Wednesday

Today was both swelteringly hot and exhaustingly busy. It was one of those days where a distinctive temperature shift can be felt as soon as the sun rises over the horizon, and you wake up sweating. Hours before clinic even started, we were greeted at the hospital entrance by a large congregation of people patiently waiting to be seen at some point much later in the day.

Many patients were admitted from clinic. Two were dead before evening rounds even started. Brett successfully resuscitated a neonate! He used two fingers to do chest compressions until he got a pulse. Then he switched to bagging until, as he says, the baby took one deep breath and raised a defiant fist in the air! 

I was called to the bed of a 4 year old patient who was struggling to breath with oxygen saturation levels in the high 80s. After arguing with the nurses that she did, in fact, need supplemental oxygen (nurses here instinctively ration supplies for when the need is dire, as you will soon understand why), yet another small child was admitted with a saturation in the low 70s. 

I heard the nurses telling the latter child's doctor that all of the remaining oxygen was being used already on two babies. "Is there anyone who doesn't need it?" she asked. I sighed. I went to unhook my peacefully slumbering patient from her oxygen. I watched her nostrils begin to flare with air hunger and her breaths become shallow and rapid as the nurse wheeled away the oxygen to the sicker child. I anxiously watched her oxygen saturation drop back into the 80s, until I became both satisfied that it was stable and scared that if I continued to watch her it would drop even lower. Then I unhooked her from the pulse oximeter and gave that to the sicker child, too. 

I would like to dedicate this post to the women of Northern Ghana, who are some of the toughest ladies I know. They smile at you every morning and tell you they feel "deswah" or better, even though they have a massive wound for which they have received receive nothing more than an over-the-counter dose of Motrin for pain relief. They balance literally everything, from piles of mangoes to bags of concrete on their heads. They are pretty top rate birthing champions, as well. Midwives have been known to slap a tired mother in the birthing chair while yelling at her to "Push like a woman!" 

One woman in particular just blows me away. She was a new mom who was finally brought in to the clinic by her husband after sitting at home with rapidly worsening mastitis for 2 weeks. I kid you not, when she walked in I thought she was swaddling her baby under her clothes. She wasn't. 

Dr. Cohen immediately admitted her and we incised and drained about a pint of pus from the abscess that night, without any anesthetic. I don't know if anyone reading this has ever had an abscess drained, but in my experience with previous patients it usually brings them to tears and causes at least one family member to pass out. the most this woman said to indicate her pain was, "woah woah waoh!" All while her husband was yelling at her for expressing her pain so verbally. It's good for the both of us I that I couldn't understand what he was saying. This poor woman must be in so much pain. 

We had to cut out dead skin and breast tissue later (using ketamine for anesthesia this time), leaving an open wound about the size of half her breast to heal on its own. Due to shortages of many medicines here, the heaviest pain killer is meperidine, and it is reserved for surgery patients. Everyone else gets a cocktail of Tylenol and Ibuprofen. Yet every time I pass by her she is smiling, nursing her baby on her one remaining breast, and chatting happily with the women in the neighboring beds. She doesn't despair over her mangled breast, nor does she complain of the smell or the intense pain. She is happy, she is downright giggly, even! I wish so much that I could understand her. I'm 95% certain she knows the secret to happiness. She is incredibly strong, and no one will ever really understand or appreciate how much. 

Tuesday-April 21, 2015

Yesterday, we examined a young boy with head trauma from a roadside accident. It was clear that he most likely had an expanding epidural hematoma and required urgent neurosurgical intervention. The family could not afford the ambulance fee to transport him to the appropriate facility. I was so proud of the students who opened up their hearts and wallets to help pay for the ambulance ride.  Apparently, the funds for an ambulance transport must be paid in advance!!! Here in Ghana the saying goes " that is life" - I have not come to terms with  that and probably never will.

 Unfortunately, we learned today that the boy died.  No details. Life in Ghana is sometimes cruel and unfair. We tried our best --but in this part of the world your best is not often good enough!

 

On another more upbeat note, I have seen a major transformation in the students. They are becoming much more confident in their skills and patient management. My heart swells with pride in watching them round on the wards and interact with the nursing staff and care for the patients. Here in Ghana,  they have crossed the threshold to becoming physicians!!!

Dr. C

Saturday

After rounds today, some of the physicians who are working here long-term took us to the escarpment at Nakpanduri. We had an amazing hike with some gorgeous views of the country (visibility was lower because of the dust still hanging in the air after a dust storm last week, but it was astonishing nonetheless). Later we visited a woman named Denise, who moved out here after serving in the area with the Peace Corps. in the 70s and runs several humanitarian missions, including one to promote reforestation, one to provide donkeys and carts to local women, and one to help amputees acquire prosthetic limbs. She was very kind and happy to show us around her farm, which included over 25,000 saplings, donkeys, chickens, one old dog, a monkey, and many white pigeons (or doves? I can't really tell the difference).

Once we came back, we had dinner with one of the Ghanaian physicians and her husband. We learned a great deal from them about Ghanaian medical training, and the customs and food of the Northern region. We discovered that in Northern Ghana, it is tradition for the groom to pay the bride's family with cows before he can marry her. The bride's family can then use those cows to pay for their sons's marriage. So it pays to have a lot of daughters here. 

At rounds tonight, I was given the folder of a patient I had seen and discharged two weeks ago. He came in for epistaxis and anemia then, and had returned for the same symptoms. We had discussed his need to see a physician in Tamale, the nearest town with a teaching hospital, because we had exhausted the amount of tests for a clotting disorder that we could run, and he needed further work up in order to prevent future bleeding episodes. Then something on his admission note caught my eye: a chronic iliac wound! How had I missed that during his last admission?! I found a translator and went to speak with him. Turns out he had had the wound less than one month, and when I asked to see it, everything made sense. He has cutaneous anthrax! The first case that I've seen in person! He had already been treating it at home with gientian violet. It must've looked like an old wound to the MA who admitted him tonight, but on closer exam you could definitely make out the eschar. It was overlying a superficial wound he had received while in a motorbike accident on his way to the hospital during his last admission. Cutaneous anthrax is very treatable, by the way (unlike the inhaled anthrax that was sent to Rockefeller Center in the early 2000's). I was pretty excited about it. It's the little things, I guess. Today has been one of those days when I can't believe I get to come to Ghana and do what I do. 

So I was asked to cover the hard hitting, gut wrenching, emotionally challenging topics for this trip. I will start with the food. I think all of us had pretty low expectations for what we were going to be served while in a very rural part of a very poor town. Boy were we wrong. My main man Bowah (not sure how to spell most people's names here) is a magician in the kitchen. It's like everyday he is given the daunting task of creating a variety of masterpieces from very limited ingredients. Have you ever seen the Top Chef or the Iron Chef episodes where the contestants have to make filet mignon from rice crispies and mayo? Bowah and his bro Ben (always reppin the TCU horned frogs) would literally crush the competition. I can't even count on all my fingers and toes how many different meals we have had all made from either cabbage, peas, corn, rice, noodles, tuna, middle eastern sharp cheddar, beef of some sort?, and guinea fowl chicken. We have even had some authentic groundnut "peanut" stew and Fu Fu. The groundnut stew is a fantastical blend of peanut butter, chicken/guinea fowl, maybe some water, and sticky rice balls. The Fu Fu or Foo Foo (you pick your favorite spelling) is smashed up yams and a sauce/topping that you slather over the yams. To make the Fu Fu there are women crowded around a large metal bowl taking out their frustrations of having to deal with rival wives on these poor yams with what seems like a small tree trunk. Dr. Cohen tried to give a little 10 year old girl a run for her money smashing some yams but with a quick giggle and a grin, she showed us all how the pros do it. Anyways, to get to the point, we have been extremely blessed to have such hearty meals here at the guesthouse when many children are malnourished just outside the baptist medical center gates. It's tough here in Nalerigu and we are doing everything we can to make it a little easier for everyone we come in contact with.

The lab is out of reagents for blood tests, and radiology is out of x-ray film. Time to put on our Osler hats and sharpen those physical exam skills!

Playing Doctor

Did you ever like to pretend to be a doctor when you were a child?  Well, I did.  Armed with my toy stethoscope and rolls of toilet paper "bandages," I set out to cure my teddy bears of all maladies and splint their "broken" stuffing-filled extremities.  My 5 year-old self didn't quite know what I was doing, but I was determined to do some good.

... 

Fast forward to now:  20 years later I'm a 4th year medical student (nearly intern) currently in rural northern Ghana volunteering at the Baptist Medical Centre for the month of April.  In many ways, this trip is the culmination of two years of planning and preparation, countless emails and conversations, with the threat of Ebola in West Africa ever looming in the background.  But we made it here.

And I can tell you that nothing could have fully prepared us for what you experience when you finally get here.  My first day at BMC, I felt like a first year (or worse even, a pre-med).  I was immediately asked to see patients on the pediatric ward on my own, and I froze.  I had never seen a case of typhoid fever, malaria, or marasmus, and so I (awkwardly) opted to observe instead.  Talk about a steep learning curve.  And to further handicap my painfully incomplete knowledge of tropical medicine, diagnostic testing is very limited here.  No electrolytes.  No EKGs.  And every other week it seems, no x-ray films or reagents for CBCs.  It's incredibly challenging to take care of patients when you often have no idea what exactly you are treating; and even if you do, the formulary is limited and drugs are frequently out of stock.  So we do our best.  

Then there's the oppressive 120 degree heat, the frequent power outages, and the travelers diarrhea that has plagued several of us already.  But when there is a child in front of you with eyes glazed over from fever, whose tiny body is limp with the burden of malaria and malnutrition, you forget about all of it.  The brain begins to process vitals and labs and poorly handwritten notes, while the hands move to examine the patient in patterns not quite yet committed to muscle memory.

Sometimes I still feel like I'm just playing doctor.  But then one of the nurses calls for a doctor, and I instinctively head over.