Case of The Week - Necrotizing Fasciitis

I could never quite get the whole story about this patient’s medical history from her family.  The stories kept changing.  She is a 70+ year old who showed up in clinic with the abdominal wound for 2 months.  The family said she had a super pubic catheter placed, then removed, and a when I saw her she had a foley catheter in place.  I took her and did a debridement of the wound under ketamine.  We did dressing changes for about three weeks until the wound was clean and then I placed a skin graft.  I just saw her back a week ago and the graft and most taken and she was doing well.  The wound I see here continually surprise me.

On admission



After doing dressing changes for about three weeks.  The abdominal fascia is all gone and those are her abdominal muscles showing.

Placing a skin graft over the wound.

 

Cape Coast

I had a great time with Megan in Nalerigu this past month and she did a wonderful job taking care of the maternity ward.  We were able to operate with each other on a few cases which was a lot of fun.  I am not sure when we will ever have that opportunity again. 

 

We were able to do some traveling in the south of Ghana which was awesome.  We traveled to the Cape Coast and stayed in the town of Elmina at the Elmina Bay Resort, which was a nice little resort tucked away on a very private beach.  If you ever have heard a reference to Africa’s “Gold Coast” that is a reference to this part of Ghana. 


Picture from our balcony.

 

The first day we went into Elmina and took a walking tour of the city and visiting the Castle of St. George.  The town is mostly a fishing village and the first Europeans that settled in the area were Portuguese and later Dutch.  It was the heart of the African gold trade to Europe in the 1400-1600’s.  The city is bustling with activity and was sort of overwhelming.  The fishing vessels, called pirogues, are colorfully painted and decorated with flags.  We had a wonderful morning walking around the city, learning about the history of the area, and then spent a relaxing afternoon poolside.

 Pirogues parked on the beach outside of the castle.

The lagoon where pirogues come and offload their catches of the night.

In the cemetery in Elmina many of first European settlers are buried.  That includes the Brothers and Sisters that came to teach Catholicism .  A group of Irish nuns where some of the first to travel and live in Ghana and their graves are marked with Shamrocks on the headstones.
 

This picture is of the “door of no return.”  The slaves left this door of the castle and where loaded onto the boats that were directly outside.  The majority of would die on those boats before reaching their various destinations. 

In 1482 the Portuguese started to build the Castle of St. George.  It is said to be the oldest European structure in Africa.  It was first build mostly as a trade center to trade arms and ammunition to locals in exchange for gold.  The Portuguese (and later the Dutch when they took over in 1637) started to trade European good for slaves instead of gold.  It remained one of the centers for slave train until it abolishment in 1807.

 

 

 

 

This is a picture of the Castle of St. George from St. Jago Hill where Fort St. Jago was built by the Dutch.  This fort served as protection for the castle.  The watchmen at the fort could look out at the bay and see any ships that might be coming to attack the city.  When the Dutch took over the castle they actually first took this hill and then bombed the heck out of the castle until the Portuguese surrendered.  They later built Fort St. Jago for protection.   

 

The second day we headed on a whirlwind tour of different sites.  We started the day driving north to Kakum National Park.  This is an area of protected rainforest in Ghana about an hour north of the coast.  We enjoyed walking on the hanging bridges and through the forest.  We then stopped at the Monkey Forest Resort where we made friends with some cute baby monkeys.  The resort is a sanctuary for orphaned and injured animals and the home of the most eccentric Dutch couple I have ever met.  We had lunch a restaurant that is built over a lagoon full of crocodiles.  For a small fee the staff will get one out of the water for you to take a picture standing next to.  Megan and I both decided that our parents would not be please if we were eaten by a crocodile in Africa so we stayed put on the deck and just watched other gullible tourists risk their lives.  We ended out tour in Cape Coast the capital city of Ghana’s Central Region. 

 Kakum National Park

Monkey Reserve

 

Cape Coast Castle was built by the British and was one of the largest slave-holding sites in the world during the colonial era.  Unlike the castle in Elmina, it was built specifically for slave trade.  Here slaves that had been traded to the British by the African chiefs for alcohol, guns, and gun powder were held for months while awaiting the arrival of merchant ships that would take them to the west. 

 

 

Case of The Week

People shoot off homemade guns here in Ghana.  They do it for celebrations and funerals.  Earlier in the year they even had a “Fire Festival” for a week and every night they shot off guns and cannons.  The guns are made poorly and end up back firing and blowing off the patient’s left hands.  I have seen too many injuries like this over the last few months.  Most of the time, I just have to amputate just a few fingers or the lucky ones just need some stitching up of the skin.  Below is the worst injury I have seen.  The hand could not be salvaged and I did an amputation at the wrist.

 

His third finger is completely missing and the bones of his wrist are exposed.   

After wrist disarticulation was complete.

Happy Birthday Megan!!!

Megan sporting her new Ghanaian football uniform including Ghana socks.  I had a great time roaming around market looking for gifts for Megan's birthday.  I also tried my hand and baking a home made cake.  I think the only thing that made it edible was the chocolate icing and the M&M's, but it was fun to make.



Bring on the Heat!

We are in the middle of the hot dry season and hot and dry is an understatement.  It is amazing how the campus has transformed since I arrived.  All of the green has disappeared as everything has died.  In the heat of the day it is around 115 degrees and it cools down to the low 90’s at night.  For me the OR is the best place to be because it has air conditioning.  I know that many places in America can boast high temperatures, but not stifling heat day after day, and in America you can go from your air conditioned home, to your car, to air conditioned work, etc, and never really notice the heat.  The worst part of the day for me is trying to sleep.  I received some friendly advice to get all of my clothes wet before I go to sleep.  It is amazing, but with a fan blowing, I actually get a bit chilled and am able to fall asleep.  I usually wake up around three or four in a puddle of sweat and just get up and wet everything down again.   
 

The way campus looked when I first arrived

Dry season on campus . . . looking at this pictures just makes me feel hot! 

The hot dry season comes after the end of the Harmattan here in Ghana.  The Harmattan is a dry dusty trade wind that blows south from the Sahara desert across West Africa into the Gulf of Guinea.  It starts in late November and goes through early March.  On its way over the Sahara it picks up fine dust particles, which it will carry across the land.  The dust was very mild this year, but I am told that sometimes the heavy amount of dust in the air will block out the sun and you will not be able to see a few feet in front of you.  The best part about the Harmattan is that with the wind comes cool temperatures into the 70’s.  On some mornings I would wear long sleeves and at night I would sleep with a blanket, but for the most part the missionaries are finally comfortable.  On the other hand the Ghanaians are bundling up.  They are in long pants, heavy winter coats, hats, gloves, and scarves.  It is quite the sight.  We showed a movie about Jesus out in a village one night and we were all in shorts and tee-shirts and the Ghanaians were huddled up next to each other under blankets for warmth.  I guess it is all what you are used to.

During the Harmattan is the coolest part of the year here in Ghana, but the next coolest is when the rains come after the hot dry season.  And that is what we are all anxiously awaiting now!

Easter

We had a great Easter on campus complete with a honey baked ham, thanks to Megan’s willingness to pack a ham in her luggage and bring it halfway around the world!  The meal was really a special treat to the missionaries here in Nalerigu.  We spent Sunday in Nakpanduri hiking the escarpment and sharing a meal with John and Denise and older missionary couple that have been in Ghana since the 60’s.  I am very proud of myself because I drove the entire 45 minutes to Nakpanduri in a manual truck avoiding rocks, pot holes, motos, trucks, and all of the other road hazards that can be found in Ghana!

 

Hiking at the escarpment with Megan and Julia Welch

Megan hugging a balbo tree

Case of the Week

This man showed up in my clinic.  He was from Togo which is the country to the east of Ghana.  He has these masses only on his face.  No other part of his body is affected.  He said that about fifteen years earlier he had two masses on his forehead removed and then after that all of these other masses have been growing.  There are clearly places that the masses ulcers on them that look like skin cancers, but I have no idea what the underlying process is.  I, unfortunately, had to tell him there was nothing that I could do to help him. 

Trauma Team to the BMC

Yesterday was Ghana’s Independence Day, which meant no outpatient clinic and a day to rest and recuperate.  Or at least that is what I had planned.  It all changed late in the afternoon when a tribal war broke out north of Nalerigu.  These two tribes have been warring since the early 80’s over a little patch of land.  There will be long times of peace and then the tribes will find some reason to start fighting again. 

The gun shots started rolling into the hospital in the late afternoon and kept me there most of the night.  As soon as I would patch up one guy and think I was done, another would roll in the door.  Eight people in all were brought to BMC with gunshot wounds.  The worst was shot right to left through the front of his face, I have never seen an injury like that before.  Everyone was extremely lucky.  Ghanians’ have no fat on their bodies.  Two men had bullets travel through the 1 cm of sub-q fat on their abdomens.  Amazing the bullets did not enter their abdomens.  Another bullet went through and through the skin of a man’s chest, not entering the chest at all.  The rest were extremity injuries, which I just stabilized overnight until I could refer them to the orthopedic hospital a few hours away in the morning. 

To make matters worse a truck load of soldiers that was actually running from the fighting (because they said the fighting was too intense) overturned in a ditch.  Nine soldiers were admitted for injuries from being thrown from the back of the truck.  It was a blessing that none of them were very injured.  I was able to tuck them all into the ward for observation. 

In the end, it will be a Independence Day I will not likely ever forget anytime soon!

Case of the Week

 

Today I removed a cystic hygroma from the neck of a 3 year old girl.  A cystic hygroma is a congenital multiloculated lymphatic lesion that can be found anywhere in the body, most often in found in the posterior triangle of the neck.  These are benign lesions, but can be very disfiguring.  I was able to resect the entire mass, which I was very happy about.  There were some very hairy moments in the case though.  The cystic structures went right down and ran along her jugular vein and carotid artery.  Resecting the mass off these structures was a bit nerve wrecking, but all went well in the end. 

Camping

The girls at the escarpment.  From left to right Front: Taylor
Coram, Elizabeth Gibbs, Emily and Abby Hewitt.  Back: Me
and Julia Welch

The missionary families and I went up to Nakpanduri, about a 45 minutes drive north, to camp on the escarpment.  It went like most camping trips go . . . You are excited to take off and had fun setting up camp.  We all enjoyed hiking the escarpment and had a great evening of fellowship telling stories and playing cards.  Jane Anne Gibbs, Mona Hewitt, Julie Coram organized a great dinner which included the special treat of beef shish kabobs and s’mores.


The teens hanging out

After the excitement of being on a camping trip wears off and you are settling down to sleep the reality of what you are doing sets in.  The tossing and turning trying to sleep on the hard ground makes one wonder why they said yes to the crazy idea of camping in the first place.  (I know the Ghanaians I work with all though I was crazy.  As I told them what I was going to do for the weekend, they looked at me with quizzical stares and I know the thought going through all of their head was why would someone choose to sleep on the ground in the middle of nowhere for fun.  Everyday life for most Ghanaians is like a bad camping trip.) 

 



The sunrise at Nakpanduri

But the next morning as you are driving home sore and exhausted you think about the sunset and sunrise you saw and all of the laughs and jokes you shared with friends and you say that wasn’t so bad, we should do it again sometime.

Our campsite . . . if you look closely at the rocks on the right you will see a few people up at the top.  That is where the teenage girls and Dr. Hewitt slept under the stars.  I happily slept away from snakes and bugs in the tent!

 

The morning after with Julia Welch and Julie Coram