29 March 2013

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.


26 March 2013

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!