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Between the Seasons of Meningitis and Malaria

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In the lightless hours before dawn in West Africa, an infant was born via cesarean section, strong pulse but no breath. Her mother lay on an operating-room table surrounded by four—attending, resident, medical student, and scrub nurse. The medical student carried the infant to the newborn table, picked up a tiny mask attached to a reservoir (a neonatal ambu bag), and pressed air into those still lungs, one small breath at a time.

I was not on call that night, so I slept and knew nothing. As the Obstetrics attending and resident completed the operation, my roommate, a med student from upstate New York, stood there in the empty night, holding that tiny being to life with his hands and a small device of plastic.

There was no neonatal intensive care unit, no ventilators, no IV pumps, only that plastic bubble of air and the hands around it. Why the infant would not breathe we could not know: apnea of prematurity, a congenital malformation, the will of God. On such a night, only so much was possible. Time ran out. Forty-five minutes was his guess. You could argue that it should have been more, or maybe less. He could have stayed up all night, and in the morning he could have passed the infant and the ambu bag along to me.

In the end, they lay down their hands. All they could do is watch.

• •

The sun rose over roads of dark red clay and clouds of dust raised by motorcycles, big municipal buses, and vans called tro-tros. The tro-tros were stuffed full of passengers, piled high with luggage, and occasionally on the roof a few extra people and a well-secured goat. A pair of steel red-and-white high-voltage towers loomed over the village. Red Vodaphone signs advertised cheap minutes.

As the dirt road led away from town, but before the buildings disappeared entirely, stood a large steel gate that opened onto the hospital grounds. There were four adult wards, a pediatric ward, an isolation area for patients with TB and other exotic infections, two procedure rooms, and two operating rooms. There were offices for outpatient visits, a lab and an X-ray room, a pharmacy, and a courtyard where motorcycles and bicycles sat in the shade of a large tree.

I first passed through those heavy gates in the late spring of 2010, just weeks before I graduated from medical school. The first person I met, a volunteer coordinator named “Russ” [all names but my own have been changed] began to introduce me to everybody else as “doctor.”

“I’m not a doctor,” I told him.

“You are to me,” he said. “I could never do what you guys do.”

A vague sense of unease passed through my mind.

At the far end of the compound, adjacent to a small dirt path that led to TB Village, stood a building: one large room, walls of stone and concrete, steel double doors painted blue. A single fluorescent light burned beneath a corrugated tin roof. A transient resting place for the dead. Many of the stories I recall most vividly have their end in this building.

• •

Every day one of the volunteers was on call and would round in the hospital in the afternoon and evening, passing through each of the wards to see any new admissions and address concerns raised by the nursing staff. We had two medical students, one to three family medicine residents, one OB-GYN resident, and an attending physician in family medicine from Canada.

My first night on call, a young woman looked past me with eyes that did not see. She had gone out to the well after dinner, her brothers said, and fallen head first into darkness and onto stone. There was a deep gash in her forehead, and as I looked more closely she began to climb off the stretcher, and a mix of family and hospital staff moved to calm her down.

Through the split in her skin I could see the dull white of bone. Her skull. I tried to project a calm I did not feel.

Outside the window, the sky was dark and alive with the cascading song of a million bats.

“Why don’t we call Kenney?” I offered the room. Joe Kenney was a quiet man from Wyoming. He had begun his career as a pediatrician before later training as an OB-GYN and picking up a bit of general surgery along the way. He practiced medicine and spread the Gospel. He was one of two supervising physicians at BMC.

One of the nurses rewarded my question with a memorable look of contempt.

“Why do you need Dr. Kenney? You’re the doctor. You do this.”

So I did.

The so-lu-tion to po-llu-tion is di-lu-tion, more than one surgical resident had told me. I drew up some sterile saline and washed out the wound. It ran about the length of my index finger, straight up and down her forehead. Her brothers told her to lie still, but she did not hear them.

The wound was clean and deep, so I decided on a partial closure. I injected some local anesthetic, then brought the two edges of one of the deeper layers together (the frontalis muscle) at three points along the wound, like a string of pearls. I tried to do the same for the skin. The idea was to keep the wound open enough to drain any potential infection but also closed enough to protect her skull from outside bacteria.

She twisted her head, and the needle was knocked to the side, brushing against one of the nurses. I checked his arm to make sure it hadn’t broken skin. Even at night it was hot and humid. In the back of the room, one of her brothers vomited into a sink.

“That’s it, we’re done,” I said.

The next morning, someone gave her a tetanus shot. No one told me I had missed an important and obvious step, but no one had to. Nor was there time to ask what other important and obvious steps I might have missed. Her brothers took her back home that day.

The attending physicians who supervised us trainees lived on campus and could be reached 24/7, so help was always available. The medical students and residents ran some cases by the attendings, but not every case. Not even most cases. There were over a hundred beds in the hospital and several hundred outpatients that passed through our doors on each clinic day. A certain degree of autonomy was necessary to keep the place from collapse.

I was not nearly as scared as I should have been. My training had prepared me to be a junior team member, but I found myself acting as a semi-independent physician.

That was the whole point of it, someone told me. Learn things no one would ever teach you in a developed nation. Not for the sake of adventure tourism, but because the need was so overwhelming. That is both a lie and a truth. A variety of factors motivated the volunteers: adventure being an important one, along with faith and a desire to learn and help those most vulnerable.

Like any expedition with a scope far beyond the available resources, things did not always go according to plan. As I have written (and rewritten) these stories over the years, the moral consequences of putting these words to paper has given me pause. What if an honest account did the institution harm, and what was it that made me want to write about it in the first place?

For transparency, I told myself. Some stories deserve to be told. When the choice is between a truth and a lie, absent a very compelling case against honesty, truth should win in the end.

• •

“Should we be doing CPR?” my roommate asked me one early morning. A young woman was pulseless in the obstetric ward—the mother of the midnight infant with no breath. Now the sun was up and she, too, was dead. We stood quietly on one of the outdoor walkways connecting the various clinic and hospital buildings. It was hot. Each night we would leave bottles of water in the freezer and take them with us in the morning. By noon the water was warm in our hands.

“Was she found dead?”

“Yes,” he said.

“Then I don’t think we should.”

I did not say that in the time he had taken to find the patient, check for a pulse, and then come outside and talk to me, any chance that might have been was likely gone. Even had he tried, CPR would not have fixed what had killed her. Almost certainly. Unless I was wrong. We didn’t even know the cause of death. We would never know. Maybe there was a one percent chance. Should I even be the one to answer this question? I already had.

We moved on. There were a lot of patients to see. I did not stop to wonder about the significance of that one percent.

Each morning we spread through the hospital at 7:30 or 8:00 a.m. to round on the various inpatient wards. Mondays, Wednesdays, and Fridays there were morning prayers at 9:00 a.m. in an open chapel just inside the gates. Clinics opened at the conclusion of service. Four to five hundred patients passed through the clinics on each of these days. Some came from neighboring countries to the north, east, and west. One man I remember had crossed three national borders to reach our hospital. Many had malaria, which we treated with atovaquone and artemesinin, unless they were sick enough to require admission to the hospital, where they received intravenous quinine. A list of available medications was passed around from volunteer to volunteer on a few sheets of paper someone had copied and stapled together.

The first morning I rounded on patients, I came across a teenager with a rigid abdomen and informed one of the attendings. Since there was no CT scanner to take him to, we wheeled him to the operating room, where we could open his abdomen and see for ourselves. He had four small perforations in his small intestine from typhoid. We carefully corrected each one with an oversew. He did well postoperatively and was sent home with instructions to find a new well to drink from, because the water in the other well was not good.

We should have sent someone out with him to shut down that well, gone out and dug some latrines, but we weren’t staffed to do that kind of work. There were always more patients to see, more work to do, and the immediacy of the need crowded out broader questions.

And then, just as you found a sense of normalcy, you would be rounding in the morning and a patient would die as you worked your way around the room from bed to bed.

There was a story about a visiting doctor who found this odd. “What is this place?” he asked one of the nurses. “How can this man die right after telling me he feels fine?”

“They don’t want to make you unhappy,” the nurse replied. “He probably felt it would be rude to complain.”

I remember one Family Medicine resident who quietly told me that she hoped she hadn’t killed too many people that day. We stood together in one of the adult male inpatient wards, sweating in the late morning heat, surrounded by ten to fourteen patients, one freshly dead.

“You haven’t killed anyone,” I told her. True, someone she had rounded on had just died fifteen minutes after she had finished her note, but the one had only described the other, not caused it. It was her second or third day. I had been there a week or two and seen many dying or dead. Sometimes we knew the reason. Most of the time we did not. The day-to-day work no longer terrified me. I might not be able to play the role perfectly, but I could do a passable, karaoke version.

The man she had rounded on had died of liver failure, a black illness, according to the local shamans, who categorized illness by color: white, yellow, red, black. Black disease meant that local beliefs and customs forbade seeking out the white man’s treatment, at least not until the patient had placed one foot through death’s door. I did not love that colonialist phrase,  “white man’s treatment,” but policing the language of rural peoples without access to clean drinking water seems . . . unnecessary.

This man’s death illustrated one of the selling points of our mission hospital in the local community and the reason so many people traveled such long distances to be seen there. Their words were both an endorsement of BMC and an indictment of the care available elsewhere in the community.

At Baptist Medical Center, they said, only those who are meant to die, die.

• •

A pregnant woman at term took some pills she bought at the market to induce labor, but her cervix did not dilate, so instead of pushing the fetus out the birth canal, her womb contracted until the pressure from the head of the infant was greater than the blood pressure keeping the front of her womb alive. As a result, the infant burst through into her abdominal cavity, swimming among intestines, where it then died if it was not already dead.

Our scrub nurse dropped the dead baby into the operating room kickbucket, a rolling garbage can. I looked down and tried not to throw up. Maybe that dead-baby toss was his way of saying life is cheap. Maybe he was tired of watching, as I looked around for somewhere to set the body. Maybe he just wanted the operation to be over. l wanted to place the dead baby somewhere that was not in the trash while we figured out what to do with his mother’s mangled womb. The tiny body was later returned to the family for burial.

Within minutes of walking out of that OR, any thoughts I might have had were crowded out by an overflow of activity. There was an elementary school student who had been kicked in the shoulder by a donkey; he sat still and silent as he was stitched up. There were hernia operations and C-sections and the small office near the operating theater with rows of decades-old surgical textbooks, where one night, decades ago, a medical volunteer had been temporarily blinded by a spitting cobra. A boy who had swallowed a coin, another boy, while trimming tree branches with a machete, severed a tendon on the back of his hand that controlled his middle finger.

I met a street vendor selling screen-printed Obama T-shirts in the market. One of the other medical students and I visited a pond where legend was that crocodiles had once saved the son of the local village chief. The crocodiles were treated as holy and were also a tourist attraction.  For a small fee you could touch the giant creatures, hold their tails, or even sit on them.

There was a speakeasy to visit outside of town, a cooler of beer and soda hidden in a courtyard with no signs and only a single light bulb. Driving through the village at night meant shifting into low gear and slowly navigating around a steady flow of people, carts, goats, and children roaming around the unlit roads. Some street vendors had lights—but as soon as the village was behind us, there was only dirt road and blackness.

There was a separate clinic by the front gates where mothers would bring malnourished children. I went for a run one afternoon in the empty fields behind the hospital campus, where a group of village kids joined me, half of them barefoot, one of them carrying a machete he called his cutlass. I ate some roasted goat meat sold by the side of the road and got sick two days later.

We treated snakebites, mostly from carpet vipers, a white-bellied snake common to West Africa and South Asia, whose venom disrupts the ability of blood to clot. A small supply of antivenom sat on a shelf for storing eggs in the guest-house refrigerator.

There was a young, thin man in his late twenties who had been bitten by a carpet viper on his forearm, which swelled up like a cartoon. I don’t remember what language he spoke (some patients spoke English, most spoke an average of three tribal languages from the dozen or so used in the region), but I do remember that he smiled when another medical student and I rounded on the men’s ward that morning. The small piece of paper from the lab attached to his chart said CLOT, which meant that he was safe for now. Later in the day we would send another blood sample to the lab, and if it said NO CLOT, he would receive a dose of antivenom until it said CLOT again.

That night when another medical student, Greg, returned for evening rounds, the young man was dead. Greg decided to begin CPR (cardiopulmonary resuscitation) or chest compressions. He asked for a backboard to place beneath the patient. There was none. He started pushing down on the patient’s chest with his hands. The staff looked at him without understanding. He sent someone to go get an ambu-bag. The slip of paper on the young man’s chart read NO CLOT.

Someone returned from the operating room with the neonatal ambu bag, the one used in newborn resuscitation. Greg yelled something to the effect of “Are you fucking kidding me?” He continued his efforts a while longer, saw it was futile, threw up his hands, and walked away.

The next few days he shit-talked the nursing staff at every opportunity.

“Incompetent, fucking stupid, lazy, just staring at me, not doing anything, brought me the newborn ambu bag, really? Is this place some kind of fucking joke? What the fuck are we even doing out here if everyone is just going to die?”

I didn’t know what to say. Correction. I did know what to say, but not how to say it without making him cry and/or hate me. Why not start with where we were. We were in a mission hospital in a village without running water where you could go for a walk, get bit by a snake, and then die. The nurses didn’t know what CPR was because the American Heart Association didn’t have instructors in rural West Africa. The next day (or maybe the day after) he began adding the qualifier, “I know that he died because of the carpet viper bite, so I guess there wasn’t any point to it, but still . . .” He could not imagine a hospital where none of the nurses knew CPR. This failure of imagination was all the more interesting because he had worked that morning, after breakfast, in a hospital where none of the nurses knew CPR.

Maybe we shouldn’t have been there. God only knows what other decisions he was making, or I was making. Maybe he was right. What the fuck were we doing there. What was that place even playing at, letting us be there. Maybe it all needed to be set on fire and cleared, like the charred fields I had passed in the countryside, black and smoking.

We did not always leave our prior medical training at home. We did not always cope well with all the dead and dying. We were in unfamiliar country. You could drive to the gas station and on the way you would see donkeys trying to kick-murder one another in the street, smiles wide and empty, throwing their back feet up at each other’s skulls.

According to xkcd, “a snake is just a human digestive tract that has escaped its host.” This one bit a man on his forearm and then he died, another victim of a quiet, violent encounter on the African plain.

• •

It began with a pregnant woman who walked into clinic in labor with an umbilical cord hanging out of her vagina. The midwife confirmed fetal life with the whoosh-whoosh-whoosh of a handheld ultrasound, knew enough to walk over to where the OB-GYN resident and I were in the middle of a procedure, but not enough to tell us what was happening, before walking away. This was the first mistake, and likely the end of any chance at life.

As soon as we completed the procedure (an evacuation of a miscarriage), we heard about the pregnant woman, ran over to clinic, but the fetal heartbeat was no longer detectable on ultrasound. Nor could I feel it in the umbilical cord, which runs to and from the placenta, the only source of oxygen for the fetus. It is an extension of the fetal circulatory system. No pulse, no life.

The OB-GYN resident, unwilling or unable to believe that the fetus was dead, ordered the OR staff to assemble for a crash C-section. This did not work because nobody at BMC had seen or participated in a stat operation of any kind before, so everything assembled at a walking pace. In the hospital where our Canadian OB resident had trained, a stat C-section is like one of those kid prodigies solving a Rubick’s cube. OR staff run around and open trays and kits, general anesthesia is induced, surgeons throw on sterile gowns, cut cut cut, baby, almost faster than the eyes can follow. Instead, it took over half an hour before we stood in the operating room. I spent a minute of this time arguing that we did not need to rush to operate, because absent a pulse in the umbilical cord, the fetus was dead. She reminded me of my place in the decision-making hierarchy (that is, it wasn’t) and told me to get my hand in that vagina and lift the fetal head off the cord (which would relieve the obstruction to the fetal circulation) and keep it there until the fetus was removed.

She then proceeded to use local anesthetic for the no-longer-crash-C-section, on the rationale that general anesthesia might somehow impair the infant’s respiratory drive, which had the predictable result of lots and lots of screaming on the part of the mother. In defense of the OB resident, she was atop a chain of command with terrifying responsibility and doing her best to manage a disaster. Once she lifted the small, still body from the mother’s swollen abdomen, then she gave the go-ahead for IV ketamine, and the room became quiet.

The infant was passed to me, and I began squeezing its chest in an attempt to bring back life. I told the midwife to pick up the neonatal ambu bag and ventilate. After about a minute, she dropped it and walked away. I called her back and told her to keep going.

“But the baby is dead,” she told me, her face dismissive.

“I know,” I said. “Just keep going for another minute.”

One or two minutes later, she again walked away. This time I did not stop her. I put down my hands. The tiny body had been pulseless for almost an hour, and each squeeze of its chest felt both futile and heartbreaking.

A review of those events would have helped. Morbidity and Mortality conferences, or M&M, are designed to identify and correct the root cause of errors. Some are fraught with political infighting, some an honest examination of choices and ways to improve, and in some hospitals they don’t happen at all, even when patients die of obvious and preventable error, for fear of upsetting someone.

There are a lot of basic human needs that stand in the way of reaching an honest account. The patient or their family may want to sue for damages. The hospital wishes to limit its exposure to liability. The physician wants to believe in his or her own skill and judgment. Acknowledging a mistake to your peers can be devastating—and to yourself even more so.

What an M&M conference does recognize is that our patients benefit if we create a structure that allows those caring for them to review and learn from challenging cases. That information asymmetry exists: that when the only person who knows of a mistake is the one who made it, when systems and trainings and personalities collide, a patient or family is not well equipped to advocate for change, so the provider and the system have a moral obligation to act on the patient’s behalf.

There is a pretty good argument that for me and my career I should shut my mouth. M&M is private for a reason, part of which is that we (doctors) all benefit from the myth of physician infallibility. No one is going to send me a thank-you card for what some will call a very public attempt to erode that faith.

What is the moral code of the physician-writer with regards to the writing portion anyway? Danielle Ofri would say to treat the stories with respect, scrub them of identifying details, obtain consent when you can, and make a good-faith effort to tell the story in such a way that it honors the patient and their experience. Janet Malcolm has written that the writer-subject relationship is necessarily an act of deception and moral cowardice.

I would like to believe that it is possible to represent oneself honestly as a writer, though in the case of this article about my experiences in Northern Ghana, I did not know that I was going to write about it, so I did not engage in whatever disclosure might be necessary. So, moral coward. A writer who hid behind his role as doctor, now using my pen to spill our secrets.

CPR is a viscerally unpleasant act, but in the moment that this unfortunate C-section was completed, it was also the correct one. It would not have felt very nice to keep on pushing against that tiny chest, but the job is not to feel nice. Who cares if it is one percent or one percent of one percent. Who cares if I was right and the infant had been long dead. The brief extension of a brutal act might have created some possibility of life, however small. There was nothing to lose and everything to gain.

• •

I continue to worry about writing so openly about Baptist Medical Center. Their website links to a list of blog posts dating back to 2006, so it’s not like there is any institutional expectation of privacy, but something does not feel right.

The supervising attendings and other staff who lived and worked at this mission hospital paid a price for their faith. They took on moral and legal responsibility for the trainees who worked under their aegis. I wonder if my writing is a betrayal of their trust. A few weeks after I left, I learned that Russ’s son had come down with malaria, and a boa constrictor had snuck into their chicken coop and eaten a half dozen birds before falling asleep, which is when they killed it and cut it open to count their losses. All of them could have chosen much easier and more comfortable lives for themselves and their families.

I am not religious, but I can see why people felt a calling to go there and serve, and how, after seeing those lives up close, it would be difficult to turn away. Early on during my time at the hospital, we went as a group to visit an elderly German couple who ran a small animal shelter about forty minutes from the village we were based in. They had a deer named “Bambi,” a monkey, and a few other creatures. The wife distributed antiepileptic medications to some local people, and they also participated in reforestation projects. She gave us four very ripe mangoes.

They told us that they were going to visit Germany for a few months, but the old man said they would return.

“I have an agreement with God. I will die here in Ghana.”

• •

I heard a knock on the door after dinner one evening and learned that a pregnant woman had been sent to the hospital after her labor failed to progress at a local clinic. Her cervix was dilated, but the fetus was high, and it didn’t make any sense. I walked her over to the ultrasound room and swept the beam of sound back and forth, following ribs and legs and arms until I found a head, then a heartbeat. On the other side another head, another heartbeat.

Trans-trans twins, each one lying across the birth canal rather than head down or feet down, which might allow them to exit naturally. I hopped into the old white truck and found Dr. Kenney and the OB resident. The C-section went fine, except that when the twins were first laid on the newborn table neither moved or drew breath. I rubbed them both with a towel and suctioned some fluid from each mouth and nose. Still nothing. It wasn’t until each had received a few rescue breaths from the neonatal ambu bag that I heard the first cry, and then her twin sister, big and loud.

Without Baptist Medical Center, this story would have likely ended with this woman and her twin girls dead. Instead there was life. Thanks to this sometimes imperfect venture that had sprung up decades ago on a piece of empty plain leased by missionaries and staffed by on-site attendings and rotating volunteers.

It is a small miracle that the place exists at all. That they can crossmatch blood, diagnose and treat malaria and snakebite. That a woman can get an ultrasound and a cesarean section in a town that does not have running water.

This does ease my guilty physician-writer conscience somewhat. There are truths that do not reflect well upon the place, and then there is the fact that for the people it serves it is essential and necessary. It is a house of tragedy. It is a ray of light.

A minute or two later the twins had cried themselves out. I watched as the first slowly opened her eyes and looked at her sister, blinking. It made me wonder. What is it like to open your eyes, to look upon the world and see it new.

• •

In the early morning before dawn, I rode out through the main gates and into the street, past the soda stall and the grill stand. Goats slept on every road through every village. At one of the larger towns, we turned left to go south toward an airport with a dirt runway. Most of the animals would scramble off the road upon hearing us approach, but a few would just turn their heads to look up at the truck, unimpressed. One or two kept sleeping, and one small goat had been pancaked into the road.

We rolled on through the dark of early morning, our headlights illuminating sleeping goats who stood and fled, only to return and lie down, waiting in slumber for the next passing vehicle.