When Wait and Watch is all you can do....

I am glad to be back in school, after 8 weeks of government stalemates that resulted in me losing the opportunity to graduate this year. Being a KCSE graduate for the last 7 years I was glad to have to update my CV. Anyway I was back to my old schedule, waking up at 6am and sleeping at 1am. I was still in internal medicine when I first met Steve*. Steve was a 39yr old man from Nyanza, he was living the African dream: he had two wives. Well it was more in theory than it was practical. His first wife had ran away. He came to the hospital in company of his second wife. 


The mass in his belly had gone on for long enough, even after countless trips to the local herbalists and countless massages from his life partner. He had walked in from a hospital in Bungoma, following an abdominal ultrasound, where they decided to send him over for further management.

I pulled out a stool, sat next to the bed and took out my writing pad. He had felt his belly swell up for seven months. At first the pain was mild but now it had become unbearable. He had also developed two masses on his scalp. His children would ask why he was developing horns. I found this curious; never had I encountered such a presentation. After a thorough examination, I noticed that his liver had put out. His eyes had turned yellow over the past few weeks and his liver was full of large firm nodular masses. He was experiencing recurrent nose bleeds and his feet were swollen. My first thought was liver cancer - Hepatocellular carcinoma. The thought of alcohol induced macronodular cirrhosis was knocked off by the fact that he did not take alcohol. I also suspected lymphoma or metastasis from other possible tumors. So I sent blood for labs. the ultrasound result from Bungoma confirmed my suspicions. As with any cancer diagnosis, ‘tissue is the issue’, and one can hardly commit to a diagnosis up until he had examined a biopsy. But Steve’s case was more of a dilemma, if we attempted a get a tissue sample, there was a great chance he would bleed out on the table. The decision was made to turn to tumor markers (this are blood tests used to help point to particular tumors). His unfortunately pointed to hepatocellular carcinoma.

This was bad, the definitive treatment would have involved having a liver transplant, this was not an option in Kenya. His HIV and Hepatitis B tests came back positive. I sat down with the couple and leveled with them taking time to listen to their questions and explain the diagnosis that we had found: it was not easy. However, they were very understanding. We tested his wife and she turned out negative for HIV and Hepatitis B, I advised her to get tested after three months.

Over the next few days, Steve’s condition deteriorated, from a man who could once hold an entire conversation to being bed ridden. He was going through the stages of hepatic encephalopathy, he spent most days asleep with his wife seated by his side. She slept on the floor beside his bed, even after having the knowledge that he was probably never going to make it. A few days earlier, he had a head CT scan that we had scheduled. When I walked into the ward, she handed me the scan with a smile on her face, hoping that it would hold a message of hope. I held up the radiograph: It had a large brain mass that was continuous with the two scalp masses I had seen. It was surprising that he was able to hold a conversation just a few days ago. She read my expression, “Has it gone into his brain?”.  

“Unfortunately, sorry.” Those were the most difficult words I had ever had to say.

She told me that she would stay with him to the very end regardless. However she requested that they be allowed home to be with family. We promised them we would do that the following morning. Unfortunately Steve passed on early that day.  

Once beaten, never shy...

Medical School has always been the toughest time in the life of an aspiring doctor. Even for the eldest in the profession, the message has always been the same. As is the case of one of the eldest and most respected consultant at  Moi University. He emphasizes that back in his day (1970’s) when he did his undergraduate, he did not enjoy the comfort of having computers, internet or appetizing literatures as is the case today. All the books he read were in black and white with little or no pictures… But that is not the epitome of my story, so here goes. You see, in med school, as in any other course, the only time that matters most is exam season. That time even the most serious alcoholics, jokers and the like turn to avid readers. All of a sudden the library is crammed as if the books were on offer.

Being in fourth year, it was all about clinical exams; four in total. There was internal medicine, Obstetrics and Gynecology, Pediatrics and Surgery. To bring to light how serious the end of year exams were, let me highlight a few facts. Each rotation represented a different or different specialties with their respective consultants. Each specialty had its own practice, protocol and science. Therefore you do agree that for a mere medical student it calls for a lot to be an internist, an obstetrician and gynecologist, a pediatrician and a surgeon.

It was during my end of year surgery exam that I had my greatest laugh, and this yes, is the epitome of my story. I had woken up at 6am so freaked out about my last exam… the rest had been equivocal. I hurriedly prepared and sat down to read, I could feel my heart pounding as I turned each page of my notepad and realized “ Ngai, haki nitapitia hii saa ngapi!?”. Nonetheless, I found myself in the surgical wards with a burns patient. Kamau* smiled and said he was tired of talking to students. I did not despair, I immediately turned our conversation into the appropriate mother tongue and it did the trick. He now sat up and said “ reu reke gutarerie uhoro”  ( Now let me narrate to you my story).

As the story goes, Kamau worked at a car wash in Eldoret town. It was Saturday at around 7pm when he left for home, he made a stopover at his local chang’aa den. He had his regular and 8 glasses later he decided to stagger home. At 10 his neighbor also college at the den had himself locked out of his house by the landlord. He begged to spend at Kamau’s. Kamau agreed on condition that he got him some more ‘good stuff’ which he brought in plenty. They drank till the wee hours of the night. Suddenly, the kerosene lamp went dim, as Kamau stumbled to bed, he kicked it and it slung pouring kerosene on his trouser and setting it on fire. For Kamau, it was unknown to him and his cotton trouser was totally burnt off: still in his person. He had not felt a thing and he retired to bed. But this was not to be for long.

 At 3 am, Am guessing the powerful anesthetic had worn of he woke up in pain. This was not in any way surprising but it was what he did that won him the award of being the first person to make me laugh within. “ Nikawakisha kiberiti na kuangalia nini ilikuwa mbaya, mguu yote ilikuwa brack” he said, “ nikaangalia chini ya kitanda na kuchukua kale kachang’aa kalikuwa kamebaki… nikamwagia mguu kiasi na hiyo nyingine nikakunywa, nililala pap!”.