Nalerigu Day 18

Nisa Nuri!

“ I touched the rain down in Africa” again! I could also say “I touched the hail”. Oh how glorious it was! As I mentioned previously, there are really only three weather reports for each day; hot, hotter or raining. Today it was hotter, but then rained. The hail was most amazing. The Ghanians call the hail ice balls and actually pick it up to eat. Ice cubes are difficult to create in a mud hut. The rain made for a joyous day.

The morning also was well. Jessie and I were able to discharge home four children from the peds ward leaving very few left. I actually was able to discharge our heart failure child (of course with close follow-up) which made me especially excited since funds were becoming quite a problem for the family. Funds here are frequently a problem. In fact, this morning on rounds a child who I discharged yesterday was still sitting on his hospital bed with his mother. Funds were the problem in this case as well. It took over 36 hours for the family to find the means to gather 40 Cedis ($29 US dollars) to pay for their 4 day hospitalization.

After am rounds, I was on call so spent the day either in the Theatre doing procedures or admitted patients to the ward. We saw so many interesting things today, so I’ve decided to make a list:

1) Patient who was talking with a resident in the morning and suddenly become unconscious with cool extremities. The resident started drugs for cerebral malaria and gave a bolus, but the patient continued to have neurologic abnormalities. This was brought to our addition (Stephanie and I were on call together today) and after further examining the patient decided on a lumbar puncture. I helped Stephanie successfully complete her third LP! Way to go Stephanie! The spinal fluid was cloudy, so we started antibiotics and sent the patient to the isolation ward for presumed meningitis.
2) We did many ultrasounds on pregnant and non-pregnant women today. The most notable patient was a 28 year old female who was having significant vaginal bleeding with dizziness. Her systolic blood pressure was 50 on initial exam, but had improved to 75 after a normal saline bolus. Pelvic exam revealed significant clots and ultrasound showed a 14 week old (estimated) fetus with a heartbeat. Her hematocrit was also low so was given a blood transfusion from a matched family member. She was admitted to the hospital and continues to be observed overnight. We hope the bleeding will stop and she will continue to carry the baby to term. We hope.
3) We also had an 18 year old patient today who refused to walk or stand. He had no history of trauma or any other abnormalities on exam other than significant pain with motion around the hip. He was also febrile. We decided that he most likely had a septic hip, but since we don’t have anyone trained well in joint ultrasound are treated him presumptively for now with antibiotics.
4) In the theatre, I did a couple incision and drainage of abscesses which are always fun. I also did a bladder straight catheter on an older gentleman with bladder cancer who is unable to pass urine due to the tumor mass.
5) One of the other medical students saw a patient with a funny toe. The baby toe looked very similar to the big toe since there was a large tumor within the area making it look large and making it protrude to the side. (see pic)

Now I come to my favorite diagnoses of the day (the kids):

1) John saw a meningomyelocoele today in clinic. See pic. This was INCREDIBLE!! Interestingly, they have what we believe to be a neurosurgeon that just started working in Tamale (approximately 2 hours from here). It’s a little sketchy whether this will be appropriately cared for, but is the best we can do. The child is moving his legs appropriately and doesn’t currently have any problems stooling or urinating.
2) A couple of the volunteers told me about a child they had seen in clinic. The story was that the mother was being seen for an incision site infection from her c-section that was done around 1 week prior. However, when the mom handed the baby to the translator, the translator felt the baby appeared ill. He then showed it to the volunteers who agreed with the translator. Apparently, the child had not been sucking well and the mom didn’t produce significant formula until day 4 following delivery. The child appeared jaundiced and hypotonic. The team then decided to admit the child for IV antibiotics and a consult from the nutrition center. They then let me know about the child. So, as you have already learned, there are no emergencies here. So, the triage people sent the baby to the nutrition center to be evaluated by them, before admitting them to the hospital. Thankfully, the baby made it through and I was able to see it this evening. Ok, now for the interesting part. I went to look at the baby and the first thing I noticed was that the baby appeared to have Down Syndrome!!!!!!!!!!!! This is NOT commonly seen here and since I am a lover of genetics (OK you can make fun of me for being very nerdy), I was very excited. Here are the findings that make this a consistent diagnosis. The child had the features of Downs including a flat facial profile, upslanting palpebral fissures, small ears, single palmar crease, large tongue, wide fontanelles, epicanthal folds, hypotonia. The patient also had…get ready budding pediatric cardiologists…a VSD (ventricular septal defect) murmur which was a loud, harsh holosystolic murmur heard best in the left lower sterna border. The child also had an umbilical hernia. I am planning on sending the photos that I have taken to my favorite geneticists at Iowa to confirm, but am pretty convinced at this point. The problem with this diagnosis here, however, is that our resources are nil. We can help the child try to feed (which will also improve the jaundice), but there is not a lot more that we can do. Please keep this child in your thoughts and prayers. We don’t see many people with special needs around here, so I’m not sure how well they are tolerated in the community and certainly will have a more difficult time if coexisting illnesses are encountered.

Other fun things that happened today…I visited the pharmacy to see what the “Uncle Kim” of Ghana is like (my Uncle Kim is a pharmacist). :) it was fascinating! One gentleman walked me through how the IV fluids are made which was awesome! Take a look at the photo for more information. I have a whole series of how fluids are make, but the internet is too slow to include them all.

We continued to admit several more patients including a patient who was an alcoholic who became unconscious and was found to have a glucose of 16. Yes, a glucose of 16 (that’s REALLY low). The patient developed seizures and is currently not responsive. It doesn’t look good for this 26 year old.

I hope that the rest of the call night goes well, but am happy to have had even a chance to tell you about my day so far. I pray that all is well with you. As usual, please keep the people of Nalerigu in your thoughts. Today I am thankful that I can have ice to keep me and my water cool at almost any time, not just when it falls from the sky onto the dirty ground.

What are you thankful for today?

Jill