Monday, August 06, 2007

Out Takes...

It seems that most sitcoms and movies these days do well in making available the bloopers in production that have been edited out for the polished, finished product. We too had our set of “out takes” – experiences too humorous or irreverent that weren’t appropriate for sharing in other installments, but nonetheless provided us with much appreciated comic relief during the year. We hope you enjoy them a fraction as much as we did.

Himba breast exam
At one point we took care of a prominent Himba chieftan for urologic concerns. The Himba ethnic group live in southern Angola and northern Namibia. They are a beautiful, proud, friendly, and pastoral people. They have resisted pressures to westernize and hence have maintained a strong cultural identity. For example, daily beauty care for Himba women includes a full-body treatment with a cream made of rancid butterfat, an aromatic bush resin, and red ochre mud – which lends the intense reddish shine to Himba skin.

While our patient was recovering, his wife (they are both pictured above) became friendly with a North American friend of ours who worked at CEML for a few months – we’ll call her Sally. Our patient’s wife became concerned that Sally (in her mid-twenties) was neither married, nor had any children. There must be a reason for this, she insisted.

“In North America, we tend to marry later,” Sally tried to explain through Kayove, CEML’s number 2 administrator and the only speaker of Himba at the Hospital. He was growing increasingly uncomfortable in this role.

“No, there must be more to it than that,” reasoned our Himba lady. “Perhaps you’re not of age yet; it’s hard to tell how old you are with all those clothes on.”

The conversation escalated this way with Kayove (now squirming) having to translate our Himba lady’s impression of Sally’s post-pubescent maturation. Finally, before Sally could react, the Himba lady had plunged her had down Sally’s blouse, giving her a bilateral breast exam. Withdrawing her hand, she sagely concluded… “I was right, you must be very young.”

Got Milk?
Angola’s fertility rate, as with much of sub-Saharan Africa, is about 6 children born to every woman over her lifetime. This means that there are always children around you being breastfed. And this is great – it helps prevent malnutrition, diarrhea, and pneumonia, the diseases that kill the most number of infants in Africa. Generally, it seems moms have little trouble with lactation, and it’s rather common to have one or two babies breastfeeding while seeing mom in the clinic. Once, however, Beth had a patient come in with the chief complaint that she wasn’t producing milk, and wanted formula for her baby. Not having dealt with this problem before, she called in our dear colleague Dra. Arminda. Arminda is an American-trained, Angolan pediatrician who works both in public health and at CEML. Arminda took the same history from the patient. “That’s not right,” she said, unsatisfied, “all our moms can make milk.” At this point she reached down the patients blouse, produced her breast, and gave it a vigorous squeeze, squirting milk across the clinic room. “See, it’s not a problem.”

Like a cabrito
About a quarter of the patients we saw in outpatient clinic came in with primary complaints of migratory abdominal pains that could manifest in a variety of ways. Some have had a burning intermittent, bloating discomfort for years. Others are concerned about the bicho – creature – in their bellies causing the discomfort. Still others are quite certain of the cobra that lives inside of their abdomen, with the head in the left upper quadrant, which bites them incessantly. At first this was a bit bewildering. Then the pattern came clear. 90% of these patients suffer from constipation – a result of their maize meal (everyone’s staple) having become so refined and processed that all roughage has been removed. This lack of fiber combined with chronic mild dehydration makes for a tough set-up for the GI tract. The rest of the interview was almost always the same.

“Any vomiting or diarrhea?”
“Any fevers?”
“Blood in your stool?”
“How often do you stool – twice a day, once a day, once a week?”
“Once a week… how did you know?”
“Is your stool soft and bulky, or small and hard?”
“Small and hard.”
Ah, sim. Como um cabrito?” ("Ah, yes, like a goat’s?")

Then the eyes light up with profound acknowledgement, as if the doctor had been given some special powers of insight – they must know! At this point the prescription is given: lots of water, vegetable high in roughage, and farelo - bran. This last one is most important in keeping that pesky cobra from biting.

Hot sex
The next few entries are dedicated to some of the more unusual patient complaints we heard over the year. In May, as another late clinic day was near wrapping up, Beth had a 55 year old man who had been waiting since 8am to be seen by a doctor.

“I have burning down there,” he stated, pointing to his genital area.

This wasn’t terribly surprising. In our experience, many pains and discomforts in our Angolan patients manifest as heat and burning, often migrating around the body. Sure enough, his burning would start in his loins, head up his belly, fill his chest, and then ascend his neck and head like fire. Reflexively, Beth started filling lab slip to check for sexually transmitted diseases.

“But what is strange,” he pressed on, “is that my wife gets it too!” When they have sex, she too gets the burning “down there,” which then envelopes her whole body. And it happens to both of them at the same time!

A bit perplexed as to how to react, Beth gave him the lab order, just to make sure; wrote down in his chart that indeed “the sex is hot”; and sent him on his way with her congratulations.

Lost wisdom
A month earlier Beth saw a 25 year old man in clinic, complaining that he would intermittently lose his wisdom. Scanning his chart, she read the detailed triage note from earlier that day from our friend and housemate, Shelley Duplantis, an advanced practice nurse, confirming the same.

“So tell me what’s wrong...”

“Well, doctora, you see I’ve been losing my wisdom.”

“What do you mean? How does this happen?”

“Well it starts as a burning in my stomach, and then it goes to my back. And then it climbs into my chest, heads up my neck and into my head. Then I go crazy. And then I lose my wisdom!”

Huh. OK.

“So, umm… did anybody come with you today? Maybe they can help us out.”

“Oh yes, my friend came – he’s out in the hall.”Enter friend.

“So can you tell me what happens to you friend here?”

“Oh yes, you see, it all starts as a burning in his stomach, and then it goes to his back. And then it climbs into his chest, heads up his neck and into his head. Then he goes crazy. And then he loses his wisdom!”

A bit at a loss, she wrote him for penicillin to treat his syphilis, though admittedly he had no signs of neurosyphilis, and asked him to follow-up when he’d finished his treatment.

O Pensador - the Angolan Thinker is a national heritage icon.
He even is printed on every kwanza bill, the national currency.
Sadly, he now reminds me of our young man losing his wisdom.
Credit to Ben and Julia Martens, the photographers.

Pulsation in the abdomen
I had an 18 year old young man present to the office with abdominal complaints. Having just seen 4 patients in row all needing farelo (see above), I had to work hard to not roll my eyes back into my head.

“So, what’s wrong with your belly?”

“Oh doc, it’s bad. I think I am going to die!”

I looked him. He was tall, thin, muscular; appeared to be the picture of health.“What on earth could be so bad?”

“I’ve got this thing in my belly. I noticed it months ago, and it won’t go away. It comes back every night as I lay down. It just sits there and pulses. I think it will kill me.”

I laid him down on the exam table… sure enough, he had a perfectly normal aorta coursing along the back of his abdomen. He was just thin enough to be able to feel it. There it lay, pulsing out his own heartbeat, carrying blood to his whole body. The seat of the human soul, some of my vascular surgery attendings used to quip.

I couldn’t take it any longer. I traded places with him on the exam table, lifted my shirt, pressed his hand into my own belly until I could feel my own aortic pulse through his fingers. “I think you’ll be OK. This thing won’t kill you at least until you reach my age.”

This one has no story. I do have to give credit to my sister, Gabriela Riviello, who was the photographer who captured this one. This was taken on the same day as Beth’s “Public Health Under a Tree” posting below. The subject is a young Huila woman and her two children. All I can say is: “Kids these days. They show no respect!”

In closing, we want to say thank you, again, to so many of you who have made our experiences possible. We wish to thank family and friends and members of our church home of Saint Bartholomew’s in Nashville, TN for your prayers for us. We believe that they were heard and that they sustained us.

We also want to thank so many of you – friends, family, colleagues, and acquaintances – who supported us with financial gifts. Many of these turned into direct benefit to the staff, patients, and infrastructure of CEML.

Finally, we also wish to thank Vanderbilt University and the Fulbright Program of the U.S. State Department who provided the lion’s share of our sponsorship through the Medical Scholars Program and the International Educational Exchange Fellowship, respectively. Below you’ll find Beth trading a Vandy and Fulbright t-shirt with an enterprising young man, so she could get the Angola Polio Eradication t-shirt she had been eyeing for months.

"But let justice roll on like a river, righteousness like a never-failing stream!"

- Amos, the prophet

Teaching, and Learning, Care

Thank you for journeying with us through what we hope was our introductory Angolan experience. Beth and I returned to the U.S. ten weeks ago and are now settled into our new home in Boston. These weeks have offered us some opportunity to reflect on our time in Lubango.

On our very first day in Angola, back in October 2006, we had the honor and pleasure of being welcomed by the American Ambassador Cynthia Efird. She had both a listening ear as well as many words of wisdom for us. Those that made the deepest impression came in the context of discussing the value of health care, current public health challenges in Angola, and how we and our colleagues would be stretched in delivering hospital services.

“Whatever you do,” she told us, “teach care.”

Over the next eight months we found that there were indeed many opportunities to teach care. We found even more opportunities to learn care. This blog entry is dedicated to a few of those who have been our teachers.

Dona Zefa
Dona Zefa finished her studies at a Catholic nursing school just prior to Angola’s civil war, and has essentially worked in the operating room her whole adult life. She is now “retired”. Which means she volunteers 4 days of work a week at CEML, she will not accept any pay, except for a Christmas bonus she received last December. Simply put, the CEML OR would not be functional without her. She quietly keeps things rolling all day long – instruments get cleaned and sterilized, operations gets started, all the staff get their lunch (this usually required some browbeating to get Robert to lunch), and at the end of the day everything is as tidy as when it started. All with a beautiful, gentle spirit.

Dona Zefa getting the work done... with a smile.

Kambali only has a fourth grade education and used to clean hospital floors. A number of years ago a couple of doctors recognized he was both a quick and eager learner and a humble partner in the work. He was then trained by Steve Collins to assist him in cataract surgery. Now, Uncle Steve is almost useless without him. And Kambali does a number of eye operations on his own. Because of his lack of credentialing, he is only paid $150 per month (compared with $250 for his nursing colleagues). We’ve never heard him complain. He cares for his aged patients with gentleness, respect, and humility. It’s inspiring.

Kambali and Uncle Steve operating in Huambo, Central Angola.

Amelia is the head nurse for CEML’s inpatient ward. Ultimately, all that happens in the ward is her responsibility and she functions in the equivalent capacity of a resident physician in the US. She was Beth’s closest and most valued ally at the hospital. Her task is enormous – managing patient care, ensuring bills are paid, and training the ward nurses, many of whom had never touched a patient prior to their first day of work at CEML. She was always steady, always able to translate our Portuguese to Portuguese, so that patients could understand, or to Umbundu or Nhanheca (the most common local languages). And she always defended the “doctora”.

Beth and Amelia (right) with Marcia, who has recovered from her rectal cancer surgery.

Israel is one of the Emergency Department nurses. He said of himself once that he is frustrated because he doesn’t know enough to do his job properly. Without a doubt he is one of the brightest nurses in our hospital. For years during the war time he was stationed in a rural health post by himself to manage an enormous range of pathologies with minimal resources and effectively no referral options. Now that he is in the city, he is taking advanced practice nursing courses to better himself while working full time and helping care for his family.

Israel and Beth in the "Banco de Urgénica"

Henriques works as the pharmacy nurse/technician at CEML. From the day we arrived he has been a friend to us. There is always a smile on his face we he sees you, laughter in his voice when he greets you, and a hug available if you’re close enough. Henriques was one of our best windows into Angolan culture and the Angolan experience of the last 30 years. We were often invited into their home, to share meals, to be with their children, to share life and understanding. He loves his family dearly, loves his work, and is loyal to his friends. He remains a dear companion.

Henriques and Beth with their children, Dalva and Terry

Beth (pronounce “Betty”) is a nurse on the ward, and is married to Henriques. Together they have two beautiful children – Dalva and Terry. Beth is singularly professional and competent in her care of sick patients on the ward. She is constantly wishing to learn more, asking questions, seeking answers, and always with a gentle and kind spirit. When she worked the night shift, we rested easy; we knew our patients were in good hands. When she called for help, we came quickly.

Lino works in the OR and has been a surgical assistant for 20 years. His understanding of surgical technique, appropriate instrumentation, and his ability to anticipate the surgeon's next move are top notch. These alone make him a pleasure to operate with. But what is most wonderful about Lino is his calm demeanor, and his caring for patients pre-, intra-, and post-op. Lino also taught me more about Angolan literature, politics, and religion than just about anybody else. A real breath of fresh air.

Lino, always dapper in and out of the Operating Room.

Pastor Moisés
Pastor Moisés took on the chaplaincy at CEML shortly after the hospital doors opened. Previously, he had been head of IESA (Igreja Evangélica Sinodal de Angola), a national evangelical denomination whose members number in the tens of thousands. Now, as the chaplain of a 40 bed hospital, he quietly makes daily rounds – visiting with patients and their families, offering ministries of presence, prayer, comfort, and spiritual guidance. He is the de facto palliative care consultant. In our mind, the greatest complements paid to him came from the dozen of patients, from various religious backgrounds, who refereed to him as “nosso pastor” – our pastor.

"Nosso Pastor"

Senhor Danny is the CEO of CEML. An administrator by training, he had never worked in healthcare prior to being recruited to CEML 5 years ago. Since then, he has worked tirelessly to get the hospital working, and, now that is has set sail, to keep it afloat. His passion is to provide holistic care for the people of the city and province. He has a servant’s heart and a wry sense of humor. I don’t think I’ll over forget seeing him drive back to work, without complaint, at 8:30 on a Friday night to shuttle the dayshift nurses home in a beaten-up old Landcruiser, after the hospital driver called in sick. 16 staff members piled in and off they drove to be distributed around town.

"O Chefe" - the Boss

There were many times that our experiences in Angola were hard and sometimes painful. These had a broad range of causes – the stress of conducting life in another language, adjusting to a new a culture where for us the rules were not clear, being subject to obstructionist bureaucracy related to visas, and being witness and companion to so many of our patients who died while under our care. Without a doubt, we still have much to reflect on, grow from, and even heal from. But we wish to express our gratitude to those mentioned above for caring not only for our patients, but also for us. Without their grace and kindness our experience would have been so much less rich. We also wish to thank so many others who have gone unmentioned, but who were vital to us this last year – our physician colleagues; hospital staff; the missionary community; family, friends, and colleagues in the U.S. and elsewhere who have loved us well.

As alluded to above, we hope to be back in Angola, Lord willing, in the years to come. And we hope that many of you will take us up on our offers to come visit, experience, share, and contribute.