4.10.2014

The Dark Side

The Maasai are semi-nomadic. They set up living fences, made of thorny acacia branches covered in spikes that are rock-hard and often six inches long. These branches take root, sprout again, and create an impervious barrier for the "boma" - an enclosed compound with round mud huts and ample space for the cattle and goats to stay safe during the night. Cattle is wealth - the daily ritual of grazing, up the rocky hill slopes to reach the open grass, where the wind is strong and you can see forever, moves life here. And in the evening, when the shadows lengthen and the air gets cold, you hear the bells again and you see the boys driving the cattle back to the boma, long sticks in hand, flowing red and blue wraps covering everything but the bottom of their skinny legs.
The old-timers will tell you with disdain that only animals eat grains and vegetables. To the Maasai, food is meat, milk, and blood. The cows are often bled daily, their life-essence fed to the children. And the family follows the needs of the cattle: they will leave the boma, and move to an abandoned living fence, setting up a new dwelling where they may live for a few months. Though they do not eat plants, they do believe in plants as medicine: everyone takes "ol-chani" (special trees), though many don't remember why. These herbs are often simmered with goat meat, particularly at ritual holidays, and thought to purify, strengthen, and balance they body and spirit.

The Sunjo are agriculturalists. One of the biggest Tanzanian tribes, they wear rich greens, yellows and blues and till fields of maize by hand. The grain, white-kerneled and rugged, is ground into a cornmeal that is boiled into "ugali", a cross between porridge and cornbread. It is rich and somewhat cloying, and is mixed with stewed beans, peas, eggplant, tomato and squash. In some fields you can even see bean vines planted between the cornstalks, twining up in a surprisingly new world way.
Every week, they travel from Sunjo in the East down the long dirt road to sell their goods at the market here in Wasso. You'll find everything from sugarcane to ginger, beans and grains and fruits, recycled sandals and Adidas track jackets, cell phones and gasoline. The banter is cheerful, the faces more round, and the negotiation skills superior. And you find concoctions, "changu", generally dark liquids brewed from a range of unspecified plants. They are sold for stomach troubles (particularly worms and amoebas), malaria and fever, and to build the blood. I find myself a little reluctant to try the formulas, often sold in recycled water bottles with no label.

I've had the pleasure of helping all these folks over the past weeks, and the work had been largely routine. There were wounds from motorbike falls, cleaning knees and shins scraped down to the bone and dressing them, stitching if needed; cleaning and removing the stitches from massive vertical cesarean sections; dressing head wounds in children whose arms are as thin around as a young, green sapling; splinting and slinging the ever-present distal humerus fracture. Yet another young Maasai came in with a lion bite, this time to both of his hands (only his right was fractured, and severely swollen). We are still helping previous weeks' injuries heal, and most patients who come through the minor theater with trauma are doing well.
I have been following my own group of patients. One showed up at our little house asking if I was around and if I had any remedies for the "sugari", diabetes. I was able to point her to a local species of Opuntia, and to the bark of the cinnamon tree - not a bad juice blend. The Maasai elder with probable leprosy is almost completely healed, using only herbal therapy. One small lesion remains on the ball of his left foot, but we hope to have that cleared up by early next week (if he would just stop walking). When he's discharged, he says, he will gift me a goat. The woman with a diabetic foot ulcer is also on the way to complete recovery, despite my own skepticism that we could heal her wound using herbs. But with twice-daily hot ginger compresses, yarrow washes, usnea powder, my own "changu" (details forthcoming soon), and the strict avoidance of bleach soaks, we're seeing daily progress - including the return of a good dorsalis pedis pulse. Many have come in for other troubles, like their severely malnourished children, and lack the funds to take care of the open wounds they themselves have. One young mother, for instance, came to me while I was working out in the grassy space between the hospital wards. Her child was in the pediatric department with pneumonia. But she had a deep, somewhat infected wound on the inside of her big toe, incurred while chopping wood for the boma. She healed quickly - young, strong, and otherwise healthy - and free of charge. So all things considered things are going well, and I am again reminded how excellent herbal medicine is for wounds, as well as for chronic disease. You just have to apply it diligently and consistently.
So another big part of my daily rhythm is gathering plants and preparing medicine for my folks. I am using a lot of fresh plant juices, which are excellent though time-consuming to prepare. My mantra has been "ninaenda kuanda dawa sasa" (I go to prepare medicine now), while I disappear from minor theater during a lull. But I am so grateful to have this opportunity: exploring the land, gathering, making, and applying. I often harvest plants and stick them in my camelback during runs. We come back together as a family at the end of the day, and share simple (and greasy) meals. We sleep deeply. In many ways, this is the life.

This morning was no different. I joked (half through an interpreter) with the Maasai elder that it seemed that a side-effect of his herbal regime was strong morning erections - something he'd been missing. Good enough. I felt the near-scalding warmth of ginger tea on my hands as I wrung out a fresh compress before applying it. I smiled at the kids whose wounds I have come to know as I clean them and re-bandage them, usually about every other day. One of the most heartbraking cases has been that of a five-year-old whose entire right arm suffered full-thickness burns from a synthetic jacket that caught fire and melted onto him. I use aloe on the superficial burns on his chest, but we are using silver cream and vaseline gauze everywhere else. I have to remove and change the bandages daily, and lots of tissue gets removed with them. He whimpers quietly, under his breath, as his mom holds him in a big, white blanket. I can see his pain increase day after day, as more tissue sloughs off. But this morning, like every morning, I still got him to smile after I was done by puffing up my cheeks, sticking out my tongue, and crossing my eyes. White people are weird. These kids are so strong.

Then the first call came in. I knew someting was off when I saw Father Thomas, the hospital administrator and chief medical officer, run across the courtyard from his office. People don't run here, especially at work. Then the 4x4 ambulances started going out. All of them. I was told to gather supplies from the farmacy: gloves, tape, surgical blades, and to make sure we were well-stocked with gauze and bandages. I went right to it. Staff was briefed on the incoming multiple casualty event.
A week or so ago, a Maasai tribesman had been caught as he attempted to graze his cattle in a Sunjo field. This, apparently, was an act of provocation and the Sunjo tribesmen cut him down - killed him. In a story that repeats itself here like the seasons, the Maasai planned and executed an act of retribution. Every morning and evening, a small bus travels from Sunjo to Wasso carrying about a dozen people. This morning, it had been ambushed by Maasai with Somali (American??) machine guns, and machetes. There were mostly high school students on board, a Sunjo driver and some other folks. Apparently, one of the kids walked right up to the Maasai gunmen and attempted to explain that they weren't tribesmen, that they had no quarrel. He was shot in the head.
I ran to the front entrance of the hospital with two boxes of gloves. Someone put a robe on me. Then the ambulances started offloading casualties. We wheeled them into minor theater as they came in, car by car. Anne and Father Franco directed rapid triage - is he alive? I checked for breathing. Nothing. Radial pulse was weak and thready, intermittent. Then I noticed the exit wound on his skull. Soon there was no pulse - we had to move on. Another young man was dead on arrival - a massive slice across his neck had severed his carotid artery. He didn't even make it into minor theater. Anne and I started working on the driver - a large man, probably in his thirties. As I cut off his pants, I saw his foot was fully turned inward, tissue was everywhere, blood was coming quick from his lower leg. As I attempted to elevate his foot and apply pressure, it just flopped free, disconnected from the rest of his leg. He screamed in pain. So I got a splint and secured his leg in place, continuing to strip off his clothes. No other wounds. He pulled at me as I held his bloody jeans and told me "money, money in there". I packed gauze into his leg, trying to slow the bleeding a bit.
Meanwhile, a girl had a deep wound on the top of her head. She was marginally conscious, had a pulse and was breathing well. The skull had been compromised, but hopefully not too much. Father Franco was stitching her up, calling for more lidocaine and yelling "cut" periodically. I helped as I could with local anestesia and scissors, while staying with the driver. Another girl had a smaller head wound, and Teresa, a visiting OBGYN resident from Germany, was stitching her up. She seemed stable. Yet another woman had a gunshot wound to the right leg that had shattered her fibula. Other patients were being treated outside of minor theater, one with a bullet in his pelvis, another with an uncomplicated gunshot wound to his upper leg. They were ok.
Anne had to leave to act as one of three surgeons in major theater attempting to repair the shattered fibula. I stayed with the driver, applying pressure behind his knee in an attempt to restrict blood flow through the popliteal artery. He was going into shock, and we got fluid going into him through a deftly-executed IV (the nurse was so smooth, calm, precise - amazing). While squeezing behind his knee, I squeezed the bag of saline. The foot was pale. His lips were going pale. He was getting cold; we covered him as best we could. A unit of blood arrived, typed and matched from the sample taken from the IV port, and they were ready for him in the major theater. Anne, Father Franco, Dr. Peter and the team would be in there for hours.

I let him go and took a moment to breathe. The young girl Teresa had helped was resting in minor theater. Two other patients came in, walking on their own or with just a little assistance - I was so grateful to see this. I cleaned and dressed a simple, small head laceration (boy do they bleed though) in a woman who was seven months pregnant. How was her baby? Could she feel it move? Yes, everything seemed normal. No cramping. No vaginal bleeding. I shaved between her tight braids, cleaned and dressed her wound. She was shaken, but fine. Another man had a small arm wound that was most likely a graze from a bullet - lucky. No stitches needed.
Cleaning up minor theater felt like an honor and was a welcome respite. We worked slowly, methodically, in silence, mopping up blood and bleaching every surface. When we were done, I looked at the blue gown that covered me from my neck to my feet. Blood. I took it off, folded it, and put it into the bin where we dump contaminated laundry. I walked slowly back towards the entrance of the hospital, now under high security. Police with machine guns. People everywhere, crying. Blood trails on the concrete pathways. There must have been over a hundred people outside the front entrance of the normally quiet hospital.
After checking with Father Thomas I walked out, almost on autopilot, and crossed the parking lot to our little house. My daughter was waiting there, home from school for lunch. I just gave her a big hug for a long time.

All told, there were eleven casualties. Two died. Four had major wounds. Five had minor wounds. I will tell you, herbal medicine is fantastic, even for first aid. But the team at Wasso hospital worked smoothly and well today, exemplifying the best that technological medicine has to offer, even in such a low-resource setting, and I am so grateful. When I returned to the intensive care unit to visit the driver and the other three major casualties, all were stable - although I bemoaned the complete lack of narcotics, even a simple opium poppy tincture (next time I will bring an unlabeled bottle). The driver's pulse, which had been so strong and almost flooding when I first took it, was barely noticeable at the radius. In many ways, this is the life. The land is wild and strong. The tribal ways are pure and uncluttered by heavy modern baggage. But there is a dark side too.

1 comment:

Ellie Bayer said...

Powerful life altering experience. Thank you for sharing Guido. It is mind blowing to believe how these situations are happening parallel to our daily reality