Nasofrontal Encephaloceles

I’m learning operations that I’ve never seen before. Some of the problems that I’m operating on, I’ve never even heard of before I arrived here. One of them is nasofrontal encephaloceles. For some reason, they are relatively common here. A child is born with a defect in the bone right between the eyes. This provides an opening in the skull for the fluid inside and brain itself to start bulging out. These kids come to me with a soft mass growing out between their eyes that has been growing ever since they were born. With each of the families, I try to get them to go to Namibia, but none have had the resources to get treatment at a specialty center. I encourage them to go because I’m teaching myself how to do these operations & the first little boy I operated on died after surgery. The 1 or 2 other nasofrontal encephaloceles operated on at our hospital before I arrived had also died. A 100% death rate is not an encouraging statistic when you get ready for your next operation. These are the tough decisions here. When should you attempt things that you’ve never done before? When should you refer? Is there anywhere to refer the patient? Can they afford to go see experts? Is the patient better off without any operation? Everyday these are the questions that I face as I see my patients.

Thankfully, my second child and third child with nasofrontal encephaloceles survived! Now I’ve got a 66% survival rate.

New Challenges

It seems like everyday brings a new set of challenges, either in the hospital or in daily life. One of my new challenges has been learning how to repair vesicovaginal fistulas. For the non-medical people. a vesicovaginal fistula is a hole connecting the bladder to the vagina. These are caused by prolonged labor, the pressure of the baby’s head against the bladder or the rectum causes ischemia (lack of blood flow) and destruction of the tissue. Sometimes this just causes scarring, but it also frequently causes a hole to form in between the bladder and the vagina, and sometimes also between the rectum and vagina.

These women then spend their lives with urine leaking out constantly. Often their husbands divorce them and their families disown these women, because they are damaged and smell like urine all the time. The surgery to fix the fistulas can be very difficult because the tissue can be very scarred, the urethra can be destroyed, the ureters can be involved. The recurrence rates after repair are quite high because of this.

A visiting surgeon taught me how to do the repairs and since June I’ve done about 30-40 repairs. When the repair is successful, the surgery is very rewarding. These are some of the happiest patients I have, even though you can’t tell in the photo up above. As soon as the camera comes out, they stop smiling, because here, you’re supposed to look serious for photos. They start smiling again as soon as the picture is taken.

There are moments when i Forget

that I’m in a third world country. Angola is a funny place. There is a mall in my town and fancy restaurants. They just opened a new “Shoprite”, which is a modern grocery store chain from South Africa. I even have “The Hungry Lion” (think African McDonald’s).

I have patients that arrive at my hospital driving Mercedes and talking on iphones. Others fly to Namibia or Brazil to get a second opinion or just to do a little shopping. Then I have the patient who comes in leaking urine for 9 years after a difficult delivery. She was in labor for 2 days and finally delivered a dead baby, but ended up with a vesicovaginal fistula (a hole between the bladder and the vagina). I have other patients who are dying from tooth infections. There aren’t dentists and they come to see me when they have necrotizing fasciitis of their face and neck. I have albino patients with giant skin cancers that are eroding into their eye sockets and skull. I have a patient who dies because I can’t intubate him and there are no hospitals in the entire region that have a functioning ventilator. I have another patient who dies from a benign brain tumor because there aren’t any pediatric neurosurgeons in the country. I have another patient who will never get a chance to speak--he had cerebral malaria when he was young and now is deaf. The family brought him to me to see if I could give him a pill or operate on him so that he could speak. All he needs is someone to teach him sign language, but there are no deaf schools near his village. I have another little girl who lost her foot to gangrene--not because of the snake bite, but because of the local health post that treated her with a tight tourniquet around her ankle. I had 3 ladies come in during the same week with unresectable cervical cancer. There is no radiation treatment in Angola & only one hospital in the capital which has any chemotherapy. One patient walks into my office in a suit and tie and the next patient walks in with only a loincloth. The patient in the loincloth pays for his surgery with crisp $100 bills and the man in the suit and tie has traditional medication, which frequently involves dung and grass, in his wound. This is Angola.

Meteor? Moon Rock? Fossilized anemone?

It has been a little while without updates. Since the last update, I have left Gabon, spent 2 months in Kenya, 1 week in Sudan and finally arrived in Angola in midMarch. I have hit the ground running here in Angola. I started work at the hospital the day after I arrived, went apartment hunting and found an apartment to live in the first 2 weeks I was here, have flown out to rural hospitals for 4 different weekends for marathon operating days, have inherited a weekly health radio show since all the other doctors are out of the country, have been on call for the last month and a half, hosted visiting doctors and medical students, have been running the hospital for the last month and a half with another 3 weeks to go. In between all that, I'm slowly starting to get settled in and as I get settled in, more updates will be coming.

I did have to share one photo from this last weekend trip to Kalukembe. Kalukembe is a big rural hospital that is run by nurses. Once a month, a surgeon flies out from my hospital to do 2 and a 1/2 days of operating and seeing consults. We arrive at about 10am and go straight to the operating room, operate until 8pm and then see consults from 9pm till 11 or 12. The next day starts at 7:30 with devotions with the nursing students and then rounds and then operating until 8pm, and consults until I can't see straight--usually around midnight. Saturday morning is operating from 8am until the plane picks us up at 5:30--usually you're racing through your last exploratory laparotomy, have just managed to remove the large tumor or mass, and then run out the door to catch your plane. I love my trips to Kalukembe. :)

The picture was an extra surpise. I was operating on a gentleman to remove his prostate and found this stone in his bladder. In real life it's about 5cm, but I'm pretty sure he's going to be feeling alot better without that thing in his bladder.