Under the moon of Chaaria

Under the moon of Chaaria

It is the dead of the night. I’m really exhausted. I look at my watch. It’s almost 2 a.m. I feel bad when I think that in 4 hours I will have to wake up for the Mass. At the same time I know that I could not sleep if I went straight to the bed because my head is almost bursting with thoughts. Perhaps this would be the right time for a cigarette, but since I do not smoke I chose to wander  to the banana plantation, away from the lights of the hospital, to contemplate the sky full of stars. Tonight there are thousands of stars that shine even more because the moon is just rising on the horizon and looks like a huge orange disc. What a day! Here, it’s a constant battle between life and death. Sometimes life wins, but often the death reminds us that we are not omnipotent and that the final victory will be only at the end of time.  It seems  as if the Lord kept on sending us messages that make us feel humble: maybe we were pleased with ourselves and thought we would be able to cope with many health problems that decimate our poor people.  Sometimes the temptation to be proud of ourselves can peep in our hearts, but then some disaster happens and you seem no longer able to do anything;  you just feel like leaving everything and submerge in  discouragement.

The day started early. It was 5 a.m. when Concetta knocked at the door of my room. I could not wake up, taking into account the fact that the previous Cesarean section finished after midnight. Concetta continued knocking like the importunate friend from the Gospel. I finally overcame the tiredness and  responded. She told me to run because there was a case of a mother in coma in the maternity ward. She said that the patient was in a very poor condition and she could die at any time. It took me 3 minutes to get dressed and I ran to the hospital, even forgetting my glasses. It was not what I expected. I surmised  it could be a case of gestosis, and I thought of doing another Cesarean. Instead,  I found a young woman in a state of agony. She barely breathed. We, doctors, tend to say that a patient is ‘gasping’, which in simple terms denotes the last minutes of breath. She had a retained placenta and was bleeding  all night long. In fact, she gave birth on the street while trying to reach the maternity in Tharaka. Women of good will had helped in childbirth, but they were inexperienced and perhaps did not tie the umbilical cord well. When the mother reached the abovementioned dispensary, she was told that they could not handle her case because they had no possibility of giving anesthesia to remove the placenta manually, and that they could not transfuse. That dispensary did not provide neither the car nor the driver, so the husband had to put his wife in the back of the bicycle. She delivered around 10 p.m. and arrived to Chaaria at 5 a.m., almost completely bloodless. We acted immediately. We found the femoral vein and rapidly transfused the blood. We removed the placenta and the mother slowly started to recover. She even began to speak and seemed completely out of danger. She asked about the baby and was happy to know that the baby was in perfect condition. She began to eat something and continued  to tell us how she had first been transported by bicycle, then a wheelbarrow and then  a ‘matatu’ rented by the spouse. I was full of joy. The eyes were closed for a very short night's sleep, but my heart was full of human satisfaction. I wanted to go to get some snack and then some sleep before returning to the new day of service. Instead of this I was called urgently to the delivery room. A mother gave birth apparently without problems, but the baby was not breathing: once again the events changed my plans. Once again in turmoil, I had to try to fight for the life of that little baby who was not able to breathe. Here too, the Lord has given us a moment of human satisfaction. Our efforts bore quick results and improved the condition of the patient. After 45 minutes the baby began issuing the first cries and then cried vigorously. Thank goodness! It went well again. It seems finally the time has come for a breakfast and at least a little prayer in the Chapel-  to repeat  to myself and to Jesus that I want to live and work for Him. But once I tried to leave, I was called again for another two C-sections. I was told these are urgent because the fetus is in danger. What to do! Better to have a cup of coffee in my office and be ready as soon as the theatre is cleaned and prepared. The Lord guided my hands and about 12.30 we had already finished the second C-section and both mothers and their children were in good condition. After leaving the room, full of heat and sweat, I got hit by a queue of angry patients  who were complaining that they had been told to wait with a full bladder for an ultrasound of the abdomen. Many of them were from Isiolo, which is really far away, and worried about not being able to find public transport to get back home. It therefore required a new sacrifice: after lunch, forgetting the little siesta, we began another adventure in the ambulatory, trying to give the maximum attention to the problems of each. The problems we encounter here are often complicated, requiring much attention and patience. It is especially difficult with women who are unable to have children. So often there is nothing to do for them, because their problems are chronic and practically insoluble. But how to tell them that? An adoption is not accepted here, especially  among the Muslim community of Isiolo. The husband is usually considered immune to sexual problems in the area, so it's always the woman to be held responsible for any type of infertility. If a woman is unable to have children, there are two options: either she becomes a second wife and has to accept that her husband has another partner to have children with (and therefore that second partner will receive far more attention), or is simply sent away (it seems like in the Old Testament!). Bearing in mind the local traditions, we know that  only men can inherit and the woman must receive the support from her husband. It means that a woman rejected because of  infertility is actually left with no chance for a happy life. Nobody is going to marry her and she has no right to inherit neither the money nor the ground from the husband who had repudiated her. The ambulatory is then made ​​even more stressful by the continuous arrival of children in bad condition who often come to us when it is too late. As in the case of Joy, who had been treated for 4 days with an antibiotic syrup at the dispensary of the village: the mother was told that the child had pneumonia and that this was the reason of his panting. In fact, when Joy came to Chaaria, she had a hemoglobin level of 3 grams (his blood was almost as water). She was so collapsed that the veins were not visible and I had troubles with inserting a jugular vein cannula. A race against time began. Her blood group was 0 positive and we did not have compatible blood in the hospital. We asked the mother to donate, but she said she was pregnant again. All that remained was to find a donor elsewhere. We asked the volunteers, but nobody was 0 positive. We were therefore forced to ask Mururu (our mentally disabled friend from Buoni Figli Center) who agreed on giving his blood provided that we allow him to go home for some days. We collected the blood, but right after connecting it to the Joy’s vein, the girl passed away. We did not arrive on time. Once again, the death was stronger.

The mother’s despair gripped our hearts, but we could not stop. Other patients were waiting for our help, so we left the mother with Judith who has tried to console us while we continued with other outpatients. It was 6:30 p.m. when I decided to take a coffee. There were no more patients tonight so maybe I could go and pray with the community. But here again the situation changes. The condition of a mother with retained placenta rapidly changes. She begins to bleed from all sides: from the gums, from the catheter... Oh no! She’s got the complications by CID. Patients with CID bleed from all over the body and we don’t have here any therapy that can stop this complication. The only hope lies with keeping the patient alive by using transfusions and vasopressors. It started again with a gasp.  We rapidly transfused three bags of blood, stayed with her, but she did not regain conscience and started to pass away. We turned  the monitor on and this increased our sense of powerlessness also visually, as we saw the heartbeat gradually decelerating and the  ECG indicators becoming more and more abnormal. We could only shrug and say to each other: ‘Also this time the patient arrived at the terminus. How unfortunate for her to be born here! If she was born in Turin, this would not happen.’ The patient had given her last breath at 9 p.m., and on the bed next to her, her baby started to cry because of hunger... Now we are here with a corpse, a newborn orphan, and the inability to contact the relatives. We only hope that they will come tomorrow. Otherwise we will also have to think about the burial. We go to grab a bite to eat, but again we are called as 3 pregnant women arrive, all with complications. I shrug and say ‘This is really the sacrifice of life.’

But how can I choose which Cesarean should be first?
Another tragic moment. It reminds me of  the book ‘Emergency’, in which Gino Strada speaks of the enormous responsibility of the physician, when he has to decide to do one intervention  and leave another, which is considered unnecessary as the patient is already in too serious condition. I visited the mothers. I have no doubt about who should be the first, because one  is a primipare with a breech presentation and a dilation of 6 cm, so it is urgent. The question is between the second and the third, because the first one is pregnant for the first time and the baby is in breech presentation. The second is a mother of  3 other children and seems to have prolonged labor from few hours because the dilation of the cervix had stopped, although the fetus was in excellent condition. I decide to do the second  cesarean for the mother with breech presentation, thinking that perhaps the last mother would finally give birth without our help, or at least could wait and be operated if she didn’t deliver before midnight. We worked well  and around midnight we finished the first two C-sections. We were very tired but also satisfied. The last mother still hadn’t given birth. She was confused and complained on severe headache. The abdomen was huge and hard and the mother  sweated. I felt a shiver of discomfort and I told the personel to accompany her to my office for an ultrasound before starting the operation. What a pain! Ultrasonography left no hope: there is no heartbeat. The fetus is dead. And the mother is going to have complications with the uterine rupture. One day someone has given me an ashtray with an inscription on it: ‘The mistakes of the doctors are buried in the soil.’ I feel bad  and try to overcome the feeling of guilt by making efforts to save the mother. We have to use forceps to pull the lifeless creature, a female of almost 4 pounds of weight. This maneuver is never nice as the mother has severe bleeding due to internal wounds: we transfused, sutured, and eventually the situation seemed under control. The mother leaves the room and  accepts the loss of her baby in a stoic way, not accusing us of anything. But that weight on my heart remained! If I changed the list of operations, maybe that child would be alive... I feel guilty and want to spend some time alone. I make my way towards the banana plantation in the dark of the night. How many stars! And the moon? It 'really beautiful and it takes your breath away as it appears on the horizon among the papaya trees. I try to pray, and as I do, the well-known question comes to my mind: ‘Why, Lord?’. I want to console myself thinking that today there were many more who left the hospital completely cured, but it's hard to detach my mind from those who passed away. I ask the Lord to help me get some sleep because in  few hours I’ll have to start my daily struggle between life and death again.

 I am reminded of the words of my confessor: "Life will win, but only after, only in Paradise." I walk towards my room hoping to get some sleep.

Br. Beppe Gaido