Note: This edition is longer than previous posts. The following account contains graphic medical scenes.

All That Is Past

Malawi, present day

Kamanga is sitting outside my office. This I had not expected to see.

He is a 30 year-old man who had come to Partners in Hope six months prior because of cardiac failure. One of his heart valves didn't function. The reason for his condition was unclear, but I had treated him for an infection on the valve after spying a growth by ultrasound.

Despite the medicines, he progressively deteriorated, coming in more frequently for injections to drain his lungs of fluid. By some miracle, he had gotten on the government list to be sent abroad for surgery. Few are so lucky. Following weeks of delay due to shortages of foreign currency--a period during which his condition worsened--Kamanga and his wife, along with a dozen or so others, finally got hold of a plane ticket and were bound for India.

I had wondered over the past month whether he would ever return. True elation and happiness flood me as we greet each other.

**

Kenya, 2004

I am walking out of the clinic. At the door I run into a young man whom I had not expected to see again. Ecstatic, I ask him, "Did you get the surgery?" He opens his shirt to show me the scar down the center of his chest. He has received a mechanical heart valve.

Like millions in Africa, he suffers from rheumatic heart disease, a consequence of strep throat as a younger person-a complication preventable by penicillin. Two wonderful young New Zealand doctors, working with us a short time, had raised the funds for his valve replacement. I remember arranging for the check to be sent to the national hospital and thinking, "Will this make any difference?"

**

Malawi, present day

My elation soon dissipates. Something is not right with Kamanga. Stoic, as are so many Africans, he denies that much is wrong--even as he clutches a pillow to his chest to stifle the wracking pain and violent coughing.

I listen to the metallic click-click (he has received not one, but two artificial heart valves, and a third valve was repaired) and notice that his pulse at the wrist is half the rate of the beating heart. The tick-ticking is so loud that I wonder if there is a pocket watch in the room.

Wading through the mountains of data from India--feeling as if I have returned to modern medicine--I learn that he spent two weeks in the ICU for heart and liver failure before finally being deemed fit for surgery. The post-operative ultrasound report lists no major problems. His blood was overly thin just before boarding the plane to Malawi. It was on the plane that matters took a turn for the worse.

I flip on the ultrasound machine. At first, I am disoriented. Does he have TB around the heart? A common disease in Malawi, the infection often shows up as a collection of scraggly worms, tendrils of protein floating amidst a sea of dark fluid encircling the cardiac silhouette. Now I see the same wafting tubules.

More likely than TB is blood around the heart, or a bacterial infection. We should remove the fluid. It is preventing the heart from filling--and hence pumping--appropriately. We call this condition "tamponade." Yet his blood is still too thin; the risk of a needle in the chest is too high.

Two years prior I had anticipated the need to thicken blood in an emergency and had ordered concentrated vitamin K from Europe. There is one vial left, sitting for some reason on the pharmacist's desk. The nurse injects Kamanga.

We need to wait. He is stable enough to allow his blood to thicken overnight. At home, I spend the evening in dread of what I know must be done the next morning. I must stick a needle through his chest and take out as much of that fluid as possible. I don't want to do this, don't want the risk or the responsibility. This is why we have cardiologists--but in Malawi, I am the cardiologist.

In the morning Kamanga's condition has not changed. He is still short of breath, clutching his chest because of the pain. The blood's clotting status is nearly back to normal. The time has come.

Kamanga lies on the table in the procedure room. Around him are two of my colleagues (one operating the ultrasound) and visiting doctors from UCLA. Just what I need--an audience. Peering again at the screen, the realization hits me:  the preferred route below the breastbone is not an option. I would have to enter directly over the heart.

The equipment awaits on a sterile field. Iodine bathes the skin. I inject a small amount of lidocaine above the rib. My hands are shaking.

**

Malawi, late 2011

"You have to go to central hospital," I tell the unfortunate man with diabetes, HIV, and a large abscess which had spread from his back along the front of his chest wall.

"I waited there all yesterday and no one helped me." He had no money or transport to try anywhere else.

A colleague and I had struggled over a week to drain the pus from the extensive wound.

"I will try to help you."

The nurse Lucy places him on the same table in the same procedure room. The chest is sterilized in the same way. He receives the drug ketamine for sedation.

I enter one end of the long abscess cavity. Little fluid comes out. Am I deep enough? I am not a surgeon. But what can I do? There is nowhere else, no one else right now. I incise deeper.

Blood shoots up higher than my head, and I panic before hurriedly placing gauze on the wound and holding tight. I must have cut the intercostal artery near the rib, not an essential vessel but an artery nonetheless.

I press and press for what seems an eternity, until the bleeding stops. Lucy affixes a firm pressure dressing. The man wakes up. He cannot see, a rare side effect of ketamine. Within the hour, the sight returns, but he still has a mortal abscess. He heads back to central hospital, and never returns.

**

Malawi, present day

I slide the needle, sheathed in a too-thin plastic catheter, over the rib, and advance my hand slowly.

Blood. Thick dark red fluid. We know from the measurements that the needle cannot be in the heart. What is around his heart is blood.

The needle withdrawn, the catheter in situ, blood does not flow. It might be too thick for the catheter, or the plastic might be kinked. The fluid must come out. Try again.

Same thing: blood, but only from the pericardial sack around the heart, and then nothing flows from the catheter.

I stand, frustrated, and look at the assembled group of six. "Ideas?"

Dave suggests re-inserting the needle and leaving it, since blood flows with the hard metal in place. He is right, but I worry about the sharp end floating around the heart, menacing the coronary artery. Poking into the heart itself is, incredibly, not the disaster it would seem. If this happens, the strong muscle closes around the hole, staunching the bleeding immediately. The concern is cutting the artery which wraps around the outside of the organ, depriving the muscle of blood and oxygen.

A new catheter and needle. Only a little blood enters the syringe. I hesitate, again shaking.

**

Kenya, late 2002

Fresh from residency, fresh in Africa, I am the infectious diseases expert. A colleague comes to me about Paul, a 16 year-old HIV-negative Kenyan who has been on the ward, and not getting better.

The x-ray shows a huge heart. Probably TB. He has already been receiving the medicines for several days. Now his legs are cold, he is struggling. Like Kamanga, tamponade.

We take Paul to the ultrasound suite. The screen shows the large sack of black liquid. I enter with a needle below the heart and remove a small amount of blood-tinged fluid. Not enough. Allan (the same Allan) also tries, and draws back a syringe full of pure blood. "Right ventricle," he concludes, meaning that he had entered the heart's second largest chamber. Our attempt to remove the fluid with a needle has failed.

"How do you feel?" I ask. Better, Paul assures me. We take him back to the ICU for intravenous fluids and oxygen. Over the next few hours I check on him frequently, and he continues to insist that he is improving. But the blood pressure is low, and the feet are icy cold. "Allan," I say over the phone, "you need to take him to theater."

Paul goes for a "pericardial window," or the cutting away of a section of the distended bag around the heart so that the fluid can drain away. This Allan does, and the blood pressure rises immediately as the liberated heart may now fill and pump, fill and pump...

Then Paul arrests. Despite multiple attempts, the heart cannot be re-started. I am stunned. My mind races: it must have been the acid pooled in his extremities, which had been picked up and distributed by the newly flowing blood.

His older sisters are beyond consolation. They scream and wail and fall on the floor.

I should have acted sooner, and more boldly.

**

Malawi, present day

I advance the needle. Thick, bloody fluid enters the syringe freely. This time I withdraw repeatedly. We only have small syringes, and the volume is hundreds of milliliters. There is still the issue of the needle point and the artery.

Again I advance the catheter and remove the needle. Finally blood drips out of the blunt-tipped plastic tube.

Although it is thick, the bloody fluid does not clot, suggesting that it is not in fact pure blood. Dave points out that if the catheter were inside the heart, blood would be pumping vigorously--like the time I cut the intercostal artery. Not entirely convinced, we collect samples from heart and arm, to compare for hemoglobin content. The results confirm my colleague's suspicion:  the catheter is in a safe position.

Now, we wait. The drips come unhurriedly. Sometimes I withdraw with the syringe, but this suction causes Kamanga pain. Jerry looks again with the ultrasound. The fluid around the heart is decreasing, but there is still a long way to go. Hours to go.

So I stretch my aching back and watch the dripping...

**

Kenya, August 2003

It is a day of waiting.

The hospital is so understaffed that just a few of us and the Kenyan interns remain. Adult medicine, ICU, and pediatrics are my responsibility. I am not a pediatrician. The younger the children, the more distant from adulthood they are, the more nervous I become.

It's a Saturday. A newborn has jaundice because of a blood incompatibility with the mother. Ultraviolet light has not reduced the damaging and potentially deadly yellow pigment being released from the shattered red blood cells. He needs an exchange transfusion.

I find Allan. (Yes, same Allan.) Surely he has done an exchange in Congo or somewhere. "Never done one," he says, "But I am glad to help."

All day we labor, hot and sweaty under the warming light of the incubator. The hospital lacks the proper blood type, so we know this effort is only a temporizing measure. What are the options? We offer transfer to the national hospital, but the mother elects to remain at Kijabe.

The idea is this: You give blood which is safe for the baby, at the same time removing some of the pigment-laden blood. The real problem in this case is that the umbilical vein catheter will allow us to infuse but not to withdraw. So, like some medieval charlatans, we have to insert a catheter into the femoral (leg) vein and drip- bleed the child.

We transfuse blood until the baby starts breathing quickly and the oxygen level falls, indicating stress on the lung. Then we stop transfusing and start bleeding him, drop by excruciating drop, until the heart rate rises too high. Then we transfuse again...for eight hours.

It works, for a day. The pigment level falls dramatically. Just as predictably, it starts to rise the following morning as red cell destruction resumes. Now the hospital has the right blood type. (I learn it was there all the time, hidden at the back of the refrigerator.) We repeat the process, this time requiring six hours.

The pigment falls and does not rise again. The child survives. He and his happy mother leave Kijabe. I never see them again.

**

Malawi, present day

About a third of a liter exits the tiny hole in the catheter. What is left on the ultrasound screen is a small amount of blood and a thicker rind of hard protein. Acute danger has passed. The pulse has improved. Yet I worry about that protein, which could encase the heart and cause long-term "constriction" and heart failure. I try steroids to reduce the inflammation.

The next day Kamanga goes home, as there is nothing to do but wait. Despite the risk of stroke, he remains off the blood thinner. The chance of re-bleeding is too high.

The next week Kamanga has improved markedly. The ultrasound screen shows a much small amount of fluid and almost none of the thick protein rind. Maybe we will avoid the constriction. The heart still does not beat as strongly, due to the damage it suffered before the trip to India. There are medicines which should help. He starts blood thinners again. His father thanks me.

**

Life as a doctor in Africa is full of the highest, most searing drama, a bittersweet mixture of tragedy and triumph almost too overwhelming to bear. The noble characters, the patients and their families, struggle across the grand stage of illness, worthy of Shakespeare. They shed tears and cry for redress, and at times even exit to joyful trumpets amid banners high.

I have been a witness.

Yours in struggle,