on Block Two
by Stefan G. Kertesz
young woman lying in the grass in front of Hospital Block Two was evidently a
problem, but it was hard for me to tell how much of a problem, or in turn, if
I was supposed to respond. She looked like she was asleep, like some of the other
women who vacated their mangy beds in order to sit on the grass and absorb the
warm Nairobi sun. But something had evidently gone wrong, and only recently so.
I might have guessed this was the case from the slight expressions of concern
I could see in the faces of the nurses who discussed her. Other women sat in the
grass, watching the nurses, watching me, in front of our hospital ward, known
as Block Two. The situation of a young woman lying out of place in the grass aroused
a confused response in me.
In my time as a volunteer doctor in that impoverished Kenyan hospital, there was a way in which all the desperate situations and all the possible human responses to those situations blurred together. It became difficult for me to know which ones to care about and respond to, which ones to highlight as "pivotal to my understanding of this unique environment", and which ones to let simply "pass on by". In the end it was hard not to let a lot of desperate situations pass by, much the way one notes but then agrees not to spend much time thinking about the fiftyish disheveled man with a prominent odor who boards a nighttime bus and talks to himself for the duration of the trip. If one began to worry about where he would stay that night, or how he became the man he is it might be too much. So one sits and lets the event of a personal tragedy unfold without giving it too much attention.
Block Two at Mbagathi District Hospital, Nairobi's smaller public hospital, was a long single-story building, divided into wards, each one with eight beds, and 6-16 patients per room. The doubling-up of patients in beds was something I wanted to discourage, particularly if there were empty beds available. The logic of putting two patients in a bed when empty beds were available in other rooms eluded me. Then again, the answers to many more fundamental questions eluded me as well.
That morning Block Two, like the rest of Kenya, and in many ways like the girl lying out of place in the grass, challenged my sense of myself as a caring person. There was so much to care about, very few fellow carers to recruit to the process of caring, and seemingly even less one could do about the things one did care about. So the amount of care I could ultimately offer seemed pitifully limited compared not just to magnitude of the problems at hand, but also compared to the amount of care I had seen myself put into things I knew I could influence: like the sensible purchases of an automobile and a television set in the United States a few months before my departure for Kenya.
But even amidst the ambiguous rewards of Mbagathi District Hospital, I had invested my energy meaningfully with at least a few patients on rounds that morning.
I had arrived to find one of my patients sobbing giant tears, speaking to herself in Swahili. It was rare that I came to regard individual patients as "my" patients, for properly they fell directly under the care of Medical Officers, a rank below me. Medical Officers, in theory, attended to day-to-day issues, leaving me to "supervise". Frequently enough, however, there was no one at the hospital for me to supervise. It had been on one of those days that this 17 year-old girl had been admitted, panting hard, looking very thin, coughing and clutching her abdomen. I recalled feeling certain she would die but also feeling that even in the worst of circumstances, 17 year-old girls deserved a fighting chance. In the absence of the Medical Officers I used my broken Swahili to construct a skeleton history and examine the patient. I ordered a five-drug treatment for what I assumed to be widespread tuberculosis in a young woman whose immune system was likely suppressed by AIDS. It had been a few years since I had placed intravenous lines, but I placed one, which fell out, and I placed it again. Over the next six days she had looked a little brighter each day.
And over those days I had asked the nurses where this girl had come from. They called her an"abandoned housegirl". Somewhere along the line her parents had put her in the service of a home which had some economic resources, perhaps because the parents had none themselves. She did household chores. I feared, however, that a "housegirl" unprotected by ties of family was uniquely vulnerable. Her job description might have included the expectation of sexual accommodation, wanted --or more likely-- not. I recalled the day my Kenyan colleagues, both women, took note of the disproportionate number of teenage girls dying of AIDS in our hospital and, shaking their heads, told me "something is not right in Kenya". We suspected many HIV infections due to the rape of teenagers.
No family ever came to see this girl in the hospital. I wondered to myself what would be the outcome of saving the life of a 17 year-old girl with AIDS, no family and no job. When I saw her crying and gibbering in Swahili, it occurred to me that she might be well enough to begin asking herself the same question. If her answer was the same as mine, she was likely to cry. I asked an emaciated woman in the adjacent bed what she was saying in Swahili. The woman said, "She is saying 'Where is my mother, where is my brother?'" I stood next to the crying 17-year-old. I had no tissues to hand her. I patted her shoulder and said nothing while she cried. It seemed to me that the only thing worse than crying was crying alone. And after a few minutes, I left her alone, and went on rounds.
The young woman in the grass came later.
Rounds that day were superb by the standards of that particular hospital. A new Medical Officer arrived, a tall thin and talkative young man. Not only had he come to work, but also he had insisted on seeing every one of the 35 patients on the male side of our block, despite feeling ill himself. His predecessor on the male side had never taken such an interest, and I was duly impressed.
Even I enjoyed a modestly triumphant moment that morning. There was a young man, apparently admitted some days before with a question of tuberculosis. No doctor had examined him. His chest x-ray lay on the bed, and on our review it revealed classic findings of a collapsed lung, a medical emergency. He lay there in bed panting, and despite his desperate status, had apparently lain there for two days, panting.
I derived a certain sense of satisfaction from making the diagnosis, despite the fact that the x-ray findings are completely obvious to a minimally trained medical person. For I had missed this diagnosis exactly five years and one month before. Early in my internship I had gone home to bed one night, having forgotten about a pending chest x-ray in a patient with AIDS. A collapsed lung was found when that patient decompensated the next morning, and the same finding was identified on the x-ray I had ordered the previous day. One look at the previous night's x-ray could have averted the morning crisis. The surgeon who treated the patient had scolded me and I nearly cried. Now, in Kenya, I could look at this x-ray of a collapsed lung, secure in the knowledge that this time someone else had failed to make the diagnosis. It's strange how, while while playing the role of Schweitzer amidst unmitigated human suffering, some part of me sought little more than a petty salve for the chagrin of past failure.
Definitive treatment for the young Kenyan man, which required immediate insertion of a plastic tube in the side of the chest, was not going to happen. The hospital had no plastic tubes. The patient's family would have to purchase a tube from nearby private hospital and bring it to us; so there would be no tube for at least a day or two.
While the medical officer made ready to proceed to the next patient, I asked him for a hollow needle, knowing from my books that even a needle could offer temporary relief. It was an emergency, according to my training, but strangely I was the only one who seemed to think the problem couldn't wait until the family came up with some money for a chest tube. I actually felt more anxious about being out-of-step with the social system of the ward than I did about an emergency whose management I had cursed myself for not recalling five years before.
In went the needle, the patient winced, but then nothing happened. I could not explain it. I pulled my needle out, fumbled, then asked for another, and put it in slightly lower. A hiss of air emerged. The patient relaxed, thanked me, and told me he felt better. I urged the medical officer to push the issue of a chest tube that day; I am not sure he did.
When we finished rounds I walked down to the women's side to check on a few patients. And then I noted a concerned look on the face of our head nurse. I saw the young woman in the grass, was she sleeping? Altogether too many flies circled about her. What had happened? Five minutes before, one nurse had watched her walk, then fall. Now there she was, in the grass, no longer fanning away the flies. Flies circled all my patients, but the sicker ones had more flies. This woman was surrounded by the most flies. I concluded she must be dead.
In the American hospitals where I had trained, the collapse of a young woman would be referred to as a "cardiac arrest", a potentially reversible situation, and it would be followed by a rush of nurses and doctors, cardiopulmonary resuscitation, and jolts of electricity. But in a Kenyan public hospital filled with patients suffering from TB and AIDS, this was going to be called "death" from the start. She lay there, and since at least half the patients died, it was hardly even news.
There was still one thing I could do. My experience in this decrepit Kenyan hospital full of death had given birth to one peculiar but important insight about doctoring: every dead person deserves a doctor to pronounce them dead. If the patient herself could not notice the service, the 20 live women sitting on the grass would certainly notice if anyone responded to the death of one of their number. Like me, they knew that death was commonplace on Block 2. But it would compound their misery if they saw it ignored.
So I stepped off the ward's patio, down to the grass, listened to the girl's chest and flashed my light in her pupils: no heartbeat, no pupillary response. She lay on the grass curled in a peculiar position. I straightened her out, closed her eyelids, and left.
I entered a small washroom where the nurses took their tea. Lacking towels, I wiped my wet hands off with my shirt, and poured myself a cup of "chai" as the Kenyans call it, a mixture of hot milk and tea. It was good and sweet. A young woman lay dead in the grass and I could still tell myself that I liked this cup of chai. One nurse and I sat, talked, and we both admitted that something about the ward made us slightly nauseated. We acknowledged that maybe the dead young woman had something to do with it that day.
I finished the chai, and walked back out to finish up and go home. The young woman's body had been removed. Suddenly I saw the abandoned housegirl who had been sobbing in Swahili that morning. She was sitting on the grass, in the sun, not far from where the corpse had lain. I waved. She waved back. She smiled at me. I went home.
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