Improvisation

I spent my first week--an abbreviated, four-day week--working in the OB/GYN ward.  The moment I walked into the room, my new lab coat still creased from the packaging, all eyes were on me.  Patients were packed into a 20X30 concrete room, holding 10 beds, with 2 patients per bed.  The day before, we had toured the private hospital adjacent to the area in which we will work for the duration of our stay here.  It was noticeably absent of patients.  That side costs extra we were told, explaining the paucity of inhabitants.  There are plenty of sick people to fill the rooms, but healthcare is a business here as it is anywhere else. 

Having little experience in hospitals of any kind, I felt quite awkward standing around with my hands in my pockets.  I announced my presence to the day nurse in charge, and she promptly sat me in front of a mound of patient charts.  "Read these," she said, and then returned to her work changing bed sheets, a chore that required a mass exodus of patients from the room until her task was complete.  This happened every morning, I learned; the head nurse was the shepherd, the patients the sheep.  By the time I had scanned through the charts, the menial task was complete. 

The first thing you see is the sheer number of patients that occupy the room.  After that initial shock subsides, you sink into a state of acute observance.  Soon, the slight breeze coming through the windows causes the gentle swaying of the nets above each bed, and you take note of the women just outside drying laundry on the dew-crested side yard.  Thermoses of tea and loaves of bread fill the cabinets beside the patient beds, and some have taken to their morning routine, eating and drinking.  Perhaps it's my presence or that of pain and illness that stifles much of the idle chatter--everyone seems to be merely existing, surviving.  No different than in any other hospital, I imagine. 

A tall, verk dark-skinned physician ("daktari" in kiswahili) approached me: "I am Dr. Mawalwi, the chief medical officer for this ward," he said with the bass of a bullfrog.  The people speak softly here, almost inaudible to my western ear, but the deepness of his voice did much in the way of transmitting the message.  Soon, we alighted to the theater (the OR in Africa) after our brief exchange: there was a woman with a massive spleen that needed surgical excision.

It was there we met the consultant, another tall Kenyan wth a booming voice.  He had the air of a surgeon, confidence to a fault, and a belly that revealed a lifestyle different from most in this country.  From gaunt to skinny, you don't see much in the way of overweight people here.  In Africa, it's malaria, in America, it's Type II Diabetes.  As for the consultant, he had traversed the 5 years of medical school, the year of internship, and had practiced privately many years before he began his consultantship.  This was the pinnacle of the medical hierarchy in Africa, being a consultant. 

The patient arrived about an hour after we had left the ward, and at this time, I had caught up with Malia, my classmate who was rotating in maternity ward.  Our separate designations, OB/GYN and Maternity, beared much resemblance in responsibility, so we stuck together for the week.  I enjoy her personality, and was happy to have a companion for this our first week.  We enjoyed a cup of tea while we waited for the surgical theater to be prepped.  Tea here is a thrice-daily occurrence.  They take it solely with milk, thus bearing the name, chai na maziwa.

During our wait, Dr. Rajiv, a medical intern in OB/GYN, began operating in the side theater on a routine c-section.  I had never seen such a procedure before, and was amazed at how quickly it transpired, from first cut to the appearance of the child.  At some point, you realize that you're cut out for the medical profession; the large grins beneath our scrub masks surely marked this point for both Malia and myself.  Little did we know that we'd be assisting on one of these procedures before the day concluded.  Who knew holding a once-gravid uterus would be such a poignant experience?

***Graphic Description Ahead***

With the main theater open and Malia assisting with the c-section, I examined the belly of the patient with the large spleen.  It was palpable all the way to the midline, and descended near her belly button.  She looked pregnant, her belly encompassing nearly twice her pelvic width.  Her liver seemed enlarged, and present well below her diaphragm.  Still, the consultant kept calling it an ovarian malignancy.  How could this be, I wondered?  It would need to be rougly the size of a basketball in order to distend her abdomen to that extent.  Plus, the splenic involvement was puzzling.  Was this a blood cancer, a metastasis?  As it turned out my approximation was wrong: the right ovary was larger than a basketball, and the enlarged spleen turned out to be her left ovary.  It was slightly smaller, but no less impressive.  Roughly 15 lbs of ovary sat on the surgical table beside the bed, with a uterus the size of small change purse sitting in juxtaposition.  This girl, no older than 20, already with two children, would never bear another.  Her chemotherapy would begin soon after, but these two massive organs would be the last thing to pass from her belly.  I wondered if she would survive, I wondered how long she had been carrying that burden. 

"Without imaging, there is no way to accurately predict what we're going to find when we go in sometimes.  Surgery in Africa, you'll learn, it's all about improvisation," the consultant intoned.