Nicholas Comninellis

Tropical Medicine Rounds - Angola Day 11

This morning I visited virtually every patient who is being cared for here at the Lubango Evangelical Medical Center. In the attached photo I’m seeing lady of 60 years who was bitten on her foot by a snake. I also examined a man with heart failure and heart valve disease for whom we can only offer medications - no surgical repair, a paraplegic with bladder obstruction and urine infection, a child with burns to the chest that have healed to the point that we applied skin grafts, a baby of only 2 months convulsing from malaria infection of the brain.

The most critical man is a poor fellow, Manuel, with a dental abscess that erupted into a massive infection that eroded the skin of his entire neck down to the trachea and chest all down to the muscles. In the operating room we pealed away the stinky, black, dead tissue. Manuel’s chance of survival is really low. We asked the pastor to come pray with him before surgery, and YOU could join us in interceding for healing from this flesh-eating infection.

Old School Orthopedics - Angola Day 10

Abel, this young man, was riding his bicycle when he veered off the road to avoid an oncoming truck. Abel’s bike struck a embankment, throwing him head first over the handle bars. The only fortunate outcome of this accident was that Abel landed on his leg rather than his head! I’m holding up the X-ray of his ankle to the window, demonstrating a very complex fracture. In the US, Able would undergo extensive surgical repair, with a plate and multiple screws to realign the the broken bones. But we have no such hardware here at the Kalukembe Hospital in Angola. So Able will instead be wearing a cast for many weeks. And what do we have available to treat his severe pain? Nothing more than Ibuprofen.

Action In The Angola ER - Angola Day 9

“Quickly, Dr. Nicholas, come to emergency ward!” António’s voice was filled with tension, and by the arm he pulled we away from syphilis patient whom I was examining. Moments later I confronted a gasping small child, Gabriel. With each breath she chest retracted and with my stethoscope I heard hardly any air moving into her lungs. The father in distress explained how Gabriel was eating salted fish when she began choking and coughing.

Clearly, Gabriel’s airway was obstructed and her skin become progressively dark as oxygen faded from her blood stream. We carried Gabriel several paces to the operating room. By now her body was limp from oxygen deprivation. We rolled him onto her back, and Annalese Oleson, our skilled surgeon, slid a laryngoscope into Gabriel’s mouth and larynx. There, just below her vocal cords, lay the tail of a fish, blocking the passage into Gabriel’s lungs. After quite a struggle she grasped it with forceps and ‘fished’ the tail out of her mouth. Gabriel’s little body was still limp, but a just a few chest compressions started air flowing once again, and later Gabriel was alert and crying in his father’s arms.

A little later at lunch the cafeteria offered fish on my plate. I passed!

Trauma, A Forgotten Priority - Angola Day 8

Over the weekend Ezekiel, in the photo above, was playing indoors and fell into the family cooking fire. As the boy screamed in agony the traditional healer smeared cow dung and herbs over the burns covering his face and chest. By the time Ezekiel arrived at our healthcare center his skin was heavily infected and covered with pus, further deepening his burns. Our first treatment was to give Ezekiel a much needed anesthetic, and then to gently scrub away the scabs and dirt. An antibiotic and topical ointment brought Ezekiel’s infection under control.

Most of us think about infectious diseases like malaria and dysentery when we contemplate child health in the world’s poorest communities. But injuries like fractures, head trauma, and burns disable great numbers of children as well. To be fully compassionate and caring should we not expand means to protect precious children like Ezekiel? What would you recommend?

Heroes, These Surgeons Are - Angola Day 4

One of the most disabling mishaps in developing nations is injury to the vagina during the process of giving birth. Here at the Lubango Evangelical Medical Center we have visiting surgeons who today alone provided repair surgery for 20 ladies who suffer from vaginal fistulas. Heroes, these surgeons are! Their bold acts of compassion cause me to think of Isaiah 58:10 “If you spend yourselves in behalf of the hungry and satisfy the needs of the oppressed, then your light will rise in the darkness, and your night will become like the noonday.” Truly such actions of compassion are evidence of the kingdom of God in our midst!

Relief For The World’s Urban Poor - Angola Day 1

Salomao lives in a shantytown that surrounds the city of Lubango in Angola, southern Africa from where I’m writing at this moment. Salomao’s family is in crisis. His youngest child Elena, three-years old, started vomiting and passing bloody diarrhea. Her two older siblings began shivering from high fever. Salomao’s wife, disfigured and disabled from polio, attempted to get next to and comfort them by sliding her body across the dirt floor of their one-room, tin roof house.

Salomao, desperate to find treatment for his children, entered the dense neighborhood of shoddy-built homes, separated by footpaths and streams of tainted water. Salomao went first to the pharmacy, but was turned away. Caring for his sick kids, Salomao has not worked in five days and had no money to purchase medicine. He next stoped at the local dispensary, but found it boarded up. Salomao, empty handed, reentered his congested community, passing neighbors who described with alarm how fever and diarrhea are spreading among their children, too.

Worldwide the number of urban poor, like the Salomao family, is increasing steadily. Later in the day, Salomao arrived at the Lubango Evangelical Medical Center – an INMED Training Site – where little Elena and her siblings were treated successfully. But stopping acute disease alone is never sufficient.

An effective, widely accepted strategy for improving urban public health includes efforts to increase literacy and general education, provide jobs and economic growth, and the most effective interventions to promote health and prevent death and disability. Relief from disease among the urban poor like Salomao will require comprehensive, sustained improvements like these.

Teaching To Shoot

I’m enjoying the company of 65 global health minded people for the two weeks of INMED’s International Medicine Intensive Course and International Public Health Intensive Course. For two years I lived in Angola at the height of their civil war. I observed first hand exactly why the nations of conflict are also the nations of child death - death from hunger and disease far more often than from direct violence. How often do we glorify violence? Just observe the glee in this child’s face, and the enthusiasm with which he is being taught to kill!

Your Suggestions To Make Short-Term Medical Missions More Effective

In May’s INMED newsletter I posed the question, “Are short-term medical missions (STMM) effective?” Responses from you the readers were plentiful and absorbing. You said that we should recognize both the pros and cons of such service: “Advantages for our mission hospital are: Coverage for staff vacations, teaching our personnel new skills, giving us fresh perspectives, and providing of a service, like eye and hearing care, that we’re not able to. There are disadvantages, too: The logistics of visitors can be draining (transportation, housing, interpreters) and they may raise expectations of our community for extra services that we can’t sustain.” - Nancy Cutherell, RN, Bach Christian Hospital, Pakistan

You also recommended that the emphasis of most STMM change from provision of episodic care toward contributing to sustainable solutions: “Add value. Don’t just come to do what the national staff is already doing. Train, mentor, encourage. Serve - but moreover build capacity. The most useful thing you will do is to train a local resident to continue providing a skill long after you have left.” - Ian Chadwell, Partnership Program Manager, International Nepal Fellowship

Many respondents resonated with the importance of developing and sustaining partnerships with host communities and institutions: “To make a real change and contribution STMMs should be a part of an ongoing program to support particular hosts. Groups cannot visit a different location every year and expect to make a real change. We advocate providing continuity and expertise. In short, we should focus our efforts.” - Doyle Word, CEO, Madaktari Africa

What does healthy partnership with host nationals look like? Such partnership embodies the virtues of respect, humility, and deference toward others. In this context, we can inquire, “What can I do to assist at your facility?” “What special services do your people need?” “What subjects can I help to teach?” and perhaps most profoundly, “What can you teach me to better serve your people?”

Are Short-Term Medical Missions Effective?

Each year some 5,000 healthcare teams depart the US to service in a developing country - usually for 7-10 days duration. A growing number of authorities are questioning the efficacy of this enormous outlay of time and resources, posing the questions like, “Do short-term medical missions actually contribute to improving the overall health of a community over the long-term?” and “Is it ethical to initiate medical therapy for chronic illnesses when there is no hope of providing continuity of care?” and “How can short-term foreigners understand the culture of another society well enough to address health behavior?” A key element is responding to these concerns is the cultivation of partnerships with host nationals - whether healthcare facilities, educational institutions, local governments or civic organizations. The guidance of partners greatly increases the likelihood that medical care will be more effective, ethical, and culturally relevant. ‘Short-Term Medical Mission Done Right’ includes 1. Find national partners. 2. Ask them what they need. 3. Ask them how we can participate.

Are You Licensed For Short Term Medical Missions?

“In Haiti over eight days we saw 900 patients, treating infections and diarrhea. The people are desperately poor and were so very grateful for the medical care.“ This young physician spoke with enthusiasm. But then his voice turned somber, describing how the police arrived to investigate the credentials of their medical missions team.

Practicing our healthcare professions in a foreign country without a license in THAT country is very likely to be illegal. Healthcare professionals must comply very carefully with licensure requirements of host nations, who rarely offer exemption simply because we may be providing free care or aid for the poor. Serving under the authority of a licensed national practitioner may be sufficient, but healthcare professionals must be diligent to verify this fact. Complying with national licensure requirements not only prevents legal complications, but is also a strong symbol of  respect for the host nation and the ethical practice of healthcare professions.

How would you go about getting properly licenses in the nation where you volunteer? Begin by contacting your national partners in that nation. They are usually the ones with greatest interest in assisting you and with greatest insight into negotiating the requirements and procedures for proper licensure.