April 16th, 2008 Posted in Uncategorized
2nd week-
It has been a great week. We have been in Ankaase this entire week and have definitely become more acquainted with the town. We went on a wonderful tour (part one of three) of Ankaase on Wed. evening. There is a security guard at the hospital named Steven who has volunteered to show us the town. He took us all over and introduced us to many of the town elders and showed us the highlights of the town.
We did have a run-in with a scorpion this week, which is apparently very odd here… Paul was on his way to the kitchen for some water in the late evening and I heard him yell for me. I knew it must be important so I ran to see what had happened. He had this look of fear and said- “Kara, there is a scorpion out here.” Thankfully, he had his headlamp on and diid not step on it. We did catch it successfully, but the scorpion was not happy and even had it’s tail curl up and his pinchers up in the air. Paul kept the scorpion in a bucket and then it eventually died- so it is now preserved in ethanol.
As far as interesting learning cases/points at the hospital….
Monday-
I also saw 2 cesarian sections at the end of the day. Once again, the surgery setting is much different here in Ghana. I won’t go into details.
I saw an 85 year-old female who was a “known stroke pt.” I first saw her in the women’s ward and did not initially admit her. So, when I went to review her chart on rounds the history and physical did not really correlate with her present state. If the previous documentation was actually correct on admission, it appeared as if she had another stroke on the opposite side. The pt. also had a BP of 190/100 on admission.
When we saw here she had been given heavy doses of antihypertensive medications and her BP was 90/60’s. The pt. was not doing well at all- her breathing appeared chene stokes in nature. I have never seen a heart working so hard- you could see the sheets on her moving vigorously. When I palpated the heart the PMI was very lateral and I felt as if my hand was being lifted off of her chest. This pt. most likely had a low O2 sat- but we do not have a machine to check this- nor did we have O2 if the pt. actually would need the therapy.
We did check minimally available labs and her potassium was low. The pharmacy did not have potassium and it is very interesting- whatever the pharmacy does not have- we write a prescription and it is up to the family to go out and try and find it at another pharmacy in another city. So, needless to say when something is urgent –it could take quite a long time to actually take care of the issue.
Tuesday-
Unfortunately, the women from Monday passed away.
I also have been rounding in the children’s ward. Most of the children have malaria. It is now the rainy season and the cases are increasing. With severe cases- requiring admission we often give Quinine. The initial treatment usually requires the Quinine to be administered IM.
On rounds one of the girls I saw was complaining of leg pain. With further questioning it turns out the child had pain where the injections were being given. After going home and reading I realized the importance of proper Quinine IM injections. They are to be given in the anterior thigh and in alternating legs with alternating doses. This poor child had gotten all three doses in the same buttock. With this mistake in administration I learned that it can cause muscle necrosis and aseptic abscesses. I have watched her now for a couple of days and we switched her to oral Quinine. Her pain is decreasing and thankfully she did not develop either of the problems I mentioned above.
Wednesday/Thursday-
Upon entering the isolation ward there was an 90 year-old man who had been admitted overnight. On first appearance the man was propped up on pillows – to help him breath, he had a catheter which was draining hematuria into a small plastic bucket, and his legs were very edematous. After reviewing his chart the pt. was admitted with the diagnoses of: CHF, renal failure, anuria, and hypertension. There was not much discussion on rounds- the Lasix was increased and we moved on. I was definitely not satisfied and wanted to take some extra time to come back and further examine this man.
I did go back and reviewed this case with my host attending. I had looked over his labs and recognized his BUN, Cr, and alk phos were all elevated high. The other labs were WNL. The labs here are ordered with a lot of thought and nothing is ordered if it is not “necessary.”
I began to think…which of his problems came first or what could they be a result of. So, we decided to check his prostate- thinking he most likely had an obstructive process (likely an enlarged prostate), which could be causing his renal failure, and then lead to his heart failure. As a side note- we were also expecting mets due to his elevated alk phos.
On exam- unfortunately his prostate was very enlarged, firm, and had irregular nodularities present. We also ordered a renal ultrasound which showed bilateral hydronephrosis. We ended up referring him on Thursday to another hospital where a urologist would be able to evaluate this man.
We have physicians from Cuba, America, and Ghana- so with communication we often encounter language barriers. We also do not have official translators, and often have to rely on the nursing staff to help us. This is very difficult because they often speak poor English and the translation is not very accurate. So, anyways… the sad part of the story was as we were getting ready to leave him and he wanted to tell us something. We did not understand, but with the help of a nurse- he said he had been crying a lot because he was in so much pain.
- If you have been reading along- the man I mentioned who had the suspected Buruli ulcer is still with us. Paul met a man at one of the large teaching hospitals who can run a PCR analysis on a wound culture to confirm this diagnosis. We are going to drop it off tomorrow and we will see if this is indeed the diagnosis. The poor man is in a lot of pain, but has amazingly avoided any secondary infections after his extensive debridement. The conditions here are definitely not always very clean.
Friday-
We are headed to Mole National Park this weekend. They have little shelters with porches where you can sit and watch over a watering hole to view many different animals. The trip will be long and the roads are not supposed to be very well, so it should be an interesting trip.
Twi-
Kootamoo- good work?
Adenye wyo- what complaints do you have? (in the clinic setting)
Acofe- cough?
I am sorry to be so behind in my blog. I have had this ready to post for 1 week and the internet access was not available. You just never know what will occur in a day here in Ghana. I have much to tell you about our trip- hopefully I can post it soon. Take care.