Outpatient Clinic

At the BMC our main clinic days are on Monday, Wednesday, and Friday.  One those days the physicians and medical assistance see anywhere from 500-600 patients.  Clinic days are a long day of work and waiting for everyone involved; doctors, patients, nurses, translators.  Patients start by picking up their medical folder (or medical chart) or registering for a chart.  Registration ends around noon, so patients need to arrive early if they would like to be seen, which means that many people travel to Nalerigu the day before or arrive on a Tro-Tro (bus) from neighboring towns very early.  After getting their folder, the patients get their blood pressure and weight taken and then they will sit and wait to be seen.  Most will wait the entire day to be seen and some will wait all day to just be sent home unseen to return the next day.  They will wait in the courtyard of the hospital or common area of the outpatient clinic.  They will wait and listen for their name to be called, which means that they have been assigned to move to the waiting area outside of a certain consulting room.  There they will wait again for their name to be called into the room to finally see a doctor.  After their visit with the doctor (which probably averages about 5-10 minutes) they will take their folder and go to the pharmacy where they will again wait to have their drugs distributed.  We start clinic in the morning as soon as rounds finish on the wards.  We break between 9:30-10am for morning prayer and then typically end clinic around 6:30-7pm.



Patients waiting in the outpatient department

Although I am a surgeon I pretty much see anything in my clinic.  It has sort of become a game to me to think what will walk through the door after my translator yells out a name.  I am continually surprised.  Below have been some of my more memorable patients. 

Fatima had cut palm very badly with a knife and came to
see me often for wound checks.

1)  A 12 year old boy came into my clinic and when asked what was wrong, he told me he was not sick.  When questioned about why he had come to the doctor, he said his friend was sick and he thought he would just come along because he had never seen a hospital before.  I then performed probably the only well child exam ever to be done in Ghana.

 

2) A man said that his neck hurt him every time the moon is a sliver in the sky and at that time he would not be able to move his neck to the right. 

  

3) A ~60 year old man complained of erectile dysfunction.  I was working with two female translators that day.  Before I even said anything, the two women were yelling at the man.  When I asked what was going on, they told me that he said he already had seven kids, all of whom were not in school, so they were telling him that his time was finished and he did need to have “relations” any more.

 

4) “When I am sad I get a sore in my anus,” was the problem another man was having.  I did not even know what to say or ask.  A rectal exam was normal so I sent him away with vitamins and Prozac.

Writing in the medical folder (chart).  These cost the patient $9 and are kept at the hospital.  The patients all have a medical number that they keep.  Everything is written all in one book.

5) If a person has a hernia the belief is that it causes all of the pain that person might have, no matter where that pain is located.  One older lady sat in front of me and said, “I have pain all over my body, you need to find the hernia that is causing the pain.”

 

6) A middle aged man complained of right body fever.  No fever on the left side of his body, just the right.  He even went so far as to take down his pants and say that if I touched the right side of his scrotum it was hot, while the left side was cold.  I politely said that I would just touch his arms instead. 

 

7) A man wanted his inguinal hernia repaired because he insisted that it was making his right big toe itch. 

 

8) An educated man that spoke and wrote English well came in with a list.  At the top was written “My Sicknesses.”  The list included: Waist pain, hip pain, foot weakness, sexual weakness, urinary problems, shoulder pain, veins with bumps in them that are large in the legs, sexual weakness (written a second time), back pain, and headaches.  Lucky for me most of his symptoms revolved around pain issues so I sent him on his way with some Motrin and a slip of paper with Viagra written on it for him to go and try to buy at a chemical store.

 

9) I was sent a consult from one of the medical assistants for a lower abdominal mass in a young woman.  I only asked one question, “When was your last menstrual cycle?”  Ultrasound did confirm that the patient’s abdominal mass was a fetus.

 

10) A very old man I had operated on for a gastric perforation, who also had hypertension came in for his medication refills.  He told the translator that all his troubles had gone away as soon as he sat down next to me.  It melted my heart.

 

11) All year people have been coming into my office saying that they were spitting too much.  One man even spit in my consulting room on the floor.  I have just sort of ignored that complaint because people usually come in with no less than 15 complaints.  I have always thought, well just swallow instead of spit!  It especially annoyed me when parents complained that their children were spitting, because I just thought that it was poor parenting . . . tell the kids to stop spitting, that is what my parents taught me.  One day, I was talking to a Ghanaian doctor about the difficulties seen in clinic and complaints of patients that irritated me and I brought up the spitting.  He casually said, “Oh if they are splitting too much that means they have worms!”  So here is my apology to all of those patients I have seen over the year that were spitting too much, you were apparently not crazy!

 

12) A middle aged woman came into my office and complained that something had crawled into her ear and died.  Sure enough when I looked inside of her ear there was a cockroach legs up died. 

Case of the Week: Breast Cancer



SF and her lateral chest wall mass

SF is a 34 year old Fulani woman who travelled from Burkina Faso (the country to the north of Ghana) to be evaluated for a mass on her right chest wall.  She stated that it started as a small sore just before the birth of her last child approximately nine months prior.  On exam, she had a large fungating mass on the lateral aspect of her right chest.  The lateral aspect of her right breast involved on exam and she had no palpable axillary lymph nodes.  The mass did not seem to be attached to the underlying chest wall so I was able to resect the mass and place a skin graft in the defect which was left.  Pathology returned as an adenocarcinoma with a lymph node that was taken during surgery positive for disease.  She recovered well after her surgery and the skin graft healed nicely.


Breast cancer is one of the leading malignancies here in Ghana.  In 2007 it was estimated that breast cancer accounted for 15.4% of malignancies and about 70% of the women diagnosed with breast cancer present in the advanced stages of the disease.  Studies have also shown that women in Ghana are more likely to have high-grade tumors that are triple negative for hormone receptors.  This results in more aggressive disease and higher mortality rates.  Breast cancer is also seen here in Ghana in much younger women.

Peau d'orange skin changes seen with inflammatory
breast cancer 

It has been my experience to see women in the late stages of the disease.  I have seen many patients with large ulcerative lesions of the chest that have totally replaced the breast and who no treatment can be offered.  Those that I have been able to do mastectomies on have all had positive lymph nodes and advanced disease.  Women delay in coming to see a physician for many reasons.  For many in the North it is a lack of education and awareness that what they are experiencing in their breast is abnormal.  There is a cost associated with traveling to a health facility that many cannot afford.  There is also an underlying belief in fatalism here in Ghana, which leads women with breast cancer to have a feeling of hopelessness and helplessness and therefore leads to denial as the primary means of coping with what is happening.

Large medial breast cancer

Women finally present to clinics when their pain has become unbearable or when the fungating lesions are so large, infected, and necrotic that they have been ostracized by their community and family because of the smell of the wound.  Once they have made their way to a clinic, the main challenge is to convince the patient of the treatment they need.  It has been very difficult to get patients who are candidates to agree to mastectomies because they see it as an amputation, which is frowned upon here in Ghana.  I have been lucky because I have an ally on my side here at the BMC.  One of our medical assistance is a breast cancer survivor and I have begun to send all of my patients to see and discuss surgery with her.  I figure she can explain to the women better why they need a mastectomy with more cultural sensitivity than I.  Since I have begun that practice, more of the patients are showing up for their scheduled mastectomies than earlier in the year. 

The Breast Health Global Initiative and the Susan G. Komen for the Cure have established a Ghana Breast Cancer Alliance to help try to decrease breast cancer mortality by increasing earlier detection.  It was announced in September that the Alliance acquired a mobile detection and education van for outreach programs to rural Ghana.  I am hoping to get the Baptist Medical Center on their schedule of stops so that better breast care can be given to the women of Northern Ghana. 

Free Range

A hen with her five chicks

I was met outside of the hospital one night by
this goat finding shelter from the rain behind
my bike

Here in Ghana all the animals are "free range."  The animals wonder free during the day to scavenge for food, it seems like mostly snaking on trash.  Goats, sheep, donkeys, chickens, turkeys, pigs, dogs, etc, can all be seen walking around town unattended.  At night the main street of Nalerigu is littered with sleeping goats (why they sleep in the middle of the road I have yet to figure out).  If you hit an animal while driving it is your responsibility to go find the owner and pay for the animal.  When a Ghanaian was asked why they let their animals roam free and aren’t they worried they would get lost, he answered, “Well don’t you know where your home is, you don’t get lost?”  Fair enough.

 

 

 

 

 

Donkey just hanging out

Goats on the move

Pigs keeping cool in a puddle

Heading to the river for a drink of water

Case of the Week: Peptic Ulcer Disease

This has been the week of peptic ulcer disease (PUD).  It is a very common diagnosis here in Ghana and in clinic we give out Omeprazole, a drug to treat PUD like it is candy.  I believe that it is a diet rich in spicy food, high use of alcohol, and the incorrect use of over the counter Motrin that can be bought at local chemical stores that is to blame for the high rate of PUD. 

This week I had three cases of perforated gastric ulcers that needed emergent surgery, all under the age of thirty.  In addition, I operated on a thirteen year old boy with a gastric outlet obstruction.  At surgery, I found scarring at his pyloris (the area that empties the stomach) creating the obstruction.  I did not have a good reason for this to have occurred in such a young patient, but after talking the case over with a Ghanaian doctor he was not surprised at the findings cited PUD as a very common cause even in the very young in Ghana.

It was probably fitting that this week I saw a lot of these cases because over the last few weeks, I have had increased sympathy for patients with PUD.  I officially know the pain they go through after just getting over an esophageal ulcer caused by Doxycycline, which I am taking for my malaria prophylaxis.  When I thought I was going to die in Ghana because of the chest pain, I reached out to a trusted gastroenterology consultant (aka my father) who said this was most commonly seen in pimple faced teenagers on tetracycline, but he supposed it could happen to me also!  After taking Omeprazole and drinking “Gastrome,” our version of Pepto-Bismol and stopping the doxy for a few weeks I am now feeling much better.  I think that it is humbling and good for physicians to be sick once in awhile so we can always continue to relate with our patients’ suffering.  Now, I have just been praying that I will not have the opportunity to relate to the malaria patients since I’ve been off my prophylaxis!  

Greetings from Nalerigu

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Some of the children from Nalerigu wanted to greet you . . . no matter what time of the day you are watching this video, there is a greeting for you!

If you educate a WOMEN you educate a nation!

I had the opportunity to host about 25 students from a private girls’ secondary school in Gambaga at the BMC.  Over the year, I met their teacher Claire, who is a Peace Corps volunteer teaching biology and running a health club.  She asked if she could bring the members of the health club to visit the hospital and learn a little bit about careers at the hospital, etc.  Since it is a girls’ school I wanted to make sure I found some good female role models to talk with the students.  I enlisted the help of one of our female pastors who is very outspoken and pro-women to help.  She did an incredible job putting together a panel of women to talk to the students about the careers they picked and how they got to where they are today.  One after the other was more inspiring and encouraging to the students.   

Midwife telling her story

Some of the stories the women told where heart breaking.  The midwife who spoke was from a very poor rural village.  Her parents never sent her to school.  She asked her friends one day where they went during the day and they told her school, so one day she decided to follow them.  She loved school and started to go regularly.  She said she did not own her first pair of shoes until she was in secondary school, so she would walk to school barefoot, running into the bush every so often when the road would get too hot on the soles of her feet.  She worked her way through school and now is one of our best midwives.  The pastor, who is in her mid-fifties, was an orphan.  She lived with some family members who also did not value education.  She had to do many morning chores before she was allowed to go to school.  She talked about how she persevered and always kept an eye on her goals.  How she knew it was up to her to make something of herself and get what she wanted out of life.  A young nurse, who just finished school, spoke about how she was from a family of more privilege, similar to the students’ situations.  She spoke about how even though they might have had an easier life, it is up to them to use the gifts they have been given to achieve something more.  That not everything will always be handed to them and it is their responsibility to work hard and better the country.

Asubonteng is a great lecturer . . . I even learned more
info about malari

After listening to the speakers we took a tour of the hospital and then Asubonteng, our PA, gave them a little lecture on Malaria. 

I think that the day was a great success.  Seeing the girls was an inspiration to me.  They all stood and said what they wanted to be and it was as diverse as any high school in America.  Nurse, doctor, midwife, politician, accountant, and teacher where the most common careers the girls wanted to pursue.  I just pray that the girls heard the messages that where directed to them and they will continue to study hard and reach whatever goals they set in front of themselves.  Because as it is said here in Ghana . . . “The surest way to keep people down is to educate the men and neglect the women.  If you educate a MAN you educate and INDIVIDUAL, but if you educate a WOMAN, you educate a FAMILY (nation)." (Quote is attributed to the Ghanaian scholar Dr. James Emmanuel Kwegyir Aggrey who was one of the most influential leaders of education during the colonial era.) 

I am not sure why we get so worked up about things in America . . . who really needs car seats for kids anyway??

Once a child is old enough to sit they are old enough to ride on a moto.  You will also see mothers riding with small babies strapped to their backs. 

If you look closely this mother is carrying three little ones home from school.

Say What?

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 it 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.”  

Life Lesson . . . Don't ride a bike barefoot!

I remember that growing up my parents had the rule that we always had to wear shoes when riding our bikes.  I assumed it was because the ridges on the pedals would hurt your feet if your rode barefoot.  Today, this poor 7 year old and I both learned why it is important to ride a bike with shoes on.  She was a passenger on the back of her brother's bike and her foot found its way into the bicycle spokes.



The girl is missing her entire big toe and part of her second toe.  The third toe is missing skin, but the bone is all intact.

Using bone rongeurs to cut off the ends of the exposed bones so that I could close her skin over the ends of the bone.

The father pulled this out of his pocket.  It is the child's big toe . . . he looked very sad when I told him I would not be able to reattach the toe.  He would not throw it away though, he is going to bring it home and bury it in the house.  I guess it is a superstition, that if a person lives and you have discarded a part of the person without a proper burial of the part then the person can die.  

Local Cuisine

At the top is rice balls in groundnut soup, the
bottom is TZ in okra soup

Ghanaian cuisine is mostly organized around a starchy staple food such as rice, cassava, yam, or maize.  Depending on where you are located in the country the starch will be prepared in different ways, making a variety of different dishes, such as fufu, kenkey, banku, rice balls, TZ.  Here in the Northern Region, where I live, they primarily eat TZ (pronounced T-zert) and rice balls.  These starch variations will all be served with some kind of soup, which is made from fish or some kind of other meat (goat, beef, chicken, guinea fowl, or pork).  Here in the Northern region groundnut soup (basically a peanuts soup) and okra soup is most common.  They will place the rice balls or TZ in one of those two soups and then give you a little side of beef. 

I actually like most of the food here in Ghana with the exception of TZ.  TZ actually does not really have a taste.  It is the texture that gets me.  It is extremely slimy and makes me feel like I am eating boogers.  Here in Nalerigu we go to the local “chop bar,” which is called Free Bar, to have local cuisine.  My favorite is rice balls and groundnut stew.  

Sharing a meal of fufu in okra soupwith Asubonteng (right)
 and his twin, Seth.  They are from Kumasi (south of the
 country) where fufu is primarily eaten.  Fufu is basically a
gooey ball of pounded cassava root or yam. 
 

When you sit down to eat the first thing you do is wash your right hand.  The left hand is considered dirty and should never be used.  In fact, they will not even use the left hand to take something from someone, always the right.  You don’t even use your left hand to wash your right like we do, that is just contaminating your right hand again.  (A child was in my office one day and I gave her a pencil after her visit and she took it with her left hand.  Her mother gave her a love pat on the back of her left hand and made the child give me the pencil back.  Then we tried again, this time the child received the pencil in her right hand and all was well.)  After you wash your right hand it is time to eat.  You scope part of the TZ or rice ball into your hand, roll it around into a ball, and dip it into the soup.  That is the worst part.  The soup is so hot and I always go away with burnt fingers.  I think the Ghanaians are used to the heat because it does not seem to faze them.  The challenge then is to get this mushy soupy mess into your mouth without dripping soup everywhere.  I always end up with soup running down my arm and making a huge mess.  My friend, Asubonteng, has told me it is because I was never taught the proper why to eat with my hands.  He said he remembers when he was a child his mother teaching him and correcting him when he was eating wrong, just like we would correct our kids if they are using a fork incorrectly.  He has given me a few pointers and I am getting a bit better!  The trickiest part is finishing the soup with your fingers.  I can’t do it at all, but Ghanaians, cup their first three fingers, scoop up the soup and then kinda wip the soup into their mouths, turning their hands upside down as they do it.  I am always amazed that they do not drip or fling soup everywhere.  I choose to finish my soup cereal style, drinking the rest of the bowel. 

Eating fufu with Asubonteng.  I find fufu is very heavy on my stomach and I can not eat much before I am full.  You can notice that Asubonteng has already finished his portion!  All of the starch foods they eat could be compared in a way to how we eat mashed potatoes.  I had a funny conversation with Asubonteng once about the differences.  He has had mashed potatoes when he shared Thanksgiving dinner with us and he can not believe that we eat it.  He hated the texture and said it had no taste.  I think fufu and TZ are the most tasteless things in the world and how he wants to eat fufu every day is beyond me. 

 Eating TZ, with my neighbor T Welch at Free Bar in Nalerigu.  TZ is made most commonly from pounded maize.

 

 This is one of my favorite meals served by the cooks at the BMC.  It is fried rice, Ghanaian style.  It has chicken, green peppers, and onions added. 

 

Behind rice balls and groundnut soup, Jollof rice is my second favorite dish.  It is a spicy dish comprised of rice cooked in tomato sauce.  It occasionally has pasta noodles and meet mixed into the rice.  It is served with meat, fish, or chicken.  Here I had it with cabbage salad (lettuce is rare in Ghana so we cabbage salads instead) and kabobs.

Red red is my third favorite dish here in Ghana.  It is a spicy bean stew made with black eye peas and is usually served with fried plantain, cassava root, or rice.  It gets its name from the palm oil that tints the stew an orange color.  It is greasy goodness.

Eating fried plantain with groundnuts on the go in Kumasi.

 

Banku can be seen in the top right hand corner of this picture.  It is made from fermented maize meal and is served with a tomato based relish that you dip the banku into (below the fish on the plate).  Banku is surprisingly sweet tasting.  It is mostly found served in the south of Ghana.  This banku was served with the best tilapia I have ever had.  Tilapia is also very common in the south of the country.