When the Potbelly Bullied the Bullet

It was another night call. I was the senior surgical resident on duty. This meant I held the department in my hand until morning when the rest of residents and consultants would troop in.

This particular call was tough. My first on call (junior resident) and I did not manage even an hour of sleep. We grabbed hot beverages here and there, after the quick early dinner. 

It is not unusual to have such calls. We would comfort ourselves with the general surgery trainees’ mantra: “sleep when you can, eat when you can and never mess with the pancreas”. 

The shift had begun with phone call after phone call from the emergency department. Then wards. Then theatre. We had split up and I had headed to theatre while my junior patrolled the corridors of the wards and emergency room as need arose. My phone kept buzzing every so often. I would stop midway through surgery and listen as the circulating nurse held the phone to my hear, or sometimes put it on speaker and placed it just within earshot.

It was not that the junior resident could not perform the surgeries independently. We had just opted to share the workload- another strategy often employed during the so called graveyard shift. 

I had descended to theatre with my laptop at around 9pm. I had just plugged it to charge and started studying in preparation for the following morning class when the alert came. A couple of injuries in casualty, then an acute abdomen (meaning anything that can go wrong in the abdomen and require emergency surgical intervention). 

Acute abdomen in Casualty

I had left my laptop on the couch and stormed out of the operating room lounge. Within two minutes or so, I was in emergency department. Having quickly reviewed the patients and adjudged none to be in grave danger, I had asked the junior resident to stabilize a couple and then team up with me in theatre as I pushed to finish the emergency surgery cases early for us to rest.

I must have jinxed the call by declaring to him that sharing the workload would get us free by midnight to catch some sleep. The torrent began, and my junior colleague never made it to theatre. 

‘Diseases come in battalions’ is a mantra in medicine. For this particular week they had presented in the pattern of gunshot injuries. Gangs of robbers were terrorizing the capital from different directions. Earlier that morning we had concluded on surgery for two family members who had sustained varying degrees of gunshot injuries. Three had been admitted- a father and two daughters, I think. One daughter had been discharged with minor injuries. The other and the dad had been scheduled for surgery following each other. 

Surgery had not gone so well for the dad. We had lost him moments after surgery. We had to find a way to navigate the daughter coming into theatre to ensure she did not know what had just happened. 

Following deliberations with the mum, we had planned to discharge her soonest after surgery so that the whole family would mourn together. 

Another interesting  fact of surgery is that what looks like a simple straight forward surgery can really take longer than anticipated. The midnight laparotomy (opening of the belly) for the acute abdomen had delayed to start- getting a proper IV, getting the patient to sleep, finding the wide pipe to intubate and all.  

Middle-aged Man shot in the abdomen

While I had thought that we had closed that horrible gunshots streak, we were here with another middle-aged man shot in a similar pattern. 

“Just keep him hemodynamically stable and wait for my directive”, I could hear the cardiac monitor alarms on the other end of the line. 

One way to know that the night is ebbing away is when you encounter janitors pushing trolleys of clean linen while brushing shoulders with the team mopping the hospital corridors.

“Doors closing. Doors opening,” the elevator kept announcing as I turned from one corridor to the other.

I semiautomatically found myself in the emergency room as soon as I was done (not quite) with theatre.

I took a quick look at the gentleman and got a certain spirit of reassurance running through me. He was fully conscious and did not labour to breathe. His blood pressure was normal though his heart rate had climbed to above a hundred. The cause of a racing heart rate in a trauma patient is a popular question for post graduate students. In surgery it is often emphasized that one has to ignore anxiety, pain, medication and all and just imagine that the patient is bleeding. 

And that is what I imagined. The next question usually becomes, ‘where is the patient bleeding from’?

I looked at his abdomen. Hairy and obese. It moved with respiration. There was an entry and an exit wound. Anywhere in between those two wounds ‘hurt like hell’ when I touched.  

Forensic pathologists will tell you how you can estimate the position of the assailant and that of the victim by tracing the entry and exit wounds. Then they will quickly add that the trajectory of a bullet tract is extremely unpredictable. It can take curves, corners and detours before exiting the body. We should always avoid  the temptation to assume a straight or curved line between the entry and exit wounds, however obvious it appears. 

I could foresee a popular discussion during the morning meeting:

“Gunshot to the abdomen with tachycardia and tender abdomen, why did you not go to theatre straight?” That school of thought would have a camp of professors and other senior surgeons. 

“The blood pressure was normal, meaning the patient was in compensated shock. Why did you not consider a CT scan of the abdomen to offer a road map before surgery?” This other camp would have an equal number of debaters, all of reputable expertise. 

It would be a kin to a hung parliament in a democracy.  

As the senior resident involved in the case, I would have to take the speaker’s seat and reiterate both observations while at the same time affirming their relevance. I would then have to justify one option. And that option would not fly if it was “ the consultant advised”.  

I took my side, and I knew what literature to quote when the debate came. I ordered an urgent CT scan of the abdomen. I needed to see the bullet tract and then imagine the trail of destruction left behind. In case of certain ‘tiger territories’ I would know that an uphill task awaited me in theatre. I would summon senior back up before putting knife to skin.  

It was nearing daybreak. Traffic had started building up from the highways you could lay your eyes on from the top floor windows. The matatu hoots would be heard from the adjacent termini. 

CT Scan of the abdomen

I passed by theatre lounge to pick my laptop. The screen had gone to sleep after hours of inactivity. ‘EVERY BLEEDING STOPS’, read the screen saver. I flipped it closed, threw it into the rucksack and headed out. 

I knew  I needed to text a couple of consultants about admissions overnight so that they would be prepared coming in the morning. Otherwise the patients could easily miss a consultant review until later in the evening or the next day. 

I finished my texts as I sat in front of the CT scanner, next to the radiology technician. He was a jovial man of short stature. He coincidentally tended to be on night duty with me on many occasions. We both tried to smile early morning greetings but the sleep, hunger and fatigue of walking the corridors all night (and previous day for me) betrayed us. In front of us was the computer connected to the CT scanner. Adjacent to it the voice controls. We were viewieng the patient from the glass screen. 

“Breath in and hold”, the scanner speakers ordered the patient as the technician pressed a button. He pressed another button and some contrast chemical was automatically pumped into the patient’s forearm. The scanner slid up and down. The patient held his hands behind his head. Then the first images started rolling on the computer screen in front of us. 

I thought the abdomen was ‘clean’. All organs looked normal. No free fluid or air in the abdominal cavity. No blood clot around the solid organs like the liver and the spleen. 

The consultant general surgeon on call called my personal number.

“Where are you Stanley?” he enquired for he needed me to show him the newly admitted patients. 

I asked him to join me at the radiology suite. He walked in some minutes past 6 o’clock with another chief resident. We breached protocol and started looking at the scans before examining the patient. We even joked how we would be frowned upon were we to be found out by the rest of the team examining CT scan images without first hearing then examining the patient. 

“There is no peritoneal breach”, we agreed in unison having peeped at the relation of the bullet tract and the outer apron of the abdomen cavity called the peritoneum. Only the skin and the abdominal wall muscles had been injured. 

Good News at the Bedside

We now strolled the corridor to the patient’s bedside to examine him and give him the good news. 

The consultant and chief resident exchanged glances with me when they saw the size of the patient’s tummy. It was a luxury we could all afford, given that even the heartrate had ground to normalcy in the intervening hours. 

We reassured him that his life was out of danger. We would do some limited surgery around the gunshot wound to wash out any dirt and debris. Then we would monitor him. 

When we stepped out of the patient cubicle, I was now the centre of the ridiculous attention. 

“Do not always look down on us because of the potbelly bwana”, said the faculty. To which the resident added that had I been the victim (God forbid), the bullet would have stopped at my spinal cord. 

In other words, RESPECT THE POTBELLY, I concurred. 

And just like that, all those comments of ‘how do you ensure diet discipline?’; which gym do you attend, I would like to recommend my husband?’; ‘we are watching what we eat, unlike you’; were forgotten. 

During the morning meeting there were no questions on my decision to send a gunshot patient for abdominal CT scan. It was an exaggerated string of low blow comments on how I should aspire to grow a potbelly. Friendly fire moment, we called it. 

Later, the professor teaching the nutrition class summed it up with an off the cuff remark: 

“If I am operating on Stanley, he will be started on total parenteral ( IV drip) nutrition from day one. As for X and Y ( well-stocked colleagues whose names will be withheld for the sake of global peace), they can starve for a week for all I care.” 

THE PATIENTS WHO PRAYED FOR ME

I was not really ready for emergency surgery. And he did not need one anyway. 

“I shall fill up the insurance paperwork and will then book you for surgery in a week or so”, I assured him at the end of history and physical examination. 

“Can I have the surgery tomorrow?” he wondered. 

Just as he did when I explained that it would take the paperwork at least a week. Hence why I was giving him a theatre booking in two weeks. 

“The diocese will take care of it”, he declared matter-of-factly. 

Meet Fr X. 

He had come to clinic around midmorning and had been patiently queuing outside with the rest. 

I had seen him at around lunch hour. My sugar levels had dipped and with them they had carried the attention, leaving behind a heightened sense of impatience. Under these circumstances, nitty gritties like self-introduction are jettisoned as my mind keeps shouting “this last patient then I take a lunch break”. 

I have realized that this is the watershed moment of my clinic room consultations. I find that as I take my lunch or coffee, I keep remembering how I could have spent an extra second listening, an extra minute explaining, an extra moment showing empathy to that last client. 

I filled the insurance forms anyway and told him that I would be more than happy to repair his hernia as soon as he was ready. 

And ready he was, sooner than I had anticipated. 

When I passed through the theatre that evening to check the list of scheduled patients for the following day, his name was there. 

The diocese had taken care of it real quick! 

The morning of surgery came, and I showed up early as usual. 

Early Morning Surgery

I changed from my khaki blue pants, checked shirt and maroon sweater and strolled through the theatre corridor. I carried a book in one hand and my coffee mug in the other. It would be another 20 minutes before everyone would be ready, assuming there was no emergency. I have always appropriated those minutes to a great length by reading a book. It helps keep me occupied and protects me from my impatient self. 

“Cometh the day cometh the hour,” I announced as I met Fr X at the receiving area. 

He was cool, calm and collected. No qualms. No repeated questions. 

He followed our directions. Turn here. Step here. Lie here. Put your hands here. We are now checking your blood pressure. All the motions before the surgery he bore with the same calmness. 

The door swung as the trolley with the operating buddle of linen and equipment was pushed in. Then it swung as the anaesthetist stormed out to get the correct sizes of the breathing tubes. The adjacent one swung inward as the scrub nurse came in, hands in the praying position, having scrubbed and ready to slide into the sterile gown and gloves. 

The cardiac monitor bleeped from the left side of the room while the anaesthesia assistant ensured the oxygen piping was properly hooked to the gas cylinder. The aircon had just been humming for a few minutes, making the chilly morning less hostile. 

We were done with “cockpit checklist” before putting him to sleep. He then sat up and suggested that he prays for us before we start. We all welcomed this gesture. 

Silence descended. Only the cardiac monitor bleeping went unchecked. 

I do not know whether his prayer was spontaneous or a recital from one of the many customized catholic prayers. His command and brevity bore the hallmarks of seasoned intercessor. 

“We make our prayer through Christ Our Lord.”

“Amen.” 

We were done with induction of anaesthesia as soon as we were done praying. We did not have any difficulties pushing the breathing tube down his throat. 

And the surgery was over in an hour’s time, as had been projected during our time-out session. 

He could eat as soon as he was fully awake, I advised in my post-operative orders. 

He is okay to be discharged

The next morning, I passed by his room in the hospital’s private wing. He was up and about and had cleaned up. The dressing covering his surgical site was clean and dry. He could walk and he could go home later that day. I only reminded him to be cautious not to lift heavy weights for a couple of months. 

Midway through my ward rounds, while engaged in another wing of the hospital, I got a phone call. 

He was preparing to go home. Staff were apprehensive that it was too early. 

“Let him go. I already saw him earlier this morning”, I concurred. 

“He will be okay, do not worry”, I was now trying to convince a colleague who called minutes later. 

It so happens that Fr X was headed to chair a school board meeting. A driver was at hand. And he carried his pain medication. The dressing would be removed in another day or two from the nearest health facility.

 

Confession before Wedding

Years later. Saturday morning. Hundreds of kilometres from the hospital. The weather is clear though the forecast warns of afternoon showers. I am already at the venue. It is my wedding day. 

Most of the groomsmen have arrived. 

As I say my “nice to see you”s and “looking sharp”s, I run into a catholic priest. He is strolling the pathway from the main church towards the priests’ residence. His pot belly holds the stole as he strokes it with his right palm. 

“Huyu ndiye bwana harusi?” he chuckles upon setting his eyes on me. 

From his unmistakable voice I can sense a de javu. We both take off our masks (yes, corona has already introduced a new normal). 

You can pick the “Eureka!” expressions from our faces. 

After another eternity of waiting, it is time to start. The program indicates that Fr X will be in charge of confession. It is customary practice for a Catholic to receive the sacrament of confession before a wedding. 

This time round we both sit in plastic chairs two meters apart. There is no bleeping cardiac monitor or the buzz of nurses setting up a buddle of surgical instruments. There are no doors swinging open to accommodate the anaesthetist with a tube, or the scrub nurse ready to slide into gowns and gloves. The room is warm but misses the humming of an aircon. There are only two souls engulfed in an eerie silence behind a closed door. He is in a cream cassock and his stole now hangs free from his neck without resting on his pot belly. He leads and I follow. He speaks softly, having heard me. We are done quickly. And I step out, my hands in the supplication position, heading to a serene corner of the church. To complete the remaining session of my private prayers. 

***

When I resumed duties after a brief honeymoon, I had a 4-year-old boy booked for repeat surgery. 

Second Surgery

He had been born with undescended testicles. Nine months earlier a colleague had performed the initial surgery. The plan being to free the testicles from high up in the groin and create a new abode for them in the scrotum. There they would be safe from trauma. There they would be shielded from sudden changes in temperature that can be inimical to their crucial work of producing sperms and perpetuating a generation. 

When my colleague got underway, he realised that he couldn’t bring all the testicles home as yet. He had to tether the left one somewhere lower in the groin for a second attempt months later. 

When I had seen the boy, I had ordered a scan to ensure that the testicle was of good size and did still have good blood flow. The results came back in the affirmative. 

And now we were here for that second bite at the cherry. 

I noticed that as soon as he got to Theatre, most of the nursing and anaesthesia staff knew him. 

“This is the prayerful boy,” they said. 

When he got to the Operating table, he pulled out an A4 foolscap with a page full of handwritten prose. 

Learning from history, the nurses paused from their pulling of trolleys and stocking up of consumables. The anaesthetist put aside her tube and turned off the gases. I stood next to the theatre table, on the right side.

Our patient began to pray, reading from his foolscap. For his age he had a great command of the English language. He prayed for himself and his family. Then for the team of doctors and for the surgery ahead. His tone was constant and his voice audibly clear. 

“Amen” came at the end. 

Then he lay on his back as he handed me over the leaflet. I could glean the original prayer in good calligraphy. Then there were a few corrections. A crossed word replaced with the appropriate one, a letter inserted here and there to ensure proper spelling, a tense adjusted from present to past and vice versa. But the original version carried the bulk of the message. 

I did manage to bring down the testicle to the scrotum and tether it there. And he went home after two days. There was no prayer session during his clinic review in two weeks. 

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**