CV19, Happy Hypoxic, “Embrace”, Anxious Needles, Hope, Dignity…

We had our first “certain” CV19 patient arrive two weeks ago in a 4WD SUV (cars never arrive in Cavango because the “roads” are impassable except for souped up off-road vehicles) on a Saturday morning, after the family experienced apathy and poor care at the large metropolitan government hospital in their city (Kuito). Two college-educated sons and a daughter traveled five hours to bring their 80y/o mother, Lela, to Cavango after she experienced fever and profound weakness for a week. The doctors at the new, large, urban hospital told them that she was fine (they don’t measure blood oxygen level). She arrived in Cavango breathing easily and her vital signs were normal, except for a remarkable blood oxygen saturation level of 61%, measured against a normal of > 93% (measured with an inexpensive pulse-oximeter on every patient in our rural clinic)! With CV19, this unique scenario has been dubbed in the medical community, “happy hypoxia”, indicating that the patient, with a profoundly low and life-threatening blood oxygen level, is not in acute distress, though their illness might be quickly fatal without access to supplemental oxygen and/or mechanical ventilation. There are several hypotheses as to how this occurs, but it is a known condition in few illnesses, including CV19, and puts other vital organs at risk because of lack of sufficient oxygen. Lela had clinical signs and symptoms that matched no other diagnoses, leaving CV19 as the only plausible cause.

After researching this strange phenomenon over lunch and becoming convinced that Lela’s diagnosis was, in fact, CV19, I left for the hospital and, on the way, had one of those intersecting thoughts that I knew was from my Father.  “Jesus embraced the leper”.  That I was to approach, touch, treat and pray for this woman like any other was clear and, as Jesus did, I could trust my personal care to my Father.  No matter the outcome to me, my role in caring for her, and interacting with her undoubtedly infected family, was certain.  She is His, and He care-fully arranged for her to be treated by His fingers, and a little “mud and spit”, at Cavango, and we would embrace her exactly as would the One who put us here. 

Our nurses had walked home for a lunch break, so I left the hospital to find a nurse and gave eight thrilled, screaming, barefoot kids their first ride in a car (photo) and, as I looked around the village for help, the electric windows got quite a workout accompanied by a yelp each time a button was pushed and a window “responded”. I found one of our beautiful nurses and brought him back to the hospital and we put Lela in isolation, began IV fluids and meds (Azithromycin and Dexamethasone) and hooked up our single oxygen concentrator (a portable, electric machine from the US that concentrates the oxygen in room air to greater than its normal 21% – we normally breathe in a bit less than one liter of oxygen/minute) to a 110/220 transducer, which was connected, via two extension cords, to a portable generator outside an open window. We began oxygen at 5L/min (5x normal) and her blood oxygen saturation level rose to 90%, which served to protect her other vital organs from her dangerously low oxygen level (hypoxia). I explained the situation to the educated family and they were quite understanding and grateful for our insight and knowledge. Nothing is done in private here, and several people overheard the conversation, which made it back to the village in the next minute or two (rural Angola “roaming coverage”), so we’ll see how people respond to our first definitive case of CV19 (we have no testing). It has now been two weeks and today Lela has an oxygen saturation level of 94% without oxygen and will return home tomorrow, completely recovered.

We’ve had a few suspected cases over these past months, but none serious or clear.  Jacinto, a 60y/o man, arrived the day after Lela, from the same city, and also had a low oxygen saturation level and all the symptoms of CV19, including volunteering that he had remarkably lost all sense of taste and smell with no cold symptoms (a common symptom with this illness), which he had never experienced. We are ever rationing care with our limited supplies, which makes for challenging decisions, often involving who will live and who will die and, in this case, we only have one oxygen concentrator.  We decided to treat Jacinto medically and leave the oxygen concentrator with Lela, and I’ve seen him slowly but surely improve over the two weeks, but I saw him this morning and his oxygen level is still 84% so we will supplement his oxygen with the concentrator, now that Lela’s hypoxia has resolved. He smiled as he said he slept through the night for the first time since his fevers and cough began suddenly at home, but still feels “weak”, no doubt from his body’s major organs essentially suffocating for two weeks. We’ll see how he responds to some increased oxygen…

A 48y/o man arrived after intermittently urinating blood for a couple months and then urinating frank blood for over a week (!). He was barefoot and had walked for almost a day to arrive because he didn’t “feel well”, complaining of weakness and dizziness. He was quite pale, his inner eyelids and nail beds as white as paper. We measured his hemoglobin, a pretty reliable test of red blood cell volume and it was 2.8. Normal in men is typically >13, meaning he was living, and walking all day to arrive, with less than 25% of his red blood cell volume! We typed his blood and that of several of our nurses until we found a match (his is a rare type) and transfused a unit into him, which likely raised his hemoglobin to about 4.0, and transported him via our ambulance (the government wouldn’t give MAF immediate permission to fly) twelve hours to our beautiful surgical colleagues in Lubango to give him more blood and find a definitive and, hopefully correctible, source of his blood loss, which is likely a kidney tumor we observed on ultrasound, which might be cured with removal of his affected kidney. He passed out once on the trip and was revived with some IV fluid, wisely administered by our accompanying nurse. This man was incredibly tough and resilient in bearing “discomfort” for so long, but he wasn’t necessarily wise to wait. Courage and fortitude sometimes don’t cohabitate with wisdom!

We’ve had the joy of another visit by 83y/o Dr Steve Collins (photos) for cataract surgeries, accompanied by Paul Holden, a missionary from Lubango, who we haven’t been able to get to know well until now. Paul worked tirelessly building shelves and remodeling our emergency “room” and devoted himself to all kinds of other tasks which will benefit many people for years, who will never know of his efforts. His work is skilled and beautiful (photos)! We’ve enjoyed several sunsets and star-filled evenings by a fire at the river and we were treated to an eagle owl eating a snake by the path on our return home one night (photos). Paul also took some great photos, some of which I’ve uploaded onto our Flickr account, with captions, accessed below this post.

Steve hasn’t had many cases (“only” 14 people arrived blind and left with sight) over the two weeks so he has joined me in doing consults and it has been such an encouraging joy discussing patients and learning from him, as he practiced general rural medicine for years before dedicating himself to the blind.  He deals admirably with severe back pain every day and, while transporting rocks for the foundation for our hospital in the back of our pickup, he ran our car into a stump, and hit his chin on the steering wheel, causing a large inner lip laceration and an instant “double chin”, which he tolerated like a champ, not slowing down for a moment.  We hiked and measured river flow for a possible hydroelectric energy source for our hospital (we still lack electricity), we moved our bulldozer and heavy equipment, he helped Paul with his carpentry work… Steve lives every day with the energy of a thirty-year-old and the gratitude of a child, always with a smile and a story.  I get to work alongside my heroes…

Pedro arrived this week in severe respiratory distress.  He is 22y/o and rail thin and his father said he had been progressively worsening for six weeks, developing intolerable difficulty breathing over the past two days.  He had a large pocket of fluid around his heart (photo), in the pericardium (the sac holding the heart), which restricted his heart from fully expanding during filling. He also had a large pocket of fluid in both sides of his chest, between his chest wall and his lungs, restricting his ability to fully expand his lungs during inspiration.  He was soaked in sweat as he watched a large needle enter his chest several times, in several locations, and his natural anxiety made for great difficulty sitting still, making the procedures quite challenging (moving target).  We removed over a cup of bloody pus from around his heart (200+ml) and he was breathing better immediately.  When I checked on him an hour later, he was sitting at the base of a tree outside of our clinic, smiling.  He has since improved daily and will recover completely with aggressive treatment for his disseminated tuberculosis, the cause of his illness.

There is a phrase in our rural dialect, “Separar se de colher”. It is literally translated “separate oneself from one’s spoon”, and means one has lost all hope to survive.  I saw a 32y/o woman a couple months ago who arrived with vaginal bleeding for a duration of several months.  We made the diagnosis of incurable cervical cancer and sat with the family and patient and described gently and truthfully that she would not survive another year.  I believe in truthful sharing of such information because it allows the patient, her family and community to prepare for their separation.  This war-torn,  impoverished culture never shares bad news and, consequently, preparation for the inevitable is stolen from them.  I described to this patient and her family that we all will face this separation, and that awareness of impending death is a gift, along with the obviously painful difficulty, and that they can prepare with God, their family and their community, for their departure.  They received the information stoically and said they would leave for home the following day.  The patient had normal vital signs and was in no way acutely ill, and she died quietly in her sleep that night.  “Separar se de colher”. 

The teen in the photo, Rosaria, has seen reversal of her rheumatic heart disease (RHD), the destruction of heart valves from untreated strep throat, over seven years of monthly injections and prayer.  I’ve seen RHD cures when treatment was begun in the first months of the illness, but never over so much time.  Her initial murmur is gone and her echocardiogram is normal.  She is thrilled and has seen her ability to breathe, work and play return to normal from an initial state of acute heart failure from the destruction of an initially healthy mitral valve seven years prior.  The Wind…

The adorable baby in the photo, taken prior to discharge, arrived in a coma with severe pneumonia, breathing more than 100x/minute.  We have so many such cases, all made possible by your generous and sacrificial financial and prayer support.

Epiglottitis (infection and swelling of the flap which covers our trachea when we swallow) was a common killer globally throughout history in the days before our expanded and excellent vaccination programs in the developing world.  Unfortunately, Angola has a small supply of globally available vaccines and many, especially in rural areas like ours, do not remain cold because of lack of electricity and, thus, lose their effectiveness.  Anti-vaxxers reading this need to visit us and see some of the diseases you will never experience or see in the US because of the beautiful developments of science available on every corner. I’ve seen perhaps a dozen young people die right in front of me during my eight years in Angola, one teen collapsing from a standing position and dying as she was (hoarsely and painfully) speaking to me at a rural clinic where I was working.  The adorable, six-month old baby presenting with this illness last week responded nicely to our antibiotic treatment and went home well (photo).

We are seeing more and more revisits by patients under our care. This is anywhere a sign of a healthy clinic. It indicates an understanding that treatment is a partnership in care between the patient and the care-giver, and that all health involves an ongoing process of care. It is also an indication of the trust that is developing in the people of the region for our care/ability/knowledge. It is a huge kingdom benefit, as well as, at each visit, the patient and their accompanying family hear the Good News of Jesus’ affection for them at our daily, morning talks. They also receive solid education about how to make decisions at home regarding general health and when to seek help regarding how to respond to symptoms and illness.

You have participated in the care of these beautiful, remotely located people over fifteen years with your “sweat equity”, contributing hundreds of thousands of dollars to care for them, in so many ways.  I hope each of you sense our Father’s pleasure as I do, because your part is as great as mine in giving life to those who would otherwise remain forgotten, or “passed by”, as was the wounded man by the religious leaders in Jesus’ parable of the Good Samaritan.  The equal role of the elbow in what the finger touches is obvious, though we sometimes only focus on what the finger is doing!   

“Do not grow weary in well-doing…” Of course, we know the real value of our work can’t be measured, but I want to encourage all of us to continue our sacrificial investment in serving these beautiful people, forgotten by all but our Father who invites us to participate in embracing and comforting them, as He pours oil and wine on their many wounds….

Along with all of the remarkable recoveries, we’ve had at least one death every day this week in our hospital.  It gets no easier to get to know someone in their suffering, to hold their hand, pray for them and pour yourself into their care, only to watch their life depart and then to experience the profound grief and loss of the family and friends.  The frustration, grief and even anger from these losses extends to all hours and the lost sleep and fatigue can taint my ability to celebrate the far more numerous joyful outcomes.  

But life and death are in our hands to the same extent that the mud and spit in Jesus hands restored the sight of the blind man (Jn 9). We must remember every morning to trust all outcomes to our Father, and endeavor to do what we can to serve those hurting… Sometimes we can help by immediately transporting the body, with our ambulance (they must be buried quickly in a culture that lacks embalming capabilities), back to their village, if possible, or to the closest river crossing (photos). Sometimes we can provide food for the journey (often lasting many hours) and always we can negate all of our costs for their care after such a loss. We are, first and foremost, called to serve, care and love whomever we can, however we can, as much as we can, and whenever we can, with dignity and honor, no matter the outcome…