Tuesday, May 10, 2016

Hope

Priscila pointed out that it's best to back up the words i used in the last post with our real patients and stories. i hope these are not too much, but they are typical to show the limits we face. The first one happened last Saturday, where at the end of rounding on childrens ward, Sr Nelson ran up with a 1 year old child he said had just aspirated a bean. It was obvious that the child was in respiratory distress and her lungs alternatively sounded completely obstructed and partially obstructed when i put the stethoscope to her chest. We took her to the operating room, but i knew the situation was bleak: no oxygen (we've been out of concentrators for more than 2 months and without cylinders for more than 3 weeks); no rigid bronchoscope, no retrieval forceps. As i limped to the warehouse to look for anything to use, i alternated between cursing the situation, being frustrated at the child and praying for a miraculous cough to dislodge the bean. The poor child was doing what all toddlers do: exploring and testing everything by putting objects in her mouth. . . i felt ashamed for being angry with her; and i felt ashamed as an emergency-trained doctor: i had no laryngoscope blades small enough, but more important to this emergency, i had no rigid bronchoscope. We tried with the best of what i could think of. Using a cystoscope as a flexible bronchoscope, i could see the bean in the trachea but had no success trying to lead in a stylet to perhaps dislodge the bean nor a foley catheter which would not cooperate to go down the airway. i tried Heimlich thrusts, but i knew i was just grasping and hoping for things we did not have. Given that our ambulance was not around and the family had no money to go to a private hospital outside Lubango (CEML), we asked the family take a taxi as soon as they could to Lubango to the Pediatric hospital in hopes that they would either provide urgent care or send the girl along to the right hospital. Apparently, they did get a taxi ride, but the taxi did not go too far down the road before it turned back and brought the child back, limp. i heard that the staff then tried to resuscitate, but to no avail. 

This could have been our child; shucks, the same week i had to pull out a stone, and then a bean and then a bead from Eliel's nostril. But the event also typifies some of my frustrations here: working in a place with few to no materials; working with an administration that seems to show no desire to pursue more materials; and at the end of it all, only being able to tell the patient or the family, "i'm sorry, i can't help." i'm not a surgeon, i'm not a pediatrician, i'm not an oncologist, i don't have medicines, i don't have a battery of lab tests, i don't have much. i wish i knew more, i wish i had more, i wish i could do more. But at the end of most days, i just want to read a book to Zeke, tickle Eliel, laugh with Naomi and talk to Priscila. This isn't heroic work. And i know, at times, i let my patients and their families down.

The next story is more uplifting, i promise. It's of the boy pictured below and his brother. They came to Kalukembe back in March, having each been bitten by a puff adder in their legs the week before. After a failed round of traditional medicines, their limbs were in bad shape. J ended with an above knee amputation and his brother, F,  fought weeks of infection that finally settled with thus far just a few toes taken off. We had no antibiotics when they came, so the family went looking around in the pharmacies for the injectables i prescribed. Then we ran out of dressings and they went days at a time without changes during critical phases for controlling their infections. And they also came at a time when we had no tetanus ( i hoped treating with penicillin and metronidazole would take care of that). In the beginning, they cried any time i entered their room. They associated me with all the painful care they had received, including dressing changes over large debrided wounds without pain medication. But over the weeks, as the debridements became fewer and the antibiotics and dressing changes took effect, they have been two of the brightest smiles on our ward. They love drawing pictures and keep wearing down the pencils i give them. Their parents haven't the money for the skin grafts they would benefit from, but i won't push the matter, either. We don't have dermatomes and our methods don't bring high success or "takes." J and F continue to show exuberance with their crutches and wild laughter any time i'm around. 

J, rather philosophical about the "V for viper" sign, as Pri didn't realize she put up the "V" above his bed. He laughed when asked if he didn't like snakes. Also note the crutches fabricated by our hospital carpenter--cool stuff

The girl below was brought by her mother last week after 3 months of progressive worsening mobility and head growth (hydrocephalus). By the time i saw her, she was comatose, dilated pupils and papilledema without a doubt. She stopped breathing that very hour, but through a nurse's persistent bag valve mask breathing and some dextrose, she pulled through the night in our intensive care, getting intermittent positive pressure. . . no supplemental oxygen, no ventilator. The next day, we finally had our ambulance but had no driver. Then we had a driver but the family had to pay for fuel to get our ambulance to a private hospital in Lubango and also decide if they would pay the costs there. Finally, she was taken and Dr. Annelise Olson operated that night and placed a ventriculoperitoneal shunt in her. As of today, i am told that she is responding to pain. No CT scan of her head will likely ever be done--the cost is too prohibitive and it's too difficult for most people to go to Huambo. But, we hope she has a benign process (something like an ependymoma, please) and her young, plastic brain will wake up. Already, it's been an answer to prayer that she has made it through the transfer process and surgery.
The morning after i first saw her; praying for transfer and recovery
Nothing to do with the stories above, but to show at least one bathroom complete!


Wednesday, May 04, 2016

While we wait




Water renovation work will be breaking ground (we hope) next week. This is exciting and we hope to see results flow! We'd also like to share some other work that has been done around the hospital in the meantime. One of the things has been renovation of the bathrooms and windows on the maternity and women's wards. And along with it, the pediatrics ward received a paint job. We hope that these small improvements will give our patients at least some encouragement. And give recognition to the staff that, through improving their environment, they could also see how their work matters to us and to others around.

                      
An example of the state on Peds ward before painting (ceiling holes, grime and fecal matter on walls, etc)

Staff bathroom work in progress 
Priscila with nursing students, putting up decals on the pediatrics ward after new paint work
Students with our cousin, Abby, who came with Elizabeth for  2 wonderful weeks. They brought decals, crafts for kids, medical supplies and presents for Zeke's and Pri's birthdays. And, oh, was it nice to eat real pepperoni! We are very glad they were patient with the difficult visa process and didn't give up after initial rejection. 
Barn scenes like this have generated interesting conversations with staff and patients ("where do you keep your animals at night? Where do you store your food for animals. . . oh, you don't keep food for cows?")
bathroom renovation in progress

These weeks have been full of reminders of how much we do not know. Patient care continues to humble us because of our lack of resources. And the projects continue to humble us because hey, we went to medical school and not business negotiation class. And less than good communication with the absent administration continue to bring me to my limits. I wish i could call all these 'lessons,' but i don't know if that is fair: not every incident or interaction has a resolution or a tidy 'answer.' But the purpose for our presence here is not, ultimately, that we feel good about ourselves or that we gain a greater maturity clinically and personally (but that would be nice!). i feel compelled to be a part of what i see this world needs: people who love and care for the well-being of others (yes, there are other things the world needs, like freely-available pepperoni). It seems to be confirmed more than rejected in our context. That God calls out to those who believe that when Jesus died and rose again, their lives and the lives of others would never again be the same. He is gathering people from every place and giving them a task: be a blessing to your world. i don't know if we will accomplish this "well" here in Kalukembe; in fact, i doubt it. But i am relieved that this task to bless others is not about what Pri or i can accomplish, but about bringing renown and appreciation to our God who emptied Heaven for our sake, claimed all our faults and sins as his own and died on the cross. And thankfully, he then conquered death so we can live with a genuine hope that we will live with him in " the unimaginable pleasures of infinite love." (paraphrasing from The Songs of Jesus, by Tim Keller).

Spring 2016 Update

Have you wondered where we've been? Still in Kalukembe and here to share our latest update.


Sunday, December 27, 2015

Bushbaby present

Last weekend, a bushbaby (galago) dropped down our chimney Santa Claus-style, and was a pleasant surprise to us and our guests! This nocturnal creature has an incredible leap, and Pri and Zeke even attest that its poop doesn't stink (i didn't care to find out). Although it was very entertaining to see it jump and hang out on our ceiling at night, we worried that it was ignoring our offerings of food and water. We thus released this delightfully unexpected guest back to its wild habitat, which he took in one leap. Merry Christmas and happy new (leap) year!


Saturday, November 14, 2015

Our malnourished patients

A sad reality in Kalukembe, AO and other parts of the world is the persistent problem of malnutrition. When young children suffer, it affects me even more. Starvation in children has complex physical and social origins, including cultural beliefs about breastfeeding, interactions with other diseases, attitudes to certain foods, poverty, etc. But the end result is the same to me: it's sad, it sucks and it shouldn't exist. At Kalukembe, there historically was a program that helped mothers of children with malnutrition grow certain high-protein crops and taught them how to maintain healthy diets for their families using the local milieu. Then up till about 2 years ago, an international and government-supported program using pre-made supplements and formulas was in effect. Now, we are back to offering little to these children outside of medicines and advice about what to buy in the market. These children often need hospital stays of around a month, so this is a financial burden most families are unable or  unwilling to make.

Our "results," predictably, are poor. We are looking and praying for ways to restore health in these children, and we hope we will at least approach a lasting solution that would be a part of restoring the well-being of our entire community here in Kalukembe.

Here are two children's stories that bring me hope, and remind me of one of my favorite Psalms:
"[The Lord] raises the poor from the dust
and lifts the needy from the ash heap.
He seats them with princes,
with the princes of their people. " 
(from Psalm 113)


B. is 5 and arrived after months of weight loss and fevers. His mother died the year before; his father never met him; and so his uncle took responsibility and brought him to us for help. His underlying diagnosis was not difficult to make: tuberculosis that had spread through his whole body. But he struggled to eat or find anything that we recommended his uncle to try for several weeks. After losing even more weight, he finally stopped vomiting, started walking again and left our ward smiling and waving.

J is the baby boy on photo right. He is 4 months old here and came weeks earlier with his mother, who eventually died from suspect metastatic cancer. He struggled with sepsis and severe dehydration; then his new mother (also with an 8-month-old girl) came and like a mother hen began looking after him around the clock. Through mostly her care and love, he is feeding again and home in loving arms!

Sunday, November 08, 2015

Beautiful Ladies


These beautiful ladies are all some of women we are helping or have helped with fistula - here a complication of childbirth that leaves a woman incontinent. There's lots of other work around the hospital, but taking care of these women is definitely a highlight! 

Often story starts out ugly and bloody.
But then we have a chance to help!
Some babies do survive (rarely) and they are so precious!

We sometimes diagnose them immediately postpartum: a difficult recovery.
Women of fortitude.
Some are so young - 15 years old. 
Sometimes our kids play together.

Awesome when loving husbands come - they've been together 17 years.










Tuesday, September 22, 2015

Summer 2015 letter


Water for life and health.

We are working on our hospital's water security. Currently, it is very insecure! The hospital has a daily need of around 65,000 liters and is barely receiving a fraction of that during 2 hours of running water from it's old bore hole. For example, maternity ward has one trash can for the entire antenatal and labor suite that is filled and a bathtub for the rest of the ward. 25 women who are rationed just that amount after the lovely mess of "giving light," as they say in Portuguese.

Part of the difficulty is with old, leaky and out-of-date water resevoirs; a weak pump from the one bore hole we have since 1976 does not manage to fill the tanks; and a spring water source off the property that is dry for at least 7 months of the year. In addition, the pipe system leaks like a colander. And we do not have bathing or latrine/toilet facilities for most patients.

Minne Prins, a Dutch businessman whose ministry is to develop Angolan businesses and infrastructure, has taken on the task to evaluate the current water system at Kalukembe and develop a proposal for renovation. He came to Kalukembe about 15 years ago to help with refugee camps and restoration of the hospital. The last time he was at our house, he tells us, cows were grazing between bookshelves! He's seen much change and is very experienced with customary practice, but gets things done with high quality.

If you are interested in participating in this water project, let us know and we should be able to get more information to you soon. 
Filing water tank for OR with well water - often empty anyway and buckets are carted into the building for hand washing and sterilization. 
Local laundry at Kalukembe 

water used for bathing and washing and irrigation just below hospital. Plenty of malaria breeding happening here!

Deluxe staff bathroom on Maternity ward. None exist on Mens or Womens wards, and the one for the ICU is at least a toilet. . . without a seat. No running water in either, note blue trashcan used for flushing.


Zeke, Eli, Naomi





Friday, August 28, 2015

Back in the saddle but still searching for the horse to leave the barn


It took us 2 years, but as of August 13th, we have been back in Kalukembe (Caluquembe with Portuguese spelling). We are sending a little update today from the provincial capital of Lubango. We are still without internet and are working on setting it up in Kalukembe through a vendor here today.

Some things gladly have not changed at Kalukembe: certain clinical colleagues are still here, persevering under increasingly difficult circumstances. For instance, government budget cuts fell hard on the health sector and procuring medicines and materials have gone from "very challenging" to "insanely challenging." We are quite inspired by the dedication of our nursing colleagues enduring with what little they have to work with. They work with the purpose of serving God and caring for the community. One of our colleagues is Gideon, a nurse clinician working in outpatient department. He laughed when i asked him how many years he's worked in the hospital. He answered with one word: "Muito"--"many."

Some things sadly have not changed: water for the hospital and home remains scarce. The most recent bore-hole is from 1976 and hits more mud than water. We still operate with barely any on the wards and in the operating room. Anyone like to guess nosocomial (hospital acquired) infection rates?

There are a number of things that have changed in the last two years and other things we just didn't know about when we were here in 2013, both nationally and locally as well as in church involvement in the hospital. But for the time being, we are glad to be settling into a spacious house and a big area to explore. We have a lot to be thankful for. People have been welcoming us generously with smiles and friendliness towards Zeke, Eli and Naomi. We hope they will have good friendships here and grow into wanting to serve God through serving others.

Like most parents, i hope our children will be better people than we are. i hope they love more, care more, laugh more, worry less, care less about financial security, and know more about fixing cars and incubators! The other day, Zeke asked if he could go into the maternity ward with Priscila because he wanted to help the ladies "push out their babies!" With so much obstetrical sadness (e.g., we cared for women with uterine rupture, eclampsia, hand presentation with internal extraction, placental acreta and a septic head entrapment that ended in maternal death on top of 3 infant deaths in the same day this week), we hope those babies come out--alive!
It's negative! And it's probably not what you're thinking! This is a rapid Malaria test for Eliel when he was febrile and with diarrhea and vomiting. 

Like some watermelon?

Church girls at our presentation ceremony

Getting interviewed by provincial TV at the presentation ceremony.  Do i really know enough Portuguese? Well, from what i gathered, i was asked if i thought it was wise to wear helmets when participating in the running of the bulls. i said yes.

Audrey Henderson reading and being a wonderful grandma to our boys. We are so thankful for Norm and Audrey in opening their home to us while we were in Lubango for a month!


Our home in Kalukembe
More beautiful than ever. 

The nursing school 3rd year students had exams this week. These chickens were breakfast for the examiners. Talk about "farm" to table service!
exploring the termite mounds in the forest

i suppose i won't be telling Eliel to stop making mountains out of ant hills