Michael Maina - A Long, Long Night Shift

 

I had just finished my medical school and I was excited. I was passionate about sexual and reproductive health rights. I was eager to take the next step, which was maternal mortality. In Kenya, the area with the highest maternal mortality is northeastern. It's in the northeastern part, a town called Garissa. They have 641 maternal deaths per 100,000 live births. In perspective, the STG target is 70 deaths per 100,000. That's almost nine times more. 

 

I wanted to make a difference and I felt I could do it. I told my friends, I want to do my internship in Garissa. They all tried to dissuade me. One said, “It's not safe. There was a terrorist attack there.” I was like, “10 years ago, it's been safe since.” They told me, “It's a hardship arid area. You'll struggle.” “But there's a hardship allowance, more money for me.” [audience laughter] One friend warned me, “If the government decides to pay you more money, you'll work for it hard.” 

 

I wasn't dissuaded and I followed my passion. I went to Garissa. I alighted the bus and was met with scorching heat. I was sweating all over. It was sandy and desert like. I went to the restaurant, had a good meal, I enjoyed the cuisine, had a drink and I talked to the people around. Lovely, I love the culture, felt right at home, but I was nervous about work. My first day I got in, the medical officer who was overseeing me welcomed me so warmly with open arms. He took me around for the ward round, showed me each patient, one by one. He explained everything. Whenever I never knew a question, he patiently explained it. I felt excited. 

 

At 11:00 AM, he left. In the afternoon, 03:00 PM, I asked the nurse, where's the doctor gone to? She tells me, “He has been working as the only doctor for three months in this department. Monday to Sunday, 08:00 AM to 08:00 AM.” My arrival signified his chance to rest. [audience laughter] Later that night, I called for a consult and he told me, “Doc, you've been to school just like I've been to school. I believe in you, just, you'll find a way.” [audience laughter] 

 

The next two weeks, I was working 20 hours a day on call. Baptism by fire. I spent most of my time in hospital and I only interacted with the staff. In particular, there was a cleaning lady named Zara. She was always nice, she always smiled and we always made chit chat. I went to my next rotation, which is maternity department. Bath was a communal event. Relatives were beside the bed. So, when you're trying to get intravenous access, pricking and missing the vein, they're all looking at you with bad eyes and asking, “Did this doctor even go to school?” [audience laughter] 

 

Our Kenya Medical Council gives you a logbook that you need to fill in three months. I saw so many emergencies, I filled it, two weeks. Yeah. So, at this point, my bedside manner, I had taken it aside. I just wanted to clear the wards, just looking at the charts, diagnosis, they give birth, go home, go home, go home. After my internship, I was absorbed to the hospital, now as a medical officer in the maternity department. Our consultant told me my responsibilities had increased. He told me, everything good that happens in the ward is my doing. Everything bad, my fault, pressure. 

 

One weekend, I was left alone to do a 72-hour shift. My colleagues and consultants had traveled for a conference, and so they left the department in my hands. At the end of the shift, I was so tired and went and collapsed in bed. I then get a call from the hospital. I hung up immediately. I get another call from the personal number of the nurse. She tells me, “Michael, we have an emergency.” And I say, “I'm not on call. Call the doctor who's supposed to cover.” She tells me, “He's not back yet. He'll be late. He's in a bus. Please come. Run, please. Thank you,” before I can even argue. 

 

So, I'm angry, cranky. I walk to the ward, frustrated. When I get in there, there's a huge commotion. I see nurses on one side arguing with relatives on the other side. I just want to tell everyone to shut up. So, I walk towards them. As I'm walking, I notice that the floor is wet. I look down, pool of blood. I look towards it and I see a trail towards the bed. Snap into action. I go there. There's a very sick patient. She's a pregnant lady who's deathly pale, is being transfused two units of blood at the same time, one on each arm. I take my speculum and examine. I have never seen that much blood from a pregnant woman. I immediately say, we have to go to theater and tell the nurses to give me the forms for consent and a theater list. 

 

As soon as her mother heard the word, caesarean section, the patient's mother said, “What do you want to do to my daughter? You want to take her there to butcher her?” I was tired, so I ignored her and focused on the patient. I told her, her condition is placenta previa. So, that means her placenta was between the head and the cervix, and she was in active labor. So, with each contraction, the head of the child will push against the placenta, causing more bleeding. And if it never stopped, her uterus could even rupture and they both die. I told them we had to go to theater and we needed consent. 

 

At this point, the patient weakly raised her hand and grabbed my lab coat. She said, “Doctor, operation, no, no, no.” At this point, I was stunned. I looked to the mother for help. Maybe they never understood. I told the mother, no matter how hard she pushes, that baby isn't coming out, and both the patient and her child will die. The mother looked me straight in the eye and told me, “Then we'll dig two graves and bury them.” I was shocked. How can a mother say these things to her child. 

 

At this point, I was just so frustrated. I felt so hopeless. I took off my gloves, threw them on the floor and just stormed out. By the time I was at the door, all the energy just seeped out of me. I found myself sitting against the wall, thinking about how bad a shift I had. I was in the hospital for three days, we've gotten a really sick patient and the only thing that was my part was getting consent and taking the patient to theater, the nurses had done the rest. But I couldn't do anything. My hands were tied. Patient autonomy, you have the right to accept or refuse, and I can only respect it. I felt so sad, just waiting to see the patient die. 

 

I was on the brink of tears when I felt a tap. This was Zara, the cleaning lady, who was always my friend. She looked at me and said, “Doc, why are you crying?” I wiped my eyes and said, “Uh, not crying.” [audience laughter] I explained the situation to her. She tells me that three years ago she was in a similar situation, but she declined to go for cesarean section. I was shocked. “Zara, you work in a hospital. You see patients go to theater, back to the wards and home, safe and sound. Why would you refuse?” She told me that in her culture, it was a point of pride of a woman to give birth to as many children and to give birth naturally, which she meant vaginally. She said, “There's no point living in a world where you're ostracized by your loved ones.” 

 

However, after someone talking to her, telling her that her body is different from others and she only needs a C-section, she accepted. I was just confused and she could read it on my face. She asked me, “Michael, do you want my help in talking to them?” I thought it was a lost cause. “Do whatever you want.” She went, and as opposed to my approach, she said hi to all the relatives, including the patient. She talked to them softly and listened to them without interrupting as they were protesting. She then talked more and opened her shirt. She showed her the scar that she had, and everyone's face softened. They then said a prayer together and she came back. I was so nervous. She told me, “You can go sign your consent and take her to theater. They've accepted.” [audience applause] 

 

So, at this point, it was a heavy burden off my shoulders. I could finally work. We rushed the patient to theater and we had surgery. It was successful. [audience cheers and applause] 

 

So, four days later, in the next ward round, with the consultant, I see the patient. She's there suckling her child, both healthy, and we're about to discharge her. I did something I never did previously. I stayed afterwards and went to have a chat with her. She told me how excited she was to see me and excited that we took good care of her, plus Zara's compassion and willingness to listen. I asked her why she was against the CS, the cesarean section. She said she heard rumors that when you go to theater, they take out your uterus. Once you get a cesarean section, you can't give birth again naturally or vaginally, as she said. I dispelled the myths, and we had a good conversation about reproductive health. 

 

Reflecting about that situation, it wasn’t our effort as doctors or nurses that saved her life. It was Zara, her compassion, her love, her willingness to listen and communicate. And having lost my bedside manner at the time, I decided to regain my humane approach in medicine, listening, empathizing, loving and caring for my patients. Thank you.