And so it didn't hit me that I was actually going back to Africa until the night before I left. The NSICU was a busy month and left me little time to think about the trip. The last 24 hours were a flurry of activity as usual with various errands, “procurement” of medical supplies, and packing. I am heading to Tanzania in East Africa, a country that I have visited before, but am hoping to become more intimately familiar with. Cincinnati to Paris to Nairobi took about 24 hours. The company supposed to pick me up at the airport never showed so I hailed a random taxi and headed to my lodging around 1AM. The guard didn't have my name on the books but I got lucky and snagged the last room for a couple hours of shuteye. At 6AM I headed to the bus station. As part of the trip I had been encouraged to hire a private car for the long journey to Shirati in rural Tanzania. However, it would be about $350 for a single person one way. I thought this was outrageous (I could probably buy a motorbike and drive myself for less than that). Perhaps a bit of an exaggeration but I opted instead to take a local bus for $10...In addition to the obvious cost savings, the cross country bus is the usual test for any intrepid foreign traveler and I wanted to see if I could still hang.
The cab driver was skeptical when I stated that I wanted to go to the bus station. I asked him to drop me off but he refused and said he would take me in personally. “There are bad people here,” he whispered. I initially thought this was ironic considering the number of cabbies I had been cheated by through the years. The bus station reminded me a lot of an Indian bus or train station. A mass of humanity and chaos. The driver almost immediately got into a fight as the parking ‘managers’ (none official and mostly self-appointed) did not let him park and forced him into the morass of buses and people in the terminal. After we got to a dead-end jammed by buses on all sides we turned off the car. I was about to get out but the driver yelled, “Stay here!” He locked the doors and scurried away. He resurfaced a few long minutes later and said he had found a bus. He grabbed me and started running zig-zag patterns through the crowd. “Follow me!” The crushing waves of people surrounded me and the hawkers hit me from all sides. There was even one guy who pointed and yelled, “Mzungu, Mzungu!” I was incredulous. Through all my previous African adventures I had largely avoided such designations. Despite my nearly native dress and confident walk this guy had found me out. Mzungu literally means ‘foreigner’ but is generally reserved for individuals of much lighter complexion than myself. This guy was pretty good or maybe it was the long hair that was the giveaway. Luckily no one else really seemed to mind.
(aerial view of Nairobi bus station)
As we approached the bus, I tried to hand the ticket guy a $20 bill (I hadn’t gotten a chance to exchange any money since I had only arrived a few hours prior). He looked at me like I was crazy: “We don’t take that.” The taxi driver started to look worried now. He grabbed my money to go exchange it for Kenyan Shillings in the back alley: “Stand right here. Do not talk to anybody!” By now a crowd had started to surround me and the ticket agent. There was yelling and shouting and pushing. I was starting to get nervous. Just then the taxi driver returned with the cash. He thrusted it upon the ticket agent and then pushed me onto the bus. “There are no more seats left. Do not lose this ticket or they will kick you off the bus. Do not buy anything. Do not eat anything. Do not talk to anybody! I will make sure your bag gets into the boot (aka ‘trunk’).” Looks like they saved the last seat for the mzungu. With that the taxi driver turned to leave. I yelled after him, “Wait! What’s your name?” He looked puzzled. “My name is John.” I smiled. “Asante sana, John.” He nodded and then hurried towards the loading crew. I've realized through the years that I often have to implicitly trust many of the people I meet in my travels. And yet I never cease to be amazed by the kindness of random strangers who go out of their way to help and often protect me.
As I began to walk down the aisle I was intensely aware of everyone staring at me. My trekking pack did not fit down the aisle and I lifted it above my head and scrambled over various packages, bundles of produce, and the errant child. Much to my dismay there were no chickens or livestock, always the gold standard for a true local bus. However the bus was packed and at first I did not see any seats available. I walked all the way to the back and realized the last seat was on the bench at the rear of the bus. I climbed over several people and squeezed in between 8 other people (7 adults and 1 child). There was nowhere to put my back (which contained all of my worldly possessions) so I placed it on my lap. The windows were shut, the heat was stifling, and I was physically sticking to the two individuals beside me. I finally felt at home.
It took nearly an hour to get out of the literal parking lot the bus terminal had devolved into. Buses were pointing every which way and interspersed were random cars, motorcycles, and people. It took hundreds of back-and-forth maneuvers to get out of the bus station without striking any other buses or vehicles. The bus ride would take 10 hours from Nairobi to the Kenya-Tanzania border. From there I would have to get on a jeep to make it the rest of the way to the remote village of Shirati in Tanzania near Lake Victoria. The additional 2 hours were mainly on dirt/mud roads through various villages.
The bus ride started with what I thought was the conductor getting up and telling everyone the rules of engagement. I thought this was peculiar since I had never heard anyone giving rules/instructions or even names of bus stops during previous African bus trips. It was all in Swahili so I couldn't make out exactly what he was saying. However, he continued on and on, getting louder and louder by the minute until he was screaming. He had the entire bus in a frenzy and everyone had their arms raised. I finally realized that he was preaching. This continued for over an hour until his voice was hoarse and sweat profusely dripped from his brow. He was succeeded by another individual and then another. I was beginning to wonder what kind of bus I had gotten onto. Everyone was in a trance and even the little children had their arms raised. It felt like some kind of cult. Bits of English would occasionally filter through. “Today will be the start of a new life!” “This is a new beginning!”
This would be a fateful day as in the midst of the sermon we heard a loud crash and the bus came to a screeching halt. Everyone stood up simultaneously. I heard murmurs at first and then screams as the bus emptied. I scrambled out into the midday Kenyan sun. Immediately in front of our bus, a motorcycle had hit a matatu (mini-bus known by various names and seen across sub-Saharan Africa) head-on. It had been nearly 48 hours straight of traveling and I was dehydrated and delirious. It felt like a dream. Despite the glare of the sun, I could make out a body lying spread eagle in the middle of the road. It was the motorcyclist and he was clearly dead. Blood and brain matter were scattered everywhere. I dragged his body to the side of the road while trying to avoid oncoming traffic. I then ran to the other side of the road. At first I couldn’t even see the matatu. It had apparently struck the motorcyclist, swerved, and tumbled off the ravine to the side of the road. I was horrified. I had taken such vehicles innumerable times in the past across several countries. They are generally stuffed to the brim with people, as many as 15-20 at a time. While usually uneasy when travelling in one (the drivers are generally erratic and speed mercilessly), I routinely do so because it is exceedingly cheap and is the mode of transportation for the common man.
(typical matatu)
This particular matatu had rolled off the side of the road and lay about 20-30 feet vertically down in a ravine. It had tumbled through thick brush and was lying upside down. As I got closer I could hear the wails of women at the edge of the road crying in despair. I pushed through the crowd that was quickly forming and started climbing down. It was incredible to see how quickly people came together to help. Women who had been working the fields came with machetes and began to cut a path for the men. As we made our way down the scene turned even more grim. There were additional fatalities and bodies were strewn everywhere. We began to carry each bloodied and mangled body up towards the road. In addition to the dead there were several critically ill passengers. I quickly began to triage in my mind. Several black tags already. Several ‘green’ tags. One man had clearly broken both legs. He calmly looked at me, his eyes pleading, and asked, “First aid? Please? First aid?” I put my hand on his shoulder and said, “Please wait. Help will come.” In fact, I did not know if any help would come. I moved on to the ‘red’ tags, critically ill people that had a chance to survive with appropriate intervention. There were several people that were minimally responsive or altogether unresponsive, likely with severe TBIs (traumatic brain injuries) or intra-thoracic injuries. Blood was pouring from scalp and other wounds so I had bystanders hold pressure. Another man was gasping for air as blood was pouring from his mouth. I didn’t have a stethoscope but he potentially had a pneumothorax (collapsed lung) and or hemothorax (blood in the chest cavity). In fact I didn’t have any supplies whatsoever. The motorcyclist could have used a thoracotomy (cutting open his chest) since he was found pulseless within a minute or two after blunt trauma. All the critically ill likely would have been intubated (with breathing tubes). The man with the pneumothorax could have used a needle decompression or finger thoracostomy (cutting the chest to relieve pressure from the collapsed lung) and chest tubes. Many of these patients would have been helicoptered to level I trauma centers in the U.S. Instead here they were languishing on a rural Kenyan road with no EMS system and no help in sight. I was reduced to assigning GCSs (Glasgow Coma Scores). Despite all my years of education and medical training, I felt completely and utterly helpless.
In the midst of despair the situation somehow worsened. The crowd surrounding us had enlarged and was growing angry. They were trying to stop vehicles and buses to help transport the victims as I presume they knew that no ambulance was going to come. They started banging on cars with windows and windshields beginning to shatter when people refused to stop. Our bus driver, fearing the growing mob, began to drive away. All the passengers who were milling about ran after the bus. Suddenly I was faced with a horrifying split-second decision. Do I stay or do I go? In my haste to get to the accident scene, I had left everything on the bus. I did not have any money, my passport, or a phone. In fact I had no idea where I was (some 4 hours away from Nairobi and still 6 hours away from the border) besides being somewhere in the rural Kenyan countryside and I did not entirely know where I was going...
...There were again stares as I walked down the aisle (as the bus sped away) but this time it was because there was still fresh blood dripping from my hands and clothing. I slowly returned to my spot at the back of the bus with a sinking feeling in the pit of my stomach. I looked out the back window and could still see the blood stain in the middle of the road from the motorcyclist. I could also see the victims I had left behind, perhaps to die? Waves of nausea struck me and all I could do was clutch my face in my hands.
Today I failed not only as a physician but also as a man. Hopefully tomorrow I will do better.
