Old Lovers Don't Die

by Anderson, Paul G

  “Let’s see what you know and how useful it’s going to be. They don’t have malaria in Australia, do they?”

  “Thank you,” said Christian taking the white coat and slipping his stethoscope into the pocket. “We do have cases of malaria in Australia, but those are usually patients who have been to Southeast Asia. So there’s a great awareness about its presentation in medical schools.”

  The greeting, or lack of greeting, Christian could understand. Doctor Nikita had been up most of the night, still had many patients to see, and did not need a medical tourist. He had always assumed that he would have to earn his stripes.

  “I’ll leave you two to it. Christian, you can find me in the office. Theodore will explain how surgery and the theatre work. I will see you later.”

  Theodore Nikita put down the folder that he had been reading and picked up a new folder from the desk. Without saying anything to Christian, he headed towards the patients on the right of the wooden desk. One woman got off the bed as he approached. The other woman who remained on the bed was partly covered by a bloodstained blanket. Her long black hair was matted with blood, her face partly hidden by the blanket, contorted in pain. In her right arm was an intravenous line, the bag of saline to which it was connected almost empty. Nikita bent over her and felt for her pulse before pushing the blanket down to listen to her chest with his stethoscope. He touched her abdomen and she winced and cried out several times.

  “She needs to be first on the theatre list,” he said, straightening up and talking to a sister in a tight ill-fitting uniform.

  Christian was surprised that he had not removed the blanket from the lower half of the woman. The gentle touch on the abdomen, which caused a painful reaction, indicated peritoneal irritation to the extent that she required urgent surgery. Something was seriously wrong inside her abdomen.

  “What do you know about recto-vaginal fistulae?” Nikita said without turning to face him.

  “In the western world, they are usually the result of obstetric difficulties. Poorly applied forceps at the time of delivering the child can cause a tear in the uterus and the rectum resulting in a communication between the vagina and rectum resulting in faecal discharge out the vagina.”

  “How do you repair them?” Nikita continued, still not looking at Christian.

  “If the bowel contents have discharged into the abdominal cavity, we would at the time of surgery repair the hole in the vagina and the bowel and leave the patient with a colostomy.”

  “Have you done any?”

  “Not recto vagina fistulae repair, but obviously laparotomies and colostomies.”

  “You can assist me this morning then,” Nikita said finally turning to look at Christian. The scrutinization from Nikita, Christian assumed, was a well-practiced look, designed not only to assess but to inform.

  “This was not the result of obstetric accident. Congolese militia raped this young girl, repeatedly. Not content with that, they then brutalized. It would not be fair to say that she is lucky that she is alive but in the extreme inhumanity, which you encounter here, she is. If you’re going to work here and make a contribution, you will need to be familiar with this kind of injury and how to deal with it.”

  Nikita pulled back the blanket far enough that Christian could see a large broken stick protruding from the young woman’s vagina. Nikita watched while Christian tried to take in the gross brutality. The image repulsed him; it assailed every decent sense he had built up over twenty-seven years. Waves of disgust rushed at him. He could not imagine how any one human being could brutalize another in such a fashion. He could not control the shock that appeared on his face. He knew Nikita had wanted to shock him, to see whether he was capable of dealing with the brutality that he was going to encounter. Christian looked at the young woman whom he estimated to be almost the same age as he was, crying and grimacing with pain. She had no family beside her, no support group, no one to turn to. Christian reached down and pulled the blanket up before walking to the far side of the bed opposite Nikita. He sat down on the bed, took the young woman’s hand, and as he did so, her eyes opened, fear and the pain openly transmitted. Christian bent over and, struggling to remember his high school French, said:

  “Nous allons prendre soin de vous et de vous faire une meilleure,” which he hoped translated into a reassurance that indicated she would be well looked after and recover. The girl squeezed his hand, and closed her eyes. “Tres bien, a good start, you may turn out to be better than the other five medical voyeurs that we’ve had here,” Nikita said dismissively before he turned towards a middle-aged plumpish woman in a white coat, who had just walked through the front door.

  “Matron Malasu, this patient needs an urgent laparotomy. Take her to theatre and arrange some large overalls for this tall Muzungu doctor.”

  Christian smiled in the direction of Matron Malasu. She looked over the top of her glasses, perched precariously at the end of her nose, and said,

  “Come and see me, tall Muzungu Doctor, when you are finished with Dr Nikita.”

  Christian followed Doctor Nikita to the next bed. Lying on it with a distended belly was a twelve-year-old girl with long hair, a clump of which she was holding in her hand. Standing next to her, holding her other hand, was a woman in what Christian had come to recognize as traditional female dress: a blue-green floor-length skirt with a red sash draped over one shoulder hiding a T-shirt with a picture of Nelson Mandela. Her hair she had pushed up in a bun, decorated with beads and two pink ribbons. Christian assumed it was the mother of the young girl. Sitting under the bed were a young boy and girl playing with a wooden comb.

  “She is a repeat offender,” Nikita said standing at the foot of the bed and looking down at the young girl. “She swallows things which block the bowel. She has had two major operations already and now looks like she needs a third. Examine her and tell me that I am right. We will operate on her after the previous patient.”

  Christian looked at the young girl; to him she did not look dehydrated or distressed which was a good sign. He asked her to put out her tongue and noted that it was well hydrated, something that did not fit with a bowel obstruction. Surgery may not be as urgent as Doctor Nikita was thinking.

  “Vous vomissez?”

  “No, she hasn’t been vomiting,” the woman said who was standing next to her. “You can speak to her in English; she understands English well.”

  Christian smiled at the woman, and explained that he was going to examine the young girl’s abdomen. He tapped her abdomen gently and noted that she did not react or wince in pain. That was another very good sign; it meant that the abdominal contents were not providing irritation. Taking his stethoscope, he placed it on her abdomen. There were low-pitched bowel sounds present, another good sign indicating that things were working relatively normally inside her abdomen. If there were no obstructions, she would not need surgery. He could feel Doctor Nikita watching him intently, willing him to confirm the diagnosis of obstructed bowel and the need for surgery. As he moved his stethoscope to the lower abdomen, he noticed a large clump of hair the young girl was clasping in her hand.

  “Does she eat her hair?” Christian asked the mother.

  “For as long as we have known her, she has done that. We adopted her when she was five. Both her parents were killed in the Congo by Kariba’s militia. “

  Christian examined the young girl’s head and found many clumps of hair missing. Those clumps could be matted together in her stomach causing the distension of her stomach. It would be, he thought, a better explanation of the symptoms. However if he suggested matted lumps of hair as a diagnosis, it would conflict with Doctor Nikita’s management. Moreover, to contradict Nikita’s diagnosis would possibly compromise the rest of his stay in Garanyi. If he was right, the condition possibly could be treated without surgery from what he had recently read.

  “So you agree with my diagnosis?”

  Christian looked up from his examination. He did not reply immediately
but put his ear on the young girl’s abdomen above the stomach. He then gently shook her side to side with Nikita watching.

  “She has a succussion splash suggesting the outlet to her stomach is obstructed.”

  “Well she still needs surgery.”

  Christian stood up and looked around the ward. The article that he had read, just before coming to Africa, had been on exactly this girl’s condition—gastric bezoars or balls of hair in the stomach. The study had found that the obstruction could be overcome by getting the patient to drink Coca-Cola. The very acid nature of the drink dissolved clumps of hair and overcame the obstruction in many cases. In the far corner of the ward was a half-empty bottle of Coca-Cola. If he could persuade Nikita, it may well save the young girl from a further operation. Christian looked at Nikita who was now standing at the foot of the bed, arms folded, his body language suggesting Christian not challenge him. Christian briefly wrestled with the thought of not replying, however something within him would not allow him to deny his findings. If it meant damning his visit on the first day, so be it.

  “I think we might be able to get away without surgery,” he said, straightening up from the side of the bed so that he could look Nikita straight in the eye.

  “So you’re disagreeing with my diagnosis.”

  “Yes. I think she’s got a gastric bezoar and from what I recently read, that half-finished bottle of Coca-Cola over there may relieve her obstruction.”

  Nikita looked at Christian for thirty seconds before replying.

  “If you’re not right, don’t come back tomorrow. Sister, give her that bottle of Coca-Cola and we will see her after surgery this evening.”

  The rest of the ward round became a bit of a blur for Christian. Out of the corner of his eye, he could see the young girl sipping away at the Coca-Cola. He felt certain his diagnosis was the correct one, but would that be enough Coca-Cola to dissolve the hair?

  They saw another young boy who had water on his brain, and then a prisoner from the jail across the road who had been badly beaten by other prisoners, but whom Nikita didn’t think needed surgery. A young man was the final patient they reviewed. He had fallen off his motorbike and badly lacerated his head. Nikita told Christian that his job would be to suture the laceration after the major surgery was finished. They would review the prisoner later in the day.

  Christian followed Nikita out through a side door. A smooth concrete pathway led twenty metres to a faded pale green wooden door, which had ‘Theatre’ in large red letters painted on it. Several trolleys for transporting patients were parked on either side of the pathway. In their original state, they were white. Now they had faded to a dirty cream with parts of the enamel chipped off exposing bare metal, which was mostly stained by splashes of blood. There were no mattresses on any of the trolleys. Just literally, they had the bare essentials on which to transport the patients from accident and emergency down the hill to theatre.

  Nikita knocked on the door and waited. Christian stopped behind him thinking about the young girl with the gastric bezoar. If he was right and it resolved the obstruction, he was not sure still how Nikita would feel. Would he view it as a challenge to his authority rather than a good clinical outcome for the patient?

  “Good morning, Dr. Nikita”, said the voice behind the door. “Come in. The anaesthetist is not yet here.”

  Christian followed Nikita into a tired, grey-tiled reception area. A small wooden desk in one corner had patient notes scattered over it. Huddled in the other corner was a large used oxygen cylinder waiting to be refilled. Next to the cylinder, was a small portable sterilizer, the door of which was open revealing several broken shelves and the charred remains of internal wiring. Two opaque windows of the type frequently seen in public toilets provided some filtered light.

  “That is the changing room,” Nikita said, pointing to the door which led off from the left-hand side of the room. “And the other door over there goes through into the theatre.”

  Christian looked in the direction of the changing room. There was no door to the changing room and it was no bigger than a large broom cupboard with half a dozen large hooks on the wall for clothes. He could see a collection of male and female clothes. As if reading his mind, Dr. Nikita looked at him and smiled before saying,

  “Not quite what you’re used to Australia, everyone in together?”

  “No, we have separate changing rooms. To suggest that we all change together would produce a fierce outcry from the female staff. Although I do recall when I was working in South Africa, we had a very glamorous German medical student who insisted on changing in the male changing room. All the surgeons started their lists on time for the duration that she was there.”

  It was the first time that Christian had seen Nikita smile. Not a full smile, just the hint of one which adumbrated, he hoped, greater acceptance.

  “To preserve dignity here, we have an agreement that the female staff get changed first, twenty minutes before an operation, and then the male staff, ten minutes before surgery.”

  In the corner of the changing room was a pile of neatly stacked blue surgical overalls. Christian found the large pair that Theresa had left for him, and put them on. Over shoes, he found next to the doorway. They were only one size and he struggled to get his size 12 shoes into them. The one on his left foot tore a little exposing his shoe and the dustiness of the outside world. He was searching for another to cover the torn defect when Nikita walked in.

  “There are masks and hats in theatre,” he said without looking up. “What do you think we use for anaesthesia here?”

  “Ketamine intravenous as a 75 mg standard dose.”

  “You have done your reading. What do you need to look out for postoperatively?”

  “Hallucinations. It’s one of the most distressing things for the patients, I believe. Otherwise it would be the perfect anaesthetic drug for developing countries, particularly as it doesn’t have a marked effect on respiration.”

  “Well, at least that’s a better answer than the last German doctor we had here. He could only tell me that it was a date rape drug.”

  Nikita pulled on blue surgical overalls followed by surgical gumboots. Originally white, the boots had faded with constant washing to a yellow cream colour. There were pink outlines where blood had etched itself into the waterproofing, resistant to constant washing. In places, the stains coalesced to give the appearance of an unmarked map of Africa. On the heel of the boots, Nikita’s name was written with ballpoint pen. Nikita pulled on his boots and stamped his feet into place before calling over his shoulder, in Christian’s direction, as he walked through the door,

  “Come with me. I’ll introduce you to Sister Teresa. She has been the scrub nurse here for twelve years. She does minor surgery and likes to think that she could do major surgery. Despite that, she is invaluable and she will also be your assistant when you start your own surgical list.”

  Sister Teresa looked formidable, dressed in similar blue surgical overalls. Christian had always wondered about the original selection of surgical overalls for surgery; they always seem to be badly fitted and more suited to those who needed to crawl underneath cars. Sister Theresa’s were no different. They were tight around her bottom and in front battling to constrain large breasts, which threatened to open all the buttons with any sudden movement. A mask hid most of her face, and a mass of tightly woven hair was held in place with a cloth cap with a Red Cross insignia emblazoned on the front. Her boots were similar to Nikita’s, although much less bloodstained; they had two red hearts drawn in ballpoint pen over the toes of each boot which he could never imagine on Nikita’s boots. Green surgical gloves completed the impression of an overweight sensitive plumber intent on clearing a drain rather than an experienced scrub nurse.

  “Sister Teresa, this is Dr. Christian de Villiers from Australia who will be joining us for three months.”

  Sister Teresa looked up from the surgical instruments that she was arranging, briefly looked at Chri
stian, and said,

  “Make sure you wash your hands for two minutes.”

  Christian looked down in the direction where she had been looking, and saw a large red plastic bowl to wash his hands in and a single piece of soap; there was a well-used grey hand towel folded neatly alongside. The theatre itself was the size of a small bedroom. All of the walls were lined with grey enamelled tiles. From a central pivot in the ceiling was a large surgical light. On the operating table directly underneath lay the patient, the piece of wood protruding offensively from her vagina.

  The abdomen and pelvic region had been liberally coated with the antiseptic betadine. Christian noted as he walked into theatre, that there was no ventilator, just a large oxygen bottle, similar to the one he had seen in the waiting room, connected via a mask to the patient. The operation would utilise only oxygen and ketamine. Christian knew from his reading that that would mean not only that there was not muscular paralysis, but the patient would be disconcertingly moving around on the table as they operated in a semi-conscious state, although unaware of pain.

  “Would you take it out first or leave it in?” Nikita said as he washed his hands in the red plastic bowl.

  “Leave it in until we have opened the abdomen so it’s possible to trace any damage to uterus/ bladder and bowel.”

  Nikita dried his hands before walking through the open door into theatre. Christian noticed the anaesthetic person strapping the arms down as the patient started to move under the effects of ketamine. Nikita stood on the right side of the operating table. On the left-hand side were the instrument tray and the considerable size of Sister Teresa. There was little space for Christian. As he pulled his surgical gloves on, he wondered how he was going to be able to see into the abdomen to assist Dr. Nikita efficiently. He stood alongside Sister Teresa who provided him with no extra space. As Christian placed his hands on the part of the abdomen covered by the surgical drapes, he felt the patient move and heard the disconcerting moan that was part of the hallucinatory effect of the ketamine. Sister Teresa began talking very quickly in her national Kinyarwanda dialect as she handed Nikita the scalpel. Nikita looked up at Sister Teresa, before he made a cut in the abdomen with the scalpel, and said in English,