MAR-A-7

 

MY FINAL OPERATING DAY AT EMBANGWENI HOSPITAL,

 WITH SEVERAL CASES AFTER MY MORNING RUN,

AND A ULULATING CRY FROM MATERNITY AFTER OUR

 MORNING REPORT HERALDING AN UNWELCOME SURPRISE;

  I TRY TO PACK WHAT LITTLE WILL LEAVE MALAWI

AS I AM GETTING  “SHORT” IN MY TIME HERE

 

Mar. 5, 2002

 

            Yea, I ran.  It is a habit I am trying to keep.  I might get out of it by just turning over, but I keep reminding myself that I will not need earmuffs and long johns here, and even if it spatters rain on me, it will be a much more user friendly day for me here than over there, and I have a lot of Mindanao non-running to make up for.  So, I have been up at dawn, about the times the magpies are going bonkers.  The sounds of night have brought the screech of the giant owl, and a few bushbabies (the tarsier primate).  There are roosting trees here for the storks that have been coming over, but silently.  I had seen flocks of wooly-necked storks in Zambia when touring on the Kifue flood plains, and they seem to be here also, but seasonally.  But the roosting trees are filled with birds, with only the magpies making an exceptional amount of noise at dawn as they become active.  On the run, I spotted a white-necked heron, and a few other birds, with one pair of hammerkopf.  I always carry my camera on the morning run, since I always see something worth photographing.  It is often the oxcart that has different functions, carrying bodies of AIDS victims off to a funeral—a daily occurrence here, or picking up sand or mud at the streambed for building materials. But it also has a yoke of oxen that drag a plow sown the road on its side.  It leaves a large scratch as they plod along.  It also disrupts the columns of army ants, which are scattered around trying to find what signal their leader ants have failed to put down.  The whole of the column is essentially a single organism, with the feelers out front being just a sensory organ for the other individuals that are essentially body parts.  Most of those body parts consist of pincers, if I can be any judge by standing around to observe them here and in other places such as the Ngonog Hills in Kenya, where I had absent-mindedly stared off at the Great Rift Valley, forgetting that I was standing near an advancing column of ants on the march, a mistake that is rapidly called to attention!

 

            But each morning I see at least one memorable vignette, if only to carry it away in the “Mind’s eye” if I am not ready with the camera which I have wrapped in its lanyard around my arm.  It is an hour I can think of how the experience I ma having can affect me.  I have thought of essays I should be writing as I once did when I was in southern Africa for a year on the Fulbright, but half of those essays are still locked up untyped in dictated tapes, so I am not sure I should put ten more that I have thought through on the run, like my observations on the “Leper Door” or the “Sky-Scraping

Steeple.”

 

            The Earth Moved!  I was in b ed at the time, but could find no evidence in cracks on the road, but the noise of the coming and going of the large roaring earthquake was unforgettable—especially since I felt it was being put on as a performance for my benefit without threatening any particular danger to me—just a reminder that I ma in the Great Rift Valley, and I am living in a small augenblick of geologic time. All this too shall pass—probably out to sea under the Indian Ocean in a few more eons, and all the concerns of the petty day to day struggles such as the current AIDS pandemic, or the temporary overfertility of one species, will be long forgotten temporary aberrations on the history of a planet on a restless move of its own, without a lot of regard to the passengers taking the ride along with it.

 

            I like the dawn runs in Africa.  When I did them in Assa, I ran across fresh carnivore tracks which could remind me that running at the rate that a human can muster is almost a tantalizing crippling pace for the large carnivores whose paths I crossed.  But, here, my only observers seem to be human, and they are all bemused that a white man with naked knees should waste the energy precious to each of us in an outing for no purpose.  I might even understand that. 

 

            When we discussed the quake that each of us had heard, even if not everyone recognized what that Doppler shift in a protracted sound had meant, I heard about a previous quake here two years ago.  That one had also happened at night, and it was uniformly said to be preceded by a bright flash of sustained light, brighter than the noonday sun, according to tow credible night watchmen on the station.   One of the station missionaries, possibly of the same era I had come from could remember the old US cold war axiom, “When you see a flash of light—Duck and Cover!”  This would not likely be a region at high risk for a nuclear attack, unless it is considered a powerless population to be subject to an atmospheric test.  But, the idea that a UFO could come down and abduct a Malawian as a typical representative of planet Earth, probably is a better sample than the average New Yorker, and is probably a better time biopsy of what has been in the Dark Ages of Humanity and what it yet may become given a very completive excess population for the 22nd century.  Behold the future—it may be Malawi!

 

            These are a random flow of ideas that comes from running at dawn through the rainy season rutted roads of Malawi—aren’t you glad you had stayed in a warm and dry bed?

 

MY FINAL “THEATRE DAY”

WHICH WAS CONSIDERABLY SHORTENED BY A FEW NATIVE MEDICINE REQUESTS, AND COULD HAVE BEEN REDUCED TO ZERO,

EXCEPT FOR GOGO’S INSISTENCE

 

            The third patient who had been booked for prostatectomy (the one who had had a circumcision in a government hospital during acute phimosis, rather then the indicted dorsal slit, and necrosed two thirds of his glans, but then could not pee without t catheter because of an obstructing prostate) has two patients whom he can see across from him who are doing well and are now peeing without the catheters they had come in with.   He had been booked twice, and then postponed, once because I had wanted to teach the third person at Embangweni how to handle emergency urinary tract obstruction in older men, having taken the other two through guided retropubic prostatectomy, and then by the Martyrs’ Day holiday—which, like the US Presidents’ Day, sneaked up on me.  Abruptly, he decided he wanted to go home and discuss this proposed procedure that he agreed was one he needed with his local practitioner of traditional medicine—the Sangoma.  George explained that would usually be OK, but this meant that he would have to carry the catheter until someone came through who knew how to do this operation, and right now there was a surgeon on site that would not be here tomorrow, so that this might be his last and only chance this year.  He had heard that I was training the others, so he figured there was no big deal about this procedure, and he might just take his chances with the other two whom I had shown their first ever prostatectomy and come on in and have them do their first unguided prostatectomy on him.  After all, aren’t all such procedures rather standardized?  He must have had an HMO from the US giving him advice!

 

            The young woman who had fallen in a fire during a seizure a month after she had been married, then sent back to her parents by her disappointed husband when she had daily seizures he had not been told about also had some complaint.  She said that nothing was being done for her here, and she wanted to go home to her local healer who would at least apply herbs to her body.  She could not have a more obvious example of what is being done for her, since she was one of the earlier operations I had done, in which I split thickness skin grafted one of there burns on one leg, while the other is still granulating uncovered.  She had the dressing carefully removed so as not to lift the graft off, and she had a 100% take of her STSG—so one limb is done and she thought she would like to have the other leg look like that one all right.  “But nothing is being done for me.”   I wanted to be sure she knew she was scheduled today for STSG to make the opposite leg look like the first one we treated, to resurface the exposed Achilles tendon, and thought that this stage should finish her treatment in one session. I was particularly eager to do her today, since I was going to show Ishmael his first ever split thickness skin graft and wanted him comfortable with this technique for burns and other denuded surfaces.

 

            She understood that, as the Gogo interpreted it through translation, but still insisted nothing was being done.  “How so?”  She explained she needed herbal medicines applied by a local healer.  We explained again how we were going to resurface the granulating area of skin.  “No!  He applies a thick black gooey paste or gum of burned herbs to my head and shoulders and other places to draw out the spirits and poisons!”  OK, score one more for African traditional medicine in doing a better sales job to their necessary, customary and usual treatments!

 

            But, the Gogo insisted she would not take her back until she had the treatment we recommended, so the procedure proceeded, and Ishmael learned how we graft skin with the Zimmer dermatome and the mesher, making a 6:1 graft expansion.  Now she can get the native medicine as she wishes as long as the Sangoma does not interfere with the grafted skin.

 

            We had morning report after the chapel service of Shadrach, Meshach and Abednego—a story that came for the Old Testament, that seemed to relate more to the current conditions in Malawi than they might in DC.  With respect to plagues, pestilences and famines of Biblical proportions, the people here have no trouble relating to them immediately.  We had joked earlier about the headlines about the earthquake that had rolled through (and mostly under) us: “Earthquake devastates Malawian economy, disrupting transportation and communications!”  How would it look different?  “Where have all the freeways gone?  Overpasses and viaduct flyovers had collapsed and major cracks have developed in the roadways--” compared to what?  One of my more useful African expressions is “You can’t fall off the floor.”  A landing by UFO’s and alien abductions would almost certainly improve the lives of almost any person picked at random from this society, so maybe the supermarket tabloids ought to place their headline attention grabbers in this setting, since both the severity of the pestilences, and the glory which is to come are more readily received here in uptake!

 

            I was feeling rather smug about the long holiday weekend and my C-section rodeo.  All of the very high-risk obstetrics that had been surgically delivered abdominally were sure losses of at least the infant and possibly the mother as well were 100% salvages.  I had made a round and they were all present and doing well.  This was to be my last operating day, and I would make one final check on the patients I had done and take on no more new ones.  So, in report, they had said they had only a patient with hydroceles, which I had done with Ishmael, so they figured to do that one on Wednesday, when I was already on my way back to Lilongwe.

 

            When we left report, I heard a ululating wailing coming out of the courtyard near Maternity, and stopped to ask, “What is that all about?”  “Baby Rainbow,” was the response.   “What?”

 

            “You know, the one that you delivered by C-section on Saturday, the first one, the one you had to disimpact with the severe deformity of the skull down in the pelvis.”  This is the baby that was doing so well, who had been taken off the IV and had even been nursing as opposed to cup feeding expressed breast milk.  So, she was doing well when seen before the rounds, but after report, Mercy found her dead when only a few minutes before she had been nursing.  This is the same baby we were so happy to have delivered alive, since here first pregnancy had resulted in an arrested labor right down at the perineum, and that had resulted in a C-section with the delivery of a non-surviving baby.  This is the second dead infant delivered by C-section to this young woman and she has only one more chance at it.  The mother was wailing in the arms of the Gogo, who was looking in long-faced commiseration with here daughter, the two of them the picture of the abject misery of the third world, in which death is such a regular event that the attachments formed to any given individual should be tentative, particularly the young.   But this mother had just accustomed herself to hope after here earlier disappointments.  Once again, the simple discovery of someone who turns up dead on the ward rounds, without explanation other than “this happens.”  It is a frequent event, so what should anyone get so twisted up in the loss of a single life, when there are so very many to worry about?  This one had even acquired a name: “Rainbow—“ the emblem of hope.  And now, there is but one more chance since the next pregnancy will result in an elective pre-term C-section with a tubal ligation.  Life, in general, of course, is unfair, but that is rarely so crystal clear as it is here.

 

            At morning report, I had heard a review of the long weekend’s admissions, discharges and events on each service.  The most impressive was from the Children’s’ Ward, reporting from the NRU.  A total of four (that is  4) starving children died in the NRU this weekend.  The same phrase was used in reporting each of them.  “RIP—I have no idea why this happened, but the child was found dead after having taken the medicines and the supplemental feedings earlier, and I am so very sorry.”  Four in the three-day weekend, among the census of thirty-four in the NRU, just too far gone to be salvageable.  The same phrase was heard before, but I had not tallied it up as I did this time, and I did again the following day.  A child each day dies of starvation +/- HIV, and an adult a day dies of AIDS.  And this is the background count against which we are trying to make a bit of therapeutic difference among the few that might respond to treatment.  The obstetric services did result in 100% salvage until this morning, but now that number is less than whole also.  “I have no idea why this happened; RIP, so very, very sorry!”

 

WHAT’S IN A NAME?

 

            I had switched from the dismal demographics to the thoughts of the anthropology in which this kind of loss rate occurs.  I had asked the meaning of various names, and a number of them were unaccountable, and a few were the source of some embarrassment, which they simply shrugged and said, “It’s just a name!”

 

            The names of the villages of the Ngoni tribal names all seemed to begin in “E” and I pointed out that the “Z” (or, as this Briticism in the UK colony would have it, the “Zed,”) is also present in many place names—Zimbabwe, Zambia, Zanzibar, Zulu, much more than would be in other tongues.  They do not differentiate between “R”: and “L”, but that is not unique, since Koreans and Japanese can never get that bit right either.  But Embangweni seems to mean the place where “people gather and ‘grab’ their claim.”  Ephangweni, the chief’s village, is also “gathering”, but Equandini means, “let us go!”  The very same place names are found in Kwa-Zulu/ Natal, as they come from the same Ngoni meanings spread by Shaka Zulu in his military escapades.  In the lower parts of what became Malawi, the Ngoni (“war-like pastoralists”) had contact with the Arabic slave traders and either killed their enemies, or sold them into slavery with the Arabs doing the transport in a very “dense pack” boat across the lake. When they got to the far side, they were marched to the sea at the final slave auction at Zanzibar by the Arabs, but they were unwilling to let such good vital hauling freight trains go empty handed to the Indian Ocean trade routes.  They were lashed together by forked sticks at the neck, but each was also to carry at least one elephant tusk, so the ivory and slave trades were linked inextricably in the Arab markets.  There are not a lot of fond memories olf the Ngoni era among the southern tribes of the Jao, the same group I had met on the other side of the Lake in Nyasa Province of Mozambique; and they adopted a different language.  This is the group of economic dominance in the southern industrial and urban lower reaches of the country and includes the current President Mulluzu, both Jao and Moslem.

 

            But, for some reason, the Ngoni did not sell their Bantu Tumbuku speakers after conquering them in the further northern regions of Malawi, and let them continue their language and customs, and made them their servants or wives.  So, there was a lot more sympathy in and among the Tumbuku for the Ngoni traditions, and they incorporated the dances and governing structure of the Ngoni military under Shaka, as I have seen with each of the Ngoni dances like the Ngoma.  This northern area is where the good Dr. Kumuzu Banda had come from—actually the village of Kuzungu where we have the last opportunity on the M-1 to purchase fuel.  Since he had his power base among the rural subsistence agronomists in the Tumbuku speakers, he disliked the pastoralists/industrialists further south around the Blantyre (named after Livingstone’s Scotland birthplace) colonial capital, and he moved the capital to the “new city” of Lilongwe, further north to be out of the territory of his rivals when he had the chance at independence from the UK.

 

            Mzimba means “the body”, so I have been operating on the “mzimbas” of the Tumbuku-speaking peoples, as the missionaries came to claim their hearts and minds for the Christian religion and Scottish civilization pattern among the dour Free Scots Presbyterians, with the archetype being David Livingstone having his single minded objective to “remove the curse3 of slavery forever from mankind, to civilize and Christianize the peoples of the dark continent,” a process still ongoing.

 

            Lilongwe means the River of the same name and no one can quite come up with the reason for the river’s name.  As with most other rivers in Southern Africa, it only flows during the rainy season anyway—as I proved by driving the “green grey greasy Limpopo, all set about with fever trees” (Kipling) in the dry season winter on the hunt from Eendvogelpan in what was still then Northern Transvaal.              

 

            “Malawi” means the rays of the sun, refracted at sunrise.  The one hundred “tambalas” that make up a “Kwacha,” are the one hundred “cockerels” that raise the “dawn.”  A lot is riding on the rising sun here in Malawi, and the special nature of the sunrise over the eastern side of the “Lake” = “Nyasa” is a proprietary symbol of the Malawi tourism board, promoting the “Warm Heart of Africa.”

 

MY QUICK TRIP TO THE TRADE CENTER STALLS IN THE MARKET

 

            I had an agenda of my own before getting out of theatre.  I ran over to the Trade Center, and went through the market to find the same stall we had visited ten days before that had the chitenji that we rejected before as being too expensive.  I also saw that they had a rack of very cheap (some used) shoes, with the new ones being made in the People’s Republic of China, carrying all the cache of styling elegance of that modish country.  I asked to see the brown pair I could see in a plastic bag.  It was said to be size 41, whatever that means, and I would have taken them, but for the fact that they had no laces with them.  They had the same “style” in black made mainly of canvas, and they had laces in the same bag.  After I got the two rights out of the bag and they found a left, also said to be “size 42” whatever that means. I bought them for 750 K.  This means I could leave my black leather dress shoes as well as the running shoes and would not have to go home in the only other footwear I still had, the flip-flops I had worn while operating in Mindanao.  I then counted my Kwacha, and bought the expensive chitenjis after all, while a crowd of very drunken partiers from the Sanju mu Laki came staggering over to point out that I should be buying all of them shoes, since they were obviously barefoot and I still had my running shoes on, so clearly did not need them as much as thy did.  I ignored the onlookers, who were eagerly checking the size and heft of my wallet, figuring out that they could stay in a state of oblivion forever with the contents of the wallet carried back to Sanju mu Laki (“Don’t Be Jealous”), but they were not coordinated enough to do anything about getting it.  A hospital worker spotted me doing my business surrounded by a group of leering, bleary eyed, slurred and reeking men, and shooed them all away from me, telling them I was far too busy an important man to be dealing with the likes of them.

 

As I scurried back to the hospital, I met Godfrey Jere’s daughter and his wife, since she had a very hard nodular recurrence of a previously excised scalp cyst.  I tried to just hold down the child under local anesthesia, and have John Sutter excise it, but the kicking child took tow to hold her down as mother fretted outside the Casualty in which we did the hurried up job, which I just quickly re-excised with a silk vertical mattress suture set for hemostasis.  The hardest part was finding all the materials we would need for the minor operation, and then having the very big and loud two year old make a very large operation out of a small one.  The next time recurrence, she will get the benefit of Ketamine!

 

DR. NGWIRA AND THE STATION MASTER COME FOR MY FAREWELL

AND DE-BRIEFING AT THE GUSEST HOUSE

 

            A courtesy call from the new medical director of the hospital and the reverend who is the stationmaster of the whole complex came that evening to speak with me to get my opinions on establishing a regular link with my medical students and my surgical colleagues, research projects, funding sources, and most of all, the scheduling of my repeated and recurring visits to Embangweni.  George is planning to return in about a year, so I will try to organize a similar trip, and I had also listed the whole alphabet soup of acronymic organizations that might be of help, especially those within Africa for further training to decrease the impossible cost of travel and living abroad.

 

            I also got a few other details for future treatment, not just of the patients, but potentially the students as well.  As John Sutter goes off this weekend to possibly go swimming in the Lake, I will carry back a couple of 40 mg doses of Praziquantel for Bilharzia, and I also got the Proguanil for the malaria prophylaxis, since I already have the Lariam for treatment.  I also have heard that Elizabeth carried a PEP Kit—Post Exposure Highly Active Retrovirals to be taken in the event of a hollow needle stick, a mucosal blood splash, or intra-op contamination—the ARV’s are given to reduce the chance of converting to HIV + status.  She left the kit here when she left, and I will need to replace that to carry back of the next extensive OR list in the future.  I also suggested to John and Elizabeth that we each do a tuberculin skin test following this exposure to a lot of TB in about a month.  John has already started treatment for something about which he was embarrassed, but he was not about to carry home a bunch of small white worms he found himself passing in quantity—an occupational hazard of dealing in the Children’s’ Ward!  I suggested the name Enterobius vermicularis—pin worms—and a single dose of Albendazole should hold down that little souvenir!

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