After Kilimanjaro Read online

  “I know this. I read my assignment. We wait three minutes so that the baby can get more blood.”

  Sarah reminded him that this third stage of labor, after the baby was out, was a critical period when dangerous bleeding could occur. And bleeding was the single-most common cause of maternal death.

  He nodded. “And that is why we should now give oxytocin now. To stop bleeding.”

  “You did great job.” She patted him on the shoulder. “Shall we go to the café for some tea?”

  “I prefer coffee.”

  George stirred four spoonfuls of sugar into his cup. “Doctor Sarah, you do not like coffee?”

  “I like espresso from freshly ground coffee beans. It seems odd that in the middle of all these coffee plantations, everyone drinks instant coffee.”

  “The best coffee gets exported. This instant stuff, it’s all I’ve ever had.”

  “What kind of doctor do you want to be?”

  “A good one.” They both laughed. “But seriously, I want to be a surgeon.”

  “Not a baby catcher?”

  He pointed his spoon at her. “What do you think is more important?”

  “They’re both important. Not enough of either. OBGYN is more basic and would directly affect more people’s lives. Just think about it. Around here, childbirth is one of the deadliest experiences a woman can encounter.”

  “So, you think I should deliver babies?”

  “You should do whatever you feel called to do. Your country needs surgeons, too.” She took a sip of tea. “What’s on the schedule for the rest of the day?”

  “Dr. Obaye is lecturing to the students this afternoon.”

  “Where will that be?”

  “In the main floor conference room. But OB fellows never go to the lectures.”

  “I guess it’s pointless if you don’t understand Swahili.” George shook his head. “The teaching is always in English.”

  “Really?”

  “Tanzania was a British protectorate for many years. We all learn English in primary school. From secondary school on, all classes are in English.”

  THE CROWDED CLASSROOM buzzed with chatter. Many students sat two to a chair. All fell silent when Dr. Obaye strode in, a tall and imposing man with a booming voice. “Today, we discuss the unacceptably high maternal mortality in our country.” He glanced around the room and did a double take when he saw Sarah in the back corner. He nodded at her before continuing. “I repeat. The mortality rate is unacceptable. We must work hard to change this. Someone tell me the commonest causes of death in childbirth.”

  A young woman raised her hand. “Bleeding is first, and eclampsia is second.”

  Dr. Obaye nodded, slowly. “Correct. Who can tell me what eclampsia is?”

  George raised his hand. “Convulsions, high blood pressure, and protein in the urine, usually in late pregnancy. But it can also start just after delivery.”

  “Good. Have any of you ever seen a patient with eclampsia? Yes, Daniele.”

  “Sybil, in Downton Abbey.”

  The students tittered, muttering behind their hands. Daniele explained that Sybil was a character on TV.

  Dr. Obaye stroked his chin. “Was it an accurate depiction of the problem?”

  Most of the female students nodded their heads vigorously. “Well, then, let’s hope it did a good job of raising awareness.” He went on to talk about the causes of eclampsia and presented the protocol they had instituted for treating this problem at NTMC.

  Then he asked the class, “What is the number one priority once a pregnant woman has a seizure due to eclampsia?”

  Several answers were called out: “Lower the blood pressure.” “Give diazepam.” “Treat with magnesium-sulfate.”

  “You are talking about controlling the blood pressure and suppressing the seizures. But are these the things that cause death? No. It is the swelling of the brain.”

  Finally, Daniele gave the correct answer, “Deliver the baby as soon as possible.”

  “Correct.”

  Daniele beamed, very glad to have redeemed herself.

  After the lecture, Dr. Obaye asked Sarah to meet with him briefly in his office.

  “How are things going so far?”

  “It’s all very interesting,” she replied. “And I’m learning a lot.”

  “Do you sometimes wonder why you were chosen for this fellowship when are not trained in obstetrics?”

  “Actually, yes.”

  “It was your essay. Mrs. Stanford, the benefactor of the foundation, was impressed by your grasp of the key role that women’s health plays in the welfare of the entire country—of any country for that matter. You seem to have a passion for women’s rights in general.” He smiled and leaned forward with his arms on the desk. “She believes that progress requires thinking outside the box. And you are definitely outside the box.” He settled back into his chair and frowned. “As for me, I was not so convinced. Perhaps I am cynical, but we have had many fellows who did not have a sincere interest; they merely wanted to spend some time in Africa. They all write impassioned essays to get the position. Not one of them has ever completed a successful research project.”

  She tried not to squirm in her seat. She had included all the stuff about women’s rights because she didn’t know much about maternal mortality.

  “So far, I think Mrs. Stanford was right. You did not object when I pointed out that you needed to do some clinical work. The students say that you are a good teacher. And you came to my lecture today.”

  “I have a lot to learn.”

  “Mortality is too high here. We are improving, slowly. But in your country, the United States, maternal mortality is increasing.”

  “I wasn’t aware of that. Why is it going up?’

  “I am not an expert on health care in your country. But from my reading, I have seen two factors cited. There are too many caesarian sections, possibly due to malpractice fears. The other reason is poor access to care. How is this possible? The richest country on earth does not have enough doctors and nurses?”

  “Doctors tend to cluster in urban areas. Also, many women don’t have health insurance.”

  “We have similar issues in Tanzania. Perhaps what you learn here will be relevant when you go home.”

  DINNER WAS A tuna sandwich on her sofa, while surfing the internet for articles about eclampsia. Her cellphone pinged with a message from her sister, Allison: Help! I’m puking my guts out. I don’t think this baby is worth it.

  It’s normal. It’s called morning sickness.

  Well I’m sick all the time. And you’re not very sympathetic. Sarah logged onto Skype and called her sister’s cellphone.

  “Hi, Al. Sorry you’re feeling sick.”

  “Thanks. Isn’t this an expensive call?”

  “Nope, I’m on Skype.”

  “Oh. Good. I need your advice. I think I’m going to stop looking for a job. Do you think that’s bad?”

  “It depends on your reasons.”

  “Well, for one thing, I haven’t been able to find a job.”

  “You’re discouraged.”

  “And now I’m feeling sick all the time. Not really in shape for an interview.”

  “Good point.”

  “Michael makes enough money for us both. But I would barely make enough to cover childcare.”

  “So not working makes sense economically?”

  “And I don’t really want to work. I want to stay home with the baby.”

  “Well that’s the best reason of all.”

  “You think so? But I feel like a wimp. Look at you.”

  “Don’t be silly. I would not wish my lifestyle on anyone. My plan was to have a baby by now.”

  “Seriously, Sam? You’ve had trouble getting pregnant?”

  “It’s not that. We want to get married first. But David says we’ll pay more in taxes, so we can’t afford parenthood until we finish training. Of course, if he hadn’t taken time out to get a PhD, he’d be out
in practice by now. And now he wants to do a fellowship, so …”

  “Sorry.” Allison cleared her throat. “How is Africa otherwise?”

  “In two words? Very interesting. Listen, it’s great to talk to you, but I need to finish reading a couple of articles and get to bed.”

  It was impossible concentrate on her reading. Allison had not asked the big question. It was the one she kept asking herself.

  Did I come to Africa because I’m angry with David?

  CHAPTER SEVEN

  BAPTISM BY FIRE

  A nurse led Sarah to a cubicle in the corner of the bustling emergency room. The thin curtain provided meager refuge from the tumult of moaning patients and clattering gurneys. A young woman lay on the stretcher, her ebony face studded with beads of sweat that gleamed like diamonds. Her mother sat beside her, clad in a royal blue shuka and a broad collar of beads, her earlobes stretched into long dangly loops.

  Sarah tried to introduce herself, using her limited Swahili. “Habari. Jina langu ni Daktari Sarah.”

  No response. Just blank stares.

  The nurse shook her head. “They don’t know Swahili. They are Massai.”

  “I’ll start an IV. Bring me some mag sulfate.”

  The needle was poised above a very promising vein when the young woman’s eyes rolled back, and a massive convulsion wracked her body. Her mother let out a blood curdling, ululating wail. The nurse came running with a syringe, and Sarah unloaded the entire contents into the patient’s hip. But the seizure continued unabated and the young woman’s lips went from dusky to black.

  A tall blond man in scrubs threw back the curtain at the head of the stretcher, a bouquet of loaded syringes in his hand. He frowned at Sarah. “Didn’t you start an IV?”

  “I can’t—not when she’s jerking around like that.”

  He muttered under his breath and injected something under the woman’s jaw. Within seconds, the patient was totally limp.

  Sarah resumed her quest for a vein. “What did you give her?”

  “Succinylcholine. Gets absorbed really fast when you shoot it into tongue muscle.” He put an endotracheal tube into the woman’s throat and connected an oxygen tank. “It paralyzed her. Brain is still seizing, though.”

  She had heard about this man. Pieter Meijer. Visiting anesthesiologist from Holland. She threaded a catheter into a large vein and attached an IV line. Dr. Meijer tossed three syringes to Sarah. “Push these.”

  “What’s this stuff?”

  “Diazepam, mannitol, steroids. They’re waiting for us upstairs. Let’s go!”

  He released the brake on the stretcher, and they raced into the elevator. The door closed. For a brief moment, it was an oasis of calm. The only sound was the rhythmic whooshing of the Ambu bag. “Your name is Sarah, right?”

  “Yes.”

  “Margo said she met you on the plane.”

  “Do you carry those drugs around all the time?”

  “Not all the time.” He adjusted the flow of the IV. “I keep an eclampsia stash on hand.”

  “That’s a little less regulated than what I’m was used to. At my hospital, the drugs are locked up in a computerized box. We have to log and request meds, even in middle of an arrest. It’s kind of insane.”

  “Two ends of the health care spectrum. Each with its own problems.”

  The elevator door opened, and they bolted out.

  Ameera and the scrub nurse stood ready, gowned and gloved. As soon as the patient was moved to the operating table, someone doused her bulging abdomen with orange betadine. Sarah went out to scrub and cursed herself for using too much soap, because the trickle of water from the tap was maddeningly weak and it took forever to rinse her hands. She walked back into a room abuzz with frantic Swahili chatter that she could not understand. Ameera had not made a cosmetic incision below the bikini line. It was a straight-down-the-middle-get-this-baby-out-now slash. Sarah struggled to pull gloves onto her soap-sticky fingers and then took her place across from Ameera. Suddenly the table abruptly tilted as Dr. Meigher cranked the head of the bed down, lower than the feet.

  “Hypotension?” Sarah queried.

  Ameera nodded, “She’s crashing.” She sliced into the womb, releasing a flood of greenish sour smelling fluid, extracted a purplish mass which was the baby, and cut the cord.

  Sarah placed the floppy infant on the back table and suctioned the mouth. He was blue and motionless, but his heart was racing. “AGAR 4,” she called out.

  Please God, save this little baby.

  She ventilated him with a mask and after a few breaths of oxygen, he wailed loudly, flailing four perfect limbs. Sarah counted ten fingers and ten toes and announced, “It’s a boy. He’s okay.”

  No one cheered. The beeping of the monitor ominously decelerated, then flatlined. Dr. Meigher threw back the drapes and started chest compressions.

  Per protocol, Ameera took over compressions after a few minutes, and then it was Sarah’s turn. She stacked her hands between the breasts that were supposed to feed this little baby and called upon the technique she had honed on a Russuci-Annie mannequin with a light that flashed when you pressed quickly and firmly enough. In her CPR class, the instructor had set the tempo by playing “Stayin’ Alive” on a boom box, so, Sarah worked to the rhythm of the Bee Gees in her head, desperate to keep this young mother’s soul on earth.

  But it was futile. After thirty minutes, there was no heartbeat, no breathing. The pupils were fixed and dilated.

  Ameera sat down heavily on a stool. “Doctor Meigher, you are the only one of us who speaks Massai. Will you talk to the family?”

  Sarah followed him into the hallway, where the patient’s mother and a young man sat on a bench. Dr. Meigher squatted on the floor in front of them and spoke softly. Before he finished his sentence, the woman collapsed on the floor, beads and fists clanking and pummeling the worn terrazzo. The young man hunched over, kneading his scalp, shaking his head. Then he sat up slowly, squared his shoulders. “I want to see my son.”

  THE NEXT DAY was a welcome change of pace: getting involved in research. Sarah and Ameera met in the library, one of the few air-conditioned spaces in the hospital. The musty smell of the old books summoned pleasant memories Sarah’s childhood: hours spent with her nose in a book in the public library. The hospital library in Philadelphia smelled of plastic and disinfectant. It had been pillaged, books destroyed and replaced by computers.

  Ameera lifted two large bound volumes from a trolley and heaved them onto the table, “Obstetrical Unit logs—lists of all deliveries.” She tapped on the newer book. “This one is last year—the other one is from 2008, the year before they initiated the protocols.” She waved at the piles of papers remaining in the cart. “Those are the medical records of the maternal deaths from those years.”

  “Okay. You know how many deliveries, and you know how many deaths … you know the maternal mortality for those years. So that’s the answer to your question, right? The hospital began following the protocols and mortality either got better or it did not. End of story?”

  Ameera shook her head. “We deliver about 3,500 babies a year in this hospital. Last year, we had eighteen maternal deaths. In 2008, there were twenty.”

  “If it’s not getting better with the new protocols, the next question is … why not?”

  “Exactly. Either the protocols are not effective, not likely, or we are not complying. So we need to review each one of these deaths and find out what happened.”

  Sarah stared at the stacks of papers in the trolley. Each chart contained the stories of suffering and motherless children, every tale as heart-wrenching as the events of the night before. Multi-colored, dog-eared pages, hand-written in variable legibility.

  “We are beginning to use electronic records,” said Ameera. “But we only have hard copy charts for the years we are reviewing.”

  They pored through the records, checking for compliance with protocols and entering data into an Excel spread shee
t. Around noon, Sarah’s phone pinged with a text from Margo.

  Just finished surgery. Can you guys meet me for lunch?

  THE HOSPITAL CAFé was an open-air space with a corrugated metal roof, its perimeters bound by privet hedges. A large plastic container full of water by the entrance had a spigot on the side for hand washing, and food was served from a glass encased steam table.

  They selected their food and settled around one of the square red plastic tables emblazoned with Coca-Cola logos. There were also a few round Pepsi tables, but Coke was definitely the dominant theme.

  Sarah poked at some white, sticky stuff on her plate. “What’s this?”

  “Ugali,” said Margo. “It’s made from corn.”

  She sampled a bit. “Tastes like grits.”

  Ameera tilted her head. “What is a grit?”

  “Kind of like polenta. Have you ever eaten that?”

  Ameera and Margo shook their heads.

  “Do you miss surgery?” Margo asked. “You must be getting twitchy to operate. You can scrub in with me any time.”

  “I’d really like that. Don’t want my skills to get rusty this year.”

  Ameera looked hurt. “We do surgery in Ob-Gyn.” Margo said it wasn’t real surgery. “Not like hernias and gall bladders.”

  “No fighting, ladies.” Dr. Meigher set his lunch tray on the table and kissed Margo on the cheek.

  She smiled and squeezed his hand. “Pieter, this is Sarah, the one I met on the plane.”

  “I have already had the pleasure to meet her. How do you like African food?”

  “I really like the chapati.”

  “Everyone likes chapati. What about the ugali?”

  Sarah hesitated a moment, pursed her lips until she thought of a diplomatic answer. “It has an interesting texture.”

  Pieter laughed. “We are not offended if you don’t like it. In fact, I can’t stand ugali.”

  “Hmph!” Margo retorted. “You do not know good food, you mzungu. Sarah, we should take you to the barbecue place Saturday night. I think you’ll like it. All kinds of grilled meat.”