Off-duty doctor??

By Dr Lucianna

Surprise twist at accident scene

A certain man was driving from Nairobi to his rural home in the Mt. Kenya region. He was an off-duty doctor, if indeed the term exists. Nah! It doesn’t! My lecturer, Dr. Kodwavalla would agree, he used to say… the moment other guests realise you are a doctor, the party is over for you! It doesn’t matter that you are off-duty! The pre-millenials will remember him as Dr Yusuf Dawood of the surgeon’s diary in the ‘Daily Nation’. I personally experienced this phenomenon especially when I happened to attend an event with my sister. I think she was more excited by my achievement than I was! The moment she introduced me, ” this is my sister, Dr. K”, the fun was over for me. From then on it was “this headache” or “heavy menses” or “that kid with a poor appetite” or “somebody’s mother’s backache”. In other words… Doctor in the house! Hey! Come hither! Party over! And by the way, how is it that all those kids said to have a poor appetite are always overweight? Just asking…

Anyway, I digress. It was very early in the morning. This off-duty doctor knew he would make it home in time. He was travelling to take his mom to a doctor’s appointment about 25km away from her home. Mom was ready, all dressed up… headscarf in place… Breakfast was ready… I’m sure sweet potatoes were on the menu and I guess she was waiting to share it with him. Today was the day for her monthly check up. She had had it clearly marked on the calendar on her kitchen wall. Every important day was marked on that calendar.

The topography in the Mt. Kenya region is exciting, ‘beautiful’ does not begin to describe it. The road rises and falls and meanders. At the bottom of almost every valley is a river. Most of them big rivers, but even the tiny ones are forever flowing, they never dry up. Arrow-roots complete the picture in the valley. During our geography lessons we read about dry river beds and our young minds could not fathom. Wadi, what’s a wadi? A dry river bed? Then how was it a river? Rivers are rivers because they have flowing water, right? We only believed it because the teacher said it was so and teachers and text books didn’t lie! At least ours didn’t. The Mt. Kenya region has exciting views to the eye… yes, but it requires cautious driving. These are not the kind of roads where you test your speedometer, no, they are the kind of roads that test your brakes!

A few kilometres from home, as he went down one particularly steep decline, he beheld a chaotic scene at the bottom of the valley. Apparently a mini-bus full of people had gone off the road and plunged nose first into the river. He approached cautiously. Screams and shouts rent the air! Everybody was pulling and hauling in every imaginable direction. Kenyan volunteers at the scene of an accident sometimes cause more harm than good. They will pull in an attempt to free a trapped victim, in the process they will pull apart broken bones. They will tear muscles and nerves and rapture blood vessels. They will snap an already injured neck completely breaking it! They will carry a victim like a bag of potatoes! One person will grab the legs while another grabs the hands! Oh, the chaos at the scene of a rescue! Kenyans don’t know that they need to stabilise an injured neck before moving a victim, nor do they know that they need to stabilise a broken leg or arm. In ignorance, they will rush to rescue those screaming the loudest. They don’t know that the guy sitting quietly, staring at nothing, is probably the one most in need of attention. All this done with a lot of vigour and a lot love. This kindness kills a lot of victims who would otherwise have survived.

When our off-duty doctor got there he forgot that he was off duty. He even forgot that he had come over 100km to take his mother to see a doctor. Adrenaline pumping, he took charge. He started by assessing the situation and asigning tasks to the rescuers. He had the most severely injured patient carefully transferred to his car. He instructed them on who else to prioritise. He drove to the nearest hospital. One look at the the patient and the staff asked that he be taken to the bigger hospital which was about 20km away. They couldn’t deal with his injuries. Back into the doctor’s car the patient was put! Other casualties from the accident scene had started arriving. The good doctor drove as fast as the road could allow, up the inclines, down the declines and around the bends. By the time he got to the next hospital he was rather desperate because his patient appeared to be getting worse. He introduced himself as a doctor and started working on stabilising the patient. After the patient was settled he walked back to his car, arms hanging limply with fatigue and hunger, his shirt blood stained.

Back at home mom was wondering where her son had disappeared to. There had neen no communication whatsoever. It was the era when only the fabulously rich had mobile phones. Generation Z, do you copy? As the time crawled by, she was getting rather jittery with the sound of every passing car and wondering whether her son had gotten into some kind of mishap. One thing she knew for sure, he hadn’t forgotten his mom’s appointment, not him, no not him. What appeared like centuries later, she heard a car drive into the compound. Pretending not to be worried she calmly waited for an explanation as she warmed his lunch. It was by now way past lunch time. After he explained, she was relieved. She reassured him that helping the stranger was very much worth her skipped doctor’s appointment.

Fast forward, a few weeks later, the off-duty doctor learnt that, sadly, the stranger he had rescued didn’t make it. He also learnt that this stranger turned out to be a cousin on his mother’s side. Can you imagine the guilt that he would have had to live with had he left him to die by the road side?

This good doctor is my husband. As I write this, it’s his birthday. Doctari, enjoy the goodness of the Lord in the land of the living!!!

Air Rescue

By Dr Lucianna

We left without the patient

It was getting late. The pilot was getting rather jittery. Ignorant of the facts, the nurse and I were having the time of our lives… Really enjoying the outing as we waited for the patient. Those air rescue missions were exciting! We got to fly all over Kenya and occasionally beyond. On this particular mission we were within our borders. From the air, Kenyan scenery is “a spectacle to behold”! We have a beautiful country, really we do. No wonder it’s the number one tourist destination! Throw in “the big five” and the whole world wants to come. Who doesn’t want to see the elephant, the lion, the leopard, the buffalo and the rhino? Tell me, who? Did I mention the wildebeest migration? The seventh wonder of the world!!

On this particular mission we were somewhere in the Rift Valley. We had gone to “rescue” a patient who needed specialised treatment in Nairobi. His team on the ground and ours in Nairobi had shared every detail that needed to be communicated. His team had been directed to the airstrip of the pick up and of course they had agreed on the pick up time. The rescue team included the pilot, the nurse and the doctor. It was getting late and those bringing the patient had not shown up. Kenyans!! Honestly they can be such terrible time managers! Annoying, eh! The pilot was getting uncomfortable. He told us we had to leave. Without the patient?? We couldn’t see how. It had really cost them to get a rescue team out there.

I remembered this incidence after Kenya received the shocking news of the military helicopter crash last week. It was reported that visibility got poor as they flew over Kajiado. The moment they realised the kind of danger they were in, the soldiers started sliding down ropes from the spinning helicopter. The ones that managed to touch ground before the crash got saved. It must have been really scary, knowing that they were going to crash. The survivors really need to have a lot of counselling. It’s not easy living with the fact that you survived while your colleagues didn’t. On one hand, you are relieved that you lived but on the other, you feel guilty that somebody else didn’t make it. It’s especially so if they had to scramble for the ropes, assuming they weren’t enough for all. I don’t know what military protocol dictates about the order in which those in danger get out of such a predicament; but when a ship, capsises, the captain is the last to disembark. Remember the Titanic? The captain and the crew went under with the ship.

Our pilot told us that visibility was getting poorer and poorer as dusk approached. He feared that take off might get compromised. We could only take his word for it. To layman eyes like ours, vision was superb. We could see kilometre upon kilometre around us. We were thinking like drivers, not like pilots. If the decision had been ours to make, we would have waited for the patient a little longer. Not that we didn’t try to persuade him, but he knew his stuff. He was after all a professional in his line of work! It was not a risk he was going to take. So like Kenyans say, “shingo upande” we accepted his decision. It was the best decision in his professional opinion. Who were we to argue?

I have seen patients arguing with doctors trying to push them to do things which in the doctor’s professional opinion are not right. They will seek a second, third, sometimes even fourth opinion if they don’t get their way. Some will even go herbal or the witchdoctor way. Agreed, it’s their God-given right but at the end of the day a lot of precious time is lost. They come running back when it’s too late. If its a cancer, they come back in stage 4!! Here is a small piece of advice: Pick your doctor right and trust him. Pick your architect right, your lawyer, your mechanic and then trust their decisions. If Mama Kiarie, tells me a certain style is not suitable for my body shape, I trust her opinion. Pick your fundi right and then trust them.

We therefore left without the patient and by the time we landed in Nairobi, it was already dark. At least airports are equiped for take off and landing at any time, day or night. Though even they, in all their sophistication, sometimes surrender to the dictates of weather. They occasionally divert the landing aircrafts or delay those scheduled for take off. Our pilot had been trained to watch out for such. He knew how to read the times, not just the time. He couldn’t allow ignorant laymen like the nurse and I to compromise him. Had he waited and then crashed, the blame would have been entirely on him. The decision was his responsibility.

What happens when danger is unforeseen? What happens when the pilot has no chance to read the signs? What happens when suddenly visibility is reduced to zero mid-air? Depending on the topography, I guess an accident is inevitable. I shudder to imagine the split second between seeing danger and crashing. Almost no time to react. Other times they don’t even get to see the danger! I wonder if they even feel the impact. I have zero expertise in such matters. I cannot even try to apportion blame. But it’s sad we had to lose our young people

Remember not so long ago, another aircraft disaster? Two young lady pilots perished because of poor visibility. They were flying over the Aberdares heading to Nairobi one day in the month of June. There were no survivors. All ten lives in the craft perished. May-June-July is a nightmare weather-wise in Central Kenya. Sometimes even driving can be a major challenge. The two young ladies had accomplished so much professionally at such a tender age. Their stars were rising. They had their whole lives and exciting careers ahead of them! We can only celebrate them.

Hear all ye good people; when an air search for survivors has been suspended, judge not. It’s because of poor visibility. It essentially means they can’t see where they are flying or what they are flying into.

Mental Health Issues

By Dr Lucianna

Suicide among the young

I had a series of wierd dreams last night. This “mùgùrùki” aka “janeko” aka “mwenda” aka “madman” kept chasing me up and down, round and round! He was wielding this sickle shaped pocket knife in his hand! At some point I found myself wielding a similar knife of my own but I was no match for him so I ran! The kind of running one does in dreams with “janeko” breathing hot air down my neck! Am I the only one who gets such dreams? Anyway, I would wake up from my dream and think, phew, it was just a nightmare! Only to fall asleep and again resume being chased around! Why such a dream honestly, why? I realised it’s because the material for the topic I was intending to write kept eluding me. Last week I was asked by somebody to write about mental health issues. The kind of guy chasing me around in my dreams is the stereotype of a person with mental illness.

After I woke up I remembered one day walking down River Road eons ago, this one for real, not in a dream. There was this “janeko” fellow, walking towards me from the opposite direction. He threw a flying kick at me! Out of nowhere! No provocation! It just happened, for sure it did. I was with my uncle, a big guy, but “janeko” was not intimidated. Then he continued on his way like nothing had happened. Mention mental health and this is the picture most people have. Last week, in one of my WhatsApp groups, a discussion of mental illness among the young came up after the suicide of a young lady doctor. The general concensus was that parents should seek help early to prevent such. One lady wondered how one could walk up to a psychologist or psychiatrist and tell them that their child had “ngoma”. Ngoma is Kikuyu for madness. She deleted her post almost immediately. That’s how bad the stigma is!

A while back, as a young doctor, I was working in a psychiatric ward in a public hospital somewhere in Kenya. There was this young man, an in-patient who was fixated on me. He would light up in smiles like a christmas tree each time he saw me. Daily, upon walking into the ward he would tell me that he wanted to marry me. I still remember his full name, his initials were JT. He would address me by my then official name which was clearly displayed on the name tag on my breast pocket, “Dr. K, I want to marry you”. I was really scared of him. His eyes were rather wild. Luckily, I think by deliberate design, most psychiatric nurses are hefty men, like bouncers, so physically, I was safe. I was protected. Psychologically I was not so good. This is the kind of mentally sick person most people know, the kind that scares you. The kind that is described by the layman as being “mad”, “mùgùrùki”, “janeko”, “mwenda wazimu”. By the way, in the medical fraternity, such terms are not used.

In the same ward some time later this girl was admitted. Immediately she saw me, she came up to me and addressed me by name, “Dr. K, thank you so much, the baby you assisted me deliver is doing well.” Of course I thought she was mixing issues up in her head. She was a mental case after all, wasn’t she? She must be hallucinating, so I thought. I gave the necessary response, murmured some “correct” words I don’t even remember. And guess what? She saw right through me! She realised that I was faking it, I couldn’t remember. And so she reminded me. “Don’t you remember when Dr. M called you for help and you used a pump to get my baby out?” “Oh! Was that you?” Of course I remembered, Dr. M was my intern. I clearly remembered in the labour ward doing a vacuum extraction of her baby who was stuck somewhere up there in the birth canal. So you see, mental health patients are not always out of touch with reality! Some are even capable of expressing gratitude. They don’t always chase you or want to scare you.

Very sadly, two young people committed suicide in Nairobi last week. Professionals in their own right. Outwardly very successful but inwardly in turmoil, apparently. I didn’t know them personally but I knew one of them through a third person. How does a successful young person go all the way down with depression without anybody realising it? The truth? It’s just that most of us are ignorant of facts sorrounding depression. Usually, when things are going wrong, there are tell-tale signs, red flags, that should alert an observant person. Somebody who knows a person well should be able to pick things like unexplainable mood changes, loss of appetite, an abnormally voracious appetite and hyper-irritability. When an outgoing person suddenly or gradually gets withdrawn it’s a bad sign. When they get unduly emotional over certain matters, its a bad sign. When you notice any of the above in your loved ones, drop everything else and prioritize their emotional well being. You’ll be saving a life.

Borrowed

Our biggest challenge with the current generation of young people begs this question; among friends, who will notice these danger signs? These so called Millenials and generation Z hide their pain behind success stories. They have underdeveloped social skills. They have fake nails, fake hair, fake boobs, fake gluteals, and fake friendships. Most have no social attachments except the very deceptive social media. Some will post enviable pictures of their imagined success and escapades for everybody to “like”. Others, upon seeing them will think how unlucky they themselves are. Poor kids, they have no idea that they are probably better off than those apparently “eating life with a big spoon”!

Hey fellas! Man is a social animal! Whoa! Whoa! Don’t go all gender on me, I mean both men and women. Associate physically with others. Go to physical church. Physically visit friends and family. Don’t allow depression to kill your loved ones! Pull them out of it.

Second chances

By Dr Lucianna

When HIV was a death sentence

Lemme admit; I never did hear her sing, but I was told she was a great praise and worship leader in her church. There was no reason to disbelieve it. She was young, indeed very young. She was beautiful! She wore a sweet smile! She was angelic! Her voice was smooth as she spoke! I could only imagine her sing! Heavenly, her melodies probably were. And she was expecting her first baby, oops! I mean babies, they were twins. At least we thought so. At C/Section, out came baby one… then baby two… then, oh, good heavens! Baby three! Triplets!!! Her husband was ecstatic, though a bit worried. He was a ball of excitement and apprehension rolled into one. “How are we going to cope?” He wondered. You see, he was also very young. A handsome young man with adoration for his wife in his big eyes. He was also a worship leader in the same church. Indeed that’s where they met and their hearts clicked into place.

Triplets… borrowed

Now they had three babies! One baby is challenging enough for new parents, but three! Oh my goodness, three!! What does anybody do with three babies? Don’t even suggest that their parents and relatives could help out, they had none. Both were orphans. They only had each other. They had individually been shaped by the school of hard knocks before they found salvation. And then they individually went into it full throttle, engines roaring. Each had a passion for Christ and for His service. They had a love for music. They separately joined the praise and worship team and thus they met. I was to later see beautiful pictures of their wedding. A match made in heaven. They had each been given a second chance in life. They were rearing to go. Wasn’t life sweet! Oh, sweet life!

Borrowed

Immediately post-delivery, within the first 24 hrs, we lost one baby. Sad. The young man’s big eyes appeared even larger as they teared in his sadness. For the time being, he had to carry this burden alone. The mother was still weak Post-CS and we didn’t immediately inform her. She didn’t make the recovery we expected. Instead of getting stronger, she got weaker. She went down… all the way down. Her HIV status was positive. She got worse and worse and despite every effort, she never left the hospital. We lost her too. I don’t remember very well, but I don’t think she lasted the week. What does a young man do with two babies under one week old? Himself an orphan and now a widower? In his early twenties? Life isn’t fair. Meanwhile, the babies were cared for in the hospital’s new born unit. Their young daddy would come to visit them daily. When they were strong enough for discharge daddy took his babies home. I remember driving them home. I used to counsel and pray with him on his visits to the hospital and we had developed this bond. A paediatrician I know volunteered his services for free for as long as he was needed.

This is one of the saddest stories of my practice as a doctor. The babies didn’t fare very well. We eventually lost baby number two. Before daddy’s tears could dry, we lost baby number three! He was back to being single, a single status that was worse than before he met his sweetheart. You see, he also turned out to be HIV positive. Before long, he started getting oral thrush and I feared for his life. In those days HIV was not very well understood and treatment was out of reach for the ordinary mortals. Those were the days when wierd treatment like Pearl Omega was being peddled at 30k per month. Imagine, 30k! It would also seem that the HIV was quite virulent. It was almost a death sentence. It mercilessly and rapidly drove it’s victims to early graves. Those days, the sight of H. Zoster would drive shivers down the spines of doctors. It was an ominous sign. There are people I know who survived it. Yeah, they beat HIV! Most of them out of shear will power to live. Iron-willed lady Asunta Wagura became the public face of encouragement. She lived and lived and told everyone who wanted to listen that HIV was not a death sentence. A lot of people drew strength from her. They lived! Some of them are alive and healthy today. Life became a bit more bearable when ARVs were introduced. The government took over most of the financial burden with assistance from the various international donor partners. People no longer died from opportunistic infections like TB and pneumocystis pneumonia.

Meanwhile, our young widower went from one opportunistic infection to another. We fought the battles together, he and I. We won quite a number of the battles but eventually lost the war. And just like that, a family of angels was wiped off the face of the earth. All five of them. What happened to life’s second chances? It left me feeling discouraged and wondering at the purpose of life.

It’s just vanity and chasing after the wind.

Why does a child have to suffer?

By Dr. Lucianna

Polycystic disease of the kidneys

“I’m scared”, she would say. I would hug her close and ask her, “do you want us to cry a little, you and I?” She would nod vigorously. She would cry, the eee, eee, eee kind. I would pretend to cry along with her, to keep her company. The unbelievable thing is, a few of those times, I found myself actually crying with her. She was only a little girl, aged about six. It was my unfortunate duty to give her some very painful injections under the skin. Her paediatrician, who was far, far away, had prescribed regular erythropoietin injections. Her guardian had been taught how to give it at home but it was so traumatic for both herself and the kid that she couldn’t cope. Injections given just under the skin are some of the most painful one can get. Those given deep in the muscle are almost bearable. Especially so the big muscle in the rear. Injections under the skin are a nightmare… and this little one had to endure them!

She had been diagnosed with Polycystic disease of the kidneys. Normal human kidneys have a smooth surface, like a goat’s. But Polycystic kidneys have multiple bags of fluid called cysts. It is a condition a child is born with. It’s not anybody’s fault. It makes the kidney larger than normal and compromises its function. There are various complications that arise from this condition. One of them is anaemia, low haemoglobin. Haemoglobin is found in the red blood cells. This little girl’s body was not able to manufacture red blood cells. The factor required to do so is normally formed in the kidneys. Her kidneys were unable to make it. Red blood cells carry oxygen from the lungs to the rest of the body. Hence the regular injections to boost her blood making process were necessary.

When she was first brought to me it was an uphill battle getting her to agree to the injection. Most people believe in pinning down a screaming, protesting kid and giving the injection. Hey kiddo, like it or not, here it comes! The same thing happens when taking a blood sample. I prefer talking to the kid and getting them to agree. When they ask, “is it painful?” The worst thing you can do is lie to them. I respond in the affirmative. This little girl already experienced pain elsewhere with this particular injection. She was hoping against hope that this time, with a new “girl doctor”, it was not going to be so painful. I couldn’t lie to her. Good girls don’t lie.

When they first came to me, the lady who brought her almost literally dragged her into my office. Both she and the kid were frustrated and miserable. I wore the calmest, kindest face I could find to show the kid that I was not a threat. I then meandered in the most roundabout manner I could to get into her heart. Once comfortably there, the inevitable reason for her visit came up: Injection. “I’m scared” She told me. I held her in a close hug and asked her if she wanted to cry in advance. She nodded and said an almost inaudible “yes” and I let her cry a little. Then I told her she would feel some pain but I would pray for her to get the courage to bear it. She was agreeable. She knew it was going to be painful but she was determined to be brave about it. After all “girl doctor” had prayed, hadn’t she? And thus our routine was established: I’m scared… Bear hug… Cry… Pray… Injection. It was always very painful but she became braver and braver as the months went by. This kind of visit to the doctor must be given time. It’s not simply a matter of “grab, pin down, inject”. It would traumatise an already traumatised kid.

With time, as expected, her kidneys went from bad to worse. Some years down the line the cysts completely overwhelmed them. The kidneys got so bad that they completely failed. The little girl had to have a kidney transplant. The financial implication is a total nightmare in Kenya. We all chipped in for the procedure but the family still had to bear mammoth costs. Her mom donated a kidney. The procedure was successful. For the next five years or so, the little girl was stable and happy. Her life was as normal as could be. She was also getting bigger and bigger. By late last year, now a young adult, the donated kidney was not coping so well. It was also failing. Her mom’s donated kidney was failing! Her doctors adviced on dialysis. She gets it done three times a week. It is a great financial burden on the parents, though NHIF covers some of the costs. Why do kids have to suffer so much? Somebody tell me!

Chronic illness is a burden on everybody. A burden to the patient and a burden to those close to them. It’s draining in literally every aspect of life: Health-wise. Physical energy-wise. Emotionally. Psychologically. Financially. Relationships are messed. Marriages break down. Some men have been known to walk out on their partners leaving them to cope alone with a chronically ill kid. It’s not that they hate their kids, usually not. It’s the strained relationship between the parents that drives them insane. Mothers are known to stick through thick and thin. They’ll not abandon the kid, no, normally they won’t. Caregivers sometimes sacrifice their jobs, the very jobs they are dependent on to care for themselves and their sick loved ones. Until you go through it you can’t begin to imagine just how draining it really is. You live your life like a zombie.

A silent prayer for all those good people out there who have to take care of a loved one with a chronic condition. I salute you, especially if you are caring for a child. Children shouldn’t have to suffer so much, should they? They don’t understand what’s going on. But then again, who am I to even ask that? Who am I??

Doing it in the bushes

By Dr. Lucianna


Mùharwo nìwe ùthingataga gathaka


Literally translated this means; he who has diarrhoea frantically searches for a suitable bush. It’s a saying among the Kikuyu that means, he who has a great need earnestly and ceaselessly looks for a solution. I was thinking about this saying in it’s literal sense. By the time it was coined, it means the Kikuyu were doing it in the bushes. They also knew that the need could sometimes be… eeh… well… shall we say, urgent? Hence the frantic search! Let’s not shy from the facts. It’s true, in the days of old it used to happen. Our forefathers were “bush-chasers”, yes, they were. No doubt about it. My generation and those after us are lucky in that we found toilets in use. At the country-side most are pit latrines, but toilets nevertheless. We don’t have to “thingata” any bushes. Not anymore! Talk of progress. Yaay!

In our fourth year of Med school, one semester was dedicated to Community health. We took it on the ground at the community level to give us a practical approach. We were accomodated in special houses in some of the villages in the then Eastern Province. Six students to a house, and each house had a designated cook. Oh, the food! Good Lord, the food! The thought of it still stimulates my parotids. It added a bonus to the already great experience. Part of our learning included conducting research on community health practices. Our aim was to establish community practices that contributed to diseases like malnutrition and tropical diseases. We moved around the villages in clusters of three, i.e. two students and a local guide. One of the questions we asked was whether the homestead had a latrine. A few homesteads didn’t, but most did. Those who did called it the chief’s latrine. We were puzzled. Before we could put a tick in the relevant box in our questionnaire, we had to actually see the latrine, to confirm it was actually there. Most were squeaky clean! Not a drop of urine! Not a hint of foul smell! Not ammonia, nor the other stuff. Clean! Very clean.

Before long we understood why it was called the chief’s latrine. There was a directive from the chiefs in the area that every homestead had to have a latrine. The villagers dutifully constructed them. The chiefs inspected every homestead, and there it was, a latrine, complete with a breather-pipe. But guess what, the people still dashed to the bushes when the need arose. No wonder then the latrines were so clean! We later learnt why they didn’t use them. It was taboo for certain people to have their stools mix in the same hole!! Daughters could not mix their stools with their fathers! Nor mothers with sons! Had the chiefs considered this, they would have instructed the families to build two separate latrines per homestead. The taboos that govern traditional Africa are very real. What they fear will not necessarily come to be, but should it happen for some other reason, they’ll attribute it to breaking of the taboo. The fear is real for those who believe. It can even cause psychosomatic illnesses.

That was such a long time ago and times have changed. Homesteads have latrines, sometimes multiple latrines. I therefore was shocked to find this sign board in a certain part of Kenya!

The board is a bit rusty, but these are the writings, done in both English and Swahili

                      KIBWANGA
IS AN OPEN DEFECATION FREE ZONE.
WE DEFECATE IN LATRINES NOT IN
                      THE BUSH
KIJIJI CHA KIBWANGA HATUNYI
MSITUNI NA HATULI MAVI


Here, apparently, people are still running to the bushes! In this day and age, for goodness sake! More than fifty years after independence! Unbelievable. It’s a community health hazard! Cats are better organised than people in that they’ll make sure to cover their stuff with soil. People will drop a steaming mould, belt up and majestically march off. A lot of infections are still spread from stools of infected people. Those who can’t squeeze their brakes until they can get to the farthest bushes are the greatest hazard. They are those people with diarrhoea! It defies brakes. They’ll relieve themselves quite close to dwelling places. Most of it is infective. This brake defiance also happens to travellers with rioting stomachs; one of the very few times I approve of anti-diarrhoeal mixtures. When the brakes in the body are threatening to fail, the vehicle has to stop. In the blink of an eye a fellow shoots out of the vehicle and ducks behind some bushes! Don’t try this in the Tsavo! There still are man-eaters. On a rather sad note, somebody once found a car parked by the road side in the Tsavo. He was with friends driving from Mombasa to Nairobi. I imagine they were looking for suitable bushes, ha, ha! It was late afternoon, 4pm, a lot of daylight in Kenya. Cautiously they approached the parked car. They found a child alone inside, a little boy aged around eight years. He said his mommy had gone into the bushes, probably to relieve herself. Being a mother she had to go completely out of the boy’s sight. The child had waited a while, so it seemed. That made them a bit apprehensive. They made some urgent calls and waited with the child. The game rangers from KWS (Kenya wildlife services) arrived and after a search in the bushes found the remains of the child’s mother. She had been eaten by a lion or lions.

This was an extreme case but bad things happen in the bushes. There could also be snakes hiding in the bushes. As you settle deeper out of sight, the snake feels threatened and it could strike. Our primary concern though, is the spread of infectious diseases. Like I said earlier, I couldn’t have imagined that it still happens untill I saw that signboard, proudly declaring, Kibwanga hatunyi msituni.

Did you know there is a “world toilet day”? Yes, November 19th.

Msinye ovyo bila plan!

Raptured Uterus

By Dr. Lucianna

Dire emergency!

I was just about to leave labour ward heading to theatre to perform two emergency caeserean sections when suddenly, priorities changed. The reason for the two operations was foetal distress during labour. This in simple language means that the baby in the womb is in trouble and unless he comes out he could die or suffer irreparable brain damage. The solution is simple: That baby has to come out the fastest way possible. In such a case unless delivery is imminent the baby has to be brought out by CS. How do we know that the baby is in danger? During labour the baby’s heart rate is constantly monitored. Just like you and me, if there is a threat of danger, the heart rate goes up. If things get worse the heart rate takes a nose dive and falls below normal. Unless he is removed fast, the baby dies in the womb. Sad…very sad. But the sadder thing is when we have to beg a stubborn mother to sign consent for CS. Sometimes mothers aren’t convinced a CS is necessary. It is especially difficult when a mother has had normal deliveries in the past and therefore does not understand what the fuss is all about. Some of them end up having a vaginal delivery. Unfortunately some babies come out with brain damage. Some very severe, others only mild.

With the above understanding, why didn’t I do those two CSs immediately? Why did priorities change? A more severe case had just arrived… A raptured uterus! A dire emergency! It can be a one way ticket to the grave unless immediate action is taken. I learnt that the mother had had uterine massage!!! I was horrified. Uterine Massage?? Who does that?? Honestly, in this day and age?? This was just my first case of uterine massage, with time I got more and more. In this particular region, massage of pregnant mothers is done as routine remedy by a traditional masseuse. The region has more cases of raptured uterus than I have witnessed anywhere else. To be honest, in all other regions combined, I hardly saw a handful! Any time I asked any of the women “what happened” the answer always was, “nimekandwa” (I’ve been massaged). The locals do it routinely for any reason, real or imagined: baby is upside down… uterus is upside down… backache… fatigue… swollen feet… headache and dizziness; name it! Blood is not flowing… Their solution is massage. It is such a crude procedure that many times it raptures the uterus.

Once the uterus raptures, it’s like opening a tap or several taps. The mother will bleed until she can bleed no more. In other words, we could lose her, she could die. We can’t let this happen. Where patient numbers are large, such cases have to be given priority. In private hospitals, there’s hardly ever a list of emergencies waiting. And even then, any two cases are prioritised according to severity and expected outcome. On the day under discussion, we immediately rushed in with the “raptured uterus”. We had to save that mother! We did save her! Fortunately, we also managed to save the two babies who had foetal distress. It’s not unheard of for a mother to deliver while waiting for emergency CS. Sometimes it is misunderstood by the patients and their relatives. “Doctors said I couldn’t deliver normally,” they sneer, “the baby came out, didn’t he?” Some may not understand that it’s not just about the baby coming out. It’s about presenting the mother with a quality baby. In a private hospital patients think that all the doctors are interested in is the surgical fees.

Somebody remarked that CSs are on the rise in private hospitals. There are several reasons for this. For one, systems usually run smoothly in private hospitals. The same goes for mission hospitals. When a problem is detected it is dealt with promptly. No delays. When a decision for CS is made, it gets done. I remember the frustration in a certain public hospital where a constant cause of delay in operation was that there were no clean operating gowns for theatre staff. The hospital laundry machine had broken down. Gowns used to be taken to a private hospital for cleaning. You would find the doctor ready, anaesthetist ready, nurses ready, all sitting in theatre waiting for gowns to be brought from wherever! Annoying! Negligent on the part of the hospital management. And it was not once, not twice, it was over and over again for quite some time. To be fair, in busy public hospitals, some cases may be delayed because of sheer numbers. I remember one night many years ago I did eight CSs! The largest I’ve ever done in one night. Due to the system being overwhelmed sometimes cases don’t get prompt surgery. Cases are prioritised according to severity, according to what’s at stake. Some patients scheduled for surgery end up with vaginal delivery. Unfortunately, some of the babies end up with some damage. Sometimes the effect is minor and leaves no residual damage.

Of great concern in private hospitals is the litigation against doctors. Under normal circumstances, the doctor will assess the patient and determine whether she’ll make it or not… maybe give her an hour or two of monitoring. But in the private sector the doctors will not take such chances. If there’s the slightest hint of a problem, the doctor will go in for surgery immediately. Otherwise, should anything go wrong, he’ll be sued left, right and centre! Who wants stones thrown at them? A patient who would probably have made it given a chance ends up with a CS.

It’s a difficult world we are living in, this third world. WHO recommends 1 doctor per thousand people. In Kenya we have just a little over 1 doctor per ten thousand! Per ten thousand!!! Most of them are in the private sector because of poor pay and difficult working conditions in the public sector. With the bulk of our patients being in the public sector, it doesn’t take a rocket scientist to understand why we are in such a mess. God help us…

Baby number six

By Dr. Lucianna

How many caeserean sections are Safe?

Everybody and everything in the operating theatre was ready. The anaesthetist put the patient under GA and said, “CUT!” I cut the skin and systematically continued to open the abdominal layers beneath it to expose the fully loaded uterus. And behold, good heavens! What do I see?? A sight I really didn’t like. The wall of the uterus was so thin, indeed nylon paper thin, that I could actually see the baby’s curly hair through it! It drives shivers down my back just to imagine what would have happened had she gone into labour at home! The contractions would have torn that uterus open and thrown the baby out. It’s not unheard of for a baby to be fished out from within the abdomen, the uterus having raptured, the baby almost certainly dead.

I found this patient admitted in the maternity unit of one of our public hospitals for elective caeserean section. I was the doctor on duty. Listen to this; she had had five babies by caeserean section! In med-speak, she had five previous scars! It’s horrifying for any doctor to do a ceaser in five previous scars! You see, during a CS, the uterus is cut open… baby removed… uterus stitched together again and returned to near normal. It doesn’t quite get back to normal. With each subsequent CS, the near normal gets further and further from normal especially if the patient develops adhesions. Adhesions are fibre-like growths from the scar to the rest of the organ and other adjoining structures. With each subsequent surgery they get worse and worse. Several surgeries distort the normal structures and it becomes increasingly difficult to navigate. The uterine wall becomes weaker and weaker around the scar.

Long, long ago, women would religiously be adviced not to go beyond three CS’s because of the possibility of complications during pregnancy and surgery. It was recomended that they have a BTL on the third CS. The fallopian tubes are tied and cut to ensure no further pregnancies. Each consenting patient was required to sign a consent form before the CS. Then came the liberation movement! O-hooo!!! Liberation! Women all over the world went to the Beijing women’s conference in China. By the time they got back to their homes, they were breathing and sneezing fire on anything that could move. Their husbands got the worst of it, poor fellows! Then unknowingly the women turned against themselves. They viewed everybody talking about women issues with suspicion and hostility. Any medical advice touching on their reproductive health was rejected. They didn’t know where to draw the line. Women started chanting about reprodutive health issues. They chanted that it was their right to get as many CS’s as they pleased. By the way, it always has been their right, the doctors only advice on the dangers. The only thing that saved them from self destruction was when they decided they didn’t want too many babies after all. They didn’t want to ruin their wonderful hourglass figures or be encumbered with child care! Aaaand… Who wants to ruin their beauty sleep anyway! The chant changed to the right NOT to have babies. Me thinks women are confused.

Back to my patient. Her story was different in that over the years it was the husband who denied her the right to have a BTL. He wanted her to drop “them babies” as long as she still had eggs in her. Here I agree with the Beijing crusaders, a woman should be in a position to make such a decision; a decision touching on her own health! She was on pregnancy number six. I tried to explain to her about the dangers of further pregnancies but she refused to sign the consent form for BTL. She said her husband had forbidden it. When the husband came to visit her I tried talking to him. She had been admitted earlier than her due date to ensure the surgery was done before she went into labour. I outlined all the dangers but he was adamant. He even warned me of dire consequencies should I try to conspire with his wife. I don’t know how he would have found out, maybe he had plants in the system, or maybe his wife would have leaked the secret.

The appointed time came and we went in for surgery. That’s when I found the state of the uterus I described earlier. Just one contraction…!! Just one contraction and the baby would have been extruded from the uterus! Another horror awaited me! I removed the baby… and THEN the nightmare began… Everybody in theatre sweat to their last drop. Let me spare you the details of the subsequent events. Sadly, she didn’t make it through the night. We lost her. She died in ICU. The baby didn’t make it either. He had massive macrosomia, a giant of a baby. His huge size had so stretched his mother’s already weak uterus, it made control of bleeding difficult. I can’t begin to explain how difficult it was to explain to the husband. He was in such pain… he kept on blaming himself… comforting him was not easy, especially considering I had also lost.

I don’t know how I can explain the dangers of repeated caeserean sections. It’s kind of like repeatedly stitching up a dress that gets torn at the same place each time. Tear it and stitch it, tear it and stitch it… over and over again. The fabric gets weaker and weaker until finally the stitches cannot hold it together. If it was a coat you would one day stretch your arms and suddenly feel it give way at the stitches. There’s no analogy that can explain this. But the dangers are real. That’s why women are adviced not to go beyond three. The “my uterus my choice” crusaders don’t really explain to the women the dangers they face. They are really not helping.

Then there is this new breed of women who refuse natural birth and opt for CS! Perfectly healthy women generously endowed with good, wide hips! “I can’t go through the pain of labour”, they say. “My uterus my choice!” Shauri yako…

A bean in the ear

By Dr. Lucianna

The unethical practitioner


In a state of panic, the parents rushed their little one to the nearest health facility. It happened to be a private clinic. I wouldn’t know whether they drove or took a taxi or ran all the way. The child had inserted a bean in the ear! In an attempt to scoop it out, they had pushed it deeper into the canal, beyond the bend and could not reach it any more. Hence the panic, total panic. They found the resident Clinical Officer, CO. Immediately and easily, he removed it. Now this being a private health facility, fees were due. (It was the good old days when government health facilities charged minimally). He charged them five hundred shillings. The father went through the roof! He was furious! “Five hundred, my foot! For what? What is it that you did?” Disclaimer: I wasn’t there. I’m only imagining the conversation. This happened in Thika. The story was in the local newspapers many years ago with all it’s gory details. The father angrily refused to pay. He felt like he was being robbed. Now that his child was out danger he forgot the panic he felt after he had made the bean do a disappearing act. How ungreatful! Honestly, how ungreatful! Shame on him!

He found his match in the CO! Daddy thought he was the only one capable of hot anger, but my! oh my, did he know who he was up against?? The CO fumed!! Almost steaming at his own ears! He felt short-changed… taken for granted! Angrily he shoved the bean right back into the child’s ear! I can imagine him saying to the father, “if you think it’s that easy, why don’t you remove it yourself?” All these unbelievable details were played out in a court of law. The CO was charged with whatever it was, negligence…! unethical practice…! unprofessional conduct…! endangering the life of a patient…! I don’t really know. All I know is that nobody does what he did! You can’t do that! How many times have patients refused to pay? Countless! That’s why hospitals insist on payment before any services, except for emergencies. And even then, just life saving emergency procedures like arresting bleeding. Patients really take advantage of the emergency situation and refuse to pay. Would I be wrong if I called them thieves? Would I be insulting anybody? Just asking… But still, normal people do not do what that CO did. It simply is unacceptable! It’s inexcusable. It’s not the done thing!

Back to objects in the ears: Don’t try to be a hero daddy. The ear canal is not just a hole, no it isn’t. It has curves and at the far end, it has a delicate membrane called the ear drum, or if you want to sound sophisticated, call it tympanic membrane. It can very easily be perforated leading to deafness. It can also give a terrible infection in the ear that can also spread to the brain causing meningitis or brain abscess, among others. It gives me the jitters when I see people use tooth picks and matchsticks to scratch their itchy ears. It also gives me jitters when I see parents, especially mothers, try to remove ear wax from their children’s ears using cotton buds! Those plastic “sticks” with a small ball of cotton at each end can be very deceptive. They look harmless, but they can cause untold damage to kids ears. And why remove the wax from the ear in the first place? Mother nature put it there for a purpose. It traps dust and other particulate matter and insects that crawl into your ear.

This reminds me of an experience I went through last month: Walking through the bushes gives one a great feeling of being one with nature, scratches or no scratces. I was in a small band of bee hunters as we weaved our way through. We were going to set up some new beehives. The particular area we were in is kind of wild, with virgin bushes. It has many different species of trees and shrubs. It’s literally bee heaven! As a result, those bees really make sweet honey and we wanted to increase our honey production base. Suddenly there was a prr-rrr-prr in my ear. Some insect had been trapped in my ear by the wax! The person nearest to me thought I was behaving wierd. I told him I had an insect in my ear. He wasn’t particulary impressed. Infact he was not unduly bothered, there was a lot of work to be done. He grabbed the next beehive and headed to the site. Meanwhile I was going bananas with the prr-rr-prr. Quite unsettling if you ask me. It felt like a whole bat was in there, enjoying itself, raising a ruckus in my ear! With my hand I flapped my pinna back and forth but it didn’t help. If anything it appeared to be more energised. Nasty little creature! And then I remembered there was drinking water in the car. I poured some into the bottle lid and tilting my head ipsilateral side up, poured it right into my ear! I hissed at the intruder, “Drown creature, drown!!” It obliged and the flapping stopped. I turned my head over to the other side and allowed the water to drain out. What relief! I grabbed a bee hive and continued with my work.

Yeah, yeah, I heard that question… How then do you clean off the wax in your baby’s ears? Simple answer: You don’t. You can only clean the outer ear. Don’t go anywhere near that canal! Don’t touch it. Don’t stick cotton buds inside the ears. They only serve to push the wax further and to pack it tightly. If your child is school going you might notice their performance going down. This is because packed wax makes your kid kind of deaf and so cannot hear the teacher clearly. When exam time comes, he flops and you chastise them for playing in class and not taking their lessons seriously. Want to hear some truth? You are the cause of his poor performance! Or the teacher might report that your kid is naughty and refuses to obey instructions. The poor fellow is deaf! You’ve made him deaf! Take him to a doctor, his wax will be softened and cleaned out and his ears will be as good as new!

Take home message: The ear canal, or external auditory meatus, is a no, no! A no go zone.

I drove like crazy

By Dr Lucianna

Convulsions

I sped down Links Road like crazy! Was I driving or was I flying low…? Must have been flying. I don’t remember the feel of rubber on tarmac, ha! Allow a lady some exaggeration now, won’t you? Anyway, the fact is I got to Pandya Memorial Hospital in record time! The baby convulsed all the way!! Not a moment of peace did that kid experience! I remembered this incidence as I did my PALS course last week, Paediatric Advanced Life Support. It’s organised by AHA, American Heart Association. It struck a jealous cord in my heart each time they said, “call for help, call 911”. Here in Kenya we have no 911 to call. Even our 999 mainly goes ignored. I managed to go through to 999 once. I was driving on Thika Road one night when I came across a car burning by the roadside. I feared for the lives of the occupants. I couldn’t stop because I’d had two bad experiences with armed robbers at night on that same spot. I was with my kid who did the dialing, and I did the talking. I digress.

Back to my story. I was working in this small private facility when a man, carrying a baby, literally ran into my office. He ignored the reception staff and almost threw the baby into my arms. The baby had a full blown convulsion, the grand mal seizure. I grabbed the baby, dashed into the treatment room and started doing everything my experience had taught me. A few minutes down the line I realised I was not going to stop the seizure. The first line drug was not working as it should have. Nothing I had was working. It was time to go to the next level. If I was in America I would have called 911. Here I had the option of calling an ambulance or using a personal car. The father didn’t have one so I decided to drive them myself. I dismissed the idea of an ambulance because I knew it would take too much time, time that would see me in the desired hospital if I chose to drive. And in any case most of our ambulances are manned by paramedics with very basic training.

When we got to the car, the baby’s dad looked at me for half a second, skeptical, doubt clearly spelt out in his face. He dismissed my driving skills. He asked me to give him my car keys because he didn’t think I could cope. At least he was honest. If it hadn’t been such a dire situation I would have laughed. I drove South on Malindi Road and took Links Road. My headlights were fully on… hazards blinking… my hand constantly on the horn, blaring away. I found myself driving mainly on the wrong side of the road. The other motorists sensed my emergency and gave way. At the city market, even the matatu drivers would take one look at the convulsing child in his father’s lap and give way. In record time we arrived at the emergency department in Pandya Memorial hospital. As he carried his baby out of the car, the father looked at me incredulously and said, “God, you really can drive!”

The first time I saw a convulsing kid I was really scared. I was in my first year of Med school and honestly knew nothing much. It was my sister’s kid. She and I were in total panic. We walked…no, we ran and walked to the nearest health facility. By the time we got there the convulsions had stopped. We gesticulated wildly as we described what we had witnessed. The baby was in the post-convulsion sleep and we thought he was going to die, or was he dead already? They gently explained to us what the problem was. Whew! At least he wasn’t going to die. We took our baby home after treatment.

What causes convulsions in a child? In our setting, the commonest cause is fever. This can be caused by all manner of infection. It doesn’t even have to be very high. A child below the age of six years can get repeated episodes of fever related convulsions. Convulsions cause brain damage. Each episode leaves a bit of damage. Subsequent episodes add onto the damage and eventually the baby has a major handicap. So what do you do? If you have young ones, please keep some paracetamol in the house. Immediately you detect a fever, give some and then take to hospital for diagnosis and treatment. If you have no paracetamol or the fever is not responding well, do tepid sponging. Warm some water, just make it lukewarm. Dip towels or bits of cloth into the lukewarm water and sponge the baby. Its more effective when you sponge the areas with large blood vessels like the neck, armpits and groin. Do not use cold water!!

Convulsions can also be caused by low blood sugars. If you have a sick baby with a poor appetite, do everything in your power to get some food into that stomach. Give anything the child will tolerate. This is not the time for elaborate meals. Give porridge, give yoghurt, give anything. If the baby is completely unable to eat, take to hospital. Low blood sugar can kill a baby. Convulsions can also be caused by malaria, meningitis and a host of other diseases like epilepsy.

My take home message for today is; don’t allow seizures of whatever origin to destroy your child. And by the way, don’t entertain myths. The wierdest myth I heard in a certain community in Kenya, was that mother’s urine, direct from the source, is anti-convulsion medicine. Picture this: A child is convulsing on the ground… everybody yells for the mother… mother runs over… bends over… directs a jet on the child… child stops convulsing. How can you disuade such a community from believing such a myth? And by the way, the convulsion was going to stop anyway! Urine or no urine, but they don’t know that!

Seek proper treatment anytime your kid is sick. DON’T DECIDE TO OBSERVE AT HOME! Early diagnosis allows for proper treatment. No jets please…sshhh

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