Sangue do Nabo (Blood from a Turnip)

One of the principle reasons I chose to spend my last weeks of medical school in remote Africa was to experience the practice of medicine in a resource poor area. It came as no surprise then that caregivers here would have unique ways of doing things: workarounds, and “life hacks” to make the most out of every little thing. That doesn’t diminish how impressive (and shocking) some of these improvisations are.  

One of my very first patients at CEML was an elderly gentleman from Bengela, a district hours and hours away by train. Vascular disease doesn’t exist here, HTN is generally a function of some other pathology (like parasite related kidney failure), and diabetes is rare. Most people who survive malaria, malnutrition, and cancer into their golden years are relatively healthy with regard to metabolic syndrome. Unfortunately, a life spent around campfires carries with it certain maladies of its own, COPD in particular. This patient has been managing as best he could with solumedrol (beta agonist that helps open airways) and prednisone (steroid that blocks inflammation), but these had reached their therapeutic limits. At this point we would normally start fitting a patient for oxygen and CPAP (an expensive machine that forces a patient to exhale against pressure, keeping airways open), but that’s not an option in Angola. The African version of respiratory therapy cost less than a penny and worked remarkably well: a surgical glove. The patient was instructed to breath into the glove when he was feeling congested, this provides the same positive pressure a machine would and helps closed airways become patent.  

Latex gloves could be pushed even further. Cutting a glove from where the finger webbing would be up to the wrist creates five individual tube-like pieces that can be pushed into a wound to create a drain for an abscess or open post-op wound. This is one of the few things that is discarded after use; there are no disposable instruments here. Surgical scrub sponges which are normally thrown out after used by one surgeon to scrub into one procedure are shared by the entire staff for a week. Cloth scrub caps are thrown back into a communal bin after use to be washed at the end of the week. Surgical instruments are hand-me-downs from facilities in other countries, there are no custom kits for specific procedures, only a 3x6’ table with all of the clinic’s instruments (some straight from the hardware store) spread out for survey. Quite often a specific tool won’t be available, so the surgeon can walk over to the table and figure out a way to improvise what they need. 

With so many patients to help, and so few surgeons, ORs must be maximized in every possible way. Each surgeon works continually by staging two patients in the room at a time. When the first procedure is wrapping up, the second patient is getting their spinal block and being prepped. The surgeon can then just wash their hands, re-gown, and go straight back to work at the 2nd table. A third patient is then rolled in as the first is rolled out, and so on. If there are enough surgeons in town, both tables will be going at once with no down time at all. In the Ob department, a laboring woman doesn’t get the luxury of her own delivery suite. Such a protracted process would occupy too much real estate for too long to dedicate to one patient. She will share the room with Gyn patients who are coming in for their normal check ups and, depending on what celebration was happening 9-months ago, any number of other laboring women. If a C-section is needed, it happens right there amidst all the chaos. This is light years beyond the Contral Hospital though where are large room of women deliver in squat position directly onto the floor, leaving it covered in a constant layer of slippery crimson. 

Urine collection bags are expensive and impossible to clean, so here catheters simply drain into a collection pan with a constand drip. In actuality this works well to show us exactly how fast urine is being produced since we can count individual drops per minute. Catheters could then be cleaned and used as tourniquettes for blood draws. Tongue depressors can be broken in half diagnoally down their length to make two double-ended tools with a depressor at one pole, a pointed pain stimulator at the other. Patients in need of “elective” procedures like joint injections can be serviced but must go to the pharmacy to buy their own steroids to bring to us. Again, this could be much worse, the Central Hospital gives patients (or their families if the patient is non-ambulatory) a shopping list for everything required for a surgery (down to the sutures needed to close). Cavango does not yet have running water, so washing bedsheets is not an option. In the exam room rubberized sheets soiled by blood, urine, or pus are flipped over to their dry side. Inpatients are asked to bring sheets with them if they intend to sleep in the wards.  

Never before have I encountered a truly cashless economy such as that which exists amongst the tribes here. The clinics and hospitals I’ve worked with ask for only enough to cover their expenses, this often comes out to several dollars for an office visit, perhaps $500 for a surgery. This might as well be God asking for a blood sacrifice from Cain though, for you can’t squeeze blood from a turnip.