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.
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.
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.
The roosters begin to crow around three thirty a.m. There are hundreds on the island, as they are used not only for food but also for entertainment. Cock fighting is popular in the Philippines, and on this island of 11,000 people it competes only with karaoke as the favorite pastime.
Besides the roosters crowing, I hear rain falling on the clay roof. I've slept well, exhausted by two solid days of travel by air, land, and sea. The eight-by-six foot tiled bathroom is dimly lit, the ceiling bulb powered weakly by the hotel's small generator. Central power for the island is shut down from midnight until ten a.m., which means the fan in my room has no power. It's 85 F with 95% humidity, and I'm in need of a shower.
In one corner of the bathroom is a water spigot, and a drain in the floor. On the floor sits a blue plastic bucket. I turn on the spigot to fill the bucket with cold water-- the only option. A scoop floats in the bucket. There is no tub, and the shower head yields a scant trickle, so I employ the standard Filipino bathing method of soaping up then rinsing with the water collected in the bucket.
I wash the clothes I wore yesterday in the bucket and hang them over the balcony outside my room, hoping the rain will stop during the day. Across the street, an elderly man is sweeping the roadside in front of his shop with a bundle of straw fashioned into a broom. It's not yet daybreak, but all around I hear the sounds of the townspeople beginning the day.
The guesthouse where I'm staying is clean and well-maintained by the owner and her adult children. The five guest rooms are small but comfortable with private bathrooms and television. A small shop downstairs sells beer, water, snacks and sundries. The building is of concrete construction, in contrast to the plywood, cinderblock, and corrugated tin structures in which most of the islanders live.
Back inside, I pour the wash water into the toilet to flush it. I have yet to see a toilet on the island that is plumbed to flush any other way. Most do not have a tank attached. Toilet paper is not commonly used, and can never be put into the toilet. Instead, one washes with the scoop in the nearby bucket then pours the remaining water in to flush. It's bad manners not to fill the bucket again before leaving the bathroom.
Today is the first day of surgery. I'm assured there will be sterile instruments to use today, though the autoclave is currently not functioning properly so cleaning them for use tomorrow will be a challenge.
We have scheduled surgical procedures for over 200 people for the next ten days. People come from the larger neighboring island of Northern Samar, traveling several hours to have surgery they otherwise would never be able to access or afford. The local clinics and hospitals provide general medical care, but not surgery, and a trip to Manila where a full range of services are available for a fee requires a day or more of travel by boat, car, and plane. Those scheduled for today will arrive at the hospital by seven a.m. and wait their turn for surgery. The order of procedures is determined by which patients show up, the availability of sterile instruments, and manpower considerations. Some people will wait for hours.
Before going to the hospital, the team meets for breakfast at an outdoor dining pavilion next to the police station. Food has been prepared for us by volunteers from the community. Today we have a soup of cabbage and macaroni noodles in coconut milk and chicken broth, SPAM rice, and scrambled eggs.
The hospital is a ten minute walk from breakfast, and we are greeted there by patients, families, and staff including Dr. Alex, the resident canine. So it begins...
I am awakened at 4:35 am with an urgent call from the Emergency Department. An eleven month old baby has arrived in respiratory distress, and a chest Xray reveals a pneumothorax. Without prompt intervention, he may die.
I'm there in ten minutes, arriving to find a team gathered around the child, who is pale, listless, and fighting to draw air into his lungs by using every muscle in his chest/neck/abdomen. In children, this is called “retracting” and is a very bad sign. I glance at the chest Xray and see that the left lung is nearly collapsed.
“Let’s get a chest tube set up.”
“I need an 18 gauge angiocath.”
I insert the needle between the second and third ribs on the left side, just below the clavicle. As the needle enters the chest cavity, there is a rush of air through the catheter. The child’s breathing immediately eases, and oxygen saturation improves. This is a temporary measure, sufficing to relieve the pressure on the lung until the chest tube can be inserted.
“He’ll need to be transferred to the children’s hospital. We should intubate him first then insert the chest tube.”
The Emergency Physician agrees. We administer medications, perform further Xrays, draw blood, insert a breathing tube, connect it to a ventilator, and insert a chest tube. Within an hour, the Pediatric ICU transport team arrives to take him to the Children’s Hospital in Portland.
FONDE BAPTISTE, HAITI
An eighteen month old baby girl comes to or clinic with her parents. She’s had a cold and cough for several days, hasn’t been eating or sleeping well, and they believe she has worms.
We’re holding the clinic in an unfinished concrete building in this village in the mountains above Port-au-Prince. Two days before, we came up the mountain in a pickup truck, and had to get out and walk several hundred yards five different times while the driver eased the truck over rocks and ruts. The distance is about nine kilometers, but the trip took us over four hours. Locals make the journey on foot or on motorcycles, which can navigate the rocky, rutted terrain more easily than larger conveyances.
There is no medical care available on the mountain, but the community is hoping to change that by building a clinic to provide basic treatment of common problems. We have come to administer what care we can, assess the medical needs of the community, and assist with strategy/planning for the future clinic. We don’t have much in the way of equipment/supplies/medications, but are able to provide diagnosis, relief, advice, and reassurance to many of those who come to see us.
It is a disheartening endeavor. For this team of six Americans, the daily reality of the villagers is appalling. The community is poor, and living conditions are primitive. Lice, scabies, intestinal parasites and malnutrition are endemic. We see children who are shockingly underdeveloped for their age, and who suffer from a host of chronic illnesses related to malnutrition.
The baby girl with a cough is typical: she appears at least six months younger than her stated age. We administer de-worming medication, provide a sample of over-the-counter decongestant, and instruct the parents on the importance of hygiene, clean water, and how to use steam as an aid for cough/cold symptoms.
An hour or so later, they return with the child, who is having a coughing fit. The mother reports the baby started crying and then began to cough. This has happened before, as recently as last night, and usually subsides in a few minutes. I listen to the child’s lungs and determine she is having an asthma attack. I have brought along an inhaler, but they can be difficult to use, even for adults. For children, it is nearly impossible to use an inhaler correctly. We need to add a spacer-- a closed chamber which affixes to the inhaler and has a mouthpiece or mask on the other end, through which the child can breathe the misted medication mixed with air in the chamber.
We do not have a spacer.
Looking around, I see an empty plastic water bottle. By cutting the bottle in half, I create a mask. I connect the mouthpiece of the inhaler to the mouth of the bottle with the finger of a latex glove, then place the mask over the child’s mouth and nose. The mist from the inhaler fills the mask chamber, and as she inhales it, her wheezing subsides. She drifts off to sleep in her mother’s arms for the next hour. When she awakens, she begins to cry and her respiratory distress returns. This time, the inhaler treatment is not helpful. Her breathing becomes more and more labored. We have no further diagnostic or treatment resources, and I advise the parents she needs to go to the hospital in Port-au-Prince as soon as possible. A motorcycle taxi is arranged, but they have no money to pay the driver, nor to pay the hospital once they get there. The team takes up a collection for the trek down the mountain, which will take about an hour and a half. The temperature is dropping as the sun goes down, and the father wants to go home to get a blanket for the baby. Delay is not prudent, so I wrap her in my sweater and the family heads down the mountain on the motorcycle.
The next day is Sunday. We are invited to church, the hub of the community, and there we are informed that the child reached the hospital but died during the night. While the community is saddened, no one is surprised. Children die often there. Two other children had died that week. The parents of the child we treated had lost another child last year.
Two weeks later, I walk through a cemetery in Edinburgh, Scotland. The graves date back to the late 18th century, and many belong to children. There are several family monuments to multiple children. I'm struck by the fact that the death of a child was such a common occurrence back then. It seems so strange in this era of modern Western medicine.
As I stand over the baby boy in Oregon, I see the baby girl in Haiti before me. One child lives, another dies. It’s nothing new, only new to me.
The question comes from a patient in the Emergency Department. She has come because of two days of abdominal pain, and diagnostics have revealed the cause to be appendicitis. As the surgeon on call, this is where I come in.
After introductions, history-taking, examination, and discussion of test results, I lay out the treatment plan. In this situation, the only curative course is surgery, which I explain in detail. She poses a few intelligent, pertinent questions which I answer. She expresses understanding and agrees to proceed. Then she hesitates, fixes me with her gaze and asks, "Are you a Believer?"
Up to this point, it seemed we had established a therapeutic rapport- she was prepared to allow me to operate upon her. And now this....
I hesitated a moment. I didn't want a conflict. I didn't want to get into a religious debate. Most of all, I didn't want her to refuse treatment because of me. I didn't want it to be personal. Then I realized that choice was entirely hers to make. It wasn't really about me at all. She asked the question -- I would give the answer.
To be entirely clear, I asked "What are you referring to?"
"Do you believe in Jesus Christ as our Lord and Savior?"
"No, I do not."
A look of distrust, contemplation, then resignation. The moment passes. I assure her I will do my very best for her. She thanks me.
I am baffled- why is my religious affiliation or personal belief relevant? Most people ask, "How long have you been a surgeon?" or "How many of these operations have you done?". But that was not what mattered to her.
As as I continued to mull it over, I came up with a number of clever or evasive responses. But that just makes it about me, or rather how I want her to think about me. The fact is, nothing I say is likely to change her way of thinking, nor should I try to do so. If my beliefs don't matter as her surgeon, neither do hers matter as my patient. They are a force of division, and of no use here.
We've become so polarized -- always looking for reasons to separate ourselves from others. We feel that separateness sets us apart not only as different, but as better. The inclination is to find fault, to condemn or exploit anything we feel is unlike ourselves-- nationality, religion, race, gender, sexuality. It is the holding on to those identities for ourselves and the labeling and rejection of them in others that divides us and causes so much suffering.
These judgements and hatred poison our hearts and minds, much as my patient's rotten appendix was poisoning her body. Had she chosen not to overlook my lack of faith in Jesus Christ, and refused to allow me to remove her appendix, her condition would have deteriorated. So must we all rid ourselves of the poisonous delusions of identity and separateness if there is to be any healing of the world.
In the developing world, pregnancy-and the complications thereof- kills more women than motor accidents (the leading cause of death population wide). In terms of death per 100,000 persons engaging in a particular activity, it is more dangerous than SCUBA diving, sky diving, extreme rock climbing, and motorcycle racing.
I recently spent a full day learning all the ways a fetus can kill its mother, and practicing techniques to prevent or manage these situations. The danger begins at conception. Implantation in the wrong place or orientation can lead to massive hemorrhage and death of both fetus and mother.
Ruptured ectopic pregnancy is a silent killer of women and a true medical emergency. This occurs when the embryo has implanted somewhere along the reproductive tract, outside of the uterus (often the Fallopian tube). As the fetus grows, the tube will stretch until it eventually ruptures. It is a silent process, as often the woman may not even be aware she is pregnant, or may not as yet sought prenatal care.
I’ve experienced this first-hand in my practice. I was called to the ER for a young woman who had reported a sudden sharp pain in her abdomen, followed by rapidly progressing weakness. A quick ultrasound revealed a massive amount of blood in her abdominal cavity, and she was in shock from blood loss.
Not knowing the source of the bleeding, but with no time to waste, we rushed her to the operating room where I performed a laparotomy (surgical opening and exploration of the abdomen).
There were approximately two liters of blood in her abdomen, and after scooping out the clots and packing with gauze sponges, I located the source: an amniotic sac containing a fetus was extruding from the torn edges of her briskly bleeding right Fallopian tube.
The fetus was well-formed. Facial features, fingers and toes were clearly visible. It was curled into a ball, floating in its liquid cocoon, and it was moving. Here in front of me was a part of life few will ever see with their own eyes- and I marveled at it.
But I also knew there was no way it could ever survive. It was doomed from the beginning. And right now, it’s mother was bleeding to death. I had two choices: end one life to save another, or lose them both.
The blood supply to the Fallopian tube (and thereby the placenta implanted into it) is the uterine artery on each respective side. In surgery, we stop arterial hemorrhage by controlling the feeding artery with clamps or ligatures.
“Clamp!”, I called.
The scrub tech looked at the fetus, then at me. Our eyes met, and in that instant we agreed.
The snap of clamp striking palm was followed immediately by the click of the clamp locking closed on the artery. Bleeding stopped.
“Call the OB/GYN.”
“What’s her pressure?”
“Two more units of red cells and a STAT ABG, please.”
As the anesthesiologist worked to correct the damage done by blood loss and shock and we waited for the OB/GYN to arrive, I wanted to look away, but found I could not. My eyes rested on the tiny form until it stopped moving.
If all goes well and the fetus and mother survive to term, birth can still be deadly. Our practice sessions focused on situations in which birth does not progress normally. There are several scenarios which are common in the developing world.
Uterine rupture may occur when the uterus has been weakened by multiple pregnancies or by prior Caesarean sections. As labor contractions intensify, the walls of the uterus may rupture from the pressure. In this instance, the fetus must be delivered within minutes to save it, and the bleeding stopped quickly to save the mother. This is done via an abdominal incision similar to a Caesarean section. As time is critical and access to care is limited, this condition is frequently fatal for both fetus and mother.
Another major problem encountered in the developing world is intrauterine fetal demise, which most often occurs when the fetus is unable to be delivered vaginally due to malposition (breech or transverse) or to anatomical limitations in the mother.
Child marriage (and pregnancy) is common, and the underdeveloped, small pelvis of a young mother often prevents passage of the fetus.
if labor begins but cannot progress to birth, the fetus will die. At this point, the danger to the mother is death from sepsis if the dead fetus is not expelled.
Today I learned a new term: Destructive Delivery. This is a procedure that facilitates passage of the dead fetus with the least possible risk to the mother. Before today, I would have thought that extracting a dead fetus from its mother would be similar to extracting a live fetus which could not pass through the pelvis- namely, by Caesarean section. But Caesarean section, as with any surgical procedure, carries inherent risks. And in a mother who is likely already anemic, malnourished, and susceptible to infection, those risks multiply. The safest thing for the mother is to facilitate a vaginal delivery.
Most of the time, the head is the largest part of the fetus, and it becomes wedged in the pelvis once labor has begun and is unable to pass.
Reducing the size (volume) of the generally results in subsequent vaginal expulsion of the fetus shortly thereafter. This reduction in volume is accomplished by creating an opening in the skull of the fetus, through which the contents of the extrude. We practiced the technique on grapefruit.
From a human standpoint, this process may seem distasteful, traumatic, even brutal.
From a technical standpoint, it's a simple, elegant solution which is easy to perform.
From the perspective of a physician and surgeon, it is a safe, practical and sound approach to solving a problem in a living patient.
From a societal perspective, it is the tragic outcome of social and cultural practices that encourage child marriage.
From a humanitarian standpoint, it is an indictment of local, regional, and global politics that make child marriage, multiple pregnancies, lack of birth control, poverty, malnutrition, and poor or non-existent healthcare a daily reality for millions of women worldwide.
I never want to cut open the skull of an unborn, dead fetus. But I know now that I can.
Most of us in the Western world will never be faced with this situation. But we should all be aware of it. We should consider how our lives- our habits, choices, actions, and politics contribute to ideologies, practices, and organizations (including governments) which either promote, facilitate, or allow the conditions that lead up to it.
It’s 2:30 on Wednesday afternoon. I’ve spent the day meandering through Glasgow’s Kelvingrove park, making my way along the river with the pigeons and squirrels. It’s a beautiful, crisp fall day with frost dusting the leaves on the path.
After a few hours and miles, I fancy a pint. The exterior of MacConnell’s proclaims it to be a “traditional Scottish haunt”, which sounds like just the place.
Behind the bar is a dark-haired woman in a black tank top who I expect is likely younger than she appears. She greets me with a warm “Hiya” and serves up a frothy pint of Guinness as she banters with the two older men at the bar.
They each have a partially completed crossword in front of them, but have paused in their progress in favor of jaunty discourse.
Peals of laughter erupt from the only other occupied table in the small pub, where four gray-haired men in jumpers are deep in joyful debate. The guffaws are punctuated with frequent “Fowk Yewh!“s. The controversy seems to involve the height of a particular sporting figure, from what I gather.
"Hey, Natasha! Come Google this for us!”
“Aye, I will do. Give me two minutes.”
The liquor delivery has arrived and her attention turns to the transaction.
Meanwhile, two new arrivals have joined the group. Standing height comparisons are made, bets taken, and I catch something about “allowing for shrinkage” which provokes much loud applause.
Natasha returns, serves the newcomers their beer, pulls out her phone, and the question is posed to her: How tall was Italian footballer Franco Baresi (whose stellar career ended in 1997)?
The answer comes back: 5 feet, 9 inches, and there are cries of triumph and consternation as bets are won and lost.
One may well ask, “Who Cares?”. But they would be missing the point. Of course it doesn’t matter how tall Franco Baresi was. What matters is these people, right here and now, taking these moments as they are and enjoying them in their companionable perfection. I silently bow to them, grateful to have been a party to it.
My glass is empty. Time to move on.
Musings on my travels and experiences as a Zen practitioner, trauma surgeon, and citizen of the world.