Across the Wide Zambezi: A Doctor's Life in Africa (2 page)

I will never forget my first caesarean
section. I was wakened by the telephone at three in the morning of my fortieth
birthday. Emilia the midwife spoke.

'We've got a breech, and it's stuck, and
we can't get it out, and there's another one inside.'

When I got to the labour ward, it was as
she said. An African woman was lying on her back on the delivery couch, her
long legs up in the stirrups. She stared fixedly at the ceiling, in all the
fathomless impassivity of her race. Two other nurses stood beside her, one on
each side. They and Emilia stared expectantly at me out of their black eyes,
over their masks.

Hanging from the woman's loins was a
small body, feet first, limp and grey, quite obviously dead.

When I applied the foetal stethoscope to
the woman's belly, I could hear the faint heart-beat of a second twin.

My first thought was that picture which
all medical students remember and never see in real life of locked twins, where
the head of the first twin is trapped by the head of the second. If the reader
lays his two fists together, opposite ways, he will get the picture.

I did not know how to deal with locked
twins, so told Emilia frankly: 'I'm going to get the book out.’

In the office, I took down an old copy
of Eden and Holland from the scantily stocked shelf, Des Brennan had indicated.

As far as I remember, Eden and Holland
informed me (rather unnecessarily) that the first twin is usually dead. The
head should be severed from the body (or vice versa presumably, depending how
you look at it), and pushed back into the pelvis, to allow the passage of the
second twin.

Armed with this knowledge, I returned to
the labour ward, and, using some instrument I dare not try to remember, severed
the neck. The body fell into a bucket, with a dull clunk.

Now I tried to push back the head. It
would not budge. The initiated will guess what I discovered next. The first
twin was a hydrocephalic - a big-headed monster. Moreover, my examination revealed
that the woman had a contracted pelvis, a common disability among the
undernourished women of the Third World. She would have difficulty delivering
any kind of baby, and this was her first pregnancy.

I decided to 'cut my way out of
trouble', by which we in the trade mean a caesarean section. I asked Emilia to
prepare for operation, while I repaired once more to the office and Eden and
Holland.

The chief medical officer in London had
told me that the classical operation is the easiest. This means a vertical
incision through the uterus. It is true it is the easiest, but the lower
segment (cross cut) operation is far superior, and any doctor worth his salt
will learn it as soon as possible.

As it turned out, the classical
operation was going to be more appropriate to this particular case.

I read up the details of the operation,
and made my way to the theatre, feeling hollow and afraid in the sweltering
African night. There was no time to send this woman anywhere else with any hope
of saving the baby, or even, perhaps, herself. Besides, country doctors in
Africa are not expected to transfer cases for caesarean section.

At the theatre, I found Mr Sackey had
arrived. He was to help me. There remained the question of the anaesthetic. I
had discussed this with Des Brennan, during our brief handover.

'What do you do about anaesthetics?'

'We do spoinals.'

'How do you do a spinal?'

'You do a lumbar puncture, and bung the
stuff in.'

Which, I might say, is not the last word
on spinal anaesthesia. I expect Des thought, if you've got to shove a fellow in
the deep end, the less said about it the better.

Mr Sackey, who seemed to know more about
spinals than me, had got a drip going, laid out the tray, and sat the woman up
across the operating table. He looked expectantly at me.

I did the lumbar puncture, and ' bunged
the stuff in'. Mr Sackey laid the lady flat, and wound the table head down for
a few minutes. Presently, he levelled it again, and set up a screen over the
patient's chest. During a spinal anaesthetic, of course, the subject remains
fully conscious, but is numb from the waist down.

Then we scrubbed up, gowned, and gloved.
I remember seeing Mr Sackey's packet of Tusker cigarettes lying somewhere, and
mentally catching at this homely object, like a psychological straw.

The operation went easier than I
expected. I removed the second twin from the open womb. It was small and inert
and covered with meconium, which is the baby's faeces, passed in distress, and
a sign that it had had little time to live, if it was not dead already.

I cut the cord, and handed the object to
Emilia, like a muddy little frog. She took it into the next room, and went to
work on it. Presently, I heard the cry of a baby.

'Is that our baby?' I asked.

'Yes,' replied Mr Sackey, impassively.

To confirm his statement, Emilia bounced
back into the theatre, bearing aloft the blindly staring little creature,
wrapped in a towel.

'Jesus Christ be praised!' I shouted.
Obstetrics can be an emotional business in Africa.

I removed the two afterbirths. Now remained
the problem of the severed head, still stuck rock-like in the depths of the
womb.

I tried to remove it with my hands. No
movement. I applied forceps. No go. Finally, I stabbed the head several times
with a pair of scissors, and it came away.

At this point, the patient woke up
(sic).

What was more surprising was that she
had been asleep so far. I have already explained that a spinal anaesthetic
leaves the patient awake. But with the screen before her eyes and finding
nothing further expected of her, she decided to improve the occasion with a
useful nap.

Lying there, with her belly and her womb
laid open, covered in blood and meconium,

she grunted something in the vernacular.

I asked Mr Sackey what she said. He
replied in these immortal words:

'She's asking for her breakfast.'

All I could say was, she would have to
wait.

I got everything stitched up, and they
took her back to the ward. Ten days later she galloped off into the bush, with
her new baby on her back.

I remember the names of my first big
cases: my first caesar, my first hernia, my first ectopic. I remember hers. It
was Veronica.

I wonder what became of her. I wonder if
she returned to the hospital for her next delivery. Perhaps not, after her
drastic experience with her first. Perhaps she is lying in some grave in the
forest, with an unborn baby inside her.

And I wonder what became of the baby I
delivered. I cannot remember if it was a boy or a girl.

It was not exactly a flight. It was mostly
a train journey. It began in the labour ward.

Emilia, the midwife, informed me that
she 'had a baby which she did not like the look of'. I went with her to see.

The baby had just been born. African
babies are not born black: then they are only slightly duskier than white
babies. They gradually turn black over the first ten days of life. This one
looked decidedly grey.

I examined it carefully, including the
heart sounds, which were normal. I decided to wait and see.

Two days later, the baby looked worse;
and now I could hear a loud heart murmur. Obviously we had a 'blue baby' on our
hands, a baby with a congenital heart defect.

I asked Emilia where we could send it
for heart surgery. She thought maybe the capital, Accra.

'Then we must send the baby to Accra,' I
said.

Midwives the world over are independent
figures as many doctors have found to their cost. African midwives are no
exception.

Emilia drew herself up to her full five
feet and declared: 'Never since I am in Samreboi have we sent a baby to Accra!'

'Well, we are starting now,' I retorted.

Emilia began to harden with that
adamantine hardness which I was later to discover was a peculiar property of
this otherwise docile race. In the discussion that followed, I referred to the
chances the baby would have in the West End of London, with other such appeals
to fair dealing. Eventually, Emilia gave way.

Once she had accepted the proposition,
she threw herself into it with characteristic dedication. We made plans.

First of all, we obtained oxygen for the
baby. The only oxygen available came, not in the handy medical size cylinder,
but a massive industrial object it took two strong men to handle. This was
connected to the baby, whose colour began to improve. Now for the journey.

The mother would have to go, as all
African babies are breast-fed. Father would be needed, if only for muscle
power. Moreover, father's consent must first be obtained. An African peasant
woman is no more placed to take an independent decision than her baby itself.
And Emilia would have to go to manage the business.

Where was the father? Another
difficulty. It transpired he was not a company employee but a 'house-boy'.
(Those were the days before we called them male domestic workers, comrades!)
The company undertook to provide unlimited transport for employees only: others
would be carried to the railhead, forty miles away at Prestea. After that, they
were on their own.

Now the railways of Africa universally
run up-country from the coast, being originally built to garner the products of
the continent rather than with any concern for the convenience of the
inhabitants. That meant that while up and down journeys were no problem, to
travel cross-country was not so easy. In short, our little party would first
have to travel down to the coast at Takoradi, then up-country again to Kumasi,
then down once more to Accra: which is like travelling from Liverpool to London
via Bristol and York.

We worked out that they would need sixty
cedis (which in those days was about sixty US dollars).

Where did the house-boy work? Mother did
not know. She lived in the 'boy's house', in the garden of their master, but it
is no part of a poor African woman's duty to know her husband's business.

Somebody said he worked for Mr Simpson.

It was four-thirty in the afternoon,
when I knew Mr Simpson would be relaxing from his labours at the bar of the
club. There I found him and told him the sorry story.

Mr Simpson was a dour Scot. He listened
throughout with a penetrating stare, which penetrated further when I finished.

'Ye mean ye want me tae find the sixty
cedis?' You've got to hand it to them for penetration!

After sundry uncharitable noises,
evidently intended to disabuse the neighbouring drinkers of any idea that he
was going 'soft', Mr Simpson drew a cheque and got sixty cedis from the bar.

I carried them in triumph to his house.

The father was rooted out of the boy's
house. He was followed by about ten other children. The story was told again.

The father appeared even more guarded
than Mr Simpson had been.

'Ah, docketa!' he exclaimed, with that
sceptical glint of the eye and click of the tongue which I was also to come to
know so well. 'Dis pickin never fit go for Accra!'

Newcomers to the Coast , especially
ladies for some reason, swear they will never resort to 'pidgin'. After a month
or two, when the limitations of the Queen's English become evident, they change
their minds.

The inevitable African crowd had
gathered. I played unashamedly to the gallery like a past master.

'I never savvy you be docketa, my
friend!'

This drew the expected laugh.

I produced my ace card.

'Mr Simpson has given sixty cedis for
the train,' I announced, drawing the notes from my breast pocket.

A small boy, who had obviously never
seen such a sum in his life, gasped: 'Sixty cedis!', clapped his hand to his
head and went through a theatrical fainting fit. I might add they are born
actors. Sir Laurence himself could not have faulted the lad - or done better.

The ambulance took the little party,
plus the massive oxygen cylinder, to the railhead. They waited all night for
the train to the coast. Then, as I have indicated, up to Kumasi, and a third
journey down to Accra. The group attracted considerable interest throughout,
which Emilia exploited as only a midwife can, commanding strong men to 'stop
staring and lend a hand' with the oxygen cylinder. Finally they emerged from
the station at Accra.

It was then that the mother saw traffic
for the first time in her life.

Vehicles there were at Samreboi, even
some very large ones, called 'loggers', for transporting the timber, but they
never added up to 'traffic'.

It was too much for the poor mother.
With a scream of 'Jee-sess!', she turned tail and clutching the baby, tore back
into the shelter of the station.

Leaving the husband in charge of the
oxygen cylinder, Emilia tore after her.

Eventually they got into the outpatient
department of the great Korle Bu Hospital. It was, like any such institution, a
sea of bodies. Emilia found a big bossy sister.

'Is this an emergency?' demanded the
BBS.

Emilia faced up to her like a honey
badger (which is well known to be the fiercest animal in Africa) to an
elephant.

'Of course it is an emergency. We have
come from boosh! FROM BOOSH!!!'

In short, the baby was admitted to the
ward, where it lay for three days before being seen by a doctor - in fact, by
the professor on his regular ward round. He just had time to demonstrate the
interesting case to the usual train of registrars, house officers, and nurses,
before the little thing expired.

  The truth was, I had overestimated the
level of the country's technology.

Which taught me one thing: the 'demands
of the ideal' (in Ibsenian phrase) have no place in Africa, where 'the best can
be the enemy of the good'