The end of paediatrics (kinda)

Warning: potentially upsetting stories about children dying

Sorry it’s been ages since writing on here. The internet at the compound has been broken for almost 2 weeks so I’m using this weird internet USB stick with my sim card that’s very temperamental + slow. Sorry it really can’t cope with pictures!

I finished my 3-week block in paeds yesterday and started surgery today. I was really happy about this. Those 3 weeks have probably been the most stressful 3 weeks of my life. That’s a bit of an exaggeration, but still it has been insane. I have never had so much responsibility over life and death (clearly I need to get a grip back home if this isn't as stressful as some other much more mundane things!).

Over the last 2 weeks I have probably been present at the death of about 15 children, almost all of which I was either the most senior person there or equal most senior with the other med student Liz. Our only qualified paediatrician left a couple of weeks ago so we’ve been running the paeds ward with the physician assistants – who are brilliant + definitely senior to me, but often not there when we’re called to see dying babies. The two of us have done so many paediatric resuscitations I’ve lost count. There have been so many that I’ve even been called to 2 since yesterday morning when I officially stopped working on the paeds ward. Thankfully some of the resus’s have been successful, but sadly most are not.

Some deaths have been really upsetting, particularly when the child has been there a while. Most of them however arrive to the hospital peri-arrest (ie on the verge of stopping breathing/heart beating). There’s a huge social problem with healthcare here. I think a lot of it is parental education – so many of these kids have been ill for days before coming in, but the parents are out in the fields working all day and don’t really pay that much attention or don’t know the signs of when their child needs medical care. There are also difficulties with transport, many patients travelling all day to get to the hospital. Another big problem that I find quite concerning is that all too often these children will be referred from small community clinics where they will have been sat there receiving very little care a few days, getting sicker and sicker, until eventually the parents decide to take them to hospital, by which time it’s too late. There is also ‘local treatment’ – the witch doctors, whose treatment is recognisable by little cuts on the skin over the site of problem.

The hardest death was probably my 2^nd resuscitation – a little two year old with cerebral malaria. He had developed a severe pneumonia probably from aspirating during febrile convulsions (ie he breathed in vomit when fitting, the fits being caused by the high temperature + malaria in the brain). Within minutes of his arrival he stopped breathing, but still had a heart beat. As I’ve said before there are no ventilators here, so Liz and I bagged him for an hour and a half (gave breaths using a mask fitted to a rubber globe that you squeeze and it pushes air into their lungs) - really the only kind of resuscitation available here. All of that time his little heart kept beating and I had this vague hope that if we kept going for long enough his antibiotics might have time to kick in… but the combination of not breathing properly during the seizures and the pneumonia had left him with fixed + dilated pupils – a sign that he was severely brain damaged beyond hope of recovery. Eventually Dr Coppola, the hospital’s head doctor who had been coming to see how we were getting on, told us to stop. That was probably one of the hardest things I’ve ever done, knowing that we had been keeping him alive, and then listening as his heartbeat slowed down. Then his mother told us this was her 4^th child who had died. We were all really upset.

It really makes you question though, surely after the first 3 children dying, wouldn’t you think to come to the hospital a little bit earlier? There has got to be some kind of educational or cultural or financial issue here stopping the parents from bringing their kids in sooner. It’s not really something I have any clue how to address.

Not all of paediatrics has been sad though. The little 3 year old boy I mentioned a while ago with the chest drain made a good recovery and was discharged a few of weeks ago. I saw him for follow up in clinic the next week. It was great to see his cheeky little face again. By the time he was discharged he’d stopped being scared of me, as his parents were so friendly + I hadn’t stuck him with any needles for a really long time! Every time I went to check on him on the ward would always give me a grin and play hide + seek behind his mum. It was great to see him again and doing so well, although when it came to time for him to leave clinic he ran up to the door and opened it and was gone before his mum could stop him. He had definitely had enough of the hospital!

The two kids from last post had really good outcomes too. The boy with the status epilepticus made a full recovery and was discharged home after a couple of days of observations. The meningitis kid took a bit longer to recover and was discharged after about a week or two with some hearing loss and possibly a mild cognitive impairment but essentially back to normal. (Turns out he’d been at a little clinic for 3 days before coming to the hospital, presumably not on the appropriate antibiotics as he’d been getting progressively worse and got better with us as soon as he was started on them).

So although it is really hard working here, it’s also really rewarding. I’ve spent most of my time here feeling pretty out of my depth, but turns out that’s a brilliant way to learn – if you don’t learn quickly, patients die, so there’s no difficulty in getting motivated!

Now that I’m on surgery I think I will be shouldering a lot less responsibility – unlike my final two weeks of paeds, there’s an actual qualified surgeon in charge.

Tomorrow I’m having my first full day off since getting here, besides ones where I was puking – woopie! I’m going to Tamale with the Coppolas –the head doctor and her family. They have 2 really cute girls (aged 6 + 9) who are a great comic relief in what can sometimes be a really depressing place to live.

There’s no such thing as an emergency in Ghana…

(written yesterday)
A couple of weeks ago I wrote about how this place made me lose faith in all that is good in the world. It’s strange working in a Christian mission hospital where they’re preaching the ‘good news’ and seeing so many people in such severe suffering. I have asked a number of the missionaries how can God be good when he allows this to happen. They gave the familiar theological answers, which, if I’m honest I didn’t find entirely convincing when patient after patient has died unpleasant and untimely deaths. I was angry at God for letting these things happen and angry at them for having this unwavering faith in God. Then I realised that I hadn’t actually prayed for any of the patients, and maybe that would help. It didn’t seem to, they still died. Until last night…

Last night was pretty stressful. I was taking paeds call (means you get phoned if patient needs seeing) and had been called in to review a baby whose haematocrit was 8% (level of red cells in the blood, which should be 26-50%). I went up to the hospital with Elaine who was on medical call for the adults. We were about to walk to the hospital when I suddenly thought, "we should take the truck". The thought just popped into my head out of the blue. We parked up and were just walking in the front of the hospital when I noticed a (11y/o) boy who looked very unwell sitting in the porch. After about 30 seconds of questions it was obvious that he had meningitis. He had textbook symptoms and looked just like the other children I’ve seen this trip with the same condition. Meningitis is something we get drummed into us at med school, though I’ve never seen any confirmed cases in the UK. The most important thing is to get antibiotics started as soon as possible, worry about getting a lumbar puncture to confirm diagnosis later. Only this is (northern) Ghana… There is no such thing as an emergency in (northern) Ghana. There is no emergency room. There are no emergency antibiotics ready. They probably wouldn’t have even seen a doctor that evening if we hadn’t have driven – if we’d walked we would have come through the back entrance and missed them. Instead they would have been seen at some point by a ‘medical assistant’ – the Ghanaian equivalent of a nurse practioner, who have limited training and are very variable in ability.

Because this is Ghana, where urgency is not a concept, the boy had to wait until he had a folder made up – probably the single most frustrating thing about this hospital is that nurses won’t administer drugs until a prescription is written in the chart. In England he would have been straight in resus, with an IV line and antibiotics given before you could blink, nurses following oral instructions, with written prescriptions later to follow. But not in Ghana… so we had to wait at the front of the hospital while the boy had a new chart made up. As you can imagine I was not very impressed with the poor man working in the booking office who was painstakingly copying down the boy’s insurance details.

While this very slow process was taking place another 11 y/o boy arrived, being carried by his older brother. He was actively seizing, had vomited and was incontinent. His brother, who luckily spoke a little English, was eventually able to explain he’d been like this for over 40 minutes. Again, textbook medical emergency – status epilepticus (continuous seizures), something drummed into us at med school: prolonged seizures give benzodiazepines, then phenytoin, then if they’re still fitting, call the anaesthetist + intubate (stick in a breathing tube + ventilate with a machine). Only here in northern Ghana we don’t have anaesthetists, we don’t have ventilators, we don’t have phenytoin and we don’t give medication until the patient has a chart…

By this point I was close to losing it with the folder-making man as he photocopied the insurance card then wrote out all the details… I wanted to say ‘this child will die if you don’t give me that f***ing chart’ but since his brother spoke some English I stuck to “this patient is seizing, I really need his chart quickly to write him some medicine or he may stop breathing”. Something I’ve noticed here, however close the patient is to death, being firm but calm gets things done quicker than getting mad.

Eventually we got the chart and made it up to the ward. I’d sent Elaine off with the meningitis kid already, and when I arrived with another (potentially dying) patient the staff weren’t very impressed. “We are full, there are no beds” they said, to which I responded “This boy does not need a bed, he can lie on the floor, he needs diazepam.” To be fair, the nurses on this older kids ward were much better than my previous experiences with the nurses on the babies’ ward in the same situation, and after a little fuss about the bed situation gave him diazepam quickly. Luckily by this point the paeds consultant who I’d phoned arrived to take control of the situation.

Allowing prolonged seizures can cause brain damage or death, so it is vitally important to stop them. Unfortunately however the anti-seizure medication causes respiratory depression (decreased breathing). In a hospital that doesn’t have any ventilators this is a sticky situation to be in – give too much meds and they’ll stop breathing, don’t give enough and the seizure will continue. Over the next 30mins or so we gave him another dose of diazepam and two doses of phenobarbital before he stopped fitting, luckily without stopping him breathing. All this was done on the dirty floor between two other kids’ beds.

When the status epilepticus kid was under control we could turn our attention back to the meningitis boy. Unfortunately the nurse who was meant to be administering his antibiotics, which had been written up, didn’t quite have the same sense of urgency as the rest of us. The antibiotics wasn’t available on the ward, so she said she would go and collect it from the pharmacy. After the 30 mins of the other patient seizing on the ward she still hadn’t collected it, and only went when I said I would go. Eventually she collected it, we transferred him to isolation (meningitis is contagious), gave him the antibiotics and I performed my first lumbar puncture, confirming the diagnosis – pussy spinal fluid came squirting out at high speed (a lumbar puncture is where you stick a needle into a patients spine to remove fluid to test for infection in the layers covering the brain).

After all this I eventually made it to see the baby with the haematocrit of 8% and ordered him a blood transfusion. There is no blood bank here so the family members find a match to donate, which can take some time.

The three kids were on my ‘will they be there in the morning’ pre-rounds check. This morning all three kids were there – alive. I checked on the first two again tonight – both were sleeping, so I didn’t disturb them. The seizure kid’s brother said he’d been awake in the day, eating and behaving normally. I was really surprised – after seizures for ~1½ hours I expected him to be comatose or at least have some kind of disability (like other kids I've seen here). I didn’t do a full neurological exam as a different doctor already saw him today and I didn’t want to wake him, but it’s sounding hopeful. The meningitis kid is still very sick, but the mum said he was “better” (they all say that) and that he knew he wasn’t at home, but still confused. He looked less sick than yesterday. Time will tell.

I started this post talking about how I was angry at God for the suffering here until last night. Over the years I’ve ranged in opinion about God from strict Christian to virtually atheist, so I completely appreciate that most of you will see this as coincidence – for a long time I would too. But last night I had this weird sense that God was looking out for these kids, and using me and the other doctors/students to save their lives. Elaine + I were so close to walking the back way to the hospital, where we wouldn’t have seen either of these children as they came in. It’s impossible to know what would have happened if we hadn’t been there, but I think since I ask God to help save the patients, I’ve got to give him credit when it appears that he does.

Today wasn’t quite as eventful, but still busy busy. Before lunch (after rounds) I removed my first onchocerciasis nodule (river blindness --> calcified parasites), aspirated a Baker’s cyst and helped Zato with a skin graft: photos courtesy of the lovely Caitlin.

First you collect your graft with a metal instrument that's a bit like a cheese grater

Then you put the graft through this machine - it cuts little lines in it so it stretches to about twice the width

Then you place the grafts onto the wound

Arrange them nicely, staple them in place

And dress the wound

Removing the onchocerciasis nodule

Niiiiice

Pictures, clinic and snake bite kid update

This week has been a bit more chilled, partly cos I was ill so missed half of it, but also cos a whole load of doctors arrived last week, giving about double the number than before, which is great.

I’ve been on paeds this week which is good, but a little out of my comfort zone. About 80% of them have malaria though, so I’m pretty comfortable with that now!

Cute Kids in town:

Me with some of the other doctors/volunteers + local kids

As I said before, Mondays, Wednesdays + Fridays are clinic days. They're usually really busy. The patients start lining up at 5.30am to register. At some point in the morning they get their blood pressure and weight checked.

Then they wait in this porch area until they're seen by one of us. Clinic usually finishes around 6pm so many of the patients are waiting for hours and hours. There's no appointments, I think it's basically first come first serve.

This is me at my clinic desk that I share with one of the medical doctors. Flying the Peninsula flag in Ghana! 

This is my colleague Elaine's patient from clinic yesterday who I diagnosed with Elephantiasis. It's caused by a parasite and is really rare in the UK, but the second case I've seen out here. The treatment here is just a single dose of Ivermectin. Later in the day the patient came back complaining that they lived very far they hadn't been given enough medicine, so Elaine gave them some paracetamol as well. Patients expect to be given lots of medicine on every visit, so even if they don't need anything you have to prescribe them some paracetamol or multivitamins or they'll barge back into the office to complain.

In England when patients demand prescriptions it's ok to say no, but here it's simpler just to given them vitamins - they probably need them anyway! 

The language barrier is a big problem here. We work with translators who are usually nurses or nursing students and vary greatly in their medical + language ability and enthusiasm. I've been getting much vaguer histories than I would in England. It seems every patient I see has waist pain, chest pain, head pain and general body pain. I try to narrow down what's going on, but the translators don't seem to understand words to describe the pain like sharp/dull/burning. Almost all of the time when you ask how long they've been ill they'll say 3 days or 3 weeks. Time is a different concept here, much less rigid. There's a nice phrase I heard the other week: 'American's have watches, African's have time' (all the non-Ghanaian's here apart from me are American).

This is the boy whose photo I put up a couple of weeks ago who'd had a snake bite (scroll down). I watched Zato do his skin graft about a week ago and have been doing his dressing changes on alternate days. It's looking really good!

Hope you're all doing well! Sorry I've been rubbish at replying to people's messages - the internet is really temperamental, but I really really appreciate hearing from you all! I wrote a load of replies the other day offline and had them ready to send, then my laptop ran out of battery and I lost them all :( I will try to write soon though! xx

Life in the hospital

Sorry it’s been so long since I’ve written anything on here, it’s hard to find the combination of time and energy.

This last couple of weeks has been really challenging, both academically and emotionally. It’d be very easy to come on here and say what an incredible time I’m having and how I’ve been able to do so much awesome stuff. That is true… but it wouldn’t be a very genuine representation of my trip.

For example yesterday I got to put my first chest drain in (w a lot of guidance) – awesome experience, something I’ve never even watched in England, let alone been able to do myself. (It’s a tube, about the thickness of a finger, that you place between the linings of the lung to drain pus/fluid/leaked air).

The other side of the story, that doesn’t make for such an upbeat blog, is the reason I put the drain in in the first place. The patient was a muscular 30-something year old man with AIDS pneumonia. He had such damaged lungs that a leak had formed, leading to air filling his chest and crushing his lung. For about 6 hours after I put the drain in and released the air he looked great; he was breathing much better and he would thank me + Jim (who did it with me) whenever we went to check up on him. I was feeling so pleased. I thought he would live long enough for the antibiotics to have a chance to kick in. In the evening however he was looking as sick as he had that morning and when we went for rounds this morning his bed was empty – he died in the night.

Every morning I check certain beds to see if they’re empty, looking for patients who the night before have been on deaths door. About 50% are still there the next day.

For every tragedy though, there is the other 50% who make it through the night, and have time for the antibiotics/blood transfusion/fluids to kick in.

One of my favourite patients is a little 3 year-old boy on paeds. He saw our surgeon in clinic with a bulging fluctuance on his chest that felt just like an abscess. We took him to theatre and Lisa talked me through my first ‘I&D’ (incision and drainage). This is normally a very straightforward procedure involving a small incision and squeezing the pus out of the abscess. Once he was anaesthetised I made the incision and the pus came flowing out, and kept on flowing. In total we drained about 500ml from this tiny guy's chest. When the flow had slowed a bit it began coming out in little bursts as he breathed – it turned out the collection was coming from the lungs and had eroded forward to the skin. This was pretty unexpected, and he now had a sucking chest wound. Luckily Lisa managed to put get a chest drain in quickly and suture him up – so glad I wasn’t doing it on my own!

The next morning I went to paediatrics, half expecting to see an empty bed. Instead I found a well looking baby and a happy dad. As soon as the kiddy saw me he started screaming cos he thought I was coming to do another procedure on him. His dad thought this was hilarious, so now every time I go into paeds his dad always gets his kid and shows him to me. The poor little kid hates me, but me and his dad always laugh so much when we see each other. Draining the pus and fitting the tube saved that kids life, so I don’t feel too bad! (Having said that he’s definitely not out of the woods yet, but doing well considering)

There have been so many times over the last two weeks when I’ve really question all that is good in the world. There’s so much suffering here, so many young patients dying. But as Jim always says, you’ve got to remember the patients you have helped as well as the ones you couldn’t.

I’ve seen some pretty horrendous things here, but I’m not really sure how much you guys want to hear about that kind of stuff… As well as being a staff + resource poor hospital, it’s the only hospital for about a hundred mile radius, and so often only the really sick ones will travel that far, giving a disproportionate picture of health in northern Ghana. Before coming here my (half) Ghanaian friend Marie kept saying ‘why do you want to go to the North, healthcare is rubbish in the North’. Well that’s why I wanted to go to the North, and I’ve really experienced that, and some. Maybe that's not fair, but it's certainly very different.

The choir at First Baptist Church, Nalerigu

My friend Hamsa

All the women carry their babies like this and little kids carry the even smaller ones