Jessica’s Blog

Tuesday, April 20, 2010

Today was girl’s day out.

Chinny stopped by early to say “hi” and to pray together again.  At the hospital, we rounded on the pediatric patients, isolation patients, and checked the procedure board.  A four year old boy has been an inpatient for two days.  He is being treated for malaria, but also has had a cough and poor weight gain for the past year.  He has crackles in his upper left lung field which are not improving on amoxycillin.  On admission, his mother was asked to collect a sputum sample to look for acid fast bacilli (test for TB).  Parents are in charge of sample collection here, and are given labeled film canisters that they keep by the bedside until they can fill them.  He is too young to cooperate with a sputum collection, and placing a PPD skin test would not be very helpful.  He has likely been exposed to TB in which case the test may be positive even if he does not have an active infection.  He has also received a BCG vaccine which could also make the test falsely positive.  On the other hand, a malnourished child may not mount a response to the antigen even if he did have TB, resulting in a false negative.  When I discussed the case with Dr. Hewitt, he said we could go ahead and get a chest X-ray.  I’ll see what it shows tomorrow.

In the line for the theater, my three clinic patients from yesterday were awaiting their procedures.  The child with the multiple abscesses was second in line and her mother waved me down. The induration around a few of the abscesses seemed slightly decreased after just one day of antibiotics.  I gave her a sticker, introduced her to Terry, and left the hospital feeling very guilty for not staying to do the I&D myself, but the girls were waiting…

The ladies, two kids, and Zion piled into the van around 9:30am and we headed for Bulgatonga.  The ride was bumpy and we talked, ate sandwiches that Steph and Rachel packed, and played “Would you rather?”  Jude and Emma, the kids, fell asleep nearly instantly.  The ride was familiar from our previous trips, as we watched the red mud huts go by.  We felt spoiled being in an air conditioned van, but the second we stepped out, it felt that much hotter.  We stopped at an ATM and discussed how absurdly easy it is to access bank accounts in America from the middle-of-nowhere northern Ghana.  We arrived at the basket outlet center, which is a concrete strip mall with rooms piled high with baskets of every color, shape, and size.  Men sat out front attaching handles.  The baskets were made by women in the villages, sent here, and then are shipped all over the world to sell in import stores.  Essa gave us a quick briefing on bartering before letting us roam.  He recommended cutting the asking price in half, then working up slowly.  I bought four baskets, one with handles that should work as a carry on purse, and three without handles.  Our second stop was the art village we had visited before.  Others were much better at bargaining than I was.  I justified my purchases saying that my contribution would “stimulate the local economy” as Dad would say, and that after converting the price to US dollars, the purchases were worth the price to me.  I went easy on the shopping compared to my friends.  The van was piled high with baskets on the ride home. The next trick will be packing and transporting.

Essa drove much faster on the ride home.  Bikers also use the road, but cars and vans have the right of way.  They beep to let the bikers know to get out of the way.  Near the towns, Buses passed us that were packed with passengers inside and on top. In the rural areas, on the rare occasion that we saw other motor vehicles on the road, tailgaiting was the rule until the opportunity to pass arose.  There are no markings on the paved parts of the road, and I did not see any trafic signs, including speed limits.  Half of the trip was on gravel roads, which get to be a mess in the rainy season.  We arrived in Nalerigu safely.  I bailed out of the van as we passed Joyce’s shop.  My skirts were finished, as were Jill’s and Lisa’s.  I brought them all home and we modeled for each other.  They are very simply made, but fit well and the fabrics are awesome!  The material is still stiff and scratchy since it has not been washed yet, but should soften and flow better after a soaking.

I wore my new bright blue flower skirt to dinner tonight and plan to wear the longer deep blue skirt on Sunday.  After dinner, we flipped through pictures from the trip then pictures from home.  I’m looking forward to seeing family and friends again.  At the same time, I can picture myself working in this type of hospital.  We gathered at the Dickens for desert.  The kids were chasing each other around with water balloons.  We chatted, ate ice cream, and watched the kids play.

Love to everyone at home who is reading this.

Monday, April 19, 2010

On call last night, I worked in the hospital from 10pm to 1:30am with Isaac and Richard.  We admitted two women with late first trimester spontaneous abortions.  The first one had a D&C that evening and the second D&C waited until morning.  A man was in a traffic accident and had wrist pain and multiple scratches.  The medical officer who triaged him had ordered an X-ray that showed a radial fracture.  It was about the fourth X-ray taken at the hospital since our arrival.  Since it was late, the theater tech wanted to wait until morning to splint the wrist.  We started pain medications for the man.  A woman was admitted for diarrhea and dizziness and perked up nicely after fluid resuscitation.  One of the pediatrics patients was in respiratory distress with obstructive apnea and supraclavicular retractions to the point of dimpling the skin with each breath so deep that the base was not visible  She was about one month old and her mother said that she had done this all of her life.  She was already on oxygen by nasopharyngeal tube, which is the only way they supplement children with O2.  The nursing staff thought she looked improved and her breathing became more comfortable as she fell asleep.  A woman came to the hospital in labor.  She was at term and had had a previous classical C-section.  Dr. Dickens came in to section her.  The babe, a boy, did well.  When I got home, I showered and went straight to bed.  It was the first night that I didn’t call Curt, and I missed him.  Thankfully, there were no emergencies the rest of the night.

This morning, I ate my mango and PB and got to the hospital a few minutes late.  It was hot and I was dragging.  I discharged two children from the pediatrics ward.  The babe in respiratory distress last night looked a little better this morning. 

In clinic, I was alone in the pediatrics room again with a single translator.  Zion and Susana joined me in the afternoon.  I admitted two patients from clinic.  One was a toddler in respiratory distress and the other was a one month old with fevers.  Jill was on call today and checked them into the pediatrics ward.  In the morning, I sent about three febrile children to the lab for blood films, and they were all positive for malaria.  All three were eating well and I started them on outpatient A-A.  A boy came in with a tight frenulum and his mother had pain with nursing.  He was 6 weeks old and had fevers.  I was about to admit him for treatment when his mother mentioned that he had just had vaccines at the public health office today and was afebrile prior to that.  They do not premedicate with Tylenol (like our new policy back home) and he had received BCG, polio, and some others.  I asked him to return tomorrow to have his tongue clipped.  The hospital did a lot of frenectomies in the past, but has tried to limit them in recent years since many people request it that may not need it.  This boy seemed to be a good candidate to me.  Two other children came in with abscesses and will return tomorrow for I&Ds. 

Many kids had history of fever, vomiting, diarrhea, and decreased appetite, but were afebrile in clinic.  Fevers are diagnosed by touch since triage doesn’t have time to take temperatures.  These patients are always the hardest to diagnose because the symptoms could be due to any of a number of common illnesses with very different treatments.  My best assessment is that many have gastroenteritis from unsanitary food preparation and lack of hand washing, but malaria and early typhoid can have the same presentation.  All patients who come to the clinic expect to leave with a medication, so I prescribe a lot of Tylenol and multivitamins.  I over heard my translator talking with a mother who was waiting for her child to be seen.  The mother I was interviewing actually answered “no” to some questions and the second mother noted that if you answer no, your child might not get medications. 

I also treated three mothers who came in with their children.  I felt like a fish out of water and had to run to ask questions and look up doses.  No one made any comments, but I think the patients lose confidence in my diagnosis and treatment when I need to do that.

During the afternoon, a storm blew in, complete with rain and hail.  The sound of ice balls hitting the tin roof and the crowd that piled into the exam room made it difficult to carry on with clinic.  The storm didn’t last long, and it cooled down afterwards.  I was jealous that I wasn’t able to be outside in the cold rain.

My admits from clinic were tucked in nicely in the pediatrics ward.  We walked home and sat for a few minutes before supper, which was chicken enchiladas and canned peas and corn with lots of butter.  It hit the spot, but I’m missing Curt’s cooking.

Sunday, April 18, 2010

There were no mice in the tub this morning.

The pediatric inpatients were doing well today with the exception of one.  My two year old boy with a positive malaria smear and clean CSF continues to have fevers on quinine.  I gave a dose of Fansidar and talked with Dr. Dickens who said that some kids respond slowly to treatment depending on the parasite load.  I had never stopped chloramphenicol which should cover any bacterial infection other than pseudomonas (which is unlikely).  Both Jill and I discharged a few patients and the pediatrics ward has cleared out, just in time to refill during Monday’s clinic.  I helped with an I&D for a man who had a motor bike accident a week ago, and now had abscesses from infected abrasions.

We changed for church and drove with the Dickens family to the Presbyterian Church.  Like usual, we arrived late and people made room for us.  Written across the front of the church was the phrase, Let Us Rise Up and Build.  There was a table covered in a white cloth with a blue cross and a pulpit in the upper right corner.  The church had a choir near the front that sang with drums and tambourine.   Members jumped up to sing along with the choir and danced.  They had beautiful low voices and great harmonies.  I loved it!  A woman sang a solo, mostly in English.  Toward the end of her song, a congregation member stood up, walked to the front, and held a one cede bill to the soloist’s forehead, then let it drop as she walked back.  We later found out that it was meant as a compliment for her singing.  The choir sang another song and the chorus was, “Sinner, if you want to get to Heaven, walk in the middle of the road.  Hurry, you better get started, before the Heaven doors close.”  The pastor spoke about how God has a plan for each person’s life.  He talked about Saul’s conversion and how he used Paul to build the church.  How Jesus’ life had a plan: healing, teaching, miracles, and most importantly, paying for our sins on the cross.  God’s plan for the Church is to show God’s love and do good works in the world.  God’s plan for Christians is to “live this way, and if you are not, go and start again.”  The plan God has for Christians is to care for the communities’ children and elders, spread the word of God, serve others, help others, sacrifice for others, and do good to others.  They took an offering and we all danced to the front to place a tithe in a bowl.  The service ended with a song that sounded familiar, but was in Mumpoole.  The tune went through my head for the rest of the day, but I could not come up with the English words.  I felt very much at home in the Presbyterian Church with an emphasis on music and an intellectual sermon.  Since I’m on call today, Joe and Isaac covered for me while I was at church.

We ate lunch as a group, then went to Market.  I went for an hour, then came back and Isaac went for an hour.  I wandered the market in search of two specific fabrics I have had my eye on since last market.  People in the hospital have worn them fairly frequently.  I found them both and bought four yards of one for 10 cedes and two yards of the other for 7 cedes.  I was quite pleased, and think I got a good deal on both.  I also bought a set of six stew spoons.  The market was a busy place with people selling dried sardines, dried chili pepers, ground up groundnut powder, other nuts, rice, soap balls, hinges, nails, shovels, crackers, candies, coco, bras, underwear, Obama T-shirts, gourd bowls, pots, flip flops, belts, ear rings, and used American clothes such as blue jeans.  Vendors began to recognize us and said, “Hello, remember me?” or, “Here, how about this one?” or, “Why do you always look but never buy.”  I acquired a third fabric that way.  On the way home, we stopped at a stand and everyone else bought sodas, but I got a string of stew seasoning packets - goat flavored.  Yes, Curt, that’s for you!

Isaac headed off to the market when we got back.  He ran there for exercise, which I thought was crazy in this heat.  The families with kids had put together a baseball game in the front yard.  We watched for a while, as the shoppers compared fabrics, photos, and then drummed until a nurse from the hospital came to inform me of a new patient.  I drove the truck to the hospital with Richard to see the young man.  He had crampy abdominal pain and vomiting starting today.  Two weeks ago he had abdominal surgery for an abscess.  We started him on Typhoid treatment and made him NPO.  He may have adhesion from surgery which are now starting to cause obstruction.  We visited the theater and saw a few people who had road rash from “motto bike” accidents.  Isaac caught up to us there and we checked the other wards for anyone who may need medical attention.  The hospital was quiet.

We came back for supper, then blogging before night rounds.  Hopefully it stays quiet for the rest of the night.

Saturday, April 17, 2010

The kids in the hospital were doing well this morning.  I discharged about four kids including a baby Jill rounded on the past two days.  He is a 7 day old boy admitted with multiple yellow pustules all over his body.  His pustules opened and are healing well on antibiotics.  The three others were treated for malaria confirmed with positive blood films.  After rounding in the Pediatrics ward, we went to the theater and I watched a foreign body removal from a toddler’s nose.  It turned out to be a groundnut (peanut).  A young lady with bilateral leg amputations following osteomyelitis came for evaluation of another area suspicious for infection versus blood clot.  The area was opened and packed, but no definite diagnosis was made.  The young lady’s name is Mary and she has expended most of her energy stores on fighting infection and wound healing.  Her arms, neck, and chest have limited muscle tone and no subcutaneous fat.  She has been in the hospital for a long time and has the thickest paper chart I’ve seen here.  She will be discharged soon since there is not much more we can do for her.

As we left the hospital, we saw a sign posted next to the call schedule indicating that insurance has not come through to pay hospital and clinic bills, and staff must compensate by delaying their pay checks.  Insurance costs about 17 Ghana Cedes per year.  Patients without insurance have to pay hospital bills before leaving.  That means the patient’s family collects money from savings, friends, and relatives on the day of discharge.  A woman with meningitis was discharged this week.  She required Rocephin instead of Chloramphenicol due to pregnancy, which is more expensive.  Her bill was between 200-300 Cedes.   The hospital bed cost ~6-7 Cedes per night, labs cost a few Cedes, and the doctor’s fee was one Cede.  The rest went to pay for medications.  I had a patient today who was ready for home other than he had not yet tolerated taking food by mouth.  His mother pulled out Coco and a spoon while I was writing the note to prove to me that he could be discharged.  The family could not afford the bills and wanted to leave as soon as possible.  I discharged him with instructions for frequent small meals.  I don’t know half of the politics here, but insurance that does not care for their patients (or lack of insurance) which limits care for the sick is not a new story or unique to Ghana.

I read about osteomyelitis after lunch, and then took a nap.  After lunch, I sat on the M4’s front step with Kwame, Timothy, and Nickolas (Timothy’s younger brother) and worked on algebra and long division.

In the afternoon, I drove the old stick shift truck (yes, I drove in Ghana) to the BMC gate with Isaac, Steph, and Jill.  We walked out of the hospital grounds and into the streets of Nalerigu.  We strolled from shop to shop to look at what people were selling and to talk with the town’s people.  We tried some Ghanaian candies (coffee flavored), took pictures of cute kids, baby goats, and mud huts, looked at shovels, fabrics, soap, ground nuts, mattresses, wooden bed frames, bikes, and people sitting around chatting.  A toddle was playing with a cane and posing for pictures until his grandfather came to retrieve it.  The little boy burst into tears and his grandfather teased him.  We stopped in an electronic shop that Kwame said belonged to his family.   He joined us for the rest of the walk.  Isaac saw a CD store and we went in to listen to music.  They had four foot speakers on the front step that blasted music to the whole town when the owner played samples for us.  There are speakers at the hospital and they were playing the most upbeat Ghanaian Gospel music this morning.  I’m going to ask the nurses about the names of the group, then go back to see if they have it.  We lost Jill and Steph while in the music shop.  We walked past the “king of Nalerigu’s” home, according to Kwame.  Isaac took a picture and a man on the curb told him to give his wife to the chief.  I think he meant me.  We moved on.  On the way home, a group of kids swarmed to hold hands and have their pictures taken.  I recognized a few from our last walk.  At the BMC gate, Isaac continued on and I met up with Jill and Steph at the truck. 

We blogged after supper, then joined the M4s and Hollynn for a dance party at their place.

Friday, April 16, 2010

I caught our fourth mouse today, again in the bath tub. This time I walked it farther out into the yard.

We rounded in the pediatrics ward at 7:30am. Three patients had died yesterday and over night. Another way that the Ghanaian nurses tell us that a child has passed away is “the patient’s status has changed”. Sometimes they don’t even tell us and we have to ask why there is a new patient in someone else’s bed. Most of the inpatients have malaria and can be discharged as soon as they are able to eat a little “Coco” which is porridge similar to Carnation Instant Breakfast and can keep their malaria medication down. I helped Richard do an LP on a boy with a stiff neck. Richard is the third year FP resident who is here to see if a permanent position here would be a good fit for him. The tap was clear and we sent it to the lab for cell count and gram stain. Results took six hours to come back and were negative for signs of meningitis.

We started clinic immediately after rounding on the pediatric patients. The nurse manager in the clinic came to the ward to hurry us along. I saw a few patients, and then devotions started for the patients. They sing and listen to a gospel message for half an hour, then fall back into their lines to wait to see the doctors. We can’t understand the Mumpoole, so we take a short break. Today, I came prepared with the fabric from market and walked to Joyce’s shop to be measured for skirts. I wore a skit to the hospital instead of scrubs so I could venture outside of the BMC gate. She was not there, but the ladies who work for her measured me and said the skirts would be done on Tuesday. I am very excited to see the final results. Picking out the perfect fabric from so many bright, flamboyant patterns was challenging, and I hope they will be fun but not too crazy to wear in the States.

In clinic, I saw patients in my own room with a translator (the medical assistants are still at their malaria conference). We worked until 1pm, then broke for lunch. The entire staff is very insistent on keeping a 30 minute morning break during patient devotions and a 1 hour lunch break. Today, all of the patients seemed to have the same symptoms: fever, diarrhea, vomiting, decreased appetite, and weakness. I had an indecisive day and struggled to make up my mind whether to treat for malaria, gastroenteritis, or typhoid, which are the most common illnesses for the kids here. Pneumonia is up there, too, but at least that has specific physical exam findings. In the morning, I sent a number of kids to the lab for blood films for malaria, but the lab does not take clinic patients after lunch, so making a diagnosis becomes more like guess work. I also saw a lot of impetigo and skin infections. A baby came in with what looked like milia all over her body. I showed her to Dr. Hewitt who told me that mothers often cover their babies in a palm aide-like emollient, which clogs their pores. The baby otherwise looked healthy and interactive.

My translator began to warm up after the morning and told me her name was Hannah. She is 24 but looks younger. She laughs and jokes with some of the other nurses, then in the same breath yells at patients, then politely asks me, “Doctor, what did you say?” I have been trying to take more history in Mumpoole, but parents will look at me and not respond until Hannah asks the same question. I will keep working on my pronunciation.

In the afternoon, Zion and Susana joined me in the pediatrics room. They took turns examining the patients with me and I put them to work calculating doses. The pharmacy likes prescriptions written in teaspoons, and the concentrations of the medications here are different than in the States. If I tried to explain to the patients what medications they were prescribed, or reasons to return to clinic, but Hannah would tell me the pharmacy would inform the patient what to do and that I didn’t need to explain anything more. She would motion the next patient to come. The other day we were told that patients don’t know what malaria is and most couldn’t tell you if they have ever had it, even though they all have multiple times. After most clinic visits, patients don’t know their own diagnoses or what their medications are for, but take them because the doctor gave it to them. Taking a past medical history is nearly impossible. I think I completed a full week without seeing a single adult patient.

Clinic ended early and we went to the procedure area to help out with what ever was left. A baby was getting casted for club feet and a few pregnant women had ultrasounds of their babies. On the walk home, we passed Greg on the path. He was loaded with rat traps for Jill and I, raid and duct tape for John and Drew, and a signal booster to try to get wireless internet from the school house to the houses. Holly walked with Jill and me to our back yard to look for a hole where mice might be getting in. We recently had some pipes replaces because the bath tub filled with laundry water each time we washed a load. The pipe leading to the washing machine was tunneled under the backyard and drained into the dirt. There was not cover on the end, and it was the perfect size for our mice. We covered it with duct tape and poked a few holes in it to let the water out. Hopefully this will be the last of the mice. I also set the traps with peanut butter, but they are pretty large for our little mouse babies.

We ate dinner as a group. Essa went grocery shopping at a larger town last week and restocked “American” food. We are back to having goat pizza, Sheppard’s pie, hamburgers (maybe cow), and vegetable soup. After supper we sat around and drummed and sang all the classic songs we could come up with from ACDC to Billy Joel to Simon and Garfunkel to Journey to Steve Miller Band to Don McLean to Jason Myraz… Richard is an excellent drummer and put the rest of us to shame. He can remember the drum parts to most songs and it actually sounds like the original, is in time, and is so much fun!

After 8am, bed time for the kids, we went over to watch movies with the Wichita group. We chatted for a while, sang along with John’s guitar, then watched Night at the Museum 2 on their laptop computer. It was a fun movie, but half of us fell asleep after a long week.

New Mumpoole words:
“E Uri” What is your name?
“E Sara” Have you had diarrhea?
“E Tira” Have you had vomiting?
“E Dira” Have you been eating?
“E Nurukom” Have you been drinking?
“E Mwara” Have you been sucking (nursing)?
“E Mari Duru” Do you have fever?
“Di Bera” Is there pain?
“Da Vela” Every thing is fine.
“Da Sakia” used to calm kids (success if variable)
“Di Zuada Beim” Don’t be afraid.
“Vu Si Ma Pom Pom” Take deep breaths.
“Chom Tim Du” Go to the pharmacy.

“Do” Boy
“Pwa” Girl

“Yinni” one
“Aba Yi” two
“Aba Ta” three
“Aba Nasi” four
“Aba Nu” five
“Aba Yo Bu” six
“Aba Yo Pwi” seven
“Aba Ni” eight
“Aba Way” nine
“Pia” ten

“Atani” Monday
“Atalata” Tuesday
“Alarba” Wednesday
“Alamishi” Thursday
“Azuma” Friday
“Ashebrui” Saturday
“Alahari” Sunday

Second Corinthians 3:4-6, “Such confidence as this is ours through Christ before God. Not that we are competent in ourselves to claim anything for ourselves, but our competence comes from God.”

Thursday, April 15, 2010

One story I forgot to share earlier:  One morning earlier this week, a knock came from the door while I was scurrying around getting ready to head to the hospital.  It was Chinny.  Chinny is a thin man with a scruffy beard who looks older than he probably is.  He wears a dirty T-shirt and scrub bottoms rolled up to mid shin.  He was treated at the TB village many years ago, and after his treatment was completed, he refused to leave.  He works on the grounds and has some mental delays.  This morning he stopped to say hello.  I stepped out on the step to chat for a moment, and then he wanted to pray.  He closed his eyes and began before I had figured out what he was doing.  I understood only bits and pieces of what he said in his thick African English.  I had to peek a few times to see if he was still praying.  Then he stopped.  There was silence for a moment and I realized it was my turn.  I prayed aloud with him for him and his family to have sufficient food, the hospital patient to heal by God’s grace, and for those caring for them to have the wisdom needed to treat them appropriately.  He seemed pleased and wished me a good day.  His parting phrase is always “Halleluiah” which has become his nick name with previous volunteer groups.

Last night, I found a third mouse in our house, this time in the bath tub.  It was a baby and could have been the same one that was in the suitcase.  I scooped it out with a water pitcher and spatula, and carried it outside.  It was dark and the bats were beeping.  I stepped out into the yard to give it a toss when something swooped down from a tree and flew right in front of me.  I threw the mouse and sped back inside.  He likely became someone’s desert last night.

I was tired this morning when the alarm went off.  We rounded on the pediatric patients and caught up with the rest of the team in the isolation ward.  The young woman who had her left arm amputated was getting ready for discharge.  She held her baby with her right arm and her left stump was freshly dressed.  She has the most beautiful smile and let me take a picture of her before she left.

Thursdays are procedure days.  My boy from clinic with a urethral meatal stenosis came in for dilation.  I didn’t get to do it because I was still in the isolation ward when he arrived.  I removed a lipoma from a man’s shoulder.  John walked me through the procedure and let me do the sewing.  I love to stitch.  We showed him the tough, yellow tissue we removed and he seemed pleased. 

A girl came in with large ulcers on her abdomen and lower back.  She had been seen frequently for the past six months for subcutaneous nodules.  Recently, the nodules opened into ulcers leading to her presumed diagnosis of Buruli Ulcers.  These ulcers are caused by Mycobacterium ulcerans, which is a similar bacterium to Mycobacterium tuberculosis, the causative agent in TB.  It is common in West Africa and the majority of cases are seen in children.  It is a difficult infection to treat and long term Rifampin and an aminoglycoside are typically used, but not very effective.  Excision is most helpful, but debriding large areas can lead to increased risk of secondary infections and disfigurement.  This girl had dark, wrinkly, thickened skin across her entire abdomen, likely due to diffuse infection.  We only removed the worst parts of the skin and started the antibiotics.  Her prognosis is poor.

Lisa, John’s wife, came to the hospital to watch a C-section.  The surgery was delayed, so she asked Jill and I to baby sit Baby Jude (about 7 months).  We collected him and his things from Rachel and took him to the M4’s house for lunch.  He is the most mild mannered, easygoing, smiley, bubbly baby I have every met.  I’d like one just like him.

After lunch I sat on the front step with Kwame, Timothy, and Felix and attempted to teach them some simple algebra.  It would have been easier if they knew their multiplication tables.  They are in sixth grade and seem significantly behind compared with kids in the States, but are also very eager to learn.  After we did math for a while, they wanted to look at my notebook.  I showed them the page with the names of all the people I’ve met (including them), the protocols I copied for malaria, typhoid, and meningitis treatment, and the Mumpoole phrases I’ve learned.  They wanted to take their turn at teaching me, so went through counting to ten (they start with the thumb, Randy), the names of each finger, and the days of the week.  I would have loved to learn more anatomy terms to use in the hospital, but the truck was leaving for market.

I quickly changed from scrubs into a skirt to wear off the hospital grounds.  I’ve grown to appreciate skirts in the heat.  They really do allow much better air circulation.  It looked like it was about to storm and we were concerned that market would close early.  We had an hour to shop and I walked around with Susana and Zion.  We bought fabric, took pictures of cute kids, and I got a whole bag full of mangos for one cede.  We stopped by the gas station on the way home and I found pineapple pop (the only kind of pop I make exceptions for).  We bought the boys each a drink for helping us bargain, and then stopped by Joyce’s shop.  A few of the girls dropped off their fabric to make skirts.  I needed more time to decide on a style and pattern, but I think I’ll go back tomorrow over the lunch hour with my two fabrics.  There should be plenty left for a wrap to “wear a baby” on my back and for Mom to do a little quilting.

Dinner was an all staff/volunteer meal in celebration of Wendy’s birthday.  Wendy and Greg are the new volunteer coordinators who will be here for the next year or so.  Dr. Hewitt and his family are leaving in June after 20 years of service at the BMC.  Dr. Dickens and his family have been here for the past 1-2 years and will be leaving in September.  Richard is a third year family practice resident who is here for a week to check out the place and will likely return after graduation to be the new permanent staff doctor.  There are a lot of changes coming up at the BMC, but God has a way of providing for his people.  Please pray for a smooth transition and for sufficient hands to continue to provide quality care for the people of Nalerigu and the surrounding area.

Wednesday, April 14, 2010

This morning, Jill called me into her room because a second mouse came to visit us.  She saw it burrow under the clothes in her suitcase.  We dragged her bag onto the front step and I lifted each piece of clothing out with a spatula, shook it, and set it aside until we found the mouse, this time a baby.  We flipped it out (after a quick photo) and it ran straight for the house.  It hid it’s head under the side of the house as if we couldn’t see it’s back end.  I didn’t have the heart to kill it.  We may be seeing each other again.  Inside at breakfast, Jill’s chocolate breakfast bars were nibbled and she started to suspect a prank since my granola bars were fine.  I reassured her it was not me, but will keep it in mind for the future.  We hid our granola bars in a pot with a lid and put it into the fridge.

We rounded on the peds ward and discharged a few patients.  The kids were doing well this morning. 

The medical assistants have a malaria conference this week, so we have more clinic space and translators available.  I saw pediatric patients from 10-1 and 2-5 in my own room.  The translator did less multitasking today.  I enjoyed the independence and can honestly say that I think I took the best care of each patient that I could with the resources available (including walking a few patients over to Dr. Hewitt’s room on occasion to ask questions.)  I admitted four kids to the inpatient ward, including an infant with clinical meningitis that looked so ill I wrote for antibiotics and labs without even completing a full exam, a baby with fevers and a painful distended abdomen concerning for Typhoid with perforation, a febrile, listless baby who was not eating, had a large spleen, and may have severe malaria, and a baby with gastroenteritis and dehydration.

There was a good variety of patient in clinic.  I saw many kids with gastroenteritis, a hypotonic, developmentally delayed 9 month old with possible cerebral palsy versus Down syndrome, three kids with stomatitis, a boy with cervical lymphadenitis, an inguinal hernia in a 3 month old girl, a urethral meatal stenosis in a one year old boy, tinea capitus, a four year old boy with right hip bursitis, three infants with bulous impetigo, a two year old with nephritic syndrome, many upper respiratory tract infections, and a few pneumonias.  I handed out stickers to the kids and they really didn’t know what to do with them.  A few kids were terrified by my white skin and stethoscope and I attempted saying “Da Sakia” which is something similar to “Do not be afraid”.  It worked intermittently.  Most kids sat quietly in their mothers laps and allowed me to poke and prod without so much as a peep.

After clinic, I stopped by the peds ward to check on the kids I admitted from clinic.  Since I was there, the nurses had me see the rest of the new admissions as well.  The baby with meningitis had died an hour or two after the oncall team tapped him.  They said the CSF was cloudy, but there were no results since the chart went “missing.”  Each time that happens, I run through each of the antibiotics, IV fluids, and treatments and wonder what I missed or wheather anything else would have helped.  This child looked so sick in the clinic, I think it was inevitable.  The child with possible malaria continued to look sick, and I would not be surprised if she is not there in the morning.  I walked home, showered, and showed up late to supper, which was an all American mashed potatoes, fried chicken, and green beans.  We drummed and chatted, then off to blog.

As mom commented, I’m thankful for how well we have it in the US and how far medicine has advanced, but I’m also thankful for the simplicity of life here. Maybe I’ll stay.

Tuesday, April 13, 2010

There wre a lot of children to round on this morning.  The baby girl in respiratory distress last night was still retracting, but more alert and with clearer lungs than yesterday.  The nurses had discontinued the oxygen and she was nursing well.  Nursing staff kept urging her mother to remove the babies nasal discharge, which was done by mouth.  I discharged about three patients.  By the time we finished, the rest of the wards bad been seen.  In the Theater, a boy with osteomyelitis came in for debridement.  He had diffuse, draining bone infections and a piece of tibia was protruding from a wound on his shin.  Two pieces of necrotic bone were removed.  He has not been on antibiotics because long term IV therapy is needed, but not available, and oral medications would not be sufficient.  He limped a little, but did not complain of pain.  Kids here are tough.  I removed a fibrous cyst from a man’s shin.  A woman came in for drainage of abscesses deep in her thigh and back, and another woman had a sebaceous cyst removed from her forehead.

 At lunch, we met Hollynn, the preceptor for the West Virginia crowd, who arrived today.  We gave her a tour of the hospial, stopping at the nutrition center next door to see the cute kids.  A few ladies came over to us with their babies.  Hollynn asked to take picutres and a crowd gathered.  We got a bunch of pictures of their beautiful faces, but also the thin limbs, ribbed chests, and protuberant bellies caused by their low protein, low calorie diet.  The nutrition center provides meals for the kids and education for their mother about sanitary food preparation and the importance of a well balanced diet.  The education may be easier said than done.  There are readily available sources of carbohydrates (yams, bread, and rice) but very limited vegetables.  I have not seen any gardens in Nalerigu that survive the heat at this time of the year.  Mangos and bananas are available, as are coconuts and avacados for a price.  The women lay on mats on the red dusty ground and nurse their babies, or wash clothing together.  The often laugh when their children run away when they see the white “Sulamingas” as we walk past on our way to the hospital.  A little girl slowly strolled up to me the other day, gathered her courage, reached out, pinched my arm, then ran.  The group of mothers found it hillarious, as did I.  Today, the mothers fought for a chance to have their child photographed and were thrilled to see the digital images.  Many of the children wear black eye make up on their lower eye lids.

We walked out the BMC gate and into Nalerigu on a quest for a Ghanaian bike for Jill.  Hollynn joined us and we took her to Joyce’s shop where we had all bought botique quilted bags last week.  A group of kids (ranging from 15 months to second grade) joined us and wanted to hold hands for the walk.  Joyce had a new style of bag in process, so I bought another.  We talked with the kids as she added the final touches.  She saw Hollynn’s bag from Accra and examined it carefully so she could try to make one like it.  The kids joined us as we headed off in search of bikes.  A lady walking by greeted us with “Neza Nuri” which means good evening, and we started greeting others who watched us carefully.  The children multiplied until there were about a dozen or more, a few for each of our hands.  The youngest stumpled and fell, and Jill picked him (or her) up.  Many children have shaved heads, making gender difficult to determine.  A goup of young men redirected us to another street and one came along to walk us to the bike shop.  We learned “E Uri?”, or what is your name.  A few of the second graders spoke English well, but were too shy to mumble more than a few words.  They were eager for pictures and surged as a mass to see the pictures of themselves on our digital screens.  We found bikes, but none were small enough (or yellow enough) to travel home with us.  The little child in Jill’s arms fell asleep.  We returned the children to Joyce’s porch where they had found us, but the little one in Jill’s arms was too exhausted to wake up.  Joyce did not know who the child belonged to, but took them and said she would find out.  She is a very sweet lady.  We walked home as a dusty wind came up.  As we chatted on the porch, part of our young following found us and came running down the path.  We took a few more pictures and sent them home before it nightfall.  We had drummed, compiled picutres on a computer, then came to the school house to blog.

Sunday, April 11, 2010 - Addendum

So, I forgot to include the beginning and the end of Sunday. I was eating my morning mango and spoon of peanut butter when Jill stumbled into the back room. She shut the door and a moment later, I heard a scream and she popped out of the bathroom door. I went in to evaluate the situation and found a rodents paddling as hard as it could to get out of the toilet. It had a small pink nose, beady black eyes, whiskers, and a bushy tail. I flushed the toiled and though the water went down, but creature did not. We shut the lid and considered our options. A spoon and container was suggested, but we attempted flushing once more (after snapping a quick picture to prove our story). This time it disappeared and I flushed four more times for good measure.

Sunday evening was spent drumming at the M4’s house. Steph, Terry, Susana, and I beat our new drums and attempted to keep rhythm, which turns out to be a bit of a challenge. After about two hours of banging away, and a little singing, we finally got into a groove that sounded pretty cool, and probably was heard all across the back quarter. We agreed to another jam session in the near future.

Monday, April 12, 2010

We rounded on the peds patients this morning and I discharged two who had improved nicely. A little boy with a typhoid perforation underwent abdominal surgery six days ago and has been slow to regain bowel function. This morning, he had decreased pain and had stooled once, but remained distended. A little girl admitted with seizures and meningeal signs remained sedated on phenobarbitol, but her fevers had resolved. I began seeing her after she had been on antibiotics for over 24 hours, so did not tap her, but should have since a gram stain may have shown bacteria and then we would have know what we were treating. On rounds, we talked about Neisseria meningitis versus streptococcal meningitis. For patients with Neisseria, if they survive the first few days, they typically do well and have minimal squellae. Those with strep meningitis may initially do better, but then may deteriorate and often do not return to their baseline mental status. The elderly man I held last week for an LP was sitting up today, flexing his arms to show us how strong he was, and how ready he was for discharge.

We saw a few clinic patients before morning devotions for the patients. Dr. Hewitt had a chat with the nurses and medical assistant (MA) and they agreed to let me share the front room and see kids. The MA agreed readily, but the nurse manager was a harder sell. She was concerned that crowding the MAs would encourage them to leave, and she did not want to lose any of them. It made sense to me to keep the local, permanent staff happy, employed, and caring for their own people instead of pushing them out of the way to make room for temporary white visitors. The MA insisted that I take his seat and he pulled up an extra stool. Next time, I’ll try to take the stool.

I saw an infant with a scratch on her chin that developed into a large submandibular swelling that was warm, firm, tender, and preventing her from eating. I admitted her for IV antibiotics and possibly drainage. Other interesting patients of the day included a playful infant with a thick, sloughing rash on her forehead and chin, subcutaneous nodules on her wrist, chest, and thigh, and brown, horny nails. We started her on antifungal therapy, antibiotics for secondary bacterial infections, and scheduled a follow up. An eight year old boy presented with bleeding after urination. I sent him to the lab, and he returned with urine results showing Schistosoma Hematobium. After we ran out of pediatric patients, I saw an elderly man with a permanent suprapubic catheter. It had fallen out yesterday and he had replaced it himself. He was back for his monthly catheter change. He also complained of poor vision. I found out that we refer all vision issues to Gambaga where there is an ophthalmology nurse practitioner.

After clinic, I asked the “sister” (nurse in training and my translator for the day) to teach me a few more Mumpoole phrases, such as “Is the baby nursing?” “Eating?” “Drinking?” “Vomiting?” and “Having diarrhea?”

I stopped by the peds ward to check on my admission from clinic. The ward had filled during the day, and the cribs that sat empty during the first week of our trip were now full. I rounded on the new patients. One infant, the sickest whom they showed me first, was in significant respiratory distress. I increased the antibiotic dose, added Albuterol, and increased the oxygen. Another came in with seizures, was given Valium, and was now sitting up and eating. If he keeps it up, he will likely go home tomorrow. A third baby had mild crackles over the right lung fields, but also had small, warm, tender subcutaneous nodules. I started antibiotics to cover for skin infections, but I’m still not sure what they are. I commented to the nurse who was translating for me that the bumps were “interesting” and he laughed at me. A fourth baby arrived with dehydration, had already started IV fluids, and was drinking water from a bag. She had not urinated in three days, but had just peed and her mother was celebrating.

Cooled bags of water, about the size of a Ziploc sandwich bag, are the popular way of drinking clean water. People bite off a corner and drink straight from the bag. The only problem is, the plastic is dropped on the ground afterwards and blows where it will.

The medical assistants/nurses have been eyeing up my Harriet Lane and tonight asked where they could get a copy. A few extra Harriets in the peds ward would be exceptionally helpful. I will share the address if anyone would like to mail a few.

Supper was chicken and rice casserole, canned peas, cabbage salad, and for dessert – ice cream from a bag. Someone must have discovered our excitement for ice cream Sundays last night.

We visited our neighbors whose kids have both had fevers. The amoxicillin here, we found out, comes in bottles with powder in the bottom which is reconstituted with boiled water. The antibiotic is supposed to be stored in a dry cool place, which is a joke here. Yes, it is still hot, but I’m acclimating well to constantly dripping sweat. A cold shower felt fabulous, then over to the school house for internet-time.