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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