One day…  On a morning run last week I encountered three hippos in the river (photo)!  I’ve been since told there are four, with a new baby among them.  I typically run that particular path twice/week and it bounces on and around the bank of the Cubango River for about 1/2mi.  It was a thrill of a lifetime and one which occurred again a few days later, and could become routine.  We have known of their presence in the area (tracks and sightings by locals) since we moved here five years ago.  Our MAF friend, Marijn, found them about a year ago with his drone and I hiked many times to the area, but never got close to them because of the thick sawgrass isolating them in a cove.  Where I encountered them was about a mile from the previous spot, so they are moving (we even found recent tracks on the unfinished airstrip).  Their call to one another was almost as impressive as that of a lion.  I will now be quite alert, especially along this route at dawn, as they are purported to be the most dangerous African wild animal in a surprise encounter (more so than lions), especially when they are out of the water and the person is between the hippo and the water, and my path is along the water.  They are known to leave the water to graze at night and return to the water during the day, so running along the river at dawn has some risk of an out-of-the-water encounter.  What a unique morning surprise!  One never knows what a day will bring…

 

On arrival to the hospital that same morning, I was greeted by my concerned nurses because our one, insulin-dependent diabetic patient had been brought in comatose, having been found unresponsive at home.  He is a great 15-year-old kid, who we have gotten to know well because he must live close by to receive his daily insulin.  Long-acting insulin is difficult to come by and we must bring it in from Namibia.  He has arrived comatose multiple times, with glucose high and low and has almost died twice (it takes time to gain understanding about the disease, diet, compliance with the insulin, etc).  This time, his glucose was 34 and he responded to some sweet soda and was speaking within the hour.

 

Within the same hour, two men arrived comatose after several days of fever, both testing negative for malaria.  I knew both men.  We had treated thirty-year-old Domingos for severe tuberculosis from January to March and he improved greatly.  His mother said he didn’t have the money to return (about $15US/month for meds) and he deteriorated gradually in the subsequent months until three days prior, when he became delirious and stopped eating, spiking high fevers.  I suspected TB meningitis and we began treatment for inflammation along with anti-TB medications.  Within 48hr, he was awake and eating, though still very weak and confined to bed.  Antonio is 69-years-old and had seen me one month prior with severe hip pain.  Always considering TB, I questioned him at length re the duration of his pain and he insisted that he had the pain “for years”, becoming severe and preventing him from ambulating over the past weeks.  With his age and history, I treated him for osteoarthritis with an injection in his hip and he improved greatly over the course of a week and walked home without a cane.  Over the past week his hip pain had returned and he stopped walking and then he, as well, became delirious and highly agitated a couple days ago.  He was unconscious and quite agitated, so we sedated him and began the same meds.  He was, as well, sitting up, eating and talking within 48hr.  He is a beautiful man, so grateful for the care we gave him and eager for our help.  We finished about twenty consultations to complete the morning, including a four-year-old little boy who also arrived in a coma and seizing consistently for two hours, our first cerebral malaria patient of the season.  There will sadly be so many like him in the next few months… We treated him aggressively and he was smiling and accepting food (and a sucker) the next morning.

 

Then… in early afternoon of the same day, Madelena arrived four hours after giving birth to a heathy baby boy at home.  After waiting about three hours for the placenta to deliver and witnessing profuse hemorrhaging in their feverish friend (she also had malaria), when she lost consciousness a group decision was made to bring her to the hospital.  Most births here are attended by up to a dozen “experienced” women in a crowded little house who freely offer noisy encouragement and counsel to the delivering mother.  This decision saved her life.  We began IV fluids and gave her some medication to help her uterus contract (contractions had stopped) and treat her malaria.  The placenta was not responding to some gentle urging and it was necessary to try to remove it manually.  Madelena was in and out of consciousness and in shock from blood loss. I found the placenta to be completely adhered to the uterus and quite a bit of horribly painful, elbow deep, manual manipulation internally was necessary to separate it from the uterus. Thankfully, it came out whole and within a few minutes her hemorrhaging ceased.  She was quite pale (a Hb likely < 4g/dl – normal 12g/dl), but her vital signs stabilized. While we were working with Madelena, one of our nurses entered the room and said her baby had arrived and was covered in blood.  I asked him to check the cord and he returned and confirmed that the cord was bleeding and I asked him to tie it. When I finally left our maternity room, I saw the sleeping baby, sure enough, exposed, shivering and covered in blood.  I asked them what had happened and they said the baby was wrapped in blankets and they were following the mom to the hospital and, when they took off the blankets outside the hospital, they saw the blood covering the baby and called the nurse.  The motorbike ride on trails was about an hour and they didn’t know how long he bled, but he checked out well and hadn’t lost enough blood to harm him, though he was quite a sight.  Both Mom and baby have done well in the ensuing 48hr and were discharged home. Virtually all deliveries happen at home in this culture and we get the disasters or, in this case, the potential disasters…  The Wind…

 

Lack of access, lack of knowledge, work demands…  Fifteen-year-old Frederico arrived in a coma, seizing uncontrollably for the past twelve hours.  His father had been traveling and his mother was staying out in her fields planting.  When his mother arrived home, she found her unconscious son and the neighbors explained that he had been in and out of consciousness for a week!  They had called the local traditional medicine guru, but (surprise) the boy’s legitimate illness hadn’t responded to the worthless, natural herbs he “prescribed” (they “cure” illegitimate illnesses via placebo).  She immediately strapped her seizing, unresponsive son between two men on a motorbike and sent him to our hospital.  He was severely dehydrated, seizing, and unresponsive. We hydrated him intravenously and began aggressive treatment for his cerebral malaria.  At this writing, it’s been about four days and Frederico is recovering, but he must learn how to walk and live again, as he suffered severe cerebral damage from the malaria.  Most in his position recover over months, but it can be a slow process, similar to one who has suffered a severe traumatic head injury.  It’s beautiful to see this father responding beautifully to the severe challenge in his son, selflessly feeding, cleaning and helping Frederico get around.

 

We had another surprise visit from our municipality’s government authorities. Two cars with about 10-12 men, about half of them police, armed with automatic guns.  They asked for copies of all of our (same) documents for about the 10^th time over five years.  One of our workers came into the consultation room to let me know of their arrival and I walked out to pleasantly greet them.  The police contingent was polite and respectful and explained the reason for their visit and we arranged for them to go to our house to get our passport/visa copies.  On my way back inside, I passed our little pharmacy and saw two men inside removing meds from the shelves.  I greeted them and asked what they were doing and they explained that they were health inspectors and they were looking for expired meds.  One of the men had slurred speech and reeked of alcohol.  I immediately pulled his leader aside (along with the compromised man, who we have known for years – we even drove five hours a couple years ago to give him a kitten – but have never seen him drunk on the job) and shared my concern (nicest way to put it) that he had someone working drunk (there were actually several), that this drunk man was going through our pharmacy and pulling medicine off the shelves, and that this same man was to then give official report about his findings re our clinic.  I told him, in no uncertain terms, that I refused to have any inspection done by someone obviously drunk and emphasized that we invited their inspection at any time, but by sober people who demonstrated some respect for us and for their authority/position.  I took the leader of the police aside with the head of the delegation and explained the same, directing them back to their cars.  I also asked them for a copy of the report they would submit to their authorities about the inspection, and they agreed (these two seemed to understand my displeasure and seemed to be appropriately embarrassed).  It was a challenging hour for all involved, but they will never (perhaps) return to Cavango drunk!

 

Last Tuesday, I had my first presentation in Cavango of an acute myocardial infarction (heart attack).  I often see people after the fact, when their resulting muscle damage causes heart failure or ongoing, intolerable angina.  63-year-old Eduardo began having crushing chest pain the previous afternoon, with profuse sweating, vomiting and difficulty breathing.  His echocardiogram (the only diagnostic test at my disposal) revealed segmental muscle weakness compatible with muscle injury.  We slowed his heart rate and gave him simple aspirin and within 2-3 hours, he was resting comfortably.  We will be able to treat him medically, as the procedures that have saved my life twice (cardiac stents) are not available in Angola.  The same morning, a woman, a child and another man arrived in severe heart failure, all unable to breathe through the night for weeks and all with little heart function left (ejection fractions – the fraction of blood ejected from the left ventricle during contraction – of less than 20%).

 

Heart failure is a common diagnosis in our clinic/hospital (we currently have 6-7 inpatients with this illness), most commonly resulting from two very different illnesses. Three-year-old Florinda had rheumatic heart disease, which had likely begun several weeks ago from untreated strep throat several months ago.  A sore throat is never perceived as a reason for these people to make a trip to the hospital and the throat infection always resolves, convincing parents that the illness is benign and self-limiting.  Several years ago, cardiologist colleagues from Canada screened kids in our region and found 13 of 100 asymptomatic, randomly-screened kids with heart damage compatible with this disease!  Statistically, that’s a lot of kids in this region with debilitating, life-threatening heart disease secondary to an easily treatable illness.  Most would survive with valve-replacement surgery, not available here.  The other common cause of heart failure is untreated, but easily and inexpensively treated, chronic hypertension.  The only patients we see with high blood pressure are those whose pressure is so high that it causes symptoms, such as recurrent chest pain, difficulty breathing, headaches and insomnia.  Many of them already have some heart damage (muscle enlargement), but more wait until they have “pump failure” as the heart has been pushing against the high pressure for so long that it begins to function ineffectively and fluid infiltrates the lungs, causing difficulty breathing.

 

Another world… Our friend, Florencia, is Betsy’s age and works for us three days per week and saw Betsy preparing a turkey for our Thanksgiving meal (see below) and shared with Betsy that she had never seen or heard of such a bird.  This made me think of the profound differences between our cultures…  People here can’t believe that there is a place in the world, for example, where people live without the constant threat of malaria.  Our friends here have, of course never seen snow and can’t imagine such cold weather. Most people in Cavango have no concept of the size of the world and have never… seen a map, ridden in a car, enjoyed an iced drink, used fingernail clippers, walked up steps in a two-story building, shopped in a grocery store, received mail, eaten at a restaurant, watched TV or worked on a computer, taken a vacation, used toilet paper or flushed a toilet, used deodorant or perfume, walked on carpet, dove into a swimming pool, slept with a fan, heard an orchestra, decorated for Christmas or opened gifts on Christmas morning, read a book, a magazine or newspaper, bought toys for their kids, seen a parade, seen/heard a weather forecast, slept in a bed, etc, etc.

 

Alice is 67-years-old and said her knees have been too painful to work or walk any distance for four years “since she was struck by a car”.  Her house is about 60km from here and made of the typical sticks and clay, with a grass roof, and she said she was sitting in the back of her house when a truck skidded off the road in a rain storm and barreled through her house, knocking her from her chair and coming to rest on top of her.  She was bruised and scraped but otherwise unharmed. In reality, Alice has chronic arthritis in both knees and has had this illness for far longer than the four years since the accident, though she made what seemed to her a “logical” correlation, which people often do, tying together seemingly related circumstances.  Also, time here is so relative, as calendars, clocks, and watches are nonexistent, so the duration of Alice’s knee pain was more accurately “a long time”.  She will respond nicely to our joint injections, but the two knee replacement surgeries that have permitted me to walk and run pain free will never be available to her.

 

I see skeletons of small animals on my morning runs and often wonder about their previous “owner”.  I realized this week that all images I have ever seen of dinosaurs are artists’ renditions of how flesh would appear on an unearthed skeleton, artists who have no template (photos, living examples, etc) to which to refer.  I have seen forensic artists’ renditions of men from the same skeleton and they can appear radically differently, though the artists certainly have an idea of a human being’s “normal” appearance.  The amount/distribution of fat and muscle, the colors, the scales, the sizes of fleshly body parts, etc can vary tremendously in artists’ imaginations.  We think we “know” how dinosaurs appeared because we’ve been inundated with artists’ drawings for so long!  No one would even question the appearance of a T. Rex, for example, and yet all we have are skeletons (and parts of skeletons).  We actually have NO idea about their outer appearance!  If you saw a hippo skeleton, for example, and had never seen a hippo, you would never imagine a 5000lb monster only by its bony frame, with no living example for validation. I wonder how much of our perception of history and of Jesus have been “tainted” by someone’s imagination?  How much of what we think of historic Jesus has been “fleshed out” by falsehoods or someone’s imagination? Yet we can study Jewish history and the writings of/about Jesus which have been better preserved than any other historic writings (which we believe without question).  The authors walked with Jesus, recorded His words, and were killed because they wouldn’t recant that about which they wrote, more than validating their testimony, and they were writing to contemporaries, people who could further validate or refute their words/stories.  What a gift/resource we have available to us!  Will we study our Father’s letters to us to find the truth about Him or believe what someone tells us?

 

It was a pleasure to have Birgit, a surgeon from Germany, in Angola for her 10^thshort-term visit, and the De Souza family visit us for a few days of surgeries (Photos).  Birgit is a joy and loves doing whatever might help, including painting the adobe, rat/bat-filled, condemned house we moved into in the southern part of Angola before we lived in Cavango.  The De Souzas are new long-term missionaries to Angola from the US, Eduardo a physician originally from Brazil, and Jocelyn, an Nurse Practitioner from the US, with their four wonderful kids, aged 3-12. They are real Jesus/people lovers who will impact many over the coming years.  Joining them was Moliti and Domingas, two beautiful Angolan surgical nurses from CEML, here for their second visit.  They were all such a delight, tolerating a very crowded, small house, even laughing off the one morning that I saw the hippos again at dawn and took everyone to the river to show them and the hippos were gone!  The kids sure enjoyed our 10 kittens (Photo)!  We had a beautifully prepared American Thanksgiving dinner that Betsy prepared from scratch for several days.  It was a feast, complete with turkey and stuffing and pie, several of the dishes some had never tasted.  There would have also been a delicious apple pie but someone resembling Betsy’s husband knocked it off the counter and right into the trash – on the morning of the dinner! Betsy is such a warm host and everyone who visits us knows they are dearly loved and valued.  We also all gained a few Thanksgiving pounds.  We hope to have them all back!