The theatre scheduling board is clean (a rare sight at the BMC) and an indication that my time here has come to an end. I will leave in the morning for Accra and then tomorrow night will fly out to the US.  I am always thankful for the time I spend here at the BMC and sad when it comes to an end.  It is a time to reconnect with friends and make new ones.  It is a time to disconnect a bit from the busy routine I live in STL and remember what is truly important . . . family, friends, health, and my faith.  It is humbling and awe-inspiring to treat and care for the poorest of the poor in this World.  There are great challenges . . . clinically, ethically, and mentally, that stretch my abilities and I know make me a better surgeon, physician, and person.

Although the board is clean now, I know it will not stay that way for long.  After I leave tomorrow the struggles of the people in Northern Ghana will continue and I will be back home, praying daily for Dr. Emma and David (two Ghanaian MDs), Dr. Haun and Cahill (missionary MDs), and all of the scores of short term BMC volunteers, that God grants them wisdom and strength as they continue their work at the BMC. 

Ewey Eyeballs

I was asked to see this lady in the isolation ward for the infection of her face.  She states that about 10 days ago, she experienced a brief pain in her right jaw.  The pain resolved but then her eyes started to swell.  I have never seen anything like this and I was happy that my friend, and current BMC surgeon Heidi Haun and returned from her travels. because truth be told . . . eye balls and surgery around eye balls sort of freak me out!   We are not sure why this has occurred but she mostly likely had an infection in one of her sinus that traveled to the skin around her eyes causing cellulitis, abscess, and eventual necrosis of the skin.  

 

Her upper and lower eye lid on the right eye was basically just two small islands of normal skin surrounded abscess and the yellow you see above and below the eye is skin that became necrotic and sluffed away.

The eye and surrounding structures are a complicated part of the body and so we went to our handy little library so look up some anatomy and check some textbooks.  There is a really useful book that is published for surgeons practicing in rural third world areas.  It was published a while ago, but is still a great resource that I often use.  It can sometimes be comical because it is written in English but in the way Africans speak English and then also, even though it is a medical textbook it will sometimes have funny opinions or running commentaries in the chapters.  At the beginning of the section about the eye it all caps large print was written, “DO NOT BE AFRAID OF SURGERY AROUND THE EYE SOCKET!!”  Well knowing that information Heidi and I felt right at home and were no longer worried tackling this unusual case!

"Saminga Hello"

Every day on my way to the hospital I pass by the nutrition center.  Here mothers and their child live while the children are being treated for malnutrition.  There has been a small child maybe two to three years old who has been there and every time I pass he would yell out, “Saminga, Saminga.”  That is what white people are called here.  I would always wave and smile at him.  Over the past few weeks he has gotten closer and closer to the path and then yesterday afternoon he was maybe only about 10 ft away.  I stopped and waved.  He seemed to approach closer, so I walked towards him slowly with my hand out to greet him.  I went until there was maybe a foot or two between us.  He tentatively came closer his eyes wide and slowly raised his hand and took my hand.  As soon as our hands touched it was if I gave him a big electric shock, he pulled away, burst into tears and ran to hide.  All of the mothers watching the scene burst into laughter.  I was sure our blossoming friendship had come to an end.  When I walked by again today there he was yelling and smiling again, “Saminga, Saminga.”  This time though safely from across a field! 

Many of the children here are scared of us.  The babies don’t really care, but then between maybe one to four I find they are deathly afraid.  They will cry or hide if you try to get near.  The older children are probably afraid also, but the children here are very stoic so if they are scared they don’t show it.  School children in town are less afraid and have fun trying to use their English and greeting me.  So when I come across a child that is not scared and gives you a hug or climbs in your lap it is a special treat.

They start early learning how to carry things on their heads!!

I have been staying in House 6 which is basically a house were short term volunteers live.  It has 5 bedrooms with multiple beds in each room.  There is a kitchen and common area with a dinning room.  I am the only one here at the moment which is a bit unusual.  Usually there is at least a few medical students or residents doing rotations at the BMC.  So it has been a bit quiet around here, especially with the two long term missionary families being away also.  It has been good though to after work just have time to read (I have amazingly finished three books) and write. 

I am staying in the room that I first stayed in when I moved to Nalerigu in 2012.  It has brought back a lot of memories.  I was really just finding my way at that time, pretty tentative about my new life and work, wondering each day what I had gotten myself into!  Now I feel like a pro, although I realize quickly each time I am here that there are still things about the culture and medicine I have to learn.

Not a very good picture, but this is House 6

Outside of the school house

This is where the missionary kids have school during the day and where I have been writing and posting my blog at night.

Case: Cellulitis of the Arm - Warning unpleasnt pictures

People often wait too long before they present to the hospital.  Sometimes it is their fault.  They think things will get better or they seek “local medicine” from a healer before they present to the BMC.  For those living in very rural villages though it can be very difficult to find their way to the hospital.  The roads to many villages are very bad and sometime impassible during times of the year like the rainy season.  Some have no means of transportation so they wait until a moto or truck comes by their village.  Sometimes that will be even a week until the next market day to be able to hitch a ride out of the village. 

What this means to us and the BMC is that people present often very ill and in conditions that are far worse than if they had come to the BMC earlier.  If they have taken local medicine they can also be much sicker from the toxins in it.  Infectious disease cases of course are the worse.  During the last two weeks, I have seen many cases that have presented too late.  Some has caused the death of the patient, others great injury that will be life debilitating.

Cellulitis if untreated will continue to spread on the limb and infect and necrosis the underlying tissue.  Often patients with cellulitis fail to present early because although they might have some mild swelling of the leg their skin remains intact and so the think the illness will resolve on its own.  They often present in very late stages with necrosis of the skin and underlying subcutaneous tissue and fascia.  These are devastating cases because you basically have to remove all of that dead tissue, usually to the underlying muscle of the limb, leaving massive wounds.  After wide debridement, they are treated with antibiotics and dressing changes and as soon as the wounds are clean with good pink healthy tissue then skin grafts will be placed.  The grafts will sometimes work, but often patients end up with chronic wounds, contractures, and sometimes eventual amputation.  I always disliked taking care of these cases and I was hoping that during this visit I might get away without seeing one or needing to perform a big soft tissue debridement, but no such luck.  Below are the pictures of a man’s arm before and after his several trip to the theatre for debridement.

Warning Unpleasant Pictures Below:

The dead skin continued around his entire arm.  You can see it is too his wrist on the left and up past his elbow.  His hand out of the picture was very swollen, but the skin heathy.

At the beginning of his second debridement.  You can see that he still has more dead skin and fascia to remove in this picture off to the right.  The pink tissue on the right is the muscles of his arm.

Ghanaian Optimism

Death of course is always a part of life, but here in Nalerigu at the BMC it just seems more real somehow, more present than back home.  I am not sure why that is completely.  Losing a patient always weighs heavy on your heart and I have lost patients in the US before but somehow here it hurts more.  I think a lot of it has to do with the fact that although I know that I did my best for the patient, I know that it is not the best that the World has to offer.  It is hard to watch people suffer and die when I know if there were better resources available they might live.  The little girl I operated on last week for a Typhoid perforation passed away.  Ultimately from sepsis and respiratory failure, things we would have been able to support her through in the US with medications and a respirator.  When I showed up in the morning her bed was empty, striped clean.  I can’t quite describe the feeling when you walk into the ward and encounter an empty bed.  The mattresses here are black and so in a ward with painted walls, full of colorful cloth and patients strewn all over other beds and on the floors, it is just a glaring black emptiness . . . saying death was here last night.  No matter how many times I have encountered an empty bed, I still hope that for some reason the patient was just moved.  I go to the nursing office to ask, just to hear, “The patient has died.”  Blunt and to the point.  To me sometimes the hospital staff seems caviler about death, but I know they are not and it is because they see so much doing what they do every day.  We have all learned that you have to compartmentalize the death we see because you have to move on because truthfully, there is another sicker patient right around the corner that needs you at your best. 

Life is hard in Ghana, especially in the poorer North of the country.   But what really impresses me is the amazing optimism people here have.  For a pessimistic, like myself, it is truly awe inspiring.  How do they muster such hope and confidence things will get better right around the corner?  The ultimate optimist was my friend Solomon, who unfortunately passed away this winter.  I don’t know how old Solomon was, in fact I don’t think Solomon even knew his age.  When you would ask Solomon a question he did not know the answer to he would just flash his broad smile, giggle and look away.  That is what he did when I once asked him his age.  I think he was most likely in his early to mid-twenties though.  I met Solomon my first week at the BMC in 2012.  Solomon had sickle cell disease and had developed a chronic wound on his right lower leg.  By the time, I met him he had already failed many skin grafts.  The surgeon at the time was handing off patients to me before he left and introduced us.  Solomon would stop by the outpatient clinic almost every week to just say hello and greet me, eventually he hung around the outpatient clinic so much that we put him to work as an unofficial translator.  Every month I would see him as a patient and evaluate his wound.  Since he already had failed so many skin grafts, after talking with the other surgeons that knew Solomon, we all decided we would not offer him any more surgeries.  We all knew what the outcomes of more skin grafts would be and it would just be putting him at risk for operative complications.  Solomon however would not give up hope that one day his wound would heal.  He would come to clinic and beg me to perform another skin graft and he was always sure this next one would work.  He had a way about him . . . he would smile at you and say “Please Doctor!”   Because of that I broke the promise and tried one more time, but of course the skin graft failed.  Over the years his leg had become slightly deformed and he walked with a limp.  He had dropped out of school and did not finish his education, although he spoke very good English.  He didn’t have a job and I frankly don’t know how he fed himself, but he would talk about how when his leg healed he would get married and have a family and work.  He was absolutely sure all of this would happen . . . that right around the corner life would be better.  Last January, Solomon approached me and asked me to amputate his leg.  He said that he was tired of the wound and he thought that maybe it would be better to have an amputation and get a new leg.  I was shocked that he was finally resolved that his wound might not heal.  I could see he had it all planned out in his mind though . . . I would amputate, he would easy peasy get a new prosthesis (very difficult to get in Ghana), then next would come job, education, and family.  I talked with him for a long time about what a life altering decision this would be.  I was extremely worried that because of his sickle cell he would most likely not heal at his amputation site.  He would have lost his leg and his independence, just to have a new wound to manage.  He was positive all would be well.  I wanted him to think about it more and I told him if next year he still wanted the amputation I would do it and then try my hardest to get him set up with a prosthesis.  I never imagined I wouldn’t see him on my return to Nalerigu this year.  No one is sure what exactly happened, but while he was down South in his village it was reported the he had a seizure and died.  He and his smile are most definitely missed around the outpatient clinic. 

On a lighter note, when I think of Solomon, I think of his smile, laugh, generosity, optimism, and when I had the funniest miscommunication of my entire time living in Ghana and I always smile and chuckle a bit.  I think that is the best way to remember someone.  I wrote about our episode of miscommunication in a past blog entitled, “Say What?”  But for easy I have copied and pasted that blog post below.  Hopefully it will make you smile.

Say What?  Posted 10/4/2013

Between the different accents and the “Ghanaian” English that is spoken, miscommunications often occur and they are usually quite funny.  Here are a few examples:





There is a young man, in his early 20’s, I inherited as a patient from another long-term missionary when I moved to Nalerigu.  He has a chronic wound on his leg.  He came to me one day saying that he needed to talk to me . . .

S (in a hushed tone):  Doctor, could you help me count my pennies?

Me:  Why do you need help with that?

S: My mother never helped me.

Me:  S, you know how to count, why don’t you just count them yourself.

S (looking confused): When I was young my pennies was never counted and I would like to count them, could you help me?

Me (looking confused):  I don’t understand, there are no pennies in Ghana.

S (looking more confused):  My pennies, my pennies, when I was a small boy my mother never helped me count my pennies!

Me (looking at S with a quizzical stare): What are you talking about!

S (now yelling a bit and talking slowly): My mother never count my pennies when I was a small boy!

Me (with an enlightened face): Ohhhhh, she never CUT your PENIS?

S: Yes!  She never count my pennies and I would like you to help me count my pennies now.

Me (relieved to be finally getting out of this confusing conversion): Okay, I think we can arrange a date for that.

  

There is a middle aged man, C, who guards our volunteer house during the day.  He tries to speak English, but it is very poor and his accent is horrible.  Every day C was going to one of the long term volunteers, Michael, and telling him that he was angry.  Michael would tell him that he was very sorry for his anger and that they should pray that God would resolve whatever it was in his life so that he could get over his anger.  They would stand on Michael’s front porch and pray that God would take C’s anger away.  This went on for a few weeks time.  One day someone else was at Michael’s house when C stopped by to tell him about his anger.  They prayed, C walked away, and then the guest turned to Michael and asked him why he prayed for him, it seemed a lot easier to just give food to a guy that is coming up and telling you that he is HUNGREY. 





Many of our common phrases are not understood here.  For example my neighbor, T, was talking to one of the drivers who makes the 2.5 hour trip to Tamale about three times a week.  T told him that he makes the trip so often he must know the road very well.  The driver agreed and then T said he knew the road so well he could probably make the trip with his eyes closed.  The driver looked at T with a very serious and concerned face and said, “Oh no, that would be very dangerous.”  

Case: Peripheral Vascular Disease

Warning: There are some unpleasant pictures at the end of this post

Many chronic disease go undiagnosed and untreated here in Ghana.  Diabetes and hypertension are two that are commonly seen.  If patients come and are diagnosed, compliance with treatment is a big problem.  With little resources at the hospital, patients are given only two months of medication at a time.  They need to then come back to the hospital for refills.  This can be difficult for patients that live in outlying villages.  You can tell in the patient’s chart when the last time they received their medication was an often it is months before.  They will always say, “It just finished,” as their BP is 210/100.  It is hard to explain to them the importance of the medication because hypertension or diabetes is not a concrete disease you can see or feel, like say a rash.  They don't feel sick.  I have learned over my time here that unlike in America where we are nice and try to politely push our patients to make the correct decision, in Ghana you are expected to be a bit more direct and I feel they are much harsher in the way they speak to each other.  During my first week at the BMC in 2012, I was shadowing Dr. Hewitt, one of the long-term missionary doctors.  A saw in clinic a patient that was not taking his hypertension medications.  Dr. Hewitt told the patient that if he did not want to take his medication he should just go to his village and dig a hole and lay next to it.  That way when he had a stroke and died his family could just push him into it!!  I was sitting there shocked with my jaw on the ground listening to this.  I don't think I have ever said anything quite that harsh, but I have looked over and seen the wide mouth gasping shocked look on the face of a short-term volunteer after something I have said to a patient.  I always chuckle to myself a little and remember back to my first weeks at the BMC.  I have learned and changed a lot through my work at the BMC.

Due to many chronic diseases, not being diagnosed and treated, the complications of these diseases are often seen.  Strokes from hypertension are always bad.  There is little that can be done for the patients.  When a stroke patients leaves the hospital to go home, you never know how they will be treated and that always worries me.  Will they be placed in a back room and forgotten, will they develop bed sores, etc?  Peripheral vascular disease from diabetes is often seen.  In America, if someone starts having leg pain or maybe a small non-healing wound they will seek medical care.  In Ghana, it is often late when folks have very necrotic and  gangrenous lower extremities (sometimes even with a few extra bugs living there for extra grossness).  Above the knee amputations is a very common procedure here.  Amputation is a very big deal and I often get a lot of push back from the patient and family.  What I love about their argument against amputation is that they always say, “I won’t be able to work with just one leg!”  They all want to get back out to their farms to work and provide for their families, which is honorable.  I just try to explain that they can’t work the way they are now and they won’t be able to work if they are dead either, so it is better to have the amputation.  Being handicapped in rural Ghana is a hard life.  If the patient is lucky they will have children that can care for them, but feeding a mouth that is not bring in an income is difficult.  It is not unusual to have a patient sitting on our ward for a week or so getting dressing changes, contemplating surgery prior to giving consent.  In the end, although there is going to be struggles, I believe most of them are happier once they have the surgery. 

Warning: Gross pictures are below

The Weather

When I first arrived in Nalerigu, the sky was clear and blue and the night sky was even more amazing.  Without all of the light pollution you can see so many stars.  As I walked home each evening, I had to keep reminding myself to stop staring at the sky and concentrate on looking for waffus (snakes) in the road.  But, unfortunately over the weekend the Harmattan wind has brought the dust back into town.  The Harmattan is a trade wind that occurs between November and March.  It blows across the Sahara Desert over West Africa into the Gulf of Guinea.  As it blows over the Sahara, it picks up fine dust and sand particles which it deposits over West Africa.  Despite the dust, the wind is often cool, but currently in Nalerigu it has remained hot and dry.  Today we topped out at 100 degrees.  As I write this now it is about 85 degrees out at 9pm, but it is forcasted to drop into the low 70's throughout the night, which is fortunately comfortable to sleep in with a fan.  When you look out it, there is just this brown haze that lingers in the air.  Everything gets coated with a fine dust.  You can see it on the furniture in the house and feel it walking on the tile floor.  A day ago, it was so dense that you could kinda even taste it a bit when you walked outside.

The Harmattan can cause different problems.  With the dry conditions fires can occur.  There were fires behind the guest house last night.  The hospital campus is usually protected because they dig a fire ditch around it each year, but you have to continue to keep an eye out.  Last month a fire broke out and came very close to catching the school house where I am sitting now on fire!  So I spent the evening every so often looking out the window to make sure the fire was not getting closer until it burnt itself out.  The fire situation is not helped by the fact that at this time of year the farmers like to also burn their fields back to prepare for the next planting.  With the dry conditions that is a dangerous situation.  We often see burns at the hospital during this when something does not go quite right.  There is a young boy right now on the wards with maybe about 50% of his body burned.  Irritated eyes, runny and bloody noses are also often seen.  It does a number on the skin, really drying it out.  I came prepared with lots of lotion but still with all the hand washing and scrubbing for surgery my hands look pretty beat up and irritated right now.

 My biggest concern about the Harmatan is that I leave in four days.  Last year I had to make the trip from Nalerigu to Accra by road (about 12 hours) because the internal flights are cancelled when the dust is thick.  There is no radar at the airport in Tamale and so if planes cannot visually land they cancel the flights.  I heard today that the flight has been flying over the last few days so I am just praying daily that the dust doesn’t get any worse!  

Case: Polydactyly

Polydactyly is often seen in Ghana.  I have seen many newborns with small appendages off their pinkies, like what is seen in the picture below.  Most of them don’t even have bones, they just hang off the side like a little stub.  When the babies are born, they can be easily removed by just tying a suture around the base and over a few days it will fall off on its own.  However, it often runs in families and sometimes the parents actually do not want the extra stub removed!  During my year in Ghana I don't even remember how many extra little stubs I removed from people of all ages.

This week I saw something here that I had not seen before.  A baby girl was brought in by her mother with a duplicated thumb.  An x-ray showed that just the last bone of the figure was duplicated.  After studying the orthopedic textbooks at the hospital for a night, I was ready to go.  It is always a big nerve wrecking to do something for the first time . . . but I just always try to remember that no matter what procedure you are doing there are basic tenants to all surgeries.  If I remember those and stick to them, things will go well.  At the end of the surgery I was happy with how this baby’s finger looked, but of course that is just half the story.  I was relieved that the day after surgery she was moving and bending it normally.  Her mother is all smiles.  I will see her back next week to make sure everything is continuing to heal.

The true functional thumb is the one to the right.  The left nail just has a small bone underneath that does not line up properly with a joint.

Sunday Fun Day

Sunday is usually a bit slower of a day at the BMC.  I started my day off at church.  Mass at St. Patrick’s Catholic church was to begin at 8:30. In typical African fashion it started more around 9.  The priest is Nigerian.  He comes from the next biggest town over, Gambaga, which is maybe 1.5-2 hours away. He comes on a moto and then basically hops off and puts his vestments on.  He will spend his Sunday travelling from town to town saying mass.  During mass, all of the reading and the homily are said both in English and Manpruli, the local language.  My favorite part of the mass is the offering.  Here they put a box in front of the church and everyone goes up and places money into the box.  They always play a really upbeat song and there is much dancing down the aisle.  I think it is neat that everyone participates in the offering even if it is just to put one coin in the box.  I also like that the Homily is not just a speech about being a good Christian, etc, but there is also always a Catechism lesson included.  It has been a long time since I was in religion class and it is sometimes a good reminder of why Catholics believe a certain thing or do certain things during mass. 

At St. Patrick’s, (it was like this in Cameroon also) people don’t sit with their families but are segregated into groups.  Facing the alter from right to left people segregate into four different sections; male students, men, women, then female students.  There is a smaller section of benches to the right of the alter where all of the children sit together.  Something that is also different is that not everyone goes to Communion.  Sometimes this is because they have not really received any sacraments, but it is also because they feel that they need to be fully worthy and pure at that moment to receive Communion.  Pope Francis spoke about this practice in his encyclical letter, “The Light of Faith.”  He wrote about how in many third world countries they practice this, but how the practice needs to be changed and that people need to be taught that they will never be fully pure enough to receive Communion, but the act itself brings you closer to God, heals you, and makes you more worthy. 

St. Patrick's Catholic Church.

When I first came to the BMC the church they had was very small, it could maybe only fit 40 people comfortably (but we always got in more like 60!).  They put speakers outside the church and everyone else sat in a courtyard under a tent.  There were pluses and minus to each place.  Inside you would be able to see the priest and fully participate in the mass, but the heat was stifling.  Outside you could get a breeze but the distractions were plenty.  Kids running around, the occasional goat passing by, people would walk around selling water packets.  About four years ago, they started to build a bigger church.  The work is done in fits and bounds when money is raised.  It is truly a church built from the ground up by its parishioners and it is neat to see every year what has been accomplish.  Two years ago, there was a roof, last year windows and fans.  This year the floor is no longer dirt but concrete and there is a great cross above the alter.  This year is the 50^th anniversary of the parish and they plan to have a big celebration and are trying to tile the floor prior to the event.  At the end of the mass they were doing a drive for pledges of money and boxes of tile.  In America, we usually have a little talk about what money needs to be raised and then have the little packets at the end of the pew you can pick up if you want to give.  Well that is not how it was done today in Nalerigu!  They basically just had people raise their hands if they wanted to pledge.  They would call out the persons’ name and how much they were giving.  It went on for a good maybe 30-40 minutes and it was excruciating sit through and I felt they were just quilting people into giving and I stuck out like a sore thumb with my white skin.  There were some older ladies in my pew that were giving me a hard time for not raising my hand and giving.  I know the leaders of the church well though and I assured them that I would give, but not in such a public fashion.  The whole thing was awkward and I was sitting there wondering why I had not slipped out after Communion.

After mass I headed to the hospital to round.  There was a man who needed a chest tube placed for a parapneumonic effusion.  The x-ray machine at the BMC is not currently working.  I have never had to solely rely on my auscultation and percussion skills to decide if someone needed a chest tube before.  Basically, on the right, I could not hear breath sounds and then when you tapped on the Man’s back there was a dull sound on the right as compared to the left.  I made the right choice though and after the chest tube was placed basically half a liter drained from his chest and he was breathing easier.

I spent the afternoon exploring town a bit, took a long nap during the heat of the day and then watched some of the first season of Downton Abbey.  Not a bad Sunday all in all.  Tomorrow, I already have a few case lined up so it will be back to a busy day at the BMC.  

A new shipment of bikes have arrived at the bike shop.  These will be brought up North on big lorries stacked much higher than they should be.  It is not unusual for the load to shift and be tilting precariously to one side and when you pass you go quickly!

When I had a bike here, this is the bike shop I would go to get it repaired, which here was a pretty frequent event.

Hernia Heaven

Since I have arrived it has been hernias, hernias, and more hernias . . . with a few emergency cases thrown in for good measure.  My days have started in the wards doing rounds on the post-operative patients.  From there I have headed to the Theatre.  On Tuesday and Thursday, we operated all day long from about 8 until 6pm.  Wednesday, I operated in the morning and then headed to clinic in the afternoon to see the surgical cases.  I thought the patients wouldn’t stop coming.  I saw some interesting things and booked some cases for next week.  After clinic, I headed back to the theatre to take a man to surgery for a gastric perforation.  It was a long day and I remembered why when I lived in Africa I lost so much weight.  It might have had a little to do with not having access to snack food and that the nearest Chipotle is 1000s of miles away, but I also think it had a lot to do with the fact that often I would get to the hospital in the morning and sometimes not leave until early evening!  I wrote about my Friday already.  Although it has been busy, it has been really nice to be back and I have enjoyed helping those I have operated on.  I even got a hug today from a little boy which is a rare event here, because most kids are a bit scared of white people.

This week, I did two rather large incisional hernia repairs.  One in a 69-year-old man and the other in an 18-year-old boy.  They both have been doing well.  I could not have done these repairs successfully if it were not for my friend, Suzy Taylor, who works for LifeCell and who was able to get some Strattice Mesh (a biologic mesh made from porcine skin) for me to bring on my trip.  These large biologic meshes are ideal in these cases because of the high risk of infection.  The theatre Staff has never seen a product like this before and the OR was standing room only during the cases.  They could not believe that the Strattice was made from pig skin and also could not believe the cost.  Most people in Northern Ghana are farmers, even if you have another job you will still have a plot of land that you farm and most people have animals.  When talking about the mesh they were very concerned about what the farmer got paid for his pigs!!  They were sure he was being cheated and not seeing the profit from the product and arguing about how that was unfair . . . I assured them they were probably correct, but I would check in with Suzy when I got home and let them know.  I am hopeful that these patients will heal well and be happy with their newly constructed abdomens.  Below are pictures of the patients prior to surgery.  They are still healing so I will hope to get a photo of their abdomens again later this week.   

This is the old man's hernia.  He had had this sore on his abdomen for many years and it is an area where the bowel comes right up to his skin.

This is the old man's abdomen on post-operative day 5, the day he was discharged from the hospital.

18 year old student with a wide keloid scar and large underlying hernia

My pal on post-operative day #6.  He was very happy with his new abdomen.  I tried to catch him flashing is broad smile, but Ghanaians have this knack of smiling right up to the moment that you actually snap a photo.

Busy Friday at the BMC

Today was a bit of a crazy day.  Friday is usually an outpatient clinic day, but I spent the majority of the day in the theatre (which is ok with me).  I started off the day by doing incision and drainages (I&D) of abscesses on three babies.  The first was just one month old and had been given an immunization and developed a large thigh abscess.  The abscess is rather big and actually connects down to the baby’s knee joint.  I am hoping that it will not disable this child at such a young age.  The two others had abscesses on their necks.  I don’t enjoy doing procedures like this on babies because they don’t give them any sedation . . . they just hold them down so they don’t wiggle away and you cut open the abscesses.  The pain must be horrible.  Doing three in a row like that was tough on my ear drums and heart.   

In the main OR I repaired two inguinal hernias in an old man, 78 years old, and a child just 3 years old.  I also took a young 4-year-old to surgery for a typhoid perforation.  If they drink dirty water, they run the risk of getting typhoid.  In the end stages of the disease the patients develop perforations of the small bowel.  This child is very sick and I am actually very worried for her.  I followed that up by doing an I&D on a young man that has a dental abscess.  That is fourth patient I have seen with a dental abscess in a week.  There is no one to go to take care of dental cavities and they will turn into abscesses.  I have drained all kinds of abscesses, but for whatever reason I think that dental abscesses are one of the worst.  They are hard to drain and they just stink! 

The last case I did for the day was a sequestrectomy.  This was a 11-year-old boy who had a wound on his leg for 3 years.  He states that it started like a small blister and slowly grew.  He denies any trauma or broken bones.  When skin infects go untreated they can move and infect the bone beneath, called osteomyelitis.  The bone tries to heal itself and grow good healthy bone, but it never quite gets rid of the infection underneath.  The bone will grow around the infected dead bone.  Sometimes the patients will heal for a bit but eventually puss will form and find its way to the skin, they get these chronic draining wounds.  In this boy, the dead bone had actually found its way to the skin and was sticking out in various places.  You can notice in the picture below.  If you moved one side of the bone you could see a little piece sticking out of the skin by his ankle also wiggle.  His father said he had not been to school in a year because the other kids make fun of him and then he gets in trouble for fighting them.  He had been to several other hospitals and they all said to return when his wounds healed, however with bone sticking out of the skin his wounds would never heal.  He needed a sequestrectomy, which is the surgery to go in a removed the infected dead bone pieces and that is what I did for him today.  He had an open wound on his leg now that will heal in over time, but all of the infected and dead tissue is gone so he finally has a chance to heal.  We will bring him back to the theatre tomorrow to do his first dressing change.  I had forgotten to take a picture of his leg at the end of the case so I will have to do that tomorrow.

The boys foot is to the right.  You can see at the left most wound there are pieces of bone sticking through the skin.  Also, all the way the right in the lower wound there is another piece of bone sticking out of the skin.  If you pulled on one side it would wiggle the other showing that it was a connected piece of bone underneath. 

This is the piece of bone that I removed from under the skin.  Inside of it was all kinds of dead infected tissue. 

This is the boys wound at the end of the case.  There is good healthy bone at the bottom of the wound.  It is maybe 3 cm deep and this will need daily dressing changes until it closes by filling is with good healthy tissue.

In between the cases, I rounded on all of my patients in the wards and reviewed other cases that they asked a surgeon to see.  I had two other patients that I was worried might need surgery but both were improved which was great news!  After finishing in the OR, I did head to clinic where stack of charts were waiting for me (as hard as I try I can never avoid clinic!).  Some I booked for a later date for surgery.  Others did not need surgery at this time.  There were some post-operative patients that others had done back for review.  I admitted a young girl with a central abdominal mass.  It causes her pain.  She had had dramatic weight loss and does not eat.  I will most likely take her to surgery Monday to see what is going on.  All we have here is an ultrasound . . . my ultrasound skills are rusty and today I could not really tell what the mass was associated with so on Monday I will just have to use my eyes and find out.

Oh Canada!

Between cases I like to sit in the Theatre break room and talk with the staff.  We talk about everything and I enjoy getting their perspective on World events, religion, politics, etc.  The latest topic today was about travel.  They were making fun of one of the staff who had not left Nalerigu in ten years!  I was a bit shocked, since Nalerigu is maybe just a few square miles in size.  He said everything he ever wanted or needed is here so why would he go somewhere else.  Anyway, I posed the question, if they could pick anywhere in the World to go where would they travel?  They all said they did not know, but they did know where they would NOT like to visit.  This was their list (in the order given) . . . Afghanistan, Iran, Iraq, Libya, Syria, Canada, and Ukraine.  Canada???  I first made sure that we were talking about the correct Canada (miscommunication is not uncommon), USA’s neighbor to the North and they assured me we were talking about the same place.  I assumed they would not want to travel there because of the cold and when I stated that fact they said NO.  The cold would not bother them, but they would not go to Canada because it is too unsafe!!  I am not sure what news reports they are hearing about Canada and I thought it was interesting that they basically placed it in a list of all of the most unsafe countries in the World right now.  I told them that for the last two summers I have vacationed in Canada.  I showed them pictures of the cottage and Big Rideau Lake and they were unimpressed and said I must have been very lucky to come home safe.  The nurse, in charge, could not believe that my father would let me travel to Canada.  He said he would need to write him a letter and inform him that it is too unsafe for me to travel to there again and if I needed a vacation in the summer I should just return to Nalerigu.  I could not break his heart and tell him that I don’t think my father would agree with his assessment of the travel plan!  I could never really get out of them what it was about Canada that made it unsafe, but I guess next time I am up there I will have to be a bit more careful and maybe even lock the cottage door.  

Around Town

This is my pal Rebecca in her store.  It is located just down the main road from the hospital.  Rebecca is an excellent cook.  Meals here have to be all made from scratch.  When I lived here I had little time to spend cooking.  Once a month Rebecca would come and cook a few meals for me that I could then freeze into smaller portions.  My favorites  . . . her Ghanaian style chicken enchiladas and lasagna.  She also makes excellent banana muffins!

I love how things change in town, new shops are always opening and changing. If you have an entrepreneurial spirit and are a hard worker you can carve out a good living.  In Ghana, there is a growing middle class, which I would say Rebecca is a part of.  Four years ago she worked mainly as a cook for missionaries families at the hospital (As an American living here you are expected to hire help).  Now, she is an owner of a shop in a prime location.  She has a freezer and fridge in her shop which is a big deal.  Since I was here last year, she now has an oven so she makes fresh bake goods daily. 

In the evening, people go to shops and buy what they might need for their evening meals.  I love the small-town community here.  Her costumers come and usually sit a bit in front of the store visiting, then get their groceries, before heading home.  I have come to enjoy spending my evenings sitting with Rebecca talking outside her store, yelling at kids that are going by misbehaving, and drinking a cold passion fruit Alvero.