The Music of Pat Metheny: "He's Gone Away"

Nestled in the eclectic works of Pat Metheny (circa 1997) is a collaborative effort between him and the late Charlie Haden (Rest in Peace) entitled "Beyond the Missouri Sky (Short Stories)". The album is a mix of original compositions and covers, and one of the most beautiful covers that they put down is "He's Gone Away".

He's Gone Away probably ranks up there with great American folk classics. I can't think of this classic without my mind gravitating towards "Shenandoah", probably the next best classic. Seeing as it's quite the old song, its history is mired in some confusion. It is probable that multiple versions exist, with new lyrics added as the song traded hands or traversed generations; be that as it may, it still retains its beautiful ballad quality.

This is one of those quiet ballad pieces where Pat excels. It is also really suited to the "plain" playing style typified by Haden. I'm not trying to Christianize Metheny's version of the tune, but this version feels like it pays homage to "Amazing Grace"; at least, my ears pick an Amazing Grace motif just after the preamble. In much the same manner, the beginning of Lyle Mays solo on San Lorenzo is also capped by an Amazing Grace motif. I don't know whose decision this was (Metheny or Haden), but it makes the rendition that much more soulful.

There is so much meditative "space" in this song. It's as if the silence (and the unsaid) in the song evokes as much passion as that which is actually played. Pat's guitar is most prominent throughout the performance. When they're evenly matching it up, it seems like Pat plays at least 2 notes for every deep note churned by Haden's bass; then they eventually segue into all-Pat. The middle portion of the song actually surprised me today. I've listened to it countless times, and only today did I realize that Pat is overdubbing himself - using the same guitar - to give that impression of a guitar duet. I always assumed the accompaniment was from Charlie Haden, but there is nary a bass note to be heard.

Towards the end of the song, with Haden again on bass, the song is more sonically filled as a result of the overdubs of Metheny's guitar (I have no idea which other one he was playing in this case) that seem to carry the same weight/gravitas that a violin and horn would. It all builds up to this beautiful crescendo conveying the full emotional force of the song, and then magically ends with what you first heard as the preamble.

Some people responded negatively to the overdubbing and feel that perhaps it made the performance less pure. It's sad that we will never get to see a live version of this piece performed. Their tour for this was strictly a duet, and I feel like getting this performance down perfectly would probably have required a second guitar player in tow. Sad! In case you do find any live Metheny/Haden versions that are labelled as "He's Gone Away", they are merely mislabelled versions of Farmer's Trust.

I'm not a purist by any stretch, and I offer this as a definitive 'keeper' from the Metheny songbook. This should appeal to anyone, any age, any leaning. A ballad it may be, but it also captivates the soul like a simple lullaby. The beauty is in the music.

God Bless

The Things That Medical School Won't Teach You (4) - Sometimes, you'll end up hating your patients!

Everyone gets a little tired of their job sometimes, it's about as natural a process as it comes. If someone is enjoying their job 100% of the time, they are probably as rare a commodity as a unicorn. I believe job satisfaction probably lies somewhere between maximizing the "ups" and minimizing the "downs" of your typical work routine.

As a medical practitioner, I can attest that medical school, TV shows and even forerunners and mentors at least gave me the impression that the medical field would be hard. The hours are tedious, the life is downright difficult, and your colleagues and their respective idiosyncrasies will prove to be a challenge. But then, no one ever prepares you for how challenging your patients will actually be; I'm not talking about your patients' illnesses because between your training and your superiors you'll have that covered. I'm talking about those little unexpected moments when your patients (and their relatives) set you up for failure.

Scenario 1: No situation rings truer than the one I so optimally used to introduce this post. If you've managed to go through your internship without your patient turning on you during the ward round, you are one lucky person. Tragically, even very recently as a medical officer, I had taken an extensive patient history that lasted about half an hour in preparation for the major ward round. As soon as the consultant shows up to listen to the history, the patient starts to poke so many holes in my retelling of the history such that even I am left in doubt as to whether I clerked that very patient. However, the embarrassment doesn't stop there; if you have a consultant like mine, you will be berated in front of your colleagues, accused of 'confabulating' (aka LYING) and dismissively asked to return to take a proper history. Lord knows I am not a spiteful human being, but whenever I have been privy to such treatment, I usually give such a patient a wide berth.

Scenario 2: There are probably fewer less comfortable conditions than morbidity. Being stuck in a strange bed, having nurses (and nurses aides) interrupting your rest on a regular basis to take care of you, and last, but not least, having to endure the ward rounds. Granted though, patients will put up with this because they understand that we're trying to get them better. I remember once having a patient in the ward who looked so sickly, like he was on his way out of this world; on the cusp of kidney failure, yellowed eyes and just a generally poor disposition. First time I talked to his family, I basically HAD to reassure them that he would get better. Eventually, we basically discover that he's only suffering from an acute infection, and we're sure that he'll recover full kidney function.

Once the relatives discover he's out of the woods, their true colours come out: complaints and demands galore. Suddenly, it's as if my medical knowledge counted for nothing, and they're the ones who were in charge. Mind you, this happened during the healthcare workers' strike, and it was beyond irritating to have a basically stable patient demand more attention than the less stable sicker patients. Can't lie: I thanked God when we discharged that patient!

Scenario 3:

Speaking of demanding, few things will irk you more than the patient who shows up at the most inopportune moments. As a rule of thumb, kind of like Murphy's Law, a patient is likely to show up needing your help when it's time for you to clock out and head home. Even worse, though, is the scenario where someone shows up at the Casualty (A&E) Department at the oddest hour of the night with an easily treatable malady. If you've been unlucky enough to work the late night shift, you'd understand that you're usually working with a skeleton crew, basically the bare minimum. As if that wasn't enough, the late night clientele can sometimes resemble the idiosyncratic late night Walmart shopper: CRAZY!

I understand that you may have your issues, but it does help if you're considerate about the tasks that we juggle in those circumstances. We operate in triage mode in the Casualty Department, meaning that regardless of the time you set foot in the department, I am going to address the needs of the most severe patient first. I pre-assessed you really quickly and I'm 97% sure you have the flu, so I'm pretty sure that between your headache and chills you're not likely to expire within the next hour. Allow me to attend to this head injury patient who's so banged up that he lacks the capacity to even complain about his situation.

Scenario 4: All hospitals are definitely not created equal! Every person working in a hospital is particularly aware of their hospital's degree of competence, and perhaps more critical of the hospital than an outsider might be. Be that as it may, we are sensitive to being criticized by an outsider. It's very much the same way you might feel comfortable calling your sibling an idiot, but God protect the individual who tries to heap such disrespect on the very same sibling.

As an intern, I once had the misfortune of having the uncle of an MCA (Member of County Assembly) admitted to our hospital to undergo prostate surgery. This was tragic on so many fronts:

1. An MCA is, for the most part, an overpaid but practically useless political post that we've somehow been saddled with since 2013
2. Many of the individuals chosen as MCAs take it upon themselves to lord the position over individuals in government institutions, like hospitals.
3. The limited staff we had in the surgical ward ended up being diverted to the VIP patient's beck and call...and he wasn't even thankful in the least.

In my opinion, if you really can pay for admission at a better hospital, why would you feel the need to game the system, and then mistreat the people who are trying to help you?

Scenario 5: The dysfunctional family. There are few experiences more trying than having to deal with a sick patriarch/matriarch who's admitted in your institution, but is pretty much in the middle of a "custody battle" that gets dragged into the hospital. Sometimes it feels like their relatives are already counting the spoils even prior to the patient's demise. Never have I run into a bunch of entitled individuals who will frustrate your management of the patient, and seem ever eager to drag the hospital into a lawsuit at the slightest perception of an insult.
For your sake (and that of the hospital), make sure to DOCUMENT EVERYTHING! Your notes had better be crisp and concise and up to date. Lord knows you don't want to be sucked into the black hole that this debacle will turn into. On many an occasion, don't forget to emphasize how inadequately your institution is equipped to handle any serious emergencies that may befall the patient, and be on hand to provide them a referral to a top-notch medical facility of their choosing.

There are a myriad of other situations, but this is all I can summon up from memory at this juncture. The commonest string that binds them all seems to be "the demanding patient"; thus, it is in your best interest to always be able to pick out those patients that are likely to be the most demanding.

 Take home message: this life can be hard, but the more prepared you are to face the other awkward stresses that come your way, the more bearable your medical experience will be.

Take care and God Bless.
   

Easter 2017

The recently ended season of Easter was quite the enjoyable experience. This time, especially, since I got to spend most of those days away from work. An eclectic bunch of memories from my past cross my mind whenever I think of my past Lents/Easters. In no specific order, I think of

1. 5-day holidays from being in a Catholic high school (Holy Thursday to Easter Monday)
2. Easter of 2014, probably the last holiday period I enjoyed before the start of my internship period. (That was an exceptionally hard year)
3. There was that one Easter in China when the church I used to go to burnt down
4. Preaching on Psalm 22 one year, only to have someone else preach a totally different (contradictory) message on the same issue a year later.
5. 2007, my first year in China, when the whole season went by without me even realizing it. 
6. 2004, Messiah College: choosing an extremely hard challenge in terms of what I gave up for Lent
7. 2004, Messiah College (redux): having one of my Kenyan colleagues concoct an April Fools' Day joke so hard it rocked the Messiah community to its core. (They were none to pleased with Kenyans for a bit there)
8. Mr. Creavey (who'd occasionally give me a lift to Elizabeth Ann Seton Church) and his sons playing trumpets during Easter Sunday mass on Patti Drennan's "Sing, O sing a jubilant song."
9. Cathy Poiesz organizing the small catholic community at Messiah for a lovely night service at a massive church in Harrisburg (possibly Cathedral Parish of Saint Patrick). I remember the choir had balcony seating and sang a haunting rendition of "Remember your love"

Apparently my most vivid memories are associated with my time at school. Seems like I'm itching for the good bit of education 4 years after graduating, but that's a story for another time. Seems like all I do these days is work, and then when I get some time away from work all I want to do is de-stress. I would've loved to indulge myself in all that the season of Lent presents, but with the exception of 2016, my mind can't really be tamed enough to meditate.

I love this season, its sombre tone, the heartfelt music. It is the most appropriate season for me to contemplate "What wondrous love is this" or "God of Mercy and Compassion". Well, in any case, I can't be too hard on myself. This (religion) is more than just the seasons in which I get reminded to reinvest myself in things heavenly. It is an everyday walk that I need to apply myself to. Thank goodness I've got leave coming up in May. I need to find myself some place quiet to just put everything in perspective, and time away from the disillusionment with medicine I've had of late.

I may have barely made anything of myself this season, but I'm hoping to make something of myself starting this week. Feeling doubly blessed after that 3-day weekend (ended up being pulled into work on Good Friday), and this week my boss is at a conference overseas so I get to exercise more control over patient management. Definitely looking forward to shorter ward rounds and more time to myself. This is what dreams are made of.

God Bless.

The Things That Medical School Won't Teach You (3) - The Giggles

I'd like to start this particular post with a very specific memory: it was circa 1997 and I was in my first year of high school. We were out on the sports field taking part in a class rugby game, and a member of the opposing team tackled me by grabbing me around the waist and swinging me backwards. It was by no means a bad or dangerous tackle (I've taken much worse hits), but unfortunately, I fell awkwardly on my right wrist and experienced excruciating pain.

I dragged myself onto the sidelines and sat out the rest of the game. Despite licking my wounds, the pain had not subsided by the game's end. From there it was off to the high school clinic, then back home, and finally off to the hospital (the former Masaba Hospital, if my memory serves me right). Just as I'd feared, I had fractured my wrist. Was probably a stress fracture because I can recall that, not too far back, one of the poles from a tent had struck that same wrist while we had dismantled a tent at school. At least it wasn't bad enough that it would require an implant; but it did require me to endure a POP cast for a period of 3 months. The worst part of this whole affair was the indignity that I was exposed to at the hospital. I remember the two female nurses taunting me for having the gall to play rugby, me being so spindly and all. Even worse, each of them kept squeezing the wrist to elicit the tenderness. Worst of all was when the doctor showed up and joined in the taunting. I remember that he was a massive fellow, but despite his stature, he claimed that he wouldn't be caught dead trying to play rugby. What on earth made me think I could indulge in the sport? Three taunting medical professionals, a fistful of pain and a dented ego made for one unbearably bad night.

Fast forward to my days as a medical professional, and the experience has been softened in hindsight. This is neither an admission that I have taken up a heavy-handed approach to patient care nor find it acceptable for other practitioners to disregard their patients; it is, rather, an admission that sometimes one person's malady can be another's (comedic) pot of gold.

I've said it once, and I'll say it again: a lot of your friends/family/colleagues who work in the medical field are damaged goods. You can attribute that to years and years of rigorous training, being part of a profession where your superiors have the bedside manner of an army drill sergeant, and impossible situations that everyday practice will throw your way. Like any good professional, we get used to the life....and then we begin to find humour in even the most macabre of situations.

Thus my disclaimer would be, "we're laughing with you, we're not laughing at you!"

Medical personnel's brains are wired a bit different from the rest of the population. In much the same way that firemen (and other first responders) are geared to run towards situations of danger, we actively seek out those situations that we've been trained to handle. A lot of times we're even fascinated by all that strangeness. A lawyer friend of mine was talking about his experiences with helping Key populations (aka people most at risk of contracting HIV - Gay men and IV Drug users). He commented that some gay people feel stigmatized when they show up with anal infections because the nurses start calling each other, "Kujeni muone maajabu!" (come see these wonders!)
Two things are at work here:

1. Bad PR because sometimes we focus more on the ailment than the person.
2. Utter fascination at getting to see things that previously we've only ever encountered in our books.

Size, complexity, consistency...really a treasure trove for the senses. If you happen to be at a teaching hospital, you and your "condition" will be celebs for the day.

Thanks to shows like House MD, which exaggerate bits of the medical experience, you can understand that our minds are trained to probe situations, sometimes to extreme lengths. So, for example, when a patient walks into the Emergency Room with a fractured penis, normal minds might stop at merely thinking "Ouch! That must really hurt!" But not your medical friend. His/her mind works a little like this

1.  "Ouch! That must really hurt!" Let me take care of the patient's discomfort first.
2. Let me document the patient's account of what happened (Will it be truthful, though? Patients lie, right?)
3. The likely cause of injury occurred when aforementioned part probably encountered such-and-such in a traumatic clash 
4. Chances are that the woman that caused this "accident" is not likely to be the man's wife, because statistics show that ...
5. My colleagues have heard about this case and have come trooping down to see for themselves what's up. Everybody's going to be giving their "2 cents" about this case.
6. How on earth am I gonna keep a straight face when I have to present this case to my consultant?

If it's a good day, I'd be putting on my stoic face and would succeed in keeping a straight face throughout the whole encounter. If it's a bad day, anything can set you off laughing. Sometimes the patient's voice or demeanor could be a trigger; sometimes the consultant will callously utter such a brash statement that leaves you beside yourself with laughter. At other times, it's just the nature of the situation. I remember getting the giggles when my colleague was presenting a patient history in the ward: this middle aged lady had been walking home in the dark and had, in a stroke of bad luck,  randomly fallen into a pit latrine that was being dug. Don't know what it was about the case, but it left me in stitches. However, God forbid that you should draw attention to yourself by randomly bursting into laughter while you're in a team of 15 conducting a ward round. You suppress that laughter like a boss and ride out the period of mirth.

Sometimes I feel guilty, like I'm headed to hell for finding some of these things funny; but, it is a coping mechanism. I think you'd rather prefer that I find your situation funny and can engage with it 100%, as opposed to fearing it and being overwhelmed by it as most normal folk would. As the disclaimer states, "I'm laughing with you, not at you!" Don't condemn us for our laughter/amusement, but appreciate that it is a joyous part of our day to find amusement in a day's work.

God Bless.    

Logan Review (spoiler free)

This was an unusual entry into the X-men universe. This finally makes this series a trilogy, which I have thoroughly enjoyed. People give the first entry in the series more grief than it deserves. As I remember it, it had the dubious honour of having a critic review an unfinished leaked copy of the movie, and then it was all downhill from there. Anyway, that's a tangent for another day.

This trilogy has been quite unique; in some ways as unique as the Captain America trilogy. It basically employed the same format, starting with one director, then shifting to a second director(s) who helmed the second and third movies. Despite this being the same director, the 2nd and 3rd movie are stylistically very different. In Captain America, it was because the Russo brothers had morphed "Civil War" into Avengers 2.5; in this case, James Mangold was aiming for a movie straddling multiple genres (Dystopian future/Western/Road Movie).

As you know from all the media hype about this movie, mutantkind has for the most part disappeared. What remains are a few vestiges; what we see of those vestiges are  Wolverine, Caliban and a 90-something Professor X. Logan's invulnerability isn't what it used to be, and the Professor is more liability than saviour at this point in his life, with major repercussions for any humans in his vicinity. Things can only get worse when Laura aka X-23 is introduced into their lives.

It was hard to watch these 2 X-men brought down to this level. Wolverine has always been the Lone Wolf who is sometimes called upon to be the ever reluctant hero. Despite all the bad that humankind has forced upon him, at least he always had invulnerability to rely on, and the choice to hit the road when he so desired. The pillar that was Prof. X is now also a distant memory; in a change of roles, Logan is now tasked with eking out a living to cater for the Prof. and his many special needs. The antagonism between the two of them gives the movie a lot of heart, sometimes intensely engrossing, and at other times hilarious when the Prof. exhibits petulant outbursts.

However, ever the heroes that they are, Laura's needs are a call to action, and even a chance to earn some redemption.

All things considered, this was a great movie, beautifully shot and well paced. I remember the joy of seeing Wolverine break out into a berserker rage in "X-men: Apocalypse", and this movie managed to one-up even that bit of gruesomeness! The R-rating on this movie is definitely used to good effect, whether it's Wolverine or X-23 doing the eviscerating. Though it's set in the near future, the movie is mostly grounded in the present, with the reavers and minor elements reflecting anything of futuristic proportions.

I have to come out and state that this movie is really its own story. Coming into it, there had been talk about them adopting the "Old Man Logan" storyline (definitely a great read if you come across it), but apart from the "Open Road" element of that comic, there isn't much of similarity worth noting.

This is (somewhat) a Marvel movie, so the complaint may arise that the bad guys are not really captivating. I don't think this will be the movie to change your mind about the dearth of characterization for villains in the Marvel stable. On the plus side, though, reflecting on Logan's tribulations will make you understand that the baddies are just an unfortunate hurdle. It could've been anything really. Anything that pushes against him so hard when he's at his most vulnerable seems downright insurmountable.

Hugh Jackman, Patrick Stewart and Dafne Keen are the heart and soul of this movie. What surprised me most was how many times Prof. X dropped the F-Bomb in this outing; all his typical decorum is thrown out the window, and he must've picked up some Wolverine-isms after being cooped up with him. For the most part, Hugh Jackman is reduced to brooding, but his emotions cover the whole range of the spectrum...with the rare smile chipped in. Even though Logan is even more reluctant to be a hero in this outing (Prof. X seems to be the one more concerned with looking out for X-23), Jackman imbues even the neglect with a true humanity. And Dafne Keen will not be afflicted with the "bad child actor who ruins a good movie" title. She has little dialogue for most of the movie, but her facial expressions and physicality convince you that she's more than a little bundle of joy. I look forward to seeing her take her rightful place in the X-men franchise.

I feel like this movie has emotionally drained me; it will take the love you have for these characters and beat you down with it. But, if ever there was a way for the roles of Prof. X and Wolverine to be retired (by their respective actors), this was it. Five star performance that's definitely worth watching. I still feel like there's more left of this story to tell, but maybe the X-men can give us that in a future installment that involves X-23 and Nathaniel Essex (aka Mr. Sinister), who was teased at the end of X-men: Apocalypse, but sadly didn't make it into this movie. Maybe some other day.

God Bless

Green Thumb

Seems great to finally have some time to just sit back and chill. The whole rigmarole stemming from this whole medical health workers strike is still dominating my whole work life. Can't change anything about that, but I can find something totally different to do on my downtime. 

I've been fascinated with plants for quite some time, but I don't think I've ever intentionally grown something; so I decided to give it a try. For my first bit, it was actually just a small transplant job. The sitting room plants had gotten worse for the wear, so I decided to switch them out for some Monstera deliciosa which is what my Dad usually had growing in the sitting room while I was growing up.  

So this is what the plant looked like after I transferred it. Most of the leaves were quite old and dusty, but these were the best Monstera specimens I could find down at Dagoretti. Shortly after some watering, the middle stalk began to unfurl a new life









And voila! dead centre, we now have the new leaf (proof that I didn't end up killing the plant).

I've also taking to spritzing the leaves from time to time to give them a nice sheen, and maybe keep them from looking so dessicated.

My second foray is more of a long term project. After spotting the above magnificent bloom from the Purple Orchid tree (Bauhinia purpurea) at the PCEA Kikuyu Hospital, I figured that I would take a stab at growing Bauhinia from scratch. From my time at Wenzhou, I'd encountered it as a common avenue tree. Even retracing my steps back to my primary school, I too found it growing vibrantly in the school compound. Thus, I waited for the blooms to give way to precious pods, and then had to wait for them to dry and time things just right before they scattered their seeds to the ground.

And this is the result. Four out of the seven seeds I planted sprouted, bearing the typical bilobed leaves.












I don't know where I'm going to put these plants in the long term, but I feel the urge to continue with the experimentation. At least, I know I'm going to use the next plants I grow for landscaping at our upcoming house. Have an eye on some Agapanthus seeds with a view towards growing up to 100 Agapanthus seedlings. Also want to do some experimentation with some local bamboo, but I want to make sure I can find the "clumping" variety, as opposed to the the friendship-destroying "running" variety.

Other than that, life is just as it should be right now, I guess. Will keep you posted.

God Bless.

Feb 2017

Dearest me, Smonday is already upon me!

I've gotta say, since the doctors' strike started, last week had to have been one of the worst weeks I've ever faced. For starters, I pretty much put in 60 hours worth of work during the week (...and none of that comes with any overtime). I think the earliest I actually got home might have been 8.20 pm, which coincidentally happened on Friday, the day most people are like to make their exits before 5.00 pm.

I've been so tired lately that I'm starting to embrace the Kenyan culture of not reading. By the time I'm done with my patients and all such related activity, I just want to get home and de-stress. My mind can't be bothered with fanciful thoughts of reading or even trying to keep up with new advances in the medical field...I'd rather just soak in some sensory deprivation and chill.

Last week, I even had the dubious distinction of being tossed under the bus by my consultant for some shenanigans that went down at the hospital. Of course I can't divulge any of the details, but it has got to be one of the most underhanded things that has happened to me while I've worked as a doctor. People don't understand how much medico-legal detail is involved in dealing with patients, and I think a lot more people would steer clear of the medical profession if the actually found out. We may have come along way scientifically, but there's still a lot that we don't know about medical practice. Sometimes it can actually feel more like practising an Art than a Science.

The patients and their relatives will see things differently though. I think medicine is one of the few careers where people feel like they can question your acumen without having even a basic grasp of the concepts involved. Even a primary school teacher is unlikely to get called out on the pedagogy that they employ to teach their students; but a doctor is fair game to everyone. We have moved away from Paternalistic Medicine to a more shared patient-doctor relationship, which I feel is more ideal; if you can understand the disease process and its respective treatment, then I believe the patient can participate more actively in the treatment. Don't get me wrong, if the situation calls for it and either their patient or caregiver is unable to fathom what needs to be done, it is my duty to go "over their heads" and be paternalistic, for the patient's sake.

There is, however, a third patient-doctor relationship that has developed lately that emphasizes Patient Autonomy. If the patient has the necessary education or understanding of their condition, this may be bearable; however, a lot of times you encounter this from a patient who merely wants to be in-charge without a semblance of a clue as to what they actually require. These are the patients (and relatives) that are likely to haul you court for some good old litigation. Thank God I have an extra card up my sleeve for such patients: I can just "Discharge (them) Against Medical Advice" (DAMA), and let them end up being someone else's problem.

I think I'm just a bit disillusioned by the medical field these days. Job satisfaction is at an all-time low, and I don't have the energy to keep myself afloat. I'm beginning to detest some of my patients and the systematic failure at my workplace is just draining. I hate this government for doing nothing to avert or even alleviate the effects of this strike; I'm annoyed at the general public for not having the guts to even try to keep this government accountable despite the egregious missteps that they have committed.

Lord knows I just need a break. Maybe a change in this 10-month routine will do me some good. Something's got to give.

Memories: A Bad Day at The Office

It's already been quite the tumultous start to 2017 down here in Kenya. The doctors' strike drags on for yet another week, and now, in much the same manner, university lecturers are also on strike due to  talk of yet another unfulfilled Collective Bargaining Agreement (CBA) from 2013. The writing on the wall is obvious: politicians can't be trusted to fulfil any pledges they make in the wake of an election year. Lord knows what other messes they'll be orchestrating in the remaining 7 months of election campaigning.

I feel like the doctors' strike would have ended earlier if we only had a limited number of people taking part in the negotiations, i.e. the president, his ministers of Health and Labour and the doctors' union. In all honesty, other groups like the SRC (Salary & Remuneration Commission) and the Council of Governors have nothing of importance to add to this issue. Devoid of such organization, we are being treated to trivialities that border on the obscene. Social media was ablaze with #IamNotSewage because the Labour Court judge (Wasilwa) hearing the case openly referred to the collective striking medical body as stinking of sewage. (Apparently judges must be skipping Decorum 101 these days). As if that wasn't enough, just recently a 'nominated' Member of Parliament tried to whittle the strike into an issue of tribalism; this earned the ire of the medical fraternity, and now we have #TribelessDoctor trending.

All the wrong people are doing the talking, which is driving the doctors irate. Has any of these sanctimonious individuals ever set foot inside a public hospital, apart from occasions for photo-ops? Can they really sympathize with a general public with whom they have nothing in common? Do they even understand the situations that medical staff have to contend with, especially those that go above and beyond the call of duty? It is probably for these reasons (and many others) that another topic has been trending - #MyBadDoctorExperience. I hear that initially the topic was created to highlight patients' bad experiences at the hands of incompetent doctors; but as later stories will attest, the doctors are currently using it to highlight the traumatic experiences they've experienced at the hands of the healthcare system. It is only a glimpse of what doctors experience, but it is enlightening nonetheless; and I guess it's time to add my experience to the fray.

*Friendly Advisory: beyond this point, some of this gets a little graphic! 

It was about mid-December 2014, and I was knee deep into the 2nd rotation of my internship (Obstetrics & Gynaecology). I believe that at that point, of the 3 interns in the department (Fiona, Lucy and myself), I was 'stationed' in the Labour Ward. I use the word stationed lightly because throughout the course of the day, we all converged at the Labour ward to handle whatever business came up. Considering how overwhelming the work could be for 3 interns, it was very typical for the 2 interns who weren't on duty to end up leaving the hospital after 11.00 pm. Only one of us was ever on night-duty, but we figured that it would be better for us to let the intern-on-duty disappear to freshen up at home; that intern would then report back to the hospital around 7.00 pm, but we'd basically have the intern relax in the call room while we cleared every issue in the wards. Some time before 11pm, we'd join our colleague in the call-room and just debrief each other before we set off. Turns out it was a great way to de-stress and keep ourselves sane.

On this particular day, around 4.00 pm, a patient (about 38 years old) showed up to the Labour Ward; (for my convenience, I'll refer to her as "Edna") by all regards, she was a stable patient, obviously in the 3rd trimester of her pregnancy, and had been admitted because she noted reduced fetal movements in the course of that day. I take down her history, and I find out that this is her 5th pregnancy; all prior pregnancies had ended in normal deliveries, but they had yielded only girls! So here she was hoping that this particular pregnancy yielded a boy so that she could call it quits procreation-wise. By all accounts everything's normal, until I dig out the fetoscope to listen for the fetal heartbeat: not a sound, no matter what position I checked for it. Undeterred, figuring that the problem was my technique, I called in one of the senior nurses to assess for the fetal heartbeat. She too couldn't find the fetal heart.

Unfortunately for us, the fetal doppler probe was not available, so the only way we could confirm the presence of a fetal heart was to perform an obstetric ultrasound. As a double misfortune, the sonographers were also not available at the hospital after 4.00 pm, so we basically had to arrange for her to be transported by ambulance to a reputable external radiology centre to have an obstetric ultrasound done. At this point, I'm really hoping that the ultrasound will prove that there's a fetal heartbeat so that I can schedule her for an emergency caesarean section (C/S) as soon as possible; worst case scenario is that she's had an intrauterine fetal demise (IUFD), and in that case I would not need to saddle her with an unnecessary surgical scar.

We arrange for the ultrasound, but end up having to wait for the ambulance to return from another emergency. Theater staff have been informed about a possible C/S being performed, but we've currently hit the magical hour: 5 - 6 pm...shift change-over time. Basically, nothing gets done during that period, and we end up having to pool our surgical cases until the anaesthetist-on-duty shows up. I keep doing the rounds on the other patients, but also take the time to read the nurses' cardex for Edna's case. During that interview, Edna had reported that she had experienced some vaginal bleeding prior to coming to the hospital (a detail she omitted when I queried her about any danger signs that she may have experienced). Around 5.30 pm, the ambulance becomes available and I'm looking forward to having some clarification on the matter. I've already discussed the option of a C/S with Edna and her husband, and they've suggested that a Bilateral Tubal Ligation (BTL) aka "tying her tubes" be performed; I've even joined up as a member of "Team Edna", and I'm really hoping that the baby is a boy and in optimum condition. And then, it happens!

A sizable amount of blood gushes from her vagina, soaking the sheets! I see the colour disappear from her face, and forget all about the ultrasound; by this point it's very clear that I have to get her into theater immediately. The nurses attempt to stabilize the patient, while we hurriedly prepare blood, get consent, alert the theater, the anaesthetist and my immediate superior (a Medical Officer). The Medical Officer gives me the go-ahead to perform the case and tells me he'll be coming in eventually just in case I might need any help. I counsel Edna's husband again about the emergency situation, and let him know it's the only option that we have left.

Under normal circumstances, I would just perform the C/S myself, but Fiona happens to be around at that moment so she makes the decision to step into theater with me for the case, which affords me several advantages; Fiona and Lucy basically taught me how to perform C/Ss. In addition Fiona is left-handed; basic rule of surgery is that the primary surgeon stands on the side of the patient which allows them the most ease to operate - so, a right-handed surgeon would stand to the right of a patient and vice versa for a left-handed surgeon. Working with Fiona thus felt like having two primary surgeons on the table at the same time, and the responsibility could be shifted without us having to reposition ourselves at the operating table.

Everything is ready for us very quickly. We jump into theater, and in a break from the norm, we are scrubbed in and gowned before the patient has even been wheeled into the theater. Soon as she's placed on the table and anaesthetized we get to work. We sacrifice most of the presurgical skin disinfection for the sake of speed, and start hurriedly. I make a wide incision and slice through skin, fat, fascia and muscle, making my way to the uterus; during this time, she barely bleeds. Once I'm through the peritoneum, I come across a pale white uterus! Gone is the pink colour of the vitalized uterine tissue that I encounter during routine surgery; the inside of her is just as pale as her extremeties.

In one swift move, I'm inside the uterus and we visualize the baby's placenta detached from the uterine wall and accompanied by a massive blood clot...Placental Abruption! Quite the atypical case because the bleeding was concealed and Edna did not experience the usual cluster of symptoms. There was nothing that could be done for this BABY BOY. With one life gone, we concentrate on Edna. With the uterus taken care of, it's time to perform the BTL. All things considered, and with the haste needed post-operatively for the patient (including the most important issue of the blood transfusion), I opt not to perform the BTL, and close her up layer by layer. Soon as we're done, the anaesthetist lets the blood run, trying to reperfuse the patient as quickly as the blood can flow.

Our part as surgeons is done, and we step away from the table to assess the patient whose life entirely relies on the anaesthetist's manipulation. Never would I have thought that the patient I met a mere 3 hours earlier would have taken this eventual turn. As if by design, her breathing ceases, and shortly thereafter her heart stops. We're ready for it when it happens and we jump in to resuscitate her.  We aren't able to achieve anything meaningful, and I lament that her husband isn't around to say any sort of goodbye. A 100% fatality rate in an Obstetric procedure.

We clean her body and place her accordingly. We then silently walk out of the operating room into the adjacent corridor, each one of us pondering the experience. We have theater notes to write, and still have more cases to perform; but more than that, we have to inform the father of four of his wife and child's demise. He's not in the reception area when we come out, but undoubtedly, he'll be arriving soon. I try to organize my thoughts so that I can deliver the news in an informative yet sympathetic manner, but I can't lift my gaze from my hands as they lie idle in my lap. In the end, I'm glad when the anaesthetist picks himself up and ends up relaying the information to the bereaved. I was within earshot of the conversation, but I don't remember hearing any wailing or sobbing from Edna's husband. He calmly stepped out of the reception area, and, as with countless cases, I know nothing more of what happened to him or his family.

With every loss you encounter, you're supposed to be able to detach yourself from the situation enough that you can function adequately come what may. After all, the work never ends and though one person's life has been brought to a standstill, the rest of the world need to move on. Even if it may not be required of you, every death is a chance for you to reflect on what you might have missed, what you might have done wrong and what more you could have done; and after that, the harsh lessons inform your practice in regard to subsequent patients.

Every doctor (/medical practitioner) you've ever met probably has a couple of these jarring experiences that they could quote for you if you gave them the chance. We carry many of these scars with us, but rather than break us, these scars make us resolute. We spend a lifetime poring over our mistakes, so that we don't repeat them to your detriment or that of your loved ones. Us asking for you (through the government) to avail us the tools to stave off death for another day is something that we are duty-bound to do. We would love the chance for every one of our patients to have therapeutic options available to them at a rate that they can adequately afford; that they would stand the same rate of survival regardless of their economic endowment.

As with all things in this life, we do our part, but we recognize that in the end God provides the true healing. In the end, He's all we really have.

God Bless.

The Music of Pat Metheny: September 15th

The music of  the Pat Metheny Group (PMG) takes my mind back a few years, to a very specific place. The year was 2007 circa April, and the exact venue was the Wenzhou University Library's computer lab. It was shortly after I had moved from Kenya to China, and was slowly but surely getting my bearings in a new land. The computer lab was where I spent most of my time because, conveniently, it had free internet. Thanks to China's love/hate relationship with foreign companies (Google et al.), I was forced to become accustomed to using "Baidu" as my search engine of choice. Great thing about Baidu was that it had an MP3 tab, so I could search for music that crossed my fancy, and a lot of times even listen to it.

The music that resonates most with that time is that of the Pat Metheny Group, specifically "The White Album". I don't know if it's because those were the first songs I played online or perhaps it might be because of that broad Midwestern quality to the music that endears it to someone on a long travel. Whatever the reason, these 2 bits of memories are etched side by side.

The song September 15th is from a whole other different album: As Falls Wichita So Falls Wichita Falls (a mouthful indeed). The album is unique in that it's basically a collaboration between the core of the PMG - Pat Metheny & Lyle Mays. (with a sprinkling of Nana Vasconcelos for good measure).

September 15th is a pure guitar and piano collaboration, and I like to think of it as a song consisting of 3 different songs. That's just how it was written! The first 2 minute portion consists of a preamble contributed by Lyle; with his synth work laying a beautiful orchestral background, Pat is afforded the chance to colour the rhythm with a sparse picking of his guitar strings. There is a tight interplay between their work, but Metheny is clearly allowed to be the front man for this section. Lyle's synths provide a sad solemn undertone, and Pat's guitar adds layers of emotion above it. Despite this song being dedicated to a fallen comrade (Bill Evans), this is not a dirge; it still comes across as a romantic ballad, particularly in its preamble.

The second part, a slight smidgen above 2 minutes, is a waltz piece contributed by Pat. If you've heard his live performance you'd no doubt recognize this part. His solo medley (for the longest time) has consisted of Phase Dance - Minuano - September 15th (Waltz) - Etc. As he tells the story, he actually wrote it specifically for another group, but they didn't end up using it; so he re-purposed it and ended up using it here. Lyle is on the piano in this portion, but does use the synths to lay down a haunting intro to the piece. This is equal parts Metheny and Mays, matching each other note for note, with the strings and keys melded into a unified whole. This is my favourite bit from the song, immediately likeable and invigorating.

The third and final part is a stroke of luck, just pure serendipity. As Pat tells the story, the written portion of the music was over, so this remaining section was open ended and built on the fly. I feel like this segment hands the reins over to Lyle, using Pat's guitar to chime in occasionally to add accents. When they played this live (during the Imaginary Day tour), this third segment actually ended up being a Lyle solo. While the opening seems heavy laden, and the middle a tad whimsical, this latter portion personally resonates with a sort of cautious hope. (I didn't write the music, but it probably inspires me in this specific way...a good piece of music does that!)

I am definitely not gifted with the musical acumen to describe this song; but then again, maybe something this complex doesn't have to be broken down further for it to be enjoyed. Basically, this is one of my Metheny/Mays staples; it never gets old and is sure to please each time. If you're looking for some inspiration or just need to appreciate some impressive artistry at work, this is the track for you.

God Bless

2017

Happy New Year!

As my blog attests, I’ve begun this year with a touch of procrastination 😃. I can sadly attest that despite being employed this year, unlike last year, the workload is quite intense. The doctors’ strike which I thought would be resolved in 3 weeks time is still going strong, and that means that a vast number of patients are headed towards the less price friendly mission hospitals (of which PCEA Kikuyu Hospital – my work station – is a veritable member). Add to that the fact that the Medical Officer interns (paid by the government, but posted to PCEA Kikuyu) have shown solidarity with the medical union and walked out on us, let’s just say I’m busier than I had ever expected to be.

All things considered, I’m very hopeful for this year. I’m going to try and get on the old education horse, and see if I can get into a post-graduate program (in China, perhaps) so I can finally start training as a surgeon. Elections will be coming in August, which presents me with the first chance ever to vote in a Kenyan election. Over the 3 past election periods, during which I was eligible to vote, I’d always been out of the country so I missed my chances to bring about any change. I’m hoping that they don’t postpone the election dates because this time I have a vested interest in tossing out the incumbents; frustration voting all the way.

I’m also hoping to pick up a useful hobby or two. For some time now I have developed an affinity for plants – especially beautiful trees – so now is as good a time as any to develop a ”green thumb”. I hope to start off with some Bauhinia purpurea whose seeds I picked from the trees growing at the hospital grounds. Maybe after that I can move on to Cape Chestnut. With this being the year that the family house finally gets built in Ngong, I would love to add some nice flourishes to the land that will make it more homely.

Lastly, I am hoping to get to write more and read more. I think I’ve hit that dreaded plateau where I can’t seem to pick up a book and get some reading done. I get back so tired from work most of the time, and when I’m home I just want to de-stress by doing absolutely nothing – my own little kind of sensory deprivation. This year things change: I’ve got Wangari Maathai’s "Unbowed" to start with, and I’m sure I’ll pick up something else along the way. As for writing, apart from more blog entries, maybe it’s time for a new independent project; or perhaps I could just flesh out my old papers. I wish I could bootstrap the hell out of "the Hyacinth Economy", but it seems like I have to address my medical career first (wish I had come up with the idea while I was in college, much younger, and with a lot more time on my hands). Time will tell what happens.

Well, here’s to an eventful 2017.

God Bless

My Thoughts on The Doctors' Strike

So, the long awaited strike finally happened! I don't call it long awaited because I've been looking forward to it; rather, I'm just bringing your attention to the fact that we in the medical field always knew it was slated to happen. I remember thinking that it would be the reason that I would end up serving a lengthy internship. (In the end, I did end up serving a particularly lengthy punitive sentence during my internship, but that's another story for another day)

I can't figure out for the life of me how the nurses ended up involved in this bit of mass action as well, but it certainly will make the strike sting that much more. As I've mentioned previously, the nurses are the true backbone of the hospital, and you couldn't hope to run a decent hospital without their help.

I've talked to a few people about the issue, and they believed that the strike would only last a short period - a few days - because of the calamity that's likely to befall the common wananchi. However, I'm sticking to my guns and reasserting that this strike will definitely last for the stipulated 3 week period...if not longer. I have experience on my side to prove this.

Back in 2014 when I started my internship, I had gone 2 months without receiving a salary. This deserves a little context: here in Kenya, medical interns typically begin to receive their salary after having worked for the first 3 months. So, basically, you skate by on pennies until you get the bountiful "boom" payment. Having joined the service 2 months after my colleagues had already started, I was assured that I wouldn't be subjected to waiting for a "boom" payment, and would instead receive my 1st salary as expected. That didn't happen! I ended up going 2 months without getting a salary, and my friends had slogged out 4 hard months without any sort of payment. As can be expected, we ended up going on strike that lasted about one month just so we could get our dues.

With that little experience, I'm pretty sure that the government's response will follow a tried-and-tested formula.

1. As usual, with all strikes we've had in Kenya, it will be declared an ILLEGAL strike. 
2. Label the striking staff as senseless heartless human beings who place profit over the lives of their patients in the hospitals. Aren't these the same individuals meant to adhere to the Hippocratic Oath - doing no harm?
3. Subvert the whole initial negotiation process
4. When forced to eventually enter negotiations, they will drag their feet, stall the process further and insist that their isn't enough time to institute the measures required to bring the strike to an end.
5. Remind everyone that Kenya is a poor country with an extremely huge public wage bill, and as such assert that the money required is not available.
6. Make excuses hoping that public opinion turns against the striking staff, or at least the consciences or better judgment cause them to end the strike.
7. Make some sort of concession, and agree to fulfil the rest of the agreement at a later date; which will of course set the stage for industrial action at a later date
8. Repeat ad infinitum

As things stand, we've successfully toed the line from steps 1 - 3; step 4 is already underway. So let's recap. It really is strange how the government runs roughshod over court decisions that do not favour its position; it's even stranger that they somehow get the same courts to later on pass counter-intuitive measures that simultaneously contradict the court's standing, and victimize the aggrieved plaintiff (in this case the medical staff). The Collective Bargaining Agreement did not just appear out of thin air; a previous administration and the doctors' union are signatories of that agreement. It is an act of bad faith to suddenly plead amnesia and refuse to honour the arrangements set forth in the document.

It is even cheaper to try to turn public opinion against the doctors. Yes, we did agree to abide by the Hippocratic Oath, and we do care for the lives of our patients. There is more than just remuneration at the heart of our grievances. It is one thing to know how to save a life; it's a whole other thing to have the tools at hand to save that aforementioned life. I've come to terms with the fact that I will see a lot of people die; it's the nature of the business. However, when those deaths are preventable, it hurts; if you run across enough of those scenarios and merely feel helpless, then you become ambivalent. The deaths that are occurring every day this strike is maintained are indeed tragic; however, they pale in comparison to the total number of preventable deaths that we are exposed to on a regular basis.

I have no idea why the government can't seem to undertake any sort of negotiations without playing hardball. Keep in mind that they delayed the implementation of the CBA, and avoided arbitration that would have forestalled this strike. When I had gone on strike as an intern, I remember our Medical Superintendent making promises week after week that we would be paid. He was of course adamant in his position, and expected us to work come what may. During the strike, we made trips to Afya House, where we were given the same empty promises by the Director of Medical Services (DMS); of course, later on they would pass the buck and tell us that our money wasn't available because Parliament had not passed the supplementary budget that would allow Treasury to release our money.

The crux of the issue is that the people in power just do not care enough for the typical mwananchi. For goodness sake, my president and his deputy continue to frivolously campaign as the country sits on the cusp of a major crisis. It is ironic that the people who are strutting about so pompously and waxing lyrical are the most well paid of individuals (pay that is many times not commensurate to their level of education or work output). How can these people have the gall to remind us that we medical staff provide an essential service, yet undercut us by providing minimal funding for that very same essential service? 

All these talks are set against the backdrop of an administration which is so plagued with corruption that it seems to lack any semblance of credibility. In this regard, I feel like public sympathy will side with the doctors, if they play their cards right (which definitely doesn't include a boneheaded move like sabotaging Private or Mission Hospitals' ability to provide services to the sick).

I should remind you that I work at a Mission Hospital, so I am in fact still offering medical services to my countrymen. I would love to see this strike come to an end as quickly and amicably as possible. What Kenya really needed was a harmonization of all the salaries in the country. It is senseless for the political class to be making as much money as they do, considering that they do the least work to propel this country forward. However, the Salary & Remuneration Commission (SRC), which was meant to take up this role, is powerless to enforce any sort of meaningful change. So we're stuck between a rock and a hard place. Only time will tell how this bit of drama unfolds.

Oh well, strike week 2 rolls on. I hope things turn out better and sober minds prevail. If not, anticipate a progression similar to the 8 steps I laid out.

God Bless

The Things That Medical School Won't Teach You (2) - Don't mess with the nurses!

This has basically been one very crazy week; a crazy year for that matter: first we had Brexit, and now...well I don't even know what to call that little stunner that our American compadres just pulled on us (Amexit hardly seems adequate). Oh well, if frustration voting is the current wave, I'm hoping it persists until next year so we can get some real change down here in Kenya.

But I digress; as an addition to my medical school series, on this occasion I'm highlighting a topic that's on a different end of the spectrum than my usual fare. So without further ado, another rule of thumb for the wise clinician: Don't mess with the nurses!

Whenever I've highlighted my experiences, they typically focus on the doctors; that's mostly due to convenience because trying to encompass everyone and the skill sets involved would make for much longer posts. If you happen to spend anytime near any sort of health facility, however, you would quickly come to the realization that most of your time is spent in the company of nurses, the true unsung heroes of the medical world.

From a lot of my posts, and a myriad of others floating freely online, you can understand that the life of a medical doctor is no mere cake walk. However, nursing is on an even grander scale of difficult. I would estimate that as much as 70 - 75% of all the strict medical work taking place at a hospital is carried out by the nurses. Nurses are so essential that - as I've experienced in Kenya - to get any sort of decent medical strike going, you need the nurses' muscle to weigh in on the matter. You can keep a hospital running with a few Consultant doctors and a full team of nurses, but you can barely even hope to run a mere Outpatient department with all the doctors in the world devoid of a single nurse on board.

As I've mentioned before,

"Contrary to common thinking, it is a team effort that helps save lives."

Therefore, the message herein is twofold: 1. Respect the nurses; 2. Fear what comes with crossing a nurse.

During my stint at the Memorial Hospital (circa 2006), I remember one of my colleagues highlighting the importance of nurses; surgical nurses, to be precise. Surgery is hands-on, and the consultant will only 'hold your hand' for so long. You are expected to gain competency in surgical procedures through the long respected traditional method: "See one, do one, teach one."
However, even in cases where neither your Consultant nor medical officer are around, you are never really alone! The surgical nurses are veterans and have participated in so many surgeries as assistants in the Consultants' presence that they could actually perform some of the procedures themselves. However, since they are not legally licensed to carry out the procedures, they can at least guide you.

Now, initially, interns may be unaware of this vast resource at their disposal. Particularly egotistical interns might even rub the nurses the wrong way and choose to treat them like second class citizens. Now, nurses are a patient lot, and will usually let things slide; however, should the aforementioned intern find himself stuck during a surgical procedure in which he is the primary surgeon, then the nurses will just be content to let him sweat things out on his own. Worse still, at the end of it all, the intern would have to call his superior in to assist him, which many times could end up with the intern being berated. To me the point was clear: Respect the nurses!

I would daresay that the greater part of the refinement of my surgical technique occurred under a nurse's watchful eye. Mr. Nyabaro taught me subcuticular suturing, Mr. Mutaroki schooled me on the surgical tools; Sr. Asiago, Sr. Lydia, Sr. Dinah, Sr. Judy and Sr. Alice augmented my effort in any procedure that I performed. When the tides had turned and I had become adept at performing a myriad of the tasks, then they all helped me teach these skills to the next bunch of interns and students.

Of note is one memory that is as clear in my mind as the first day it occurred. I remember on my very first night on call in Obstetrics/Gynaecology, there was a lady who had an obstructed labour so she required a caesarean section. However, I froze up on the table, and I couldn't extract the baby; the scrub nurse was the one who successfully pulled the baby out. In the same procedure, I had yet another stroke of bad luck: I was unable to find the edges of the uterus, so I was unable to suture it and progress any further. At that point, I had to call the Medical Officer to assist me.
He was livid! From the moment he made his way into the changing room I could hear him protesting and cursing me out! He made his way into the operating room and scrubbed in amidst all sorts of threats. At the end of it all, he told me to either shape up or he would have me dismissed from the Obs/Gyne rotation. It was at that point that I made up my mind to be as self-sufficient as possible; also, I decided that I'd rather rely on fellow experienced interns or nurses to get me through the rotation.

There is a silver lining to this particular story, though: the scrub nurse was so disgusted with the behaviour displayed by my medical officer, so she made a point of reporting him to my Consultant; personally, I'm more of a "let-things-slide" kind of person (Lord knows I didn't want any bad drama), but the nurse stood up for me, and in the end won me some respite; and for that, I am deeply indebted to her.

That's right...nurses protect the doctors too! I can give two example in this regard: when (as a fledgling doctor) you mess up and write up the wrong medication, dosage or route of administration, the wise nurses will bring it to your attention, correct you (in private without embarrassing you), and prevent you from causing major harm to the patients. Also, recalling the "perception of impending death" that experienced nurses develop, the nurses will be able to draw your attention to the most critical patients. Depending on the kind of hospital you work in, sometimes the workload is overwhelming; this means you have to be able to triage the patients so you can divert a limited resource (your time, energy) where it's needed most. To the inexperienced doctor, it might be easy to get overwhelmed by the work, and to come to grips with the challenge of managing patients in a resource poor setting; however, the nurses will keep you on track, thus protecting you, the patients and the hospital's reputation all at the same time.

Don't get me wrong, I have no delusions that all nurses are good people. Some particular painful experiences during my internship came courtesy of nursing staff. Like I've mentioned previously, (medical) school doesn't teach people how to be good doctors; the very same truth applies for nurses. What I am highlighting is the positive outcome that comes from working with good nurses, and in my experience most of them have been very good individuals. There is an unparalleled synergy that just makes the job a delight. I would compare it to a good marriage where you're so in-tune with your partner that eventually you become aware of their thought patterns and can complete their sentences. I remember trusting some midwife nurses so much that if they told me that they would be unable to deliver a child naturally, everything else became academic; I would schedule the mother for a caesarean section on the spot! (You know yourselves Sr. Zipporah, Sr. Lilian, Sr. Elizabeth, Sr. Rose, Felix and Nyambane). When people give you their best each and every day, then you in turn can give your best.

This post wouldn't be complete without me reminding you to steer clear of vexing the nurses. It is one thing for nurses to bear the heavy load associated with their work; it is yet another for them to feel underappreciated, especially given the nonchalant and boneheaded manner in which people of authority have usually dealt with them. Kindly, do not add to their stresses by treating them disrespectfully for they can act out with a vengeance; keep in mind that the camaraderie between nurses runs deep, and one slight against one of them could be technically be viewed as a slight against all of them. Imagine trying to get your work done without the aid of the nurses! Thus, act accordingly and pick your battles; you can't win if you pick a fight with the nurses.

Patients too should be mindful of the manner in which they treat the nurses. In the course of their practice, the nurses develop an acumen in simple things...like knowing the least painful way to administer a certain medication. Acting belligerent towards a person who might end up with the task of injecting you with a multiple cocktail of medications throughout the course of the day can end up causing quite painful ramifications. Therefore, please, be kind to your nurses (for your own sake).
Have a Blessed day.

The things that medical school won't teach you (1)

It's been a bit overdue, but I guess I might as well jump into that whole list of things I stated about the "fine print" with regards to things medicine; let's start things off with a biggie: You will sacrifice a great deal in caring for your patients that will never be compensated.

I actually mentioned this as number 6 on my list, but it is as fine a point to start with as any other. Poignantly so with the latest spate of medical strikes that have occurred in different counties all over the country.

I don't know if there's any analogous experience outside of the medical field that can really prepare you for what practising medicine really entails. I should know: I've taken quite the long route to get to where I currently find myself - 10 years of post-secondary education (4 years of Pre-Med Biology and close to 6 years of Medical school). Interspersed somewhere in there is some volunteering and doctor-shadowing.

The medical profession is still one of those very revered fields (seems like the reverence currently far outweighs its economic incentives). I'm making a calculated guess that any parent would feel proud if they were to hear that their child had chosen to pursue a medical career; sadness may creep in, though, when they realize how much money they would have to invest in that decision. So we make the decision to follow this path, put in all those hours of work and commitment, choose the right schools, get adequate extracurricular activities that reflect well on our character; also, lest anyone forget, medicine today, just as it was in the past, is learned through apprenticeship; therefore, having a good mentor in the field helps keep you motivated, and can show you up-close the sacrifice entailed in your career choice.

So, when you eventually make it past medical school, you eventually settle down to one year of basic serfdom aka "the internship". I'm thankful here in Kenya we only spend one year doing our internship, because my Ghanaian colleagues have to spend two (dreadful) years as interns. As I mentioned earlier, learning medicine is done through apprenticeship; the nature of that apprenticeship can very often mirror boot camp at the mercy of an unkind Drill Sergeant. I would be lying if I claimed that any two internship experiences are alike; some people have relatively calm internships, while some people (myself included) go on to have troublesome internships (the universe can be so unkind). You may find yourself dealing with many a cantankerous consultant; if you're unlucky, the medical officers might also decide to make your life a living hell. In my case, I run across the foul trifecta while I was rotating in the Obstetrics/Gynaecology Department - the Consultants, Medical Officers and even some of the Nursing staff took turns dishing out grief.

It really is quite the sad turn of events. Despite all the knowledge we rack up in medical school, nothing quite compares to full hands-on experience with a living breathing patient. What we do in medicine is definitely far from the norm. Normal people aren't supposed to do the things we do. Normal people aren't supposed to see the things we see; poking/prodding/probing and incising/ligating/exploring the human body all while assuring you that we mean you more good than harm is a hard deal to pull off. And in case you haven't noticed, a lot of your friends in the medical field are a tad unhinged - possessing a wry sense of humour and unmatched fortitude. It's just the nature of the business, and unfortunately, you pretty much have to learn it on your own.

That's right, there is plenty that is learned on the job. One of the more fascinating facts about medicine is that despite the fact that we deal with death on quite a regular basis, no one actually teaches you how to deal with it (breaking news to the patients' relative, how to inform someone that they have a poor prognosis); no one lets you know how to deal with the fact that your actions (in)directly may lead to a patient's death; also, no one teaches you to develop the sense of detachment from the patient that keeps you objective come what may. Something else they may not emphasize is that you also become really adept at knowing your limits with regards to saving lives. Sometimes you walk into the ward and you have a pretty good feel about the patients most likely to perish on that day. At first, it unnerved me a bit that nurses would just mutter that

"the patient in bed so-and-so is a goner!" (rephrased). 

Dastardly as that might sound, it actually is a "good" thing because it lets you know where to focus your intervention the most. Also, it lets you know who needs to be referred out for special care that you may be unable to provide. However, if you're in a resource poor setup dealing with poor patients who obviously can't afford to go anywhere else, then you prepare yourself for the worst. We don't get to wash our hands of the impending death, but we can at least assuage our consciences of the guilt.

Sometimes people assume that this stuff is easier to deal with because (apparently) doctors make a ton of money. Personally, on many occasions, I've had people step up to me and state that "medicine is a calling!" When you have people from all walks of life constantly reminding you that your chosen profession is a calling, you better believe that the money will definitely not be commensurate to the amount of work you'll put in. If the money's the reason that you're choosing medicine as a career, I'd prefer that you chose one of a host of other jobs that require less schooling, afford you more free time, better salaries, and a life free from frivolous litigation and egotistical individuals. Apart from medical professionals, the only other professionals that gets reminded so much of being "called" are probably teaching staff. (that's not exactly what I'd consider good company!)

Despite all the challenges and pitfalls, there are many good doctors who are in this profession and conscientiously make the effort to care for their patients no matter what the circumstance; who aim to do good by their patients with whatever they have at their disposal. They take care of your precious defenseless children, they support you in your times of weakness, will care for your aged relatives when their feeble bodies fail them, and will add life to any person's days that they encounter.

It is a hard life, but it's a life that I enjoy; I've witnessed some crazy stuff, but it's interesting to share treasured war stories with my colleagues from time to time. Though, I do wish the government would do its part in helping us take care of our patients. I would definitely prefer the job satisfaction that comes with being able to adequately address my patients' needs over a pay rise. The government has absconded its commitment to the health sector and the majority poor; without giving us the tools to care for this society, they turn us into mere palliative specialists. Like I've already mentioned, I have already learned to be pretty detached in my line of work - for my own sake, and my patients' too; but having my hands tied any further would only make me bitter, cynical and ambivalent...qualities you do not want in any of your doctors.

Take home message: if you choose this life, prepare for a gamut of challenges, and for the reward to mostly be in the work itself. That being said, you should also remember that it is a noble profession, it is God-ordained. Not many jobs have as immediate of an impact on the people served; so embrace it, and make your mark in this world as only you can.

God Bless.

Dr. Strange Movie (Spoiler Free) Review

This has definitely been a superhero heavy year, and here comes another addition to the long list of superheroes to hit the big screen. As long as they're making great movies and telling good stories, I won't be succumbing to any comic book movie fatigue anytime soon.

From all the vibe surrounding this movie, and the praise for its visuals, I was definitely poised to watch this in 3D, and definitely at the IMax Theatre. My twin brother organized this one on the fly, thus, despite not necessarily being a fan of being in downtown Nairobi that late, we settled on the 9.50 pm showing yesterday night. (I can attest that this time the IMax didn't do us dirty by starting the movie while we were still lined up outside the screening area. I gotta say, though, the IMax has one of the worst concession stands I have ever come across; drab and inefficient, it really spoils what should be a good total experience).

I'm pretty sure that this movie has already gotten a myriad of comparisons to other movies of yore. Of course there's the alternate reality type of thing entailed in this movie's plot, so The Matrix and Inception (especially due to the trippy visuals) will get tossed around a lot. This is an origin story, and Dr. Stephen Strange is an egotistical individual, so Iron Man will also get mentioned a lot. At the end of the day, it is clear that Dr. Strange is its own unique movie, and it one-ups all those other movies it gets compared to.

The movie is a linear narrative, detailing everything from the evil turn of the antagonist, to Dr. Strange's fall from grace and his desperation, and finally to his humbling and metamorphosis into a hero. Benedict Cumberbatch shines as the fledgling hero, interesting to watch in all his emotional turns, and lending gravitas to this comic book movie. His arrogance is more akin to Dr. House MD than to Tony Stark. He's not a bad person, per se: his demeanour is just atrocious (like some great doctors). By the time this movie even comes to an end, he's not yet even become the great Sorcerer Supreme that people usually know him to be; but, he's a humbled man rising to the challenge that has been unceremoniously tossed his way.

We have some good turns from everyone involved, especially Chiwetel Ejiofor, Tilda Swinton and Mads Mikkelsen. Seems like they threw an extremely gifted bunch of thespians into a mere comic book movie, but I'm not complaining. However, in setting up Kaecilius in a role that the comics usually reserve for a certain unnamed villain (no spoiler here!), I feel like some of Mads Mikkelsen's role might have been sacrificed. Therefore, as usual, people will complain that we've been given yet another weak Marvel villain. In the grand scheme of things, he's a secondary antagonist - similar to Loki playing second fiddle to Thanos in The Avengers, but being the biggest sinister presence within that movie. Fortunately for Loki, he'd had a pretty well established history by that time.

It would be very remiss of me to fail to mention the visuals of this movie, which are very much an unsung character in this movie. If you've ever picked up a Dr. Strange comic, you'd know that trippy visuals are par for the course with this character. This comic truly was Inception (and then some) before Inception was an inkling in Christopher Nolan's mind. However, bringing those visuals to life as beautifully as it was done here is in itself a superhuman feat. Once the Ancient One lays her hand on Stephen Strange's head, you are in for the ride of your life. I'm pretty sure Astral Projection has been done before, but this movie sets a new standard for what astral projection SHOULD look like. I'm not sure whether Dr. Strange has a faithful animal companion in the comic book, but this movie filled that role by imbuing the Cloak of Levitation with that manner of sensibility. From the moment the Cloak make its onscreen presence, it will be delightfully seared into your mind. As for the locations, London, New York and Kathmandu are stunningly shot and a beauty to behold.

This is a Marvel movie, so the colour palette is warm, and though the mood get heavy at times, it is lighthearted most of the time, and the jokes do hit the mark. I also love the characterization portrayed in the movie. Typically, Stephen Strange is the resident egotist who needs to be humbled. However, everyone in this movie, even the well-meaning sages, are shown to be flawed. Even the well meaning good deeds performed with the best of intentions can sometimes backfire terribly, and those ramifications are what will be explored further in what is to come in this franchise. It really highlights the Yin and the Yang really well; that there's a bit of good in the most evil of people, and likewise a bit of evil in the most good of individuals.

I had only one gripe in this movie, and it comes during that otherworldly visual street chase scene pitting Dr. Strange and Mordo against Kaecilius and his minions. In most of this movie, Dr. Strange and Mordo, whether they're winning or overwhelemed, are typically stoic and keep fighting. However, towards the end of that scene, they appear unnecessarily powerless and feeble, which serves as an exaggerated prelude to the tragedy that follows. It could have been played out differently, but like I said, minor gripe.

This movie is a beautiful addition to the MCU, and is probably their best Origin movie story to date. I'm looking forward to seeing how the Sorcerer Supreme will fit into the MCU from this point onwards. I can only rate this movie as an A+; I suggest you give it a watch in IMax 3D if you get the chance (wouldn't want you ruing missed chances of you wait till it comes out on Blu-Ray).

God Bless.

The Music of Pat Metheny - Farmer's Trust

I've been an avid fan of Pat Metheny since being introduced to his work in the form of his beautiful song, 'James,' some time circa the early 2000's. Truth be told, my first true introduction to him came in the late 90's as a result of the Walt 'Baby' Love countdown show, which used 'Here to Stay' as a segue piece.

Since that time, I've gotten to listen to a lot of his music, and he is quite the busy artist with prolific output. Some of the stuff he puts out is straight ahead jazz, other stuff (example, 'Here to Stay') borders on smooth jazz; and then some of his stuff is just straight out of this world experimental.

Today, I'm focusing on 'Farmer's Trust' from his live Travels album, which consists of a slew of the Pat Metheny Group's hits recorded during live sessions in 1982 (yep, this recording is technically as old as I am). This is my best song on the album, and probably one of his all-time favourites. I believe the best way to describe the song would be as "...a melancholic chant, a soothing lullaby, a celebration of life in its simplicity and just a hint of an ode to Mother Nature"; at least those were the words I used when I wrote to the Q&A page on his website.

My earliest introduction to the song was via the Kevin Costner movie "Fandango". I remember perusing through the PMG website and finding out that some of the group's songs were a part of the Fandango soundtrack. If memory serves me right, there should be 3 songs: It's for you, September 15th and Farmer's Trust. "It's for you" received the most screen time as part of a dance routine; unless you're really familiar with "September 15th", you'd miss it as only a smidgen of it plays out on a landing strip. "Farmer's Trust" is the setting for a particular memorable scene: the movie's closing. As everyone departs, we are treated to a long goodbye between two characters (Phil & Dorman), and after that Kevin Costner's "Gardner" casts a long glance back at them from a vantage point overlooking the party. Originally, I remember being distraught because I felt like the track itself was part of the movie's score, and thus something I would be unable to come by; however, with a bit of luck trying out the one PMG group song I was  unfamiliar with, I found my song.

This ballad has that open plain Midwestern charm that's at the root of Metheny and Mays' humble beginnings. It sounds like they concocted it as they sat out over some open plain late past dusk, and tried to evoke the mood of the calmness settling over the earth. Nana Vasconcelos (rest his soul) provides the delightful bird chirping that gives this song an ethereal quality. I couldn't believe that he actually used a rubber duck to pull off such an impressive feat! (the man was a wizard).

The interplay between all the moving pieces that are the 5 musicians involved in crafting this gem works so well that it actually seems like a really simple song. (Jim Hall & Pat Metheny in fact have a very beautiful rendition of this song that only comprises of the two of them on guitars). It has this great use of silence interspersed within it; sometimes Metheny on guitar shines through while everyone else takes a back seat, then Mays on the keyboard takes the lead; Rodby lays out a beautiful bass line, Gottlieb's drums as just the slightest hint of a whisper...and finally, Nana's got the chirps. I think what's really impressive about this band - in all its permutations - is its ability to fill up space orchestrally with their notes. It feels like they use the bare minimum of notes here, and it works perfectly.

If I were on a deserted island, this is definitely one of those tracks I'd have with me. There's just so much hope at the core of this song.

God Bless

Driving in Kenya: a long journey

Well, I do believe I've officially been driving in my home country for 5 months now. What an adventure it's been! Gotta say I never thought I would never make it to the point where I'd actually enjoy driving. Sure, this seems a little dramatic, but I haven't had the easiest of starts when it comes to this driving business, unlike my twin brother.

He and I took a very divergent route after the end of high school. He was wiser and took the driving lessons, somehow I ended up taking French lessons that haven't really counted for much in my life thus far; thus, he ended up becoming a pretty competent driver early on, and I just remained jittery ol' me.

Not long after that, I shipped out to the States to attend college, which is where I started to learn how to drive. Manual transmission was the exception to the rule then (kind of how it is in Kenya these days), so my driving experience was relatively easier on an automatic transmission;  in addition, Central PA had some of the nicest drivers I had ever encountered: people were courteous on the roads, followed basic road rules, car horns were sparingly used, etc. Also can't forget that those were some of the nicest spacious roads I had encountered, though some PA natives seemed to complain that PennDOT's spending on road maintenance was 2nd to last nationwide. It was a rocky start though, considering Heather Norris' crash course in getting me driving - Day 1 and Day 2 : Parking lots, Day 3: HIGHWAY! Sure, it was her car, but that was just bananas :)

Anyway, serial procrastinator that I typically am, I gained confidence on the roads, but I never ended up getting licensed. In retrospect, it would've made things easier because I could've just converted the license once I returned home in May 2005. I really didn't think that my experience in the States had changed me much; however, reverse culture-shock was deep, particularly on the road. It seemed like bedlam incarnate on the Kenya roads: people didn't follow basic rules, road signs or any sort of instruction, the drivers were aggressive for aggressiveness' sake, and the roads were narrow, poorly marked and poorly maintained. There was no way I was ever thinking of getting behind the wheel at that point.

Fast forward 2 years down the road, and it was my time to jet off to South East China (Wenzhou) to study medicine. China is a land of many achievements, but their driving culture is sadly not one of them. Chinese drivers are even crazier than Kenyan drivers! I guess the only thing they have going for them is the wider roads. I saw the Chinese commit so many sins on the roads that I was always left in wonder as to how I managed to come across such few incidences of road accidents. The pedestrians were a hazard, darting across the roads without a care in the world; people on bicycles, scooters and those in cars were just as bad. The safest drivers I ever came across were the bus drivers, which was well and good, because that was how I mainly got around. China did do me a favour by relieving the fear I felt on the Kenyan road, which was more evident when I'd travel back home for the holidays.

So, 6 years later (2013), I was back home again after finishing med school. Towards the end of the year, I finished my driving-lite course, and got licensed. (Truthfully speaking though, driving school in Kenya is a joke! The licensing process is an even bigger joke!). Anyway, the license took forever to show up, I never really practised, and then soon it was time to be shipped out to Kisii for an ultra long internship. Once I abandoned the western part of Kenya for the chance to be closer to Nairobi, it became apparent that I could no longer escape the task of having to drive. My current work station - PCEA Kikuyu - has a terrible public transport situation. Sure, matatus ply the route; the problem is that I need about 3 - 4 separate matatus to get to the hospital. Therefore, I had to "properly" learn to drive stick-shift...and for the most part develop the confidence to see things through.

5 months down the line, I have all the confidence in the world. I love driving fast (not illegally fast), and the freedom it affords me. In the beginning I avoided slowing down a lot, because there's nothing quite as demoralizing as having the engine die out on you in the middle of the road. Amateur mistakes occur less often these days :) Granted I still complain about the craziness of the whole system; I still hate the aggressive driving style, especially that of matatu drivers; I hate that people risk their lives periodically walking across the roads without respecting their lives, or those of the drivers who have to protect the lives of those same nonchalant pedestrians. (Can you imagine having your car torched because an irate mob takes it upon themselves to dish out "justice" for a perceived grievance, yet the instigator was the selfsame careless pedestrian?)

The system isn't perfect, but I'm learning to live with it. I treat every drive like a day at the operating theatre - start it with a prayer. With all the things stacked up against you on these roads, you might as well invoke the Divine to improve your chances.

At some point, I can talk about my newfound pet peeves on these roads; but for now, have a great day and God Bless