Paga and the Crocodile Legend

Today I visited the town of Paga, which is located in the Upper East Region of Ghana along the Ghana Burkina Faso boarder.  There we visited a sacred crocodile pool.  The pool is said to hold over 200 crocodiles. 

With Elizabeth Gibbs and Julia Welch

Crocodiles are sacred to the tribe living in this part of the country and residents traditionally view killing a croc to be as sinful as homicide.  Local tradition states that Paga was founded in 1670 by Naveh Kampala who was the grandson of an important chief, whose totem was a crocodile.  When Naveh’s grandfather died, Naveh’s father Paniogo lost out in the succession dispute for the chief position.  He and his followers were forced to flee from their village.  Their way was blocked by a raging river and with the new chief and his soldiers in hot pursuit, Paniogo desperately asked a nearby crocodile to help them cross the river, in exchange he and his followers would never again harm a crocodile.  The crocodile agreed and swam to the middle of the river and beat his tail so hard that the waters of the river parted and group was able to pass safely to the opposite bank of the river before the waters crashed back blocking the pursuers’ path.  The group settled in a place called Kampala (which today is located in Burkina Faso) and Paniogo declared the crocodile to be sacred.  

Many years later, Paniogo’s son Naveh was out hunting and fell into an aardvark hole and was trapped for two days.  A crocodile living in the hole saw that Naveh was dying and showed him an escape route and took him to a pool to quench his thirst.  In thanks, Naveh reaffirmed his father’s pledge to the crocodile, but when he returned home he realized that the town’s people had broken their promise by killing and eating crocodiles.  He decided to move away from Kampala with his family.  After many months of searching he came across the banks of a crocodile-infested pool and cried out “A yi paga ywo!” or “This place pleases my eyes!”  The name Paga is derived from this statement and Naveh become the first Paga Pai (Chief of Paga) and instated crocodiles as the town’s totem. 


We made a pledge with this croc . . . if it did not eat us,
we would feed it a chicken!

It is said that no person has ever been harmed by one of the crocodiles of Paga; although our guide stated that many goats have wondered a bit too close to the pools and have gotten “chopped!”  

Traditional Dance

Earlier in the year the hospital had a celebration to honor the workers.  Throughout the evening there were some traditional dancers that performed.  Here is a clip from one of their performances.  My favorite part is the old lady that that brings up the end of the line, she was not part of the group.  I guess she just had the urge to dance!

I have experienced my fair share of trauma here in Northern Ghana’s premier level one trauma center the Baptist Medical Center.  The most common injuries we see are orthopedic injuries caused by moto accidents or people falling off of lories (large trucks).  RTA (road traffic accidents) as they call them here.  No one wears helmets so we see lots of head injuries, unfortunately with the resources available here most of those severe injuries are fatal.  We have the occasional kid that falls from a tree or even worse I have had many pregnant women fall from trees. (It seems absolutely crazy to me, but they are 7 months pregnant climbing trees to collect firewood.)  Two serious liver lacerations came into the hospital in the same week.  I have seen many hand injuries from home made guns backfiring and had one crazy night of multiple victims with gunshot wounds when a tribal war broke out.  And then there are of course the crazy random trauma stories you hear that you just can wrap your mind around how it really happened, but if the patient says that is what happened, well who am I to doubt him.  But my favorite trauma to see out of everything is the penetrating trauma via a bull’s horn.  I have had many men come in after being impaled by a bull (one unlucky fellow got it right in his business).  Today, as I operated on the boy below I got a lesson on how it happens.  The long and short of it is, never get in front of a bull that you have spent the day whipping and not feeding so you can get your fields plowed . . . the bull will probably be angry with you and lash out.  Don’t say I never warned you.

Omentum coming out of the patients gore wound.

 

 

Today I had a really great moment in clinic.  I saw back one of the first patients I operated on last October.  He is an 84 year old man who came in with a gastric perforation.  He had been hospitalized the month prior for another illness and when he went home he told his sons he was sure if he ever had to go to the hospital again he would die there.  As we were wheeling him off to surgery, his sons told me he had said good-bye to everyone in the village as he left and told them he would not be coming home.  Talk about pressure to save a guy. 

He did great though.  He flew through surgery and the post-operative period without a hitch.  On the second day after surgery he was sitting up in bed and told me he was going home.  When his sons and I told him he could not go yet, he told us if his sons would not take him home he would just go catch the bus.  He was in the bed directly across from the entrance to the ward, so every day I was greeted by him sitting up in bed, with his wide smile showing me how strong he was by lifting his arms up in the air over his head.  He has three sons and all of them are as cheerful and energetic as their father.  They all stayed with him during his hospital stay, always laughing and joking with him.  You could tell they really loved and respected him.

Today he came to clinic to get a refill on his blood pressure medications.  We give patients two months of medications at a time.  It is hard to keep tract and remember all of the patients because we see so many, but as soon as he walked in the door and flashed me that smile I knew who he was.  I think he was surprised to still see me still working here.  He gave me a big enthusiastic hand shake and then he told me that as soon as he sat down next to me all of his troubles and pains went away.  What a line . . . as if it was taken right out of a movie.  It was great to see that he was still doing so well and I am honored that I was the one that was here who helped get him home.

Tribal Markings



One of the most complex abdominal markings I have seen

Here in the villages it is still very common to still see people with different markings.  Each tribe will make different markings on the face to distinguish their tribe from others.  I am still unclear why they make the markings on their bodies.  When people are having pain or other aliments they will also go to “local treatment” and get cutting performed.  For example, we will see patients with large palpable spleens have their entire left upper quadrant of their abdomen cut up with dozens of scratches.  You can tell how long something has been bothering a patient by then amount and age of the cuts on the region. 

This is the most common abdominal markings I see.  Most everyone has umbilical hernias so I guess they decorate them with the cutting.

Tribal facial markings

Tribal facial markings

Ghanaians LOVE Obama!  It makes sense . . . he is living every Africans’ dream, which is to immigrate to America and become wealthy.  The funniest thing is that there are Obama themed items sold in market from notebooks, to underwear, to book bags.  You name it they have put Obama’s face or name on it.  Many times when meeting a boy they will introduce themselves as Obama as a joke or they will tell me their real name and ask “Do you know my brother?”  I’ll answer, “Who’s your brother?”  “Barack Obama” they will exclaim! 

Boy's Obama Underwear

These are the notebooks the kids buy for school.

    

Happy 4^th of July!!  Here in Ghana, Monday, July 1^st was a holiday.  We were off work on Monday to celebrated Republics Day.  When this holiday came around I was very confused because we already celebrated Ghanaian Independence Day in March.  I as assured though that this was a very different holiday to be celebrated.  My understanding is that when Ghana won independence from England they did not immediately have an elected government.  They were ruled under a dictator.  Thus, Republics Day celebrates the day they had their first elections. 

Here on campus, the volunteers and I celebrated the 4^th with a BBQ.  We had a special meal of chicken and beef kabobs and all of the other important BBQ sides.  It was nice to have a special meal.

 

Case of the Week - PBL style

For all of the Mizzou grads out there missing all the fun we had in PBL . . . here is a case for you!

 

PBL CASE

Page One:

28 year old female presents to clinic with lower abdominal pain.  She states that she is 6 months pregnant.  She denies any nausea, vomiting, diarrhea.  She denies any urinary symptoms.  Denies any fever.  ROS is otherwise negative.

PE:           Vitals:  BP 132/85, HR 78        HEENT: No pallor

                 Chest: CTAB, RRR             Abdomen: Gravid, Non-tender

                 Extremities: No pedal edema

What further questions do you want to ask?

What is your differential diagnosis?

Page Two:

The patient states that she has been attending the anti-natal care clinic.  When reviewing the records from ANC, you see that the midwives have never been able to hear a fetal heart rate.  On further questioning the patient states that she has not felt the baby moving.  She denies any recent bleeding, discharge, or loss of fluid.

What is your differential diagnosis?
Should any further diagnostic testing be performed?

Page Three:

An ultrasound of the uterus is performed and the image obtained is below:

What is your diagnosis?

What further testing and treatment needs to be done?

Page Four:

Ultrasound of the liver was normal.  CXR was normal.

A suction dilatation and curettage (suction D&C) was performed.  The tissue below was expelled from the uterus.

What is your diagnosis?

What further management and treatment does this patient need?

OBJECTIVE: Molar Pregnancy

Otherwise known as gestational trophoblastic disease, a molar pregnancy is an abnormal form of pregnancy where a non-viable fertilized egg implants into the uterus and grows into a mass.  A molar pregnancy can develop when an egg that is missing its nucleus is fertilized.  They are categorized into partial or complete moles depending on the number of chromosomes present.  A complete mole is caused by a single sperm that combines with an egg that has lost its DNA.  The sperm then replicated its DNA to make a “complete” 46 chromosome set: typically 46,XX but occasionally 46, XY can be seen.  In contrast a partial mole happens when an egg with DNA is fertilized by two sperm or by one sperm that replicates its DNA.  The genotypes usually seen are 69, XXY or 92, XXXY.

Hydatidiform moles are seen occurring once in every 1000 pregnancies in the US.  Rates in Asia are much higher and in Indonesia are up to 1 in every 100 pregnancies.  Potential risk factors may include defects in the egg, uterus abnormalities, or nutritional deficiencies (diets low in protein, folic acid, and carotene).  Women under 20 and over 40 years of age have a higher risk of developing a molar pregnancy.

Molar pregnancies usually present with bleeding in the 4^th-5^th month of pregnancy.  The patient usually experiences more vomiting then would be expected with pregnancy and hypertension.  The uterus is found to larger than expected for the given month of the pregnancy.  Blood tests will show very high levels of hCG.  Diagnosis can be made by ultrasound.  The mole resembles a “cluster of grapes” or “snow-storm” on ultrasound.  However, definitive diagnosis requires histopathologic examination where one will see increased trophoblast proliferation and enlarging of the chorionic villi.     

The treatment for a molar pregnancy is to evacuate the uterus by suction or by curettage as soon as the diagnosis is made.  After removal of the mole the level of hCG in the patient’s blood is followed until it reaches undetectable levels.  80% of moles are benign, however 2-3% of cases, the mole may develop into choriocarcinoma (complete moles have a higher risk than do partial moles).  This is a very rapidly-growing, malignant, and metastatic form of cancer; however despite these poor features the rate of cure after treatment with chemotherapy, most commonly methotrexate, is high.  Over 90% of women with non-metastatic disease survive and retain their ability to conceive and bear future children.  In women with metastatic disease, 75-85% are cured, but usually their ability to have future children is lost.

I am learning a lot here in Ghana.  I missed this diagnosis the first time I saw it.  I had to show the ultrasound to the long term MD here because I had no idea what I was looking at.  Since that time I have seen a few more cases while here in Ghana.  This case was actually brought to me by one of the PA students to review because he was having a hard time “locating the uterus.”  How things have come full circle in just a few months! 

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Outcast Camp

Over the years the missionaries at BMC have developed a relationship with the women at the Outcast Camp, or as the locals call it the “Witches” Village.  I have visited the village a few times and it is always an interesting experience.  It is located in Gambaga, the next town over (~8km away) and is a village where women accused of witchcraft live.  The idea of witchcraft runs deep in the culture here in Northern Ghana.  There are various reasons why a woman would be accused of being a witch, but to me it seems like a convenient way to take care of family or personal rivalries.   Polygamy is practiced here in a Ghana.  So for example, if one wife’s child dies, she can blame another wife for the death saying that it was due to a spell she cast.  If confirmed a witch, the wife would be killed, thus a rival disposed of.  I am sure there might be a little bit more to it than that, but as an outsider looking in, that is what it seems to be all about.  (Lucky for me I can never be accused of witchcraft because I am white.)    

Does that really look like the face of a
witch!!!

So if someone is accused of being a witch how is it confirmed?  It depends on the village they are from, but most often a chicken’s neck is cut and after the bird flaps around a bit as it dies, they look to see how the chicken finally lands, on its’ back or on its’ stomach.  Depending on how the chicken lies confirms whether you are innocent or guilty of witchcraft.  I found this a bit interesting because during the Salem witch hunts they also sometimes use a chicken or duck to prove women guilty of witchcraft.  If I remember correctly, a woman would be weighed and if she weighed more than a fowl she would be confirmed a witch.  I guess in light of that system, the women here in Ghana are lucky because they at least have a 50/50 chance of an innocent verdict. 

In the past, the women were always killed after being confirmed a witch.  In the late 19^th century the Chief of Gambaga started to allow these women to come to his town and he provided protection for them.  He said that as Chief he had powers to counteract their witchcraft and as long as they lived on his land they could not use their powers.  He set up a village on the outskirts of town where the accused live with their children still today.  There is debate about whether this camp is truly a sanctuary for the women or essentially functions as a prison where the women are forced into slave labor for the Chief.  The women work the Chief of Gambaga’s land for free and cannot leave unless they get permission.  If they want to go back home the Chief has to be bribed into performing another ceremony to assure that the witchcraft has left the woman (basically a repeat of the original sacrifice of a chicken). 

Making soap

The Gambaga Outcast Home Project works with the women at the village teaching them ways to make extra income and also trying to perform outreach and education in the women’s communities, in hopes that eventually might be able to move back home.  The women make beads, jewelry, and soap that are sold in the local market.  This year a grant was given that was able to buy land for the women to farm for themselves.  The key is to empower these women to earn money for themselves and their families and to make they realize that they are not the castaways of society they think they are, but that they have valid and important roles to play.  The work that goes on in the Outcast Camp and the Ghanaians that risk everything to work with these women is incredible.  These women come to the camp in complete poverty and shame and are lifted up to start living their lives with pride and purpose and it is truly inspirational to see. 

 

 Making jewelry

 They make not only the jewelry, but also the beads.