how i feel

It is important to me that I take a minute or eighty and reflect on my trip.  As a preamble, this post has proved the most difficult  to write.  And I do not know why.

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I have been in the land of the free and the home of the brave for forty-one days.  My return was quite entertaining thanks to both jet lag and reverse culture shock.  My better thirds (roommates Ben and John) scooped me up from Columbus Municipal Hangar and laughably oriented me.  "Zach, we are your friends."  "Zach, this is a McDonald's."  "Zach, this is where you live."  We were up until 2:00am or so swapping stories.  Having gotten much shut eye IST --> ORD, I was wide awake.  This was opportune to finish those slides for my presentation.  I finally turned in around 8:00am and snoozed through the middle of the day.  The presentation went swimmingly and it was on to a fancy place nearby to watch the Bucks ruin Indiana's senior night.  Quite a first day back.  Thankfully, though, iCal showed the rest of my week with little to do.

After seven days, I felt generally returned to my former self.  The most difficult changes to reconcile were constant Internet access and ever-available food; the most pleasing was smooth roads.  Any mental attention still divided was called into focus on Monday, March 11th at 12:00pm, when graduating medical students were informed whether or not s/he had matched.  40,803 applicants for 29,171 spots and a career of academic progress leading to this point made my pulse quicken upon receiving an e-mail.  I matched!  So began Match Week, culminating in Friday's Match Day.  The 200+ members of my class, flanked by family and friends, tore into envelopes after the air horn blew at noon.  I am overjoyed to report that I matched Med/Peds at The Ohio State University/Nationwide Children's Hospital, my first choice.  It is a rite of passage in medical training and a day that I will never forget.  It was especially meaningful to share the day (and liquid evening) with my family and friends.

So, obviously, life quickly resumed all ahead full but my free moments in thought were spent in Angola.  Time has certainly been doing its kiln-like thing: my fresh experiences are now hardened reflections.  Approaching a conclusion to this blog, I want to share such reflections, forecasted hopes for Angola, the current state of things, and where I am headed.

Two days after returning home, I scribbled a list of what I gained and what I had lost.  I gained an appreciation for the ability to be mobile, to travel freely.  I gained new insight into Black History.  I also gained an introduction to an entirely other way of life.  I lost twelve pounds.  I lost medical innocences, seeing in sharp relief the burden of disease.  I lost tolerance (empathy? patience?) for the complaints heard among first-world life.  This columned approach is reaffirmed by my two central reflections: the prevailing human condition and the idea of choice overload.

Our communal ability to survive, to succeed owes thanks to judging differences among people.  This is central to the way we navigate everyday life.  The truly beautiful thing, though, is our sheer commonness.  Smiles, laughs, tears, love, hunger, and fatigue have no language.  With words, I can only hope to come near the impact of seeing, 7,000 miles away, a vain young mother, a patient drawing breath after hearing the word, "cancer," and a five-year-old birthday girl just as they are 7 miles away.  We have and should resolutely retain our respective cultures and identities but is it not one of life's most precious gifts that we share the same foundation of feeling?

It was most auspicious to read that generational article on the flight to Angola.  "Choice overload," is not a concept that I had heard before.  In one month's time, it is now something that I deeply care about and strongly identify with.  We, in the first-world, have at our disposal a laughable amount of things.  For example, I routinely frequent three groceries, six gas stations, and five coffee shops (but only one Chipotle).  Extrapolate that to daily decisions about which outfit to wear, what shows to watch, and with whom to spend time!  While, thankfully, this also lends itself to a competitive market and advanced technology, I feel the personal ramifications to be net negative.  It is kindling for inefficiency, let alone anxiety.  Fueled by the ongoing share vs. humble brag that is social media, choice overload is an issue.  My mind was freed in Angola because of a limited menu of activity, food, and clothes.

Angola has an incessant need for not only medical but also humanitarian relief.  The most frustrating aspect here is that the country itself can do so much better.  Their land is one rich in resources, vast, and protected from international turmoil.  The government's blatant corruption and neglect of its citizens are embarrassing.  The quasi-communist ability to control the discussion and so much oil deservedly places all the blame and shame one can muster squarely on the ruling elite.  When will the paradigm shift?  Who will be the new voice for the people?  I long for the day when, like a banyan tree, a shade of prosperity spreads from Luanda to cover all Angolans.

I have positively enjoyed fielding questions about my global health elective.  Especially nice, though, was a dinner last Monday at Northstar.  I met Diane Lui, Ohio University student matched in pediatrics, who was less than a week returned from Lubango.

We had originally envisioned travelling together but circumstances led us a month apart.  In the wake of Match Day and the abrupt resumption of our lives, it was special to share so directly with each other.  We clandestinely joined forces to say thank you to the Kubacki family (chocolate, Vera Bradley notebook, cumin, calligraphy pens, Starbucks coffee, plastic baggies) and I was glad to hear about their receiving our gifts.  I had received an e-mail from Dr. Dan Cummings that morning upon receipt of an oxygen saturation monitor I had sent, in which he shared updates about patients we had seen together.  We discussed patient care and personal feelings.  Diane had such great insight into the ongoing meaning of visiting for our lives and we shared many laughs and a few sighs.  That dinner was a perfect venue to revisit our thoughts, not indirectly leading to writing this final entry.

And so, as I move forward with life, I feel fortunate.  I am, in so many ways, where I want to be.  Though (and thankfully) not perfect, life is a wonderful thing.  I don't know about you, but I really enjoy the thought that when I sleep, those on the other side of the world are awake.  But, as a man once said, the world ain't all sunshine and rainbows.  I turn twenty-six next month and I have one major complaint to file with life thus far: how quickly everything palls!

I am saddened that even the most amazing of experiences is allowed to seem old hat, especially so soon.  Those new toys lie forgotten, the Harlem Shake disappears as quickly as it came on the scene, and the ardent African thoughts fade to fond memories.  Thinking about this more, I take solace in that it clears room for new and deeper feelings: no satisfaction without desire's retreat, no love if not for infatuation's waning.  What I am getting at is my lament for how quickly Angolan details slip from my short term memory.

My name is Zach Rossfeld and I logged a hundred and seventy-one clinical hours in Angola.  I lived and learned among a talented and diverse group of people.  I cared for the sick.  I saw a different land and a different way of life.  I am changed for having done so.  Thank you to all who supported my trip and followed along.

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There's a feeling, unlike the myriad others I imagine we are all prone to feel, that I've felt a certain few times in my life.  First, as a kid, with that first death in the family.  More recently, it's after I close a just-read book or take a poignant patient history.  The feeling is that of something you passively experience affecting you in a real way.  The power of what you've just heard and saw, you then actually feel.  A very 1, 2 situation and something entirely different than empathy.  This experience, in some way, transformed me from that passive, "oh," to an active, "okay."  For this, I am, and will remain, forever thankful.

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All this, though, only forty-one days returned.  Time and change will surely show how firm the impact of having grabbed life by the horns.

Finis.

ready, set, OH

I am writing from my re-encounter with exile, Istanbul.  It is currently 12:23am in Columbus which puts me almost exactly one spin around our axis from my own bed, toilet, shower, and kitchen.

Oh to be alone with  thoughts during an eight-hour layover!  You know that feeling as soon as your plane lands when you have all the gumption in the world but are inevitably subdued by an epoch of taxiing, deplaning, and sign-following?  My friends, I am living in that frustrating place right now.

I can sit here, amused by how much business Burger King is getting at 7:25am, and stare at my calendar all I like.  With no option for Internet access though, I am able only to make to-do lists.

My Grandpa Rossfeld once referred to me as, "always putting 10 lbs. in a 5-lb. bag."  Part of me loves this descriptor in a way reminiscent of my beloved high school job, where we actually sold 5-lb. bags.  Some other fraction of myself loves this descriptor for its self-deprecating quality: I land in Columbus Monday at 11:52pm and have a year-end project presentation to the Department of Internal Medicine bigwigs Tuesday at 6:00pm.  Although I am not (too) worried, my slides are not finished.

The overarching sentiment here is that I am ready to be home.  All the more so when I get nerdy and tabulate that I've spent eight and change percent of 2013 away.  I also want to get home after hearing the single greatest item of news in recent memory.  In an attempt to decompress, let's run the list of my returning wants and my returning needs.

I want not to sleep in a twin sized bed.  I want to listen to music as much as I am used to (Foals with a new album since I've been gone, Sky Ferreira and Father John Misty on my to-listen-to list).  I want ice cream.  I want to go swimming.  I want to binge on DVR'ed Workaholics and Girls.  I want to hit up the new Short North spot, The Pearl (raw oysters are a minor contributor to my reason for living).  I want not to live out of my backpack and duffel.  I want to be able to read the news (e.g. Benedict, yo, what was that all about?  What is a/the Harlem Shake?  Sequester, eh?)

I need reacquainted with this superb Big Ten basketball season.  I need to go see new babies: the previously mentioned Xavier and, making me an uncle six times over, João Paulo.

I need to see my friends.  I need to recommit to the conquest of Breaking Bad.  I need to sit down with my family.  I really need to clear the air about residency, having now had four vivid dreams about Match Day.  I need to wish someone a happy first birthday.

My work:good times ratio is fantastically latter-heavy in the next months.  To be sure, this is a prime time of my life: finishing one chapter and patiently approaching the next while just having had my eyes/heart/mind/soul opened in Africa.

I can't help, however, but to feel a concurrent tinge of selfishness.  So acutely knowing sub-Saharan life, the prospect of seeking out my first-ever Shamrock Shake seems callous.  Perhaps all of life is just adjusting.  I know what my boy Jim Morrison said about comparisons but I'll allow myself one here.  Going forward, the African people will have an ever-smoldering place in my heart like that of my first real love: not directly connected but yet formative and never forgotten.

There is much on my mind and perhaps even more on my schedule.  Despite the literally world-class people watching between sentences here in Turkey, I am just ready to be home.

at last

My tardy posts reflect my Internet access rather than my attention to writing.  Sorry?

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I passed my final African week at Chiulo, a rural hospital some three and a half hours removed from your and my idea of urban.  I linked to the pertaining Kubacki blog post and showed some pictures of the place previously.

This is somewhat of a throwback but to, "reiterate," the travel coordinator for CEML happened to be on furlough back home in Canada during my time.  I have zero knowledge as to whether the resultant surplus of visitors was conscious or not.  Regardless, my mood's nadir prior to Kalukembe was tied to the trainee claustrophobia.  You might imagine the education and personal experiences being diminished if always watching over someone's shoulder.  Importantly, I want to communicate - I want to remember myself - that this does not represent bad but rather a diminished good.

Kalukembe was a small step for me, one giant leap for my education being privy to the tropical medical all-stars: filaria-positive elephantiasis, leprosy, schistosomiasis, etc.  I had essentially now earned the merit badge for the textbook diseases of the developing world.  True: I held the resorbed hands of leprosy patients.  True: I examined the massive scrotal edema of the gentleman whose lymph system was gummed up with filaria.  False: I had independently recognized the disease entities and suggested treatments.

This, thankfully, is where Chiulo comes into play.  I consider it the crowning jewel, the parting gift, the hands-on medical experience I had been seeking out; you know, doing more and watching less.

Last Sunday (Feb. 24th), Andre, the hospital's driver arrived in Lubango to pick up Dr. Dan Cummings  and I.

Dan is awesome.  Get this, Dan was born in Grand Rapids, MI, lived in Japan through high school, worked as a ranch hand in New Zealand for a year after graduating, attended college at Pitt, worked a summer in college on a fishing boat in Alaska, returned for medical school at Rochester, completed Emergency Medicine residency at Christiana (Delaware), and is now married to the Dutch-Brazilian naturalized American Priscilla and they have an almost two-year-old son Ezekiel (Zeke) who has dual U.S. and Brazilian citizenship and they have served in Niger, Haiti, Zambia, and some other places.  I imagine they have some badass world map smattered with thumbtacks somewhere.

Preparing to head out, I felt extra-manly as it was communicated that we needed to procure all our provisions for the next seven days.  We swung by Shop-Rite, the surprisingly super modern western-style supermarket, and loaded up on perishable items.  We were off.  Kinda.

Andre has six children, two of whom live in Lubango and he is only able to see occasionally.  We made some brief paternal detours and were on the road a little after 11:00am.  We made three more calculated stops at roadside vendors on the way: mangos, bananas, and chickens.  It was pretty fun to try and drive a deal for mangos.  The produce was so fresh, so delicious.  I did not eat the chickens.

Having then made our way down the perfectly paved highway and cratered, "road," that repeatedly jams one's knee into the door, we had arrived.  Chiulo is staffed/maintained by an Italian NGO called CUAMM.  There is a fenced enclosure of five small cottages where all the folks live.  We happened onto the fifth birthday party of Laura's (the administrator) daughter.  It was a blast.  They had some sweet jams playing and the authentic Italian food was divine.  The party was very much in the American style with adults sitting around talking about anything and the kids absorbed in play.  Such an awesome Sunday afternoon arrival surprise.

Dan and I then got settled in our just-as-you-might-imagine-it two-bedroom cottage.  We had exactly four forks with only two being alike.  The towels had the particular scratchiness and smell from having been in a closet for some time.  We then made the first of our three minute walks to the hospital, crossing a pasture and an old colonial road.  The pasture is now cow central but as recently as the early 1990's there were elephants!  Too bad a civil war and illegal ivory trade ruined my potentially pachydermal commute... As you can also see, the weather was niiiiice.  We are talking low 90's and blue skies everyday.

The nurses were elated to see us.  There was much cheek-kissing in greeting everyone.  My favorite staffer was Agosto, a nurse in the men's ward.  He had a sunny disposition and a visage that somehow reminded me of either a thin Steve Harvey or a Milwaukee Brewers sausage.  We passed quickly through the men's and women's wards to get a sense of how many patients were in the place.  With no laboring ladies, we then dropped by the pediatrics ward.  All told, we had about ninety patients in house.  It is the tail end of the rainy season here in Angola.  Apparently, during the dry season, the hospital is twice as busy as we found it.  We were, by no means, going to be sitting our hands in the coming week but I would describe the patient load as more manageable and less completely overwhelming.

We got back to Cottage #3 as the sun was doing its ptotic thing in the west.  I was feeling motivated; motivated by the clean air, by being outside of the city, by a non-surgical role, by the prospect of a new opportunity for the week, and so went for a jog.  Turning to the left on the dilapidated Portuguese road outside the compound it made a dead end at the old Catholic mission and I continued out into the surrounding scrub.  Winding between sandy two-tracks and cow paths (there are as many cows and goats as humans here), it was a lot of fun to ad lib a route.  One of the best parts about the setting down here are the baobab trees!  These large, funky looking things are special and they are everywhere.  I turned to head back at a particularly fat-trunked baobab just as the sun eased below the horizon.  Running became an at least daily activity at Chiulo.  Dan is fleet-footed as well.  Although stray dogs and smells reminiscent of the south end of the Allen County Fair were intermittent challenges, exploring the land around the hospital certainly added to the greatness of the week.

Days started early, in the 6:00am hour.  I again had rooster alarms (these guys had a much better, "-do," than their brethren at Xangalala).  With a bit of breakfast and some barely tolerable instant coffee in the tank, we made our way over for Day 1.  Angola being Angola, the nurses were not ready for us even at 8:00am.  We eventually got going in the women's ward.  In about two and a half hours, we made rounds on the twenty-some inpatients.  A mix of tuberculosis and complications of HIV/AIDS with some random things like Brucellosis were our medical to-do's.  We next headed over to see the children.  In about three hours' time, we saw forty five peds patients and sent twelve of them home.  It was some serious medical culture shock as we sat a desk and worked our way along the treadmill of a bench of mom's with kids in their laps.  HIPAA rights and exam rooms were replaced with open eavesdropping and lots of breastfeeding.

We broke for lunch in the early afternoon.  That whole siesta lifestyle is not so bad!  Returning to see the men's ward is more of the same: tuberculosis, malaria, HIV/AIDS, trauma, urinary retention, etc.  There was then a longer break in the late evening for dinner, a jog, and some time to hang.  When the night shift came on, we headed back to pass through each of the wards again.

Nights are a slightly different beast at Chiulo.  There about 8:00pm the patients' families start setting up their tents on every bit of the verandas.  The other noticeable change: the infestation comes to life.  Especially the pediatrics ward, all of the buildings are completely overrun with insects.  Now with U.S.A.-grade internet I can post a video!  I was so appalled by the scale in the kids' ward that first night, I had to hit record.

Other pretty crazy things about nighttime: making rounds in the isolated measles ward (yes, I am seeing measles in 2013 and no, there is no electricity in this building), wives sleeping below the beds of the their husbands, the call system (on our front door) for when we were needed in the middle of the night, and a CHICKEN in the pediatrics ward that nobody ever seemed to mind.

This then, chicken and roaches included, became our daily routine: women and children first, men if there was time before lunch, return in the afternoon to ultrasound and do procedures, night rounds, and then anything emergent overnight.

Some isolated patients, experiences, and the like I do want to detail.

There are some other examples of, "Chiulo being Chiulo."  It being the major hospital for the area, there are ambulances, right?  The answer is yes.  The better question is: do they work?  The answer is no.  The one on the left is of a certain Chinese make for which there are no spare parts on the continent and the key of its dexter brother has been lost (lol).

With the HIV/AIDS burden, dedicated treatment is a priority.  The medication repository and outpatient clinic is housed in a shipping container + awning contraption.

Oh man, did I see (and probably inhaled a touch of) tuberculosis.  There is a small prison unit at Chiulo that sardonically used to house pediatrics.  Here, with birds and gazelles still painted on the walls, nine of the nine patients were TB+.  In the top left of the chest X-ray picture (patient's top right) below is an ovoid area.  That, my friends, is some tuberculosis nastiness.  

Remember Andre, our driver?  His sister came in with some chest pain and difficulty breathing.  Listening to her lungs, I, for the first time, heard bronchial (tubular) breath sounds and on percussion it was just night and day the dullness on that left side.  I don't need no X-ray.  Diagnosis = pleural effusion.  To both ease her symptoms and make our definitive diagnosis, it was time to do a thoracentesis.  It was my first.  Passing my needle above her eighth rib and then down at a sharp angle, I was into her lung cavity and out came the classic straw-colored goodness below.  We took a liter of that fluid out of her lung.  Andre's sister has tuberculosis.

Something important to document is the incredible lack of ancillary studies available.  We could reliably get malaria blood smears and hemoglobin and HIV tests in a day or two.  Otherwise, there was nothing.  No EKG, no basic electrolytes, no liver enzymes, TB sputum samples rarely resulted, no white counts...  Dan and I had to rely heavily on our physical examination skills.  Easily, the most tenuous case was one of our overnight calls.  

In came an 87 year-old lady with mental status change and cardiopulmonary troubles.  She had an irregular heartbeat at 46/minute and home girl was out of it.  She was on her side in apparent pain and not very responsive.  Her medications included both digoxin and Lasix.  I can't adequately tell you how instantly she would have had labs (especially potassium) and monitors (continuous telemetry, formal EKG) in any equipped medical establishment.  Thankfully, we were able to help her with medicines and fluids and she was a typical walking, talking, eating great-grandmother by the end of the week.

We had a 93 year-old man with a rock hard prostate and urinary retention (and a nasty UTI) who presented.  The next day, his wife showed up to take care of him.  This chick was hardcore.  Her triceps were chiseled.  She slept only a blanket on the cement.  She did not smile.  I seriously thing Mrs. Urinary Retention could have hang cleaned 225 lbs. on the spot.  I had to take a picture of this bra-ed wonder.  Oh and that's Dan.

Thursday turned out to be a slower day.  Dan and I took off on a forty minute walk to the nearby village's market.  I was in search of more mangos.  Dan was out of bread.  We did find these staples but the majority of this wooded flea market was clothing and booze and dried fish.  Just aimlessly walking, only about five feet from leaving behind all the clothing, something caught my eye.  And there, in its youth medium sized glory, thousands of miles from the Oval, I found it.

As much as they educated me and moved me personally, I want to close with some pediatric patient stories: a progression from interesting to heart wrenching and to close on a very positive note.

The incidence of umbilical hernias is increased in the African population.  I am not exaggerating when I say that thirty percent of our babies had some bowel peeking out of their belly buttons.  Many of these naturally close as the child grows but a significant number eventually need surgical correction.  The child pictured also suffers from Down Syndrome.  Oh!  It being March 6th, I implore you to go here.

One of the patients we spent a lot of time with (her teen mother added significantly to the draw on our time) suffered from congenital syphilis.  Although I don't believe her dysmorphic, "bug eyes," are necessarily from her disease state, she was certainly a particular kind of cute.

Ok, let's get to the tough stuff.

The six year-old below has a congenital heart defect.  When looking at her heart with ultrasound, it was easy to see the right-heart enlargement.  Angola has a national system in place for children to go to the capital, Luanda, and have corrective surgery.  Lacking, however, are support services to access this program.  She has no means of familial support with which to get to Lubango, have a formal evaluation, and be set up for life-saving surgery.  She is not uncomfortable right now (actually a very smiley and inquisitive little girl) but her story will not have a happy ending.

Let's talk about malnutrition.  In an arid climate with many laborers making $2/day, access to food is often problematic.  The pediatric unit has these wonderfully standardized yellow forms for assessing a child's goal weight and monitoring progress.  We would enroll and enroll and enroll in the feeding program.  The specialized formula is as calorie-dense as 36 kcal/oz.  Normal baby formula is 20 kcal/oz.  The incredibly frustrating part, however, is the apparent indifference and lack of education that so many parents displayed.  The boy pictured here is five years old.  Just picking him up, I was frowning and with heartache.

February 28th, though, was a day that I will never forget.  A day of such juxtaposed emotion.  News form home that day was the happiest kind.  My cousin gave birth to a healthy, 8lb. 12oz. boy!  Welcome to the family Xavier, so anxious to meet you.

My clinical day was the worst kind.  Her name was Laurindha Segunda and she was eleven months old.  She had previously been enrolled in the malnutrition program and had gained weight.  Her mom, however, left the hospital against medical advice for whatever reason.  Mom brought Laurindha back to us on the 27th.  She weighed 4.5 kg (9lbs. 14oz.).  Now in my life were kids no days old and almost one year old who weighed pretty much the same.  She was so feeble, so marasmic.  Her hair was falling out and she struggled to keep her eyes open.  She had vomited once in the morning and we were thinking of putting a nasogastric tube in so as to force-feed.  Returning a bit later, we learned that mom left to get food outside the hospital and had taken Laurindha with her.  Laurindha Segunda passed that day, just outside the building that was her only chance.

I was ticked.  I was pissed off at the mom.  I was just so incredulously irate at the situation.  Kids shouldn't die of starvation.  Kids deserve a chance.  Kids deserve a chance in the nowhere of southwest Angola just as much as they do in the somewhere of the developed world.  I also remember an overwhelming melancholy when, later that day, I felt hungry.  Eating my next meal required effort.

Thankfully, there are happy stories too.  A pregnant mom, way out in the sticks, had a fever.  She ended up giving birth prematurely without any medical personnel present.  The baby lived.  After a couple weeks she grew concerned that he might not be growing quite right.  Sure enough, weighing only 1.6kg (3lbs. 8oz.) came to us a neonate with a completely normal exam!  He turned out to be malaria positive and we were able to intervene in time that mom should absolutely not be giving cow's milk.  WIth his fever breaking and his suck strong, the little guy looks like he is going to be just fine!

Some week that was.  I am thankful to have had a medicine/pediatrics experience so inline with my soon-to-be training and career.  Chiulo, thanks to the patients, nurses, and especially Dr. Dan Cummings was the perfect way to wrap up my global health elective.  Another parting gift was the night sky.  So removed from civilization I finally saw with my own eyes the woolly swath, stretching from horizon to horizon, that is our Milky Way.  The Southern Cross hung just above the hospital; beautiful stuff.

I was back in Lubango by noon on Saturday with a 9:15am flight home the next morning!

fifty-four hours

Trying to rid myself of some midweek blah, I was very much looking forward to last weekend’s visit to Kalukembe, CEML’s affiliated bush hospital.

I was supposed to be at the guesthouse a little before 7:00am on Thursday.  Home to my fellow visitors, the guesthouse, a five-block walk, is where I have been taking meals and doing the whole wardrobe wash/rinse/dry thingamajig.  Anyways, I was up until 4:00am the night before packing, working on a school project, and writing.  Thanks to the human capacity for rationalization, I figured that a 7:10am arrival would be totally okay.  No one was there.  Now devoid of a cell phone and acquaintances, I was about ninety seconds from a complete histrionic episode when I heard a honk.  Opening the compound's blue steel (c.f. blue steel) door back to the outside, I saw Dr. Foster’s SUV idling.  Apparently they had just arrived and the numbers had worked out such that they were coming to pick up only one of the previously departed us.  To the airport!

Now, as I had introduced, one can either fly or drive to Kalukembe.  I have long aspired to fly in a prop plane.  The last (and only I believe) such aircraft that I was on I proceeded to jump out of.  The result I am trying to describe here is an outward Zach that is democratic and respectful of the number of people on this month’s trip and awareness that it is a small plane with a weight restriction and an inward Zach squirming to make Team Plane.  As it turned out, there were nine bottoms for the Cessna's nine seats.  Our group included Dr. Foster, Birgit (German surgery resident), Keira (Australian med student), Matt and Esther (engaged Canadian docs trained in family medicine and training in OB/GYN), Laura and Sandy (Canadian med students), and Joao (an anesthesia nurse from CEML).

Passports in hand, the group made its way through Lubango’s airport security gauntlet.  Thereupon we met our pilot, Gary, and our plane, call sign Charlie-Gulf-Whiskey-Oscar-Hotel.  Tossing our totes into the undercarriage, Dr. Foster quasi-mumbles, “Zach, are you going to be our co-pilot or what?”  Channeling my trip advice from friend, fraternity brother, and wizened voice of a generation Chris Hayes to, “never say no and always say thank you,” I agreed.

I now found myself wedged against all those switches and knobs with terrifyingly mechanical names.  Gary’s good-humored but honest directions were that if I became anxious during the flight and felt the need to grab something, that it be my own head.  My natural response was a progression from chuckle to serious nod.

We pushed down the runway and into the wild blue yonder.  Privy to the radio chatter, I gathered we were on vector 078 for the next fifty minutes or so.  As both the plane and my adrenaline leveled off, I hear Gary in my headset ask, “Zach, ever flown a plane?”

For a little more than twenty minutes, this kid flew an airplane with nine souls onboard.  Being already familiar with the concepts of pitch, roll, and yaw, Gary was able to breeze through an introduction.  The biggest surprise was the tail rudder tied to foot pedals.  It was a blast and I took to it really quickly.  As I maintained altitude through turns and stayed on course, Gary double-checked, “so you’ve never done this before?”  This came as an acutely personal compliment to me.  My maternal grandfather, Perry Wilson, passed before I was born.  He flew.  I savor the thought of having another vestigial connection to accompany the red tinge of my facial hair.

The coolest bit of flying happened as we started to make our descent.  As I am not an instrument-rated pilot, I was not allowed to fly through clouds.  Well tell that to the lazy clump of water vapor directly ahead.  I banked a bit to the left.  Again Gary in my ear, “extra points if you can put the wing in.”  There opened a small concavity and with cloud above, to the right, and below, I shot the surprisingly turbulent gap.  Now on cloud nine (see what I did there?), I graciously relinquished control as Gary circled the hospital and swooped to make our final approach.  Our, “runway,” was the pre-planned strip of dirt pictured below.

Our arrival was obviously The Event of the Day in Kalukembe.  The gawking-mass-of-cute-African-kids-thing finally happened as we deplaned.  I felt obligated to take a picture with my flight instructor.  Also a pretty cool experience, the lead hospital nurses (bearded Antonio and potbellied, jolly Nelson) had brought with them a copy of the OR schedule.  And so as we quickly loaded our bags and bodies into a couple cars and headed in, we scouted the awaiting patients and procedures.

Our motorcade travelled the only road in Kalukembe past its hotel, its bank, its soccer field, its school…you get the picture.  The population is too few to support any kind of redundancy.  Something memorable are the speed bumps in this hamlet.  Their nickname is, “spring-breaker.”  My collegiate smirk was erased when we hit our first rectangular bump; these things are poured at right angles.  Not wearing a seat belt and sitting over the rear axle of an ambulance, I was jostled.

The hospital campus is beautiful.  We hung a roger down a dirt lane and into the open-armed layout of Kalukembe.  A dead-end round-about is flanked on the right by inpatient wards, ahead by the outpatient facility and laboratory, and on the left by the operating room and ICU.  The hospital is a weathered stucco but with plenty of shady trees, including the first major stand of palms I have seen, and fragrant foliage all around.

Bypassing this main entrance just a touch, we circled back and to the left.  A five-minute-walk or so down a makeshift road (or wooded trails) and one arrives at the residences.  Dr. and Mrs. Foster actually lived at Kalukembe for more than ten years in the 70’s and 80’s.  His former house became our current house.  With parietals in effect, Matt, Joao, and I were to the right in the help’s quarters.  The metal roof made for some excellent nocturnal white noise and the bathroom made for a brain freeze during my minuteman showers.

Now to the medicine.

What a whirlwind this was.  That Thursday we were wheels down at 10:00am and started rounds at 11:00am.  Seeing only the hand-picked complex cases, we made our way through pediatrics, maternity, men’s, women’s, and the ICU by 2:00pm.  In attempt to describe the state of disrepair of the hospital, I have included a picture.  The niceties of western life were cast in sharp relief when seeing something as simple as a bassinet.

One of the most affecting moments came in the pediatric ward when, from directly across the hall, came primal screams.  Again, trauma and burns are quite common here.  Pain medication, even local anesthetics, though, are not.  The heart-wrenching noise was coming from the little girl pictured here who was having her wound dressing changed without any kind of pre-medication.  Tough stuff.

After a short caloric-intake break, it was time to do some surgery!  Just before 3:00pm it was full steam ahead.  Running two rooms and a total of three beds, our team got to work.  These theaters, however, were old at best.  Anachronisms in action, get a hold of the lights (WWII-era I'm told) and general appearance of the place.

There is no intraoperative monitoring of a patient’s vital signs.  That’s right, not even pulse or oxygen saturation.  If we ever did care to use the dust-covered EKG, I was quite reassured knowing that it’s Y2K-safe.  Good looking out Angola!

Something important to communicate here regards surgical anesthesia.  In the U.S.A., we paralyze people.  That is why folks are put on breathing machines and it makes the life of surgeons much easier.  In Kalukembe (and much of the rest I have seen), we use either spinal/local anesthetic or ketamine.  Wrap your head around this: cesarean sections are done with only local anesthetic until the baby is out! 

Another stark difference is patient transport.  I am used to a board on rollers with which a cohort of support staff transfer the just-cut patient from table to stretcher.  In Angola, we have able-bodied men for that.

We operated into the night.  The generator did not.  With intermittent electricity for ten minutes or so, we adapted.

The pace and turnover were incredible.  Resecting bone sequesters from children with osteomyelitis, removing uteri encased with fibroids, shunting babies with hydrocephalus, draining and correcting hydroceles, etc.  That first night we broke for dinner at 8:00pm.

The day was not over.  At 9:00pm we returned to see the long-waiting outpatient consults.

We made it through the pediatric patients on the schedule and wrapped up just past 11:00pm.  It did not take any of our group long to get to sleep that night.

The second full day started with breakfast at 7:00am.  Church services were held for patients and staff respectively.  We made rounds at 9:00am and were in the OR by 10:30am.  We, again, operated into the night and then saw outpatients.  This time we headed home early, at 10:30pm.

Saturday morning was more of the same with another pass through the wards and to the OR.  We were supposed to meet the plane at 3:00pm.  Just after 2:30pm, Gary buzzed the hospital.  We, as you might imagine, were not quite done.  Powering through two last cases, we were wheels up after 4:00pm.

The gang was due to split up.  Birgit, Keira, and I were heading back to Lubango.  The rest were on to Cuvango.  Dr. Foster’s sister lives at this mission and serves at a rural health post.  The crew was going to visit and Dr. Foster to attend a Monday meeting.  While saying our goodbyes and well wishes, we were met with another mass of children.  This time, I opted for the obligatory picture.

With Gary and Birgit as co-pilot manning the controls, we made an about face and touched down in Lubango just as the sun set.  It was an absorbing view to see, from the air, the sun above the city’s mountainous rim and then to descend into the shadowed dusk.  Pushing our own plane into the hangar, we were arrived.

Our group was on the ground in Kalukembe, Angola for fifty-four hours.  In this time, we rounded on some eighty patients, saw ninety outpatient visits, and performed forty-two surgeries.

checkpoint

Well then.  That’s fourteen days in the books and eleven yet to go.  If you’ll oblige, I would like to take stock of things so far.

Having been

The city of Lubango itself has been a surprise.  I knew that it was a large city and all but somehow the population density, noise, and lights are not jibing with whatever paradigm I had for sub-Saharan Africa.  The amount of pollution – water, air, and ground – are more than I could have imagined.  The hilly streets are ever-busy and I imagine a Lubango-themed Frogger proving…impactful.  Having seen the countryside this past weekend, I appreciate why Angolans would flock to urban areas in search of employment and sustenance.  The end result of such congestion, however, is a Lubango that I did not envision.

A highlight of the trip was meeting and living with the Kubacki family.  There are those persons out there whom you meet and immediately say to yourself, “yes.”  The five sixths of the family that I spent time with have sincere passion for their calling and, in committing their lives to others, have a beautiful sense of self.  I believe it to be true that I am, in some way, a better person for having shared a roof those ten nights.

CEML both has and hasn’t been what I had foreseen.  It is, “the clinic on the hill,” as the locals colloquially refer.  It is a tertiary referral center with an emphasis on surgery.  It is a wonderful place to learn and develop further my fundamentals.  I was not expecting the surge of people waiting for outpatient visits daily.  Sure, there is to be follow-up once discharged but to fill the hallways for hours and hours per day?  Another thing about this hospital, which has pros and cons, is its revolving door nature.  The flux of domestic students, foreign students, residents, doctors, missionary doctors, and affiliated folks is impressive.  The pros are a wide array of exposure and opinion.  The cons are a lack of institutional memory and the gaggle of white coats roaming through the wards on rounds.

Another impression I need to touch on is the sense of community shared by the missionaries and expatriates in Lubango.  With Mitcha (the walled compound where Dr. Foster and about five other families live) as a home base, these, mostly North American, people function in an impressively cooperative group.  Pizza Night Fridays are a nice adhesive but the real good comes from a positively connoted groupthink.  Random favors, organizing group trips, co-op purchasing, and constant radio/phone communication all contribute to a collectively higher quality of life.

Is

My Portuguese ability is not where I would like it to be.  I don’t know whether this is the result of too high an ambition or too low an execution.  Let’s say some of both so that I don’t feel too bad about myself either way, OK?  Thankfully, I do have some faculty in the clinical setting but my, “conversations,” otherwise are about eight seconds long.  I am sensing the value of the so-called immersion programs whereas I go home through the week and away on the weekends speaking English every which way.  I am, though, certainly improved and understand more everyday.

I am living a much more natural, simple life.  Most of the food is not processed.  Especially at Shangalala, I was up with the sun around 6:00am and to bed after dark by 9:30pm.  One must ensure access to clean drinking water for the day.  I have not seen live television since arriving.  I wear scrubs and eat meals that are prepared.  I am immune from so much of the decision-related clutter of my regular life.

Today my rank order list is due.  A sentimental milestone along the medial training path, it is now just twenty-three days until I open my envelope.  Where is it that I will be completing residency?

This is really just whining but I am tired of bad smells.  Trash, people +/- their infections, bat poop…

I am feeling a bit run down.  The last couple days at CEML have been particularly trying.  The weight of more deaths, one very unexpected, and a string of sad surgical cases are upon me.  I debated whether or not to include the pictures below.  In sharing, I am honoring my commitment to posting honestly and am also dealing with some blue feelings.  I struggle a lot with the late stage at which so many of our patients present.  Also chief among my thoughts is the lack of medicines and machines so commonplace in the States.

An 82 year old male.  He presented with a much-progressed basal cell carcinoma.  I thought of my anesthesia-bound roommate Ben when approaching intubating and preparing such a case.  Unfortunately, his tumor had invaded both of his maxillary sinuses and his upper jaw.  We resected much of the middle of his face.  With no ventilator available outside of the OR, I am writing this wondering if he is still alive.

A 26 year old albino male.  We see many albinos in Lubango.  The expression of this recessive trait is the result of local inbreeding.  Their skin, as you might imagine, is incredibly frail under the equatorial sun.  He has an advanced squamous cell carcinoma.  We were able to save his eye for the time being.

A 23 year old female.  Hers is inflammatory breast cancer, now fungating, that has totally penetrated her chest wall.  Twenty-three years old...

Will be

The rest of my time here will be very different from that already passed.

In the morning, I leave for Kalukembe.  A one-hour flight in a nine-seat Cessna or a three-hour drive away, this is the bush hospital associated with CEML.  We make monthly trips and operate pretty much non-stop for two and a half days.  This hospital has some 200 beds and is staffed totally by nurses.  The patients seen and cases performed are those complex enough to have been, "saved for the doctor."  Pending my own experience, I will direct you to a video produced by the aviation ministry here in Angola.

I will return to Lubango Saturday afternoon.  Only to re-pack and depart on Sunday for Chiulo.  I am particularly excited by and fearful of this opportunity.  As a budding medicine and pediatrics doc, the surgeries I have seen are very interesting but not so directly beneficial for my future practice.  Chiulo is a hospital with 250 beds - children in 100 of them - that will be a less surgical experience than CEML.  I am visiting for a week with Dr. Dan Cummings.  He completed an Emergency Medicine residency some three years ago and is exploring sites for a two-year commitment in the future.  His presence also is a stopgap for the chronic staffing issues at Chiulo.  I had an opportunity to take a peek on the way back from Xangalala.

The front entrance to the hospital buildings:

The hospital is currently staffed by a single doctor: a Russian surgeon with a humorously stereotypical name:

When visiting your family members in the hospital, please be so kind as to leave your hand grenades at home:

The hospital routinely has more patients than beds.  Here is the extension of the women's ward onto the veranda:

Established in the late 1940's by the Medical Missionaries of Mary (an Irish order), Chiulo is now run by an Italian NGO.  The original Catholic mission:

Again, in advance of my own time there, I direct you to Dr. Kubacki's reflections from two weeks at Chiulo.  Be forewarned by the gravity of his post.

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All in all, I am feeling as if I were a passenger in my own car: the space is familiar and the controls the same but for whatever reason, it is difficult adjusting to the parallax.  I mean that I am still Zach: I sleep heavily, I enjoy the night sky, I feel good about myself when I remember to floss, etc.  It is just that I am passing the same twenty-four hours a day in such a different way, in such a different place.

Here’s to some more Life Experience ahead…