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


Stephanie Gillenwater said...

Hello Riviellos! This is Stephanie Gillenwater. Robert was a huge part of helping my precious daddy, Stephen Gillenwater, become cancer free. I am so excited that I found this blog the other day when I Googled your last name!!! You two are awesome! All the people you have helped in our country and others. Many, many, people. I wonder do you realize that when you help the actual patient that you also help their family.

I have an e-mail address I hope is still good. I am gonna send some pics! I will go for now. Keeping you two in my thoughts and prayers.

Thankful for you,
God Bless,

Robert and Beth said...

Wonderful to hear from you. Your father should be coming up on his one year anniversary of his operation (as well as your birthday!). I am thrilled. The email address you have for me is still active. Please give your parents and sister my most heart-felt greetings. All the best,
P.S. I would love to see pictures.

Stephanie Gillenwater said...

Hey Doc!
How very cool that you remember my birthday. I figured you would remember the surgery. I imagine it is not often that you do transversial esophagectomies. (spelling?!!!) I hope not anyway. I am so glad to see that you got my message. I was not sure if I did it right. I tried to send you an e-mail but it sent it back. My e-mail is, if you get a chance shoot me one so I can make sure that I have your address correct. Daddy got his third clean bill May 1st. He is doing well. He had all of his teeth taken out in January and got some new ones about 3 weeks ago. Now we are just trying to fatten him up! He is still pretty thin. I am keeping you, your wife, your colleagues, and your patients in my prayers. Thanks be to God for calling people like you to medicine and thanks be to you all for following his call and working so hard to get there.