A new Ghanian Adventure Begins!!

Many years ago, I learned about the Mercy Ships organization and the free specialty surgical care they provide to underserved communities in Africa. It has always been a dream of mine to serve on one of the ships, but because of their volunteer requirements—and my pesky full-time job—it was never really a reality. Until now!

One of the benefits of locums medicine is being able to choose your assignments and work locations, which has finally given me the opportunity to volunteer on the Mercy Ship for a month.

I’ll be leaving for Ghana on September 11th to begin my month aboard the ship. I’m incredibly excited, but at the same time, I’m very nervous about the whole experience. I’ve completed the online training, which somehow managed to create more questions than answers. But at some point, you just have to jump in with both feet, hope for the best, and figure things out one day at a time.

I’m nervous about being completely stir-crazy living on a ship. Will the other volunteers be nice? Is the food going to be horrible? And perhaps most importantly…who will be my roommate?!

What I do know is surgery.

And that gives me some comfort. No matter what new things I encounter on the ship, the surgeries themselves are the same ones I’ve been doing throughout my career—whether that’s in St. Louis, at my new locums assignment in Farmington, Missouri, my future job in Alton, Illinois, at BMC in northern Ghana, or floating somewhere on a ship.

Surgery is surgery.

Operating rooms, for the most part, are the same. A table, lights, an anesthesia machine, and instruments are all you really need for a successful operation—although my training in northern Ghana might challenge the premise that you need all of those things, all at once!

In the end, it’s simply the surgeon, the patient, and the OR staff coming together in a unique situation to hopefully change a patient’s life for the better.

I know that. I can do that.

So as I look forward to this adventure, I keep reminding myself: if I hate everything else about this experience, I LOVE surgery. And in the end, the patients and I will just have to come out on top.

When I first applied to Mercy Ships more than a year ago, I didn’t intend to serve in Ghana. At the time, the Global Mercy was in Sierra Leone and the Africa Mercy was in Madagascar. But as fate would have it, the Global Mercy arrived in Ghana on August 19th to begin an eleven-month period of service to the country.

Although I was initially disappointed that I wouldn’t get to visit and experience another country, honestly, this feels right.

I know and understand the culture, which I think will make adapting to everything else a little easier. It will also give me the opportunity to travel to the Baptist Medical Centre in Nalerigu for a few weeks after I leave the ship—which I am, of course, super excited about.

Over the next six weeks, I hope to share some of the adventures, challenges, surprises, and experiences from my time aboard the Global Mercy and up at BMC.

I hope you’ll enjoy coming along for the ride!

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.