Wins, losses.

Tuesday, May 09, 2006

Up until 3 last night. The moon is waxing and the natives are getting restless. My first clue was coming back to the hospital late in the evening and noticing a blood trail from A&E leading toward the major theatre. I was off-duty but figured I’d see if they needed some help.

There were three patients. bleeding One man had been attacked with a machete (they call it a cutlass here). He had one gash in his head and another, a defensive wound, in the undersurface of his forearm that severed tendons, the radial artery and key nerves. Lucky for him the bleeding had been controlled.[1] All was laid open to view. A good anatomy lesson. The Cuban orthopedist on call got that one.

The other two were another victim and his assailant. The victim had been at a mini-mart, keying some numbers on his mobile phone when a short, drunk man he didn’t know attacked him with a broken beer bottle. The attacker’s handiwork included a small, deep gash across one knuckle, a foot-long superficial cut to the victim’s left upper arm, and a deep, triangular excavation to the underside of the man’s right forearm. The victim was a well-dressed man with thick, muscular arms. A huge flap of skin lay contracted over what looked like chunks of stew meat simmering in blood.

For an hour and a half, Lamin, the “theatre” (operating room) nurse, and I stitched the guy back together with a fluorescent desk lamp for light, tucking in pieces of meat here and there, and inserting a drain to keep blood and other fluids from accumulating. In the middle of the process the hospital lights went out. A bystander unfolded his mobile phone for the light the screen provided. I directed him to fish my LED penlight out of my t-shirt. We continued the operation by electric torch. Twenty minutes later the generator kicked in (it turns out the generator man was sleeping) and the lights came back on.

Shortly, we heard a commotion in the hall outside. The still-drunk assailant had been brought in by the police to have his cut ear fixed and he’d started an argument with the victim’s friends who were waiting in the hall for me to finish my suturing. The cops had been told to keep the assailant outside so an altercation with the victim’s supporters would be avoided, but these cops were not the brightest bulbs in the marquee. They brought him in anyway.

The voices grew louder and soon we heard thumping noises. I went out into the hallway, bloody rubber gloves and all. Mr. Drunk Assailant was grappling with one of my patient’s buddies. The police were standing around looking interested but doing nothing. I waded in and separated the two men, telling the constable to do his “f…ing” job and keep the peace. He asked me what he was supposed to do. Meanwhile, Mr. Assailant, still drunk, was trying to fight everyone else there. I grabbed him and told him this was a hospital not a street brawl and he had to leave. He spat at me and said they didn’t need any white bastards telling Gambians what to do. When he started to go after me the police finally stepped in and escorted him out. Then I went back to finish the suturing.

By the time all was stitched and glued, seams straight, bandages on, etc. I looked up and it was 2AM. We had to get some antibiotics into my patient but the hospital pharmacy was closed. I went off to one of the wards where a friend had been admitted that day, borrowed two of her amoxicillin, and fed them to my patient. God knows, he’ll need it. There’s no way to maintain a sterile field with the setup at this place. Aside from any bugs introduced in the initial stabbing we certainly added plenty with our operating technique.

Christ! These people are tough! They have to be to stay alive!.....and to survive what WE do to them!

Wednesday, May 10, 2006

So I get to work this morning and before I get a chance to get oriented one of the docs notices that a woman on the second exam table is seizing (convulsing) and has bitten her tongue badly. She’s choking on her own blood and secretions and there’s blood coming out her nose and mouth. I get her over on her side and run for a suction machine but the one I find doesn’t have a plug on the end of the cord. So the nurse heads off looking for the other suction machine and somebody else shows up with an endotracheal tube and laryngoscope and this lady’s inhaling her blood like there’s no tomorrow. We can hear it gurgling and when she coughs it blows out her nose in a spray all over the place. It spatters us and the floor and walls and the nearby patients. I’ve given her IV Valium but I can’t get a laryngoscope in because her jaws are too tight from the seizures. So Dr. Conde, the wonderful Cuban head of A&E, finally gets a tube in her nose and into her trachea but then it gets pulled out while Dr. Conde is putting in a central line and we have to try to get it in her all over again except this time it won’t go in so we give her more Valium and get her mouth open enough to do an oral intubation. And I’m sure she’s inhaled so much junk her lungs will never recover. And eventually she’s wheeled off to the ICU and I never did find out what she was here for.

And for the rest of the day I’m treating people with malaria and with anemia, and a stroke, and with malaria AND anemia. And it’s not even malaria season yet. And there’s the guy who was asleep under a truck and someone drove the truck away and it ran over his leg. The leg is broken and the skin over his calf muscle has been stripped off neatly so the whole gastrocnemius muscle lies there, neatly covered in its intact fascia, pulsing and twitching like a computer-animated photo from an anatomy text. Meanwhile, the owner of the anatomy lesson lies on the gurney conscious, showing no emotion whatever.

The fruit are ripening and daily children are brought in who have fallen from mango trees. It is a yearly ritual. Mango trees grow big and full; deep green and magnificent. But the limbs are fragile. So we have a 13-year-old girl who has fallen from a mango tree. She is unresponsive, pupils fixed and dilated. We assume her neck is broken or perhaps a head injury. There is nothing to do for her. The treatments available back home are unavailable here. She will die.

And in the midst of it all a hospital courier comes in with a letter for me from the administration telling me that the lease on the house I am about to move to expires at the end of August and at that time I will be responsible for my own accommodations. I think I may have to have a discussion with the administrators. They’re getting an OK deal so far: an American doctor at the price of a room they haven’t had to pay for.

My sewing project from last night did show up this morning. He looked good and told me he really didn’t have any pain. I can’t figure that out. That forearm wound looked like hell before we got it stitched up and I figured the man would be in agony. There aren’t any pain-killers available here stronger than a weak Tylenol/codeine combination but he said he didn’t even need them. Tough people!

I’m off to Marong Kunda for food.

Thursday, May 11, 2006

Shitty day! No details. The young soldier from yesterday is dead. The woman who spattered me with gore yesterday is dead. The young man who came in vomiting blood continued doing it until he died.

I wasted my kora teacher, Alhaji’s, time and pissed him off. And other petty annoyances.

Dinner with Allen and Margaret. Their trip to Senegal was lovely. We ate huge prawns and drank gin-tonics and lousy white wine and laughed a lot. Capped off the dinner with the last of their Talisker Single-Malt.

I drive them to the airport on Tuesday, and then move into their house. I hate to see them go and have reservations about moving into the house. I’ll be trading connection to my family and the Banjul aliveness for (relative) luxury and isolation. I’ll try it for awhile and see if it is worth the exchange.

I returned to Banjul in the dark to the sound of drums and singing. I followed the sound and found a crowd in one of the side streets. Darkness, drums, and people doing a slow, counter-clockwise, circular dance. I stood for a long time listening and watching. No one paid me any attention. Eventually a young man appeared from one of the houses with a tray of some sort of drink in plastic mugs. When he reached me I asked what the program was. “We are praising Allah”, he told me. The beverage was tart and complex and savory, not overly sweet like most things I’ve had here.

Perhaps the words were Arabic and Muslim but the music was pure African. Whatever the name of the god that was being praised the form and practice came from Black roots, not anything bred of Arabian sands.[2]

En route back to the hospital a small, long-haired dog decided to play with me. The dog didn’t look Gambian at all. The usual critter here is a short-haired, nondescript cur with fly-blown ears and a belly so full of worms that play is out of the question.

The hospital dogs in action.

At the main gate the security guys asked me to sit with them and wanted to know about America. What was the biggest city? What was Colorado like? Georgia? Dallas? Did they drink ataya in America? Is it cold there? It was a cool evening, but I was sitting in my Hawaiian shirt in comfort while the guards were putting on coats.

To bed. I’ve got to kill more patients in the morning. I’m out of my depth and we’ve got nothing to work with here!

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[1] As clinical instructors like to say, somewhat cynically, “All bleeding stops eventually.”

[2] These celebrants are Mourides, or followers of the Sufi saint, Sheikh Amadou Bambá Mbakke, who died in 1927. The Brotherhood is centered in the Senegalese city of Touba, which the Saint founded, and the annual pilgrimage to the holy city attracts 2 million people yearly!