Nalerigu Pics day 7

From the left: Isaac (WVU), Joe (WVU), Jeff (WVU), Terry (SUNY), Me, Jessie, Stephanie (WVU)

Lisa carrying Jude in true Ghanian fashion. I am planning to learn this trick before I leave.

Cystic Hygroma

Fibula (leg bone) of a boy with osteomyelitis

Nalerigu Day 7

Greetings from Northern Ghana!

I'm sure you're all interested to know that my traveller's diarrhea has resolved. Hooray! I was back to full strenght this morning. Today was another interesting day as usual. We started out in the peds wards where another child had died overnight. Jessie and I split the room into two and got several of the kids seen on our own today. It's nice to feel sort of independent. I wasn't ready for that when we first started. One interesting fact I learned today was that the patient with the blue spots all over didn't have a blue spot disease at all. When we actually were able to talk with the family we found that the child did have lesions over their entire body, but the blue color was actually violet dye that the family had used for the wounds as a home remedy!!!! The child does have a fever and most likely septic, so remains very sick, but it's nice to know what the blue discoloration was from. Amazing!! They sure fooled me.

A happy story for the day was that one child we have been seeing on the wards who had been in status epilepticus (seizing for too long) actually sat up to eat and drink today and was talking with his mother. We were very concerned that this child would be neurologically devistated from the event, but are happy he is improving. This was one patient where we feel we truly saved this patient's life. It's a good feeling.

The morning was also filled with surgeries. Most of the surgeries of the day were gross. :) The surgeries today have led to the disease of the day which is osteomyelitis. Osteomyelitis is essentially an infection of the bone. Most of the cases of osteomyelitis are initially treated with IV antibiotics. The problem in Africa...people don't come for IV antibiotics. So today a child with osteomyelitis came who had an open would with his osteomyelitic fibula (bone in the leg) sticky out. My attending touched the bone tip and an entire piece of the bone was removed (see picture). There were several other patients today that had similar symptoms.

Another interesting case today was a patient with a cystic hygroma (see pic; mass in neck). The cystic hygroma was drained today, but without surgical resection it will persist. We won't have a surgeon here again that can do such surgeries until June, so she will have to wait until that time.

Wound therapy and incision and drainage of abscesses were also frequent and disgusting today. I have left out some pretty gruesome pics of this for those who don't enjoy that. I wouldn't want anyone to faint reading this blog!

On to discuss lunch. :) For lunch we were served another Ghanian dish which this time I did not eat. The food was called "bean cake", but it looked like a piece of liver or spleen to me so I passed and ate rice instead. The rest of the volunteers assured me it tasted like beans, but I felt like just trusting them on that one.

This afternoon was excrutiatingly hot!! I took a nap for a short time, but when it's 100 degrees in the house napping is difficult. I then headed back to the hospital with Jessie and Joe the med student to see more patients. The afternoon was fun, but the heat was overwhelming.

At dinnertime, we were greated by a new family that have come from Kansas and will be living here for 6 months to 1 year. She is a nurse and he is an accountant. They have three children. Their mission is to coordinate all of the guests and volunteers that come to the village. I bring this up because I want others to know that you don't have to be medically trained to help out. I look forward to getting to know them more.

After dinner, we had an evening of fellowship which included song and prayer. It also included chocolate cake!!! There are truly wonderful people who are here. It is great to meet people that have dedicated their lives to serving those less fortunate than them.

Tonight my blog is shorter since the evening was longer. We will be losing one West Virginia student and his preceptor tomorrow, but will be gaining another preceptor and two students from Hong Kong all in one day!!!

I hope as usual you are all well and staying cooler than we are!! Tomorrow is another day of rounding and clinic which is almost certain to bring in something interesting. I'll hope that another man cut by a machette (sp?) doesn't come crawling down the clinic floor again! Best wishes as always!

Jill

Nalerigu Day 6

Read the below to learn more about this pics..

Hello again from Africa!

Today is day 7 in Africa which has made for perfect timing to experience my first bout of traveler's diarrhea. Oh yes...I awoke this morning to so much joy and fun (this is sarcasm). The experience that I had this morning makes traveler's diarrhea the disease of the day today. This disease is most frequently cause by one of the non-hemorrhagic straings of E.Coli. It starts between days 5-15 upon entering the country. It normally causes diarrhea and vomiting which is self limited. The treatment is either with a flouroquinolone antibiotic like ciprofloxacin or with azithromycin depending on the region you are traveling. The most important thing with this disease is rehydration. I've started my antibiotics that were prescribed for me, took some immodium (which the Sanford guide says is OK to do) and began oral hydration and sleep for the morning. Bummer!

Unfortunately, my illness means that I missed rounds this morning. What I can report from morning rounds is that the baby with severe jaundice that I posted about previously has died. There is so much death here and children are a large part of that. I'm not sure what caused this baby's jaundice, so won't know what could have or could not have been done.

I won't go into detail about my morning as certainly know one wants to know that, so it leaves me with only the afternoon to talk about!

For lunch I served myself one crescent roll and water. :) I then went to clinic which was an INCREDIBLE experience. On clinic days there are hundreds of people waiting outside the clinic to be seen. It appears to be total chaos, but somehow/somewhere there is organization and the patients are called into the clinic rooms one by one until all are seen. It's amazing. I saw so many interesting things today! When I first started, Dr. Hewitt gave me a kind lesson on the general structure of seeing patients in clinic. He then let me off to see patients on my own with the help of a Mampule interpreter. I was very excited because Dr. Hewitt had separated his pile of patients and let me see the pediatric patients until they were done when I started to see adults. I love seeing kids! So, some of the pediatric diseases that I saw today were:

Pneumonia

Asthma

Child his the stomach when playing soccer with right sided abdominal pain (he looked just great)

Hepatitis with significant ascites

Gastritis

...and of course malaria

The two most interesting patients of the day were the following (see above pictures):

1) 3 week old child with severe fever and a rash for 3 days. The rash was almost blue in color. It was difficult to determine if the rash appeared that color because of the increased melanin in the African skin making this a sepsis or meningitis case or if this was congenital rubella. Regardless, I started the patient on ampicillin and gentamicin (US NICU treatment for sepsis) and admitted the child to the hospital. I need to read more about African skin diseases.

2) 6 year old female with right sided hand swelling. When looking at her hand it appeared that she had some fascitis (hand tissue infection) that started in her hand causing swelling up near her elbow. She also had several blisters around her hand. She otherwise looked very well. I treated her with Septra to cover strep, staph and gram negatives since we didn't have oral therapy for anaerobic coverage. She'll follow-up in the clinic on Friday for re-evaluation. I hopeful we can keep her out of the hospital, but am not convinced. The antibiotic coverage we have is limited so we do the best with what we have.

On to the adults...

I saw several patients with hypertension which can actually be treated fairly well here. I saw women with menstrual cramps, pneumonia, malaria, gastritis. I saw several patients with "thin man syndrome" or HIV. There was a woman with a keloid (overgrowth of a scar) on the umbilicus (belly button) that was causing her pain. There was also a man with a terrible anal fissure and fibrous tumor in which surgical therapy was not an option. Hepatitis with ascites was also very common.

There is never a dull moment here. Just when you think you've seen everything, the next day comes. :) Oh! One funny thought I had for today which the UofI people will enjoy...after clinic is finished the hundreds of people stand in a line to receive their medications from the pharmacy (everyone gets some kind of medication, even if it is just a multivitamin). When I left the clinic I saw a picture someone similar to what it is most often like outside the Pomerantz Pharamacy at the University. The only difference...this pharmacy dispenses their medications in VERY timely fashion. All of the people where gone within 30 minutes!!! :)

After clinic I went back to the house for more fun with my traveler's diarrhea. Yes, Joe and Dad I am drinking my fluids as I am able. It was then time for supper which is always a nice part of the day. Today they served my favorite Ghanian dish which is chicken with a peanut sauce. Unfortunately due to my illness, I had some rice with just a small amount of peanut sauce over the top. At the end of dinner, however, I was starting to feel a little better so thought the piece of chocolate cake looked delicious. Yes, it was!! I feel that is a good sign that I am on the road to recovery.

Many of the American missionaries have decided on favorite foods they have learned to enjoy here. Some feel mango is clearly the winner, while others have decided on plantains. Some people love the yams. My favorite treat is sweatened iced tea. I used to despice this drink back home, but now find it to be one of the things I most look forward to. It contains a little sugar and takes MUCH better than my warm water that I lug around everyone. Yum!

So it is evening again and I am at the school house typing. Tomorrow is another day of rounding and surgeries, though nothing here is "just another day". The surgeon that had been visiting here from Texas, Dr. Cargisle, is leaving tomorrow which is disappointing for all of us. He is certainly the kindest surgeon any of us have ever met and a great teacher.

I have couple other thoughts before I sign off...

I live in a home that would certainly be low-income in the US. It does have running water and a refrigerator, but that is the extent of it's riches. With that, I still feel incredibly guiltly for the place that I live here. I have a bed to sleep on that is not dirt. I have a roof that is real, not straw. I have a shower and a toilet. I have food provided to me at every meal. I have clothes to change into every day. I have shoes to wear. I have a pantry full of medications for whatever minor ailment I may have. I have a book, pen and bookbag. I have. Others do not.

Funny and not funny quotes from the Ghanian people...

"Money is like a servant. If you abuse it, it runs away"

"If two people carry a log, it does not press hard on their heads"

"Treat your guest for two days and on the third day give them a hoe"

"A good wife is more precious than gold" (This one is for Joe)

"If one person eats all the honey, they are sure to get a stomach ache"

"If power is for sale, sell your mother to get it. Once you have it, you can then get her back" (Watch out mom, I may consider selling you when I get back!)

"Just as someone has looked after you when you grew your teeth, so should you look after them when they lose theirs."

OK all. I hope as always you are well. Your are in my thoughts and prayers often. Please think and pray for the people here and once again find something to be thankful for.

Jill

Day 4 and 5 pics

Sorry for not putting the pics up from yesterday! The rain stopped me!! I also apologize if it seems disorganized! Enjoy!

Today:

Another Ghanian dish...chicken with cabbage and yams. Yum!


Yes, this baby did look this yellow. It is normally very difficult to identify jaundice in an African child due to their dark skin color. Amazing!

Today's snake bite treated at home with Black Stone (read the blog for more info)

Yesterday (in opposite order of the day, i.e. evening to morning):

It's raining!! What a relief! This is Stephanie one of the medical students from West Virginia

The rain!!!! Joe and Jeff. Also from West Virginia. Joe (on the left) reminds me of the guy in John Krakauer's (sp?) book/movie "Into the Wild"

Our minor surgery room

Sign in the hospital

Doors to the back of the hospital from the isolation house

Our one nice piece of equipment for pediatrics

The peds ward when very few people/patients are around

Painting in the peds ward

Sign in the pediatrics ward

Sign in the hospital

Our wheelchairs

Us with our purchases and the owner of the shop. The baby on her back is named Susan. She is adorable! I am planning to have someone show me how to wrap a baby on my back before I leave. Hope to get a picture of that!

All the Ghanian colors!

This is at the shop I talked about in the blog (our cook's wife's shop). Beautiful work!

Some children who thought I looked silly with my white skin

Not many young girls have braided hair. Most young girls have shaved heads which is culturally appropriate.

A small child that came up to us in the village.

Children playing with a wheel and stick. This game has a name, but I can't remeber it right now.

I bought this fabric from a shop on the street to put over our dirty couch.

It is very difficult to get Ghanians pictures. They frequently don't like it. This boy was just standing at a post in the village looking at all of us. I took this picture with the camera on my side, not looking at the viewer. It is definitely one of my vary favorites!!!

The tailor that made Joe's shirt.

Our hospital from the front

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Nalerigu Day 5

Hello again!

Today was another exciting day mostly filled with medical work. This morning started with am rounds. Our little girl with necrotizing enterocolitis seems to be improving. The 6 year old boy with CNS malaria and seizures continues to awaken and appears more vigorous. At this point it seems that he may have some neurologic deficit, but time will tell. Interesting disease of the day: n. meningitis. Today we saw a pregnant woman around 32 weeks gestation who had altered mental status which is likely n meningitis. I have NEVER seen a meningitic woman carry a pregnancy. We did an ultrasound (one of the radiologic modalities we do have) and the heart beat appeared normal. She's now in the hospital being treated for the disease. We will continue to hope and pray the baby does well. Interestingly, several babies even around 1.5kg have survived at this place according to the obstetrician that lives here. Incredible as we do not have any method of respiratory support other than nasal cannula for oxygenation. The African people are extremely resilient.

Surgeries of the day: many inguinal hernia repairs, major laceration repairs, typhoid perforation repair in a young child and a skin graft.

Ultrasounds of the day: MANY! Looking for all sorts of things including abscesses, masses, pregnancies, etc. Today we had a woman who is 1 week postpartum and came in with abdominal pain. I examined her and found a right sided mass. We then took her to ultrasound which showed a large right sided abdominal mass that doesn't appear to be attached to anything. If any of you have any ideas of what this could be let us know! She is having absolutely NO other symptoms.

Another interesting medical problem we see here are snake bites. There is a certain kind of snake here called the carpet vipor which is extremely venomous, usually causing people to bleed. We do have antivenom which frequently works to stop the bleeding, but not always. The local people occasionally try home methods such as black stone to stop the venom. Black stone is actually part of a cow's thigh bone which goes through some processing including boiling. The bone fragments are then placed onto the wound which is thought to create some sort of suction that pulls out the venom. Dr. Hewitt said he hasn't found it to be very successful, but many local people really believe in it. I have a picture in the next blog.

After lunch, several of us went back to the hospital for more interesting things. I saw a boy whose classmate put a stone in his ear. Unfortunately he perforated the eardrum and all you could see in the canal was blood. We put him on antibiotics and are planning to see him back on Thursday to look again. That's the best we can do here. We then had several admissions including malaria, tuberculosis and a child with a large spleen who needed some blood.

Oh! I almost forgot to mention one of the most interesting patients of the day for Jessie and myself. As a pediatrician we have seen many cases of jaundice (yellow skin). Today, however, we saw the most significant jaundice I have ever seen. Even one of our attendings who did a pediatric residency before OBGYN said he has never seen jaundice this significant. She was a 5 day old little baby with severe jaundice that has led to kernicterus (problem in the brain). Mom was breast feeding well and there was no significant liver enlargement. The problem here...we have no capability to find out what the cause is. Normally we would check bilirubin levels, maternal and fetal blood type, etc. Here there is nothing. she could have a liver problem, she could have red blood cells breaking down, an infectious disease and on and on. There is no way to know. She is eating, has some fluids running and has been prescribed a "sun bath". This is essentially the natural bili light. Mom just takes her out into the sun every once and a while to allow the bilirubin to break down. Incredible! This girl is glowing! I have a picture of this one as well.

So those are the intersting medical cases of the day. I apologize for those of you who find this stuff boring. It is SO interesting to me!!!

That brings me to this evening. I am now on the computer, have been on "skype" with Joe and plan to return home, wash clothes and sleep. Tomorrow is a big day of clinic where hundreds of people come to be seen and only two attendings are available. Should be VERY interesting!!

Best wishes to you all. Please find thankfulness in your day today.

Jill

Nalerigu Day 4

Hello all you Sulamingas (Non-Africans),

Today was another interesting day in Nalerigu. The weather here was again sunny and hot. As usual the day started at 0800 for morning rounds. Interesting disease of the day: CNS malaria. The day started with Jessie (my cohort from Iowa) and I as we made decisions independently in the pediatrics ward. We reviewed the decisions we made with our attending physician and all seemed well. Then later in the morning, sadness once again overcame the hospital. We initially started with a small child around 6 months of age that had seizures and likely CNS malaria as their blood film was positive. We were then told by the medical assistants (who are fantastic) in the ward that another admission had come in with similar symptoms. We went to see the child who was already having abnormal posturing and lack of pupillary reflexes. Since labs take a very long time to come back we were unsure of whether this was malaria or meningitis which we also see quite a lot of here. We started therapy for both, but prior to therapy discussed the patient with our staff and decided on a lumbar puncture just prior to initiation of antibiotics. Jessie did the lumbar puncture (which is definitely different and less sanitary here) and started an anticonvulsant medication. We then continued on with our rounds.

Soon another admission came in who apparently had been in convulsions since the evening before. We (myself and Joe a medical student) went to see this 6 year old patient . Upon our arrival, the patient was having agonal breathing (close to death). We did the same management, but excluded the lumbar puncture since the patients convulsions had stopped and the symptoms fit more consistently with CNS malaria. We were fairly certain this child was going to die. When I went to talk with the nurses about the situation, they agreed that the child was close to death and told me that in Nalerigu, when a patient is at this point and nothing more can be done, the treatment is to pray to God.

Right after these two terrible pediatric admissions, we then caught up with two other medical students who were seeing a woman with vaginal bleeding. They appropriately brought the patient back to the ultrasound area for further evaluation. They then decided to perform a vaginal exam at which time a deceased 18 week old fetus was found hanging between the mother’s legs (I apologize for this description, but it is true and appropriately depicts life in poverty). This mother had attempted self abortion as she did not wish/feel she could care for this child. I held the child in my hand.

As soon as we finished the D&C on this patient with our medical staff, we then heard the news that the first child with CNS malaria had died. We went to see the family and were amazed to find no tears, only acceptance. Death was a sad sort of commonplace in the ward and within the village.

Our other patient with CNS malaria continued to do poorly in the early afternoon. We maintained the only management able. I returned this evening to see him and found him sleeping much more comfortably. He had even awoken shortly before to ask for water. Amazing! He, however, is not out of the woods yet. Not only does he need to get through this infection, we are also unaware at this point how much neurologic deficit he has suffered from having seizures for such a long time.

I have a whole new respect for CNS malaria…

Debate in my head today…there are so many medical needs in this community. On a normal clinic day, hundreds of patients need to be seen with only two staff physicians. Is it better to allow 4th year medical students to see patients independently just so that the people might receive care or is it ethically inappropriate to send less experienced trainees to see these patients without staffing?

On to more fun things…

Today we went outside of the medical center to visit the main road which is filled with members of the community selling all sorts of goods. I bought an African shirt for Joe as a keepsake, made by one of the male tailors in town. I also was able to get a small piece of inexpensive fabric to cover our very dirty couch in our house. After our visit, we came back to the complex for lunch where we met two new residents and their children from Wichita, KS. They have come to spend a month here also doing medical mission work. They seem great and I look forward to getting to know them better.

After lunch some of the local children brought math homework that was sent by Jessie back to our house, complete and correct. She filled them full of more math problems and sent them on their way. We then went back out the main street to visit the shop that is run by our cook’s (Yasah) wife. She is a wonderful person who I believe has the most beautifully crafted goods in town. I enjoyed supporting her business by buying several items to bring home and share. I also enjoyed the adorable young child she has, Susan, who was carried on her back. I’ll shop there again if time before I leave. I also need Yasah’s wife to show me how to carry babies that way!
Dinner was next and again was great! I am definitely not going to lose much weight here. I am trying, however, not to overeat as I feel that would be inappropriate considering the people that I serve. Following dinner, we played some cards and then were surprised by the most enjoyable event of the day…RAIN!!!!! I have never loved rain as much as I did today. I even felt cold for a while, but stood outside with the rest of clan, soaking wet, just to feel relief from the hot sun. It was FABULOUS!!! We sang the song “Africa”, but in true Christiansen fashion couldn’t remember all of the words. We came back inside for more cards games and now plan to enjoy a semi cool evening of sleep. I can’t wait!

Tomorrow is a day of surgeries. I will try to remember all of the interesting things I see to share with you all.

Best wishes as always. Please pray for the people of Northern Ghana.

Jill

Nalerigu Day 3 pics

Teaching the local children math

Eating salt and drinking water and eating more salt

Easter cake at the Hewitt's home

Hut outside the Hewitt's home

Easter Church

Abigail finding her easter egg