Sunday, April 29, 2007

Trauma in Angola

Hello friends and family,

Our next clinical installment will touch a bit on trauma and burn care in Angola. It’s important to recognize that trauma (accidents, homicide, suicide, war) is the third largest killer of people on the planet (after cardiovascular and infectious diseases). But when you consider that trauma tends to prey on the young and the working members of societies, its impact is felt by all. Again, I’d like to give a glimpse by sharing a few clinical vignettes.

Head injury
Maria is 4 years old. 4 days before we met her, she was in a motor vehicle accident where she was thrown from the motorcycle she had been riding together with her parents (a very common practice as transport is expensive). Her scalp laceration was sewn up at a local health post. She was brought to the hospital 3 days later with fever, pus draining from her wound, and altered mental status. Her wound was drained by the ER nurses. Physical exam then revealed a depressed skull fracture. Steve took her to the operating room, where he elevated the compressed area.

Here’s Beth sewing her up at the end of the case.

The next day, Maria was singing in the wards rather than moaning in her stupor. She was not exactly right, but much better. It will be a long time before such families can afford car seats and safety helmets that are a given at home.

Motor Vehicle Collisions
Back in November, as we were coming back from the coastal city of Namibe, we came upon this single-vehicle wreck on the side of the road. The driver we found face down in a ditch, laying in his own blood and vomit. To my surprise, and before we could take spine precautions, he scrabbled to his feet, reeking of alcohol and clearly head injured. A taxi van pulled up at that moment, and agreed to take him the rest of the way into the Namibe general hospital.

We never heard how he fared, but we’re grateful that nobody else (including ourselves) was on the road when he lost control. It also vividly demonstrated for me that alcohol and driving kills in Africa just as much as in North America. Having a death wish doesn’t help either (note ornamentation on the driver-side seatbelt; which, of course, was unused).

It’s not just bad decision making that makes for road vehicle accidents in the Global South. This vehicle was one of a dozen overturned trucks that Beth witnessed on her eye trip in December.

Road vehicle accidents remain one of the greatest killers worldwide. Poor road conditions and devastated national infrastructures remain an enormous challenge to improving safety of travel.

Burns are also a problem all too common in Angola today.
Felicia is three years old and was sleeping face down under a sheet which caught fire when a nearby candle fell on it. She sustained severe burns to her back, buttocks, arms, scalp, and some on her face. Her brother sleeping next to her died that night. She will need to undergo continued daily, and painful, dressing changes while her skin slowly grows back, as the conditions at this hospital in Kalukembe are unlikely to allow successful skin grafting at this stage.

Katarina, nineteen, was burned a year ago, when the thatched roof of her mud brick home caught fire and fell on her. Her skin was also allowed to merely grow back slowly with time. However, given the location of her burns, she developed contractures – debilitating scars from burns which impede normal movement – of her elbow, shoulder and chest wall. With skin grafting and simple reconstructive techniques, we were able to release her shoulder and elbow contractures. However, she will never be able to breastfeed.

Because of spartan living conditions and lack of electricity, burns disproportionately affect the poorer strata of our population here, as in most of the developing world, as demonstrated by both of these cases. The pain and disability keeps these individuals from being able to work and thus from being able to improve their lot. Seeing this has compelled me to work to improve the treatment of burned patients in this part of the world.

Angola suffered 27 years of civil after its independence in 1975. Thankfully, a lasting peace was established 5 years ago. But the scars of this conflict will take untold numbers of years to heal – for both the landscape and for human souls. Countless landmines (estimates between 500 thousand and 10 million) were placed during the war as a means of controlling population movements. These remain a deadly legacy to Angolans and a blight to development as otherwise arable fields linger untouchable. Fortunately, Angola’s government, together with Halo Trust, has been actively demining the countryside, and was recently applauded by member states of the Ottawa Anti-Personnel Landmines Convention for its efforts.

As with so many conflicts around the world, summary executions occurred right here in our backyard during the war years. These are the skeletal remains and uniform of someone thrown off the edge of nearby cliffs years ago. A sobering reminder, in such a beautiful place, of the atrocities of war.

Personal Violence
Gratefully, we have seen comparatively little intentional violence here in Lubango today. At the end of the war, demilitarization efforts succeeded in drastically reducing the number of small arms in country. Violence against women, however, remains largely undocumented and unrecognized. And violence in schools, though uncommon, does occur in Angola as well. Joaquim, 7 years old, was brought by his mother to the hospital with a 2 day history of an acutely swollen, draining eye, which started during school. He denied being attacked, but on operative exploration, it was clear a stick or a pencil had been shoved through the globe. His eye was destroyed, and it required an enucleation (removal of the eye). Next to him is Rob Mutter, a visiting Vanderbilt medical student, who we had the pleasure of hosting this last month.

This will be the last somber update. But we feel somber truths need to be spoken.

In personal news, we have only two weeks remaining of our time here in Lubango. Hence, we are simultaneously making preparations for our return to the US and our move to Boston, and investing in the relationships and work we’ve been given here. Thank you for journeying with us. Until the next update!

Beth and Robert

Saturday, April 14, 2007

Public Health Under a Tree

I (Beth) asked Dr. Karen, who runs a rural hospital and public health center nearby, whether I could visit for a day. I refer all of my suspected tuberculosis patients to Karen, and I am always struck by the thoughtfulness of her notes as she refers patients back to me. I wanted to learn her clinical skills, and learn more about the public health work she was doing. Robert’s sister Gaby and Jessica, an American pre-nursing student, were also interested in going. Karen invited us to do a little teaching, then accompany her nurses for a trip to administer vaccines.

I was the driver for the vaccine trip ... without four-wheel-drive and without basic skills like how to change a flat tire. I was not encouraged that Karen insisted I take her tire pump for the journey!

We started driving and soon turned off onto what appeared to be a footpath, which then disappeared altogether. The nurses instructed me where to turn: “left by that tree; no – that one”, “don’t run over those beans” … as far as I could tell, we were randomly weaving through the countryside, trying to avoid killing crops and chickens.

The "road" to the vaccine site

Then one nurse opened a window and started shouting announcements about the vaccine campaign in Mhuila, the local language, with a bullhorn. The bullhorn squeaked and crackled at great volume while the car bounced and bucked along. I had to laugh out loud at the sheer craziness of it all.

We finally arrived … at a tree. A small village of about 8 huts was nearby. We pulled the car under the tree to keep it shaded, and unloaded our gear. One nurse explained the benefits of handwashing both after pooping and before eating to the gathering crowd. She then led the villagers in a rousing song about the diarrhea, vomiting and death that occurs when one doesn’t wash one’s hands. The whole group – young and old, clapped and sang. She then reminded the villagers of the measles epidemic that had killed their children three years earlier, and explained that the vaccines would help to prevent this. Another nurse translated all of this for me from the local language into Portuguese. In this rural village, I met only one woman who spoke Portuguese.

The vaccine "clinic"

After the nurse spoke, the “mais velho” (pronounced “mishe velyu” - oldest man, or chief) of the tribe gave another vigorous speech about how important it was to vaccinate all the kids, how he fully supported the vaccine efforts. It was truly inspirational.

Then we started registering the kids – they produced their vaccine cards and one nurse marked what vaccines they needed that day. Another nurse set up the scale for babies (a cloth sling that hangs from a tree branch), and another started giving vaccines.

Gaby, Jessica and I were led to the village to the home of the mais velho, to do prenatal exams. The chief’s hut consisted of two small rooms with a rickety wooden chair, a few beer bottles, and a grass mat that we used for the prenatal exams. We had a bathroom scale, a tape measure, and a very old fashioned stethoscope-like contraption for listening to babies’ heart beats. After the prenatal visits, we returned to help with vaccines.

Gaby and Jessica doing a prenatal visit

Two hours later we were packing up, being handed roasted corn for the journey home. Somehow we made it back … with the excellent navigation skills of the nurses. We had done 16 prenatal visits and vaccinated 56 kids and pregnant women.

In addition to vaccination campaigns, the Chiambengala hospital also runs preventive care clinics in eight outlying communities for pregnant moms and kids under five. The project’s community education focuses on tuberculosis, malaria prevention, maternal/child wellness, and HIV. They recently did a door-to-door survey of 10,000 people to find undetected cases of tuberculosis, and to educate the community about the disease.

It’s funny – I’ve always believed in public health in theory – clean water, mosquito nets, health education, vaccines. But I’ve never wanted to do much public health. I just love the one-on-one interaction of patient care; that’s why I went into medicine. But this year, for the first time, I believe that public health is important in reality, not just in theory.

I have lost far too many patients to cerebral malaria – who either got no treatment for days, or got inadequate or misdirected therapy from local health posts before coming to the hospital. Malaria can be treated very easily, but it has to be treated early and completely. It can also be prevented by things like mosquito nets and DDT wall-spraying campaigns. I would like to work on preventing malaria transmission, educating families about the need for early treatment of fever, and training local health posts about appropriate treatment of malaria. I am tired of losing patients who could have lived.

Likewise, hypertension. I regularly see patients in clinic with systolic blood pressures over 200. Many have received various anti-hypertensive medications for 1-2 weeks at a time. Very few have ever been told that hypertension is a disease that requires lifelong control. This would not have struck me so much, except that we also regularly see people who now have irreversible brain damage from strokes. This week two of my patients died in one day from sequelae of strokes. The community and its health posts need education about hypertension. We need to introduce continuity of care, which appears to be virtually nonexistent.

While I personally get more daily satisfaction from sick people made well, public health under a tree sure is fun, and it is Good work, and I hope to be a part of it in the future.

Daily we are grateful for the time we have here, for our ever-smiling staff, for our generous patients. Please pray for our wisdom as we work, and for healing and hope for our patients. Thanks all!!! Beth and Robert

Surgery in Angola (part 1 of 2)

Some of the following photos of surgical pathology may be
too graphic for certain audiences.

Greetings from Lubango!

It has been a while since we have updated our blog with news from our corner of the world. Our time in Angola seems to be flying by. CEML remains tremendously busy. In the next few updates, we hope to give you a flavor of this.

It seems every great talk or book on international health needs a section on surgical pathology. It is important to note that the difference in our surgical cases from those in North America comes not so much from different pathogens as it does from the lack of access to proper health care. To quote one of my mentors at Vanderbilt:

In low and middle income areas extending 23.5 degrees on either side of the equator, most situations encountered by the volunteer surgeon are better described as “surgery in the tropics” rather than “tropical surgery”; the majority of operations will be for conditions encountered in a Western surgical practice with the primary difference being late presentation at an advanced stage. Infrastructural challenges of deficient and intermittent water, electricity, and supplies cause more concern than exotic pathogens.

John Tarpley, Margaret Tarpley, and Donald E. Meier. “An Alternative Vacation: Surgical Volunteerism.” Article in submission.

As if to demonstrate this reality, we had four young women who presented with advanced rectal cancer. Ranging in age from 23 to 45 years, all of them had blood in their stool for over two years. All were slowly getting weaker and more anemic. All had seen many practitioners looking for help. Not one got any better. No one had ever done a simple digital rectal exam which would have diagnosed the problem. By the time they were seen at CEML and diagnosed, their tumors had grown extensively. All four of them required abdominal perineal resections (APRs), which involves removing the whole rectum down to the anus and creating a permanent colostomy. Two had to have their uterus and ovaries removed because the tumors had grown into these. In North America, all would have received chemotherapy and radiation pre-operatively to shrink their tumors, and may have avoided such drastic operations. Gratefully, all are recovering well, gaining weight and feeling stronger.

Angolan OR
While the majority of our time has been spent in Lubango at CEML, a few weeks ago we had the opportunity to travel. A team from Lubango flew about 45 minutes to an older mission hospital in the town of Kalukembe about 300km from here. We spent 2½ days there, did 45 operations, saw about as many new consults. Here is a picture of our operating room. Fairly typical of a busy African OR in the bush.

Back in October, about a week after the hospital opened, Segundo presented with his father for evaluation. He was 13 years old and his left knee had been “swelling” over several months. Multiple attempts with traditional therapy in the village and antibiotics at the health posts failed to provide any improvement. His knee swelling was firm and bony. This was concerning for a malignancy. The x-ray confirmed the classic appearance of osteogenic sarcoma of the distal femur. A bad cancer, put a potentially curable one. We recommended amputation at the level of his thigh, and arranged a date for his operation. Sadly, he did not show up, and we have never seen him since. I doubt he is still alive. I’ve often wondered what deterred them – fear of amputation, cost, other reasons.

Uterine Myosarcoma
Ana is a 24 year old woman, and when we first saw her in clinic, both Beth and I thought she was pregnant. And so did she, until things didn’t check out in her pre-natal visit. A large uterine mass was found on her ultrasound (performed by the head nurse at Kalukembe). On exploration we found a huge tumor of her uterus, likely a uterine leiomyosarcoma. It weighed 3.3 kg (7 pounds, 4 ounces). This required removal of uterus and ovaries – tough at 24 years old, but she recovered well and is home now. Of note, that is my sister Gaby assisting me (we had the privilege of hosting her and my parents during the month of March), and Beth administering anesthesia.

Antonio is a 34 year old who has had several bouts of pyomyositis (pus in the muscles) of his calf and thigh. This time it got out of control, and gangrene set in. Living a couple days journey from any hospital, he has significant barriers to seeking the medical help he needs. Though it took 4 days after being admitted, he finally consented to the above-knee amputation that would save his life, after receiving several blood transfusions he needed to overcome his severe anemia. He has required several operations for drainage and debridement. But he is now getting along nicely on crutches, his wounds slowly cleaning up and healing. His story exemplifies the consequences of inadequate access to care and generalized poverty.

Squamous Cell Cancer
Helder is 35 years old and has grown up under the African sun as an albino, with no melanin to protect him from ultraviolet radiation. A few years ago, he developed a large squamous cell skin cancer of the face. Steve Foster resected it and covered the area over with a flap of tissue from his chest. On opening day of the hospital in October he presented with an awful recurrence that had grown into his maxilla and orbit, pushing his eye out of its socket. One of our first operations, he received a radical resection, including removal of his eye. The other thing to know about Helder is that he has a beautiful, gracious spirit. Upon waking from surgery, with a huge hole in his face, he thanked me for all we had done, his pain was now gone. Helder’s wound is now almost all covered with tissue and skin; but it has taken 5 months. At home, such tumors would be treated with pre-op radiation for shrinkage. Intra-op pathology reports would confirm clearance of all cancerous tissue, and allow immediate closure of the wound. Helder doesn’t have those options, but he thanks me every day he sees me.

Mesenteric Mass
Kachanjo is 16 years old, and lives a three-day journey by foot and public transport from CEML. His presenting problem last November was a large mass that had been slowly growing in his abdomen. Fortunately it wasn’t obstructing his intestines. Ultrasound in my hands was not very revealing. The nearest CT scanner is 700 miles away in another country. On surgical exploration I found this 15 x 15x 20 cm mass growing off the small bowel mesentery (connective tissue that carries blood supply to the intestines). With some difficulty it came out without requiring removal of any of his bowel. He recovered great, was out of the hospital in 4 days, and after two weeks I discharged him to home in the bush. I was relieved last week when I received his pathology report (5 months later) – mesenteric fibromatosis, a benign tumor.

Continued in the next entry...

Surgery in Angola (part 2 of 2)

HIV and Kaposi’ Sarcoma
Lucas is 27 years old and has HIV. He is still waiting to get placed on antiretroviral therapy in the regional government HIV center. He came to see me for a growing tumor on the base of his toe. Measuring 6cm across, I presumed this to be Kaposi’s sarcoma – a tumor much more common in people with HIV/AIDS. His toe was amputated and we have not seen a recurrence yet. Early diagnose and antiretroviral treatment would allow this tumor to be removed with simple cryotherapy (freezing it off).

Marta is 45 years and her neck has been slowly swelling. She was starting to have trouble swallowing and breathing. She had a multinodular goiter – a benign growth of the thyroid usually caused by iodine deficiency in the diet. They are more common in highlands further from the ocean, as iodine is scarcer in such environments. Iodized salt has dramatically decreased the incidence of these tumors in developed countries. There is no iodized salt available where Marta lives. She required a major operation to get most of her thyroid removed. She now swallow wells, breathes well, and her voice is normal.

Sigmoid Teratoma
Leonora is 28 years old. She noticed something firm and round in the left lower quadrant of her abdomen. Physical exam and ultrasound findings both suggested a complex cyst of her ovary. We were quite surprised to find at her operation that her ovaries were normal. Instead, she had a complex tumor hanging off the side of her sigmoid colon. When I opened it, I found fatty tissue, glandular tissue, and bone. A teratoma (Greek for terrible tumor), benign in appearance, a tremendously rare presentation.

Dona Iria is 67 years old and has lived for 2 years with an atrial bradycardia (slow heart rhythm) that keeps her heart rate between 35 and 40. She was often tired. A pacemaker is the only treatment. The nearest cardiologists are 800 miles north or south; bad roads or an expensive flight either way. All things considered, she was doing quite well – contentedly awaiting the arrival of volunteer Canadian cardiologists scheduled to arrive January 4. Christmas morning she fell ill, and showed up at the door of Dr. Steve Collins (see the previous blog entry), her neighbor. Her heart rate was even slower, she looked ashen. She was admitted to the hospital. Two days later, she had a seizure in front of me, stopped breathing, and her heart stopped. Amazingly, she recovered with CPR. A doctor conference and family conference immediately ensued. We presumed poor circulation to her brain led to the preceding cascade of events. The only treatment again was a pacemaker. She was too fragile to fly to Namibia to get one placed. Waiting another 10 days for the cardiologists to arrive seemed too long to wait. The remaining option was to place one ourselves (the device had already been donated by an American cardiologist). With Dona Iria’s and her family’s consent, we took her to the OR the following morning, with appropriate apprehension and prayerfulness. Steve had contacted the donating cardiologist for a few pointers over the phone. We placed the device, unfortunately without the usual x-ray guidance, having only a heart monitor to monitor her heart rhythm. She responded well enough, heart rate in the 60s, most of the time, and was discharged home. The visiting cardiologist did have to fine tune the placement in January, and now she is doing great.

As one can imagine, surgical care in Angola has been, on the whole tremendously gratifying. It seems that daily there are new challenges, new pathology, new fields to tackle. And many people do very well. All are extremely gracious, and even forgiving. While the above stories read as a list of victories, there have been many failures and many heartbreaking stories. Children and young adults lost to diseases like typhoid fever, abdominal tuberculosis. Some are lost to surgeon error. But many of our surgical deaths tie directly to lack of care that was standard 30 years ago at home. Lack of post-operative oxygen, inability to check and correct electrolyte and acid/base imbalances, and minimal nurse education has lead to a large number of our surgical complications.

Thank you for following us on our journey. Stay tuned. Next week: less gruesome pictures and reflections on public health from Beth!

Cute kido after her operation for an ey tumor.

Me and Steve Foster after a long day in the OR.

Sunday, April 08, 2007

Easter Sunday

We started the day with an impromptu sunrise Easter service. As we looked out over Lubango I thought of all that Angola has suffered over the years, and the hope for Redemption before her. I thought of you - family, friends, colleagues, supporters - and prayed for your hope and health.

These words from the classic hymn spoke to me:

Crown Him the Lord of peace,
Whose power a scepter sways
From pole to pole that wars may cease,
And all be prayer and praise:
His reign shall know no end,
And round His pierc├Ęd feet
Fair flowers of paradise extend
Their frangrance ever sweet.

May wars cease, may peace and healing reign both in Angola, and in all our hearts and minds.

Grace be with you,
Robert and Beth