One Morning, Gatekeeper, EP, Seeing…

One day last week, I did something I had never done in several thousand morning, pre-clinic talks with our patients and their families. I asked our nurses to lead us in several songs in Mbundu, one of several native languages spoken in the homes of many of our patients, and wrap up early. The singing was beautiful and enthusiastic and we prayed, disbanded and walked over to the clinic. We were immediately greeted inside the front door by Madelena, a wonderful servant who works for our hospital in cleaning/laundry. She had on bloody gloves and had just delivered a baby (!) whose mom had arrived unexpectedly about thirty minutes prior, right after the nurses left to walk over to our meeting. The baby delivered about when we were wrapping up our shortened “talk” and Madelena told me that it had been “a couple minutes” and the baby wasn’t breathing. Mom and baby were on our delivery table in the corner of our maternity room, the bed already occupied.

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A quick examination of the gray and floppy baby, covered in blood and meconium (“poop”), revealed neither respirations nor a beating heart. We clamped and cut the umbilical cord and I quickly and aggressively dried and suctioned the baby and began chest compressions and mouth-to-slimy-face breaths. After about a minute, I thought I felt a couple sporadic heartbeats in the chest and, after another minute, I felt a strong and palpable pulse, increasing in rate. Still no breaths. Another minute of artificial breaths and chest compressions, and the baby gasped. He was breathing! Soon thereafter, he uttered his first cry. Throughout the day, it became clear that he had no deficits from the several minutes without breathing and heart activity and he went home several days later, healthy. “Let’s just sing a few songs today…”

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In the bed next to this delivery and resuscitation, in our very small maternity room, was another recent arrival, a 60 y/o man in a coma, who had lost consciousness the day before and, with no one in labor, he had been placed in our single maternity bed, which sometimes doubles as our “ICU”. His glucose measured “Hi” and we immediately began to resuscitate him, as well, with fluids. Within a few hours, he was awake and responding to words, though he was unable to speak or move his right side, secondary to the severe CVA (“stroke”) he had suffered at home the previous day. He died a few days later.

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At the same time, a woman, already receiving inpatient tuberculosis treatment at our facility, was carried in and breathing more than 50x/minute, barely conscious, yet quite agitated. As I began examining her, I was told that there were “several” other people (of our more than 100 inpatients) that I needed to see “right away”. The family of this 23y/o girl said she had begun to struggle to breathe during the early morning hours. Her oxygen level didn’t register on our oximeters and we immediately placed her on supplemental oxygen (via a concentrator connected to our new portable generator outside the window) and began resuscitating her, as well, with IV fluids, as she had no measurable blood pressure and her heart rate was 180/min. She received antibiotics and several liters of fluid throughout the day, improved gradually and was talking in full sentences when I left for home. Her “septic shock” during the night had, undoubtedly, began as pneumonia, growing quickly on the TB wounds in her lungs, then spreading to the rest of her body.

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Then an adult woman arrived in a wheelchair, unable to breath, her tight abdomen about twice the size of a woman ready to deliver. She wasn’t pregnant. We put her on a cot in our “closet” and drained almost three gallons (12 liters) of liquid from her abdomen, after which she was smiling and breathing easily. Another victim of the Shaman “cure all” which likely destroyed her liver.

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I was then led to the room of 50y/o, Emilia, who was in excruciating pain, having developed a large “tumor” in her lower abdomen during the night, which I couldn’t touch because it was so tender. Emilia had a fever for a week and was brought in the day before, with severe abdominal pain but no tumor. She, then, developed, during the night, an “orange-sized” mass in her abdomen, undoubtedly an abscess secondary to an intestinal perforation from Typhoid. Under ultrasound, we were able to identify the mass, aspirate about a cup of frank pus, and “wash out” the abscess with fluid, after which, a couple hours later, Emilia was almost pain-free, sitting up in bed and complaining of hunger! She went home a few days later, pain-free and well.

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Afonso, a sixty-year-old man, was breathing rapidly and was crazy pale (his nail beds and inner eyelids paper-white). We measured his hemoglobin to be 2.6 (normal 12) and he needed blood immediately. We know our workers’ blood types and our administrator, Rodé, was a match. We whisked her to our emergency “room” and our nurses were unsuccessful in tapping a vein, as was I. We pulled up the ultrasound machine and found a deep, healthy vein in her upper arm and successfully removed 500ml of blood from her which we immediately transfused into Afonso. Within an hour, his blood pressure was normal and he was breathing easily, after which he received another unit of blood from his wife, less rushed, and his color improved, with a some pink beginning to show on the inside of his lower eyelid. We later searched for a cause and found a tumor in his colon, the clear source of the bleeding and likely cancerous, so he will visit our beautiful colleagues in Lubango to see if they can resect it and extend his life.

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A man rushed in his 68y/o mom, Domingas, in a wheelchair telling us that she would not wake up today. I asked the guys to check her vital signs and her blood pressure was off the charts. She had been with us for several days and was receiving treatment for TB, breathing easily after we had drained about a liter of pus from her chest on arrival, but the challenge with her has been her blood pressure. She is on all the meds we have for this condition (five) and we haven’t made a dent. She was not responding at all and was likely manifesting signs of TB meningitis… After a few days Domingas woke up and spoke without deficits, and a few days later she was walking and eating, with her blood pressure high, but acceptable.

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While working on getting blood from Rodé, a 50y/o woman hobbled into our crowded ER holding onto a man wearing a helmet, with a torn rag wrapped around her knee, having just arrived by motorbike. When we opened the bandage, she had a six-inch, gaping laceration above her knee, obviously cutting the muscle below – exactly where she had been severely burned the night before – the reason for her 3hr trip to the hospital. The motorbike had crashed and she had fallen, cutting her severely burned leg on the ground. The skin and inner tissue were macerated and dirty and well beyond my ability to repair. We cleaned her wound and she will visit Lubango in coming days for surgery to, hopefully, preserve her ability to walk.

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A familiar mom waited through all of these encounters and brought to us her 1y/o baby who she said hadn’t stopped crying all night. We knew this child and we have been treating her for generalized tetanus for two weeks, one of two children who are currently battling this disease in our hospital. What an awful illness. This child came to us with her face fixed in a tight grimace, all of the muscles in her body in spasm and unable to open her mouth, after sustaining a wound on her foot a week prior. We hydrated her intravenously for days and have been treating her with pain meds, muscle relaxants and antibiotics specific for tetanus. She has been improving, though quite slowly, and she will survive – the majority with this illness don’t. She had been swallowing liquids and nursing the last several days, but still was in such pain as to cry out all night… One of my many teaching phrases that applied to this situation, “A crying baby is better than one who can’t/won’t cry.”

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Mom brought to us (again) one-year-old, Francisco, whose neck had swollen severely (again) over the past 24 hours. We wonder at many sudden deaths, but there are also so many like little Francisco, who remarkably survive deadly illnesses. We drained his new neck abscess – for the fourth time. He has been with us for over a month and his story defies understanding. He arrived with his entire face swollen, unable to open his eyes, with severe difficulty breathing (stridor) because of his neck swelling. We incised and drained three abscesses in his neck the first day and he breathed more easily. A few days later, he developed difficulty breathing again, secondary to pneumonia, and required high levels of supplemental oxygen, near comatose throughout most of a week. When his oxygen levels wouldn’t improve we discovered, via ultrasound, that he had developed an empyema (pus in his chest cavity), collapsing his lung. We aspirated thick pus from his chest cavity twice over several days, after which his blood oxygen levels improved. He is receiving treatment for TB, the likely inciting event, along with a tooth infection, which became severe and spread to his neck, face and lungs because of his compromised overall physical health secondary to the tuberculosis. He has survived three life-threatening illnesses!

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It was almost 9a, the waiting room and outside lawn were full of people waiting to be seen, and we were ready to begin our day…

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Your contributions to this work were scattered all over our hospital on this eventful morning and no one will ever know…

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We are thrilled that Laurel Bennett, an NP from California, has decided to make Cavango her home and serve with us. Her presence this year has been such an asset, as our patient volume ever increases. If you would like to assist us in the construction of her simple house, please see “Contributions” above and identify your contribution as for this project, which we hope to complete by early 2023.

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One of the significant joys in my work in Cavango is seeing the patients return after we send them to our mother ship, CEML, a mission hospital in Lubango, for urgent surgeries, over 100/year. This past two weeks we’ve seen many return well after their treatment, including a boy and woman with peritonitis secondary to a Typhoid intestinal perforation, a young boy who had ruptured his appendix, a woman with an ectopic pregnancy, a woman no longer with a hole in her vagina constantly leaking urine after a traumatic delivery (bladder-vaginal fistula), a woman who parted with several, grapefruit-sized ovarian cysts and several people who had cancerous tumors removed, all returning to Cavango, via MAF, with transformed lives.

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The real life-saving work for these folks happens at CEML and we are simple gatekeepers – directing each to the appropriate place for treatment for their particular urgent illness.  Our surgical colleagues in Lubango are beyond skilled and bring to those we send vast surgical experience equal to, or better, than our patients could get anywhere in the world.  I consistently marvel at what they are able to do for our patients, for a fraction of the cost of what we would pay in the US.  Because of the urgency of each situation, we pay for their surgical care, asking them for a commitment to reimburse us after.  We recoup about 10%.  “If someone asks you for your cloak…”

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We also have the enormous privilege of partnering with our ever-serving MAF pilots/mechanics, who transport these patients two hours by air to the urgent care they need. MAF is beginning the construction of a dirt airstrip on the Cavango property, to be operational by the end of the year, which will greatly help facilitate these transports. MAF plans on relocating a plane and pilot to our property, as well!

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Many of you help pay for these urgent surgeries, their hearts continuing to push and pull only because of so many contributions – such a beautiful illustration of Jesus’ body functioning as He said it would, when He told His followers, “Greater works than these you will see….”

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We treat each person as if they were our mom, sister, or child and seek the best care for them possible. We seek to honor each rural person as if they were Jesus, Himself, as they are made by Him, in love and with purpose, very real extensions of Him. Jesus indicated that there is no coincidence in what we see as tragic circumstances but, rather, opportunities for Him to serve each through us, His arms and fingers, and to demonstrate to those hurting, and to their families and communities, their value in His eyes. All healing is temporary, as even Lazarus died again, yet we look forward to soon gathering with many of these beautiful, fully healed individuals around our Father’s throne, honoring the One who has created each, sustained each, provided for each, and invited each to know Him and be known by Him… forever.

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Eternal perspective…

Blessed are the humble, the meek, the hurting, the poor and lacking, those mourning, those single-heartedly passionate to know God, those painfully hungering to see righteousness overcome evil…  the Kingdom of Heaven is theirs…  they will see God…

Blessed are those who go, send, contribute, encourage, serve… without seeing…

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