Kenya Notes, February 2017
A caution: The following contains descriptions of medical scenes which may be uncomfortable for some.
When the pulse is 145 beats a minute, I don’t like to put patients on Kenyan roads. The young woman had suffered a severe nosebleed around midnight. Her nostrils were stuffed with protruding red gauze. The family wanted to take her to another hospital. Visions of a precipitous dip into a pothole, or a precipitous rise in the air, dislodging the gauze or blood clot, clouded my vision.
“Let’s give her a unit of blood and make sure she doesn’t bleed again. Then they can take her tomorrow.” In hindsight…
The bleeding began again in the evening. The newly minted Kenyan doctor and I struggled to stop it as basins filled. The patient became more unstable and that familiar knot formed in my stomach: The situation is slipping beyond our control, and the patient with it. Strangely, I wondered, is this why I now run a charity? Maybe I can’t handle bad outcomes anymore.
I called Dr. Tony Mwenyemali. Tony is a Congolese surgeon whose training AMHF sponsored. And had he not been in Maua that day, this story would have a very different, and sad, ending.
Tony also tried our approach: Take a Foley urinary catheter, insert it in the nose, and blow up the balloon meant to keep the tube in the bladder. If inserted in the right spot, the balloon will “tamponade,” or squeeze, the gushing vessel. The problem is that we could not get the catheter to stay in one place; it kept sliding toward the back of the throat and gagging the patient. In the US, specially designed dual-balloon systems prevent this problem. We didn’t have one of those. The nurses had to run around just looking for more gauze.
Finally, Tony managed to stop the bleeding and left. Another transfusion — there would be four in total — was arranged. Soon the bleeding returned. So, again, I called Tony. He was right outside the ward, watching a YouTube video on how to stop nosebleeding (epistaxis, in medical parlance).
This time, he took a roll of gauze and coated it with petroleum jelly. Now it was a kind of semi-solid gelatinous mass into which he sewed a suture. The Foley catheter was guided through the nostril and threaded to the back of the throat, where Tony grabbed it with forceps and pulled it out the mouth. This maneuver he performed on both sides and then attached via thread the soaked gauze to the mouth-end of each catheter. In the middle of this life-threatening crisis, the patient resembled a kind of ridiculous Rube Goldberg contraption, with flexible pipes hanging from multiple openings.
[Let it not be said of Tony as a character remarked in Dostoevsky’s The Brothers Karamazov: “ The old doctor who used to cure all sorts of disease has completely disappeared, I assure you, now there are only specialists and they all advertise in the newspapers. If anything is wrong with your nose, they send you to Paris: there, they say, is a European specialist who cures noses. If you go to Paris, he’ll look at your nose; I can only cure your right nostril, he’ll tell you, for I don’t cure the left nostril, that’s not my speciality, but go to Vienna, there there’s a specialist who will cure your left nostril. What are you to do?” ]
Now for the coup d’état: The nose end of the catheter was pulled, dragging the sutured jelly-gauze through the mouth, up the back of the throat, and into the posterior nasal passage, where Tony cinched it tight. The process was repeated on the other side. And, finally, mercifully, reprieve.
During the several hours we struggled to save this one person’s life, absorbing the time of multiple nurses, the other 45 patients on the ward just had to wait. With a nationwide doctors’ strike in Kenya, the government hospitals are paralyzed. Only the mission hospitals and (for a few with resources) the private hospitals are functioning. (A colleague at another facility told of a young severely dehydrated child, his veins carrying the equivalent of salt-water, being turned away from two private Nairobi hospitals for want of a $3,000 and then a $6,000 deposit. Like Maua, the hospital accepted the patient, and, like Maua, will suffer financially for it.)
Our patient would bleed again mildly at midnight and just before transfer to the ENT surgeon, but by that time transfusions and saline had stabilized the blood pressure. The family had some resources, making it possible for the private ENT specialist 90 minutes away to see her and provide definitive therapy.
Tony spends most of his nights in such a way now. A boy brought from a village in the park gored by a buffalo, the horn having gone through his palate and up through the nose, barely missing both eyes. A woman with an intestinal obstruction. And then there was last Friday.
“Oh,” I thought to myself, “how nice! They are ringing out the week.” The church bells pealed for a noticeably long time while I contemplated my book and ice coffee, ready to welcome another gorgeous Kenyan evening.
It wasn’t to be. The bells were an all-hands-on-deck call. At Kijabe, we used to receive a 999 page for a mass casualty. In Maua, they ring the bells (not sure how the signal is interpreted on Sunday mornings). Tony called, obvious distress in his voice, asking for help.
The casualty was carnage. Maua, like most old hospitals, just isn’t set up spatially to deal with this kind of onslaught. Patients spilled out into the corridors, were bundled onto wheelchairs, or, if deceased, laid in back rooms. Staff ran with stretchers. A crowd of over a hundred formed outside the gate, desperate for news of loved ones. A nurse stole a moment to console a wailing wife. From cleaners to guards to nursing students to doctors to administrators, a kind of chaotic emergent order arose, each cadre attaching itself to the right level of acuity as the triage process took shape out of the formless void.
Then there was me. I am an internist for a reason: lots of thinking, not much doing. Spotting a senior nurse who could cover for my lack of trauma skills, we began caring for a man who was injured but stable. A few broken ribs, a scalp laceration, but otherwise manageable.
The next patient was a different story. His level of lucidity was remarkable given the blood coming out of his ears (signs of a fracture of the base of the skull), deranged shoulder, and mangled leg. As we cut away his clothes, money spilled out of pockets. It had been a market day, for which Somali tradesmen come from further north. They were returning home with the proceeds.
“Somebody count the money,” ordered an administrator. And, while I tried to focus on resuscitation and wound care, a nurse dutifully counted out about $250. She was waving the bills in his face, saying essentially: “This is yours. It’s what you should get back from us.”
Leg splinted and pain assuaged, at least temporarily, he was trundled off to the surgical ward, to be packed into the already crowded, poorly lit rooms like a sardine. As badly off as he was, he would not be operated on that night.
Tony was trying to stabilize chest and pelvic wounds. In the meantime, one of the three young Kenyan doctors the hospital had managed to hire during the strike announced that he had to go perform an emergency C-section: Mothers and babies don’t wait because of a car accident, no matter how catastrophic.
And it was catastrophic. A truck carrying passengers had lost brakes and plowed into four other vehicles before rolling to a rest against a house near the road. As many as nine were dead upon arrival; another died at the hospital. An additional 30 had varying degrees of injury which would take time to sort out. Those who could afford were discharged to hospitals closer to Nairobi. For most, transfer is not an option.
The provincial capital possesses a government referral hospital, but no doctors. A few smaller mission hospitals don’t have a surgeon. The next biggest mission hospital, with a surgeon trained like Tony by the Pan-African Academy of Christian Surgeons, is about three hours away. Except that surgeon was not there. He was operating in Congo, Tony’s home country. Because the missionary surgeon usually in Congo was in Iraq, operating. It’s like moving around a few precious gold chess pieces on an insanely large board. Sooner or later, you just can’t cover it, no matter how larger-than-life the Kings and Queens.
Tony had mercy on me. “We don’t want to make our internist start suturing.” I went home to sleep. Tony and his team were up most of the night — again.
Dr. Jon Fielder is the President of African Mission Healthcare Foundation