Escapades in Africa: 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.