Monday, May 01, 2017

Extending care

One of our hopes in working in the Kalukembe area is that we would be able to help people who are helping people help people better! Visiting a couple clinics that the hospital oversees (the IESA denomination oversees around 25 clinics) monthly this year helps us help this way that much more. Hope this following small description helps give a picture (Have you ever noticed how much "help" shows up in our blog? i apologize; often, my self-editing skills fail).

Caconda is a town about 45km north of Kalukembe, has an established IESA clinic that has fallen on difficult times since the national financial crisis. In addition to fewer medicines in their pharmacy, the number of patients seen per day fell from 60-80 to 10-15. Our hope has been to see patients with them and help generate income to pay for more medicines and salaries. The needs from Caconda certainly never waned, as most of our cases at the hospital of uterine rupture come from the are from there, as well as liver failure by traditional medicines. Sitting and eating with staff after seeing patients together has brought great opportunities to learn about other workers' queries and knowledge levels. Augusto, the nurse clinician, has had a good list of questions each visit and a real heart to help the people of the area. Going into these visits i thought what the clinicians could learn would spread greater healthcare value than what i could do in seeing numbers of patients. But even in a place not too far from our hospital, there are people who cannot go farther to see a doctor, either financially or through other constrictions. So even if it was to diagnose terminal cancer and have heart-to-heart talks and prayers, I've been touched by the direct connections with patients there.

Chituto is another place with a new IESA clinic about 170km from Kalukembe to the southeast. This is the youngest clinic in the denomination, opened in 2016. The nearest government hospital has one nurse, barely any supplies and performs no procedures. Even though it qualifies to have doctors, none have ever been there. Most patients are among the poorest of the region and the nursing and lab staff rotate from Kalukembe hospital. Just getting there is exhausting enough, driving in rainy season through the lakes of mud; but fun to share time with the clinic's administrator who also is an outpatient nurse clinician at Kalukembe. In March, Dr. Steve Senichka accompanied us and made lighter work for ultrasound visits. About 80% of the ladies who've been seen for prenatal ultrasounds had no prior prenatal care until seeing me and over 90% were in their 3rd trimester. Though it's not what i usually do, i hope prenatal counseling even from this emergency medicine-trained doctor will translate into wiser decisions women and families will make about labor.

We hope we can continue to share positive developments through interactions with staff at these clinics and in the communities they serve. Concretely, several patients have been referred and operated on in our surgical weeks at the hospital. Likewise, several patients have been started on tuberculosis treatment; and chronic ailments probably continue to nag both patients and myself :) And we keep leaving advice for increased community outreach through the clinics. . . perhaps one day, there will be more public health offered through these places. But also relationally, we hope to share a growing bond with our staff who serve in limited and challenging circumstances--no easy online resources or CME conferences to attend. But they keep working with what they know and what they have. We're grateful to these hard-working servants.

Ok, time for a diary of pictures!

Patients lining up at Chituto clinic. Only 45 of the 110 registered were attended to that day. ...

"What? Another S3 heart sound?" Dr. Steve Senichka examining another patient with heart failure at Chituto clinic. It is common to see patients in advanced stages of heart failure. The most frequently seen causes of heart failure range from infections to pregnancy to untreated hypertension

With the team of lab technicians and clinicians at Caconda clinic. Augusto is at picture far  right
Zeke and his friend, Bruno, making charcoal to sell. It's a steep lesson in  supply-and-demand economics.  . .  Zeke's 400% mark-up price for a bag of charcoal hasn't captured many enthusiastic customers with so many other competitors underselling the same product. Keep at it, bud. You'll figure out a way to buy a bike some day.

The kids outside of our tent in the yard. For Zeke's 6th birthday, we had a boys-of-the-family sleepover in the tent. They outlasted me: i fell asleep reading Robin Hood in mid-sentence. 

And happy birthday to the most beautiful woman! i am so glad we can share life, work, and chickens together!

Thursday, March 30, 2017

Fear. Friendships. Faith.

We have a group of half-dozen neighboorhood children who we love. The brothers Nuchu, Innho, Inginho live in an adobe house with their father who lost both his legs to a land mine. They are too poor to go to school and mostly gather branches to sell as fire wood to patients. Their smiles light up any room. There are the siblings Luis and Filomina, intelligent, articulate kids whose mother is an old fistula patient who has been abandoned by her family. She sells charcoal for 30 cents a pile to other patients to earn money for food. They've recently started to go to school! And then there is Bruno whose tiny body and funny shaped head is probably a consequence of neglect and abuse (which he casually mentions), but whose gentle heart has broken mine. 

They are all sweet, generous, trust-worthy and kind. They are the best gatherers of wild edible fruit - and our boys now often go hunting with them. They are fun playmates who join us on many walks. On our walks they also introduced us to the "River Kukala" - a small stream nearby where cattle come to drink (and poop), ladies wash clothes (and diapers), and snails with schistosomiasis live (we suspect - they certainly live is MANY places around the country). Schistosomiasis is an insidious, dangerous disease. The version we have can cause bladder cancer, chronic infections, infertility, etc. . . I'm afraid of it. Well, to be honest I'm afraid of lots of things (malaria, typhoid, earthquakes in large cement houses, rabid dogs, etc). . . but when I think of my sweet babies I worry even more. So what do I do when they want to join their friends swimming, running, playing, jumping, washing in the river? I  wring my hands. I say no. But then I often capitulate. We go down to the river. They have a great time. I don't know if this is the right answer. But I do know that this world our God created is so beautiful. Our friends and children are intensly enjoying, celebrating and glorifying Him in it. Should I stop this? I know that Jesus walked in dangerous paths, traveled in storms, and even took his disciples into these places. I'm not trying to say that going down to the river is the cross I've been asked to carry... but it causes me to pause and pray... then thank Him and (as my Nana Mary Spencer reminded me) to hold everything I dearly love in the palm of my hand... an open palm. 

PS. We will be occasionally, empirically taking praziquantel :)





Friday, February 17, 2017

Resuscitating Shinseiji (Neonates)

A hearty thanks to our friend and colleague from Huambo, Jordan Yarborough. She endured rough roads south to reach Kalukembe last week. And then put on a great course for nurses and students, our 3rd annual resuscitation of the newborn. Over 60 students participated, including nurses from the district's government health posts. It was especially sweet to have nurses from these government positions participate so that we might have opportunities for closer collegial relationships with them. With so much lack of cooperation in Angola's health care sector, it was a big bonus for me to hear that one of the government nurses came back another day to repeat the course because, as she said, she didn't remember all of it the first time.

In case you didn't know, Angola is ranked worst in the world for neonatal mortality and children under-5 mortality. A course like this that Jordan did is immensely helpful. i remember when we first arrived, the first thing nurses seemed to do when a baby came out limp from a c-section or vaginal delivery was to draw up (too much) epinephrine and stick it in the baby, flick the chest and watch. Now, there is an improved culture of drying and stimulating the baby, moving to positive pressure breaths and chest compressions before drawing up (still too much) epinephrine.

To give a picture of the challenges to better outcomes for women and babies, i'll lay out a typical story of a woman who might get transferred to our hospital. Most women might get one or no prenatal visits during pregnancy. And even if they go for prenatal visits, they often do not get good counsel about laboring at or near a health facility. So a woman might labor at home or go to a 'clinic' by a 'nurse' in the village who likely would not do any monitoring during labor and give several injections of oxytocin. If these measures did not produce, then the family might take the woman to another health post often by motorcycle; this post in turn might refer to a health center where the woman may or may not be checked for progress of her labor. If discovered that the woman has uterine rupture, she would be transferred to our site. But if not, she might have another step in the delay of care and sent to the government hospital across town (another motorcycle ride) where no materials are available for a cesarean delivery. Then, after further delay, a transfer would be arranged to our hospital. After perhaps 2-3 days of labor this way, it's no surprise then to see sad outcomes: neonatal death or sepsis; birth injury to the mother leading to vesicovaginal fistulae later on; uterine rupture; uterine necrosis; postpartum hemorrhage; you name it and it's probably happened.

Enter this course. It's one act of good beating back the forces of darkness! There's no question that one of the babies born to our hemotherapy survived during the course week because of direct application. One life saved for sure, and many more we hope will be impacted!

Naomi and her Angolan building blocks. Pretty sure this ranks well with developmental milestones

Eliel: our Lord-of-the-Flies boy. That's Mulberry juice, in case you wonder

Zeke in his superhero costume. Smashing!

Jordan and some of the nurses from the neonatal resuscitation course. Proud resuscitationists!

At the staff appreciation snack/closing ceremony. Great work, guys!

Saturday, January 14, 2017

Boa Entrada

Happy New Year! We've enjoyed wet and warm weather here in Kalukembe, in its midst of rainy season. 2016 will not be remembered as lacking excitement or strenuous times, both on the global stage and in our personal lives. It's wonderful knowing you are genuine partners in our efforts here. And 'efforts' is the right word; we often don't feel like there's much to show for results, but we hope to be found faithful in trying. And so, thank you to those who join hands to loosen chains of injustice, to find cloth and bind up others' broken hearts, to comfort others in mourning, to share our freedom in Christ. Thanks!

The stories are sometimes heavy. . . but we want to share the good and bad; our struggles and successes. Stories from here are often dramatic because, well, life and death matters ought to be considered such. And the One here with us is Jesus... even when we are without medical tape and gauze for dressing changes; when normal saline and Ringers' lactate ran out yesterday and we are "resuscitating" with D5W; when our operating technicians have shown up little to work this week and yet we were able to operate on perforated peptic ulcer, intestinal volvulus, intra-abdominal abscess, intestinal tuberculosis, gastric tuberculosis, gangrenous legs, perforated typhoid, ruptured ectopic pregnancies, procedures for septic knee, hemopericardium, empyema; broken ultrasound machine just prior to our campaign for free prenatal ultrasounds (more later); no lidocaine; nurses who have disappeared from wards; etc; we go with intermittent electricity; due in part to government "diversions" of medicines, we have not had TB medicines since July last year; no rapid HIV tests; no hospital ambulance that can make a transfer to the provincial capital. Ahhhh!

But Christ is with us here. From the beginning of the Bible and throughout, we see God moving to us in trouble (see Psalm 10, especially v. 14: " But you, O God, do see trouble and grief; you consider it to take it in hand. . .") The One we believe in knows our and our community's troubles and does not turn a cold shoulder. This week an elderly lady with advanced bladder cancer reminded me that she has a God who is holding her in her last days on earth. This was not an empty conversation. It was weighty because i didn't have anything to really offer her beyond an inevitable prognosis and over-the-counter pain medication. There are eternal issues that weighed on her heart and mine. . . . The life and death matters we face at work draw us into these eternal matters. The late Helen Roseveare reminded me the question is not, "Is this all worth it?" when we're in a difficult context; the question should change to "Is He worth it?"

On a brighter line of thought, we are pleased with the results of this week's free prenatal ultrasound campaign. i don't know the exact number of ultrasounds, but somewhere in the range of 150 with the lion's share handled by our nurse colleague, Antonio Salomão. In spite of Priscila's portable ultrasound breaking down just weeks before, the big surge in outpatient numbers was managed. Due to some miscommunication, a large number of ladies from a neighboring province arrived to see Priscila for gynecologic complaints and, well, any complaint really! Even goiter or other odd bumps or whatever seemed to concern them. The week turned out well, as there were many first time prenatal visits for women who've even had several prior pregnancies. And as for incidental findings, there were several ladies with chronic hypertension, an intrauterine fetal demise, and (crazy but true) two ladies with ruptured ectopic pregnancies. Those ladies are doing much better now after their operations. It's your support and partnership that helps us reach out to others in this way. And it's a small step forward in addressing Angola's maternal-infant troubles (worst country in the world for infant mortality).

Ok, pictures!

Naomi with big sister Mina, Christmas eve swimming in the local creek

Naomi and Eliel putting water for the garden to another use

Thanks to your partnership! Through your help in sustaining us here, this mother with her newborn will hopefully have a happy year ahead. The mother brought in her child septic from an imperforate anus (no hole in the baby's bottom). She couldn't afford transfer so Priscila placed a temporary colostomy until the baby grows. Baby was discharged, growing, feeding, and gladly pooping out of his temporary opening :)

Area kids have been using recently cut grass and bamboo to construct  houses in our yards. These led to stories from Helena, our house helper, who lived in such makeshift homes during the civil war when they were hiding in the bush. Very difficult years; so glad we could hear stories that had not known about--all out of these elaborate constructions that our kids love.

Nurse Antonio Salomão and his assistants ultra sounding one of our lovely pregnant ladies who came during this week. He was a huge assistance. The idea behind offering free prenatal ultrasounds was to combat our very high obstetric complication problem in the area. For example, around 25% of our C-sections at the hospital turn out to be uterine ruptures--a sign of very prolonged labor. A large percentage of our C-sections deliver dead babies. And the weight of our campaign has been highlighted by 3 maternal deaths in the last 3 weeks (eclampsia, perforated typhoid and postpartum hemorrhage). So we hope that, providing exposure and counseling ladies about things to expect in labor and encouraging coming early to the hospital, these preventable tragedies would diminish. Again, thank you for your partnership with us in this and other programs we have planned for the year 2017!



Sunday, December 04, 2016

Continuing to learn

One of our desires in working here at Kalukembe hospital is to assist with ongoing learning opportunities for the staff. Access to materials is always poor for our colleagues, and so having the pleasure to host an expert such as Dr. Ken Foster is just that--a real pleasure. This weekend, Dr. Foster taught through discussion, lecture, demonstration and hands-on practicum a group of 20 nurse clinicians. His emphasis was on management of hand and bone injuries and illnesses, rooted in good fundamentals of care. As has happened in previous seminars, he challenged "standard" practice and introduced improved ways of thinking about and managing injuries and infections. Because of his past connection with Kalukembe (visited as a medical student in the 80's and then worked as a surgeon for a couple years in the 90's), his visit was even more profound to all of us.

As much as the technical learning for the nurses encouraged us, i was even more encouraged by Dr. Foster's very approachable nature and his openness to share his experiences from other places with us. He has served for years in Afganistan, and it especially struck a couple of nurses as we sat around after lunch yesterday that there are other places in the world that suffer deeply. It brought the suffering in our context into perspective--that there are others who suffer too: thieving governments, lack of materials, poverty, iatrogenic damages that leave patients worse off than where they began with their sicknesses. 

Priscila also lectured about vesicovaginal fistulas, with good feedback about sharing more about this common condition in public gatherings. i hope and pray some will take initiative to do this and that we can help them with basic materials (like a kamishibai-style presentation, perhaps). 

Dr. Ken reading to Eliel, Zeke and Naomi, shamelessly wanting stories at 6 am.

suture session for skin and tendons on pig's feet

African multi-tasking: nurse from Lobito breast feeding her son while intently watching Dr. Ken's demonstration

A break from bones and joints: Priscila lecturing on vesicovaginal fistulas. Dr. Ken had pearls of wisdom for fistula care from his experiences in Afghanistan

More African-style learning: this patient received procedural sedation in the classroom so  her fracture could be "set," or reduced then stayed to recover while Dr. Ken carried on with his teaching. Amusing to me, given all the paperwork and monitoring i have to put patients through in the States before giving the same medicine and that she still received good care. 

Wednesday, November 23, 2016

Thankful for returns and personal hygiene

Happy Thanksgiving to our American friends! We have some thanks to share to all. On Sunday while we were at church, our house was broken into and, among other things, our wireless modem was stolen. Today, through private detective work by our hospital maintenance and administrator, the thieves were nabbed and most of our stuff was returned (minus the money and functional hard-drives). We are extremely thankful to have our internet modem back. The one we have can't be found in the country anymore, apparently. Not that ours is THAT fast, but it does give us ability to post this blog, which other modems have not had enough speed do do.

We are also very thankful to the hospital community support here and glad we can rejoice together. While we were cut off from any outside connection, we were given solid hands of support here at the hospital. Although we're bummed that we lost access to files and movies, some presents, etc, our kids especially are glad that the robbers never took their beds or books or bikes :) Interestingly, our family has been memorizing Psalm 121, a psalm that goes over and over God's watchful protection. Even if we let our guard down and the threat of future theft remains, we have a Lord who never tires. 

In even more thankful news, Jaime, one of our nurses, has shown himself to be quite an active speaker for public health. Yesterday, he shared information on personal hygiene that was well-received. We've been hoping for a member of the hospital staff to engage the community in health matters; he's shown quite some promise. 

As for the water project, the work is continuing. A few solar panels have been placed and tests for the water pump show it works. We can't wait to see how the tanks fill. And in the meantime, public water points are still getting set up. 

Hope you will be surrounded by family and the ones you love this Thanksgiving!

Naomi, sharing one of the dolls we brought from Canada on Pediatrics ward (thanks to Mrs Vanderkruk!)

Exploring down by the community gardens/farms, where we found a water snake, amphibians and other interesting wildlife that live in streams and irrigation canals

The community was more than eager to be a part of the test drive for the solar-powered water pump on Sunday. And our boys were more than eager to direct the water distribution

Jaime giving his hygiene information session yesterday. Only a fraction of the turnout pictured. And already requests for more!
Entry by unwelcome guests. We pray the burglars will make better choices in their lives
This sweet little toddler has survived a horrible dental infection and we can now plan to remove the dead parts of her jawbone. Reconstruction will be left in the capable hands of Dr. Annelise Olson in a hospital in Lubango. Bad dental infections are common around here, especially for those who choose to try and treat with traditional medicines. 

Wednesday, October 12, 2016

Returning to Angola from vacation

Though it was almost 6 weeks, our time in America breezed by quickly and we are airplane-, airline- and airport-hopping our way back to Angola. We were blessed by many, including time with family on both our sides; colleagues at Christiana; City Line church; Chinese Gospel Church; friends in Philly and Pittsburgh; and even a last minute opportunity to share at West Chester Chinese Evangelical Church.

Can't ever say i am fully ready and prepared for the type of work we do, but we are refreshed in spirit and continue our term in Kalukembe. Eliel and Naomi speak a few more English words, Priscila's CME is up to date, and she even has a beautiful new haircut.

One thing brought to my attention while back was some hesitation of friends to share their struggles and concerns with us. . . something we heard along the lines of, "well, what i'm going through is nothing to what you deal with over there." Perhaps the scale of suffering is more severe because the consequences hinge much more on survival, but it never was our intent to be in a business of life comparisons and gain high "holier than others" marks. i'm very glad the Bible never presents a point system for our suffering: like an 85 for metastatic cancer, or a 40 for a divorce, and perhaps a 5 if the door slams on your thumb. It's all before God suffering and, like Psalm 130, ought to generate a cry to Him. As our Father, it's what he wants us to do. So, i hope we never discourage others from laying their burdens before God, seeing he cares even for the minutiae in our lives as we should hold each other in them as well.

till next time, more pictures!

Tia Ruth reading with the cousins, Lily and Bella

Eliel climbing some rock in Philly, with Uncle Caleb!

Fishing in Canada with Chantal

hiking and camping in northern PA

Beautiful fall foliage

Reading with Baachan Cummings and cousin Leia

Tuesday, July 19, 2016

Marching on

Due in part to odd hours of internet access (alas, after midnight is not my favorite time to get online), in part to my own procrastination, it's been quite a spell since the last post from the Calamity Cummings. . . but we're still here, still not deported or fired or any number of things that could happen to us! And we even had our visas renewed in record time last month.

Since i've been asked a few times, yellow fever has affected a few people around our locale. As far as i know, no de novo cases have occurred in Kalukembe, which would be hard since we don't have the right type of mosquito up here (but we do have enough trash around to harbor them if they ever were to migrate!). But other tragedies persist. The lack of tetanus vaccine for more than a month hit home when a local man came in with a leg laceration then later developed tetanus and died last week. It is ironic that with this yellow fever outbreak, you can get the vaccine as you leave the country in Luanda's airport but we still have not had yellow fever vaccines or sufficient hepatitis B, pneumococcus or tetanus vaccines in our province this whole year. . . . Our record number of pediatric blood transfusions for the month of May backed off last month as malaria has "died down," though we now have more children with burns. A nurse was incensed about the negligence of a local woman  who left her small children to watch soap operas at a neighbor's house, then lost them both when the house burned. But every burn patient in our hospital right now is there because family members were away at funerals. Negligence is no new cultural practice with the advent of television.

We are glad for a few successes with small projects here. Priscila's most pleased with trash cans on hospital grounds and clean up of underbrush around outhouses that have reduced general and human waste in unwanted places, respectively. The hospital is now mostly connected via an internal telephone system. It's a new learning curve for students and nurses who have never used landlines before (imagine if we used rotary phones!). And lighting a pathway between student housing and the hospital has already seen an immediate drop in assaults and theft along that path. The electricians will be placing a couple more high output LED lights on the paths in the upcoming days.

The water project continues to move along, albeit slowly. We walked around campus yesterday with the project manager to see where public water taps would be installed, and Eliel tested several grey water systems (i.e., open drainage) by falling into several. A quick fix to our borehole occurred last week when Feliciano, an employee for the project, dislodged a stone inside the pump tubing. We now have an instant pressure increase when water comes to the house. Priscila's even talking about taking a shower. Give that man a raise!

Much more to share, but let's see pictures!

Eliel (with 'school bag') and Zeke (with lasso), sitting comfortably on new benches outside maternity

Note the date: August 24, 1984! Fortunately, this formaldehyde is still good for use :) Priscila's incessant push to clean up led to some fascinating finds in the medicine warehouse. She even came upon a certificate of training completion in leprosy for the founding surgeon. 

Progress on the building that will house solar battery system for a new borehole.


Sister solidarity. Several of our beautiful fistula ladies showing support for each other. Priscila has cared for over 30 women suffering from fistulae this year. Two of our funding sources, the Fistula Foundation and Hope For Our Sisters, allow us to provide free care for these ladies.

Narnia? Hogwarts? This young owl appeared in our living room (via chimney) one morning. Such a small beak, but man are those talons sharp!

Let there be light! Santana and Bernardo, our electrical team, putting up lighting along our path to the hospital. Thanks to your generosity, the nursing students and we have a safer commute at night!

Jamba sporting the new phone communications technique. Yes, gloves and masks required for strict hygienic purposes :)


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!