Everyone has their morning routines.  Mine has always been pretty typical.  I press snooze too many times before finally dragging myself out of bed.  Take a shower, throw on some scrubs, feed my fish, rush out the door with a cup of tea to go, and then ultimately drive a bit too fast down the highway as I try to make it to work on time.  Here things are much the same except for a few things.  I now race away from home on my handy orange bike and I have the pleasure of not feeding my fish, but having an entirely different animal encounter almost every morning. 

Not in a million years did I think my morning routine would ever include chasing geckos around my bathtub before taking my shower, but here I am in Ghana setting my alarm clock just a bit early everyday to give me enough “get the gecko out of the tub time.”  My house is full of geckos, which is nice because they eat all of the other bugs.  Not so nice because they try to walk on the tiled wall in my bathroom and end up in the tub because they can’t stick to the wall.   Most of the time it is just a little guy and they are pretty easy to chase around a bit and then ultimately scoop out of the tube.  I have one large gecko that lives in my house though and when it makes its way to the bathtub it is always a chore to get out.  One night I went to take a shower and chased the large gecko around for a good 20 minutes before finally getting it out of the bathtub.  Right after I rescued it, I received a phone call from the hospital and ran up there to see a patient.  When I got home later, tired and just wanting to take a quick shower and hop into bed I found that pesky gecko back in the tub . . . I have never been so angry at a stupid reptile before. 

 

Why in the world does my neck hurt?

In clinic the two most common symptoms that women complain about are waist and neck pain.  To this day I still do not really know what they are talking about when they say waist pain or what the cause of their waist pain is . . . but I have a pretty good idea what is causing their neck pain.  

Starting Young!

They will carry everything and anything on their heads.  In the hospital I once saw a patient caring her patient folder (basically a small notebook) on her head.  The best is when the patients are on IV fluid and ambulating they put the bag of fluids on their heads!

The girls start very young here carrying things on their heads and babies on their backs.

Comfort, one of the scrub nurses, bringing in a sterile instrument pack into the OR

 

A day in the life of a "bush" doctor

Today my day started off with a 4 am C-section. This was followed by rounds on the male surgical ward, women’s wards, maternity, teenage ward, and isolation ward; about 33 patients with varying diagnosis from spontaneous abortions, typhoid perforations, wounds, empyema, snake bites, malaria, gastritis, abscess, pre-eclampsia, preterm labor, etc.  Later in the morning, I did a second C-section.  I performed an EGD, incision and drainage of two massive abscesses (one on the neck, the second was basically the patient’s whole chest wall), reduced and splinted a distal radial fracture, debrided two patients’ massive limb wounds in the isolation ward, did a breast biopsy, cleaned and sutured the ear of a boy that was stepped on by a cow, did four pelvic exams, six ultrasounds on pregnant women, and saw 52 patients in clinic.  My patients in clinic had a wide range of problems today; infertility, hypertension, vesicovaginal fistula, gastritis, various aches and pains, chronic wounds, typhoid, some skin rashes, pharyngitis, inguinal hernias, seizure disorder, lots of malaria, arthritis, a huge neck mass, and one poor man that was coming for follow-up after a bull had bored him in the scrotum a few weeks ago and we had repaired his injuries.  And I was still able to get home by 6:20 pm and have enough time before it got dark to get beat in a game of marbles (that’s right . . . marbles) by some of the local kids.  All in all a busy but fulfilling Friday.  I'm praying though that the weekend will be a little less hectic!

Case of the Week - Waffu Bite

This has been the week of snake bites or Waffu bites as they are called in Mampruli, the local dialect.  At any given time we have two or three snake bites admitted to the hospital, but over the last week our wards have been full of snake bite victims.  The reason is that it is planting season here in Northern Ghana so everyone is out in the fields.  Although seen all year around, the snake bites peak in planting and harvest seasons. 

This patient was bitten on his foot

The snake that causes the most trouble here in Nalerigu is the Carpet Viper (Echis carinatus).   These are very aggressive snakes when disturbed.  The venom is a hemotoxin, meaning that the victims’ blood will not clot properly.  Depending on the amount of venom that is injected through the bite the symptoms can be as mild as just continuing to bleeding from the site of the bite, to internal spontaneous bleeding, which usually will lead to death if unable to reverse the clotting process.  Most typically we see swelling and blistering of the bitten limb.

When a patient comes in reporting that they were bitten by a snake the first thing we test is a Whole Blood Clotting Time (WBCT).  A small sample of blood is taken and left for 20 minutes.  After 20 minutes the blood is tipped on its side, if it is still liquid that means that no clotting has occurred and the patient was bitten by a carpet viper and has a hypo-fibrinogenemia coagulopathy.  The bites are treated with Anti-Snake Venom (ASV).  After given the ASV, the patient’s blood is tested 6 hours later to see if any clot will form.  If no clot forms they are given a second dose of ASV.  The process continues until the patient has three consecutive “clotted” WBCT and that point we will send the patient home.  Although it seems like an easy diagnosis and treatment, patients still do die from carpet viper bites.  I have seen at least three kids die over the course of my stay here.

My neighbor T holding a Cobra killed
outside a missionary's house

The second most common poisonous snake in Nalerigu is the spitting cobras (Naja Nigricollis).  Unlike the vipers, these snakes are generally provoked into attacking humans.  The bite of the cobra causes skin necrosis of the bite area that usually will spread to the fascia.  The cobra also can spit poison into the eyes of its victim causing a venom opththalma, which is characterized by corneal abrasions.  Treatment of the bites is giving ASV as well as local debridement of their necrotic wounds.  In the case of opthalmia, sterile eye irrigation and antibiotic eye drops are given to prevent secondary infection. 

The other creature the stings people here in Nalerigu is the scorpions.  The effect of a scorpion sting is mostly just severe pain at the sting site.  Very rarely are systemic symptoms seen.  Treatment is local injection of lidocaine or marcaine at the sting site for local pain control.

The people here in Northern Ghana are deathly afraid of snakes or “waffu."  Dr. Hewitt, a family practice doctor who has been stationed here over the past 20+ years, has been nicknamed Dr. Waffu by the locals, because he enjoyed carrying around a plastic snake to scare people in market or in his office.  Overall, my favorite part about seeing snake bite victims is when they bring the dead snake in to show you in clinic!  There is nothing like a patient sitting down on the stool next to your desk and pulling a snake out of a plastic bag. 

Welcome!!

I know it took me over 6 months to set this up, but you do not have to wait any longer!  Over the last few months I have been writing posts down, but never posted them, so some stories and things will be post dated at first so keep looking through to make sure I have not posted new pictures or stories. There will be some medical pictures posted also, so if you have a weak stomach you should scroll past them quickly :)  Enjoy!

Case of the Week - Yaws

This is a picture of a patient’s leg that is suffering from yaws. 

Yaws is a tropical infection of the skin, bones, and joints caused by the Treponema pallidum pertenue (a relative of the spirochete that causes syphilis and pinta).  Yaws can be found in the humid tropical regions of South America, Africa, Asia, and Oceania.  It was introduced to the America’s and Europe through the slave trade with Africa.  A mass treatment campaign in the 1950 eradicated it from many developed countries and greatly reduced the worldwide prevalence, however incomplete eradication led to a resurgence in the 1970’s with the largest number of cases found in Western Africa.  The majority of people affected are children under that age of 15 years of age and it is spread by skin-to skin contact with infective lesions allowing the bacterium to enter through a pre-existing cut, bite, or scratch.  Earlier in the year we had an outbreak of yaws in the school in Nalerigu and the surrounding area.

This infection, like syphilis, has three stages.  The infection starts as a painless but distinctive “mother yaw” lesion.  The infection can continue and have “daughter yaws” appear around the infection site over the course of a few months.  These lesions usually resolve by six months.  Secondary stage yaws can occur months to years later and is characterized by widespread skin lesions of different appearances.  About 10% of people will progress to tertiary yaws where bone, joint and soft tissue destruction is usually seen.  It is seen often as destruction of the bone and cartilage of the nose.

The distinctive "mother yaws" lesion

 

The treatment of the infection is a single injection of penicillin.  However, I have seen the destruction that occurs from the disease is much harder to treat and takes a much longer time to heal.  The skin lesions left behind after infection can take months to heal (some needing skin grafting) especially when the people are malnourished and live in dirty conditions. 

The disease is highly localized which makes case tracing and treatment of potentially infected individuals easy.  For example, when the outbreak occurred in the schools earlier in the year, the public health administrators went to all of the schools and gave the children shots of penicillin.  The cases of yaws we saw in clinic after that dropped dramatically.

This patient is currently admitted to our isolation ward and is undergoing dressing changes to her legs (her other leg not in the picture has similar wounds, as well as her buttocks and left elbow).  Her wounds are nice and clean and we will see if she will start to heal the wounds or if we will have to skin graft some of the bigger wounds.

A Royal Visit

The Nayiri is the man in the red sitting next to me

Yesterday I met the Nayiri.  He is the paramount chief of the Mamprusi empire and his palace is located in Nalerigu.  Each village has a local chief and the Nayiri is the head chief of all of them.  He makes all the major rulings in the area when it comes to law and order, etc.  I was supposed to meet him when I first arrived, but things are been so busy that we finally got around to meeting him now.  He had a large compound in the main part of town.  You are not supposed to walk or drive in front of the palace.  The first month I arrived a volunteer and I drove in front by accident.  These men ran out after us with sticks, but I told her just to gun it and not stop.  I did not really want to be in trouble my first month here.  When I met Nayiri yesterday I did not mention that little infraction of the law.  His palace is a huge compound made of painted white stone and is very distinct from the rest of the structures in Nalerigu.  He was very kind and grateful of all of the work we do at the hospital.  He asked me if I would consider staying another year at the hospital.  I told him my mother and father would miss me too much.  I was not sure culturally how I was supposed to answer that question.  We had to take our shoes off when entering his viewing area and then you need to squat as low as you can and clap when greeting him.  He does not speak English so we had a translator speak for us.  He seemed to have a sense of humor and enjoyed the meeting.  We gave him a gift of a bag of rice and a jug of oil.  In return he gave us a present of a guinea fowl. 

 



With our guinea fowl

I have enjoyed my first week back at the BMC.  There is a large volunteer group here, so I have been able to concentrate on working with and learning from Dr. Andy Norman.  His focus is on female vesicovaginal fistula and rectovaginal fistulas.  These kinds of fistulas are very common in third world countries as complications of pregnancy and prolonged labor.  Over the last few months, I have been collecting cases for Dr. Norman to help me with this week.  We did a number of fistula cases, as well as some other GYN cases.  I learned from him how to do a Le Fort operation for uterine prolapsed, which is an ideal surgery in elderly women instead of putting them through a hysterectomy.  I also started to learn how to do vaginal hysterectomies.  I think I am going to be sticking to abdominal hysterectomies for now, until I can do a few more vaginal cases with someone else because the anatomy to me was all backwards, but it was great to start at learning a procedure.

Back in the Gu!!

After a long trip back to Ghana, I am finally home in Nalerigu.  It is really nice to see everyone here.  All of the staff kept telling me I looked “refreshed.”  I was not sure if that was a compliment . . . I just kept thinking I must have looked really worn out when I left.  I was later informed by a long term missionary that they are actually telling me that I have gained weight and look fatter than when I left, not that I look more well rested.  I guess enjoyed the food back home a little too much!

Case of the Week - Omphalocele

I have had two cases of omphalocele since I have arrived.  One presented around 2 days after birth and the second was born in a very rural village and came about 2 weeks after.  The covering over the defect was necrotic and the child was septic.  I was able to close both defects and the babies went home.  On follow-up a month later, they were both growing and looking healthy.

 

After repair

My favorite part of the this picture is that it shows how we do cardiac monitoring during our surgeries here at BMC.  It is old school with a stethoscope just taped to the patients chest.