Ben Cavilla’s Blog

Angola Week 3

Well it’s been quite awhile since my last entry and needless to say a lot has happened. The badness seems to come in waves around here and the last week has been a calm…hopefully not before the storm.  The wards are now relatively quiet and thankfully quite a few patients have made it to discharge lately.  I only lost one elderly woman to the ever-present Tubercolosis last week compared to the wave of deaths, both young and old the week before.  Tubercolosis has become my nemesis here in Angola as I am sure it is elsewhere as well.  A disease with a history dating back farther than medicine itself, TB continues to evade modern diagnosis and treatment (neither of which are available here). In the majority of cases (save those cases of Pott’s disease and TB of the knee which have fairly classic presentations) I am unable to rule-in or rule-out TB in most cases.  It seems everyone has abnormal x-rays here and the classic finding of a “casseating granuloma” of the superior lobe is as rare as an albino Angolan (have now seen 3 of such unfortunate individuals with horrible skin cancers). We rely mostly on the patients recount of their illness, exposure to family members with “coughing sickness”, the classic constitutional symptoms that we all we’ve all read about in the books and very non-specific erythrocyte sedimentation rates!  Unfortunately there are no capabilities for bacterial cultures here and TB skin testing is a waste of time as it is positive in almost everyone.  In fact, I beginning to wonder if BCG vaccination for TB should be abolished as it seems to offer mediocre protection against infection and makes definitive diagnosis in this setting almost impossible. A similar situation exists with Plasmodial infections as well.  I am only rarely able to say with any sort of conviction that a patient’s symptoms are due to malaria.  Unfortunately most people here have signs of P. Falciparum in their blood making the establishment of causal relationships difficult to say the least!  Everyone who comes through the door is tested for malaria (after all, it is the great pretender …as is TB…as is syphilis) and 8/10 come back positive!  As such everything from hemorrhoids (malaria can cause portal hypertension) to headaches (malaria causes hypoglycemia which leads to headaches) is caused by the ever-present malaria…. Personally I think it to be a ridiculous notion but the practices are entrenched.  Anyways, I digress… but suffice to say I am learning to live with a considerable amount of diagnostic uncertainty.


Anyways, I am sure you are all waiting for an update on my blog from last week.  I am sorry to have left you all hanging with what in hind-sight was a fairly sad posting.  The little girl that I spoke of took a turn for the worse and ended up with perforated intestines and a belly filled with fecal matter on Sunday morning. Thankfully I had initiated antibiotics through a tenuous IV in her little hand the day before and she survived long enough to make to the operating table first thing on Monday morning when Dr. Foster returned.  When we opened her belly a fountain of browny-green liquid spurted several feet into the air and flooded the floor (and my scrubs), confirming what we had suspected, and after a careful search of her little bowels we identified 4 holes in all, each of which was sewn over in turn before stitching her up and sending her to the “ICU”.  In spite of what I would call a very abysmal prognosis 7 days ago, I am very happy to tell you that I arrived this morning, after a week of gruelingly slow recovery to see her sitting up in bed with her mother… truly it was one of those moments in medicine that makes all the hardship seem worthwhile.  It looks as though she has made it through the woods now and I am hoping to send her home next week.


So all in all, the week gone by was a positive one and I am feeling less defeated than the week before.  For once there were more patients getting better than getting worse and I was able to spend quite a bit of time in the operating room and was given the chance to perform several procedures I would not normally dream of doing back home, including gastroscopy, colonoscopy (I was happy to learn there were two different scopes available for use), and a diabetic foot amputation.  But I have to say the coolest thing of all was the symphysotomy that we (and by “we” I mean Dr. Foster) performed for a labouring woman with a stuck baby.  Who would have guessed that the one procedure that no one teaches anymore is the easiest and quickest way to deliver in a crunch… unreal!  So needless to say last week was a nice reprieve from the week before.  No one  died unexpectedly and we even managed to make a few people better…but this is the story of medicine I guess… it’s an emotional roller-coaster.  The higher you go the faster you fall… but when you hit bottom you can only go up… you take today’s highs with yesterday’s lows and you do it all over tomorrow.