Lead Us Not Into Careerism

August 2nd, 2019 by Nicholas Comninellis
Posted in INMED Action Steps For You|

Imagine, highly skilled professionals who bless hundreds of people each year with refined expertise. Then, upon reaching a particular age or financial status, they simply withdrawal from service all this proficiency. I call this careerism. What a tragic loss for those served, and often for the professionals, themselves. Some persons, of course, must retire for circumstances that limit their capacity. But otherwise, Lead us not into careerism, but deliver us from evil. Is evil too strong a term? Perhaps, but please hear me out…

 

For physicians, the most commonly cited rationales for retirement are not age or wealth, but rather burnout, lost sense of autonomy, and psychological stress. But then, retired physician often struggle badly over loss of identity and loss of their relationships with peers and patients.

 

Let me propose an alternative to traditional retirement: Refocus. Apply your expertise, financial resources, and healthy life years to maximally benefit the world’s poor. One-quarter of all INMED learners are middle age professionals doing exactly this. I often hear them express, “It’s finally time for me to do what I’ve always wanted to do: Serve people who are most disadvantaged.” Such career refocus is not without psychological stress. But it’s usually accompanied by profound satisfaction.

 

Ted Higgins refocused. A mature, highly successful general and vascular surgeon in Kansas City, Ted established Higgins Brothers Surgicenter of Hope in Haiti. Says Higgins, “We are not only helping Haitians, but by helping train Haitian physicians and employing top quality Haitian surgeons on our Surgicenter staff, we will sustain this level of care for a long time.”

 

Dr. Higgins refocused his skill, wealth, and health towards a mission of deep significance. You can, too. And for those south of retirement age, dream big as you proceed toward a point when you, too, may refocus your career, praying along the way, Lead us not into careerism, but deliver us into a great endeavor.

No Atheists Here – Angola Day 24

July 27th, 2019 by Nicholas Comninellis
Posted in 2019 Angola|

“Angolan people respect the power spiritual forces,” explains my friend Cesar. “Thirty years of communism did nothing to impede their deference and fear of the unseen world.” Cesar, a nurse who rose to Provincial Minister of Health, continues, “Christ’s message of power over death and forgiveness over offense is especially relevant to Angolans. It provides legitimate liberation from their distress over demons and dark powers.”

 

Today, my final in Angola for 2019, I and a crowd of patients and families enjoyed an inspiring treat: Six singers at Kalukembe Hospital presenting a harmonic, elegantly choreographed suite of songs expressing how, “Our God is light and life, beauty and hope, healing and mercy, limitless in scope.” And on this high ‘note’ comes to a close my 17th summer in Angola.

Nurse Practitioner Continuing Education – Angola Day 22

July 25th, 2019 by Nicholas Comninellis
Posted in 2019 Angola|

These 30 radiant individuals are the nurse practitioners to single-handedly staff the outlying health posts connected with Caluquembe Hospital. located in central Angola. On the back wall to the left is a plaque commemorating Rodolph Brechet, the Swiss physician-founder who began pioneering this ministry in the 1950s. How his influence continues seventy years later, giving me as well the opportunity to stand upon his shoulders!

 

During our continuing educations days together, I guided these bright people through the thought processes connected with making diagnosis. For example, I presented the case of a six-year-old with cough and fever, and ask them to create a differential diagnosis. We then used clues from the history and physical exam, sometimes complemented by a small amount of laboratory data, to arrive at the most likely cause. Of course, consideration of local context is very important. Out here, cough and fever frequently or caused by tuberculosis and malaria – diseases regarding which these nurse practitioners are themselves expert.

Rugged Touring – Angola Day 18

July 21st, 2019 by Nicholas Comninellis
Posted in 2019 Angola|

Angola will not soon rival Greece or Italy as a travel destination, but for you seeking more rugged, challenging vistas, it’s a wealth of waterfalls, beaches, rivers, mountain passes and escarpments. Here I’m overlooking Serra de Leba, a 95-turn length of highway plunging from the high plateau of central Angola, to my left, downward towards the beach city of Namibe. Like the final scene from The Gods Must Be Crazy, I tossed a rock from this point, and a full twelve seconds passed before impact = 2200 feet straight down.

 

So, begin planning your Angola vacation! And while you’re here, please include a couple of weeks with us. Sure, healthcare professionals of most all genre can play a role. But teachers, technology specialists, engineers, agronomist, and therapists have made precious contributions, too. In fact, the most important qualification of all is simply a willing spirit!

Dangerous Gold – Angola Day 16

July 19th, 2019 by Nicholas Comninellis
Posted in 2019 Angola|

CEML Hospital is home to a 24-hour emergency department, staffed by talented on-site nurse practitioners with a physician on call. We frequently see those injured in motor vehicle trauma and children suffering from acute infections. Another predictably frequent emergency presentation is children who swallow coins.

 

Unlike American currency, Angolan coins are brilliantly designed, colorful and inscribed. No wonder children are tempted to put these in their mouth and inevitably swallow one. The dangers are multi-fold: coins can obstruct the airway causing immediate suffocation. They can also become lodged in the esophagus.

 

This x-ray is from a nine-year-old girl I saw yesterday who swallowed the coin four days ago. No breathing problems, thank goodness, but she has been unable to swallow since the ingestion. The solution? General anesthesia, visualization with an endoscope, and retrieval with forceps. And as for prevention, please tell the mint that perhaps boring, unadorned coins are nevertheless more ideal for children.

Where There Is No Oncologist – Angola Day 14

July 17th, 2019 by Nicholas Comninellis
Posted in 2019 Angola|

This young woman arrived at our emergency department with a mass growing within her right knee for about six months. It was not painful, but the resulting weight and leg weakness made walking impossible. Her family brought along a very poor-quality x-ray, which nevertheless showed multiple egg-shell-like layers of calcification surrounding the joint – quite characteristic for osteosarcoma, a bone malignancy.

 

Cancers in this part of Africa her frequent: skin cancers, breast cancer, lymphoma, and cervical cancer are especially common. But mature diagnostic capabilities, such as PET scanning and histo-pathology, or unheard of in the nation whose national health expenditure is on the order of $180 per person per year. And therapeutics, which are often successful for osteosarcoma, are sparse.

 

That evening, we gently explain to the young woman and her family the gravity of her cancer, and that the only therapeutic option was amputation of her entire leg. Even then, we could not guarantee that her cancer might recur at a different location. They became very quiet. The following morning when I return, her bed was empty. In a land where there is no modern oncology, family had already taken her home.

What Is The Leading Cause Of Death In Africa? – Angola Day 12

July 15th, 2019 by Nicholas Comninellis
Posted in 2019 Angola|

Helena, this four-year-young girl, arrived in our emergency department last night. Her parents explaining that for one week she had been coughing, running fever, eating poorly, and making wheezing sounds with each breath. First assistance, as is common in this culture, was provided by a traditional healer. But with no visible improvement, the family caught a public bus here to CEML Hospital.

 

Often, our patients arrive very advanced diseases and complex histories. This girl, by contrast, had a short duration of illness and classic physical signs: fever to 38.5 degrees, respiratory rate of 60, oxygen saturation 85 percent, rales and wheezes on chest exam along with intercostal muscle retractions.

 

To make a correct diagnosis, in addition to history and physical exam, some knowledge of epidemiology is very useful. In our world’s poorest nations, pneumonia is by far the leading cause of death. Poor nutrition, low vaccine coverage, and difficult access to emergency medical care compound the risk of these deaths.

 

With all evidence pointing to pneumonia, we proceeded with basic pneumonia treatment: hydration, oxygen, ceftriaxone IV, albuterol/salbutamol inhalation therapy – and treatment of her coexisting malaria infection. This morning, Helena appears more alert, with less wheezing, and less likelihood of succumbing to the leading cause of death on the African continent.

Recognize This Infection? – Angola Day 10

July 13th, 2019 by Nicholas Comninellis
Posted in 2019 Angola|

This twenty-year-old man traveled from Luanda, the capital city, because he heard we have a dermatologist. While this is not true, I have special interest in tropical diseases, and I was impressed with his account: numerous painful leg ulcers that persist in spite of antibiotic treatments. His lesions bear resemblance with leshmainasis – a protozoal disease transmitted to humans by sand flu bites. Additional clue: this patient enjoys the Angolan beaches. In addition to mucocutaneous disease, Leishmania protozoa can also cause visceral disease (Kala-azar) with fever, weight loss, hepatosplenomegally, and anemia. Left untreated, visceral leishmaniasis is usually fatal within months.

 

Diagnosis is made by serologic tests or by identification of the organism from liver, bone marrow, lymph nodes, or the margin of cutaneous lesions. Unfortunately, we have no such diagnostic capabilities at CEML Hospital. Rather, I embarked on a presumptive trial of therapy, prescribing for him the oral medication miltefosine, He’ll return in two weeks for assessment of whether or not his treatment is effective. Stay tuned for a real-time tropical dermatology update!

What Is This Disease? – Angola Day 8

July 11th, 2019 by Nicholas Comninellis
Posted in 2019 Angola|

This twenty-five-year young soldier arrived today with a perplexing story of a motorcycle wreck and low back injury two years ago. He fully recovered. Then, one year ago he began again to have low back pain and developed gradual angulation in his lumbar spine. He has not had cough, fever, nor any significant weight loss. As is typical in Angola, he received consultations at a number of health posts, and was prescribed a variety of analgesics and antibiotics without improvement. On exam, he has no back tenderness, can touch his toes, has a normal chest exam, and normal CRP laboratory results.

 

The above image shows the angulation in his lumbar spine, and corresponding findings on lumbar X-ray. What do you see? What is the most probable diagnosis?

 

The history of motorcycle injury and back pain is not likely related, given that he completely recovered. And, his recurrent back pain and progressive spine angulation one year later was slow in onset. Another important clue from the history is that a family member in his home is being treated for tuberculosis. Most likely, this man is suffering from tuberculosis of the lumbar spine, causing to collapse of the L 2-3 vertebral space, highlighted in the red circle above.

 

Extra pulmonary tuberculosis most often infects cervical lymph nodes, weight-bearing bones, and kidneys – all of which sport the presence of high oxygen tension necessary for TB growth. One outlier in this case is the normal CRP Laboratory finding. CRP is usually elevated in cases of tuberculosis.

 

How would you manage this patient? TB culture from extrapulmonary sites is rarely positive, and in Angola we have no TB culture facilities. His diagnosis is at best presumptive. Treatment will be immediately initiated with four anti-tuberculous medications. And what of the orthopedic injury? No corrective surgical procedure is available in our low resource setting. But the reassuring news is that his deformity is not likely to progress, and in this we are quite satisfied.

Not-So-Complicated Obstetrics – Angola Day 6

July 9th, 2019 by Nicholas Comninellis
Posted in 2019 Angola|

“The baby delivered four hours ago, but the afterbirth is stuck!” explained our nurse midwife. She was frazzled and fatigued, being on her feet with this delivery for the entire night. At 5:00am, the new mother spiked a fever and began bleeding from her uterus.

 

When I arrived, a quick exam revealed her placenta was still attached to the inside of her uterus. Retained placenta is a well-known risk of pregnancy. If it continues, women develop bleeding and infection leading to sepsis. With treatment, this a not-so-complicated obstetrics. But without treatment, death is commonplace.

 

With a bit of anesthesia, I placed my entire hand into the vagina, and then up through the cervix into the cavity of her uterus. Unlike the rough, firm texture of the uterine muscle, a placenta feels like jelly. I encompassed the slushy placenta in my grip, and slowly extracted it with one pull. The midwife sighed with relief, and the mother gave a shout of joy.

 

Labor pregnancy continues to needlessly kill some 100,000 women each year, almost entirely in poor communities. One of our highest priorities at INMED and at CEML is to training healthcare personnel with basic obstetric skills such that no woman dies from not-so-complicated obstetrics.