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!