Communion

Yaoundé, Cameroun

Centre Hospitalière Universitaire (CHU)

April 2013

Last day at CHU

                              

I flipped open my patient’s blue cardboard folder. Groupe sanguin. Blood type. ---

***

The day before, I'd gone to the blood bank at CHU.

It was the first time I'd ever donated – my more than 6 months straight in Western Europe since 1980 disqualify me by Red Cross standards (mad cow disease/CJD). And even if that ever changes, after living in Africa, there's no way I'll ever be able to donate blood in the States.

The irony. I can donate in Cameroun. I explained to the phlebotomist that I can't donate blood in the US, trying hard to make my explanation make sense, without the questionable undertones of the Red Cross rules rejecting African or "African-ized" blood. It was my last day at CHU. In a month, I had watched people die, and I had maybe, minutely, helped. I had spent a night on call learning about how overstaffed the hospital really is, when compared to the resources they have for patients. Compared on that alone. The nursing censuses are lower. The doctor censuses, even, are lower. There were so many eager med students (their education, not mine), working zealously on med student-thorough, handwritten H&Ps in French or in English, that they sent me to the resident call room for an hour or two of sleep. The GI fellow was in there, and she woke up enough to kick off her shoes, move over, and give me part of the twin bed. I felt hesitant and unnerved; they were treating me like a doctor (and four months later, firmly enmeshed in my intern year, I finally don’t jump to attention at the appellation “med student”).

The transition from dark to dawn is the same in every hospital. There are the early evenings hours. There are the middle ones that stretch forever—nothing good happens, then. Either people are asleep. Or they are very sick. It's the slight undertone to complacency on a quiet night. In the US, we have pagers; if you lie down, you will be awoken. In Cameroon, there are cell phones, of course, but there is almost no reception in the hospital. And no one knows who is there.

---

I learned—and taught—chest compressions. I helped “consult” 140 patients in two hours by kerosene lamp in a cement block school room after a 21 hour trip and sleeping in a field. I gave hundreds of shots. Hundreds of deworming pills (mebendazole). (That, the last, is the only thing that rivals blood in real utility, real helpfulness).

The public health self gave mebendazole.

The doctor self gave blood.

And it was only one unit of blood. One g/dl hemoglobin. And it’s not type O. I’m no universal donor. I’m A negative. The phlebotomist exclaimed over and over how rare it is. A raw moment of guilt. My blood type.

“Will it help, anyway?” I asked. Hesitant. A real question. How long does it keep. To whom do you give the units. How well do the generators work that maintain the freezers. Let this not be mainly to make myself feel better. I don’t know the epidemiology of A or AB in Cameroon. In brief genetic terms, I can donate to A pos or A neg and AB pos or AB neg. And I can only receive A neg or O neg. But it also means that in emergency situations—when you don’t know the person’s blood type and don’t have time or lab availability (and the lab closed or out of reagents or on strike about one third to one half of that month)—you can only use type O. Not mine.

Let there be a point to this. Rather than just calling it an early day and going to lie down on a table, arm out-stretched, awaiting a quick sugar reward. Tired, on my second-to-last shift of a long month; days in the hospital and weekends on health campaigns in villages. A congratulatory and regretful marker—why did I not think of this years ago. There are useful ways to leave pieces of yourself where you do, regardless.

***

Mr. C needed whole blood. He needed fresh blood. I don’t remember the medicine of why or if I understood it in the first place. Fifty-two, seemingly healthy for the ICU, had some sort of job, I think, and he was weak but awake enough to talk, and he had a wife, and there was a cousin with a moto or a friend’s moto taxi who was going to the other hospital’s blood bank or to find someone else to donate or to find money to pay for the materials to transfuse.

Those were the ICU days. Sylvie (ER resident from Belgium) and I had decided to go downstairs from the ER (every other emergency department I've known is on the ground floor or near enough). Maybe it would feel less futile. Patients there had gloves and beds. Some had blood draws. They had family. They had windows, near the open air conference balconies.

Mr. C needed blood within 24 hours of its donation.

What did I bring on that trip but a suitcase of scrubs. Another medical implement to leave. Concrete. Gauze pads, tape, saline, alcohol, needles, suture, scissors, gloves, and a small cache of medication I imported directly from Mexico. Everything suddenly feels small, that one can bring in regulation-sized checked bags. Sub-Saharan Africa, unlike most of the world, still allows two.

***

Last day at CHU

I opened Mr. C’s blue folder. Groupe sanguin. Blood type.

A positive.

I had waited until the late afternoon. No one thought I should return to work minus a pint of blood. So, it was the last act of my second-to-last day.

My A negative and I, my exclaimedly difficult venous access and I, requiring the head blood bank nurse and her no-nonsense deliberation and needle (I'm accustomed to apologizing for my veins. I'm accustomed to directing the one holding the phlebotomy tray) were hours too late.

I set this up as a too obvious story. But it was a too obvious omission, that day, that I hadn’t looked first. Had I read his chart the day before. Had anyone asked. It was a pat irony, or an obvious one. This is the way the story goes. Some people give patients bus fare or metrocards. Some people give blood, marrow, and organs to friends, family, or strangers. I could have given my blood to my patient.

Just hours before. Would it have been too personal? Too martyr or savior-role, anyway?

***

NYC

Mr. D came back from surgery. Mr. D was bleeding. Mr. D was losing so much blood that he was getting dizzy. Mr. D needed blood. I put in the order, printed a label and stuck it to my hand, and walked quickly, the way doctors do, to the blood bank. “I need blood for Mr. D. We already called.” Here, only physicians can sign for blood. Sign out blood. Blood, plucked from freezer to fridge to a brown paper bag clutched in my hand, with implements for transfusion. The most useful thing I did that day was to walk to the blood bank and walk back. But here there’s no shortage, and here no one in Mr. D’s family had to donate in kind.

We asked. We were given. We gave it.

***

Yaoundé, Cameroun

There is not enough blood here, or water.

Peripheral

I look idly at the hand grasping the laundry basket. “That’s a beautiful vein,” I think. “Someone would be lucky to get to slip an IV into that.” And like everything that gets accidentally carried back from the hospital—venipuncture kits, 4cm x 4cm gauze (think: measures I am learning), alcohol swabs, tape, fecal occult blood cards and guiac solution, gloves—I have the materials to do it. But I’m not the one I would need practice on. It’s the patients with scarred veins  (drugs, fistulas, too many hospital visits) or overloaded with fluid—the “vasculopaths”— that take skill. A patient with good veins is a good patient. Ones that don’t roll or slip away from you. Ones that leap to attention under tourniquets and alcohol.

We are vampires not only at night.

It’s using your hands (not trusting your head), taking ownership of each step of the process, delegating tasks (most) that don’t take a medical degree to yourself.

I’ve caught myself thinking “I wish I had a med student for this.” To get patients’ weights while standing (find the heavy scale, wheel and weave it through the hallway, support the hesitant frame). To get orthostatic vital signs (vital. Life. Here, to check the difference in how fast and how hard the heart beats, how much the veins and arteries contract and relax, when equilibrating between lying down and standing up). It takes minutes. Five. Or more. I picture third year of med school, two hours per patients, an afternoon to sit and talk…

Or carry blood.

It’s the beginning and the end of the day’s menial tasks. I learned to relish the quiet moments, years ago—coffee and morning labs. Keeping track of numbers. Comforting shapes (mean: which value is this. Which electrolyte, element, atom. Which part of your blood) scattered across the paper—it used to be the pride, the insider-ness of using them and starting to understand what they meant. Now, it’s the morning labs. And in the evening, it’s entering orders for the next day’s labs. (What do I need to know about the inside of you. What am I following). It’s still trying to be careful and responsible with language, when entering notes into the permanent medical record. For example: patient refused the dose.  Or, patient declined the dose. Patient refused the exam. Or, patient declined to participate in the exam. Participate in the exam. Or follow commands. Or not.

For so much of the day, it’s numbers. Numbers correlated with symptoms. Refusing the medication lactulose, for example, means Ms. A’s liver disease will cloud her mind. I picture a shroud of permanent damage (cirrhosis. Hepatic encephalopathy). Septic flood waters rising into the brain. We have a medication for that. And we’ll titrate it, we’ll base our decisions upon how many bowel movements recorded in a day. The septic systems pulled down from the brain, down, down, and out. It’s one of the most important medications. It’s critical.

“Patient refused the dose.” And sometimes, this is followed by documentation of “Dr—notified.” And sometimes not.

The patient’s mental status is a temporarily soluble problem. There are so few problems we can fix. This one. We can help. But she refuses.

Because a 57 year old woman who brought up her (I found out today) 28-year-old severely autistic niece, who used to draw caricatures of tourists on the street, whose house slippers are red, does not actually want to soil herself and the bed (how many do I want) four times per day. When I read the “1”, “2” in the morning I’m disappointed. So I increase the dosage. It’s not working. It’s not working. And she can barely move to get up, and when she does, it’s certainly not swift enough for something this powerful.

In the middle of the day, I know this. At the end of the day, I finish my progress notes. “Ms A was cloudy today because she declined two doses.” But, I think, upbeat, she has a PICC line (peripherally inserted central catheter). It’s an IV inserted through the arm into the heart. It’s a longer-term and deeper-inserted IV, which is so easy to use and consistently get abundant blood flow for labs that it’s equivalent to a sigh of relief anytime I realize I need more information about my patients’ insides. Patients with PICCs are the sicker ones, whomever will need that many blood draws and that many days, weeks of IV medications.

I want blood from a sick patient. These labs will be quick. I’ll draw them myself. This is the one easy moment of the day.

I sit down, on the bed or in a chair pulled close, with the labeled, carefully colored-tubes beside me, and biohazard bag, two syringes full of sterile saline, gauze, alcohol swabs, and vacutainer adaptor. And gloves. For the one minute I’m here, knowing that I’m not causing any pain or discomfort, and doing something almost effortless and overflowing with potential, I am completely relaxed. I am accomplishing something – to check off – necessary.

And my patient and I can talk.

New site

Now also posting at: www.scalpelwithwords.blogspot.com

Where there is air

A warning: the cliched "not for the faint of heart." It's not that. This is brutal and real and written in the way it was lived and that now, three weeks later, I remember. I don't dissimulate because, well, why should I. If you don't want to read it, and there's nothing wrong with that, then don't.

There is much more to write that I am writing or have almost finished, and I'll send those, too. There is more that is, actually, happy. The month was that, too, but this is the medical part. 

These are no longer chronological -- and -- I'm currently back in the States.

I started this piece during a workshop I was leading on public medical writing, and for some reason I decided to leave myself (explicitly) out, though in truth I was very much a part of all of it. A lot of what was happening was both the resident and me, or I was giving and carrying out orders that she gave. And yell is a more appropriate speaks strongly, or gives orders in an emergent situation because it's necessary.

I hesitated about writing and then about sending this one. I am anyway. Because it's the truth, and because it could have been written more graphically and more difficultly than it is.

                                          ***

The trauma room is caked in mud: people’s shoes, falling off of clothes, some mixed with blood but all mixed with small rainy season.
The aide from that week’s emergency room team was sweeping.
The patient had been wandering around for days, slightly bored and healthier than most. She couldn’t speak. She looked almost comical, if you’re allowed to think that sort of thing. Tongue protruding (macroglossia. Medical term, like hypothyroid? I still hadn’t read the chart; there kept being something else to do) from her mouth. Larger than tongues are. When she made sounds, they might have been words and just unintelligible. I’d never tried a conversation. The thick bandage is wound like spools around her neck. Her bed was in the front room, where it never made sense who stayed and who went to the other, quieter observation rooms with four beds and curtains or eight beds and curtains. In the big room, the front one, everything was open. So many nurses sit at the triage table, close enough to see most of the patients, bored. There are the two men in, basically, comas, another one with machete injuries who is too large to move, and her, sitting on her bed or wandering. I don’t know if she had HIV, after which I’d have to say “too,” adding to the list of so many others in the department.
 It happens fast. No one screams or someone does, and enough were in the room as she grabbed at her throat. It must have been uncomfortable and hot, anyway, in equatorial Africa, the highest level hospital has no air conditioning (and no mosquito nets in the big room). One nurse starts to unwind the bandage. Slow. An ER resident here from Belgium for a rotation yells for scissors. There aren’t, or no one knows where, or no one tried to get them. They keep unwinding. She keep grabbing at her throat. The bandage was off. And she was on the floor. Bed. Fell.
The aide kept sweeping.
The resident looks at the nurses. Move the other patients over. Make room. We need her in the middle. Is she breathing.
She is not.
The aide kept sweeping.
It's the second time for chest compressions in two days, the nurses had started to learn the first new rule – thin, gym-like mattress to the floor. No point in compressing a bed that’s only springs. There aren’t any boards here. Mattress to the floor.
The aide kept sweeping. The resident yells. Points. The aide left the room.
Oxygen, get oxygen, she says. There isn’t. But we did this yesterday, she says. Someone move her to it. Someone get the tubing and the mask. Minutes, minutes. This time, someone goes to get the adrenaline when asked. Someone else doesn’t have a syringe. Wait. Where to get a syringe. Steal it. Steal it from the other patient.
The intubation kit. After asked. After pounding on the chest for however many minutes (still a pulse), with the ill-fitting mask, some oxygen, bagging it into her lungs three times after every thirty compressions (still a pulse).
 Are there any other doctors? Get anesthesia! The resident yells at a nurse. The nurse walks. The nurse starts to run. Minutes. Thirty compressions. Three breaths, or pulses from the bag into the mask into her mouth. No pulse in-between. A nurse kneels hesitant, holding the wrist, slight pressure on the radial artery. The resident yells. Femoral. You won’t feel it there. Femoral. The nurse kneels hesitant. Hand moved to the other pulse. Is there a pulse (no) are you sure (no) are you sure (yes). Still waiting.
The resident tries to intubate. A tube. A larger one. A smaller one. The laryngoscope has a light. The woman is choking to death. Her neck is swollen beyond recognition of what a neck might be. There is no way to pass a tube. She needs a tracheostomy, she needs a hole in her neck to help her breathe. The resident doesn’t know how. There is no one else.
A nurse is back. Slow. Anesthesiologist is in the OR. Get him! The resident yells. Slow walk away. Is he findable. A doctor appears, the ER one, but either he’s new to codes or he doesn’t believe this patient will live anyway or he doesn’t believe any patients in this hospital might survive. He leaves. After the gesture of wrist pulse to groin pulse to a few compressions. Minutes.
He returns with the ENT attending and a resident. A kit. They start to prepare the tracheostomy. Is there a pulse? (not sure) Compressions stop. Does that rock the hands of the attending trying to cut into the neck? (Yes) Should they keep going? (yes) Thirty. Three breaths.  Starting a hole to the outside air. Minutes. Is there a pulse? (no) Tracheostomy finished. Is there a pulse? (no) Is there air? (no) How long? (Ten. Fifteen. Maybe). Compressions stop. There is no pronouncing in this hospital. There is sitting back and leaving the tools and closing her eyes and trying to close her jaw.
Then close her eyes. A nurse tries to close her mouth. Then pull her dress back down, the sheet up. Not fast enough. Not good enough at finding the pulse (why is that hard). It is.
There is finding the charge nurse and asking him what we say. There is calling for her garde malades, again, thinking or knowing that they weren’t there because the last three times we called no one came and the others standing outside—every family knows the others, at this point, and so many of them sleep outside—said they were gone. (How do we tell them).
This time, they came. Must have been away for a few minutes. They didn’t know. Two men. About her age. The doctor said, the one who’d called the ENT. I can’t remember the words in French, now. They nodded and pulled out their phones and started making calls. In this culture, in this hospital, the women who start to grieve wail, scream, exude, ululate grief. You know, everyone knows when someone has died. The men, first, pull out their phones.
The day before was the first time I had ever performed chest compressions. For anyone who’s taken the Red Cross classes, one of my first thoughts was that those dummies are actually pretty realistic. That is what it feels like to pound, press all of your weight into, compress a human chest. They tell you not to be gentle, at all, not to be afraid of breaking ribs because that means you’re pushing hard enough. That doesn’t matter. I almost hoped that I would break a rib. That day, the resident and the doctor and I were sitting in the consult room. Slightly stunned. He pulled a jus (bottle of soda) out of the fridge. Something I do after a death, he said. People might think it’s insensitive or irreverent. I don’t. We took a minute, there, to drink, to be quiet and think.
So on this day, the second day, I change my clothes just enough to be decent to leave the hospital. walked across the treacherous like all in Cameroon) road, andI buy the same jus we’d had the day before. I bring it back. Let’s do the same thing, I say, again. It’s right. And we do.
Later, I go to get her chart. I hadn’t known her name, or her age, or remembered them. Now I do. M---*. Twenty-six.
There are so many people we can’t save. There aren’t resources or they’re too far away. The blood bank is closed. It’s not fast enough. There’s not money.
We could have saved her.
We didn’t.
We could have saved her. 

Let there be equatorial light

le 27 mars 2013

I used to think of writing (or doing anything inside) by headlamp as spelunking. It was certainly more practical than my first year PCV strategy of candles and kerosene lamp propped on various books and papers—before I had a table—and sitting hunched over to the in the right part of the penumbra.

It’s a funny thing about light.

The Constant Gardener came out weeks before I left for Peace Corps in Cameroon. Without mention anything else I love about the movie (which was great for terrifying many parents of about-to-be PCVs about to move to Africa), the light struck me. The quality of it. I’d noticed years before that Paris has its own quality of light. Some photos, movies capture it (Amélie does). I don’t think you can successfully pretend that something is filmed in Paris.

This light, though, the Kenya-in-the-movie light, was unlike anything I’d ever seen.

And then I moved to Cameroon.

It’s the same light. Gazing across the city at very familiar views this morning (Yaoundé, like Rome or San Francisco, is a city of hills), I remembered it. I have photos of the same view, and in the US they look—faded. Light-stained. But that’s how things actually look.

The forest almost never comes out, either. I think it’s more greens than the human eye can discern (we can see sixteen shades of gray, I recently learned, on CT scans).

**

I was reminded of why the old Snickers ad (Not going anywhere for awhile?) and Green Day (“I’ve been…waiting a long time….) used to enter my head so often. It took almost three hours to print and copy one document, for various reasons. On the way to the second printing place, though, I heard someone call my name. I turned. And it was a friend I hadn’t seen in 4 years. Now, he’s at the hospital where I will be this time, Centre Hospitalier et Universitaire de Yaoundé, a different one from where we were previously (he’s a resident). Currently, he’s working in the ICU, which is reanimation here. It’s about coding. (“Code blue”). Come back from the dead, make something alive or lively. Resuscitation, they call it, instead of our Intensive Care. Shortened, it’s “Réa” – it sounds flip in a hopeful way.

This—the chance meeting—is something that happens. In Ebolowa, my provincial capital, I couldn’t go anywhere without seeing people I knew; it was amazing and heartening a year and a half after I’d initially left. And it used to happen in Yaoundé, occasionally. When I had my first chance run-in in NYC, I knew I really lived there. And here? Apparently, I still do.

**

I’m waiting for the chief medical officer of the hospital to meet me and certify that I can be here. All I know thus far about the hospital is from the two French nurses who just left. They saw an upper GI bleeder come in. Died. They didn’t know exactly what was done or what happened.

This time, I’ll learn about the medical management here—what’s the same, what’s different, and what doesn’t exist. I learned some of that, before. And that you have to buy everything down to the IV tubing.

ER. Six weeks ago, I was in an ER in Guatemala (working, not sick). Small rural hospital compared to one of the top four in Cameroon, a major teaching hospital. There, they were oddly over-staffed. Here, I am the functional sub-I, or intern to the residents, or whatever approximated role.

Here, I walked in to see the repair of a scalp laceration, and by scalp lac I mean the cut penetrated to the dura mater, through the skull. Assault by machete. I’ve seen that, but the one I remember was due to a machete accidentally dropped from a tree. That kid looked like he was partly scalped. (And that was one of Doc’s gleeful moments, showing anatomy on monkey bones). Now, I wonder if, in the US, we’d put a JP brain in before closing the laceration. The kid is going to CT. Don’t know.

Next case. Moto accident led to a comminuted tibial fracture and a shattered fibula. We waited while the patient’s brother bought all the supplies requested. (Were I not there, would they still have had him buy two pairs of sterile gloves….? How to reconcile “teaching hospital” with patients paying for everything you use on them?

It was the first time I’d sutured in over two years. The light is weak and far away, we can’t raise the bed, the patient’s ankle is a mess with visible bones, he hasn’t had any pain killers and crying/screaming…(we did use local anesthetic)… But medicine is already (re)baptism by fire. Everywhere. This is nothing new. It’s vaguely remembering hand tying and instrument ties (it slowly returns), correctly angling the crescent-shaped needle, with the surgery resident showing me where to close because in that erratic wound with jagged layers, I have no idea.

Later in the day, I go to Hôpital Centrale to meet Dr. Bwelle for his medical student teaching rounds. He shows me the tall, modern glass-and-brick structure that looks like an added-on center to the other, spoked buildings. It was a Swiss project, he says, supposed to be dedicated to neurosurgery. But the people building it forgot that they were building a hospital. The floors are all completely flat—in ORs, this means nowhere to direct water. It’s all stairwells, for four stories. No elevators. The building has been empty for the past four years.

This is all too common a story.

**

As always, every day is every emotion. Aggravating (the personal level—dérangements, harassment, etc), but then also the men speaking in Bulu about me this morning led to “mintangen a wôk” – you know, the white woman understands you. And then I sat down with my spaghetti omelet and bread and “coffee,” (I’d forgotten about the sweetened condensed milk) and we chatted over their morning beer. (or, it’s evening for at least the one who drives trucks overnight).

But running from hospital to hospital (and angry when the taximan who had accepted my negotiated price then refused it and wanted more money), an exquisitely-peeled (not a good enough word. It’s beautiful, geometric) green-fleshed orange is just perfect to raise blood sugar back to awake-enough levels.

**

63 year-old woman. Altered mental status, sudden onset. Fever. Tachycardic. (and immunocompromised…) My mind starts racing through differentials, I try to rule out meningitis, I start to think about how to work up…and, wait, what we can work up, and I go talk to the attending. “It’s probably neuro-malaria.”

Oh. Right.

~j

The almost-doctor returns to Cameroun

Dear all,

I'm writing from Yaoundé, Cameroun. I will be updating my blog again during the next month, as I am working with Ascovime (www.ascovime.fr), an NGO here that does health campaigns in rural villages, among other things, incorporating clinical work and public health. 

I will do some writing in French, but Spanish...lo siento. 

I'm less than two months from my medical school graduation. 

Everything comes full circle. I took the MCAT weeks prior to leaving for Cameroon, the first time. I got my MCAT scores while in Bandjoun for training--my parents called. My fellow (then) Peace Corps Trainees knew I had been waiting to hear, and they were ecstatic for me--if I had to take the MCAT again, it would have been 3 years later, delaying medical school more (at the age of 22, I thought that time like that mattered). I saw my first surgery in Cameroon, a week and a half after arriving at post--December 30th, I think, 2005. I set foot in the OR in Mvangan in chacos and capri pants, probably with sunglasses pushing back my hair. My job was to hold down the patient's legs, so he'd stop kicking Doc who was trying to repair the perforated bowel piled in loops on top of his abdomen. I counseled my first patients, there--HIV, malnutrition. Learned and taught health professionals about preventative and public health. I ran a health district.

And then I applied to med school. Middle of my second year of Peace Corps service, June 2007, AMCAS--I turned it in the first day it opened; I'd had time at post to prepare the essays with help from my Peace Corps Volunteer friends. Everything was ready ahead of time because it had to be. I couldn't guarantee when I'd be in the city, and even if I was, when power would be working, when internet would be working...etc. Before that, I remember taking the (few years old) book of medical schools from the Case, our Volunteer house in Yaounde, and poring over it on the woven plastic mat in my house in Mvangan, by candlelight. I crosslisted schools by research rank, primary care rank, and school of public health (and then it turned out that the best one for me doesn't actually have a school of public health (well, at Berkeley, across the Bay), and I went for MFA and not MPH). I knew no one else applying, that year, I knew little more about the schools and process than what was in the years-old book, and everyone around me was supportive and helpful. A friend brought me my old laptop from the US, and when Doc's generator was on in Mvangan (and he always generously connected it to my house), I'd type furiously for my secondary essays, writing and editing otherwise by hand, and emailing/updating every 2-3 weeks in Ebolowa (almost missed an interview invite. Didn't). I scheduled all the interviews while I was in Cameroon, and I started interviewing a week after I returned to the US.

Medical school is why I left Cameroon. I very seriously considered extending my service for a third year and delaying med school, or staying for 6 months, or somehow going back to the States to interview on home leave and tell them I was planning to start in 2008--and then defer until 2009 after I got in. But my MCAT scores were expiring, for some schools (including UCSF), and so I left. In the end, I decided because I wanted Mvangan to have (two!! health and agro) volunteers for two more years, it was better to leave; I wouldn't have added enough time.

And for the first two years of med school, at least, I considered dropping out - frequently. Several per month. In order to go back to Peace Corps, do Peace Corps Response (then Crisis Corps), be a UN Volunteer...I was on email lists for all kinds of positions, and any time not being there felt like too long away. After being in the US for about 6 months (when I finished my service, interviewing for medical school, etc), I had the opportunity to go back to Africa, Kenya this time, for public health research (funded) - and I ran. I was away from Africa for 6 months. Then, 10 months. And now...three and a half, almost four, years. A friend said to me once, "it's hard to imagine there was a time when you'd never been to Africa." True.

I was called "dokita" for the first time in Cameroon; http://jenny-and-cameroon.blogspot.com/2006/05/paging-dr-jenny.html. I was introduced as "Docteur Stella, une etudiante..." by Dr. Ndom when I went back the summer between my first and second years of medical school. And now? It won't feel disingenuous. I'm returning to the States from Cameroon in order to graduate. I've finished all my credits. Really, I'm done.

In Cameroon, in Mvangan, I found the kind of medicine and public health that I want to practice. I had to leave in order to learn. My "back up plan," I told people, if I didn't get into medical school, was to stay, learn with Doc, and buy a medical degree (quite possible in Cameroon). Now? I'll be signing my residency contract in Cameroon and sending it from the Peace Corps office in Yaounde. 

When I was there, Bush and Cheney were on the walls in the office (in federal offices, required). We shuddered every time we walked in. Now? Much has changed.

My name is still on the wall, I'm told --- literally. My group decided that we would sign the wall in the Case when we COSed. Since then, some others have, but not all. My name, my writing, is still on the wall, just like it is in homeless clinic here.

---

As I was flying in last night.

The capital city is barely lit. At 2 miles up, it's 51°F. 66°F, a mile and a half.

You wouldn't know this was the second biggest city (I don't remember if Douala was more lit, arriving at night). Quiet. The only thing about this country that is. The rainforest, every night, was loud and exultant. Insects make noise, animals, people. Silence usually implied ear plugs. 

The way to the airport is dark. Pitch, in this almost-on-the-equator country with 12 hours of each day and night. 73°F at 3000 feet. The plane feels it, already. It was dark as we edged over the Sahara. Sahel. I know where we are and what it looks like. This, too, is rainforest. 

We land. The entire plane erupts in applause.

Outside, I will kiss my fingertips and press them to the ground. It's a mark of reverence, of respect. In African dance, we do this in front of each drummer, at the end. Here, I do it when I leave.

And every time I return.

On est ensemble - we are together - estamos juntos - bi ne vale!

~j