Case of the Week: Sigmoid Volvulus

I have had many people come with bowel obstructions.  There have been many causes: incarcerated inginal hernias, internal hernias, and malrotations of the bowel.  I when I started the surgery in the 24 year old male below I assumed it was an internal hernia or some sort of band obstruction.  I was shocked when I opened I found a sigmoid volvulus.  This is most commonly seen in elderly people, but can also occur in people that have chronic constipation.  I performed a sigmoid resection on the patient and he did very well with surgery.   

 

A distended Sigmoid Colon, it was twisted twice at it's base

Working on the sigmoid resection

Just Another Friday Afternoon Clinic

Asubonteng Atta, the physician’s assistant at BMC, had some fun at clinic on Friday scaring all of the patients and staff with a dead snake a patient brought into the hospital.  This snake is a carpet viper and if someone is bitten it will cause a coagulopathy and the patient will bleed if not given an injection of anti-snake venom.

With the rainy season comes grass growing around the campus . . . with the grass comes snakes . . . we are scared of snakes so we like to keep our grass cut short.  This makes me glad that we have lawn mowers in America!

Case of the Week: Typhoid





A little girl after surgery for her typhoid perforation.

Typhoid fever is a common infection caused by the bacterium Salmonella Typhi.  It is transmitted by the ingestion of food or water contaminated with the feces of an infected person.  Typhoid does not affect animals, and therefore, transmission is only from human to human. An estimated 16-33 million cases of typhoid fever occur every year.  The incidence is the highest in children and young adults between the ages of 5-19 years old.  It is estimated that typhoid caused about 190,000 deaths in 2010.

 

An ulcer seen in the terminal ileum that is not yet perforated.

If a patient goes untreated, after being infected with the bacterium, the disease process can be divided into four stages, each lasting about a week.  During the first week of infection the symptoms are varied and nonspecific.  They may develop a fever, malaise, headache, or cough.  They will often have mild abdominal pain.  A white blood cell count will often be low and the Widal test (the test for Typhoid) is usually negative.  At this stage the infection often mimics malaria and the patients if they come to the hospital are usually mistreated for that.  In the second week, the patients will have high fevers and bradycardia.  They will complain of abdominal pain and often start to have diarrhea, up to 6-8 bowel movements a day.  Often after they have the diarrhea they will switch into a state of constipation.  The patients will have an enlarged spleens and livers.  The Widal test will usually be strongly positive during this stage.  If continued to be untreated, during the third week of infection a number of complications will start to occur.  The most common complication I have seen is intestinal perforation.  Most commonly the distal ileum perforates.  If untreated the patient will become septic and die.  Intestinal hemorrhage as well as encephalitis can be seen.  The patient can present in this stage with various neuropsychiatric symptoms, often with picking at bedclothes or imaginary objects.  Abscesses can be seen, cholecystitis, endocarditits, and osteitis can develop.  High fevers are seen during the third week of a typhoid infection.  If a patient does not develop one of the serious complications of the infection and die during the third week with no intervention, then the fever will start to subside by the fourth week of the infection.  When untreated, typhoid fever persists for three weeks to a month and death occurs in between 10% and 30% of untreated cases.  If the infection is not completely cleared from a person’s body they may become an asymptomatic carrier. 


A perforation in the terminal ileum.

About 5% of people who contract typhoid continue to carry the disease after they recover.  These carriers have no symptoms, but are capable of infecting others.  The infection is spread through poor hygiene habits and poor sanitation conditions.  The most famous of these carriers was Mary Mallon (Typhoid Mary).  In 1907, she became the first American carrier to be identified and traced.  She was responsible for a typhoid epidemic in New York that infected 53 people, three of whom died from the disease.     

 

Diagnosis can be made many different ways:  blood, bone marrow, or stool cultures, and the Widal test (shows salmonella antibodies in blood).  Here in the Gu though we use clinical decision making for when to treat for typhoid.  When a patient has been treated for malaria and is not better then that is usually followed by a treatment for typhoid.

Prevention is the most important aspect of typhoid control and treatment.  Education about sanitation and hygiene are essential parts to any public health measure to prevent typhoid.  Typhoid spreads in environments where human feces or urine are able to come into contact with food or drinking water.  Careful food preparation and washing of hands is critical.  Here in Ghana the beginning of the raining season is a time we see many cases of typhoid perforations.  The rains come and wash the human feces into streams and rivers where people collect and drink the water.  If it is not boiled and prepared correctly they may become sick.  There are also two vaccines available for typhoid, although these are both too costly to be given as routine vaccines in endemic areas.

Incidence of Typhoid Fever

Red: Strongly Endemic Regions, Brown: Endemic, Gray: Sporadic Cases

 

Different antibiotic regiments can be used to treat Typhoid.  Where resistance is uncommon, fluroquinolones (ciprofloxacin) can be used.  Alternatively ceftriaxone or cefotaxime can be used.  Oral regiments that are used to treat typhoid include: chloramphenicol, bactrim, amoxicillin, and ciprofloxacin.  When treated with antibiotics the fatality rate drops to ~1%.    

During surgery if a perforation is found most commonly is can be over sewn and closed primarily.  Occasionally, a small bowel resection will have to be performed if there are very large or multiple perforations in a small segment of bowl. 

Below is an article that was published in the INMED (Institute for International Medicine) Newsletter in December.

A CALL TO DIE

Nicholas Comninellis, MD, MPH

Born with his intestines lying outside his abdomen, death was imminent for a baby in West Africa. His grandmother gathered up the newborn, scrambling with hope that someone could save her grandson. Lisa Mohrman, surgeon on watch at Ghana's Baptist Medical Center, received the baby and in the operating room repaired his abdominal deformity. "A month later," recounts Lisa, "his abdomen has healed, he's gaining weight, and seems to be developing normally. I am glad that I was the one to touch this baby's life." Lisa responded to a call, a call to die to herself - to her comforts, her entertainment, her material prosperity. She chooses to live simply, so that others may simply live. Coming to embody this virtue was a process for Lisa. "I was first inspired by the service of Dr. Tom Dooley to the underprivileged of Laos. INMED gave me the opportunity to explore this desire as a medical student through the International Medicine Certificate program at Banso Baptist Hospital in Cameroon. I spent the next 5 years of my surgical residency yearning to return to Africa." "Today, I am serving in Ghana as the INMED International Medicine Fellow. Over the past months working at the hospital I have gained a new understanding of dying to myself. Working here can be overwhelming, with so many patients in need and so many that I cannot possibly help, no matter how great my desire is to make them well. But then I remember that I touched at least one little baby, a baby who is alive today in part because I am here." Dying to self. Living simply so that others may simply live. INMED is committed to enabling healthcare students and professionals to do just this. Are you looking for inspiration or simply need to take the next step towards your calling? Join us at the annual Exploring Medical Missions Conference on May 31-June 1, 2013. Register today and be among those who discover that a call to die can actually mean living to the fullest.

BMC



I realized that I have never posted any pictures of the hospital at which I work.  It is hard to get the feel of the place from a few pictures, but at least you can see what it looks like.

 

The main OR



A doctors office in the OR (it is a bit cleaner since I took over and the picture was taken!)

Pediatric Ward

An example of how everything is used again here in Ghana

The male medical ward

 

The "Clerks Office" a.k.a. Medical Records

 

The clean minor procedure room . . . here we do biopsies, mass removals, suturing, etc.
 

 Laboratory

 

 Dentist's office

 

The male surgical ward

 The "dirty" procedure room . . . I know that it does not look much different from the clean one, but we pretend the clean room is more sterile.

 Nurses' station

 IV solution

Main hospital hallway.  All of the wards come off of this hallway to the left.

A tree behind my house in bloom

The rains have been coming regularly now which is a nice change from the dry heat.  The campus has become green again and everything is blooming.  The rain has really cooled the weather off also.  In the afternoons it now only gets into the mid-nineties and at night around 80 degrees.  It is surprising how much I have adapted to the heat; I am actually cold at night and wear a long sleeve shirt and pants to bed! 

The storms are intense when they come.  They mostly come from the northeast, starting out with intense wind and then pelting rain.  When the wind starts to blow, it is a sign to get up and close your windows because it is going to start to storm.  The rain is especially noisy on our metal roofs.  The branches of a fruit tree are over my bedroom roof, so when it starts to storm I get the added bonus of fruit falling on the roof.  It sometimes sounds like the house in under attack. 

Naa Jaringa Wall

 

The tallest part of the wall remaining today.  It is maybe just a
 foot or so taller than me.

Today, I went to see the remains of the Naa Jaringa Wall with Mr. Zaato, the head of the OR staff.  The wall is found a short distance outside of town.  It was a cool day so we had a pleasant ride on our bikes to get to the wall.  There he told me the story of Naa Jaringa.  

Naa Jaringa was a very powerful warrior and the king of the Mamprugu Kingdom during the 16^th century.  He built the wall that surrounded the entire village of Nalerigu for two reasons.  The first was to protect the village from slave raiders and other warring tribes.  The second was as a monument of remembrance.  It is said that he had many children, but only one son.  His son was blind in one eye, therefore was not acceptable as a successor (here in Ghana if you have a deformity you cannot become a chief).  He was upset that after building such a powerful kingdom he did not have someone to inherit it and that his lineage was ending.  Worried that it would be the end of his glory and that no one would remember him, he built the great wall.  The wall was built of stones, mud, honey, and milk.  It is also said that if anyone refused to work on the wall or complained of tiredness, as it was being built they were placed in the wall alive.  

Looking down a long section of the wall.

Today there is just a small amount of the wall remaining.  Unfortunately, it is not well protected or preserved so erosion has taken its toll on the wall.  Mr. Zaato said that when he was a small boy growing up in Nalerigu, it used to take two boys to boost one up onto of the wall and the wall was so thick that they would play and lay on the top of it.  One account said that it was originally about 13 meters high.  I was trying to figure out the length of the wall, but could not find out that number, but Nalerigu is not a small town, it stretches over quite a distance, so it is very impressive that this wall was built to surround the entire village.

 

 

Today I finished early in the OR, so I spent the afternoon making myself sick on Cherry coke and Twizzlers!  Thanks to William Haun, who brought me the Cherry Coke from his travels in the Ivory Coast, and to my parents for their great package of treats from the States!   

Mampruli Greetings

Here in Ghana greetings are very important.  Before any business can occur the proper greetings must be performed.  You also should greet anyone you pass on the street or come in contact with.  I find the greeting here complex and tiring.  There is no word for “hello” in Mampruli, instead the greetings used are good morning or good afternoon, etc.  The proper greeting can go on for several minutes as you greet everyone that is present before you can get down to the business at hand.  What I find frustrating is that if there is an emergency at the hospital greeting still must take place.  In English a typical greeting would go like this:

                “Good Morning Doctor”

                “Good Morning”

                “How was your last night’s sleep?”

                “My sleep was there.”

                “How is your health?”

                “My health is there.”

                “How is your house people?” (family)

                “Their health is there.”

                “Please Doctor, I need you to see the patient in bed two, he has stopped breathing.”

                Me wanting to bang my head against the wall, but calmly saying “Ok, please take me to him.”

I have listed the greetings below.  You use a certain greeting depending on the time or day or location / situation you find yourself in.  No matter where you are it always appropriate to use the time of day as the greeting so I tend to use those because I forget the others.  The universal response to the greetings is to say “Naa,” which is pronounced with a decrescendo intonation and is drawn out.  I have learned if you say a short quick “Naa” that means that you are angry with the person greeting you or that your relationship is not on good terms.  The greetings below are written phonetically, the capitalized syllable being the one to emphasis.

                Good Morning                                  DAH-su-bah

                Good Midday (noon-4pm)              NEE-wun-TAHNG-ah

                Good Evening                                    NEE-zah-NO-ree

                Good Night                                         ah-nee-WOO-la

                Welcome                                             ee-JAAAH-ree

                At work                                                nee tu-MAH

                Carrying water from the river         nee ee KU-liga

                Having a conversation                      nee eeSWAriga

                At Market (to one person)              nee ee DAH

                At Market (>1 person)                   nee yah-DAH

The greetings above are followed by questions about your health and families health.  How many questions asked depends on the person you are talking to, but most often in the morning they will ask about my sleep, my health, my mother’s health, and father’s health.  Since Megan’s visit, I am also often also asked her.  The response to the questions is simply “health is there” or “ah-LAH-fee-ya.”  If one is sick, the response is “kah ah-LAH-fee-ya.”  If you were sick, but are now better, the response is “DISHWA.”

                How was your last night sleep?                  EE-sa-don-WU-la

                How is your health?                                      ah-LAH-fee-ya BEH-nee

                How are your house people?                      ee-yeer dee-ma

                How is your father?                                       ee bah beh WU-la

                How is your mother?                                     ee mah beh WU-la

                How is your husband?                                   ee-seerah beh WU-la

                How is your wife?                                           ee-pwa beh WU-la

                How is your child?                                           ee bee-YAH beh WU-la

                How are your children?                                 ee bee-SEE beh WU-la