Erin’s Blog

Random Things - Tuesday, May 25 to Thursday, May 27

Tomorrow will be my last day in Nalerigu. This week is going by quickly. A few random things from the week. . .

I’ve seen tetanus and it is not good. It is a horrible, painful way to die. Get vaccinated!

On Tuesday afternoon we walked to the well and reservoir. The boys and men drive donkey carts and fill up big metal barrels at the well. The women and girls go to the reservoir and fill up buckets to carry on their heads. We got caught in a thunderstorm on the way home and were completely drenched. Several people offered us shelter, but the rain felt wonderful.

There is a local oxytocin that women here take. I asked the nurses about it last night. It is a charcoal like substance that they brew into a tea and drink. It causes contractions, but rarely cervical dilation. It is responsible for many intrauterine fetal deaths. A woman came in last night with an abruption (placenta separated from the uterus) and a dead fetus. Happens all the time.

I have seen more low hematocrits than I ever care to see. Anemia is almost universal here. A hematocrit of 20% isn’t that bad and we often don’t transfuse until less than 15%. I’ve become a pretty good judge of anemia by looking at the pallor of someone’s conjunctiva. I also am doing the febrile to touch thing!

Some bad food or mass hysteria hit the girl’s secondary school in Gambaga. Five girls all gasping, screaming, and complaining of chest pains were wheeled into our clinic exam room. There was nothing obvious wrong with them. We gave them either Demerol or valium and they all became very comfortable. Something fishy was going on. . .

Last night I had a heated discussion with a nurse about a child’s weight. The chart said 18 pounds. The kid looked like she wayed more than that. I asked the nurse to weigh the girl again. He said, no-no the child is malnourished, that is why she weighs so little. I didn’t dispute the fact that she was malnourished, but I needed to transfuse her (hematocrit 9%!) and her weight didn’t seem accurate. Finally he weighed the child again and she weighed 25 pounds. He was still muttering about “these doctors not understanding malnutrition” when I left the ward.

Tomorrow is my last outpatient clinic here and I will be leaving for Tamale at 4 AM on Saturday morning to catch my flight to Accra.

All in a day - Monday, May 24

12:15AM - I’m laying in bed, listening to the noises of the night, wishing I could fall asleep when I hear a soft knock at the door. I roll out of bed and go to the door; I’m on call and the nurses need to me see a patient at the hospital. A woman is having rectal bleeding, I look at her chart and a note had been made about bloody stools in the AM. No one brought it to my attention until now. The woman’s hematocrit had fallen and her blood pressure is now low. I write for fluids and a blood transfusion. Before I leave, I see two other patients. One week ago, a woman delivered at home and is now febrile and agitated. I examine her, but can find no cause. I order a blood film and CBC and start antibiotics. Her baby is laying on the next bed and is emaciated, his ribs are showing and his skin is loose. After much arguing I am able to convince the nurses and family to feed the baby formula NOW.

1:00 AM - I sit down in the nurses’ office to finish writing a not. I’m visiting with one of the young nurses with whom I’ve become friends. She reminds me of some of the nurses where I work in Wisconsin. A rat runs into the office, I jump and scream, and she laughs. She says they are friendly and wouldn’t hurt anyone. I don’t belive her.

1:15 AM Back in bed, trying to fall asleep. The mefloquine induced insomnia is getting to me. Suddenly the air cools, the wind picks up and a thunderstorm starts. It’s refreshing, but I still can’t sleep.

4:30 AM - The door bell wakes me up. One of the nurses is at the door with a chart. Too sleepy to speak, I climb into the truck and drive to the hospital. This lady is in labor and reportedly has a transervse lie (the baby is sideways). I checked her cervix and couldn’t feel the head; unfortunately I accidently ruptured her bag of water. I cursed to myself, check for a cord prolapse and donn’t feel one; crisis averted. I use the ultrasound to check the position and confirm the baby is vertex (head down).

5:00 AM - Still can’t sleep.

7:00 AM - My roommate is up and I try desparately to fall back to sleep. I give up the hope of sleeping in, shower, dress, eat breakfast, fill up my Coleman water cooler, and head to the hospital.

7:30AM - Rounds in ward 1. Almost everyone has a snakebite. I sit on a stool in the middle of the room and the men hold up their feet so I can see where they were bitten. I check the clotting time reports, discharge a few, and order a few more clotting times. We all smile and laugh. I send an old man with gastroenteritis home, he looks much better.

8:00 AM - Rounds in ward 2. A man was trying to shoot a guinea fowl and his gun came back and hit him in the eye. I take off the bandage. The pupil is fixed, dilated, and I think I see blood in the vitreous. He can not see anything out of the eye. I discharge him so he can go to Tamale to find an opthalmologist. A man in the next bed cut his foot with a stick two days ago and is now complaining of “lock jaw.” I suspect tetanus.

9:00 AM - I find Jim and ask him about tetanus. I write orders; transfer to the tetanus room, flagyl, valium, fluids. Tetanus has a 60% mortality rate and is vaccine-preventable.

9:15 AM My first clinic patient of the morning is someone that I saw on Friday. A thiry year old woman was brought in by her mother because she was “sick.” After spending six years in Accra, the patient had returned to Nalerigu and was thin and weak. I ordered a sputum AFB (for tuberculosis) and a public health number. HIV status is taboo here, someone’s status is not openly discussed. We never say HIV/AIDS in front of a patient, only immunosuppressed or retroviral infection. An HIV test is ordered as a public health number and is reported as PH# 278 (negative) or PH# 279 (positive). She was a 279 and I sent her to the “special needs” room. There she was supposed to receive counseling and referral to the government sponsored treatment program.

9:30 AM - Break while the patients have a devotional — this is a Baptist Mission hospital after all. Back at the house the two new volunteers arrive!

10:00 AM - Back in the clinic room I share with Jim, the interpreter doesn’t arrive until 10:20. She tries to write the patient names in the registry book and interpret for both of us. It doesn’t work well. I take over writing names in the book, filling out insurance forms, and looking up dosages while Jim sees patients.

11:30 AM - Another interpreter arrives and I start seeing patients. A 26 year old man comes in with an eye injury three weeks ago — poked in the eye by a cow. His globe was already deformed and the anterior chamber eye is filled with pus. He will never see out of that eye again.

12:40 PM - We break for lunch, grilled cheese and soup at the guesthouse.

1:40 PM - We are down to one interpreter for the afternoon. I regain control of the book and are room is a smooth-flowing patient seeing machine. Lots of malaria, some typhoid, a child with a chronic draining leg (likely a chronic bone infection).

3:30 PM - Crisis hits. Jim is seeing a patient, a nurse from the wards brings lab results for Jim, whose on call, to look at, another nurse brings in a patient having an asthma attack . In five minutes we had sorted everything out and the calm returned.

4:20 PM - Last patient seen! Between Jim and I we had seen over 100 patients in our room that day. The hospital sees over 10,000 outpatients a month.

4:30 PM - I stop at the pharmacy to pick up a few vials of anti-snake venom. We keep the serum in the refrigerator to be used at night when the pharmacy is closed. I walk to the guesthouse, then back to the hospital to see what procedures needed to be done in the theater.

4:45 PM - There aren’t many procedures to do. A line of ladies sit on a row in the bench outside waiting for ultrasounds. There is one gentleman with a boil on his butt, the I happily lanced. Another man thrusts a chart in my face, the clinic is full of disoriented people at the end of the day. I pointed him to the men’s ward.

5:00 PM - Home! Time to check email and write a blog post.

6:00 PM - Dinnertime. We wait for a half hour for two guests, but they never arrive so we eat without them.

7:30 PM - I’m exhausted. I shower, change my sheets, and head to bed. I read for awhile, then drift into an ambien-induced slumber.

Bolga and Back - Saturday, May 22 and Sunday, May 23

Saturday was the long awaited trip to Bolga to go shopping. After a rather sleepless night of call and early morning rounding it was time for a road trip. Bolga is a city northwest of Nalerigu, near the border with Burkina Faso. The group of Canadian volunteers who were at BMC this week had possession of a well-used LandRover so we finally had transportation! The two guys road up front and us three girls crammed into the back seat. There was no airconditioning so we hoped that the rain had settled the dust enough for us to keep the windows down. The directions were simple - turn left at the gas station, then turn right at Wale Wale.

We took the same road when we came from the airport in Tamale and maybe it was the rain making everything green or maybe it was my time here, but I saw everything with fresh eyes. Initially, only the round mud huts built into compounds, people carrying huge loads along the road, the mosques in each town had registered. Now I saw people living their lives, families working in the fields, people gathered around tro-tros on the side of the road, weathered schools, children running and playing. Children would see our truck and either stare, point, scream, jump around, wave, or do a combination of all of them. A little toddler was standing naked (except for a string of beads around her waist) along the side of the road. She saw us and, continuing to stand perfectly still, covered her eyes with her hands. It was precious.

There are several police check-points, tolls, and customs stops along the way. Just outside of Nalerigu we were stopped. A young man in police fatigues asked James, who was driving, for his driver’s license, how long he had been in the country, how long he was staying, and why he was there. James said that we were doctors volunteering at BMC and the policeman replied that he was having a problem and would be coming to the clinic later in the week. He then reminded us to wear our seatbelts and waved us through. His calm slow voice was intimidating, but it was the most pleasant, intimidating traffic stop I’ve been through!

Bolga is a growing city, loud, dirty, and crowded. We parked along a street, guessed which way the market was and started walking. We guessed wrong and walked in a complete circle back to the truck. We did, by chance, come across several shops selling baskets, wood carvings, and masks. From one little shop I bought a shallow wicker basket, then went across the street to look at another shop. The man who had sold the original basket ran right behind me; turns out he owned both shops! Two quirky quilted shoulder bags caught my eye and I bought them from three young women who had their sewing machine in a small shack on the side of the road.

After consulting the map, we realized that we had parked just next to the market. We wound through the crowded stalls selling every kind of bean, seed, dried herb, and piece of used clothing you could imagine. Hot, thirsty, and exhausted we came across a small restaurant and hotel with a French name - the translation of which was So-So. This place was probably the height of style in about 1960. The courtyard in with small covered tables had a fountain and the walls were covered in chipped and faded pink stucco. A group of middle-aged ladies dressed in the popular bold colors and patterns were having what appeared to be a power-lunch. We ate, relaxed, and bought a few more trinkets from a man who came by our table. Someone wanted to see a further selection of some cards that he had. He disappeared for about thirty minutes and returned slightly breathless with a new selection.

The Islamic call to prayer was being broadcast from a mosque as we walked back to the truck. Someone pointed out a flock of vultures in a tree by the side of the road. We stopped to buy fruit and the vultures started to circle directly overhead. They must have sensed the weakness of a bunch of white people standing in the hot afternoon sun. We had come to Bolga for a craft market and never found it. We were disappointed, but starting to doubt it’s existence, besides it was getting late and we wanted to be back to BMC by dark.

I was on-call on Sunday. We rounded in the morning and did a couple of minor procedures. I spent the day reading and wandering up to the hospital.

Helpless - Saturday, May 22 (12:30 AM)

It was almost midnight as I walked into the hospital. I could hear the screams as I walked down the corridor to the women’s ward, a hot, cramped room in the middle of the hospital. She lay on the bed, naked from the waist up, moaning. Her eyes were open, but were not seeing. Her breathing was noisy and rapid. She pulled away and screamed as I shined my flashlight into her eyes, trying to elicit her pupillary response. I listened to her lungs. I wrapped a blood pressure cuff around her arm; her skin was cold and clammy. I did not inflate the cuff, I already knew what her blood pressure would be. I sat on a stool across the room, looking at her chart and desperately trying to think of something else I could do to help this woman. I quietly asked the nurse to get valium to control the convulsions. Two women, one at the head of her bed and the other at the foot, were fanning the patient and holding her limbs. A dozen women - patients and families - watched as she writhed and screamed. I could not help but think that they were watching me too; I did not look up.

The young woman screamed, her limbs stiffened and shook, then fell limp. The woman sitting at the foot of the bed shook the patient’s legs, but she did not respond. Slowly I stood up, walked the six feet across the room, placed my stethoscope on her chest and listened, nothing. I shined my flashlight in her eyes, this time she did not scream in protests. The nurse arrived with a syringe of valium, but there was nothing left to do. I sat down and wrote one final order - release body to morgue.

People should not die of malaria. Over a million people die every year of a disease that is largely preventable. Most are children in sub-Saharan Africa. Some are young women with families who have to watch a violent, painful death.

This woman did not deserve to die of malaria and I could not help but think that this woman deserved more than me. Someone who, until three weeks ago, had never seen a case of malaria. She was helpless and I could not help her.

http://www.who.int/mediacentre/factsheets/fs094/en/

Rain - Thursday, May 20 and Friday, May 21

Rain! Glorious, wet, cool water falling from the sky. The past three days it has rained in the afternoons and evenings, soaking the ground and leaving puddles in the morning. It was cloudy all day today and definitely cooler. The farmers were headed to the fields to begin planting, old men wore coats to the hospital, and my mood improved remarkably. Rain!

This week we have been fortunate to have three Canadian family doctors at the hospital as the two staff doctors are out of town. We have managed quite nicely and things are running smoothly. After work today we walked down the road to “Chesterfield’s Guesthouse” for a drink. We carried our own plastic table and chairs up the spiral staircase and sat in the rain enjoying Ghanaian beer and Alvaro (a non-alcoholic malt beverage with pear flavoring — tasty!). A group of little boys followed us after seeing someone with a camera. They danced and yelled “hey white man” and made quite a ruckus.

The senior doctor with the Canadian group has been coming to Ghana for many years, after having spent time volunteering in several (very dangerous places) with Doctor’s without Borders. His cousin is a priest in Tamale (a city two hours south of here) and connected him with a Ghanaian doctor. This local doctor runs two free clinics for the destitute in Tamale, takes around food to widows and lepers, and seems to take in all sorts of downtrodden souls. This man, who receives financial support via word of mouth, seems too good to be true, a modern-day saint. I would love to meet him and see some of the work that he does.

Yesterday I went for another walk, my afternoon activity of choice. It was breezy and not so hot. Everyone smiles and waves at me. Several people asked if I was exercising and why I didn’t run, not even small-small (slow). I didn’t explain that I am against running in the heat on principle, even small-small. I walked out past TB village, a program run by BMC where people who are receiving directly observed therapy (meaning someone watches them take their TB medication) for tuberculosis can stay. It is nothing fancy, low concrete buildings, painted white with blue numbers on the side. The sunset was gorgeous as I walked back to BMC; I must taken twenty pictures of the clouds and trees.

Medical work continues at BMC, things that two weeks ago made my head spin now seem almost routine.

Yesterday a woman walked into the procedure area with an infected hand for the last five days. Thankfully she hadn’t eaten so could give her ketamine prior to incising it. I put on my best “hand surgeon” persona, stuck a scalpel into her thenar eminence (plam of her hand) and pus just poured out. She was in a ketamine stupor so I pushed and more pus. I stuck a curved hemostat into her hand, dug around, and more pus drained out. Maybe ten or twenty milliliters of pus came out, so satisfying! She was placed on antibiotics, the wound was packed, and she will likely do just fine.

This morning I walked into the men’s ward to see a thirty-something man with Cheynne-Stokes breathing, GCS 3 or 4, and sluggish pupils. The reported history was of a CVA, I was skeptical. The history I initially received from his mother was that he had been in a motorcycle accident four days ago and was fine until yesterday. This was concerning for an intracranial bleed of some sort, so we went to see if tools for making a burr hole (a hole in the skull to drain blood) existed at BMC. For future reference they do exist here! However, when I took a couple of the other doctor’s back for the requisite second opinion/see this interesting case the story changed. He had been having seizures and fell several times but he wasn’t in a motorcycle accident. Then the story changed again and he was having seizures and was in a motorcycle accident. Who knows what the story really is! Seizures, tumor, meningitis, intracranial bleed, subdural hematoma. It is difficult to say. So he was started on dexamethasone and antibiotics and was unchanged when I checked on him later in the day.

One of the medical assistants brought a 12 year old boy into our exam room in clinic today. His right eye was swollen shut and there was a layer of pus under the conjunctiva and slera. The whole eye was almost white. The other voluteer doctor looked at me — he is quite experienced in tropical medicine — and we started antibiotic coverage for everything we could think of!

I was rounding tonight when the nurses called me with an “emergency” which usual means that someone is dying. A young woman with malaria was having a seizure and respiratory distress. Her blood pressure was 70/40. After some valium, albuterol, and a bolus of fluids she seemed to stabilize. I continued her treatment for cerebral malaria.

DEET - Tuesday, May 18 and Wednesday, May 19

I am constantly covered in chemicals of some sort. The day starts with a heavy layer of SPF 50 and ends with a shower of DEET. Since we’ve had a few rain showers this week mosquitoes are becoming more common. I would like to avoid malaria as well as the constant, annoying itch of the bites. The DEET is particularly important because I am sitting on the porch of the guesthouse tonight, enjoying some cool night air and the new wi-fi access — the husband of the volunteer has been fixing the wi-fi system here and has been doing a great job!

Nighttime is loud here! There is the constant chatter of insects, bats, monkeys, and birds. On my first day here I was walking to the hospital and about 100 bats flew out of a tree — huge bats, with bodies the size of rats. There is a monkey that lives tied up in the backyard, he used to belong to one of the missionaries and apparently hates women. The birds have all sorts of different songs, a couple sound like my pager which makes me a little jumpy. Several of the birds are beautiful, bright yellow or blue.

A few interesting medical things. . .

Today in theater we did an ultrasound on a six year girl with a palpable mass taking up about half of her abdomen. It looks like she has a Wilm’s tumor coming from her kidney. It could be curable with surgery, but she would have to go to one of the main cities and her family would need to come up with the money for the procedure first. Very sad, because it is likely a death sentence for this child.

In clinic today the nurses brought a young man in on a stretcher. He was writhing, covered in sweat and agitated beyond belief. The nurses thought he had hydrophobia (rabies). It is more likely that he had malaria. Seeing someone in that much agony is common for me, but one of the volunteer’s in the room is not a medical person and he said it was disturbing to see someone in so much pain.

The other night when I was on call I admitted a nine month little girl with marasmus (severe malnutrition). She had been sick with diarrhea for a month and her mother’s breast milk supply was decreasing. The mother’s two other children had both died before the age of three from causes unknown to us — likely infection or malnutrion. The child will be referred to the nutrional rehabiliation center at the hospital where both the mother and child can receive proper nutrition and the mother can be educated. The amount of malnutrition is astounding here. . .

Translation - Monday, May 17

There is no polite Midwestern sense of personal space here. In the hospital patients are in wards — nine or ten patients and their family members in a large room. Two or three feet tops separate the beds. At night people are sprawled out on the floor. During morning rounds other patients and family members chime in to add to the history. Often none of the nurses speak the patient’s language so there is a search for a patient or family member who can translate. Rounding becomes an endless game of “telephone” with the answer to my question of “any vomiting?” becoming “no, no diarrhea.”

In clinic today there were several patients who spoke a language that our translators did not know. They pulled in a man from the waiting area who happened to speak English. This “random guy” interpreted for three patients and did a great job. Turns out he had brought his other wife to the clinic to be treated for some sort of, um, communicable disease that he had been diagnosed with a few days prior. He seemed to enjoy interpreting and sort of had to be scooted out of the room.

At one point today a four way translation was occurring. English to Mampruli to another and yet another language. We can only hope that the message carried through!

Even though it is hot and crowded and chaotic, people seem to be endlessly patient. Clinic days start with patients all gathering in the morning to register. They then wait to be called to a waiting area where they wait to be seen. If they are lucky, after being seen they stand in line at the pharmacy to pay their bill and receive their medications (everyone gets some sort of medication at every visit). However, if they need labs they go to lab to wait for the test then return to wait to be seen by the doctor again. If they need a procedure or ultrasound they wait outside the theater for hours. Many patients and families spend an entire day waiting in various lines for they five or ten minutes they spend with the doctor. I am continually amazed by their patience and resilience.

To the Mountain - Sunday, May 16

Sunday at BMC was quiet. Rounding was uneventful, there weren’t even any procedures to do. I was home by 9:30, read for awhile, ate lunch, did some writing. Nothing very exciting. The plan for the afternoon was to walk to the mountain. These aren’t mountains really, just a long line of hills off to the east. A few people had gone running to them last week and ever since my compulsion to walk up things kicked in.

We left in the late afternoon, not surprisingly it was still hot. We walked along the fence of the hospital compound, then towards the “mountains.” There is a dirt trail/road that winds through the fields. It crosses a riverbed at one point, there is no bridge. Today we saw some women and children washing clothes in the stagnant, smelly water. We continued on, takingi pictures of trees, goats, and little round houses with thatched roofs. Occasionally we would pass people on motorbikes or walking with loads on their heads. We saw a few boys driving donkey carts. Eventually we veered from the trail and walked through the bush, passing a little garden plot of foot high cones of dirt. I’m not certain what grows in them.

Finally we scrambled up a ridge covered in slippery red rocks. We could see for a long distance, but the heat and the haze made the view less than amazing. After a brief rest, turned around, walked through the bush, back down the road and continued home.

Today is the last day for one of the volunteers. Soowhan, a fourth year medical student, is headed to Accra in the morning. He shared his photos with us. We will miss having him around. A group of Canadian doctors is supposed to arrive at some point today and it will be nice to have a few more hands to help.

Night and Day - Friday, May 14 and Saturday May 15

Friday started pleasantly. I was cheerful, the hospital wasn’t that full, clinic started a half hour early. Our clinic ran smoothly and by 3:30 there were no more patients to be seen. I went through the wards and only had to see two new pediatric admissions - a 3 day old with difficulty breathing and a toddler with malaria. I got home in time to use the internet at the schoolhouse before supper. Side note - we are very fortunate to have internet access here, but it is really slow and checking my Gmail account, Facebook, and writing a blog post takes over an hour.

One of the translators, David, stopped by for awhile and we took the opportunity to ask him about the local culture. The native tribe in Nalerigu are the Mamprusi (forgive me if I spelled that incorrectly). The chief is considered the local “mayor” and the position of chief rotates through the three of the different clans. David said that even though he was born in Nalerigu, his family is from a different tribe and he is considered a foreigner. Different tribes can be identified by their language or dialect or by different scars that are placed on their bodies as small children. These scars are really common and I’ve seen all different sorts of combinations of lines on faces and abdomens. Having more than one wive is also fairly common as is paying a bride price in cattle.

I was on call Friday night and things started to pick up at the hospital. The hospital at night is, in my opinion, a spooky place. People linger about, standing in corners, sleeping on benches in the outpatient area, laying in the hallways. Family members stay at the hospital to care for patients and they sleep in the hallways or on the floor of the wards laying on the cement or blue plastic bags that are also used as sheets on the patient beds. There are large mice and rats that sometimes run around, usually many of them and they will run over the patients as they are sleeping. Occasionally a cobra will be seen in the hospital at night. I’ve heard a story (and don’t know if it is true) that a visting surgeon walked into the doctors’ lounge one night and a cobra spit in his eye.

There was a whole array of interesting cases on Friday night. First was a middle aged man with an incarcerated inguinal hernia, that even after valium and Demerol I could not reduce. Luckily our surgeon stopped by and popped it back into place. An 8 year old boy fell off his bike the day before and the handlebars hit his abdomen, which was now very tender. An ultrasound showed only a little bit of fluid and his blood count was normal (hematocrit of 30% which is more or less normal here), so we just watched him overnight. Two older ladies with abdominal pain, one looked sick, the other did not. A young woman with vomiting and diarrhea who had been seen several times in Accra and somehow ended up at BMC (14 hours away by truck); I gave her antibiotics and fluids. I expelled some clots from the uterus of a woman who had a miscarriage at 5 months. Another woman had a intrauterine fetal demise (stillbirth) during labor and we decided to let her try to deliver vaginally overnight.

There were a couple of new admissions in the pediatrics ward. A beautiful chubby two year old came in after being sick for a week. She had received treatment elsewhere but had not improved. When I walked into the ward she was convulsing and her eyes were rolled back into her head. Her blood film was positive for malaria and it was likely that she had cerebral malaria. I loaded her with quinine and continued antibiotics in case she was also septic, which is possible. With no sense of urgency the nurse gave some IV valium after I had asked several times and he had finished passing out some other medications. Of course, the child had been convulsing on and off for a day now, so a few minutes wouldn’t make much of a difference.

Finally, I was leaving the hospital, eager to get some sleep when I walked past a nurse rolling a patient in on a stretcher. I turned around and walked back into the hospital. A 26 year old woman had been well until the afternoon when she developed a headache, fevers, chills, nausea and diarrhea. She had been transferred from a rural hospital to BMC. On arrival she was hypertensive with a blood pressure of 60/40, febrile, withdrew from pain, but had normal papillary responses and a nontender abdomen. Sepsis, bleeding into the brain from an aneurysm, gastroenteritis, malaria, meningitis. Labs hadn’t been drawn yet, there were no imaging studies to perform and all I had was a blood pressure and a tactile (!) temperature. She felt warm and looked sick! I started her on my new favorite combination of medications - ampicillin (for pneumonia), quinine (for malarai), and chloramphenicol (for typhoid or meningitis). Only thing I didn’t add was flagyl.

As I was seeing this lady, a thunderstorm struck. Flashing lightening, wind, pounding rain, thunder. The temperature dropped nearly 10 degrees instantly and it felt amazing! Of course, at just that moment a young boy who had surgery that night to repair four bowel perforations started vomiting dark brown material. He already had an NG tube down, but they can’t be put to suction, only a device sort of like a JP drain.

Finally, I drove home, realizing that the windshield wipers on the truck don’t really help much. I spent a more or less sleepless night on the couch, expecting to be woken up at any minute, but I wasn’t.

This morning on rounds I was surprised to see that almost everyone of my sick patients had done well. The man with the inguinal henia showed no signs of dead bowel. The boy from the bike accident was stable with an unchanged blood count. The young lady who had driven up from Accra felt better. The lady with the 20 week miscarriage had a D&C. The lady with the stillbirth at term ended up having a ruptured uterus, but according to the OB resident did well after surgery. The little girl with cerebral malaria was still alive, unfortunately I suspect that she will have some permanent brain damage if she does survive. The final lady who came in very ill and hypertensive was sitting up in bed and talking.

Over all I was surprised at how well these people did. In my mind quality care needs ICUs, monitors, scans, cultures, consultatns. I am continually amazed at how well our patients do when we have such limited resources. There is a constant feeling of uncertainty, but after putting the history and physical findings together, coming up with a differential diagnosis and treating for (usually) more than one possibility things often turn around.

When I was leaving the hospital this morning, I heard an awful sound. Someone or something was screaming. I looked out to the street and a donkey was running (no cart, no rider, no harness) down the street, braying at the top of its lungs. I’m not sure where it was headed, but it was free and in a hurry.

Today, we ventured out for street meat. It was sheep on the grill today — two goats were tied to the stand so tomorrow might be goat day. I must say I was not a fan of the sheep, nor of the fried rice that we bought from the “Assembly Lady Fast Food” stand. Might have to try again some other day.

Today was also market day and we down to buy fabric. Ghanian fabric is bright with huge patterns. Women wear long pieces of cloth wrapped around themselves as skirts or dresses. They also use them as a kind of sling to carry babies on their backs. I bought a rather calm dark green floral print that I will take to one of the local seamstresses to have made into a skirt later this week. I also bought some fabric with a blue background little suns printed on it that I might make into a quilt when I get home.

At the market little kids shyly come up inspect us. I’m sure that I look fairly exotic (being all white and freckly) to these kids. They are just adorable! One little boy starting following us around and I thought we might have to take him home, but he eventually toddled back to his mother.

Goats are everywhere, including my dinner plate! In town they just wander around. Today in the market a little white goat stopped to munch on some greens that were neatly laid out on ground ready to be sold. The owner of the booth yelped. The goat kept on eating until a passerby kicked the goat in the butt, then it trotted off with some leafy greens hanging out of its mouth.

I can’t wait to go back to the market on Tuesday!

Going out and Walking - Wednesday, May 12 and Thursday, May 13

Thursday, May 13 - Walking

After procedures are done, the afternoons can be long. We wonder from room to room in the guesthouse, sit on the porch, go to the schoolhouse, all in an effort to find someplace cool and comfortable to relax. Even though Thursday was one of the warmest days yet I decided to go for a walk. I turned south out of the BMC gates, down a red gravel road. The sun was hot, but a cool breeze made the walk refreshing. I passed lots of people, men and women on motorbikes, children on bicycles, women carrying loads on their heads all going somewhere. Me? I was just walking. Everyone smiled and waved. Some said hello in English or the local language. I always gave a little grin, a wave, and a quiet “hello.” I must agree that the people here are incredibly friendly and pleasant. A few looked at me like I was crazy - why was I walking just to walk.

The landscape is beautiful, dry red earth covered with low green bushes. A few trees rise up in the fields and provide a bit of shade. In the east there is a low line of hills. Pigs, goats, chickens, donkeys roam around eating the bushes and whatever else can be found.

I walked for a long time, it was relaxing and peaceful, until I realized that I needed to get back in time for dinner. Tonight was GOAT night! We’ve been talking about having goat for dinner for days. Our cook, Bawa, had procured and butchered a goat (in our kitchen) on Wednesday. When I goat home Esa and Caleb were grilling goat kabobs in the front yard. It smelled wonderful!

All the families came for dinner. I unintentionally sat at the children’s table and heard great stories about DisneyWorld and SeaWorld. A bit more entertaining then snake bites, malaria, and abcesses. The goat tasted wonderful, it was crispy and tender and spicy all at once. I loved it. The next step in culinary adventures is street barbeque this weekend.

Medical stuff from Thursday. . .

I discharged the man I wrote about last weekend. After 8 liters of fluids and lots of lasix he still made no urine, unless you count 50 mL of pus. I sent him out with antibiotics, medication for nausea and pain. I’m not sure how he will do, but he was remarkably healthy considering he had made no urine for over a week. I still wonder where all of that fluid went???

I did a paracentesis and drained 2 liters of fluid from the 13 year old boy’s belly. He too doesn’t look as sick as I think he should.

Removed some lipomas, one on the wrist — it took forever because I kept checking that I wasn’t hitting an artery.

Wednesday, May 12 - Out

After dinner on Wednesday night, we decided to venture out into the town. There is an outdoor café called Iceberg owned by a person who is related to a person who. . . That sort of connection. We piled into the rickety old Mitsubishi and headed out of town. After, literally, reaching the end of the road, we turned around, found the correct side road, made a wrong turn, backed up then finally arrived. We were the only ones at the café. We helped ourselves beverages from the cooler and sat on plastic patio furniture under the stars. The nights are incredibly dark here and the stars are just amazing, makes me sad that my knowledge of the constellations starts at the Big Dipper and ends at Orion’s Belt.

We had a lively discussion about our work here. What is sad, what is frustrating, what is done well, what can be improved, how the limitations in our skills limit how much we can help. I have so many questions about the people, their culture, their understanding of health and disease — things I never really take time to consider at home.

Around 10 o’clock we settled our bill and the owner turned out the lights. We offered her a ride back into town and she accepted. We dropped her off at her home just, outside of the hospital gate.

Wednesday was a market day, which apparently means that clinic is not quite as busy. It still seemed busy to me, in the two and a half hours before lunch I counted twenty patients that I’d seen and I’m sure I lost count. There were three volunteers and two interpreters in our room again, partially controlled chaos that I only handle marginally well.

A few interesting things. . .

I saw an albino lady with multiple skin cancers on her face and the rest of her exposed skin was covered with actinic keratosis.

My last patient of the day was a 13 year old boy whose family brought him in after a year and a half of abdominal and lower extremity swelling. He had massive ascites (fluid inside his abdomen) and his legs were very puffy, the rest of him was thin as could be. No one seemed to speak his families language, so I gestured my way through explaining that he needed to be admitted and treated.

I continue to see lots of malaria, some typhoid, lots of vague complaints, too. Since our history taking is so limited here, I’ve had to rely on my physical exam skills more than ever. The number of positive exam findings and dramatic pathology is remarkable. It is a living textbook every day.