New Year’s Eve 2017

I woke up in a motel 75 miles from home, with a dead dog and a nasty head cold. I was on call for two hospitals that day, and there were eleven patients I had to see and some who would need surgery. I sat up in bed and nudged Lucy with my foot. “Time to get up, LazyBones.” She didn’t move. I reached down to shake her awake and felt how cold and stiff she was.

Lucy was old for a bulldog. We’d had nearly ten good years together, and I’d begun to fear she would die soon. I wrapped her in an old sheet I got from the housekeeper and placed her on the back seat of my Jeep then drove to the hospital. She lay there all morning as I rounded on inpatients, saw a new patient in the emergency room, and scheduled surgery for the day.

I took her to the crematory between operations. The gentleman who operates it out of his home in the country was kind, but not overly solicitous. He told me that the fee was based on weight, and took Lucy into the back of the shed which served as his office. Returning a moment later, he informed me the cost would be forty-two dollars.

I handed him my credit card, and burst into tears as he handed it back. He hugged me lightly and gave me a handful of tissues for the road.

An hour later, I was elbow-deep in the tangled intestines of an elderly woman who was suffering from acute ischemia of the gut. She was already gone in shock on arrival to the hospital, and without surgery would certainly have died.

It was a busy day. I removed a gallbladder full of stones and a rotten appendix. I inserted a chest tube into a pedestrian who’d been struck by a car, and drained an abscess resulting from intravenous drug abuse.

I met with the family of a very ill and severely debilitated man who were struggling with whether to place a feeding tube and keep him on a ventilator, or “let Nature take its course.” They felt he’d “had a good life” and decided not to continue aggressive treatment. The breathing tube was removed, medication supporting his blood pressure was stopped, and I sat with them as his heart ceased to beat.

I went back to the motel, put a frozen dinner in the microwave, and changed into sweats and a T-shirt that- like most of my clothes- were covered in dog hair. Exhausted as I was, it was hard to sleep without Lucy curled up at my feet.

My mother has OCD. And 12 cats. This combination was responsible for the nightly ritual known as “counting cats”. We were a family of five in a standard three-bedroom ranch style home in El Paso, Tx. My two sisters and I dreaded bedtime. I, for one, had been known to slink off to bed early just to avoid participating. Before you judge, let me describe the scene to you:

”Bedtime!” my mother announces. We all know what that means. My sisters and I crowd into the one full bathroom in the house to brush teeth, wash faces, apply moisturizer, and whatever else our toilette entails. The cats, of course, scatter to the four winds.

Everyone changes into pajamas, and it begins.... each cat must be located, it’s location reported and confirmed. Don’t even try to pretend you’d found one when you hadn’t. If your veracity was at all in question, someone would be sent to verify your claim. Woe be to the prevaricator! Not only would they be punished (lying was the greatest evil in my mother’s mind), but when the cat you said was inside was actually left out all night, suffering a cruel death at the mercy of the elements and/or the coyotes, upon your shoulders is where the blame would firmly rest.

Those of you who know cats will understand when I say I’m convinced they took sadistic glee in finding impossible hideaways at this time of night. The cat who sat on your homework all evening, the one continuously howling for cream in the kitchen, the one snoozing peacefully on the sofa, the one biting your toes under the dinner table, the one who’s so old and fat it lays in the same spot in the hallway twenty-three hours a day- all disappear.

“None in my room!” cries Tammy, the middle sister. Her room is neat and tidy- nothing out of place. A cat could not go unnoticed in there, even under the bed or in the closet (Standard Search Protocol).

”I found Juby in my room!” reports Tara, the youngest. She and Juby have a special bond. They’re each the youngest and the smallest of their litter. Make of that what you will.

“Prince is in the bathroom,” says my mom. Prince, an affectionate, languid, long-haired Persian mix who’s favorite hiding place is the towel closet, is the reason every time I get out of the shower and dry myself, I’m covered in fur.

Four cats down, eight to go. The search continues.
​
“I’ll check the laundry room,” I announce. Just then, Katie, a shy calico we found living in the woodshed with her newborn kittens (whom we obviously took in), leaps down from the shelf above the washer, narrowly missing my head, and darts past me. “Katie’s here!”.

The only kitten of Katie’s we were unable to find another home for was Marilyn. Now a full-grown, cotton-haired white cat whom we suspect is deaf, and who is perpetually covered in mats due to an aversion to self-grooming, resides primarily under my bed. She’s called Marilyn in honor of Miss Monroe, due to her lush white fur and habit of lounging about and gazing provocatively at anyone who passes. Don’t try and touch her though; she bites. I spot her (without touching her) lying in the far corner under my bed.

Someone has located Kelly, a large, fluffy, motherly calico, asleep amongst the couch cushions. That leaves only “The Boys”, who are likely outside.

Once my mother is convinced every room has been thoroughly scoured, she heads for the front door to round up the stragglers.

“Heeeeeerrrrre KittyKittyKittyKittyKittyKitty!” she calls.

And again. “Heeeeeerrrrre KittyKittyKittyKittyKittyKitty!”

Nermal comes sauntering in. He heads directly to the kitchen, expecting a treat. Tara obliges him with a saucer of milk.

My mother continues to call for several minutes, then enlists me to take over.

Reasoning that perhaps they simply couldn’t hear her well enough from the doorway, I venture out onto the porch. Standing under the porch light, I begin to call.

“Heeeeeerrrrre KittyKittyKittyKittyK.....AAAAAHHH! Stupid bugs! Heeeeerree KittykittykittyKITTY! Help!!!”

The porch light has attracted the usual array of moths and June bugs, and now there’s a June bug entangled in my hair, buzzing frantically near my right ear, its creepy little legs crawling on my scalp. I’m generally considered the least squeamish and the boldest of the family, but June bugs are my Kryptonite. As I dance around yelling for help, Keaton ducks past me and scratches at the front door. Tammy opens the door and he runs in. She manages to get the bug untangled from my hair and takes over the cat calling.

Back in the kitchen, I trip over Nala. “Where did you come from?” I ask him. He mewls at me, indicating the empty milk dish.

“All right,” says my mother as she comes into the kitchen. “Who’s not here?”

I run down the list with her: Juby, Sugar, Pepper, Prince, Kelly, Katie, Marilyn, Nermal, Keaton, Nala. Only two missing.

Momentarily, Tammy opens the door for Shadow. “Just Cowboy left to go”, she reports.

Cowboy is a rogue and a rambler: a large, lanky, orange tabby who prowls the neighborhood from dawn to Last Call. There have been a few nights we finally gave up and let him stay outside (against my mother’s better judgment and ability to sleep). When he does come inside, he sleeps in my bed- curled up on my pillow just like when he was a tiny kitten. I feel a particular fondness and a responsibility for him, so I volunteer to brave the porch again, thinking maybe he’ll come for me if no one else. This time, though, I avoid the June bugs by turning off the light. Cats can see in the dark anyway, right?

After another twenty minutes of calling with varying tones, pitches, and ululations, he appears. I scoop him up in my arms, kissing his head and scolding him for causing so much worry.

​My mother announces it’s now truly time for bed. All is well. Until tomorrow night......

​The pager went off at 6:42 pm. "Full Trauma -- ED 6"

I hurried down the stairs and into the Trauma Bay. Several team members were assembled around the room

"What have we got?", I asked.

"24 year-old male, GSW to the chest. CPR in progress". (GSW = Gun Shot Wound)

"Get the thoracotomy tray. Have we called Blood Bank?"

"A box of blood is on the way. EMS three minutes out."

We heard the stretcher coming down the hall. A moment later, the unconscious patient was lifted onto the gurney. Nurses and techs went into action: placing EKG leads, starting additional IVs, stripping off blood-soaked clothing.

"What has he had?", I asked the medic.

"This is liters two and three of lactated ringer's. We've given epinephrine twice. He's in PEA."

"Stop CPR.”

​I felt for a pulse at the carotid artery and there was none.

The monitor showed an electrical rhythm but there was no pulse, likely because there was insufficient blood in the vascular system to generate an adequate blood pressure.

"Resume CPR."

"Rapid infuser is ready," said the trauma nurse. "How much blood do you want?"

"Hang a unit of cells and keep it coming, alternating with plasma every two units."

Meanwhile, I had opened the surgical tray and grabbed the scalpel. With one long, smooth stroke, I made an incision along the upper edge of the fifth rib from sternum to armpit, slicing through skin and fat down to muscle. I traded the scalpel for scissors, cutting the muscle between the ribs to enter the chest cavity. I could see pink lung tissue inflating and deflating with every squeeze of the AMBU bag.

"Stop CPR.”

The chest compressions were obscuring my view of the pericardium, the tough sac that contains the heart. When they stopped, I could see it was distended with blood which was crowding out the heart so it could not fill and pump. I cut a hole in the pericardium with the scissors and blood rushed out- over the lung, out of the chest, off the gurney, and into my shoe. There was clearly a large hole in the heart or one of the large vessels associated with it.

"More blood! Keep it coming!”

I took up the scalpel again and extended the incision across the sternum and onto the right side, an exposure known as a "clam shell". I now had access to the entire chest cavity, which was held open by a Medieval-looking instrument called a "rib-spreader".

The heart was not beating, and it was flaccid and flat- EMPTY. Blood was pouring out of a hole at the junction of the inferior vena cava and the right atrium. I put a finger over the hole. The heart filled and began to beat weakly.

"Suture!"

With my left index finger on the hole, I took the suture in my right hand and started sewing. Meanwhile, the nurses continued pumping warmed blood into the veins. As I completed closing the hole, the heart began to beat more strongly. The monitor showed a rapid but normal rhythm. Blood pressure rose. A sigh of relief went around the room.

"Call the OR- we'll have to take him down and get him closed. Do we have an ICU bed ready? Let's get a set of labs. Warm blankets, please. He'll need a Foley catheter and a nasogastric tube."

We'd done it. Life saved.

"Family is in the consultation room," said the Chaplain.

I looked down at myself. I was a mess: arms smeared with blood to my elbows, scrubs soaked with blood from chest to knees.

"I'll have to change before I talk with them."

Someone ran to get me a clean set of scrubs and I set about washing up at the sink.

"Pressure is falling again!", announced the trauma nurse.

I turned from the sink.

​“Check for a pulse. Give epinephrine. How much blood has he gotten? Do we have labs yet?"
​
The respiratory therapist read off the numbers. They indicated sufficient blood volume and oxygenation, acceptable acid/base balance and electrolyte levels.

I looked back at the heart. The sutures were intact and there was no bleeding. The heart was full, but barely beating. I began rhythmically squeezing the heart between my hands to augment its contractions. Soon, they ceased. Medications to stimulate heart activity were administered, I kept pumping, and we spent another twenty minutes working with no recovery of spontaneous heart function.

"We've lost him.", I said.

I continued manually pumping the heart while verbally running down the list of what had been done so far, what the current status was, then polled the room.

"Is there anything more we can do? Can anyone think of anything we've missed?"

No one could.

"I believe we have reached the limits of what we can do, so I propose we discontinue resuscitative efforts. Are there any objections?"

There were none.

"Time of Death: 7:51 pm.”

The pain began suddenly last night, woke her from sleep. It wasn't the first time, but was worse than before. The ER physician diagnosed a gallbladder attack, and that's where I came in. Surgery is often indicated for recurrent gallstone problems.

"L" was surprised to hear the diagnosis. She had assumed it was yet another pelvic infection caused by an STD, just like last time.

As as we talk, I notice the pasty texture and pallor of her skin. Her eyes are bleary and bloodshot. Innumerable scars and scabs cover her body. Her sparse, greasy hair is pulled into a messy ponytail.

"I need a cigarette."

I've seen the medical chart: opiate overdose, methamphetamine use, anxiety disorder, history of sexual abuse, migraines.

I glimpse broken, discolored teeth through cracked lips as she tells me she's feeling better now and wants to go home. I explain the nature of gallbladder disease, my recommendation for surgery, potential complications and likelihood of recurrence.

"I don't want those scars on my belly. And I'm fine. Just let me go."

It's her choice, her decision. I feel hopeless. Her gallbladder was the only thing I could fix. I take her hand and wish her well. Her father is waiting by the door. He thanks me for my help.

I write the order: Discharge to Home. All I can think of is what "home" is for her.

She's twenty-eight years old. She looks fifty. I doubt she'll make it that far.

Migori, Kenya

Esther is sixteen years old. She is dying. For the last year, her father Charles has taken her to clinic after clinic looking for a diagnosis and a cure. She has lymphoma. The only hope for a cure is chemotherapy and a bone marrow transplant. Neither is available nearby or affordable elsewhere. Esther and her family live in a mud hut with no electricity. She is the eldest of six--soon to be seven--children. She lies in the bed she shares with her siblings. It is an agony for her to even turn over. She is bone thin, and developing bed sores on her hips from lying too long on her side. She doesn't eat much, but when offered rice and lentils today, was able to take a few bites. She does not complain, but the moans she cannot always suppress keep the family up at night.


Sandy is a farmer, and a resident missionary. Charles works as a laborer on the farm, and through him Sandy has come to know of Esther's plight. Sandy senses Esther's end is nigh, and comes to me for help. She is hoping to ease the pain and suffering of these final days. I agree to prescribe and administer medicine for pain.


Pablo, a surgical technician on the team, hears Esther's story and asks to accompany Sandy and I on a visit. We walk the half mile or so, Sandy greeting neighbors along the way. On arriving at Esther's home, Charles and family usher us inside. Esther is grateful for the company, and puts on a brave face. I examine her, confirm the diagnosis and prognosis, and explain that we have brought medicine to ease her pain.


She cringes when she sees the needle. I reassure her it will only hurt for a moment, then her pain will subside. She submits. Her father holds her hand as I inject the medicine into her shriveled thigh. I explain that we have brought several doses, and will return to administer them each evening so that she and her family can rest. Pablo says a prayer, and we depart, having done all we can for her.


The next two days are consumed with surgery, but Sandy keeps me updated on Esther's condition, as she has been making regular visits. Another, more effective medicine is added, but it causes itching. I give Sandy my personal stash of Benadryl to combat this side effect. On the evening of the third day, we learn that Esther has died. This is the reality of life here.

The housekeeper returned for the third time since 8 am. It was now 11:20 and I had slept in, exhausted and sunburnt and maybe a bit hungover with wine. Since his previous visit, I had risen at last, showered, and made a cup of tea.
"Are you OK?"
"Yes. I'm good."
"Are you needing anything?"
"No, thank you."
"Did you get the water?"
He'd left two bottles in the porch earlier.
"Yes, thank you."
"Do you need more?"
"I have enough, thanks."
"So everything is okay?"
"Yes. Everything is ok. Sawa sawa."
"Hakuna matata. One thing only: do not leave the door open. The monkeys are so many and they do not fear you. They will come inside looking."


He left, closing the glass door firmly. Moments later, she appeared. I watched her climb the door, rattling it in an attempt to open the latch. Her fingers searched the cracks at the edges. She scrambled up to the top where the window screens foiled her efforts.


Dropping down to the ground, she sat and gazed at me through the glass. I sat on the floor and gazed back. Her right ear was torn, her teats sagged, and the skin of her hands was wrinkled. I had no way of estimating age, but I knew at least that she had seen injury and childbirth. She was indifferent to my presence-- neither afraid nor curious, affectionate nor antagonistic. She was simply looking for food.


I remembered a small bag of almonds in my suitcase. I took out a handful and dropped them through the crack of the door frame. They scattered on the porch. She gathered and ate them one by one, looked around briefly for more, then left.

Biri, Philippines
February 2018

​She is forty-two years old. She knows she will die soon. Even from the end of the hall, I can see how pale and frail she appears. As she draws closer, I notice the smell. It's the odor of death and decay. The chart indicates she was diagnosed with Stage IV breast cancer last year and it has metastasized to her bones. She understands there is no cure at this point. "I just want to be able to not stink so I can go out in public", she says. When I open her gown, the source of the stench is evident. Her right breast has been replaced by a tumor the size of a cantaloupe, and areas of the tumor are necrotic. She is literally rotting away.

We enter the operating room and she climbs onto the table. I hold her hand while the anesthetist puts her under. The surgical nurse cleanses her chest with Betadine. We are all near to gagging from the smell.


I remove the cancerous mass, but doing so has left a large open crater of a wound on her chest. It takes me nearly two hours to devise a way to close it by incising and rotating nearby tissue into place. At last, the bandage is applied, she awakens drowsily and is taken to the recovery room.


The stink is gone. It's all we can do, and it's enough.

The driving distance from Nairobi to Migori, Kenya is 371 kilometers or 222 miles. I'm traveling with a team of 15 other Americans, divided into three vans. We will spend the week in Migori, providing surgical services to the surrounding communities which do not have local access to such specialized care.


The road winds through city, town and countryside for nearly seven hours, providing an overview of this land and a glimpse into the lives of the people here.


A man shovels red dirt into a wheelbarrow, with no one and no structure anywhere in sight.


Small boys clad in colorful shawls of woven wool tend a herd of goats along the roadside.


A gaunt steer saunters past a row of ramshackle shops, pausing for a moment in front of Dimples Butchery, Bar & Restaurant.


Two young girls walk along, talking and laughing. Each carries a large bundle of sticks on her back.


A father walks hand in hand with three small children, past a group of donkeys nosing for food amid the roadside garbage.


Traffic creeps behind a long line of laden trucks, struggling up a steep hill. A family of baboons, including a mother with a tiny baby clinging to her back, gather at the edge of the road, hoping for scraps of food to be tossed from the trucks.


A teenage girl runs, laughing, to hide behind a shed as a boy of four or five looks around for her in an apparent game of hide-and-seek.


Acacia trees, with their distinctive silhouette, line the road and dot the distant landscape.


Birds pick at the bloated corpse of a cow lying in a ditch.


Groups of school children in scarlet uniforms smile and wave, shouting "How are you?" before bursting into giggles.


A family of five speeds past on a motorcycle.


Sheep wander between pieces of furniture for sale in front of a small cement building labeled FIVE STAR HOTEL.


Higher up in the hills, it is market day. Bunches of green bananas and bundles of sugar cane are piled high in makeshift stalls of sticks and cloth. A man selling chickens dangles them by their feet through his fingers, three to hand. Women sell vegetables from coarsely woven baskets piled high with potatoes, peas, tomatoes, and squash. Shoppers haggle over produce, testing mangos, avocados, and melons for ripeness. Small fires covered with metal grates provide a means of roasting ears of corn which are sold as a snack to passersby.


The rainy season is just beginning. We pass through showers here and there which turn the dirt portions of the road to thick red mud pocked with deep pothole puddles.


Shortly after dusk, we arrive at our destination. Migori is home to approximately 30,000 Kenyans from several different tribes. It is located 4500 ft above sea level, in the southwest corner of Kenya, just north of the Tanzania border.


Tomorrow will be spent touring the facilities, getting a crash course in how things are done here, and organizing team and supplies for the work ahead.