Case of the Week: Gunshot wound to the abdomen

A volunteer group has just arrived at the BMC to do hernia surgeries over the next week.  They were asking me about what cases I have been doing over the last year.  One question in particular was about penetrating trauma and I told them that I have been very lucky this year with not having much penetrating trauma.  In a low resource hospital a critical patient with a penetrating trauma can be very hard to manage. 

I told them about the tribal war earlier in the year when I had gotten 9 gunshot wounds (GSW)  in one night, but luckily 6 were extremity wounds, one was a GSW to the chest that only needed a chest tube, one was through and through the 1 cm of fat the patient had on his abdominal wall (a few millimeters the other way he would have been getting surgery), and the final one was a patient that was shot through the face, who I quickly stabilized and sent south to a larger teaching hospital.  Other than that one night the only other penetrating trauma I had seen was bull horns to the abdomen and in those patients although I did surgery to make sure everything was fine, I never found an injury.

About two hours after that conversation, I received a phone call from the physician on call that a young girl had shot herself in the abdomen by accident.  I rushed to the hospital to find Abena in the males ward because when they brought her the nurses had mistaken her for a boy.  She was alert and talking and when I peeked under the large bandage on her abdomen to see the wound my heart sank because the entrance wound was in her upper abdomen right under where her breast bone ends.  Many important  structures live right below that area and I was just praying we would be able to do something to help this little girl. 

Abena on post-operative day six . . . It drives me nuts because
Ghanaians will not smile for a camera and she has a
great smile.  Just before this picture she was smiling and laughing
with me and then I went to snap the photo and she got all serious,
which makes it look like she is sad and not well.

Everything at the BMC seemed to work perfectly that afternoon.  I ran to the lab were they happened to already have a unit of blood in the blood bank that matched Abena.  The anesthesiologist arrived quickly and the staff readied the OR and Abena.  We were able to get started in the OR in less than thirty minutes, which is record time.  One of the visiting surgeons with the hernia team first assisted me in the OR, which in a traumatic case like this is so important to have a good skilled first assistant.

The bullet had passed through Abena’s abdominal wall and blew off a crescent shape wound on the edge of her left lobe of her liver.  It then traveled through and through her stomach leaving about 5 cm defects on each wall.  The bullet tickled the distal end of her pancreas before lodging itself into her spleen.  During surgery I did a quick splenectomy and packed her liver to control bleeding.  I then repaired the holes in her stomach and explored the rest of the abdomen for injuries.  After packing, her liver injury was not bleeding so I left it alone and placed a drain into her abdomen to watch for pancreatic enzymes leaking from her pancreatic injury or bile leaking from her liver.

Abena has done remarkable well and on post-operative day one she was sitting up begging me for food!  I held off feeding her for several days because of the extensive injury to her stomach and the small pancreatic injury.  Today on post-operative day six she is walking, eating, only taking Tylenol for pain, and most likely heading home tomorrow!  This was a great save and a great case to end my year in Ghana! 

Nalerigu Market

Market days in Nalerigu are every three days.  On market days, women travel from the outlying villages to sell their produce.  Depending on the season different things are available in market, but there are always staples that you can buy; onions, tomatoes, cabbage, peppers, dry fish, rice, ginger, bread, beans, yams, and bananas.  Half of the market sells food items when the other half the stalls sell fabric, clothes, and other house hold goods.  There is an area in market to get meat (I always avoided this area, because they just butcher the animals on the tables in front of you.) 

 

I feel like going to market was an ordeal.  You negotiate prices for your food which is always interesting.  I always pay more because I am white so over the last few months I have been able to form a relationship with a Ghanaian women who will go to market for me.  It has been a huge help because often I cannot get to market because I am working at the hospital.  It also gets old because as a white person you are constantly being yelled at to come see stalls.  It is the highlight of Nalerigu’s week, but we all dread going to market, missing the opportunity to just whip into a nice cool grocery store at anytime we would like to pick up whatever we would like!

 

It is extremely hard to describe an African market and I don’t think that pictures really do it justice either.  Going to market is truly stimulation for all of your senses.  Here is a list of adjectives I would use to describe Nalerigu’s market: smelly, loud, no personal space, colorful, sweaty, crowded, busy, tight spaces, dirty, hot . . . I’m sure the list could go on!

Party!

I hosted my first Ghanaian party this evening for the operating staff at the hospital to thank them for their work this past year.  My friend Rebecca helped me to navigate the cultural differences.  One difference is that everyone expects to go home with a present, similar to a goody bag you would get at a kids birthday party.  She helped me to make jollof rice and chicken, which I served for dinner and then we sent everyone home with a goody bag of more rice, chicken, and a drink.  Making jollof rice for plenty of people is a lot of work and Rebecca was cooking all day long in my back yard.  I think in the end the party was a success.  

I have found that the supplies need to host a party here are much different than in America!  There is a large bag of coal on the left, the biggest bag of rice I have ever bought in my life, which goes along with a huge cooking bowl and charcoal cooker. 

Rebecca cooking the chicken

Preparing the soup (broth) that then the rice is added to which makes it Jollof Rice

Pikworo Slave Camp Entertainment

The slaves at Pikworo Slave Camp (see prior blog about more details) would be entertained at night by drumming on a rock that makes different sounds if you hit it at different points.  Some locals from town came out to give us an example.  I got up and danced at one point, but I could not get the video to load so you all will have to use your imagination!

Exploring the Upper East Region

Last week, I was honored to accompany the Coppola family on an expedition of the Upper East Region Ghana.  We stayed in the town of Sirigu, at the Sirigu Women’s Organization for Pottery and Art (SWOPA).  It was beautiful, with grassland pastures surrounding the guesthouse, which was set up as a traditional family home.   In the mornings we learned about the traditional art of the area from local women and in the afternoons we struck out in the car exploring new towns.  Over four days we covered over 300 miles of dirt roads (a bigger feat than it sounds) visiting chief palaces, crocodile ponds, local chop bars, a slave camp, and even made it all the way Ghana’s northern border where we waved hello to Burkina Faso.  The best part about it was getting away from hustle the hospital for a few days!

 

I am not sure what this is called but Tongo Hills was full of this tree.  It grows right up out of cracks in the rocks and the pink flowers really stood out.

Enjoying fresh lemongrass tea for breakfast



The "Senior Wife's" hut at the Chief's palace at Tongo Hills.  Above the door and to the right are offerings made for various reasons.  They still practice animal sacrifice, in fact while we were visiting the compound they were boiling a dog for a sacrifice. 

 The Chief's palace at the base of Tongo Hills.  They are known as a tribe that resisted the British rule and eluded the British by hiding in the many caves in the area.  There is a shrine in one of the caves for peace, but we decided not to visit since everyone that enters has to do so topless.   

 We thought that these rocks looked liked kissing dogs!

 In the evenings we played with the local kids of Sirigu.  Here I am trying to learn game from one of the girls.  I was not very successful at learning their games because they were all about jumping and clapping to rhythm . . and I have NO rhythm.

 On the watch tower rock at the Pikworo Slave Camp.  This camp was active between 1840-1870 and was the most important slave holding area in this part of Ghana.  Slaves were gathered from the surrounding areas of Ghana and Burkina Faso and would be held at Pikworo until they were sold to slave traders that would march them south to the Cape Coast (you can see an earlier post on Cape Coast).  Here in Africa you realize how complicated the slave trade really was and how Africans and Europeans are equally as guilty that it occurred.  Pikworo Slave Camp was not run by Europeans, but rather Africans that wanted good like gun powder, ammunition, cloth, etc, in exchange for people that were captured in tribal wars or enslaved due to crimes committed.   

 

 These are bowls cut into the rock at Pikworo Slave Camp, where the slaves would eat their meals.

 Grinding millet at the Pikworo Slave Camp.

 The view across the grassland from the rocks at the slave camp.

 Traditional homes in the upper east.  They are very different from the homes found around Nalerigu.

 

We had a great time playing Ghanian Bingo in the car!

Wearing a traditional battle helmet

The entrance to the rest house in Sirigu which shows the traditional painting style of the area

The SWOPA guesthouse. We had meals in the courtyard, a great breakfast every morning and dinner under the stars in the evening.

 In the SWOPA workroom with the Coppola family.  It is farming season right now so there were no local women working on projects, but a women from the community came to teach us about the traditional painting.

 A fish is the symbol for a happy home

 In Sirigu the women traditionally painted the exterior of their homes.  SWOPA has taught the women of Sirigu to transfer their traditional symbols and techniques to canvas paintings that can then be sold and bring extra income to their families. 

 Putting the finishing touches on my painting. 

The outside of the SWOPA workshop. 

We visited the Chiefs Crocodile Pond in Paga where we met this beast.  This is the second time I have held a crocodile tail since I moved to Ghana . . . basically the definition of insanity.

The Basilica of Our Lady of Seven Sorrows is located in Navrongo.  Northern Ghana is predominantly Muslim, but in Navrongo a Catholic mission was founded in 1906 by a Canadian priest, the church was built in 1920 and Navrongo became the home of Catholicism in Northern Ghana.  

 The interior of the Basilica was painted by the women of Sirigi in their traditional style.  It is beautifully simple

 Mark and I eating at a local chop bar in Bongo.  I had ground nut stew and it was the spiciest meal I have ever had in my life . . . my lips were literally numb by the end and I think my face was as red as my shirt!

The chop bar in Bongo is typical of those that you will see in Northern Ghana

 Playing with the children in Sirigu.

Over the course of my year here I have met many other missionaries.  We were able to visit one missionary family in their town of Zibilla.  I was amazed at how rural the area was and isolated they live.  It made me feel really blessed to have lived the year on the BMC compound.  We went to church with them on Sunday.  This church was in the middle of corn fields about a 10 minute drive out of town.

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.