I’m home and relaxing today after almost a month away at Caluquembe, a small mission hospital about 300 km from Lubango, in the middle of nowhere. I shared some stories in a previous post and will share a few more that come to mind as I sit here taking a much needed couple of days off. There are so many human stories that I won’t remember…
A 65 year old man was in the ICU my entire time in Caluquembe. The ICU has eight beds, no machines, and is reserved for critical patients in that they have one nurse covering only eight people. Most people in the ICU are in a coma, either from trauma, meningitis, or malaria. Some, especially the kids, have respiratory distress from pneumonia or TB. There are no respirators and no cardiac patients. This man, “Pedro”, arrived on my first day and had virtually continuous seizures for over two weeks. Every morning the story was the same. We first treated him for cerebral malaria, as this is the most common cause of new onset seizures and coma. When we saw no response, we treated him for bacterial meningitis, as this is the next most common cause for his symptoms (both causes are common, as we admitted several new onset seizure/coma patients each day). When this yielded no response, we began treatment for Tuberculosis meningitis, as this is also common. After three days of this treatment, the seizures stopped, after 5 days he opened his eyes and after a week he said a few words and began to swallow food and water. I couldn’t believe that after having almost continuous seizures for that long, he will likely make a full recovery. The clinicians say that they have seen it many times, though it is rare to survive any of the three above diseases well (during the same time period that this man was seizing and recovering, we had about 8-9 deaths in just the adults with seizures and coma).
I hate TB. It is a huge killer and maimer here, spread simply by the respiratory droplets from one with the disease. Many people at Caluquembe are literally suffocating to death over weeks to months. We saw so many in just one month with disfiguring tumors, broken vertebrae, permanently destroyed joints, and the sequelae of brain-damaging meningitis. One of every three people worldwide is infected with TB (about 10% of these actually get sick), it is one of the top killers in developing countries, and it is completely treatable and curable, if caught in time.
I wired the jaw of a 23 year old man without anesthesia. He screamed bloody murder throughout the thirty minute procedure, snotting and spitting (not with intention), but he held still and will end up with healed mandible and maxilla fractures (from a helmet-less motorcycle accident).
A 20 year old man came in because of shoulder pain after falling 4 weeks prior. He had a dislocated shoulder! Because of the time frame, it took some wrestling with anesthesia, but we got it reduced. I can’t imagine anyone in the US (including me) living with a dislocated shoulder for four days, let alone four weeks, without seeking medical help.
I performed two Cesareans one day and both women sang throughout the whole procedure (done with only local anesthesia – numbing of the skin incision). It was a beautiful demonstration of human fortitude.
I delivered several babies using forceps, which is rarely done anymore in the States. In one case, I needed to perform another symphisiotomy (cutting open the pubic bone) because there was not sufficient space in the pelvis. Baby and Mom did well.
Another day, I was able to deliver three babies via Cesarean. It has been so nice to learn and then do so many of these procedures, and this will be a valuable tool in the future when we are helping population groups who have no medical help within hours or days. Baby and mother injury/death at birth is common in the developing world (in 10-20% of births when Cesarean is not available). In Sub-Saharan Africa, Cesarean rates are < 2% of all deliveries (in rural areas, near 0%) and in developed countries the rate is about 20% of all births.
Luke and Ben run most days for an hour in the rough hills and mountains surrounding the city. With the mile elevation and the rugged terrain, they are in remarkable shape.
Malnutrition is so common. The Pediatric ward is full of emaciated, swollen bodies. The malnutrition typically occurs around one year of age, when the mother becomes pregnant again (they believe the nursing and pregnancy don’t mix) and/or the baby is weaned from the breast to food. The babies don’t eat well as the food isn’t palatable and the mothers don’t have the means to offer many alternatives. The most common food is a corn “mush”, the consistency of mashed potatoes, with literally no flavor at all (pronounced “foonjh”). The children often refuse this or it is all they eat, leaving them protein malnourished. They typically arrive at the hospital with malaria or pneumonia (lowered immune response due to malnutrition), all bones and belly. They have swollen feet, red hair and swollen bellies. They are weak, barely cry, and are severely dehydrated. I lost count of the number that arrived and died within a few days. Malnutrition is a combination of ignorance and poverty. They know so little and yet have so little with which to work to make necessary adjustments for their baby. They truly care for their child, but live without resources to provide the necessary care to sustain life.
Twice, a baby died in the Pediatric ward moments after we examined him/her and determined that he/she was gravely ill (we were in the same room, examining the next patient). There was no “code” called, no panic in the parents when they noted their child not responding, there was no blame or complaining, there was no exclamation of self-pity, etc. There were quiet tears, assistance from others in preparing the body and personal things to be carried away, and within five minutes, the bed was empty and the family gone. The bed was filled by another child within the hour. There is here a general attitude that health workers and medications might help but they don’t control the destiny of the patient (in fact, a hospital visit is a last resort). There is no sense that an error of commission or omission affected the outcome (life is not in the hands of a doctor or nurse). There is a human sense that everyone is helping a difficult situation. There is no abundant gratitude expressed when the outcome is favorable and no abundant grief when otherwise.
Death is such a normal part of life here, accepted though not necessarily embraced. I am still far from understanding this culture which has dealt with 30+ years of civil war. We marvel at stories from our own civil war 150 years ago and this generation of Angolan people lived through the same. Brothers killing brothers, villages bombed by fellow Angolans, so much injury and death. The hospital leaders described the conditions at the hospital during the war and the chaotic efforts to help the hundreds of wounded arriving during nearby skirmishes. The conditions here were not much different than those in the US in the 1800’s. I can’t imagine what the people that work with me lived through for so many years.
I was examining an unconscious man from a motorcycle trauma one morning who had his bloody head wrapped in an ace-type bandage. One eye was covered so I thought I should examine under the bandage and I found a 5 in. x 1 in. piece of plastic from his bike embedded in his eye. He died that day.
We saw nearly 50 cases of Typhoid Fever in the first two weeks of June, a devastating disease unknown in the US.
A cheer is heard every day at our apartment in Lubango between about 6:00p – 9:00p when the city electricity comes on. We use a generator sparingly otherwise to provide partial electricity to our apartment. Our small hot water heater can only run on city power so if we don’t have city power, we don’t have warm showers. Our days are in the 60s-70s with 20% humidity and our nights in the 30s-40s. Cold showers are cold! Most people here have no running water.
A young woman was in labor in a village and her labor suddenly stopped and she began hemorrhaging. The breech delivery was progressing through the birth canal when this happened. The baby died suddenly because of a uterine rupture and was “stuck” in the birth canal. The hemorrhage was occurring because the placenta had separated from the uterus and the uterus could not contract because of the body of the baby still lying in the uterus. The attendant at the village saved the life of this mother by decapitating the baby and delivering the body (which allowed the uterus to then contract, stopping the hemorrhage). She then sent the mother to our hospital, two hours away, for delivery of the baby’s head. We did a Cesarean and delivered the baby’s head from outside the uterus, in the abdominal cavity. This is the type of situation that advocates of “partial birth abortion” claim can sometimes save the life of the mother. In Africa, where most births occur in village homes hours or days from modern medical capability, exceptional cases like this occur. In the US, where most births occur in hospitals which have emergent Cesarean capability, the claim has no merit today.
I delivered many dead babies, who would have been delivered easily by Cesarean in a modern hospital setting. In a village, labor began with a healthy baby and ended with a death. Stress of the infant is one indication for an emergent Cesarean, noted in the US with fetal monitoring and close observation of labor’s progress. None of this happens in the villages where often, at some point during labor, something doesn’t seem right and the woman comes to the hospital, too late to save the baby.
Bets, Ellie and Mer walk for exercise through a part of town where wild monkeys roam. They’re entertaining to watch both on the ground and in the trees. We have watched “Castle” episodes as a family for the past couple of months on our computer. Everyone except Dad has gone on several weekend trips to visit friends, and to the coast. We bumped our car into a pole and we’re dealing with an Angola insurance company. They want to avoid paying for the damage!
Ellie is our first to contract malaria. She had a rough couple days and is doing better. It’s everywhere. The only kind in this region of Africa is called Falciparum, the most dangerous of the four types and potentially deadly if untreated. It’s in all of our future. How blessed we are to have easy access to treatment. The pediatric unit was especially full of very sick kids with malaria. Any fever is treated for malaria. Living here, it is understandable why fever to our grandmothers was always to be taken seriously. It is here (like it was for them) almost always an indication of a serious, life-threatening illness in a developing country (malaria, TB, Typhoid fever, yellow fever, pneumonia, diptheria, plague, measles, polio, meningitis…) Out of 100 people I saw in the clinic who came to the hospital to consult re. an illness, perhaps about 10 said they had no fever. The rest all had fever and the vast majority had an illness worthy of aggressive treatment in the hospital.
We saw so many cases of osteomyelitis. This is infection of the bone and this illness highlights the place for modern medicine in these folks’ lives. A wound occurs and becomes infected and they “ride it out”, likely with significant fever and pain. They don’t consider that medicine will help. The infection festers and festers, eventually reaching the bone, where it continues its destructive process. I removed from many people (especially kids) large sections of dead bone which had been tolerated for weeks or months (pain with every step). I operated on one girl who had an open tibia fracture 5 weeks prior and lived with this broken shin bone (exposed bone through the skin). She was walking on it on arrival and they came to the hospital because of the smell of the decaying bone. Just about her whole tibia was rotten and needed removed to save her life. What they deal with here is simply incredible.
I was called to the ER to see an unconscious 17 year old girl, brought in by her friends. She was faking it.
I saw a 96 year old man who was on a ladder, fixing a hole in in roof, when the ladder gave way and he fell to the ground, breaking his hip. He was in the hospital for the first time in his life and took no medication. That same afternoon, I saw a 97 year old man complaining of abdominal pain who also was taking no meds and was the picture of health. Both remarkable in a culture where life expectancy is less than 40 years.
The men’s ward is virtually all trauma-related injuries, most bed-ridden and in traction for 3-4 months for femur or tibia fractures. Trauma is the leading cause of death in young men and virtually all is the result of vehicular trauma (here-motorcycles), and almost always involving alcohol. I’m sure this sounds familiar to my ED colleagues in the States. “It will never happen to me” is alive and well in Africa, as well.
A 21 year old woman came to the hospital when she thought that her labor wasn’t progressing well. She had delivered three dead, healthy-appearing, babies at home over the past three years. This time she decided to try the hospital. I was called to see her and it was clear on initial exam that her pelvis wouldn’t allow passage of the baby. We delivered a healthy baby boy via Cesarean and the woman wept throughout the painful procedure, the whole time with a smile on her face. She had a baby boy! She had been through three seasons of joy and anticipation, each ending with the trauma of the death of her newborn child. Now she had a son. She was a Mom. Her joy was contagious and everyone in the room was smiling throughout the procedure. It was one of the most beautiful scenes…
Her joy, while enduring such pain (the Cesarean without anesthesia) made joyful all those near her. This was such a picture of God’s kingdom. Our joy, our peace, our love… contagious to those around us.
Christianity is not about becoming a good or better person, Christianity is about becoming genuine. Genuinely joyful (like this new Mom), genuinely loved, genuinely burden-free, genuinely connected, genuinely concerned for another… We miss the mark when we strive to be light. We don’t try to be like Jesus or behave in a “christian” manner, we become light by living connected to the Light. Then the darkness near the light, becomes lighter. We change our environment (like light changes darkness), not by what we say, but by who we are. We can do this only by knowing how we are so valued by our Father (the message of the cross) and living connected with Him in the darkness.
Light in the darkness… A small light (we all are small lights) has little value at midday. How different that same light appears in complete darkness. Let’s go where it is dark. Where is it dark? Where there is neglect, abuse, unmet basic needs, rejection, indifference, hate… Let’s uncover the light that is in us, and seek out the darkness. There are so many pockets of darkness throughout our families, our neighborhoods, our cities, our countries, our world. There is such need for our love, our encouragement, our embrace, and our service (our light). I think of the women with fistulas (see previous post), whose odor is intolerable. What would an embrace mean to them? An encouraging word? Having someone serve them? Jesus went to the physically hurting, to those who’d screwed up their lives, to the rejected and to the “unlucky” (those living in darkness). Those called by His name do the same.
This morning, as we again connect to the Light, let’s invite our Father to either bring darkness to us or to take us to where it is dark. Let’s ask Jesus again today to put us into trying circumstances, to bring affliction and tribulation into our lives, and to take us to pain and suffering, so that the Light in us can transform the darkness.