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.