Sheila’s Blog

Goodbye Baptist Medical Center

So our last week has come and gone, and I have not blogged.  It went by so fast!  Monday was a holiday because Sunday, March 6 was Ghana’s independence day.  It was nice to have an extra day off of clinic.  Although Disa and I were on call every night this week since we were the only volunteers at BMC for the last week, we didn’t receive very many late night calls.  Morning rounds were not bad either.  Looks like we really did become more efficient and comfortable. 

On Thursday, we wanted to make sure we visited one of the nearby schools and saw the orphanage.  There are two girls from Germany, Lina and Jaqueline, who are volunteering their time teaching at the school in the morning, and playing with the oraphans in the afternoon.  These girls are amazing - they are only 19 years old and they are doing such a great thing.  I am impressed that they are so young yet mature and capable of spending time in such a different country.  Lina is in Ghana for 3 months, and Jaqueline is in Ghana for 5 months.  Anyway, the name of the school is Happy Child and it is such a neat place.  There is an American volunteer named Cathy who has put in a lot of work decorating the walls with very pretty paintings.  The students learn French, English, Math, Art, and some other subjects I am not sure of.  There are children of all ages.  There is a toddler’s area where children as young as 2 learn ABCs!  They are so smart.  We took really cute pictures of them because naturally they were enthralled with us and would not let go of our hands during the entire visit. 

The orphanage is an interesting place. These children are not orphans in the traditional sense. They actually have a mother, but her husband is dead and she is remarried and the second husband does not want to be a father to the children. These kids are at the orphanage all day and then actually go home at night. They are definitely not very loved and are starved for attention. They are very dramatic whenever they get hurt just to get our attention. Regardless of the sad story behind some of it, they are a great bunch of kids and it was fun hanging out with them. We brought them jumpropes and frisbees and they had a good time with that. They are naturals at jumprope! It was so cute to watch them play and sing their songs.

Some interesting patients this week:
- Success story: girl with peritonitis who I thought would have to have surgery, but we tried medical management with her and it worked! She left the hospital happy and healthy
- Young boy playing with a gun (don’t know where he got it from) and it accidentally went off and now he has no thumb or index finger
- Old man who came in with a chief complaint of blood in his urine. The medical assistant diagnosed him with a urinary tract infection. I was thinking that sure, it could be as simple as an infection or a kidney stone, but what if it’s cancer. Just to be thorough I performed an ultrasound on his bladder and it turns out he has has a pretty large mass there.
- New mother with a baby born at 30 weeks who weighs 1kg!! The baby is doing great, somehow. In a sense, he can make up for the numerous children we have lost since the start of our month
- Funny chief complaints from patients in clinic
“Doctor, my body feels very warm at night, and when I sweat, I sweat only on one half of my body, usually the right side. When the right side sweats, I feel pain in my eyes.”

“I am having white urine.” To this, I thought of possible a sexually transmitted disease. I asked him if this white stuff comes out of his penis even when he is not urinating. He responded “Yes, even when I go to toilet, it comes out of my penis.” By the way “going to toilet” means passing stool.

“I have a hernia in my neck.”

There is a attitude here that if you are bleeding from anywhere, you are a serious case that needs immediate medical attention. So one of the coordinators in clinic told me that I should see a patient because she is bleeding and it is very serious. She tells me, “I am pregnant for one month. But this month I am having bleeding.” I asked her if it was similar in flow to her normal menses. She replied yes…..her ultrasound showed no pregnancy, so she was just having a period.

I am really going to miss the BMC and all my experiences there. I am ready to go home and find out where I am headed for residency, but I am so glad I had this experience and I am ready to take on my next international medical rotation. As I watch the news at the devastation from the earthquake and tsunami in Japan, I wish I could just pack my bags and go there to help. I know that international aid is definitely my calling - can’t wait to make my next trip!

Last Sunday in Ghana

Today was a pretty relaxing day.  Though it was Independence Day, unfortunately there were no celebrations here in Nalerigu.  We watched some of the events in Accra on the television in the hospitals and handed out candy to the nursing staff and patients to celebrate.  In the evening we had dinner with the Nyus family.  They are Baptist missionaries who are spending a year in Nalerigu as volunteer coordinators.  They are a very sweet family - they have three kids: Carter (10), Aiden (7), and Sukonya (7).  Sukonya was adopted from India and she has taken quite a liking towards me because of that.  I call her my little twin  I have shown her pictures of India and am teaching her a few Hindi words.  She loves it, and it makes me wish I had a little sister.  After dinner and after the kids went to sleep, Disa and I spent some time talking with Wendy and Greg (the parents) and it was a really great conversation about feeling called towards various things in life, whether it is a calling from God (which is how they see their purposes in life) or whether it is from an innate desire.  It’s interesting because some people think that me spending a month in Africa is a big deal, while I have met so many people here who are spending a year or even a lifetime serving the community here - I admire them for truly giving up a more comfortable life in order to help others.  We also talked about the challenges they have faced with adoption and since I plan on adopting one day, it was good to hear how they handled the frustrations.  I cannot wait to travel more and see more of the world.  I love meeting people from all over and learning about their different purposes and callings.  It’s all about perspective, and it’s all relative.  I have definitely been left with some interesting thoughts this evening….

End of third week

I’ve been writing less and less now, but I can’t believe how fast the days are going by.  I think the days are finally getting routine, in a good way.  I am settling in and getting used to things.  Some of the highlights this week included a 4-year old boy that we biopsied for likely rhabdomyosarcoma, 1-year old who tripped and ended up biting her tongue almost in half, lady with large liver cancer and likely mets, yet another motobike accident,  but I actually got to see his open fracture - his tibia was sticking out of his leg and he was still conscious enough to tell me how the accident happened.  We went to a restaurant called Las Vegas, haha.  We basically had chicken and rice, but it was delicious.  Apparently Ghanaians like their food spicy, and I have NO problem with that  

Last night was a little hectic.  There was a lorry accident and the vehicle was carrying somewhere around 20 people.  Here, aside from the people in the vehicle, there are usually another 10-12 men sitting on the roof.  I personally was expecting lots of lacerations and gaping wounds, but to my surprise, only one person died and only 5 people were admitted with fractures.  All the other people only had minor injuries and didn’t need to be admitted.  I did kinda freak out though.  To all the people I saw who did not seem ill, I simply asked them if they were bleeding from anywhere and if they could walk and move all their extremities.  If they had no bleeding and could do that, I sent them home with Ibuprofen.  What made it more difficult was that most of people crowded around were people NOT in the accident.  There is no such thing as crown control here, so the curiosity of the community made for a lot of chaos in the lobby of the hospital.  We couldn’t tell who needed to be seen and who was simply there to watch. Anyway, I’m glad it was not more serious.

Today, after rounds, we had another adventure. We traveled to Paga, which is a town in nothern Ghana, just near the border with Burkina Faso. It is about 2.5 hours from Nalerigu. We went to a crocodile farm where we fed the crocodiles live chickens and then got to sit on the crocs and take pictures. Pretty wild, but how many opportunities will I have to sit on one? We also did a little shopping again, which of course was fun. Now I am exhausted and happy that I still have more weekend left over. Monday is a holiday because tomorrow (Sunday) is independence day. I don’t know that there will be much celebration in Nalerigu, it seems there is a big parade in Accra. I will let you know what happens!

Nurse’s Documentation

The way the nurses communicate to us about the declining status of a patient is pretty hilarious here.  Usually, if we get a call overnight, the conversation goes something like this.

Nurse: Doctor, the patient’s condition has changed
Doctor: What has changed?
Nurse: The respiration condition has changed
Doctor: Is the patient breathing?
Nurse: No, he is not
Doctor: Is the patient dead?
Nurse: Yes, I believe so.

Even funnier is the nurse’s note I saw in the chart the other day.  It was a non-clinic day so all the docs were eating lunch.  One of the nurses stopped by our house with the patient’s chart saying that a patient’s condition had changed.  He showed me the nurse’s note.  It said “Patient’s respirations are non-satisfactory.  Pulse is not felt.  Needs immediate MD attention.”  It seems like the patient needed immediate MD attention before his respirations became “non-satisfactory.”  HILARIOUS!

Update and some random things

This week is flying by - I just realized that I haven’t written anything in three days.  But a lot of stuff has happened.  I will start with a happy story.  There was a 13-year old female patient I had been seeing in the wards for the past 3-4 days.  She was admitted for a very bad tonsillitis/pharyngitis.  The first day I saw her she really scared me because her tonsils were so inflamed that I could not see the back of her throat.  The first thing I thought about was airway compromise, but because we have no ventilators here, if something happened, there would be no real way to save her.  She could barely open her mouth because of the pain.  She could not eat anything, only take some liquids.  She had almost a 103F fever.  Anyway, I changed her antibiotics over the few days, and although normally within 24-28 hours  you see a difference, she had not changed much after two days.  Then on Sunday evening as I was passing through the wards, I saw her eating - I have never been so excited to see someone eat potatoes!  I came over to her and gave her a hug and a big smile, and she smiled back.  Here, a smile from a child is HUGE deal.  I’m not sure if it’s because they live a hard life here or if it’s because they are so disciplined, but the children overall do not smile and laugh very much.  It is a treat to see a happy child, at least in the hospital - the ones that are half naked in the streets yelling “saminga” are very happy.  Anyway, I discharged her yesterday, after she was able to open her mouth without pain and I could visualize the back of her throat.  I was caught up with another patient when I felt a tap on my shoulder - she waved bye to me and smiled.  I gave her a hug  That has definitely been one of my more rewarding patients.  After clinic finished on Monday, Disa and I had a few procedures, one of which included draining a huge abscess from a man’s upper thigh.  The pus squirted out like a waterfall - pretty neat stuff.  Draining abscesses is immediate gratification.  You cut it open, drain it, and the patient has immediate relief - once they get over the incision you made in their skin.  But at least they don’t have hot swollen infected skin anymore.  I have started doing rounds in the meningitis isolation wards now.  I really like it.  I think I might start rounding in the tuberculosis wards too.  I just really like treating sick patients.  Even though you lose a lot of them, when you save one, it is such a dramatic recovery.  Which explains why I hate clinic - regardless of which country it is in.  Here patients present in one of two ways: they are almost dying and need to be admitted to the hospital, or they have general symptoms and are healthy and you  are stuck choosing between Tylenol or a multivitamin in order to appease their desire to get something from the doctor’s office.  The typical office visit is a patient who has all of the following: headache, chest pain, waist pain (otherwise known as low back pain), abdominal pain, and fever.  Don’t forget it’s Africa and it’s always hot, so people always think they have fevers, they probably don’t drink enough water which is why they get headaches, the women carry babies on their back and heavy pots on their heads which is probably where the waist pain comes from, and the water is full of who knows what, so the abdominal pain is not surprising either.  But the hard part is knowing when to be worried about malaria or typhoid, which could kill one of these patients if you write them all off as not being sick.  One of the funnier things about people here is how they are so eager to make sure you use your stethoscope on their skin directly.  In the States, patients don’t even offer to remove their sweaters or sweatshirts.  Here, as soon as you gesture towards your stethoscope, they remove their entire shirts to exposure their skin - even the women, which was a little awkward at first since they have no problem exposing their breasts to everyone in the room.  Procedures for me today included a lumbar puncture, a paracentesis, and putting a pessary in a woman who had a prolapsed uterus.  After I put it in, I wanted to make sure she was comfortable and not in pain, so I told her to walk around the hospital floor with me.  There we were - just the two of us: “doctor” and patient who just got a pessary, just taking a casual walk through the hospital - it was kinda funny.  Anyway, that’s about all for now.  Can’t believe tomorrow is already Thursday…..

Church in Ghana

One of the nurses in the pediatric ward (Bruno) invited Disa and I to church this Sunday.  We figured it would be a good experience, so we went.  The men sit on one side, and the women on the other.  The first hour was lots of singing and dancing.  People danced up the aisles and gave offerings.  That part was fun.  Once again, the kids were fascinated with us, so they all wanted to come and sit on our laps during church - it was cute.  The second hour was the sermon.  I can’t say I enjoyed it very much, I really have no idea what the pastor was trying to convey.  Don’t think I will be going to church again while I’m here, once was enough.  It was a busy Sunday.  Our most interesting case is a Fulani lady who is about 7 months pregnant.  Fulani people are an ethnic group here that are identifiable by their features and their clothing/hair.  They are looked down upon and made fun of by the rest of the people here.  That really annoys me, but I can’t do anything about it.  She has been in the hospital almost as long as I have been in Nalerigu.  She came in with severe anemia and we have tried to transfuse her several times, but we can never get her hematocrit stable.  She is pancytopenic (low white cells, low red cells, and low platelets) and we figure she most likely has a bone marrow disorder.  Her numbers are impressive: her white count is 0.9, her hematocrit is 7, and her platelets are 5.  Big surprise, she has a nosebleed that won’t stop because she has almost no platelets.  She has had the nose bleed for over 24 hours now and everytime we try and pack her nose, she refuses.  There is a lack of education, difficulty communicating, and frustration playing a role in her care.  We finally convinced her to go to a bigger hospital with more resources in Kumasi, which is a few hours  south of us, in the Ahanti region (Nalerigu is in the northern region of Ghana.)  I am really tired from the weekend and not feeling like I have much energy for a clinic day tomorrow, but oh well.  I have no choice.  Let’s see what week 3 brings.

End of the second week

This second week has flown by.  One of the other 4th year med students, Jake, is leaving tomorrow since he has finished his one month here.  He is a really smart, compassionate person who wants to OB/Gyn.  He has been like a senior resident to me here, and I only wish that I could be as comfortable now as he is with seeing all these patients.  We went out last night to celebrate his last couple nights in Nalerigu at the BMC.  We had a busy clinic day and then had a few procedures: I did a D&C on a lady who had a spontaneous abortion and I assisted Disa with an I&D on a girl who had a huge abscess on her right hand.  Since we were on call, we ended up having to go the hospital after our night out.  We got there at about 1am sadly, a premature infant ended up dying from respiratory failure.  Yesterday was another rough day for deaths.  I was called to the floor in the afternoon to see a 25-year old male whose “pulse stopped.”  Then during clinic, I went to ask one of the residents, Jess, a question about a patient.  While I was waiting in the room, a crying mom came in and brought her child in who was about 3 years old.  She was holding him in her arms and looked at Jess with help in her eyes - the child was already dead.  We could not get a clear history about what happened.  We pretty much sat in silence for a good minute.  One of the patients I had was a 60ish year old lady with postmenopausal bleeding for 3 days.  When I did my bimanual exam on her, there was so much blood it trickled off the table, onto my skirt, and then onto my right foot.  I couldn’t believe the hardened nodules I could feel on her cervix.  Needless to say she has advanced cervical cancer, and even more upsetting is that as I tried to explain to her the disease and how we don’t have the technology here to see how advanced it is, I could tell she totally didn’t get it.  It’s even more annoying to have to go through a translator to explain something like that.  The premature baby dying was the last straw for the day. I left the hospital pretty pissed - I guess I’m not as used to all these deaths as I thought, which is probably a good thing not to get numb to it.  Today during morning rounds I did an LP on a patient who ended up dying later in the afternoon.  Thank goodness we had some fun plans for Saturday.  After rounds we went to an escarpment near a town  called Nakpanduri about 18 miles away and did a short hike.  At the top we could see the edges of two neighboring countries: Burkina Faso and Togo.  It was very relaxing and the scenery was very pretty.  It was nice to do something physical and forget about the hospital for a few hours.  Tomorrow we will be going to church with a couple of the nurses.  It should be fun to see how church is here.  I will update you all on how it goes!

To the village we go

Today was a nice change from regular clinic.  I decided that instead of doing clinic at BMC, I would go out into the village with the dentist and pediatrician (Dr. Prine) and see patients there.  This will be my last opportunity to work with Dr. Prine since the big group he came with is leaving tomorrow to go back to the States.  I have learned a lot from him about pediatrics and critical care - he has been inspiring and motivating, and he is overall an intelligent, compassionate, competent doc.  We rounded in the morning, and then took off for the village at around 10am.  We rode in a truck and all together there were 10 of us - Disa and I sat in the bed of the truck with the 3 translators that came with us.  It was about a 1.5 hour drive - it probably should have only been 45 minutes, but the “road” was literally a bunch of rocks and ditches that we had to navigate through.  Thank goodness we had a truck.  Once, we got there, we set up camp and as we expected there was a huge line of mothers with their children.  The dentist had his own line of people waiting to get their teeth pulled.  We told the mothers that we wanted to see the sickest children first, but naturally that didn’t work.  It was extremely hot and hectic. While initially we had a good area of space to work with, it slowly became stifled by the mothers and their many children crowding closer and closer towards us to make sure their kids were seen first.  They even began arguing with one another and it would get so loud that I had a hard time listening for heart and lung sounds.  Most kids were healthy - they had very general complaints like diarrhea, cough, vomiting, but no real sickness.  For those kids we gave multivitamins.  There were a handful of sick kids that we saw for malaria, typhoid, pneumonia, and some other things.  One child that Disa saw had a temp of 103, so we actually ended up taking her back to the BMC with us so that we could hospitalize him (that was Dr. Prine’s idea - I told you he was compassionate  I definitely felt overwhelmed and frustrated with how aggressive some of the mothers were, but I tried to remember that they don’t have access to doctors/medicine, so it’s only natural for them to want their children to be seen regardless of real sickness.  It was really a fun day.  At the end, although we were not able to see all the kids, they still chased after the truck as we drove away, waving and smiling, and of course, calling us Saminga  The road back was even crazier than the way into the village.  We literally drove through a steam and twice during the course, we had to push the truck to get it over several rocks, or to get it through thick sand - it was quite a scene and very hilarious.  After we got home and showered and had dinner, we had a meeting with all the volunteers and the volunteer coordinators - this happens every Thursday night.  One of the coordinators who has lived in several other countries as a missionary mentioned what a great experience it is getting to see how people can live with so little and still be happy.  He mentioned that it’s not about what you have, but it’s about being content because you are with people that you love and enjoying being with.  I totally agree with that.  I am really glad that Disa is with me on this trip and we met some really great people.  My mood is definitely back to high spirits today

My blood does not save lives

Quick update on the cases from yesterday’s depressing blog: I never got to check in again on the confused elderly lady because one of my colleagues discharged her without me knowing (I was kinda mad about that), the little boy who was bleeding because of the snake bite is better and finally not bleeding, and the 10-month old boy was initially doing better, so I donated another 120mls of blood to him, but he ended up dying.  Basically, it was a day of mixed emotions.  I ended the day by putting about 10 stitches in a lady whose C-section wound dehisced.  Disa and I were on call last night.  Finished rounding at 9:30pm, got a maternity call at midnight, then a pediatric respiratory distress call at 3am.  Both cases turned out well, so good news there.  My mood is on the upswing…..

Frustrations

There are some days here where I feel like I am ready to start residency because my knowledge is sufficient for an intern.  Then there are other days where I think I should start medical school all over again.  Today was a mix of up and down feelings of confidence as I treated different patients.  I ended the day feeling bad, and I am just hoping tomorrow will be better.  Here is what happened.  The whole morning was pretty slow.  Right now there are three medical students, two FP residents, a pediatrician, and Rich who round on patients everyday.  This makes rounds go pretty quickly.  There was little do and I ate lunch slowly and didn’t go back to the hospital until 3:30 in the afternoon.  Then, as it always eventually does, hell breaks loose.  There are some general things about working at the BMC that make it very hard to treat patients.  One is that patients have VERY general complaints.  They will say they have abdominal pain, but when you ask them exactly where, the will never point to one spot or area, it’s always the entire abdomen.  Another is that no one ever has just one complaint.  It’s always abdominal with a headache and low back pain (or “waist pain” at they call it here.)  Or headache, chest pain, and waist pain.  Also, no one ever denies that they have a fever.  If you ask them, they will always say they have a fever.  And regarding vomiting and diarrhea, there are so many things here that can cause those symptoms that you never know how serious to take it.  It could be as simple as viral gastroenteritis, or as serious as typhoid complications.  Plus, the interpretation of diarrhea varies from person to person, so I can only imagine that it also varies from culture to culture.  Here are the patients that we saw.  Case #1: older lady who comes in after passing out while on the toilet, has had fever, nausea, vomiting, and diarrhea for 7 days, is completely confused and can hardly follow commands.  I would love to do a CT scan of her head because she has no idea if she hit her head, and her son is concerned about her confusion.  The medical assistant who admitted her to the hospital put her on medicine for malaria, but we basically do that to everyone, and I’m not sure if it’s right.  So I write to hold the malaria meds, and I want to check her urine for an infection since UTIs are a VERY common cause of sepsis in older people and commonly cause confusion.  I put her on an antibiotic that will cover the UTI in case the tests come out positive.  When I go in to check on her hours later, she still has not produced urine - now I’m concerned.  Is she having renal failure?  Of course, they do not have the labs here so that I can check that, plus she looks worse and is still vomiting.  Disa said she thought we should just prescribe typhoid medicine.  I felt frustrated because I was trying not to do the easy thing and just prescribe typhoid and malaria meds for every patient that comes in.  But maybe this time, I tried too hard and missed something obvious??  I don’t know, but it made me feel stupid.  Plus, then I had to worry about sepsis and calculate how much fluid resuscitation I need to give her, which is also hard because I do not know her kidney status and the labs I ordered to check if she has any infectious process going on are not back yet.  So I had to do the obvious and put her on typhoid medicine.  We will see how she does in the morning.  Case #2: an 8-year old boy had a snake bite five days ago (they have carpet vipers here that prevent your blood from clotting) and he has been having nosebleeds.  As I’m talking to him, I see some blood drip out of his mouth, then his nose starts bleeding.  We try to stop the bleeding for 15 minutes and are getting nowhere.  We know we need to pack the nose, so we call Rich and try to put a nasal tampon in his nose.  The bleeding continues.  We try for over an hour to pack his nose successfully and are making some progress.  Then he starts complaining of ear pain.  We look in his ear and he has a ruptured eardrum with blood coming out.  There is nothing we can do about that, so we finish packing his nose and will recheck things later.  About 2 hours later, his father comes and grabs us because the boy has vomited all over the floor and it’s full of blood.  Now I start freaking out.  We talk to the surgeons who say that he will have problems clotting for weeks since the venom has been in his system for days now.  There is nothing we can do except give him anti-venom (although at this point, it will not do much) and make sure his blood count stays up.  He already had one unit of blood, so I ordered another one and gave him the anti-venom.  His father thinks he is going to die, and although I told the translator that based on his labs, he would probably do fine, I don’t think she conveyed the information sympathetically.  Plus, his father donated the unit of blood for his son earlier, so he cannot give more.  Now he is worried he will not be able to find someone to donate blood.  At this hospital, the families are extremely important in the patient’s hospital stay.  The hospital does not have the money to provide food, blood, extra clothing/sheets, or help cleaning the patient/assisting them to the restroom or physical therapy.  Plus, the nurses here are overworked because they see so many patients and are used to seeing people die.  While I wanted to comfort the father, I could not do it myself, and I could tell that the translator did not care.  In the States, we place a big emphasis on being empathetic and communicating with the family.  It’s just not like that here.  Case #3: 10 month old with severe anemia, extremely pale, in respiratory failure.  We gave him a breathing treatment, treated him with antiobiotics and steroids for sepsis, and he started to improve.  But he needed blood and when the mom went out into the village to find the person who told her she would donate blood if needed, she could not find her.  She was upset and started to panic.  I decided I would donate blood for the child.  I’ve always wanted to donate blood, but since I have been to India frequently, they won’t let me do it in the States.  Who knew my first donation would be here.  The baby was stable when we left, but again, we will see tomorrow.  Most of these patients that come in really sick don’t make it.  But I will try and stay strong-spirited so that I don’t become too cynical.  The other day one of the nurses here told me that my spirit is inspiring to him - I must use that in my motivation to stay positive and never stop working hard for these patients, regardless of the limitations here.  Here’s hoping for a better tomorrow…..