The Final Push

I'm writing this last blog post from the comfort of my bed in chilly England. It's good to be home!

The last couple of weeks were filled with the usual level of stress and excitement - I had my last week at the BMC then one week travelling in the south.

On the Monday after my last blog post (16th Sept) I went out with public health for a change of scene. They were doing vaccinations in the local schools, so we stabbed about 600 children that day:

Whenever I (or any of the doctors) walk out of the compound we're greeted by shouts of "salminga salminga!" (white person, white person) by all the local children in the village, who come running out to gawp at us. You can imagine the level of excitement then when a salminga went to their schools. I thought at one point I was going to get bundled, but the nurses I was with were very firm and kept shouting at them. Instead they played a game of chicken - who could touch the white girl the longest before getting in trouble.

Despite this they were (as usual) the most well behaved population of children I've ever met when it came to receiving the vaccine. Out of the ~600 kids to be stabbed only about 3 cried, all of which were under the age of 4. The rest came up willingly with their sleeves rolled. I've had grown men faint on me in England from smaller injections than these kiddies were jostling for and grown women cry - shame on you England! Hahahaha

On Thursday Zaato supervised me doing my first circumcision:

Then in majors we had a patient with a massive ovarian cyst. She was about 12 weeks pregnant, but looked term because the cyst was so large. Lisa + Lynn meticulously removed it and let me dissect it afterwards. I won't show pictures of the inside cos it was really gross - we found two teeth, meaning it was a teratoma.

Lisa with the teratoma

Friday was my last day at work and certainly lived up to the usual craziness. After rounds I cut off a melanoma:

(Edit: I wrote this because that's what the doctors in Ghana said it was, but having done 4 months of plastics back in England, I'm pretty sure this isn't a melanoma. Still not sure what it is though!)

Then I went to maternity to check on the 3 labouring women, hoping to catch some babies on my last day. While I was there Michelle came in with a premie baby that had been discharged the previous week. The baby had been doing really well in hospital but the mother was desperate to get home, so Dr Coppola had said she could go on the condition that they came back to clinic on Monday. They didn't show up to clinic until Friday, when the baby was barely breathing, with neonatal sepsis. Michelle and I bagged it for about 2 and a half hours in total, as it had a very poor respiratory effort but a good heart rate. Eventually we decided it was fruitless, as it had fixed and dilated pupils and hadn't improved at all over that time.

But for every death there is new life... shortly after that baby died it was decided two of the labouring women needed C-sections so I got to scrub in on one of them and help bring the healthy screaming baby into the world.

After lunch I said my goodbyes to the nurses and then finally got to clinic.

Paeds nurses (sadly Matthew insisted on taking the photo)

Me and Zaato

On Saturday I left for Accra. I spent 4 days living with a Ghanaian family, friends of one of the docs. This was a really fun experience, although I found Accra a massive culture shock coming from the Gu. Nalerigu (where I spent 9 weeks) is in the rural north, where the majority of people are farmers who live in mud huts. On my first day in the capital we went to the largest, most swanky mall I've ever been to in my life. I found it a bit overwhelming. Then we came home to hear the news of the Westgate shopping mall.

On Wednesday I took the bus to Cape Coast, which I had heard was the most beautiful coastline in Ghana. If I'm honest, my first impressions weren't great. The town is pretty run down, full of derelict buildings. It didn't help that when I first arrived the sky was full of dark clouds making the ocean look grey and gloomy.

This building is still used as a church despite only being half build and half collapsed.

But then the clouds cleared and the sun came out and I could see, on the coast at any rate, why it was classed as being one of Ghana's beauties.

In the mornings the local fisherman can be seen pulling in their nets along the beach

I met a load of other travellers there, mostly from Germany, who were all really friendly. Almost everyone had been there for work placements like me or volunteering. It seems Ghana has very few (pure) tourists.

Me and Neele - a German medical student who'd been on her elective in Accra

On Friday I went to the Cape Coast slave castle - a slightly surreal experience. The castle was used to store captured slaves before being shipped across the Atlantic.

This is the 'door of no return' - all the slaves would pass through here to leave the castle to get onto the slave ships, never to be seen again

In the afternoon I met up with Michelle who'd just finished her month at the BMC. She very kindly let me share her room at a fancy hotel in Elmina for the night. When we got there, looking rather bedraggled, they asked if we'd come to use the pool (you can pay 10 cedi just to use the pool for the day). They looked a bit shocked when she produced a room reservation - I don't think we fitted in with their usual clientele of smart businessmen!

Getting home wasn't too stressful, except for a few minutes at immigration in Accra. Turns out my visa expired 2 weeks ago... at least I bought a 3 month visa but when I arrived in Ghana they'd written (illegibly) 60 days on it. Since no one told me and it clearly said 3 months on the original, it didn't occur to me that it might not last that long. For a few minutes I was worried they might not let me fly, but turns out I just had to pay a fine. Since I only had 10 cedis left on me (about £3) that's all I paid.

So finally I made it home after a long and stressful 10 weeks, but also incredibly rewarding, beyond my expectations. In that time I saw many children die, many get born, did many procedures a lot of junior docs haven't done and held more responsibility than I ever have in my life... not to mention get covered in more bodily fluids than I ever have in my life! But it was an amazing trip and one I'd definitely recommend to anyone currently planning their elective. I definitely plan on going back, hopefully in the not too distant future - hopefully before the current long termers have left! It's been fun writing here, hope you've all enjoyed it =) Looking forward to hearing about everyone else's electives in a couple of weeks!

(Sorry this is a bit of a mammoth blog - more like 3 rolled into one due to lack of good internet/time recently)

Babies are like buses

Potentially gross stories about babies getting born (although really you should just man up...)

This week has been filled with drama as per usual for the BMC. I've finished my 2 weeks in surgery and now half way through my final 2 weeks in obstetrics.

I've been trying to catch some more babies but kept missing them, so on Friday I left clinic every couple of hours to check the maternity ward. There were two women in labour, and every time I checked the midwives said they were each 8 and 5cm dilated (the cervix needs to dilate fully to ~10cm for the baby to fit out before the mother starts pushing, usually it takes about 1 hour/cm). I think it turned out that the first person who'd examined one had been a bit generous with her '8cm' hence apparent the lack of progression and the last person to measure the 5cm had been under generous. I missed that one at about 3pm so after clinic I sat in the labour room waiting, determined not to miss the other one. By this point another woman had arrived in labour so I was hopeful I would get at least one.

After about 4 hours neither of the women had made much progress, but I was determined to catch some babies having waited that long. For each of them it was all down to that last slither of cervix to dilate. Eventually they both did - at the same time. The primip (first time mum) was surprisingly much better at pushing than the lady who'd had 3 babies already so hers delivered first. When catching babies it's important to stop the head from coming out too quickly or it can cause a tear. Unfortunately, despite resisting the head to slow it down she still had quite a big tear, which bled a lot. The midwife gave me a suture expecting me to suture it up - something I've done only once before in that location, and with the consultant obstetrician talking me through it. This time there was no consultant and I could hardly see the tear due to the combination of bad lighting and the excessive amount of blood that kept covering it every time I wiped it away. I said I really wasn't comfortable doing it, but for some reason the midwife wouldn't take over. I put one stitch in, which seemed to make no difference, then luckily the consultant walked in the door. She'd been home for dinner but decided to check on how we were doing. I was incredibly relieved because the women had lost a lot of blood and I really wasn't confident about what I was doing.

At this point the midwife decided that the lighting wasn't good enough so the woman should sit on the other bed where there was the (only) lamp. This meant the other woman who was actively trying to push her baby out on that bed had to switch places with the one who had bleed all over the floor. Clearly this was a ridiculous idea, but Ghanaian women are strong and stoic. They barely make any noise when delivering; even the women being sent for emergency C-sections walk to the theatre, so the midwife wasn't about to get a stretcher any time soon. They both stood up, but due to the excessive amount of blood loss the one who'd delivered with the tear collapsed to the floor, luckily caught by the midwife and then me + Dr Coppola. At this point it was deemed reasonable to get her a stretcher and she was moved to by the light where Dr Coppola sutured her up.

While this was happening the first woman decided to push a little harder. Only the bed which she was meant to be on was covered in the other woman's blood so she set herself up on the floor, just centimetres away from the large pool of blood + amniotic fluid. So I delivered her baby on the dirty floor of the labour ward, kneeling on the nice skirt my mum sewed me! As I was waiting for the placenta to come out another midwife rushed in saying a women was delivering in the bathroom. Carmilla quickly rushed off and caught that baby on the bathroom floor. We'd waited all day for these babies to arrive then 3 came at once.

The bed the woman with the tear delivered on (old photo of Erin or Saly's minus the blood!)

The bed with the light - they're in the same room, divided by a thin screen (seen on the right)

I had a bit of drama whilst on call yesterday too which I was going to share, but I think it might be a bit much for some readers! Or at least I think it's a really interesting case from a medical point of view... but potentially upsetting for those of you who aren't quite as objective! Anyone who's interested feel free to ask.

Assabunteng (a Ghanaian PA) with a snake - we get a lot of patients with snake bites and often they'll bring the snake in with them to show us!

A different snake

Fighting for their lives

Today I read this article written by the mother of an American boy with a brain tumour.

http://www.rageagainsttheminivan.com/2013/09/what-i-want-you-to-know-about-having.html

It made me realise just how different our cultural attitude towards childhood illness is in the West than here in Ghana. I’ve been working at the hospital here for almost 8 weeks and over that time I suppose I’ve become desensitised to the differences. But reading this article really reminded me of how different things are back home. Back home parents will fight with every fibre of their being to prolong their child’s life by 5 minutes. Here… it’s very different.

In my first week here I had a patient with a ventricular septal defect (VSD) – a whole in the heart, so blood goes the wrong way. Although now, as a baby, she is relatively healthy, eventually the girl will develop heart failure (and probably die) if this isn’t repaired. One of the volunteers here had some money raised from home that he was willing use to pay for the girl to have surgery to fix it in Accra (the capital). It would cost somewhere in the region of $2000. Everything charitable here is done through the hospital’s chaplains, so we went to speak to them about the girl. They pointed out the importance of the family taking ownership of the girl’s treatment and suggested that they ought to pay for transport and accommodation. Although this was nothing in comparison to the cost of the surgery, it would make them take some responsibility and stop it being a hand out. We spoke to the mother about it who found it difficult to comprehend as her child is currently relatively well, but was still keen for the surgery (she couldn’t even read her own daughter’s name, so it’s hard to know how much explanation got through by the translator). The chaplains drove to the village to speak to the girl’s father who hadn’t come to see her in the hospital. They explained the situation and the proposal for the surgery, including his involvement of paying transport and accommodation. The father refused to pay. Instead, he said “I have another wife who has already produced another child, I have other older children from this wife, why should I pay? If this child dies, I will have another one.”

At the time I found this heart breaking. How could he love his child so little that he wouldn’t even pay a small amount of money to save her life?

But I think there is a huge self-preservation element to it. Although this has been the most extreme example to date, I think generally people here expect some of their children to die and so prepare themselves for it mentally. I’ve been with many parents as they watched us attempt, unsuccessfully, to resuscitated their dying children and they just don’t react the same way as Western parents do. When we performed a C-section and one of the twins was born dead and handed to me, I asked where shall I put it, and all the Ghanaian staff answered “in the bin”. I couldn’t do it and in the end one of the doctors put it (probably in another bin) in the other room, but at least it wouldn’t spend the rest of the surgery at my feet… The majority of stillbirths don’t get buried here or have any kind of funeral. There’s a concept of a ‘good death’, which would be an old man who has lived a long and successful life and died peacefully, where as a baby born dead is classed as a ‘bad death’ and is therefore not worth the same respect.

In the end, the father of the VSD baby agreed to allow the baby to have the surgery if all of the costs were covered, so she will have the repair… but it’s sad to think how little he values his child.

To be fair, not all parents have been like that here. The hospital (possibly country?) has had a massive shortage of anti-snake venom (ASV) for about a month now. Previously ASV would be covered by the Ghanaian health insurance, but since the shortage families have had to buy it from the black market. Where before patients would normally only need 1 or 2 viles, with the black market stuff they were needing 6 or 7. There’s some question as to whether this is due to it not being refrigerated during transport or if it was even ASV at all. Each vile from the black market costs 160 cedis – more than a month’s wages. Many parents would buy vile after vile of the stuff for their (older) children, bankrupting themselves, so they obviously did care a lot for them. Now the pharmacist has bought in a large quantity and is selling it privately for 100 cedis a vile – still a lot of money, but at least this stuff is actually working.

Sorry this is becoming a bit of a depressing blog! I’ll have to come up with some more penis stories… I have seen another patient who almost got his cut off in January when his shirt got caught in some machinery. He had scar tissue circling all the way round, but luckily apart from some chronic pain, he had regained normal function. Not quite as scandalous as the last one! 

I love this photo of Liz's - all the kiddies get weighed like this before they're seen in clinic

Photos from Jen's birthday, hospital stuff and scandal in Nalerigu

I thought maybe you guys might like to see some pictures from the last month that I haven't been able to put up before with the internet being broken...

I've been looking through loads of photos (mostly taken by my lovely friends) and got all nostalgic so some of these go weeeks back.

Stargazing on my 2nd (or 3rd?) week here

A baby born with spina bifida

All the scrubs/OR sheets etc get hung out to dry. Now that rainy season is fully underway and it's raining every day we have a big problem with drying enough gowns for surgery. The local staff don't want to hang them up in doors because of they believe the sun kills bacteria (luckily they use a steriliser too afterwards)

Jen's birthday

Me + the Coppola girls made a princess castle cake

And Erin + Saly + Elaine (and possibly some other people?) made an Africa birthday sign

One of my favourite photos!

Group photo strike 2 (sadly without Caitlin... also not sure where Saly is?)

This picture sums up everyone's enthusiasm for clinic pretty well!

Chini - a TB patient who sits outside on my porch everyday... not really sure why... he's very friendly but there's definitely something not quite right up there!

The other week we went to Nakpanduri - an escarpment thing...

Standard drugs cabinet

There's one incubator in the hospital that intermittently works so normally is at full capacity with 3 babies squeezed in. Any other premies/neonates who need it end up on the paeds ward in the open.

This is a baby I saw in clinic the other day who probably has craniosynostosis - a disorder where the skull bones fuse too early causing compression of the brain

I have got some other cool pictures of medical things, but at the risk of grossing you out I've decided not to upload them! If you want to see them you'll have to ask when I'm back in England.

Actually before I go, just time for one quick, potentially gross story mwuhahaha! The other week a man came into the hospital having been pretty badly beaten up. Turns out he had been having an affair with a married women. The husband somehow found out and rounded up his mates who then proceeded to travel to his village and CUT OFF HIS PENIS!!!! So now he has no penis... this was pretty big scandal here in Nalerigu. There's even a video somewhere on the internet that everyone keeps playing. As the story goes, one of the friends who'd been assisting with the assault had accidentally dropped his phone, while being distracted by penis cutting one can only assume... For some moronic reason he then decided to go back for it and the villagers by this point had come out (presumably having heard the agonising screams of a man-minus-penis) and killed him.

Apparently the penis choppers + the women who had the affair have been prosecuted (she told her husband who she'd slept with in the knowledge that he was planning revenge), though I don't know what happened to the villagers who killed the attacker.

Anyway, hope you're all doing well wherever this meets you!

xxxx