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.

Where I am

I have arrived at the Baptist Medical Centre in Nalerigu, Ghana.  This is the same hospital where I lived and worked in 2012-13 and have travelled back to the last few years.  I left Accra early this morning on a 6am flight.  My friend, William Haun, who now lives at the BMC with his wife Heidi and their children travelled North with me.  I am used to making this trip on my own, so it was nice to have a travel companion.  His wife is the current surgeon at the hospital.  She picked us up in Tamale, the biggest city in the North, and then we travelled by car to Nalerigu.   

Ghana is located in West Africa and has a population of about 27 million people.  The capital, Accra, is located along the southern coast.  The official language of Ghana is English, but many still do not speak English and instead only speak their tribal language.  In the village where I work the language is Mampruli.  Ghana is this beautiful and strange combination of old world tradition meets modern development.  The cities are busy growing metropolitans were you can find the latest and greatest, while just outside in the villages people are still living in huts with mud floors. 

Nalerigu is in the Northern Region of the country and is one of the poorest areas.  The Northern Region is mostly undeveloped and is inhabited by people that live in small villages that are connected by a network of small dirt roads and foot paths.  These people make their living farming small plots of land that have been passed down through generations.  Nalerigu is considered a bush village.  It has hard to estimate the population but is probably about 1-2 thousand people.

The Baptist Medical Centre (BMC) is a very well respected mission hospital that was founded in 1958 by a general surgeon, Dr. George Faile.  It is currently a 123 bed hospital that serves the surrounding population of about 600,000 people, as well as people that travel from as far south as Accra and from neighboring countries like Burkina Faso and Mali to the north and Togo and Nigeria to the East.  In a given year about 60,0000 people are seen in the outpatient clinic, 10,000 people are hospitalized, 1,200 major operations are performed and 2,500-3,000 minor procedures are performed!  I am excited to have the opportunity to return again to the BMC.  

After being picked up at the airport, Heidi filled me in on the news of the hospital and also did a checkout of the patients.  She and her family are heading today to Burkina Faso, the country to the North of Ghana, because her son has a passport issue that needs to be worked out.  They do not know when they will be back so I will be holding down the fort.  This week I have a variety of hernias scheduled, a mastectomy for breast cancer is on the books for tomorrow.  A 5 year old boy, had an accident with a gun and shot off his middle and index finger.  She completed the amputation of the middle finger and attempted to save the index finger.  Right now it is not looking like it will survive, so that might have to be amputated this week.  There are a variety of post-operative patients on the wards I will be looking after.  After arriving at the BMC today, I basically threw my bags in a room and headed to the theatre and repaired three hernias!!  I am happy that I don't have much of a problem with jetlag, but I am looking forward to a nice nights sleep tonight! 

In Accra

I have arrived in Accra!  The flight over was long and uncomfortable, so I am happy to be here.  No matter how many times I arrive in country, what always surprises me is the heat that just hits you as soon as you walk off the plane.  We de-board on the tarmac and walk to the terminal which I don't think helps the situation, but pretty much as soon as you are here you start sweating from places that you didn't know could sweat!!

I am staying the night at the Baptist Rest House, it is basically like a hostel for missionaries coming and going from the country.  When I arrived the rest house was pretty quiet and looked like I would be the only guest.  I was a bit disappointed because in the past I have enjoyed meeting other travelers who are involved in projects around the country and in the neighboring Togo and Cote d'Ivoire.  Everyone knows everyone else in the Baptist missionary community.  Since I started coming here on my own through a different organization, I don't know everyone, but constantly hear names and stories.  It is nice when we would have a chance encounters in Accra, to place the face with the name. 

I decided to take nap for a few hours while I was waiting for my friend William to arrive from South Africa.  When I awoke a few hours later, a bit hot and sticky (because I didn't realize that I could run the AC for free here!), I was pleasantly surprised to see that another physician I know from Dallas was hanging out for a few hours prior to his flight out tonight.  We have not seen each other in a few years so it was great to catch up.  After William arrived, we all went down the road for some Chinese food because why wouldn't you want to eat Chinese food in Africa!
  

I am going to have an early night tonight, enjoying the AC in my room and will be picked up at 4:45 am, to head off to the airport for my flight to Tamale.

Ready to Go!!

I am packed and ready to go with 12 hours to spare . . . a record for me!  I have two 50 lbs bags packed tight with medical supplies and a few random gifts for friends in Ghana.  My clothes all fit into the Adidas bag, which is making me slightly nervous that I am leaving something very important behind.  Last year, I forgot to bring a stethoscope, I pretty big faux pa for a doctor and so I have made sure at least that is packed away safe this year.

I am excited to start my journey.  Tomorrow afternoon,  I will fly to DC and then from there to Accra, the capital of Ghana.  I will arrive in Ghana on Sunday morning.  I heard today that the next leg of my travels, a flight in country to a city in the North, Tamale, was cancelled (no explanation why . . . when you travel in Africa you just kinda get used to the fact that scheduled things are sometimes just optional).  So right now, I am not sure if I will be spending Sunday in Accra and heading up there on Monday or possibly catching a flight on another airline.  Being flexible with travel plans has certainly been something I have gotten used to over my years traveling to Ghana!! 

Ghana or Bust

            Well my bags are packed and tonight I leave for Ghana.  I can’t really describe what I am feeling.  I am so excited to be seeing my friends and to be back working at the hospital helping the people of Northern Ghana, but I feel a bit apprehensive at the same time.  I know that so much has changed at the Baptist Medical Centre in the year I have been gone. 

            When I picture my time in Nalerigu, I remember not only the work I did at the hospital, but the missionaries that called the BMC home.  I will never forget the fellowship of the Coram, Hewitt, Welch, and Gibb families and I know they will be missed these next two weeks.  On the same note, I can’t wait to see the Coppola Family and hang out with the two cutest Americans girls in Ghana, Sarah Grace and Elizabeth.   I am also looking forward to spending more time with William, Heidi, and Trey Haun.

Playing games last year with Sarah Grace, Elizabeth, and some local girls.

            I have to admit I am nervous about the medicine.  I have spent the last year engrossed in Western Medicine, starting a practice and gaining confidence in my first year in practice as a surgeon.  I am worried I have forgotten all my tropical medicine.  I know I will be spending some quality time on the plane reviewing the hospital protocols and reminding myself of the presentations of various diseases.       

            I know that next two weeks will be filled with great fellowship, as well great challenges and I am looking forward to finding out what lays ahead and hopefully sharing some of it with you through this blog. 

Bonjour Dakar!

I am spending my last week in Africa with a friend in Dakar, Senegal.  Dakar is the capital of Senegal and is located on the Cap-Vert Peninsula on the Atlantic coast of Africa and has the distinction of being the westernmost city on the African mainland.  Because of its location, Dakar has developed into one of the most important ports in Africa for trans-Atlantic and European trade.  The population is estimated at about 2.45 million people.  Dakar was a French colony so the people speak French as well as local languages, which is making traveling around the city interesting as I try to pull the little French I can remember out of my brain.

The modern feel of the city has surprised both Julia and I.  Dakar is actually a very wealthy city with over 1/3 of the population making more than the average American per year.  This can be seen in cars they drive, the fancy restaurants around the city, and the products that are being sold in the mall and grocery stores.    

Yesterday we arrived at 2am so we slept for part of the day and then went and bought groceries and had a mini tour of the city by a missionary that lives here.  I think I am defiantly experiencing some reverse culture shock, the entire day was very overwhelming.  The city is amazing and although there are still some parts that are clearly Africa, it feels like a western city.  There are actually lanes on the streets and people follow rules driving.  I was absolutely amazed at the things that could be found here in Dakar.  We went to an American import grocery store were both Julia and I were shocked about what you could find.  There was a whole isle of American candy and snack food, not to mention syrup, pancake mixes, Manwich, Olive Garden pasta sauce, American brand juice, etc!  It seemed like the entire day all I kept saying was “Julia!  Look at this; I can’t believe they have this here!”  We ate lunch in a mall food court which looked like any food court in America; I was amazed I was still in Africa.  So much more development, advancement, and wealth than you see in Ghana (even in the capital of Ghana). 

Today we visited the Le Monument de la Renaissance Africaine.  It is a large monument which stands 49 meters high (3 meters taller than the Statue of Liberty) and sits on top of a 100 meter hill so it is easily visible no matter where you are in the city.  It was finished in 2010 at the expense of 27 million US dollars.  There is much criticism of the monument especially surrounding the cost in a country and region of the world that is so economically depressed.  In addition, many objected to the fact that although it is suppose to show African pride and represent the new Africa after independence that it was designed by a Romanian architect and built in North Korea, a communist country with no freedom.  The local imams (Muslim leaders) objected to the statue since it depicted a half naked male and female figure.  Overall the statue is pretty impressive, although not that pretty.  We climbed 189 steps to reach the top of the hill and from there had a nice view of the city.  We then when up a tiny elevator and looked out over the city from the head of the man. 

Julia and I then visited the most western point of Africa and had crepes in a little restaurant where we surprisingly enjoyed free WiFi and a semi-ocean view.   I think that we will plan to visit this site again for dinner some night and watch the sun set over the Atlantic!

On the western most tip of Africa with the Atlantic ocean in the background!