breaking the news.

Exhilaration, elation, sprightliness...these are some of the words that describe the emotional states that engulf many an applicant when they receive that admission letter to pursue any of the medical related courses. I bet it must be true with all the other courses too. It's however believed by many that the medical professions have a higher premium to them.. This is may be attributable to their employability. Who wants to tarmac after college? So competition to pursue these courses is always tougher and which brings me to where i started off; the states that many find themselves in when they get this chance. It however is true that many are motivated only by the prestige, employability, family pressure, and other superficial motivators. We all know of colleagues who struggle hard to get in but once in lose all interest. At that point few truly comprehend what they are getting themselves into. It is the reason why some fellows with mellow constitutions fail the ultimate aptitude test by repeatedly fainting at the sight of a cadaver or worse still blood. Then they realise that this is not what they desired after all and many have jumped ship at this early stage. But some have overcome these initial frights and went on to make excellent practitioners.
Amwayi-that's Mose's surname, had gotten past this stage and went on to complete his college coursework. He liked Amwayi because he said it fitted him properly in his skin, but people found Mose easy. He was now settling down in his internship and the medical rotation was just fine. Dr Akhungu was one very agreeable fellow and so you can say Amwayi was enjoying himself immensely. In the evenings, he would listen to his friends' tales of tribulations in their rotations and laugh himself silly! Not that in any way he was disposed to revel in the miseries of others but as he put it himself, 'why cry now and cry again later', what an apt philosophy. That was his nature. But he too was having knock-abouts.
 There was in the private medical ward a special patient. Yes, special. There was at any particular time a bed reserved for him in the room next to the nursing office. He was an elderly longstanding diabetic and hypertensive. The number of times he'd been admitted here were innumerable. Dr Akhungu had been managing him for so long that he was now openly referred to as Dr Akhungu's patient or 'number one'. His two conditions had been under good control but as he aged more they became erratic and hence his frequent admissions. Any time he felt unwell Akhungu would be amongst the first persons to know and he would make adequate arrangements at the hospital. On some instances the hospital ambulance had been deployed to get him to hospital. Akhungu would be on hand to personally supervise as the blood pressure, sugar measurements and other vital sign readings were taken. This was the one patient that was never managed from the comfort of the couch!
A chronic hypertensive and diabetic, the family had come to honestly trust that he would add so many more years to his life. It therefore should not startle one that they had never considered his demise even as he became more frail. The bet is even if they had they had not imagined that it would come to him the way it did. They had an astounding confidence that he would surmount any small setback and live on to a ripe old age. Such was the expectation one evening as he was brought in with pneumonia. Dr Akhungu had promptly set to work to fix it and managed to stabilise him. For several days he was in a state of recuperation and evident restoration back to health. Then the day before he was due for discharge home it happened.
Amwayi had been on his usual evening lap around the hospital and for some inexplicable reason sauntered into the private wing. The sight of nurses in a frenzy met him-one busy dialing numbers, another with a tray and yet another in the hallowed room one frantically doing chest compressions. Naturally he joined in the resuscitation efforts. Thirty minutes, nothing. Well they had tried. Dr Akhungu could still not be found on phone, having gone off in his usual evening ride. Till that point the daunting task they faced had not fully registered itself. It however did immediately the daughter to the late walked in through the door and in an uncharacteristic manner handed the nurse a 'small' package, ''sister i brought you some kuku''. The small team quickly retreated to the nursing office. Who would break the news? Who? This couldn't wait for Akhungu.
Amwayi; sister you do it..
Sister; No you do it you are the clinician here..
Amwayi; sister, i have never done this before..
Sister; just tell her we tried but failed..
Amwayi; no sister..

All this tugging was interrupted by the daughter who alarmingly inquired what was going on and if all was well. The nurse pointed to Amwayi and directed her to talk to him.
''Hmm...ok mzee's condition is not so good''. Big mistake.
''What do you mean mzee's condition is not so good? Is he breathing really?''
"Ok, what i meant is his condition just drastically deteriorated and all our efforts to revive him came to naught".
"What do you mean drastically deteriorated? Is he dead? But what happened between morning and now? Where is Dr Akhungu?" The lady in a climaxing emotional torrent and agitation came down hard on him. He was in the thick of a situation here and he was alone, the nurses had busied themselves in some activity or the other which in all honesty was pretentious, they were keenly following the proceedings from a safe distance!
His okays and hmms lost all meaning and he was on the verge of losing all cool. And where on earth was Akhungu? As if on cue in he walked and making a quick assessment of the situation went straight to the bedside.
As Amwayi had recounted the incident to his friends after wards it struck him as rather ironical. That the primary aim in in every patient's care was the making hale again. And yet they had always been taught that to be expected as an eventuality even remotely was death. Cases abound of the slightest of infections or a minor operation leading to death. It was a common joke that if you were asked the complications to any condition and you ran out of responses sooner that you imagined the was the time to throw in death.
Any one in the medical profession will confess that the practice of his or her line of earning a living brings him or her into closer proximity with the 'distressed man'. Is this frequency one of the reasons responsible for the aloofness that some of them display towards patients or their relatives in these states? They have seen it all and nothing new will shake them out of their thick skins. But how ironical.. He recalled an incident in his final year at college. A nephew of his had been brought in the hospital with bad pneumonia. It's only after he had been stabilised and admitted that he had rested easy confident that the child would live. Then he had gone back to his duties in the casualty. You can only imagine his state when one of the sisters walked in and bluntly told him that the child had died. Then she had walked out again. The image of a sniper on a mission had never been stark.
Breaking bad news,,,

Internship-reminiscences..

A GPA of three in his FQE had left Mose feeling quite good with himself. As he embarked on the 'arduous and treacherous' one year of internship, nothing could dampen his spirits. He would be paid a 'small' subsistence allowance by the hospital. He was also upbeat because after the grueling coursework he would not in a very long time hit the job market. Together with three of his classmates, they had been required to open bank accounts. This was a requirement he had promptly complied with and submitted the details at the accounts office. Maybe he had only imagined it but the month had never seemed to labor in it's travel as it did that particular one! It felt good to operate a bank account, he regarded this the first real and palpable sign that his life was just officially setting off. He knew many of his colleagues who struggled to find an internship place and even then got paid nothing at all, in effect they had to devise and resort to unscrupulous means of making money at which some became so good at (but what choice had they really) So the other thing he had done was to consider himself lucky.

The arduous and treacherous year..
That's what internship was exactly. It was the limbo of medicine, suspending one between the dying life of studentship and the resurrection as a qualified clinician or doctor. Most consultants who had to supervise you started off from where they had left you at college or during the FQE practicals. Soon you would be a product on the job market shelves or you would yourself be a shopper on this very market so you had to have a certain premium or worth to you.. There was no or little inhibition in their determination to really refine you the product or shopper. There were no hard feelings, that's just how it was even though it's true some were unrestrained in their meanness.He had been all psyched for this though.

He had to read still, but not for examinations or assessments or assignments but for the real thing. In most instances it would be him who would make the first contact with the patient and what went on during this encounter would be keenly scrutinized by his superiors.
To determine who rotated where and when a raffle had been done. He was lucky to start with the medical rotation which was regarded the easiest of all. He would use this to prepare for the other heavier rotations.
The consultants. Them that loomed menacingly over the intern's head. There was Dr. Maloba the head honcho. A surgeon by specialization, his reign at the helm of the hospital was not a particularly rosy one. He was known to take some small matters personally and this usually isolated him for all sorts of vitriol, contempt, unnecessary confrontations and eventual frustrations. He had only one or two known friends in the whole hospital. It may be observed that if he had come in a competent and well meaning doctor, he left a bruised and dejected man.
His ward rounds were always anticipated with apprehension for the smallest of matters would upset him and then every one would have a fair share of his wrath. Many were the times he sent away not only the interns but even qualified nurses and junior doctors to the library to go and read up then report back to him equipped with information. A thin streak of melancholic humor overflowed in him. A man had to have his flaws yes but Mose believed his brought him more misery. He could not change. He was an outstanding surgeon but the intern's worst nightmare.
Dr Akhungu was the hospital physician with a phlegmatic disposition. He smoked hard and drank harder. It was rumored he was involved in a very queer romantic relationship with two nurses who were the best of friends. Otherwise he led a distinctly solitary life, his marriage said to have been one sad tale. He was a hopeless hypertensive and asthmatic; he had an evident reminder by way of a limp from a stoke he had suffered some years back. It was said it's this that had brought him problems in his marriage and cost him his job in the U.S. It was an open secret that his hypertension was poorly controlled. An avid chess lover he could not hesitate to invite you to his house for a game. That is if you impressed him as intelligent. Each evening without fail he took a ride in his benz to just have a feel of the great car. His queerness did not end there; he could come to ward rounds with stodgy novels in his coat pockets and as he found very few literary mates to discourse with, was heard to frequently lament the dearth of reading. He was what they call a man of the world. Too entrusting in the abilities of others when it suited him, he found it no big deal to let the intern conduct the ward round or better still conduct it himself over the phone from the comfort of his couch. Such was the fluidity of his work philosophy.
Dr Sinoma was the other senior member of staff. The oldest actually. Russian trained and without a specialty, it was no secret that both Maloba and Akhungu regarded his merits with suspicion. Every decision he made on a patient was openly questioned by the two. Naturally a genial man, one day he got worked up by these grillings and countered that the surgeon knew no medicine. It was fireworks and the meeting ended with open disagreements. The physician and surgeon might have began on one side but soon parted ways as the physician not in support of Sinoma but because he soon picked his own battles with the surgeon. This actually characterized the morning meetings. Akhungu might have been laid back in his approaches but he was keen and sturdy in any discussion, when the surgeon told him to practice modern medicine, he reminded him how in his earlier days he had won scholarships and awards for his excellent publications and researches. A thing you need to know is that the physician had been the surgeon's lecturer at university and so you may not begrudge him if he passed off as openly erudite. He usually adopted this attitude in their many friendly professional confrontations. A common contentious point apart from the common prescription practices was the physician's always giving the surgical wards a wide berth whenever he was on call, so the surgeon or another doctor had to cover them. But Dr Sinoma was their common punching bag.
Dr Sande was the obstetrician. He was the guy that minded his own business. If you were the average learner you would actually gleam so little from him. If you asked him a thing he would give you the on-point answer. No prelude, no body, no tail. Just what you wanted. Contrast him with Maloba who took his time to detail to you the nitty gritty of pathophysiology and all, not that this was bad, it was his imposing stature that dwarfed you in any discussion. Akhungu went about it in a friendly, jocular manner just like child's play.
Dr Rapando was a doctor off the old mold. His ward rounds were to be loathed for their longevity. He took particular interest in any patient in his ward. Even what was regarded the simplest and straight forward of cases turned out to be a focal point for a lengthy discussion. All the possibilities had to exhausted. By the time the rounds came to a close every one would just be too exhausted from the standing and drawn out lectures. A habit with him was the references to cases he had met at various points in the course of his practice. Then he would point out the mistakes he had made and in the context of the case under consideration make comparisons. He seemed to see in every patient what every one could not imagine. Above all he was an exceptional pediatrician.
That was the motley of consultants, now the real thing...

turf woes, tough wars.

The doctor had asked her, ''doc, how do you treat trichomonas vaginalis here?'' she had repressed the urge to ask him how it was treated elsewhere, jokingly she had responded that she was well above such student-like questions but at the end of her answer had placed 'flagyl'
''What, flagyl!'' he had seemed genuinely taken aback and whether it was the disbelief at the 'simplicity' of the remedy or the distrust for the respondent was not clear but he had summoned one of the senior clinicians at the facility to inquire if this was true.
''What dosage?'' now it was their turn to be pleasantly surprised.
As they had worked side by side(actually they shared a table) she had been under great duress from the laughter she had been suppressing.
This was in the comprehensive care clinic of a sub district hospital cum provincial rural training center. He was the head of the senior clinical team that came here twice weekly to review the seemingly hard boiled cases. She was a newly recruited clinical officer on her three month mentorship program.
Even during the consultation she had sneaked out time and again to go laugh at him and spread this little bit of news to anyone who cared to listen. She could not fathom how a senior medical officer could fail to know such a simple remedy.
Over lunch hour this had been the topic of discussion.
"Some conditions are rare and it's possible to forget their treatment", one clinician(let's call him Mose the defender) had asserted in defence of the doctor. This had only opened a barrage of fresh assaults on the poor doctor's competencies.
"But he works in a referral facility"
"And he is supposed to be the consultant here, he should know everything"
"It was just a simple, harmless, inquiry, why should you ridicule him for his honesty?" our good guy Mose had gone on.
"Ok no issue for forgetting but why doubt the response, does he believe 'we' are all idiots?"
"Besides we all know he's your friend so you have to defend him but he is a doctor for heaven's sake!"
"And the way he is always hard on us"
"You can't afford even a small mistake with ARVS and you know that very well", Mose had quipped.
"That's not in contention, it's just that this has to apply to all other conditions and medications"
Mose had finished with his lunch and left the others at their happy and demeaning chatter about competencies and incompetencies.

He had always been the silent conversationalist at such like cadre-staking discussions. But now he was riled by what he considered a complete senselessness that pervaded these discussions. He was a clinician himself and he knew they were not the downtrodden of medicine, but he also acknowledged the coldwars that existed between the nurses, doctors and them. This was the one discussion in which any meritorious argument always got subdued by the mudslinging that followed. The two contentious issues were the skewed working conditions and remuneration. Doctors were only on call-called only when required. All the while it was the others who sweated it out in the various departments. Of course this sentiment was not entirely true but it formed the base of the grouses that nurses and clinicians had against the doctors. Who was the real donkey here?
Nurses on the other hand regarded the clinicians as equals; they went to the same colleges and attained the same level of certificates. Did clinicians take this view? This was best played out in the health centers and dispensaries! And did doctors 'look' down clinical officers and nurses?
Mose appreciated the fact that these supremacy contests were no good and this was best seen when the care of a patient went wrong at the facility, then it was a good reason for fault finding, crocodile tearing, backstabbing, obsessive defenciveness and fixing each other.
The differences in remuneration against the services offered was the other thorny point; thorny indeed...

What infuriated Mose was the way this 'sibling' rivalry debate was going. On television and social media it was 'mudslinging, and unbridled contempt open season', the benign grudges festered. Had the various unions failed to reign in their belligerent members or at least some of them? But did the unions effectively execute their core mandates? There had to be a doctor, a nurse and a clinician. In his college training he remembered how much he had learnt from nurses and doctors. Why did genuine grievances have strains of bitterness against the other cadres? This did not apply to only them but the others as well, the unions had slept on their job but this was no license for the decline in the mutual respect amongst the three that perhaps shared the closest clinical kinship..

mother knows..

The sun was well up, this he verified by pinching aside his bedroom curtains and sneaking a quick peep outside. This was to him a daily ritual, for nothing filled him up with sprightly gusto like a bright sunny morning or even just the prospect of one. This was his gauge, his unconventional indicator that the day would turn out just fine. So as he went about a task here and there in preparation for the day, he whistled a tune, actually it that old bobby mc ferrein`s song, `don`t worry be happy`. He had it somewhere in his collection but could not locate it then. Today he would be handling the MCH and as that was one sure drainer, he `stuffed` himself proper, this he began at the house with a glass of cold mango juice and a couple of some cakes, he ended it at the hospital food canteen with hot chapati and beans laced with beef soup. Now he was set and well barricaded against the hunger pangs that would assail him later.
The morning presented to him nothing new that he had not yet encountered before; common respiratory infections, malnutrition and dehydration in their many forms, treatment defaulters and failures are all cases that he dealt with on a daily basis.
The mid morning was usually the heaviest period of the day but a conversation between a subordinate staff and a colleague of his caught his ears and was enough to distract him. It was about the sub`s ineligibility for some vacancies in the department because she was HIV negative. His heart sunk. One week earlier as he had labored to get an IV access on a very sick, he had some how misplaced the first canular he had used. This was compounded by the fact that the safety box had been taken away during the cleaning exercise and had not been returned. A replacement had taken long in coming and as this could not `delay work`, he`d carefully displayed all the sharps on a clean paper in one corner, later he`d dispose them off in the safety box. But this particular one had missed him. This particular subordinate had come to remove the bed sheets which had been soiled by another child and had she not borrowed cotton from him he would have missed the injury she had sustained from the sharp. On further inquiry he had found out it was the missing sharp. Matter of factly he had instructed her to go for post exposure prophylaxis to which she coyly laughed.
He had been newly deployed to the department at the time and had believed she was already infected because she was a peer educator. He had gone about his duties and this event had somehow escaped his attention. Earlier the following week he had remembered and when he`d inquired how she was doing with her medication she had laughed saying she did not take the drugs, this he took it as confirmation she was already infected.
Now here he was learning that she no peer educator and that she was HIV negative or purported to be so...and about two weeks after the incident..
As he lost himself in thoughts and thoughts a day old boy was brought in, not sick but that she had been discovered in a disused pit latrine. On examination he was found to be as sound as is probably possible and this was surprising. The rescuer mother never ceased for a moment to thank God for the wonderful gift of a son(she only had girls) Already she had grand plans for the boy and even had christened him, Blessing. The child had however to be admitted just as a precautionary measure and later she had to go through a lengthy adoption procedure before she `took the son home`. Nothing dampened her cheerfulness. This spectacle had nearly brought activities to a halt in the department as everyone wanted to have a good look at the baby, after which they would curse the real mother..
As matters settled down leaving only a heavy scent of the disgust in the air a lady in her late pregnancy was brought to him. The nurse rapidly explained why she had brought her to him. She had tested HIV positive but had declined any form of intervention to protect the baby from infection. She was a high school teacher and this was her second visit to the clinic. She was due in about three weeks time and what had actually brought her today was a urinary tract infection.
He had spent with her close to half an hour going through all the aspects of her status but she had been adamant she knew what she was doing. She was actually still angry with the husband for having infected her and this she said informed her decision. Could he call this stupid obstinacy? He did not quite place it or did it matter? The point remained what was he to do? The more he tried to convince the more candid she actually got and he knew if this could be equated to a contest then he had been outwitted...a certain irritation crept upon him and he politely asked her to leave but give serious consideration to what they`d discussed. She was reluctant to leave, may be she was on the verge of tears but she showed no trace of it.
`God bless the child` he muttered under his breath as she walked out through the door and as he went back to the rest of his patients a distant sadness descended over him; for those things he could influence but failed to and those courses he could not influence but which he strove to have a hand in.