June 20th, 2018 by melindaroney

I have been seeing patients for 2 weeks now.  Both in-patient and out-patient medicine are much different than at home.  Diagnoses are made clinically for the most part.  We can do a malaria test, a complete blood count, blood type and cross match for a transfusion, clotting times, blood sugar, Hepatitis B and C, HIV, sputum testing for TB, urinalysis, urine pregnancy testing and stool for ova and parasites.  They can analyze a few things on the cerebrospinal fluid to help diagnose meningitis.  We have x-ray but it is not always in a timely manner.  The doctors here are quite proficient at sonography.

There is a ton of typhoid here.  This is related to sub-optimal sanitation.  Headache, fever and abdominal pain are the usual complaints.  Malaria presents with similar symptoms.  We haven’t seen much malaria yet as it is just the beginning of the rainy season.  Everyone with this clinical picture gets a malaria test and if negative is treated for typhoid (with an antibiotic).  A major and common complication of typhoid is a perforation of the small intestine.  These patients present with an acute abdomen.  Surgery is life-saving.  I watched Dr. Faille do a repair 2 days ago.  This boy had only one small perforation, but it had allowed bilious fluid to escape into the peritoneal space (inside the abdomen but outside of the bowels and organs).  He closed the hole with suture.  Then he took the bowel wall about 1 cm from each side of that area and stitched that together over the closed perforation.  He said this will reinforce the repaired bowel. The peritoneal space was then suctioned, irrigated and suctioned again before the patient was closed.  This took about 30 minutes.  He repaired 4 perforations on a patient yesterday.  He had another repair today.

Snakebites are a huge problem here.  Since it is the beginning of the rainy season, everyone is farming.   The bites are either from the carpet viper or spitting cobra.  Most bites are on the feet or legs.  The snake venom causes a bleeding disorder.  The patients are hospitalized and receive anti-snake venom until the bleeding disorder is corrected.  If the leg is significantly swollen the patient is also treated for cellulitis and given tetanus anti-toxin.  Each vial of anti-snake venom costs 200 cedi (about $45 in the US).   The usual dosage need is 2-4 vials.  This is quite expensive for most people and is in addition to the price of hospitalization.

Everyone must pay their bills here, in cash.  Even with the state insurance, the bill must be paid before discharge.  Hospitalization is fairly reasonable by our standards, since BMC is a not-for-profit institution.  I saw a bill of 1150 cedi for surgery to repair typhoid perforations with 3-4 weeks of hospitalization due to complications.  That is around $255 US dollars.  My understanding is that at the larger hospital in Tamale, it is more expensive.  Apparently they want you to purchase your own supplies like IVs, catheters, etc. and once you acquire these items they will use them to treat you.

My third day rounding I saw a woman die of tetanus.  It was horrible.  There was nothing anyone could do.  Her teeth were clenched and she could not open her mouth.  Her head was drawn back due to the muscle spasms.  Anti-toxin and muscle relaxants were given but could not overcome the spasms that prevented her from being able to breathe and clear her saliva.  Google images of “lockjaw” and “opisthotonus” and you will see what I saw.  Then make sure your tetanus vaccine is up to date.

One of the men on the floor was unresponsive when we rounded one day.  He had had a stroke and was showing signs of increased intra-cranial pressure.  He died later that morning, on the floor, with family nearby.

I saw a lady about my age in clinic for a boil.  She told me she had been having it treated locally by a healer, but that it was not better.  She also showed me a black ulcer on the bottom of her foot about the size of a half-dollar.  She said it started like a mole but had grown to the current size.  The “boil” was a hard mass the size of half a football in her left upper thigh/groin region.  She received her clinical, terminal diagnosis of metastatic malignant melanoma in clinic when she expected to get treated for a boil.

I saw a 58 year old woman today who had post-menopausal vaginal bleeding for the past month.  Her exam was consistent with a cervical cancer with at least local spread.  She was referred to a Gyn specialist ASAP in a larger city.  I hope she can afford treatment (if there is treatment here) for her stage of cancer.

Dr. Faille told me about a patient he had seen with esophageal cancer.  He thought it was at a treatable stage.  He referred him to Tamale.  For some reason, the doctors there repeated much of what had been done here before the referral.  When they were ready to treat him for the cancer, he could not have the treatment.  He had spent all the money he had on the testing.  He died of his esophageal cancer, twice evaluated.