Ben Cavilla’s Blog

Angola Week 4

Well I made it through my third week here in Lubango, Angola, and like those before it this past week was an experience to say the least.  Unfortunately the weather has not been very good and it has been raining most days. And when I say raining I mean bucketing….torrential downpours!  The sound of the pounding rain on the tin roof is so loud at times that it makes having regular conversations with the patients difficult!  So needless to say, my tan is not coming along very well and when you add this to the chronic dehydration resulting from the non-stop diarrhea I’ve had since I arrived, I look slightly less pale than the albino patients that have seen on occasion in the clinics.  Despite drinking filtered water and eating only that which I can cook or peal, I have managed to contract a nasty bug which so far has evaded two courses of antibiotics.  I feel pretty crappy most of the time (pun intended) but I am surviving….anyways I digress.

So the last week was an interesting one on several counts.  Between peering into the far reaches of one colon after the next and taking a wrong turn which led to an accidental bronchoscopy in another (I knew something wasn’t right when the ‘esophagus’ split and headed off in two different directions), I have managed to develop of level of comfort in steering an endoscope.  I have to say that the fact that the endoscope does not turn left did not make my learning experience any easier…

My most interesting case in the past week was a 33-year old man who presented himself to the emergency department with difficulties breathing secondary to a massive humpty dumpty-like abdomen.  By the time I saw him, his diaphragm was just below his collar bones and his head looked like it would blow off at any moment (this would later be a key point in his diagnosis however I failed to appreciate it as such at the time).  The massive swelling of his normally stick-like legs was a dead give away that this was not a belly full of air (as is often seen with typhoid fever) but rather a belly full of fluid…dark yellow fluid to be exact (I thought I had put the needle into has bladder at first)!  And after reassuring myself that this was not urine (it didn’t smell like urine) I sat for 45 minutes while 3 liters of fluid drained out of his abdomen through an 18 gauge catheter and into a bowl on the bed beside him.  Needless to say he was very relieved and very thankful.  Unfortunately the fluid recollected 2 days later and I had to do the same dramatic puncture all over again in an attempt to buy some time.  And as I sat beside him watching the still bright yellow fluid dribble out, I ran through the signs and symptoms again…it just didn’t make sense.  This guy was 33-years old, drank no more beer than myself in a standard week and had a massive hepato-splenomegaly (his liver was about the size of football and his the tip of his spleen was somewhere below his belly button) which was presumably preventing the drainage of fluid from the lower half of his body…or was it?  I ran it buy another doctor who thought that it was likely alcoholic cirrhosis which is apparently seen quite often here.  But alcoholic cirrhosis at the age of 33 in a guy presenting with a big liver and spleen, a roaring mitral valve murmur, an exploding head and a blood pressure of 80 on nothing?  Something didn’t add up but my inexperience made it difficult for me to figure out why.  Later that night as I lay awake in bed going over it all again in my head it came to me and I bounced out of bed and burst into the med students room (much to his chagrin) yelling “ it’s his heart!!!” He was thoroughly startled and confused to say the least, but he listened intently to my 2 a.m. my inadequate explanation of cardiac physiology and right-sided heart failure.  I was as sure of this explanation as I was that my diarrhea would never go away and sure enough when the x-ray came back the next morning there it was….a heart shadow as big as a house.  Unfortunately we did not have the technology to make the distinction between a big heart and a little heart with lots of fluid around it, so I ended up sticking a 6 inch needle up under his ribs and into his heart in the hope that I could draw off a decent amount of fluid…but no such luck. A few dribbles of clear fluid and then a gush of dark purple blood and a fairly striking arrhythmia on the heart monitor after advancing the needle another centimeter, was I all I got.  He had a massive baggy heart likely due to a viral infection and in the end we cut a hole his belly just below belly button and sutured in a drain to let fluid drain off and give his heart a chance to recover. As disappointing as this was for me (it would have meant almost an immediate cure for him) he was very thankful for his new release valve which drained 7 more liters of fluid over the next 24 hours and has drained steadily ever since. Despite this, and the very poor prognosis of an unrecognized viral cardiomyopathy (I should have realized it the first day when his head was about to explode) he has continued to improve, day by day and was walking around the hospital when I arrived today, which encouraged me greatly.

But as always, bad news follows quickly on the heels of good news. Aurora, the little girl with the perforated bowel has taken a turn for the worse again and I am once again scrambling to keep her alive.  She has developed another hole in her intestine this past week and the tube that was draining away bowel contents has fallen out. Her little body is burning with fever and she is now just skin and bones. I have spoken with Dr. Foster but he will not operate again as he thinks she would die on the table. I will continue to do everything possible for her but hope for her is fading with every passing day.  Sadly all I can do at this point is watch and wait.