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.
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