The Last Patient on the Last Day

November 2nd, 2023 by barrybacon
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I’m sitting in the quiet living room of a patient whose home we are visiting. The wall ahead of me is a faded orange, the wall to my right sea green. They are made of rough, uneven cement, the roof over me is open wooden poles with metal roofing visible from below, light sneaking in around holes in the ceiling and walls. Electrical wiring is visible from the large sofa where I am sitting. There are no other chairs. A stand with a television is directly in front of us, some dried flowers to the left, a mirror, an empty bottle for decorations, a well worn gray and black striped rug under our feet. We are waiting to meet someone.
Sam has invited me here for a home visit, part of a palliative care program that was recently launched in an attempt to help those who are dying here where there is no home health care and the great majority of folks have no health insurance. The patient’s sister has warmly welcomed us already to the swept courtyard, through the doorway into the modest kitchen and the living room. Her smile is broad, but her eyes betray her grief. She is 19 years old. The patient is her older sister. At age 20, she is dying of ovarian cancer.
The patient is entering the room. She wears a loose, wrinkled long tan shirt. Her frame is emaciated, her face sunken, her belly swollen with fluid, evidence of the deadly disease she is carrying. She smiles weakly at our presence, and shuffles on flip flops to the seat next to me. I can see her ribs through her shirt. Her eyes bulge slightly, all the fat around her eyelids is gone. Her lips are dry, her hair is covered with a wig. She speaks slowly, as though even speaking is an effort. Her breaths come in short, shallow gasps, her diaphragm unable to move downward against the pressure of the abdominal fluid. She is telling us that she can’t eat, she feels sick, her pain is intense, but she is glad to see us.
Sam and the young man who is a nurse at the hospital patiently explain the disease she is suffering from. Troublesome comforters we are, we cannot lie, we are bound to tell the truth. I see the pain in their eyes, the sister alternately melting to the floor, and covering her eyes, hoping to disguise the pain from which she cannot hide. I am choking up. I look at the patient, then I cannot bear to, and I look away. Their suffering is so intense. We bring no hope, only pain. Our words are daggers to the two sisters.
Her suffering is only part of the story. The girls’ father died 10 months ago. Their mother died six months later. Then this young woman was diagnosed with this terrible disease.
The sister brings her medicines for us to inspect. Someone has placed her on liver supplements. It’s not a liver disease. Someone has given her lactulose, a powerful laxative used for end stage liver disease. It’s not liver disease. Someone else has prescribed TB medicine for her. It’s not TB. I can understand why practitioners gave her the medicine; they were hoping against the evidence that there was something treatable they could offer her. It is false hope. So my friends and I are here to comfort her, but we are doing a disastrous job of it. My heart is breaking. I have so many questions. Who is her support? Who provides for the family? Who will be with her as she lies dying? Does anyone pray for her? Bring her food? Sit with her? Read to her?
We advise her on her medicines, talk about the future, offer the support that we can, and I sit silently listening, considering her desperate state. Sam asks me to pray for her, and I lay my hand on her frail shoulder, and I choke out a prayer for her comfort, for peace, for God’s presence, for her pain to be less.
We prepare to leave. A young boy enters the room, barefoot, clad in t shirt and shorts. He smiles, and the room lights up. “What is your name,” asks Sam in Portuguese. “Anselmo.” “How old are you?” “Two,” he replies incorrectly. “No,” his mother corrects. “not two. You are three now.” “Three,” he says, but not convincingly. “Show them how many fingers.” He struggles and holds up two. Mom counts on his fingers. “One, two, three.” He grins and holds up three fingers.
We step respectfully out of the dim house, gripped by grief as it is. I look down at Anselmo, walking beside his mother, accompanying us to the gate. I wave. He reaches up and takes my hand. We walk together, hand in hand to the gate where his mother, the sister of our patient, thanks us and bids us goodbye. She’s smiling, but her eyes are overwhelmed, terrified, filled with sorrow. Anselmo waves happily as we climb into our truck. They are happy to have us come. But they hate our reasons.
I’ve gained my composure again. I ask Sam my questions as we drive away. “They are alone,” explains Sam. “They have an uncle who works a long way from here. An aunt lives on the other side of town somewhere. The sister goes to work every day, leaving the small boy alone with the patient. She can hardly get out of bed or take care of him.” I don’t ask any more questions. But I’m thinking them.
How can it be this way? How many more are there? People who are forgotten about, swept under the rug, their potential, their futures, their contributions, their joys and families lost, without access to healthcare other than the wrong medicines.
One person can’t fix everything, I know that. But there is something we can all do, we can reach the person who is suffering right in front of us. We can make things a little more just, a little more comforting, a little more compassionate.
I’m heading to the airport now. I review the goals I have had for this trip to Angola. Have I learned what I came here to learn? Yes, but not the way I thought I would. I found that my hands are still good, my mind is still capable of learning, my health is still strong, my Portuguese is terrible. I learned that there is desperate need for high quality family medicine training here. I learned that there is a 100 bed mission hospital in a remote village that is the best option for care for thousands of people, but they can’t provide safe c/sections. Not yet. I learned that there is a 20 year old girl dying almost alone in a modest African home, a three year old boy who deserves to be a kid, and a sister who is already grieving all that has been lost and all that will be lost. I’ve learned that there is something I can do. And I will.

There’s a Snake in the Lecture Room!

November 2nd, 2023 by barrybacon
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Today is my last full day at the hospital, and I am giving a second training on “Helping Babies Breathe,” a class for safe resuscitation of newborns. The class is appropriate for an American audience but is also appropriate for many other parts of the world. The basis of the class is that a couple of fairly easy interventions- setting the baby directly against mom’s skin at the time of delivery, and use of a bag valve mask device (ambu bag) when needed can save 50% of the newborns who currently die. It’s easy to teach, interactive, and fun. We leave a kit with the students so they can in turn teach another audience of nurses, midwives, or physicians.
I’ve got an audience of about eight nurses. My interpreter is an intern named Anna. All of us are standing around the table, and I’m demonstrating the equipment that I will be leaving with them, the washable and reusable ambu bag and the handheld suction device, the teaching kit as well. Suddenly, a nurse who brought her infant to the class shouts, “There’s a cobra on the floor!” I look down at my feet. A small creature, like a large millipede lies coiled up just two inches behind the place where I was just standing. Everyone jumps back. I don’t know what to do, but obviously the lecture is over unless I dispose of the creature somehow. I grab the thick plastic ziplock bag that accompanies the teaching kit and wrap it gingerly around the animal’s body, still not certain what it is. The crowd gasps and shouts their concerns for my safety. I carry it outside, all seven inches of it, and place it on the ground. It’s tiny head emerges from the coils. Sure enough, it’s a small dark colored snake. People are shouting at me to move back. A nurse grabs a flat stone and throws it at the fearsome beast from a safe distance of eight feet, striking it on the back. In a few minutes, the dangerous episode is over, and we go back to saving lives.
The students are eager, interested and engaged. They all appreciate learning about the use of the ambu bag, and they are able to demonstrate competency. We discuss some of the challenges we see here. Obstetrical injuries. Transportation challenges. Fistulas. Newborn resuscitation, lack of equipment, lack of training. I hand them the “Helping Babies Breathe” kit, for which they are grateful. At the end of the lecture, I tell them the story of the resuscitation of twins whose mother had placenta previa and had been bleeding all night, how we used the ambu bag to raise the pH in their blood so that the brain and heart could wake up. Both had no signs of life when they were born. One of the nurses remarked, “when a baby like that is born at the general hospital, the baby is simply set aside and left to die.” That’s why I told you that story, I reply. I want you to see that there is a way to successfully resuscitate babies. You can save lives with this technique.
I assist on a couple of surgical cases in the afternoon. The day is winding down, and as it happens, a couple of the medical interns are in the room where I am hanging up my coat for the last time and putting my stethoscope away. “Dr. Barry, I heard that this is your last day,” begins Ilda. Yes, I smile. “We hardly got to know you.” She sits down alongside Anna. They study me, want to know something more of where I come from, my family, my work. I brag about my wife, and tell them about our children, about our work in Kenya and Ethiopia, remodeling homes and training homeless men in Colville, developing housing for people in Colville, working at the clinic for people who struggle to access healthcare. Of the incredible life I am living, how grateful I am for this life, that I can’t imagine retiring as long as my mind is good and I have my health. They tell me of the challenges they have witnessed, the lack of health insurance for the great majority of folks, the extremely wealthy people in their country, the lack of distribution of that wealth, the lack of accountability, the struggles of honest people as inflation drowns their static salaries and makes them paupers. I wish we had more time. It’s clear that they do too. There is something that happens when you connect with people who genuinely understand what it means to respond in compassion to the suffering we see. Those are always special people. We’re drawn to each other. We say our goodbyes and hope that there may be another chance to work together.

Mosquito Wars

October 31st, 2023 by barrybacon
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Mosquitos, Crochet, and the Cost of Free Medical Care
Amanda has declared war on mosquitos in the housing dedicated to the women suffering from fistulas. It’s bad enough that they are suffering, but then to get sick with malaria when they are waiting to have their surgeries seems to add insult to injury. “There are hundreds of mosquitos in there,” she exclaimed as she came to the hospital with a can of insecticide, “and all of the mosquito nets are gone except one.” Periodically, the nets need to be replaced because folks take them home. No one has apparently checked on this recently, and they have disappeared again.
“We’ve had a couple of deaths from malaria for these women who are taken to surgery,” explains Sam. Getting sick around the time of surgery adds additional stress and can overwhelm a woman who has just had this major operation. Anemia, fevers, vomiting, and other complications from malaria worsen the outcomes from surgery. It’s important.
Amanda provides support to the women in another way. The women stay for an average of four weeks, one week in the shelter, two weeks in the hospital and another week in the recovery area. Amanda and others support the women by teaching them crochet. It gives them something to do, a skill they can use, and the companionship of other women who do not ostracize them. Makes them feel human.
Sam told me that he had a conversation with a young colleague who works at one of the clinics, but there aren’t any medicines there. We talked about the system of care, which is free, but there are challenges within that system. While the leadership is working hard to fight graft, there are examples of medicines not being available in the hospital, but the exact medicines could be purchased at the pharmacy. There were rumors that medicines intended for the hospital were diverted to pharmacies where patients who were supposed to have free care had to pay for them. It’s hard on his young colleagues, Sam says, because they genuinely want to help the patients, but they are without the tools to care for them.
(On the same day, I received an email from our peace initiative in northern Kenya. “We are out of vital medicines at the clinic,” wrote one of our project leaders. “and we think that the medicines intended for the clinic may have been diverted.” It appears to be a common problem in many areas.)
Later we saw a child with a distorted face. She looks like she is 15 months or so. The right eye is bulging and pushed to the right. The nose is distorted to the left and completely plugged. The face is bulging on the right side as well. It is clear that the child has a mass growing in the right maxillary sinus and behind the right eye. The family came from quite a distance to get help. They brought some xrays with them which shows loss of bone. The child will continue to deteriorate unless the problem is addressed rapidly. We order a CT of the facial bones so that whatever surgeon cares for the child will have the best information possible prior to doing any procedure on the child. But we are told that the hospital where CT’s are done is not accepting any “outside” referrals for CT’s. It’s hard to know how to proceed. The child needs our help, so we need to advocate for our patient. We write the order anyway, hoping they’ll make an exception.
A Day at the Office
Bridgett arrived last night in Lubango. She is a surgeon from Germany who has come to this hospital annually for the past 14 years and has supported the hospital by providing surgical care for a few weeks so that one of the surgeons could take a vacation. She is bright, chipper, and my goodness, does she love surgery. She said, “just put me on call for the next six weeks,” and she means it. Whatever she can do to help, she is ready to work. She used to use these trips to Angola in place of her vacation time. That meant she worked for years without a vacation. Now, she uses unpaid leave to come here to help, but she still takes vacations. She loves mountains, so she travels to places like Pakistan and Kyrgystan for a nice relaxing vacation climbing mountains.
I scrubbed in with her today on several cases. She really hit the ground running. The first was a patient needing a gallbladder removed. “I’ve never seen this before,” she expressed. The gallstones were sitting on the outside of the gallbladder, sort of stuck to the thickened gallbladder wall.
The next patient was very ill. At 19 years of age, she was emaciated, a poster child for Auschwitz, two tubes in her kidneys draining her urine, an open wound in the front of her abdomen draining infected material, and a colostomy tube with a makeshift bag over it. She is very poor and comes from quite a distance. We have no records to know what really happened in her case. She is here for a cystoscopy, a look at her bladder to see whether things can be fixed on her insides.
We attempt looking in the bladder. There is no urethra. How does that happen, we wonder? We examine her vagina. It’s only a centimeter long. We wonder out loud what in the world happened. The best we can do is piece together information from her report. In July of this year, she had a baby. Might have been complicated, we don’t know. A couple of weeks later, she was bleeding heavily and was infected. She had a surgery, which we think was a hysterectomy. We think the surgery went really badly. Tied off both ureters so that the nephrostomy tubes were necessary? Uterus was taken along with the bladder and urethra was injured as well? Most of the vagina? There was a story about urine leaking into the abdomen, suggesting that the bladder was injured or removed. We really don’t know.
We have no idea if any of this is fixable. We attempt an ultrasound, but all we can say is that the kidneys are both there, and the right kidney is only minimally affected by back pressure We can’t see a bladder. “The only way to even make a plan is to look inside,” concludes Bridgett. Sam agrees. “We need to have a look at what’s there, whether she has any bladder left, whether the ureters can be reattached and whether a urethra can be remade.” Before the surgery next week, she’ll need to be fed with some fortified rice mix so she can get a little stronger than she is. Our patient lies listlessly on the exam table, her cheeks sunken, ribs all visible, muscles of her thighs and arms wasted, two tubes in her back, murky drainage coming from her abdomen. There is no way she can survive without our help. There is no guarantee she will survive even if we do everything we can. Another casualty of becoming a mother.
Other cases today, a weird abdominal wall mass that bleeds like crazy, a man with his right arm stuck to his chest wall due to a burn from a year ago, a colostomy that is taken down. We talk during the cases about life, hiking, the joy of our work, her (and my) time in Ethiopia, splitting our time between home and Africa, the importance of teaching, and the 19 year old patient. We keep coming back to her. “You know, these fistulas and obstetrical complications can virtually all be prevented,” says Bridgett. I nod. “They need good obstetrical care, prenatal care and access to c/sections.” I nod again. She gets it. She just underlined the reasons why we dream of doing our project in Cavango. One mission hospital, one site, on medical training program at a time. Timely screening of obstetrical patients to identify high risk individuals, improved delivery outcomes at the hospitals so that women feel like hospital delivery is better than at home, and timely c/section access. “You don’t need to learn these surgical techniques for fistula repair,” she goes on. “You need to teach the doctors how to prevent them.” Spoken like a family doctor.

I Have Been Requested to Ask That You See My Grandfather

October 28th, 2023 by barrybacon
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It was a slow day, frustratingly so. People who weren’t really sick but worried about being sick took much of the time at the clinic today for the interns who work at the mission hospital in Lubango. Worry can be a killer, as can stress. The folks we saw were suffering in their own way, but desperately trying to find help in testing and imaging that continually comes back normal, frustrating the patient and causing them to come back repeatedly for prescriptions for their suffering. I left with Audrey and Anna, a Canadian missionary and her niece after clinic ended.
“I hope it’s ok if we take a small detour,” Audrey said as I climbed into the truck. I looked in the back seat. We had a couple of visitors. I guessed what was happening. “This man has just been released from the hospital and is too weak to walk all the way back home.” No problem, I understood. We dropped off one passenger a few blocks away, then meandered off on a side road over dirt paths for about three miles between fences protecting the grounds of large farms to a rocky pasture area in between. We bounce our way slowly over rutted dirt paths to a modest enclosed compound. An 8 by 8 foot stick enclosure where I can hear a couple of pigs relaxing. Multiple healthy appearing goats nibble at shrubs outside. A beehive shaped earthen oven stands beside the pigs’ enclosure. They don’t seem to be worried about the implications. Inside are Abino’s uncle’s family. They greet us with smiles and welcome us. Mud brick homes, a swept dirt floor in the courtyard, a menagerie of chickens, goats and a pig come to greet us. Small and larger children poke their heads out of doorless doorways and windowless windows, curious to see the visitors. The man of the house appears, well worn clothes, a 1960’s jacket with “Texaco” on the sleeve, a young woman with a baby on her back. The baby looks healthy. All of the rest of the children and the adults appear malnourished and growth stunted. A child coughs repeatedly from inside the house. “This man was near death a few months ago from TB,” Audrey explains. “He says he feels well now. He used to be skin and bones.” He looks like he hasn’t fully recovered.
We say our goodbyes and head back along the dirt path past a rural soccer field. A few neighbors line the path and motion that they wish to talk with us. Audrey interprets, “I have been requested to ask you to see my grandfather.” A young girl, eyes hopeful, clothing well worn stands at the window. “Where does he live?” asks Audrey. The girl gestures in the direction. We don’t see anything but a field. We are puzzled. She points again. There appears to be a pile of rubble flattened in the distance. “That place looks like it burned down,” declares Audrey. We are dubious that it could be a dwelling for humans. We pick our way over rough stony pasture to the point where it appears we can’t go any further in a pickup. We step gingerly around cacti and thorny bushes to the entrance of the enclosed living quarters. A eucalyptus tree stands at the end of a fence row. A seven foot high stick fence encloses the courtyard, a four foot high door swings warily open for us and we step over and duck under the wall and into the courtyard, tidied by daily sweeping, a mature vine growing in a metal canister on either end, winding its way up and over the tops of the buildings arranged in a square. Curious children emerge from the 8 foot by 10 foot mud brick shelters, their tin roofs held on by some scattered stones and the vine draped over them. A rectangular sign reading “N’gola POST” hangs on a small woven table. It is upside down. No one in this enclosure can read. A man shuffles from under a branch covered awning into the light rain, his stooped thin frame wrapped in a heavy cape, bare feet, pants worn, the cuffs long gone, a ragged t shirt over his chest, visibly shaking. “He is a person of some influence here,” Audrey whispers. He greets us warmly and takes a seat. Audrey explains that I am a medical doctor and would like to examine him. I look at him carefully while Audrey learns a few details about his illness. His eyes are watering, his skin a little pale. He has virtually no fat reserves, he appears weak, his skin is warm, he coughs and shakes from having chills.
I reach for my stethoscope, tucked away in my computer bag. “He’s been sick for three weeks,” Audrey interprets. “Chills, fever, body aches. Drinking and eating a bit. Coughing a lot. He went to the government clinic and was tested twice for TB, but the tests were negative. Wasn’t tested for malaria, and wasn’t given any medicine. Just a shot for his fever.” I nod. They are missing the diagnosis. Listen to his chest, hand the stethoscope to Ana, who is a premed student. Crackles and wheezes in his lungs on both sides. Feel his skin. Listen to his heart, and have Ana listen to its rapid cadence. Seen it a thousand times before. He has pneumonia, likely malaria too. He needs medicine soon. It’s Friday evening and terribly inconvenient to get him some. We ponder over what to do. Audrey will be seeing some family members on Sunday morning for church. Perhaps she can get him something by then. She explains to the man. He sits, shaking, nodding, he understands, he appreciates us coming. I turn away.
My heart is breaking for this human being. How can life, how can this world be this unfair? He has nothing, he is dirt poor, grinding poverty, unable to escape, children can’t go to school because the older ones need to care for the younger ones. He has no transportation, can only walk, but he can’t walk without terrible risk to himself to get help, and then he doesn’t get help. What’s he supposed to do? How many more are like him? I look around the courtyard at the faces of the children, the women, old and young standing there expectantly, silently, hoping. He is their provider.
Audrey steps forward. “Do you want to say a prayer for this guy?” I ask. She nods. We place our hands on his shoulders. There is still a little muscle there, still a little fight. Perhaps he will make it. “Amen,” we say together. I hold his shoulder just a bit longer. Then we are gone, a fleeting moment, through the courtyard, around the eucalyptus tree, past the cactus and thornbushes, to our Toyota pickup. “Could you turn down the a/c a bit?” request Anna. “I’m freezing back here.” We wave at the girl standing behind us, watching, wondering at our lives as we wonder about hers.
“They don’t send their children to school,” Audrey explains, “because they don’t see the point. They need the children to help them. Although that’s changing a bit.” She tells of the young man who we brought home from the hospital. At 23, he is working to finish the sixth grade, and might go to an accelerated seventh and eighth grade as well. Children come out of nowhere and stare as we drive slowly by. There are many, far too many to be sustainable on this modest strip of land between the well-established farms surrounding their impoverished pasture.
A teenage boy drives cattle home from the field. Audrey points to the church she and her husband established sitting on a hill a kilometer away. I want to know if all of her church members are this poor. She laughs. “We didn’t plan it that way,” she states. I get it. It’s nicer to have rich people in your church, that’s the way we plan things. Who wants a church filled with impoverished villagers? None of the tele-evangelists would be successful with these people as their parishioners. But this is the church she and her husband have chosen. They scrape together financial support to treat their medical problems as they arise, stretch their dollars as far as they can.
We bounce back across the rough roads, swapping tales as we go, of peace initiatives between two warring tribes in northern Kenya, patients who recovered from TB, developing medical programs in Ethiopia among the refugees, teaching women to sew and crochet, malaria, TB, human suffering, and how blessed we are to live this life. And what do we do about suffering. We’re just 3 miles off the main road to Lubango, but we are on another planet.
As we approach the tarmac, and what some of us call civilization, the houses become bigger, with cement walls around them, and gates. A small herd of cows peers through the unfinished gate of a house in progress. They’ve moved to the other side of the tracks, it seems. Where grinding poverty meets material success. My mind is on Kalinga, the man in his little, neatly kept scrap of earth, the place he clings to as his home. Someone once said, “Blessed are the meek, for they shall inherit the earth.” I’m trying to find out what that means. It seems to me that Kalinga is the definition of meek. I don’t understand everything about heaven’s justice, but this makes sense. And I trust that some day, this little scrap of earth will be replaced for Kalinga with something of far greater value. And he will be home.

Flight to Cavango and Other Adventures

October 26th, 2023 by barrybacon
Posted in Uncategorized|

“You Should Talk to Marijn About It”
We flew back in the rain, wet, tired, excited to get back to internet and our own beds and rest. Marijn is our pilot. He’s been here in Angola for several years, flying for MAF. Multiple mission stations that he services, but a couple of hot spots include Kalukembe and Cavango. After we landed back in Lubango, Marijn gave me a ride to a party for one of the folks working at the mission. He told me of his plans to move to Cavango. His family is excited. It’s a remote site without internet, electricity (except for solar), or a house, yet. He hopes to move there to oversee the building of his house, perhaps as soon as next month. His oldest boy loves to explore the wilderness, and this is an ideal spot for a kid with such an inquisitive mind.
Later, we spoke together with Andrew, a second pilot for MAF here in Angola. I learn that Cavango is a 100 bed hospital. But they don’t do any surgeries. Every patient who needs a c/section currently is being flown to CEML hospital in Lubango for care. The doctors in Cavango are interested in expanding their services, but the two physicians who are providing care at the hospital are overwhelmed. The flight team really wants to expand their medical outreach to other remote areas, but right now they can’t because it is one of the doctors at Cavango who was doing this. MAF is looking for their own doctor to hire to do this kind of outreach, since the doctor at Cavango doesn’t have the time.
It started me thinking. Could there be another solution? Maybe someone with c/section skills who could stay with the doctors at Cavango for a few months while they hone their skills, launch the c/section program, and look for a third partner who will help them permanently? This would solve both problems- allow for outreach by one of the Cavango physicians; and allow women requiring c/sections to be cared for locally, greatly reducing expense and risk for the patient. There are a few issues that need to be addressed, including approval by the government. But the goals are worthwhile and life-saving.
Overnight I contacted the folks at the headquarters for MAF and also the physicians at Cavango. I received a response from Cavango. They really like the idea of making this work. I’ll put the idea out to other colleagues to see if anyone is available to provide this level of support.
More medical encounters
“Dr. Barry, can you come and take a look at this patient with me?” one of the interns asked me. She was performing an ultrasound on a large mass in the lower abdomen of the patient. The young man had needed surgery early in his life because neither of his testes had descended into the scrotum. We performed an ultrasound of this part of the body, then turned our attention to the large mass in the right lower abdomen. It was the size of a large kidney. The ultrasound appeared to show a large tumor. Subsequent xrays failed to show any additional disease. Dr. Annaliese will plan for surgery for this patient in the near future.
Other procedures today: two surgeries for vesicovaginal fistulas, the leaky messy complications from lack of access to c/sections, by Annaliese. One was terribly complex. The bladder is almost completely absent. She needed to attempt to completely reconstruct a bladder from the vagina. Meanwhile, Sam and I worked on a young kid who needed reversal of a colostomy and fixing a wrecked lower leg. Lots of orthopedic cases here. There are plenty of opportunities for additional medical care. Lack of well qualified surgeons is a disparity. In this province, for example, with a population about 2 million, there are five general surgeons.
It’s not possible to fix everything. But I know where there is one mission hospital where there is no surgical capacity where we can make a difference for patients by introducing c/section services. I will be visiting the site tomorrow.
Cavango Visit:
Today I visited Cavango, an outpost mission hospital 147 miles from anywhere. Surrounded by villages in remote central Angola, 3 hours over rough 4 wheel drive road (first hour) and tarmac to go shopping for groceries. It’s what you might imagine a mission hospital to have been 60 years ago, but it is still the reality for many remote areas of Africa. West of here, what we call civilization gradually grows as you move toward the sea. East of here, you would need to redefine civilization. I am flown here today by Marijn and Andrew to talk with Tim and Betsy Cubacki, an ER doctor and his wife who have worked and sweated and rebuilt this place over the past 10 years after it was decimated by war. In the old days, it was a leprosarium. Then it was destroyed. In 1970, another physician built a clinic which ran until 1975 when it was destroyed again by war. It sat dormant, only foundations, until 2013 when Tim and Betsy arrived. It is remarkable how much has been done since then. 100 beds. Multiple additions just for TB alone. An emergency department, an ICU, consultation rooms, operating room, maternity room, multiple inpatient wards, a laboratory, an xray room, a pharmacy.
The day didn’t start out so great. There were supposed to be four patients to travel back to Cavango with us on the plane, but no one showed up- folks Tim and his colleagues had referred to Lubango for care. We don’t know why they didn’t show for the flight back home. No one seems to know where they are. So we must leave without them. We fly over miles of cultivated farm land for a little over an hour until we reach a green area covered with forests which go on for miles, and rivers that flow first into the Okavanga River then south to Botswana where the river empties its bounty into the desert sands and creates an oasis for wild things. We do a touch and go landing, then circle around and land again. We see the hippo pool, the cascades, a boggy area, and finally land on a dirt runway shaped like a hyperbola. Betsy is there waiting in a maroon Toyota pickup with a topper to haul us and the bounty of supplies we brought back to the mission less than a mile away. “We used to land two hours away,” explains Marijn. “Someone had to come all that way to pick us up. This is so much better.” I look around me at the trees, the flaccid wind sock, the red clay soil runway that drops off into the bog on each end. I like it.
We drive down the well rutted road to the mission homes, off load a few things, then on past the locally made brick church positioned next to a soccer field, and make our way to the hospital. A small covered area where women have created a local market. Steel containers with supplies stacked on top and inside. Well kept grounds, beautiful buildings constructed of block and plaster, steel frame and roofing, all recent developments as the need has dictated. We meet Tim, and he takes a break from the lines of patients he is seeing in order to show me around. He knows I’m on a bit of a mission.
We start in the operating room, a plain cemented room without adequate lighting. This is where they have been doing procedures up until now. They have a bed, a sink, some tables and equipment and medicines. We’ll make a list together for other things needed for what we are imagining. The room next door is the maternity area. It’s dingy and poorly lit, a few items available for deliveries. The ICU is next door. It’s full. There are no monitored beds. A couple of oxygen concentrators run by solar power. A few curtains divide the patients from each other. A woman who delivered her baby a week ago lies alone. She had been in labor for three days, then came to the hospital, difficult delivery, the baby needed resuscitation for 15 minutes, then stabilized on oxygen, but died the next day. A few days later, the mother came back to the hospital with fever and bleeding, hemoglobin dropped to 4 (normal is 12), severe infection of the uterus, needed blood, but her blood type is O neg. The staff went from sick bed to sick bed hoping to find another hospitalized patient who matched this blood type and who was willing to donate blood. Finally found someone, one unit was transfused, but the patient suffered a reaction to the blood so they needed to stop. In spite of all of that, she is getting better.
Another patient nearby with heart failure who needed three liters of fluid removed from around her lungs. She ran out of medicine at home and didn’t have transportation to get back to get some more medicine. Another young woman with rheumatic heart disease and a bad heart valve. A baby with a tight airway, maybe epiglottitis. Another recovering from pneumonia. A chicken under someone’s bed.
We look around the grounds. Tim shows me the generator room. Mostly everything runs on solar, but there is a generator as backup. Water is spring fed from up in the hills, feeds into the hospital’s water system. Water pressure is weak. TB wards, individual houses built for insulin dependent diabetics who keep running out of their medicine and come in comatose. “We’ve had a rat problem,” explains Tim. “so we decided to collect four cats.” Patients didn’t seem to mind the rats nibbling on their toes, but Tim wasn’t pleased with the rats chewing up the wires for the generator. “Now the rat problem is taken care of,” he points to one of the new and improved mousetraps ambling around the courtyard.
“We had too many animals wandering around the grounds. So I started paying anyone $10 for any dead animal they brought me- pigs, goats, dogs. We eat the goats and pigs, and the others we bury.” Sounds a bit like Stevens County where I live.
We visit the pharmacy, inpatient and TB wards, the xray department (they have the exact xray machine, a Battaray, that I use in my clinic at home), nice ultrasounds, the lab with a microscope and some nice chemistry and cbc analyzers. We look over the brand new hospital being built, larger than the others, and the covered area where worship and health education are provided each week. This is a remarkable place, I think to myself.
We head to the consultation room. On the way, I use the bathroom. They have one. It has a faucet and a toilet that flushes. It’s wonderful.
Tim sits down with an interpreter, and between questions, fills me in on what he is seeing and thinking. He practices medicine here a lot like I do. Practical, based on probability, not ordering every test, looking for treatable causes and ignoring largely what can’t be treated. Because there are many diseases here that can’t be treated. On the other hand, there are many lives to be saved. Tim knows the difference.
The translator goes from Portuguese to one of the three local languages. Tim moves from Portuguese to English, for my benefit. I recognize some of the words. “sansa” is vomiting in Chichewa, from Malawi, and also here in this part of Angola. “ati” means “he is saying,” like “akuti” in Chichewa.
We’re called next door to evaluate a woman whose liver is failing. Tim tells me that many women die here after consulting with a traditional healer for infertility. They haven’t been able to determine the particular herb which causes liver failure, but it is deadly. Slow, gradual death, but if they catch the process early enough, they can save some. This woman has the telltale signs on her ultrasound. Fluid in the belly, liver that looks like a piece of cardboard. Fortunately, no jaundice yet. “She might make it,” explains Tim. “She came in after only a month.”
Back in his office, an array of problems awaits us. An elderly woman with dementia. An elderly man recovering from delirium due to pneumonia. Low back pain. A young woman with TB of the spine. She pleads with Tim to be treated as an outpatient so she can continue with school, but he says no. There are reasons based on his experience that I don’t yet understand. He insists on treating everyone with TB for the first two months as inpatients. Then he leans forward, hand on her shoulder, and prays for her as she attempts to hold back her tears. A 3 year old boy with swelling of his face, hands, legs, cough and lack of appetite, most likely malnutrition due to parasites. A skinny guy with pancreatic TB. I asked about HIV prevalence here, but Tim doesn’t know. For years, Angola was isolated due to the war, but now that the borders are open, HIV is spreading rapidly. A couple of folks with hypertension. Someone with heart failure . Another with a pericardial effusion, fluid around the heart, most likely due to TB. Another person with bladder cancer, a complication of a parasite called schistosomiasis, second leading cause of parasite death in the world after malaria. A 29 year old woman with huge tumors in her liver. Peptic ulcer disease, typhoid, malaria, abdominal pain, comatose patients nearly raised from the dead. Patients from near and far, having heard of the reputation of the hospital, they come from hours away, from cities where there are doctors, but looking for someone with competence who cares. Ten people a day from the cities. All word of mouth advertising.
“The first two years were terrible. Everyone died,” Tim laments. “That’s because only people ready to die came to see us. Now things are different. The last five years, things have exploded. We’re overwhelmed with patients.” As a result Tim has stopped doing outreach clinics. He just can’t make it work with the volumes of patients they are now seeing. Which is half of the reason I am here. What if we found someone who could help for a little while so you could start the outreach clinics again, I had written to him in an email two nights ago. The pilots want to restart that program again. In fact, their organization is willing to hire a physician themselves to do just that. Tim had responded overnight, elated that I had asked. Here I am to see for myself, thanks to the pilots of MAF and the supportive team back at Lubango. They understand my mission here.
One thing puzzles me though, and it is related to the second reason for my trip here. Why do so few pregnant women get their care here? Tim responds that few even get one prenatal visit with them. The ultrasound is a big draw, so some will come. But he needs more opportunities to see them, screen for conditions that really should be delivered at the hospital, like twins, breech babies, placenta previa, and conditions of pregnancy like preeclampsia, anemia, diabetes, malaria, etc. As it is, only the very worst cases come to the hospital, which doesn’t help their image, nor the health of the community. There will be work to do in order to achieve what we dream of doing. We want to launch a c/section program so that women can safely have deliveries locally, rather than airlifting each one who needs a c/section to Kalukembe at great expense and risk. That’s our goal. Find a physician with the skill set to do precisely these things.
Later, Betsy talks to me about the living situation. There is solar power. A generator as backup to each home, of which there are an adequate number. Spring fed water source, and a well for some of the more distant houses. Cell phone coverage is 2 kilometers away. Wifi internet, so Whatsap is the communication link to the outside world. Grocery shopping happens once a month, and the MAF pilots bring in supplies regularly.
It all leaves me wondering, hoping, dreaming again of what is possible. But wouldn’t it be great to save some lives, get Tim back on the flights to distant, more remote and primitive places to provide basic care, down along the Zambia/Angola border? Hard to imagine that we are only half way across the country, and there are places more remote and isolated beyond us to the east and south. And give the team the ability to provide safe c/sections here. There is much to be done. We have a plan and confidence that we are not alone in this venture. We will take this as the chance to bring a bit of justice to this part of the world.

The Trip to Kalukembe and Other Tales from Deepest Africa

October 22nd, 2023 by barrybacon
Posted in Uncategorized|

We’re up and ready to go by 6:15 a.m. The team travels silently to the airport where we wait for our pilot from MAF to arrive with the flight plan and load us in the prop jet. I’m the co-pilot today while representatives from anesthesia, nursing, medical internship and surgery travel together to our destination. We fly at 11,000 feet to Kalukembe, which sits at an elevation of 5500 feet. We make one pass about 50 feet above the runway to alert the neighbors that we are coming in so that they can stand guard and keep animals, people and traffic from crossing on the road which transects the dirt runway. We are greeted by two vehicles driven by smiling hospital personnel and some of the local police force.
Kalukembe was hard hit during the civil war years not so long ago, when it was held in rebel territory. Much has been rebuilt, but the memory of those years is not gone from the local folks. Much of the town was destroyed and had to be rebuilt. Staff struggled to keep the hospital open, many risking their lives by coming to work each day, even creatively flying in to avoid being shot down by antiaircraft weapons as they continued to provide medical care under duress.
The mission itself was established over 100 years ago, and the medical work here was started in the 1940’s. The hospital has grown to over 200 beds with pediatrics, obstetrics, surgery, adult medicine, rehab and TB wards. Its important work reaches out to a large area around Kalukembe but it’s always a struggle to keep sufficient physicians. Much of the work falls on the nurses, and there is a strong nursing training program here on campus.
Today we make rounds on a few selected patients which the physicians and nurses have asked that we see. Dr. Annaliese prepares to perform several ultrasounds on patients, but the power is out. I offer my butterfly ultrasound, which I brought along, thinking it might be helpful. The connection is finicky, but we finally get it to connect and perform one ultrasound before the electricity is back on. Mostly patients with symptoms such as wasting, abdominal pain, pelvic pain, urinary obstruction, cancer.
We then observe a gastroscopy, and the intern, Dr. Hermenegildo, performs a methylene blue dye test for a woman with a fistula. The abnormal connection between her bladder and her vagina has healed and we congratulate her. Surgical cases follow in quick succession. Prostatectomies, hernia repairs, mastectomies, hysterectomies, a newborn with gastroschisis (large loops of bowel outside the abdominal cavity), lumps and bumps and GI perforations from typhoid fever with an occasional c/section thrown in. I help with as many as I can, including a c/section for twins, the first in breech position. No one told me there were twins so it surprised me a bit to reach in for the placenta and pull out another baby.
At around 7 p.m., things wind down and we go to the clinic to begin seeing consultations. There are around 56 of them today, and Annaliese wants to complete all of them tonight, knowing that tomorrow will be busy as well. Dr. Hermenegildo sees patients in an adjacent room and comes to precept those patients with Annaliese or me. I perform many of the ultrasounds for Annaliese so she can get caught up with her writing and instructions to the patients. Patients with abdominal pain, lumps on their heads and backs, pelvic pain and bleeding, urinary obstruction, orthopedic concerns, chronic hoarseness, hypertension, headaches, fainting and collapse, weakness and weight loss, shortness of breath, chest pain, all come to see the surgeon and the intern. I realize now that Annaliese and Sam are the family doctors of general surgery. They do everything. Out of necessity and compassion for the patients they serve, they have learned from their colleagues and from each other not only general surgery, but also orthopedics, urology, ENT, maxillofacial, ob/gyn, and they often manage hypertension, diabetes, liver disease, anemia, heart failure and more.
In the middle of the exams, mayhem breaks loose as patient skips across the room and begins joyfully screaming at seeing Annaliese. They shake hands and embrace, Annaliese equally excited to see her. The patient shows her right arm, hardly able to suppress her laughter. “She is six weeks post op from a surgical repair of her right humerus,” the physician explains. “Her bone hadn’t healed, and I put a nail down the shaft of the humerus, cleaned it up, and freed up the frozen elbow. Look at her now.” The woman couldn’t stop shouting for joy. Reminded me of a story I heard about a lame man who went walking and leaping and praising God after he was healed. I applauded the doctor and her patient.
We finish our work at a little before 11 p.m and ride wearily back to the place we are staying. “I was getting cranky there at the end,” confesses Annaliese. “I hate when I feel like I didn’t give the patients my full attention and concern.” I hadn’t noticed, but I confessed to her that my brain was not fully in gear by the end. Over a late meal of potatoes, vegetables and coffee, we talk about the meaning of what we are doing. I want to know why she chose this life. I know it’s personal, but she doesn’t mind sharing. It was a promise she made when she was in the 9th grade. “I was reading a Time magazine article,” she recalls, “about Ethiopia I think. I realized in that moment that I could turn the page and ignore any compassionate response to that evoked in me. And if I did turn the page, the next time would probably be easier to do the same, and I could live a comfortable life where it would be easier and easier to ignore compassion speaking to me. Or I could turn back to the article and feel its impact on my life and make a promise to God that I would live my life committed to respond to that calling every day. So that’s the promise I made.” I smile in response. These are special people who refuse to let the power of compassion slip away for the sake of convenience or position or money. They have left all of those things behind in pursuit of something better. “I made the decision at first out of duty,” she continues. “I didn’t expect to like what I did, only to fulfill my vow. What I discovered is that I love what I do. It is the best work that I can imagine. I didn’t see that coming.”
We sleep for a few hours, then we are back on our feet. “Oh, they made eggs this morning,” croons Annaliese. Funny how small pleasures bring great joy in a place like Kalukembe. We head in for morning report where each department debriefs on the activities and admissions of the night. Another full day awaits us, with gastroscopies, fistula checks for two newly diagnosed women with this obstetrical complication, kids with typhoid complications, bowel perforations, we check in on the infant with gastroschisis. Annaliese reviews fluid calculations for infants and children. Filling in gaps in knowledge and skills all day is what she does, every day, every case is a teaching opportunity, of which I am a recipient. “Reach in and feel down into the urethra,” she says during a prostatectomy case. “See how the tissue separates here and how you can create a plane to dissect the prostate away from the surrounding tissue? OK, I’m going to pull out my side, then you reach in and do your side.” The organ shells out with relative ease. Clinical prowess honed out of necessity and practicality.
More lumps and bumps, weird cysts and wild hysterectomies, ectopic spleens and fungating breast tumors. We wind down at 5 p.m. and prepare to head to the clinic for more evening consultations, only about 27 tonight. Someone is briskly wheeled into the OR. “You are welcome to stay and help with this emergency c/section,” suggests Annaliese, “and then come and join us afterward.” I ask the crew in the OR in my best Portuguese, which is really really bad Spanish. They reply that they could use the help. The crew is cleaning up after the last patient and preparing him to be moved out of the OR, while simultaneously preparing the c/section patient for an urgent delivery. The OR is large and allows for two cases to be performed at the same time with a modest sized “HIPPA compliant” barrier between the two cases, often men and women having their bodies exposed and private organs removed or worked on a few feet from each other while awake under spinal anesthesia. No one complains. Everyone is happy to have care for their nearly always long neglected surgical issues.
I don’t know anything about the case, just that it is an urgent c/section. I scrub quickly, gown and glove and step aside to allow others to prepare. I prep the abdomen with betadine and step to the other side of the patient as instructed. The surgical assistant hands me the scalpel and I begin. I am used to standing on the opposite side of the patient, but not today. I am used to a low transverse incision, but the vertical incision is preferred here. I’m upside down and backwards, which is a bit disorienting, but I adapt and we move forward. The patient is squirming a bit, but unconscious, I assume, due to an eclamptic seizure. The baby is likely in trouble. I work through the abdominal wall, into the peritoneal cavity, stretch the wound with my assistant and plunge into the uterus. I remove the infant, which is still and without signs of life. I am dubious that any resuscitation will be successful. We hand off the baby and turn our attention to the mother, removing the placenta, examining the uterus, which has an extension of the incision down the right side toward the cervix with some extra bleeding going on. I repair the organ in layers, taking care to place the sutures for their maximum benefit as I near the large vessels which supply the uterus from the sides. Satisfied with the closure, I place the uterus back into the abdomen and close the abdominal wall. The assistant, who is a well trained surgically trained nurse, completes the skin closure with what is called a running vertical mattress suture, a cosmetically pleasing closure which takes longer to put in, but provides additional reinforcement for the skin as well. The surgery is successful, but the outcome for the mother is devastating.
I find my way through the maze of buildings to where Hermenegildo and Annaleise are finishing with the consultations. Between exams and ultrasounds, we talk about training locally in Africa vs training in the U.S. I comment that it is so important to medicine in Africa to teach locally. Annaliese shakes her head. “There is no way you can get the same outcomes teaching in the U.S. Medicine isn’t practiced the same way, even since I trained. Robots and laparoscopes, and endo procedures for vascular repairs have largely taken over in the U.S. Most surgeons being trained now don’t know how to do what I do. We need to train locally.” She refers to the PACS program, training surgeons in Africa at Christian medical institutions, and underlines the importance of PACS’ continued existence.
I ask whether she thinks there will be an expansion of family medicine in Angola, at CEML specifically. There are plenty of clinical experiences available for a medical training program, and with the planned launching of CEML as a PACS site, there will already be a residency for surgeons, but enough clinical experiences left over for family doctors. “I think what we need is a dedicated family physician here,” she says thoughtfully. “We have an ER doctor, and an ob/gyn here at Kalukembe, but at CEML in Lubango, it’s just us surgeons. I think it’s important for those in training to hear the family medicine perspective on management of disease and health promotion.” I nod thoughtfully. I’ve heard her wax eloquent on prevention of diabetes, and lifestyle treatment of hypertension and promotion of health. She understands much of what family medicine is about. It’s kind of her to give recognition of the uniqueness of my specialty.
Days are long here, but wonderful. We wind down at the end of the day over rice and vegetable and bean soup. “Oh, did you taste the potatoes? They are so good!!” Funny how a simple pleasure like eating simple foods can become a highlight in a remote place, especially after straining over patients all day and long into the night.
On our final day at Kalukembe, we have a deadline. The small plane flown by MAF leaves at 4 p.m. regardless of where we are in the cases, and we need to be ready to leave. We round on a couple of patients. A boy lies in his bed, large surgical wound draped with gauze and tape, restless and fidgeting. He had a bowel perforation from typhoid fever, a common complication in these parts. The patient who had a c/section yesterday lies solemnly in her bed. An older man lies in the same big postoperative room in the adjacent bed, having had his prostate removed yesterday. But it is a smaller patient we are looking for this morning. The infant with gastroschisis is on our minds. We didn’t feed her yesterday, and today she is on oxygen. The bowel needs rest when it has been outside of the body like she had. (Annaliese placed the bowel back inside her abdomen yesterday). On the other hand, we need to feed the infant. There is no IV TPN available. We need to be cautious about how rapidly we advance the diet. Unfortunately, the belly is quiet. We are concerned that the baby won’t tolerate much in the way of feeds. And we are leaving town today, so it is important to observe the child for a bit to see how the infant will tolerate some calories. Annaliese decides to try a very small amount, just a few milliliters every hour. It’s dicey, but her fear is that once we leave, there will be essentially no one to help guide the local physicians, all general practitioners without the benefit of residency training, with the next steps of management.
We head to the OR and begin our cases. A big crazy looking ulcer on a leg. A gallbladder that needed to come out, but the patient had a perforated duodenal ulcer as well. A thyroid that is growing out of hand and needs to come out. A uterus that is the size of a volleyball with so many spiky fibroids on it, it looks like a model for a covid 19 virus. A shoulder that has been dislocated for three months and probably won’t go back in. a guy that fell into a fire during a seizure and needs his eye sewn shut so it isn’t damaged. (he can’t close his eye due to contractures of the skin due to the depth of the burns.) A scared young woman with a breast lump.
We hear a sound on the roof. Someone confirms that it is raining. I tease that now we are stuck here, but no one seems to be concerned. A few minutes later we hear report that our baby with gastroschisis has pooped. We are celebrating baby poop. It means the bowel is working. The child may survive after all.
We pack up in the rain, wet, tired, stiff, greasy from too many hours standing over patients and too little warm showers. We load into the plane glad to be going and glad that we came. The staff thank us for coming. We have to explain to one poor guy who has been waiting all day that now we need to go, and we can’t take care of his surgery today. Fortunately, he lives in Lubango, and we will take care of him there. We lament that we couldn’t do more.
If I were to summarize this trip to Kalukembe in a few words, I would say overwhelming, mind stretching, amazing learning and teaching, very sick patients, dedicated staff. And there’s something about meeting people who have committed their whole lives to service, to blessing the world with their lives that stops you in your tracks and makes you realize how beautiful our lives can be.
Smoky leaves smoldering in the cool morning air. A girl sitting beside the road, nibbling at a bowl of rice and tomatoes. A woman in a police uniform and a stocking cap making her way toward the hospital. Guards and children peering into our vehicle, trying to make out what manner of visitors we are. An older man shuffling off the road to make room for us. Crazy, out of control diseases and suffering met head on by a team of people who would rather give their lives away than do anything else. No thanks needed, no praise, no honor or financial reward, just the thanks of knowing you’ve done your best to help with someone else’s suffering and you love what you do. And every once in a while, someone comes skipping into your office bursting with uncontrollable joy and can’t stop hugging you because now their elbow works and they can scratch their nose after years when they couldn’t. That’s what I call a good life.

“You Have Now Performed a Hemi-Mandibulectomy”

October 22nd, 2023 by barrybacon
Posted in Uncategorized|

“These patients can exsanguinate,” explained Dr. Annaliese. “That’s why I’ve followed this technique of ripping everything out quickly and getting the bleeding under control. It works much better than carefully dissecting everything out and having so much blood loss that you can’t control anything. Once you get the mandible out, you can see where the bleeding is coming from and easily control it with pressure and cautery.”
Dr. Annaliese, a medical student, an intern and I are working on removing one half of the jaw bone of a young man who developed a large, deforming and painful mass which pushed the left side of his face outward in a dramatic fashion. Who knows how long this has been causing trouble for him. Dr. Annaliese has carefully split the face in half, cut through the middle of the chin with a Dewalt multitool vibrating saw, and separated all of the muscle and other attachments from the left side of the jawbone all the way to the temporomandibular joint. There is a gaping hole in the inside of his mouth where this growth has collapsed and allowed all manner of debris to enter. His tongue, mouth and teeth are involuting or distorted in some way. Anna, the intern, and Maxim, the student are holding retractors and gauze. I’m holding his head as Annaliese pulls at the stubborn jawbone. “Here,” she says nodding at me. “I’m going to hold pressure down here. You’ve got a better angle. Just grab that thing and yank it out.” I feel my way around the back of the mandible, deep into the recesses of his neck, around to the place where the jawbone creates a joint with the skull, the temporomandibular joint. Then I start pulling. Tissues, muscle, periosteum, vessels all give way as I tear the bone from its moorings. “There,” Annaliese sighs. “You have just performed your first hemi-mandibulectomy.” I ask her if she will write me a letter of recommendation. She nods. I laugh.
She rests for a moment, gloved hands deep in the cavity we have created, pressing on stubborn vessels that just need a moment to adapt to their new role of having nothing to do. She uses the moment to walk us through the procedure we have just witnessed, her treatment plan, her differential diagnosis, the risks of the procedure. She is a gifted surgeon and teacher. I hand off the surgical specimen to the surgical technician. It looks like an alien, unhuman thing. We control the bleeding, then close the gap with layers of suture and a drain in place. I look up at his vitals as we finish cleaning and wrapping the wound. Puls 140. Blood pressure 69/53. I ask Maxim, “are those really his numbers?” “Yup,” she replies. She has already been here in Angola long enough that this is just part of the expected roller coaster of anesthesia care. There is some blood and IV fluids slowly dripping in an IV, but it’s late and slow. His next blood pressure has improved to 88/60. We’re getting closer to where we should be.
Earlier, Sam put a long orthopedic nail down the shaft of a humerus that hadn’t healed for years. The bone looked healthy enough, but perhaps due to the way it had been casted, or perhaps due to nutrition, the bone had never grown back together. By this procedure, he is trying to give the bone a fresh start. It’s a rough procedure in the sense that orthopedics involves a lot of drilling, power tools, hammers, slide hammers and screwdrivers. It’s not like other medical specialties. During the procedure, the oxygen levels keep dropping, but we can’t think of a reason for this. 60’s, 50’s, 40’s. it gets a little dicey, and it’s distracting. I’m observing this procedure, since I came in late to the case. I presented a neonatal resuscitation course in the morning called “Helping Babies Breathe,” (more on this later) so decided I wouldn’t disrupt the case by scrubbing in in the middle, but would simply observe. I stepped out during the excitement of the low oxygen levels to grab my stethoscope and be prepared to help with airway issues should this be necessary. The anesthesia tech was able to straighten things out by reducing the anesthesia, and things settled down so that Sam could finish the case. Everything turns out well.
On the way home, we talk over the day. The surgical cases are wild and difficult. The techniques used are of necessity practical, careful, but without the glitz of every imaging study or material needed. Sam had to make due with the size nail he had on hand, for example. We talk about anesthesia and means that have been tried to improve the consistency of the quality of the care provided. We discuss concerns about supply challenges. Of the ortho cases we have witnessed to date, I asked Sam, “if you had your wishes, what would you need?” “I wish there was a manufacturer in Africa of the antibiotic resin kits for osteomyelitis. Those work really well for chronic osteomyelitis, but the supply is inconsistent because we need to order those in from outside.
At the end of the day we share a wonderful meal of tortillas, falafels, vegetables, cheese and potatoes. We relax together smiles all around. “What did you do in school today?” I ask Bella. “Nothing.” “I learned about bones,” I told her. Sam and Maxim both laugh, knowing the brutal orthopedic procedures we were part of today, and how I was sparing her all of the gory details. Amanda. Maxim and Bella play a game called “Cat Crimes” while I relax for a few minutes and prepare for tomorrow’s trip to Kalukembe, which promises to be remarkable.

“I have a Problem Patient”

October 18th, 2023 by barrybacon
Posted in Uncategorized|

“I Have a Problem Patient”
Today has been a full day of making rounds, changing dressings, performing operations. We begin by making rounds on a number of the patients who are hospitalized, then reviewing the admissions of the night. On Tuesdays, we all pack into the treatment room, nearly climbing over each other to care for three patients at once in a room designed for one. I will scrub in with Dr. Sam today while next door Dr. Annaliese is doing some cases, including a fistula repair.
Our first case is a gentleman with a chronic draining infection from a fractured leg which didn’t heal and then got infected. We anticipate that this will be a mess and it is. Trimming away diseased bone, cleaning out pockets of infection, then resetting the bone with an orthopedic “nail” and screws, the leg considerably shortened due to the amount of bone that needed to be removed, is a major deal. Sam describes what will be needed to ultimately fix the shortened leg. There is a device which can actually gradually lengthen the leg back to it’s original size. The time frame to clear the infection, allow for bone healing, lengthen the leg and rehabilitate the patient will be close to a year. But as it is now, his leg has been completely useless for months, so it’s a good investment for him.
The second case is a woman with a large breast mass. Her cancer is too far spread to be able to treat her effectively, but the bulk of the tumor will be removed by mastectomy. We find at least three nodes in the axilla as well and perform a debulking procedure.
Over lunch of corn meal mush and beans, Maxim, Sam and I talk over the cases. I remark that I think I found a bone fragment in my beans. Maxim says she has a hard time with the cow intestine that they put in the beans. OK, we’ve both lost our appetite.
At the end of the cases, Sam steps outside to discuss the findings with the family. Quite a group have gathered to hear about the status of their loved one, the woman who has breast cancer. Sam reviews the case with them. The family nods, asks a few questions, tries to read his face and thanks him for his work. We don’t think we’ve cured her. Her options for curative treatment are very limited in this part of the world.
We hang up our coats and prepare to leave. On the way through the waiting area, one of the nurses stops us. “I have a problem patient,” she tells Sam. “You seem to collect problem patients,” he teases her. She tells him of a fifty year old male who came in with six days of difficulty with urination, fevers, right flank pain, treated at other hospitals with vitamin B6 and some other therapies. He became worse, and developed confusion, dark urine and vomiting. His kidney function tests show that his kidneys are shutting down. His pulses and blood pressure are difficult to find, and his breathing is labored. “He’s septic,” says Sam. I nod. “He’s in shock. He’s delirious.” The nurse replies, “the doctor on call has started him on IV antibiotics and IV fluids, but fears to give much in the way of fluids because of his breathing status.” It’s true, the doctors are walking a careful line between maintaining his blood pressure and circulation, while not flooding his lungs with fluid so that he can’t breathe. They are stuck. The patient needs the support of a medicine like dopamine or norepinephrine, but you can only give these medicines very carefully by continuous IV drip in an ICU setting. Sam gives the nurse some instructions and we exit the hospital. The family of the patient is waiting, and Sam spends a few moments reviewing his status so that they understand. The man is in a very precarious, critical condition.
We climb into the car and talk over the case and the plans for further development of the hospital, including development of an ICU. We are dubious about whether or not the patient will survive. Sam shakes his head. This is a common scenario, he tells us. People have been to multiple other facilities, but the most urgent, life-saving medicines (in this case, he needed broad spectrum antibiotics early in his illness) are missed. Speaking of the development of an ICU, Sam continues, “You have to count the cost. It’s not just the doctors’ training. You need to have a full complement of nurses and other staff, and there needs to be a sufficient volume of patients in order to keep their skills up. We would need to charge $300 per day to stay in one of the ICU beds.” He gave an example of another hospital in Kenya which seems to be pulling this off successfully and has become a referral center for care. Here in Angola, if good care is being provided, it seems that patients will come. But it’s a balance between providing excellent care and charging sufficiently to cover the costs of that care. The economy here is so different from where I come from.
Sam told us earlier that the average income for folks living in Angola is $40 per month. Prices have gone up dramatically recently so that even staples like flour and sugar are out of reach for many. There is considerable unrest since the price of fuel has doubled recently. Angola is the fourth leading producer of oil in Africa, but there are no refineries in the country, so fuel can be difficult to come by. There are other countries investing in Angola, and truckloads of natural resources such as granite and minerals are leaving the country. Yet the income from these riches doesn’t seem to filter down to the common folks very easily, and they struggle. All sorts of fruits and vegetables can be grown here, but people struggle to afford more than just the very basic, least expensive foods.
At the end of the day, we sit down together and enjoy a meal. Bella tells us that her favorite class today is PE. I tell Maxim that I am practicing that Dutch cheerleader song about “don’t leave the lion standing in his pajamas” for a karaoke opportunity. Bella begs for a second piece of apple pie and we tease her mercilessly. We can’t fix everything. Our patients suffer despite our best efforts. In spite of the limitations of our humanity, our attempts to heal whenever possible, and show compassion always is making a difference. And it’s good at the end of the day to let our minds rest and spend a few moments caring for each other by sharing apple pie with Bella.

She Has a Pneumothorax

October 16th, 2023 by barrybacon
Posted in Uncategorized|

“She has a pneumothorax”
I held the xray up to the light emitting from the ceiling and shifted it back and forth, carefully reviewing the film. “Looks, she has a pneumothorax,” I commented to the resident physician I am working with, a second year resident named Maria. “Oh, wow. I wonder if anyone told her that,” she exclaimed. “No,” she said a moment later. “They called it normal. But you can clearly see that half of her lung has collapsed.” The patient was seated before us, looking comfortable and relaxed. We looked at the date on the xray. Sept 3. Today is October 16. Not likely this issue is causing any problems now. The patient explained that she had been in a severe motorcycle accident, thrown down on the pavement and knocked unconscious. In her coma, and in all of her subsequent visits, the collapsed lung was unrecognized. Fortunately, the condition resolved spontaneously without causing harm.
Next is a patient with one leg considerably shorter than the other with multiple draining wounds from the thigh. He too was in a motorcycle accident several months ago. He has had three orthopedic procedures at other hospitals which failed and now has come to the mission hospital hoping for a cure. The surgeon, Dr. Annaliese, evaluated the patient and reviewed the plans. He will need removal of the hardware from his thigh, debridement and antibiotic therapy, then another surgery to cure the condition.
We have seen multiple patients today with failed surgeries from other hospitals. It seems to be a common theme. Many of the other patients today have neglected their care or have seen other providers, suffered much and now finally are coming in for care. Skin cancers, goiters, complications of childbirth, bone infections, heart failure, diabetes, parasite infections and unstable knees. About half seem to have been in a motorcycle accident. (motorcycles are the taxis in much of the country).
There is a ward at the hospital for women who have had complications of childbirth. When women are unable to deliver their babies but don’t have access to a c/section, they frequently suffer a complication called a vaginal fistula, where urine or bowel contents leak into the vagina. There is a foundation which provides support for the surgeries necessary to repair these complications. Every week the hospital has five or six cases. This is a huge burden for the country and many other areas of Africa where the first child is born early in a woman’s life or the baby is too large or improperly positioned for a natural birth. The results of the reparative surgeries are encouraging, but mixed, in that there are some inevitable failures. The best treatment is fistula prevention- ultrasound during pregnancy to identify large or malpositioned babies, delay in maternal age of first baby, and improving access to high quality c/sections when needed. Unfortunately, looking at availability of physician level care in so many areas of Africa, it’s going to be a while before this becomes a reality.

On the way home, Dr. Sam, Maxim (the visiting medical student from Holland) and I talk about what we have experienced. Maxim asks me what I’ve noticed about this particular hospital, whether it is similar to others I have visited during my years in Africa. I’ve taught or practiced in at least 30 different hospitals in seven different countries in Africa. I respond that this hospital and its staff are unique because the quality of care they provide is high. They come to work every day. They believe in their mission. There is a high level of commitment to teaching, to providing the best possible care for the patients, to compassion, and this combination of characteristics is far too uncommon. The students and residents are serious about their work. They spend time with their patients. They develop carefully thought-out diagnoses and create reasonable plans for their therapy based on their history and physical exam. So yes, this is an exceptional place to learn.
Later, we talk further over supper with our host family and another guest, Brian, who represents SIM, a support organization for the mission. We share with him the diagnoses we are seeing, the suffering of the people, the care that is being provided. Sam and Maxim share the story of a recent surgery on a patient who had the largest goiter Sam has ever seen, weighing in at 2.5 kgs. “It was bigger than the baby that was born the next day!” he exclaimed. “We named the baby Little Thyroid because he was smaller than the surgical specimen!” More stories of remote suffering, unusual conditions related to the use of traditional medicines resulting in liver failure, bladder cancers in very young patients as a result of rampant schistosomiasis in remote areas, other wild and unbelievable health disparities. I throw in a few stories from my years in Malawi and elsewhere, but it’s hard to match Sam for stories from African medicine encounters.
At the end of the day, we relax by watching the Netherlands’ soccer team play against Greece to try to qualify for the European championships next year. Maxim attempts to teach us a song to cheer on the Netherlands team, something about “don’t leave the lion standing in his pajamas.” I offer to learn it and sing it in the Amsterdam airport next time I pass through. “Oh, they would love it,” laughs Maxim. It’s the end of a full day.

The Long Road to Lubango

October 15th, 2023 by barrybacon
Posted in Uncategorized|

The Long Road to Lubango

“The flight has been cancelled,” the airline employee reported as Tim, Janet and I stepped up to the check-in desk.  “You will need to talk to the woman dressed in orange.”  We attempted to reschedule our flight in the next couple of days, but options were limited, and the flights were full.

The woman in orange did her best to help us but couldn’t make any promises.  With the help of a teenage girl from Miami who translated for us, I was told to come back the following day and go as a standby passenger, no guarantees, while Tim and Janet decided to ditch the idea altogether.  Their time in country was very limited, so they would stay in Luanda and create their meetings remotely rather than risk another failed attempted flight.  Each of us had already had multiple changes and cancellations in flight plans. We dragged out luggage back out to the curb and headed back to the hotel to regroup.  We contemplated traveling by bus, but we were told the roads are rough and the trip is a grueling twelve hour day.  After our long flights from the US, such a trip didn’t sound appetizing.

The following day, I said goodbye to my new friends from SIM and loaded into the transportation service vehicle which our hosts from Lubango had arranged to take me to the airport.  I noticed an unusual new vibration which shook the small SUV.  “Hmm,” I thought.  “I wonder when this car was last serviced.  I just hope it makes it to the airport.”  Suddenly, the vehicle shook violently and came to an abrupt stop.  I took off my seat belt to see how I could help, but the driver waved me off.  Several animated calls later, he assured me that help was coming.  We reloaded the luggage into a second vehicle and took off at warp speed for the airport.

Inside, I was handed off to a man wearing green, who through a series of phone calls and conversations and negotiations while I sat by.  After an hour, a woman dressed in a dark suit with a bright orange scarf was able to secure a boarding pass for me.  I grinned at the woman behind the desk and brought my hands together in a gesture of thanks.  She nodded and smiled in return.

Beyond security, I took a seat in the least crowded corner of the waiting area and worked on budgets and tax items for our nonprofit back at home.  I suddenly realized that I had miscalculated, and it was already time for the gate to close.  I rushed back downstairs and showed an attendant my boarding pass.  She reassured me that I should take a seat, and that the flight had not boarded yet.

Suddenly, a wall of people erupted loudly and stood in line.  Someone shouted “Lubango” over the din, and I weaved to the end of the line.  “Is this the line for Lubango?” I asked a fellow traveler, showing him my boarding pass.  “I hope so,” he laughed.  “We’ll find out when we get there.”  Two bewildered Chinese travelers were pulled out of line.  I showed them my passport, explaining that this was the line to Lubango, and where to look on their boarding pass for their destination.  I don’t think it helped.

Inside the plane, I was offered a complimentary bottle of water as my snack.  I took it.  My entertainment was a Sudoku book I brought along for the trip.  I fell asleep quickly.

I exited customs and immigration, got my luggage, including an added piece from Tim and Janet to be delivered to friends when I arrived, and went out to see who was there to transport me.  I was greeted warmly by Sam Fabiano and his daughter Bella.  We climbed into their pickup and drove through the dark streets to their home where I met Sam’s wife Amanda and a visiting medical student from the Netherlands, Maxine.  We swapped stories over a warm meal of locally grown broccoli, cassava, plantains, salad, and cupcakes baked by Bella.  Maxine described the amazing cases she was witnessing and the many things she was learning from the medical team.  I spoke of our work in Ethiopia and of why this trip was personally important in developing additional skills to train family physicians in Africa.  I told them a story from Malawi, of transporting a woman having a heart attack who needed a pacemaker to Johannesburg, South Africa, of the failure to procure a spot on a commercial jet, resuscitating her on the airstrip, returning to our mission hospital in Blantyre, getting her on a private jet the next day, flying over civil war torn Mozambique, arriving safely in Johannesburg only to be told that the patient didn’t have proper documents and would need to return to Malawi.  We laughed together at the relatively small inconvenience of the flight delays of the past two days.  “You’re no stranger to travel changes,” remarked Amanda.  She’s right.  In the big picture, the long road to Lubango will just be a small, inconvenient footnote.   I smile at the thought.  I’ve arrived.