Winter 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. 

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. 

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

Summer 2016 update

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 :)

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!

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.

Winter 2015/16

Sampling of our water challenges this week.

Water on maternity on Wednesday.

Water on maternity on Thursday.

Sampling of broken sinks.

Sampling of broken toilets. 

Our condemned steam sterilizer circa WWII.