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.