decision. Being fully alert, I did not expect any challenges with obtaining informed consent for the second surgery.

Yet it did not come.

The patient sent for the relatives. Even after arrival of the relatives, there was another key stakeholder that was required before the patient could give the go ahead. Another day!

As we waited for the consent, we kept searching for the ever scarce blood.

Hata mwîchiaro alikuja na wakamaliziana sasa tunaweza kuendelee na surgery.”

I was taken a back with this update. 

I was later to learn that Mr BK was convinced he had  suffered this tormenting disease because he had wronged someone from an îchiaro clan. His family had brought the aggrieved to lift the curse that had befallen our patient in the form of a flesh eating bacterial infection.

I can only imagine what wrongs he may have committed and why it should manifest through a danger to his private parts.

Having gotten this clearance, now the anaesthetist was allowed to review and ‘clear’ him for surgery.

Since that day, Mr BK demonstrated such strong spirit and hope that he agreed to surgery and actually started recovering very well. 

Build More Hospitals, Not Airstrips

Over 7 days ago, we lost a celebrated legal mind. The late Nzamba Kitonga, an award-winning jurist is said to have collapsed while in rural Kitui and pronounced dead on arrival to Hospital. May his soul rest in peace! 

While from the news we have heard many complain that poor transport infrastructure delayed his intervention, the real problem was actually lack of access to health. If there was a well-equipped and staffed health facility within reach, why would the late Kitonga require air lifting to the capital?

The headlines running that a lack of air strip cost the former constitution of Kenya review boss his life are inaccurate and deceitful. They propagate the learned helplessness that Kenyans are slowly settling for. That our public hospitals are second class to the private ones in the capital.

Mr Kitonga may not have needed an MRI to save his life, but a well-stocked hospital with a qualified doctor to address the life threatening emergency and commence intervention. When it comes to emergency medicine, time is life: the sooner the intervention, the more the likelihood of saving a life. Airlifting a patient from a remote Kenyan village to the capital would not be the wisest first thing to do. Attending to them, stabilizing them and making the correct diagnosis would be. Airlifting can always be done later, even to far countries across oceans. 

Born in the penultimate years of the country’s independence, Kitonga must have celebrated the independence government’s declaration of war on poverty, illiteracy and disease. Having steered the 2010 Kenyan constitution writing, Kitonga must have looked with satisfaction at article 43 of the said document that guarantees every Kenyan the right to highest attainable health care including emergency healthcare. 

Kitonga’s death took me down memory lane.  Eight years ago in Malawi. The president, Bingu wa Mutharika suffered a cardiac arrest and could not be revived. Word has it that the state of health in the country was so poor that hospitals may have lacked the emergency drugs that would have given him a fighting chance. Even when confirmed dead, the health institutions lacked sufficient electricity to preserve his body. He had to be flown to South Africa. Access to an air strip and a private jet did not safe him. 

It is easy to remember the Kitongas and the Mutharikas lives because of their position in our society. But how many children under 5 have we lost since the promulgation of the new constitution? How many 64-year olds have collapsed in interior Kitui and could not be revived? 

What Kitui and the rest of the country needs is not an airstrip but accessible fully equipped, stocked and manned health facilities. Please, do not take us to the contorted argument of the acuity of having an airstrip in Kitui. The Kitui governor will remember with nostalgia when as the health minister,  her motion to bring universal health coverage was brought down in 2004. Even her boss, president Kibaki, could not support it because of the implications to the economy. If it had sailed through, Kitonga’s story may have been different.

We are known to copy and emulate British precedence on many things. If the airstrip in Kitui was functional, there is a likelihood that Kitonga would have been airlifted to  Nairobi then to the United Kingdom. The interesting part is that the United Kingdom health care is fully public funded through the National Health Service (NHS). It was not easy starting the NHS. The labour health minister met resistance from every angle. Yet today NHS stands as one of the sources of national pride in UK. 

Funding health is not easy. But for those who value their citizens’ lives and wellbeing, there is nothing too expensive. Hii pesa sio ya mama yako!

The next child to suffer a snake bite in Kitui will not require an airstrip. They won’t afford it. They will require a close by fully stocked and staffed hospital. But then again, a snake bite from rural Kitui may claim a life but is unlikely to catch the headlines. 

*Part of this blog appeared on the Daily Nation of 3rd November, 2020*

‘WAIT AND SEE’ IS A DANGEROUS APPROACH TO BREAST COMPLAINTS.

(Input from Dr Moki Mwendwa

When I was in college, my undergraduate tutor once observed that the only two things that will take an African man to see a doctor are blood or pain. I have since learned to extrapolate those two symptoms to what they mean to any patient- scare or discomfort, respectively. 

This month, I encountered this phenomenon in a lady. I discussed it with my colleague Dr Moki who has added the final paragraphs of this piece. 

In her 70s, on this Tuesday morning, she queued with the rest outside my clinic. She had covered nearly three hundred kilometres from her village. Under her traditional garb she carried a monster that had been gnawing at her flesh. 

When she walked in, I allowed in her relative as a necessity. I needed him as a translator. 

She had a breast problem. I spent an agonizing length of time trying to decipher from the patient whether it was a lump or a disease.

“Anasema matiti ni mgonjwa,” the reply would come back from the translator. Simply that the breast was diseased. The same script replayed when I enquired about the duration of symptoms. I assumed the worst and went on to skip the rest of history taking and proceed to examination. 

I assumed it was going to be easy examining. After all, my eyes and fingers would do the talking and listening. How wrong I was. The translator seemed to be ordering her to jump onto the couch even when I felt my voice had been measured in my request. 

To start off, I asked her to lift her hands high above her head for me to examine the symmetry of the breasts, their movement and any obvious masses or skin changes. It was the same lengthy process. Instead of lifting her hands up, she carried up her legs to the head-side of the couch. It took another moment of instruction-interpretation-action cycle to go back to the beginning.

Her breast bore an ugly ulcer. ‘Of course, it is cancer’, I thought to myself as I proceeded to examine both breasts.  She giggled and wiggled when I touched her armpits to feel for the enlarged nodes. The whole encounter here bore the hallmarks of a tragicomedy. 

I wrote down the series of investigations that she needed. First, a needle core biopsy, then a mammogram and staging CT scans before the next course of action. 

I am happy she came to see a doctor. I would have been happier had she come 6 months earlier. 

The single most important determinant of outcomes in cancer management is the stage at presentation. When detected early, localized breast cancer has a 5-year survival rate of 100%. Meaning in 5 years the chances of this lady being alive would be similar to those without breast cancer. On the contrary, when it presents late with regional or distant spread, survival periods are as low as 18 – 24 months. 

Almost one in every four women sees the doctor with a breast related problem at one point in their life. Although pain is the commonest breast symptom, it is not a common presentation of breast cancer. Majority of cancers will be painless. 

The presenting signs and symptoms of breast cancer include a breast lump, nodularity, nipple discharge, nipple crusting or other changes in the nipple and its surrounding pigmented skin. Changes in the shape or size of the breast or skin dimpling and ulceration can occur, as in the case described. 

For various reasons, the number of Kenyans presenting with advanced breast cancer is disproportionately higher than the west. 

As we mark another breast awareness month, our plea is for every Kenyan woman who has a breast complaint to clear any doubts of cancer by getting evaluated by a healthcare worker. Even if you do not have any symptoms but you are aged 40 years and above, be safer than sorry. Get screened this October. Do not ‘WAIT AND SEE’. It is dangerous! 

***Part of this blog appeared as a column in the Daily Nation of 20th October, 2020** 

Eaten by a Lion But Lived to Consult a Surgeon

Tunaitikia mtu mmoja tu. Wengine wangoje nje!” 

This was my refrain in Swahili for the entire day as I ran the surgical outpatient clinic during the new normal times of Covid-19.  

And so, anyone who dared protest was met with a firm but polite reminder that we were trying to ‘komesha korona‘ and flatten the curve. 

Of course some would put up a spirited fight. To which my answer would be a simple stare, hidden beneath a veneer of the now ubiquitous face mask and my omnipresent spectacles. 

“Can he speak in English? Swahili? Kimeru? Then just leave”. Usually after this, there is no further bargain. 

It was time to see the 17th patient. 

As soon as I saw him from the door, I knew I would have to accommodate the relative. 

He was in his sixties, clad in a shuka and a jungle green top akin to the ones worn by the police reservists. The ornamentals enriching his ear lobes, the neck and the limbs told me he must be a plain Nilot from either Isiolo, Marsabit, Laikipia or another of the neighboring counties. 

He wore akala. You know those sandals fabricated from old tires?

This was a dejavu moment for me. I have worn such in the past. Damn those sandals! They are the reason I bear scars on the inner side of my ankles. It so happens that when you walk, depending on your style and gait, you could hit your inner ankle with the opposite foot as it swings. It is such a painful experience.

Just when you think you have mastered the perfect gait and style, and the wound has started healing, you hit yourself again. At the same spot. If you are in the wilderness looking after livestock, flies of numerous species congregate on these ankle wounds. It seems they can somehow sense the smell of fresh blood, decaying tissues or the broth that is pus. Whether the instinctual needs these wild flies seek to assuage are of thirst, hunger or reproduction, I have no idea. All I know is that the encounter hurts even more. Even if you have a handkerchief or a torn piece of old cloth tied around your wound. And of course their probosces are dirty, leaving you guaranteed of wound infection. 

Beautiful Bracelets

I looked at this chap like he was a victim of such predicament. I even thought  for a moment that he was here to see the surgeon because of such. But his ankles looked healthy. They had neither handkerchiefs around them nor a swarm of flies circling in vicinity.  Instead,they had beautiful bracelets. The type any western tourist will pay an arm and a leg to buy at Maasai market.

This doesn’t mean that his gait was perfect. He was an expert at a safety modification that is as old as the sandals themselves. A smaller piece of the strap material, say six to eight centimetres long, placed perpendicular to the sole to lie directly covering that bony protuberance we call the medial malleolus, the focal point of the occupational injury I have expounded on above.

He sat on the wooden chair next to the door and placed his walking stick between his legs. One and half meters away I sat on my swivel chair in front of the computer which contained his biodata. 

His son stood next to him, clasping at two radiology department envelopes. From their sizes I could tell that one contained CT scan images.  The son was dressed like any millennial in a Kenyan city-maroon slim fit chinos and a turtle neck sweater. His feet were covered in Levi’s sneakers worn over well chosen low-cut funky socks. 

The only connection to his rural home in Wamba was his language and the belt he adorned that was decorated with white and blue beads up to the buckle. 

The old man complained of abdominal pain and distention for months. He felt his stool was hard. He needed be to assisted. 

His son did much of the translating but once every so often the patient would break into some descent Swahili, giving the translator some needed rest.  

He got on to the couch and I descended on his abdomen with the voraciousness that every doctor bears when approaching a difficulty diagnosis. The abdomen is a jungle, we say. 

Marks on the Abdomen

On his tummy skin I found various marks, we describe them as therapeutic marks. His were those made using some heated pieces of wound to treat pain. His belly had some fluid-ascites in medical parlance. There was no area that hurt. But I noticed what looked like surgical marks along his right rib cage. I had to counter check with my urbanized young translator. 

“Did he have surgery?”  

Alikuliwa na simba akiwa mtoto.” 

Well, if I was to translate this into English, I would say “He was eaten up by a lion…” 

So why was he here? Did the lion leave some left overs? Any way, I digress.

But that is the beautiful Swahili with local accent that the different ethnicities of Kenya can identify. Another thing to tie the modern young man to his roots. 

The CT scan had revealed a growth in the right lobe of his liver. He needed a needle thrust through his right rib cage to get some biopsy for diagnosis and planning of treatment. 

I jotted down the request card. As I signed it off I thought , the needle will have to go through one of these lion bite marks.

Another day in the village surgeon’s clinic!

To Cry or to Laugh when having a Rectal Exam?

An old mzee walked into the clinic. I asked his son to remain outside. 

He came with urinary complaints. He cannot hold, he has to rush to the gents. Otherwise he wets his pants enroute. 

At night he wakes up 5 times, everytime going back to bed not satisfied that he has completely voided. 

As is the case, he threw the lab and scan slips at me. As is the case I tossed them to the desk and faced him:
“Tell me your story first, we shall revisit these slips.”

He was hesitant, as is mostly the case, when I offered to examine his prostate. I understood. I reassured. He complied. 

Then off we went. Gloved fingers, lubricant and some toilet tissues in the ready. 

Usually patients are apprehensive. So was he. 

But when the doctor’s lubricated finger gets to the prostate and starts feeling for the size, the contuors and any errupting nodules, patients get uncomfortable. For those with an infection of the prostate (prostatitis), this discomfort graduates to true pain and the exam has to be truncated. 

The senior citizen here began laughing! He chuckled so infectiously that my colleague joined in the laughter. 

“Now let us look at these slips”, we got back to the beginning. 

“Hii kipimo ni ya ajabu!” 

He could not help but marvel at the crazy and invasive examination I had just performed. He complained why I was the only one doing this crazy thing. I loudly wondered why he was the only one doing the crazy laughing. 

It was a draw!

The chronicles of a village surgeon