Ben Cavilla’s Blog

Drawing to a Close

Needless to say our little excursion to the far reaches of Angola was an experience I will never forget and despite the horrifying images that are now burnt into my memory I would not trade it for the world.  It was a perfect mixture of adventure and medicine and a dream come true for an aspiring humanitarian like myself…. a truly amazing experience in every possible way and a perfect note on which to head home to Canada the next day.

As a final note, many of you have been following my stories intently and holding much hope for the patients I have been fighting for.  I thank you all for your thoughts, prayers and constant encouragement.  I am happy to report that by the time I returned to the hospital in Lubango Sunday morning our little girl with perforated intestines was up and walking about enjoying the sunshine with her family, and I was able to send my much  less humpty-dumpty looking patient with heart failure home with a promise to return next week for follow up with Dr. Foster.

Thus ends my experience on the great African continent.  It was truly amazing in every way.  Difficult at times but amazing.  I will never forget the people and patients that I encountered here…those I lost and those that survived to see another day.  I hope you all appreciated hearing about my experiences here and were able to get a picture of just how desperate the situation is for these people.  I know that I have certainly come to appreciate on a new level, all that I have back in Canada and how much we all can afford to spare.  And for those of you who likely are wondering…. I will undoubtedly be returning to Africa with the Flying Doctors of Canada at some point in the near future.

I miss you all and hope to see you soon,

Ben

Angola Week 5

Well my last and final week in Angola proved to be everything I had hoped for and truly made all the prior frustrations worth while.  After an early rise last Thursday morning we piled into a 1985 Cessna Caravan single-engine airplane and lifted off with a team consisting of myself, Dr. Foster, two “nurses”, an Angolan med student and the two Canadian pre-med students.  It was only about an hour flight and despite a clueless motorcyclist on the run way forcing an abrupt pull-up and fly around and a flock of birds who veered off the approach path just in time on our second attempt, we landed safely on the bumpy dirt runway in the small town of Kalukembe late Thursday morning, where we were met by hoards of children and other equally curious spectators.

Kalukembe Hospital is an ancient looking structure amidst the jungle of northern Angola scarred by years of civil war and turmoil.  Nonetheless, it stands defiantly bursting at the seams, supported day in and day out by the superb nursing staff that are particularly adept with a knife despite their lack of pathophysiologic knowledge.  Needless to say, our arrival at the hospital was greeted with much fervor and scurrying about which was somehow refreshing to see after the likes of the hospital in Lubango, and we were quickly escorted through ward after ward, each filled to capacity with patients and their attentive families who welcomed us cheerfully with the typical “Bom Dia Doutores!” that is seemingly appropriate for all mornings, regardless of the actual state of affairs.  The Angolan people have a way of glazing over everything from a poor nights sleep to a recently amputated limb with a simple “obrigado” (literally meaning thankyou, but probably translating to something more like “my amputated leg is fine…thanks for asking!”)

What ensued in the following days is difficult to articulate, but suffice to say that even my time spent in the cities of Angola did not prepare me what I was to experience in Kalukembe.  There are far too many stories to tell here, but some of the more interesting cases we encountered included a baby born the day we arrived with anencephaly who we could not help, a woman who arrived with her decapitated baby’s head still inside her womb (apparently the nurse who attempted the breech delivery thought this was the best option to save the mother after he was unable to deliver the after-coming head) and the little boy who came in with triangular puncture marks all over his body after escaping from the jaws of a crocodile!  These of course were all complete firsts for me, but were surprisingly not the most bizarre of my cases (incidentally, when you hear hooves in Africa you think of Zebras long before Horses…).  Taking first place in the long list of bizarre cases that I saw in ‘Disturbia’ was a woman who came in with a story of being pregnant for 10 months without any fetal movements for the past 4 months and black, foul liquid pouring out of her….not a good sign to be certain.  According the reports of the local ultrasound technician, we were led to believe that she had a bizarre thing called a molar pregnancy (really a malignant tumor of the womb) and we booked her for surgery.  However, things went from bad to worse on the operating table and with some urgency secondary to her continued bleeding and rapidly falling blood pressures, we removed her womb which much to our surprise (and disgust… this is one of the few times since I began medicine that I have actually gagged behind my mask) the womb contained a partially decomposed fetus that was unfortunately all too recognizable as such.  I will spare you the very graphic details of it all, but suffice to say the whole thing was horrendous.  Needless to say, this is not an experience I would ever choose to relive again, and despite being mislead by the report of a molar pregnancy, the hysterectomy  was probably life-saving in the end, as her septic shock and hemorrhage left her barely clinging to life as we closed her up.

Anyways, as always the lows are followed by highs and I was given the opportunity to perform three sequestrectomies on my own later that afternoon…. Despite it’s very typically complicated medical name, a sequestrectomy is quite a simple operation in which you use chisel out a trough in the bone in search of dead and infected chunks of bone in what used to be the marrow space.  As strange as it may sound, there is a triumphant feeling of satisfaction (those of you who have ever struggled with eating fresh crab out of the shell may relate) when you pull out a big chunk of dead bone all in one go and by the time we left late Saturday afternoon, I had successfully removed 3 such morsels and assisted Dr. Foster with 46 other surgeries in just over 36 hours… incredible.


Angola Week 4

Well I made it through my third week here in Lubango, Angola, and like those before it this past week was an experience to say the least.  Unfortunately the weather has not been very good and it has been raining most days. And when I say raining I mean bucketing….torrential downpours!  The sound of the pounding rain on the tin roof is so loud at times that it makes having regular conversations with the patients difficult!  So needless to say, my tan is not coming along very well and when you add this to the chronic dehydration resulting from the non-stop diarrhea I’ve had since I arrived, I look slightly less pale than the albino patients that have seen on occasion in the clinics.  Despite drinking filtered water and eating only that which I can cook or peal, I have managed to contract a nasty bug which so far has evaded two courses of antibiotics.  I feel pretty crappy most of the time (pun intended) but I am surviving….anyways I digress.

So the last week was an interesting one on several counts.  Between peering into the far reaches of one colon after the next and taking a wrong turn which led to an accidental bronchoscopy in another (I knew something wasn’t right when the ‘esophagus’ split and headed off in two different directions), I have managed to develop of level of comfort in steering an endoscope.  I have to say that the fact that the endoscope does not turn left did not make my learning experience any easier…

My most interesting case in the past week was a 33-year old man who presented himself to the emergency department with difficulties breathing secondary to a massive humpty dumpty-like abdomen.  By the time I saw him, his diaphragm was just below his collar bones and his head looked like it would blow off at any moment (this would later be a key point in his diagnosis however I failed to appreciate it as such at the time).  The massive swelling of his normally stick-like legs was a dead give away that this was not a belly full of air (as is often seen with typhoid fever) but rather a belly full of fluid…dark yellow fluid to be exact (I thought I had put the needle into has bladder at first)!  And after reassuring myself that this was not urine (it didn’t smell like urine) I sat for 45 minutes while 3 liters of fluid drained out of his abdomen through an 18 gauge catheter and into a bowl on the bed beside him.  Needless to say he was very relieved and very thankful.  Unfortunately the fluid recollected 2 days later and I had to do the same dramatic puncture all over again in an attempt to buy some time.  And as I sat beside him watching the still bright yellow fluid dribble out, I ran through the signs and symptoms again…it just didn’t make sense.  This guy was 33-years old, drank no more beer than myself in a standard week and had a massive hepato-splenomegaly (his liver was about the size of football and his the tip of his spleen was somewhere below his belly button) which was presumably preventing the drainage of fluid from the lower half of his body…or was it?  I ran it buy another doctor who thought that it was likely alcoholic cirrhosis which is apparently seen quite often here.  But alcoholic cirrhosis at the age of 33 in a guy presenting with a big liver and spleen, a roaring mitral valve murmur, an exploding head and a blood pressure of 80 on nothing?  Something didn’t add up but my inexperience made it difficult for me to figure out why.  Later that night as I lay awake in bed going over it all again in my head it came to me and I bounced out of bed and burst into the med students room (much to his chagrin) yelling “ it’s his heart!!!” He was thoroughly startled and confused to say the least, but he listened intently to my 2 a.m. my inadequate explanation of cardiac physiology and right-sided heart failure.  I was as sure of this explanation as I was that my diarrhea would never go away and sure enough when the x-ray came back the next morning there it was….a heart shadow as big as a house.  Unfortunately we did not have the technology to make the distinction between a big heart and a little heart with lots of fluid around it, so I ended up sticking a 6 inch needle up under his ribs and into his heart in the hope that I could draw off a decent amount of fluid…but no such luck. A few dribbles of clear fluid and then a gush of dark purple blood and a fairly striking arrhythmia on the heart monitor after advancing the needle another centimeter, was I all I got.  He had a massive baggy heart likely due to a viral infection and in the end we cut a hole his belly just below belly button and sutured in a drain to let fluid drain off and give his heart a chance to recover. As disappointing as this was for me (it would have meant almost an immediate cure for him) he was very thankful for his new release valve which drained 7 more liters of fluid over the next 24 hours and has drained steadily ever since. Despite this, and the very poor prognosis of an unrecognized viral cardiomyopathy (I should have realized it the first day when his head was about to explode) he has continued to improve, day by day and was walking around the hospital when I arrived today, which encouraged me greatly.

But as always, bad news follows quickly on the heels of good news. Aurora, the little girl with the perforated bowel has taken a turn for the worse again and I am once again scrambling to keep her alive.  She has developed another hole in her intestine this past week and the tube that was draining away bowel contents has fallen out. Her little body is burning with fever and she is now just skin and bones. I have spoken with Dr. Foster but he will not operate again as he thinks she would die on the table. I will continue to do everything possible for her but hope for her is fading with every passing day.  Sadly all I can do at this point is watch and wait.

Angola Week 3

Well it’s been quite awhile since my last entry and needless to say a lot has happened. The badness seems to come in waves around here and the last week has been a calm…hopefully not before the storm.  The wards are now relatively quiet and thankfully quite a few patients have made it to discharge lately.  I only lost one elderly woman to the ever-present Tubercolosis last week compared to the wave of deaths, both young and old the week before.  Tubercolosis has become my nemesis here in Angola as I am sure it is elsewhere as well.  A disease with a history dating back farther than medicine itself, TB continues to evade modern diagnosis and treatment (neither of which are available here). In the majority of cases (save those cases of Pott’s disease and TB of the knee which have fairly classic presentations) I am unable to rule-in or rule-out TB in most cases.  It seems everyone has abnormal x-rays here and the classic finding of a “casseating granuloma” of the superior lobe is as rare as an albino Angolan (have now seen 3 of such unfortunate individuals with horrible skin cancers). We rely mostly on the patients recount of their illness, exposure to family members with “coughing sickness”, the classic constitutional symptoms that we all we’ve all read about in the books and very non-specific erythrocyte sedimentation rates!  Unfortunately there are no capabilities for bacterial cultures here and TB skin testing is a waste of time as it is positive in almost everyone.  In fact, I beginning to wonder if BCG vaccination for TB should be abolished as it seems to offer mediocre protection against infection and makes definitive diagnosis in this setting almost impossible. A similar situation exists with Plasmodial infections as well.  I am only rarely able to say with any sort of conviction that a patient’s symptoms are due to malaria.  Unfortunately most people here have signs of P. Falciparum in their blood making the establishment of causal relationships difficult to say the least!  Everyone who comes through the door is tested for malaria (after all, it is the great pretender …as is TB…as is syphilis) and 8/10 come back positive!  As such everything from hemorrhoids (malaria can cause portal hypertension) to headaches (malaria causes hypoglycemia which leads to headaches) is caused by the ever-present malaria…. Personally I think it to be a ridiculous notion but the practices are entrenched.  Anyways, I digress… but suffice to say I am learning to live with a considerable amount of diagnostic uncertainty.


Anyways, I am sure you are all waiting for an update on my blog from last week.  I am sorry to have left you all hanging with what in hind-sight was a fairly sad posting.  The little girl that I spoke of took a turn for the worse and ended up with perforated intestines and a belly filled with fecal matter on Sunday morning. Thankfully I had initiated antibiotics through a tenuous IV in her little hand the day before and she survived long enough to make to the operating table first thing on Monday morning when Dr. Foster returned.  When we opened her belly a fountain of browny-green liquid spurted several feet into the air and flooded the floor (and my scrubs), confirming what we had suspected, and after a careful search of her little bowels we identified 4 holes in all, each of which was sewn over in turn before stitching her up and sending her to the “ICU”.  In spite of what I would call a very abysmal prognosis 7 days ago, I am very happy to tell you that I arrived this morning, after a week of gruelingly slow recovery to see her sitting up in bed with her mother… truly it was one of those moments in medicine that makes all the hardship seem worthwhile.  It looks as though she has made it through the woods now and I am hoping to send her home next week.


So all in all, the week gone by was a positive one and I am feeling less defeated than the week before.  For once there were more patients getting better than getting worse and I was able to spend quite a bit of time in the operating room and was given the chance to perform several procedures I would not normally dream of doing back home, including gastroscopy, colonoscopy (I was happy to learn there were two different scopes available for use), and a diabetic foot amputation.  But I have to say the coolest thing of all was the symphysotomy that we (and by “we” I mean Dr. Foster) performed for a labouring woman with a stuck baby.  Who would have guessed that the one procedure that no one teaches anymore is the easiest and quickest way to deliver in a crunch… unreal!  So needless to say last week was a nice reprieve from the week before.  No one  died unexpectedly and we even managed to make a few people better…but this is the story of medicine I guess… it’s an emotional roller-coaster.  The higher you go the faster you fall… but when you hit bottom you can only go up… you take today’s highs with yesterday’s lows and you do it all over tomorrow.

Angola Week 2

Well it has been a few days at least since my last posting and needless to say a LOT happened here in Angola.  It was a tough week to tell you the truth.  The hospital was full of sick patients and we lost 3 more in the last day.  One patient with terminal AIDS at the age of 37, one elderly woman who came in with a rock-hard abdomen and a liter of puss in her belly, and a young guy with Typhoid Fever.  That was a hard one for me as I had been caring for him since admission.  Like happens all too often here, he presented with a fairly advanced infection.  He had been already feeling unwell for almost 10 days by the time I saw him and his eyes were a bright yellow color and his abdomen was full of gas and tight as a drum.  He also had Hepatitis B working against him but I was unable to tell if this was a new or chronic infection as we do not have the necessary lab tests here to tell the difference.  After initiating urgent IV antibiotics in our small Banco Urgencia (ER) I transferred him the 3 bed “reanimation” unit (ICU) which is really more of a holding cell where patients wait to die.  There are no automated ventilators and there are no vasopressors….just bags of saline and very attentive family members who will take shifts squeezing an Ambu bag around the clock if necessary.  Unfortunately 3 days after admission I received a call at 7:00 in the morning saying that things “were not going so well” and in a haze of adrenalin and grogginess, I rushed to the hospital in our rickety Land Rover (driving in Angola is another story that I will have to save for another time). By the time I reached the hospital, the boy was semi-conscious and there was blood spewing from his mouth and nose.  For almost two hours I yelled out broken Portuguese orders to the nurses while two wide-eyed premed students tried their best to do as they were told…. but after 3 liters of saline, one unit of blood (via a central line that was hard fought for) and one vial of dopamine that I manage to find in a drawer, I couldn’t keep up with the blood loss and his heart stopped beating.   He was 21 years old.   And as his family all looked on, I called off our efforts and covered his body with a sheet.  I could see the despair in their eyes and I could not stop the tears as I told them the news….truly one of the most difficult experiences that I have had in my short time as a doctor.  As I walked away, they began the wailing that is customary on such occasions here…it is a sound I will not forget.

Even as I write this recount, I have to fight back the tears.  So many times I feel so helpless.  The paradox of being a doctor but not being able to cure is something that I am struggling to deal with.  Fathers, mothers, sisters and brothers die here everyday… it is almost expected. They come to this “modern” hospital in a final act of desperation in the hope that we can save their loved ones…but for most it is too late.  I do my best to carry on and cling to the memory of those few I have helped.  But even now, I am thinking about the little 6 year old girl under my care who is quickly succumbing to Typhoid Fever and Malaria. I have just transfused her with a third unit of blood in as many days. We are running short of blood and I will donate my own O negative blood tomorrow if she makes it through the night…

Angola Week 1

Well today is bright sunny morning (really one of the few since I have been here) and I decided to get up early and do some writing.  So far I am still as white as a ghost so I have taken to sitting in the window (literally…I sit on the window sill with my feet hanging over the street below) and catching some morning rays from the African sun.  So far the weather has not been great.  Many days are overcast here and there are a few that are cold (I actually had to put on a coat!) which was pretty surprising.  Anyways, I am told it is the rainy season here.  I guess I should be thankful that I don’t have to work all day in suffocatingly hot conditions.  My days are pretty full as I am in the hospital from 7 am to 7 pm and I wouldn’t have anytime to enjoy it anyways….

Anyhow, things here are going well.  I was a bit of a rough start with “the boss” being gone for my first 48 hours in Angola. The hospital was a bit of a disaster, nobody was doing a damn thing and people were dying all over the place.  When the cats away…. but as of yesterday morning Dr. Foster was back and everyone was on their best behaviour again.  After starting the morning off with some very exuberant singing of strangely familiar hymns in Portuguese out in front of the hospital with all the would-be patients for the day, I headed off to the wards for morning rounds with my trusty translator in tow.  My translator is an 18 year old Canadian kid from Toronto who is very keen green medically speaking, but has passable Portuguese and as such is able to translate for me.  We get along quite well and he is more than happy to help in any way that he can.  Unfortunately I lost my first patient during rounds that morning (the nurses did not think it pertinent to tell me he wasn’t doing so well until his heart stopped).  He was an old man with a really bad heart so I guess he was on borrowed time…but still….it was frustrating.

My first afternoon in consults was full of interesting cases to say the least.  My first consult was a young woman who had brought in her 7 year old sister because of a lump she had “in between her legs”.  Expecting to find some sort of cyst or something equally as common I asked her to take her pants off and sure enough just beneath the sparse layer of hair there was a lump in her left labium.  The feel of it rolling between my finger and thumb was strangely familiar and reminiscent of my time spent in Pediatrics.  My mind raced back to the mundane embryology lectures during my years in medical school (I slept through most of them) and my eyes wandered up her to her little chest…no breast buds.  Very strange.  This was something I had never seen in any book before let alone encountered.  I excused myself for a moment and poked my head into the next room where Dr. Foster was seated with another patient and sheepishly said,  “Excuse me doctor…I feel a little silly even raising the possibility of this, but I think that the little girl in my room has a testicle in her labium…do you think you could give me a second opinion?”  He of course laughed at me as we wandered back into the other room, however his smile quickly faded as he examined the girl, finding one by one the clues that I too had seen.  The lump in the labium, the pubic hair, the lack of breast buds.  A less mocking smile crossed over his face….“I think you’re right…we’ll have to take that out!”  The little girl was indeed a hermaphrodite (she later produced a piece of paper detailing in English her XY genetic makeup)!  Prepared for the worst I began to explain to the woman that her younger sister was actually her younger brother, however much to my surprise her reaction was very subdued.  And when I had finished explaining the reproductive ramifications, the necessity of the operation to remove the aberrant testicle and the likely need for hormone therapy (which would undoubtedly be unaffordable), the woman calmly reported that she had had the very same operation as a child…. Que Raro!  A hermaphroditic family!!!  And from the there the weird and wonderful cases rolled on. Pott’s Disease (TB of the spine), a girl with fused toes, a woman with a giant worm coiled in her thigh, and a little girl with a severely narrowed heart valve and resultant heart failure.  I think I saw more strange cases on my first day here than I have seen in all my years combined!

Well I could keep writing all night about the crazy things that I see here, but I suppose that I should sleep.  Tomorrow is another day and given today’s stampede of zebras it will likely be a busy one.  As they say here “Boa noite e ate logo” ( Good night and until then).

The Start of It All

After traveling for the better part of 4 days, I have finally reached my destination of Lubango Africa! The trip from Canada to Angola was a long one to be sure and I was utterly exhausted to say the least, but other than losing my passport, my boarding pass and $200 US dollars in the Vancouver International Airport, only to have it turned in to my departure gate by some very kind person, my trip so far has been quite uneventful. The flight from Vancouver to Frankfurt was brutally long and I was almost certain I would have bilateral leg clots by the end of it.


After another very long flight from Germany lasting in excess of 10 hours (I am pretty sure I had clots after this one) I arrived in the infamous Jo-berg…the huge and sprawling South African city toted to be among the top-5 most dangerous places in the world. Needless to say, I was not too keen on leaving the airport so I did not really see much else in the 4 short hours before departing to Windhoek, Namibia. Most of you have probably never heard of Namibia let alone Windhoek, but it was quite a neat little place hidden away from the hustle and bustle of South Africa and seemingly insulated from the violence that has plagued its neighbors to the north and west. And the fact that “Branjolina’s” son was born there makes it even more bizarre than it already is. Basically a Dutch city in the middle of an African desert, it’s claim to fame is not windmills, cheese nor dykes but rather Jagermeister liqueur which flows like water ….literally…its on tap! Unfortunately my stay there was quite short and I was really so utterly exhausted that I basically slept until I had to leave again early the next morning. Nonetheless, I was very excited to be finally heading to Angola so there was no looking back. “Nowv you vill tsee dee real Africa” they said in Windhoek…they were not kidding.

The flight from Namibia to Angola was a short one but I found myself feeling a little worried given the parting words of my Namibian inn-keeper. “Just veemember….if you get into trouble, just stay the nice and veelax ok?” As it turns out, there was not much trouble at the small table they called Customs in Lubango when I arrived.  I was met by two Angolan employees from the CEML (the hospital where Dr. Stephen Foster is Director and where I was to work) and after a short conversation in Portuguese describing my purpose in the country and my association with Dr. Foster, I was escorted through the line of people and out the front door with little or no hassle!  The whole experience was  a bit bizarre and left me in awe of the apparent influence Dr. Foster held, but I was glad to be free at last. 

My initial feeling was a bit surreal. The city of Lubango looks like what I would imagine Beirut to look like…..narrow dusty streets lined with ramshackle homes, burning garbage everywhere and more stray dogs than even Guatemala!  I had only been here for less than 48 hours and already I had seen more poverty than can be realistically be imagined. I mean, I must have seen hundreds of pictures of these types of places over the years but it is just so real that it is truly overwhelming. So many people and so much poverty.  Where to even start would be a monumental question…

Fortunately for me, “where to start ? ” is not a question I had to answer.  Within minutes of my arrival at the Centro Evangelico Medicina do Lubango (CEML) I was asked by a young Brazilian doctor not much older than myself, to see a young woman who had been sick for almost one month and was getting worse by the day… and so it began…and like the blind leading the deaf we stumbled through the young woman’s story in order to come up with a treatment plan… at least for the night. My initial impressions were clouded by my inexperience but I am quite certain at this point that she had malaria of the brain….In the end, despite our best efforts and advice, her family took her home to die.  It was difficult to see this happen, but death is an everyday occurrence here.  It is difficult to separate life from death when it is such a frequent thing.  Even the death of young patients seems to be somehow not unexpected.  In the first two days of my time here, we have lost 4 patients.  Among them one baby with pneumonia, one young man with severe malaria falciparum infection, one young man with Cerebral Palsy and HIV (one wonders how he got this) and one elderly lady who passed in the night from unknown causes.  The self preserving part of me is thankful that none of these patients were under my care, but the realistic side of me knows that I will soon face this reality.  When it does come I just hope that I will have what it takes to know that I did my best with what limited supplies we have and to move forward…  I have spent my first two nights here reading by candle light in my small room, with the constant fear that I will not know what to do when the time comes… this fear eats at me but at same time drives me….hopefully not insane.  Tomorrow is the start of the new week and I am looking forward to meeting it head on.