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.  

Futbol

Been enjoying playing futbol with the locals. I'm amazed at how beautifully they move and work the ball around the field. More impressive is the pitch which they play is composed of half sand, half dirt, with creek beds running through the center. I've been trying not to break my ankle and end up being patient in the hospital. Luckily we have Jeff here with some orthopedic knowledge if anything happens.


-brett

By the way, did you know there were other people on this trip? I tried to get them to post, but they are very shy, and like to record their thoughts in a more burnable, paper format. One of my travel companions already has his own blog, so for more info on our work in Ghana so far, as well as some awesome photos, hop on over to our resident photojournalist Brett's blog at http://www.bmagner.blogspot.com

I treated a young nursing student for malaria the other day. She wanted to go home. I asked her about her symptoms, and in a nonchalant way of making conversation asked if she had ever had malaria before. She looked at me with an expression that made apparent what a quaint American thing that was to say. "Many times," she laughed.

On Giving Blood

I was asked to donate blood for a patient yesterday. There is no blood bank at the BMC, which is why protocol asks that you wait until the hemoglobin level is below 5 or 6 to transfuse (the cutoff in the US is 7). All the same, it is not uncommon for patients to meet this criteria. I've already seen a handful of people walk (literally) into the hospital with a level below 3. What happens when someone reaches that threshold is a family member is asked to donate their blood, which is then immediately delivered to the patient as whole blood (in the US the red blood cells are separated from the rest of the blood to be given in a concentrated dose). And what happens when family members are not around? Well, you can probably guess by the title of this post. 

The patient I donated for was a young woman who was about 34 weeks pregnant when she was bit by a snake. She came to the hospital 3 days later. There are two poisonous snakes in this area I hope I never meet: one is the spitting cobra, appropriately named for blinding its victims by spitting poison in their face; the other is the carpet viper, whose venom is a potent anticoagulant. This lady was bit by the latter, and after 3 days without anti-venom she was bleeding profusely and mostly from her womb. Her hemoglobin level was about 2.7. 

The trouble was that she had travelled here from a village very far away, and most of her family had not travelled with her. The ones who had had already donated 4 units (roughly 2L) and her hemoglobin was still 5. So her doctors began scouring the hospital for willing, healthy volunteers with an O blood type, which narrowed the pool down to me. 

Basically what I want to get across is this: it's quite selfishly scary to be asked to give your blood in a developing country for the first time, especially when everyone keeps reminding you to make sure the needles and tubing come from new, unopened packaging. But when a hemorrhagic pregnant lady is at the other end of that request, you don't even have to think twice. It's the easiest decision I've had to make regarding a patient's care since I got here.

I was stupidly nervous about giving blood. You should know that although the lab was not much to look at, their procedures are routinely sterile. Nonetheless, I kept remembering a former volunteer saying that the tubing for paracentesis procedures was reused frequently. I crossed my fingers as my blood was typed and crossed that the patient would not need another transfusion after all. I tried to calculate how long it would take to pay for Sovaldi. I was being, for at least the hundredth time on this trip, the silly little white girl with her first-world misconceptions about medicine in Africa. The procedure itself was terrifically anticlimactic, and the lab techs soon handed my blood to the patient's grateful husband to take to the maternity ward.

I stopped by the maternity ward on my way out of the hospital, and saw the patient lying asleep in her bed as my blood dripped into her veins. Her nurses said she was getting better. Her husband said a whole slew of words in another language that someone translated simply as, "he's thanking you," and once again I felt so ridiculous for my selfish concerns earlier, and so grateful for this experience. I felt a strong sense of peace walking home to dinner that night, where I promptly found out from her physician the good news that she was now clotting and did not, in fact, need my blood after all.

Today is Saturday the 11th April. After being "incapacitated" for the past couple days, I was able to round with the team at the hospital. We saw a host of new admissions including a new HIV patient as well as a  female patient with chickenpox and possible HIV.  We also evaluated a patient with possible tetanus, who more likely has meningitis. Things are never clear!! Patients with diarrhea, anemia, malaria, venous snake bites, typhoid, and chronic liver disease fill the male and female wards.

Jeff  performed an I & D on a man who had cut himself with a saber used in clearing  the fields. The patient  developed an abscess as a result of his laceration involving the left posterior thigh. Surgical  technique was excellent-the abscess was incised and drained and appropriately packed. We hope the patient will improve significantly after this procedure. we continue to be amazed at the resilience of the patients and their tolerance for pain. We performed this I&D with only local lidocaine infiltration!!Even the women in labor seem to have their children with only a minor squeal.

After lunch the gang went to a local seamstress, Joyce, in the village and is having several articles made of the local fabric. Can't wait to see the results. Jeff and Brett purchased a surgical hat made made of local Ghanaian cloth.

 We continue to press on despite the fact that we at times are treating patients without a specific diagnosis. The usual battery of tests are not available - the most we have are a few limited tests whose results are questionable at best! In this part of the world, medicine is an act of intuition, guesswork, and faith. We hope our efforts and endeavors are beneficial despite our lack of appropriate tests and knowledge. 

We are learning a lot about the local customs and traditions including how people in this village play soccer. Brett has become an official member of the local soccer team. Who says white men can run!!

Clinic day

Post-dated from April 8.

Holy moly. What a day. We had our first clinic today after morning rounds. Someone estimated the clinic typically sees 300-500 patients on a clinic day, but today was the first clinic day after they had been closed for 1 week, and it was a market day, which also boosts the number of visitors. And on top of this, our attending physician was too sick to work. That's right, 5 med students, 4 doctors, and hundreds of patients. It wasn't a clinic. It was an onslaught. Basically picture the Helm's Deep scene from LOTR only instead of orcs they were all friendly people with infectious diseases.

Here's how we did it: we didn't, exactly. We couldn't... But we tried. Every time we thought we were making some headway on our stack of charts for patients waiting to be seen, another stack would appear, or we would peek outside to find absolutely no change in the massive hoard of people waiting to be seen. We saw as many patients as we could until dark, then told the still-gigantic throng to return tomorrow if they hadn't been seen. I felt bad. We admitted a lot of people, and there were still more who likely needed admission. We had enough time after clinic to head back to the house, eat dinner, and check on Dr. C (who says he has turned the corner, for those concerned) before turning back around for evening rounds at the hospital. But don't feel bad for us: Dr. Victoria still has to take overnight call in an overflowing OB ward, and operate tomorrow on patients we scheduled for surgery. I can't even imagine how she does it.

Today has been Jeff's day to shine. After being primary provider on one shoulder dislocation and a possible gnarly osteosarcoma v. Rhabdomyosarcoma, he is now being sought out for orthopedic admissions. In reference to the sarcoma case, Brett took a photo that may be documented on his blog. We've been concerned about protecting patient privacy, which is essentially a moot point when you consider there are about 20 patients plus their families per room with no partitions. 

I won't lie, these first few days at the BMC have felt long. There is such a steep learning curve for the diseases here alone, not to mention the time it takes to get used to the customs, the language, the culture of medicine, the formulary, the climate, etc. It is easy to really appreciate the value of having a long term commitment from a physician here. 

The BMC has done a very good job in that sense (in my humble opinion). It's founder lived and worked here for most of his career, and his son, who grew up in Nalerigu, returned to work here for 22-ish years, and still visits at least once a year. One of the family medicine docs here is halfway through his two year commitment, and a surgeon is about to begin a four year stent at this hospital. The Shumperts manage to return at least twice a year on top of their other commitments in the surrounding region, and there are two Ghanaian doctors working here that the BMC hopes will stay on full time. I like to think of our role as relief pitchers, and hopefully some of us will be returning after completing more training.

Today was Easter Monday. Easter is not "celebrated" in the same sense that it is in the US, but it is observed. Basically people go to church for a sermon, and clinic is cancelled. Today will be our first night on call ( at least it will be Dr. Cohen's), so we may be in for some excitement later. I am mostly concerned that we will receive a call concerning a patient who was rounded on in the pediatrics ward today. He is a 1 year old who was admitted last night in respiratory distress with presumed cerebral malaria (everyone is presumed to have malaria). He was on quinine and ceftriaxone. When I first saw him this morning, he was lying limp on the bed taking slow, agonal breaths. I can't adequately convey how frighteningly sick this child looked. We kept trying to think of anything else we could do. We knew there weren't any ventilators, but was there a BIPAP? No, only nasal cannula. What about ampicillin? No. Zosyn? No. Transport? Would not make it in time. In the end we added Augmentin, just to be doing something for him. I know we will get a call about him later, or worse, we will show up for night rounds and his bed will be empty. Codes are rarely run here, as they are very rarely effective. We don't even have a EKG machine, so how would we know what to give? 

Not to leave on a depressing note, I will report one success story, in which an elderly patient came in reporting complete loss of function in his legs after being treated somewhere else for an acute illness (I'm not too clear about the details as it was somewhat lost in translation). They did not know what he was treated with, or his previous diagnosis. We were initially thinking Guillan Barré, or a diabetic neuropathy (common here), but in a typical House-like moment, Dr. Cohen surmised he had been given an anti-hypertensive agent and was now hypokalemic (low in potassium). There is no way to measure electrolytes here, which makes the diagnosis all the more impressive. The man walked out of the hospital the next day! 

The rest of my posts will not be as long I had a little extra time today, considering it is a holiday. We are all doing well, and are healthy and enjoying our work. 

Easter weekend

Just completed our 3rd day at the BMC, and stole away to the schoolhouse for some brief internet and AC time. The schoolhouse is the only building witha working window unit, and since it rained today every other building is muggy and buggy right now. Every one of us had a dozen or more gnats stuck to our skin after returning from the hospital. So, ya know, basically Georgia in July. 

I honestly can't say I notice the heat much while I am in the hospital. Yesterday evening, we saw a fungating breast mass, which is the term for a breast cancer that has erupted through the skin (I would not recommend googling it). It occurs when a cancer goes neglected for a very long time. Typically, patients with terminal cancer here are taken home, but this woman and her family actually opted to be referred to a treatment center in the nearest large city. Our team spent a good deal of our time today trying to manually reduce the largest hernia I've ever seen (think grapefruit-sized). We were debating over whether he could wait until a surgeon is available to operate next month, or if he needed a more expedient repair, when the patient called us over to show us he had reduced it himself! It will definitely come back, but makes us feel a lot better about being able to wait for Dr. Faile to operate when he arrives in May.

The most memorable patient we saw yesterday evening. A pregnant woman with no detectable fetal heart rate, vaginal bleeding, and a hemoglobin of 2 (very severely anemic). On exam, she had a very irregularly shaped abdomen. They were concerned about uterine rupture, but she appeared relatively stable for such a severe diagnosis. Jeff and Brett scrubbed in for her surgery, in which they found what was likely a bicornate, or abnormally shaped uterus, that was weak in parts and close to rupture. Unfortunately, there are no blood products kept here, so a family member has to be available to give blood when it is needed. She had gotten less than one unit before she went into the OR, and did well during surgery, but died later that same morning. Definitely a sad experience. Jeff and Brett stayed late into the night assisting the physician with her surgery, and when we showed up for rounds she was just gone. 

Will try to post more tomorrow about our trip to the market yesterday. 

Sunday April 5 2015

Today is Sunday, April 5 Easter Sunday

Made rounds at the hospital. Unfortunately a lady with a impending rupture of the uterus from pregnancy died during during her operative procedure. Dr. Victoria's tried her best to save this patient but she had to do surgery with a hemoglobin of 2.0  During the operation the patient at least got one unit of whole blood but this was not enough to have any life-saving impact. One of the patients we admitted with obtundation died as well. We we at times don't know exactly what we are treating and don't clearly have a good idea of what is going on with our patients. When they do get better we are very grateful.

We are getting a better grasp on the culture. One of the patients had a home circumcision. He is of the Muslim faith and approximately 25 years of age. He apparently could not afford to get a circumcision at a healthcare Center and therefore his father arranged for a local religious leader to perform his circumcision. Unfortunately he developed  severe cellulitis from this procedure. I saw a woman today with disseminated chickenpox. She apparently acquired this from her infant. I'm concerned they both may be infected with HIV. According to one of the nurses, the women here of Christian faith have only one husband but their husbands can have several wives. I'm not sure we have a good grasp of the amount of HIV in this area.

Jeff saw a patient with a large incarcerated inginual hernia. Fortunately it was reduced by Dr. Tim although I am not sure how long it will stay within the abdominal cavity. Although Jeff  has orthopedics on his mind he was ready to intervene with the knife to repair this patient's inginual hernia. 

All in all, we are enjoying everyone's company and learning a lot about the frustrations and joy of delivering healthcare in northern  Ghana and Nalerigu.

                                                          http://bmagner.blogspot.com

Good evening!

We have completed our first full day of work at the hospital. We were expecting a full day with inpatient rounds and clinic, but when we got to the hospital we realized clinic was closed due to the observance of Good Friday. It was just as well, as we were rounding slowly due to our unfamiliarity with the charts, the staff, the patients, and formulary. Fortunately, the hospital has a protocol for new doctors that has been extremely helpful. A list of some things if saw today I've never seen before: malaria, typhoid fever, snake bite, adult primary varicella infection, and shigella. We are all very good at treating snake bites by this point, and consequently terrified of coming across a snake on the way home from the hospital.
Unfortunately, one of my sicker patients I rounded on this morning had already died by the time we returned for evening rounds. We still don't know what really made him so sick. In the US, he would've have been CT'ed, pan cultured, placed in an ICU, and eventually ventilated. None of that is available here. You have to take your best guess with what you have available and treat might be curable.
 I will have to post more later, since we need to get up early for  morning rounds at 7:30. Good night!