An Open Heart (9 page)

Dave grunted. “Eat fast.”

Ten minutes later, Jace trailed Dave as they walked into the casualty department. Dave walked fast, and Jace felt as if he were a medical student again. They met an intern, Margaret Mwaka. “Show me the head-injury patient first,” Dave said.

The Kenyan intern was professional and controlled. “Over here,” she said, pulling back a curtain. “Twenty-eight-year-old male thrown from the back of a pickup truck. Arrived conscious with a GCS of fourteen. We got a chest X-ray and C-spines and saw no fracture. Ten minutes after arrival back in casualty, he blew his right pupil and GCS dropped to six.”

“Is theater ready?”

“Waitin’ on you.”

“What else do we have?”

She pointed at an old man in a shuka, traditional dress for the Maasai tribe. “Hasn’t been able to void all day. Bladder palpable at his umbilicus. Nurses tried a Foley and failed.” She moved to the next stretcher. “This gentleman has a large perirectal abscess.”

“Set our urinary retention patient up in recovery room. I’ll show Dr. Rawlings here how to get a catheter in while you prep the trauma patient for the burr holes.” Dave looked at Jace. “Think you can drain the perirectal abscess while we do the head trauma?”

“Sure.” Jace spoke with feigned confidence and followed the seasoned general surgeon to the theater.

Dave didn’t look convinced. “How long’s it been since you’ve done any general surgery?”

Jace shrugged. “Residency.”

“Do you want me to get the intern to drain the abscess?”

“No. I, uh—I can do it.”

Dave nodded. “Okay. I’ll be in the next room if you need help.”

Jace changed into scrubs and watched as Dr. Fitzgerald deftly placed a Foley catheter using a flexible metal stiffener, resulting in over a liter of urine.

The surgeon nodded. “Normal capacity of the male bladder is around 450 ccs. This guy will need to keep the catheter for a few days to let the bladder muscle recover. We’ll likely need to do a prostatectomy to help his flow.” He paused. “Do you have any experience in prostatectomy?”

Jace shrugged. “I’ve never even seen one.”

“I guess I’ll just have to show you how.” His voice was pleasant, but his expression gave a clear message:
Worthless subspecialist!

As Dave went off to start the head-trauma patient, a nurse came out of the second operating room. “I have the patient’s spinal in. We are ready for you to drain the abscess, Dr. Rawlings.”

Jace wished he’d had a chance to look the procedure up. He took a deep breath.
Hey, I can do cardiac valve surgery. How hard can this be?

He followed the nurse into the room to see the male patient up in stirrups as if he were ready to deliver a baby. At least the problem was obvious. An angry reddened swelling looked ready to burst. Jace nodded at a scrub assistant. “I’m Dr. Rawlings. First day,” he added, shrugging.

“My name is Michael. The scrub sink is out there.”

Jace stepped back into the hall and began scrubbing his hands at the sink. In a moment, Dave Fitzgerald joined him. “This ain’t heart surgery, Jace. You can stop scrubbing now.”

He felt his face flush. He stepped to the door.
Wow,
he thought.
If only my cardiothoracic surgery partners in Virginia could see me now. Big American heart surgeon draining a perirectal abscess.
He chuckled at the irony. Surgery could be humbling stuff.

He pushed open the swinging door.
It’s just a test, Jace. They want to see what you’re made of.

He positioned himself between the patient’s legs, and the assistant handed him a knife.
Thank God for an assistant who knows what to do.

He felt the skin, tense and stretched over the abscess. He stood with the knife poised over the skin.
Here goes nothing.

He stabbed the skin, releasing a large amount of pus. He smiled behind his mask.
Just like riding a bike.

He stood looking at the operative field for a moment, saying nothing. The tech asked. “Would you like to irrigate?”

Sure, that’s the next step.
“Irrigation,” he said.

He irrigated the wound and applied a gauze dressing. Standing back, he mused how as a heart surgeon he had dreamed of coming to Kenya to do open-heart surgery—high-tech, critical operations. Yet here he was doing what many surgeons would consider the most basic and useful of operations: the evacuation of pus. His dreams were being downsized, one notch at a time. First, an overnight in the local jail, suspicions of local Kenyans inside and outside the government, and now, an opportunity to operate at last—and what do they give him to do?
Butt pus, the bane of all surgery.

He walked out and washed his hands again before walking into theater number one. There, Dave Fitzgerald was instructing the intern over a sleeping patient.

“The dilated pupil indicates increased pressure inside the skull, likely from a bleed. Where do you make the first burr hole?”

The intern was confident. “Temple area, above and in front of the ear.”

“Which side?”

“The side with the dilated pupil.”

“Correct. What if both are blown?”

“On the side with the pupil that blew first.”

“Okay. If you don’t find blood at the first burr hole, where do you drill next?”

“Occipitoparietal.”

“The third hole?”

“Frontal, at the hairline.”

“Excellent. What’s the prognosis?”

“If we are quick to drain the blood before there is serious damage, the reversal of symptoms and the recovery can be very rapid. If all we do is a burr hole, the intervention is quite minor. He could be normal in a week or two.”

Jace listened intently.
Yes, I know that from personal experience.
He wished for a piece of paper. He needed to be taking notes. The intern knew more about head trauma than he did. The last time he’d treated a head-trauma patient, he was an intern at the University of Virginia—and there, they had a CT scan to show the surgeon exactly where to drill. Here, out in the middle of remote Africa, the surgeons had to rely on physical findings and the patient’s clinical course in order to decide when and where to drill. Without the advanced technology available in the West, the surgeons in Africa had to be
better
than their American counterparts. That thought was new for Jace.

His gut tightened. How would he ever be able to face everything that came through the casualty doors when he was on call? Who was he fooling? Certainly not himself.

When the surgery pair started drilling the first burr hole, Jace was mesmerized. He raised his hand and explored the tender scar well hidden beneath his hair.

It had only been eight weeks since he’d been the patient in an identical operation.

An hour later, after the lights in the operating theaters were out and the orders were written, Jace exited the hospital beneath the expanse of the African sky. He felt out of control. He longed for cardiac cases, where he knew what to expect and where he enjoyed ruling his small kingdom. But here, he felt alone and on unsure footing.
Why does everything have to be so hard?
He raised a fist to the sky.

And listened.

Around him, a chorus of crickets faded to background noise as he tilted his head, turning an ear to a silent, mocking sky.

There were no answers beyond the accusations in his own mind—the guilt that drove him, occasionally with the sharpness of a surgeon’s scalpel, but always with a dull emptiness asking for satiety that never came.

Then suddenly, he laughed. Not from joy, but from the irony of a tiny speck that dared lift a fist in the face of the universe.

And Jace knew, as certainly as he understood the complexities of the physical heart, the muscle he’d dissected a thousand times, that the heartbeat of his soul had faltered along the way.

He’d been avoiding a confrontation with the source. He lowered his fist and slowly opened his hand, watching an involuntary twitch and pushing aside a doubt about his readiness.

Beneath the twinkling of the night sky, he again turned toward the cemetery.

A few minutes later, he entered the graveyard via the dirt path leading from the hospital parking lot toward the housing units on the other side. As was so typical for Kijabe, cool wind rose from the floor of the valley and swept across the edge of the Rift Valley escarpment, battering the leaves into rhythmic applause. The grass was tall and needed cutting, something that would be done by hand with a Kenyan sickle. Gravestones, mostly small, some leaning as if they were burdened with age, stretched in rows on either side of the path. Rows of dead patients. Rows of the missionaries who came to serve on the African continent, lives given unfairly and prematurely to malaria, typhoid, and Rift Valley fever.

This, to Jace, was the ultimate slap in the face. What kind of divine message was this—that sacrificing a life for God would mean the loss of loved ones in return? Parents had come to Africa, filled with glorious hope of converts; instead they had buried their children.

He slowed his pace, aware of the moonlit shadows of tree limbs dancing on the ground in front of him. They swayed to a funeral march. Two-thirds of his way through the field of death, he paused, looking at the branches of a eucalyptus. Hands lifted high toward a distant God.

Jace turned, his heart quickening. He moved forward, his legs parting the tall grass. Ahead of him, and to the right, a blur of fur startled him. A mongoose had been digging at the foot of a gravestone. He took a deep breath and continued, counting the stones from the edge of the path.

At twelve, he stopped and leaned over a flat stone. He knelt in the tall grass and began to brush away the dirt from its surface, his hand trembling.

“Janice Elaine Rawlings,” he whispered, tracing the letters with his finger.

“O-okay,” he stuttered. “I’ve come back. Now what?”

Twenty meters from the edge of the cemetery, Lydia Otieno leaned over the kitchen sink and squinted at the outline of a dim figure in the moonlight. “John,” she said. “I think you’ll want to see this.”

The chaplain rose from his chair, switched off the kitchen light, and stared out beyond a row of bougainvillea. In the cemetery, a solitary figure knelt over a grave marker.

“It’s Dr. Rawlings,” he said softly.

His wife nodded and placed her hand on her husband’s shoulder.

“The battle is beginning,” he whispered. “We need to pray.”