“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.
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