Patients with Brancheal cleft cyst and Lafort I,II and mandibular fractures

Right brancheal cleft cyst and left brancheal sinus

Lafort Fractures

Photos of daughter Beth's visit

Daughter Beth arriving in Tamale

Beth and I at Christmas party

Watermelons at Tamale main market

A Christmas visit from my daughter

Modifying my actions to the Dagomba culture and the Dogomba nurses using the microscope and headlight are slow and awkward modifications of behavior. But, it is happening.

I have chosen to do only elective surgery until both iodine antiseptic is obtained to properly sterilize the patients’ skin and all my equipment is unpacked and organized. The hospital wards are in need of paint and freshening up, but seeing a rat emphasized the low standard of maintenance. For the privilege of being brought to the front of the line and being introduced as a family member, the patients pay the staff a fee. A common occurrence is the acceptance of a patient’s death when there is no available equipment, funds, and/or specialist to perform the necessary treatment to save a patient with a curable disease. Our proposal to renovate the hearing assessment room was denied because the original non-government agency has changed its mission. On the positive side, the chief ear, nose and throat nurse cancelled his travel plans in order to help me with an emergency tracheostomy.

A woman patient, who had been treated for asthma for three months, actually had stridor from an aryepiglottic, submucosal swelling which necessitated an urgent tracheostomy. Deeper biopsies will have to be done if the report is non-specific. Her swelling has reduced on post-operative antibiotics. Several thryrotoxic goiter patients with congestive heart failure and stridor had disappearance of their stridor when medically treated. Another patient with acute epiglottitis presented, but this patient also had jaundice and leukopenia. His human immunovirus test was negative. A sixteen-year-old boy with multiple facial fractures, Lafort I and II, and mandible was successfully referred and treated at Kofu-Annochi Hospital, in Kumasi.

Delighted to have my daughter Beth, visiting for Christmas.

Weekend Break in Accra

My wife and I spent this weekend in a different world from Tamale, in the Ghanaian capitol, Accra. There is an international influence in Accra. We ate in several fine Indian and Ghanaian restaurants, and stayed at a nice Ghanaian Lodge, all fine by anyone’s standards. After working every day, with our evenings busy trying to ready a rented house for occupancy, it is a refreshing break.

Several adult cases of acute epiglottitis were treated. Although Homophiles Influenza bacteria is the usual cause, Dr. Kitchner, chief of the Otolaryngology Department at Korle Bu Hospital, said Adult Immune Deficiency Syndrome might be the underlying cause and these patients should be tested for human immune virus.

We refer many profoundly hard of hearing children to the school for the deaf. Their deafness is often caused by malaria and/or its treatment. I saw a patient with severe permanent deafness resulting from artesinate, amodiaquin and ciprofloxin treatment. The patient was asymptomatic for malaria, but when he presented with eye disease and tested positive on a blood smear for malaria he was treated with this tragic result. Ghana states that its disability incidence is ten percent. Although the figure is hard to determine, it may be too low.

My United States colleagues have been kind enough to offer advice and supply me with articles regarding some of the difficult surgical cases shown in the photos.

After a lapse of several years, a new clinical conference at Tamale Teaching Hospital was attended by eighteen enthusiastic physicians. Five of these physicians were (housemen) residents, rotating through the hospital during their training break.

Work is hard, exciting, satisfying and worthwhile.

Medical Photos and Descriptions

This woman's enlarged thyroid has caused hyperthyroidism and heart failure.

This one year-old girl has a complete cleft lip and palate.

The man below had an infection of the mouth at age three which resulted in a deformed and elevated lip.

The young girl below has a deformed jaw and abdominal mass. This is the most common cancer among African children-- Burkitt's Lymphoma. Besides the lymphoma in the facial bones, she has an abdominal mass of lymphoma.

This man below had some herbal medicine placed in his nose that ultimately caused chronic sinusitis and fistulas from his sinus into his cheek and mouth.

This young girl developed a frontal sinus mucocele which is displacing her right eye.

Progressing Slowly

Ghana has a national health insurance that costs $8 per person per year. Many people cannot afford this and therefore, when they become sick they have to pay before being seen and treated. Since the average Ghanaian earns $2-$7 per day, it can be a hardship to first pay $3 to register at the Out Patient Department and then pay another $5 to see either the eye specialist or myself (or even the ophthalmologist or otolaryngologist nurse practitioner). Pre-surgical blood tests and surgical costs add another $16 or more. Many patients who should be admitted for hospitalization decline because of cost or fear. There is no other Ghana welfare system in place, that I know of, to allow for the indigent to receive care.
Two children were seen last week - a five year-old girl with a piece of chalk in her nose and a three year-old boy with a coin in his esophagus. The families of both chose not to return for the needed procedures. One was probably due to the cost charged by the hospital while the other expressed fear of the child dying during general anesthesia and oral-esophageal extraction of the coin. A third patient, an elderly man with a superficial, skin cancer on the neck, simply refused treatment because for him, surgery meant death. The chance of dying during these procedures is less than one in two thousand and without treatment, death is a possibility in the child with the coin obstructing the esophagus and the gentleman with the skin cancer.
Unfortunately, patients arrive in a late stage of disease after having tried everything else, - herbal remedies, diviners, etc. A five year-old girl, having Burkitt's Lymphoma, presented last Wednesday with a deformed cheek, hepatomegley, and an abdominal mass. Regrettably, her prognosis is extremely poor. It was recommended that she travel 200 miles to the medical school in Kumasi for chemotherapy, which is also a financial burden for the family. The young father asked me for help to bring the child to Kumasi.
There are many chronic ear infections with perforated eardrums and referrals come from hundreds of miles. The nurses mentioned they've heard a radio announcement about the arrival of an ear, nose and throat specialist in Tamale so word is spreading. Before I came, there was no physician in the Ear, Nose and Throat (ENT) clinic and as I may have noted before, none with my training in the entire Northern Region. The north's population is five million and people here feel they have been neglected by the government in comparison to those in the south. At any given day, hundreds of patients line up early at the hospital to be seen and when the few doctors on staff are gone at the end of the day shift, the examinations are performed by nurse practitioners.
One problem situation for me is dealing with the deluge of hospital staff personnel and their family members who have virtually no medical problem but want to be examined. It's a constant battle to make them wait until the end of the clinic so we can see the people who are genuinely sick. And, more often than not, the patients with the most serious diseases appear at the end of the day.
Thursday, I performed a nasal and sinus operation on a sick man who three months before on a diviner's recommendation, had placed an herbal treatment into his nose and as a result developed fistulas draining into his cheek and mouth; he also had an osteomylitis of his orbital rim. I successfully commandeered the TV from the OR lounge and used this as a video monitor for the camera attached to the sinus endoscope. The nurses were impressed with the technology as they were able to see on the TV screen the internal nasal and sinus anatomy as the operation progressed. This equipment, donated by JedMed and Karl Storz, along with a pulse oximeter from Nelcor, a headlight from Surgitel, and many other instruments generously donated by various medical companies, has been a godsend. A Pillings light source acquired several years ago still works too. My sterilizer, brought over in the container, is also set up and functioning well. Previously, clinical sterilization consisted of boiling the instruments half out of the water in an emesis basin for a few minutes. Special thanks go to my very capable and hard-working medical secretary in Kearny, Carolina, who spent innumerable hours arranging and packing all the equipment for transport.
In any event, the medical care denied or unavailable to so many people because of their inability to pay the fees set in place by both government hospitals and private clinics is disturbing. Because I am presently trying to practice within the system of a government run facility, patients are first obligated to pay the hospital charges before being treated by me. Perhaps I can hope to circumvent this situation as best I can by covering the cost of those cases I judge to be truly in need with some of the funds donated for my work here.
Every day is a learning experience, - never dull, often frustrating and always challenging.

Working In a Ghanaian Government Hospital

Yesterday (Monday), confirmed my fears of the bureaucracy and indifference of working in a Ghana government hospital. An eight year old boy presented with abscesses of the right ear, mastoid and neck after being treated by the ear, nose & throat nurse in the nurse's own private clinic (outside private practice is officially forbidden when one is employed in a government facility). I had previously wondered how this nurse afforded his two cars. When the child was scheduled for surgery with the nurse anesthesists, they wished to do the patient on Thursday, the official ENT operating day. When they were told it was an emergency, they demanded several lab tests. When the lab results were found to be adequate by noon, the senior nurse anesthetist had already left the hospital and had turned off his cell phone. The back-up nurse anesthetist who had also left refused by phone to come back to do the case because his senior had said it was not an emergency. The chief executive officer and the medical director were sought out but they too were not around.
I then operated on the child under local infiltrative anesthesia and 60 cc of exudate drained from several areas. His culture was sent to the lab at 5PM but because the lab was closed, the specimen was placed in the refrigerator. This will kill the bacteria, preventing us from learning the proper medication to use.
Illness is frequently looked upon as a punishment from an offended ancestor or retribution for an act considered taboo such as having sex in the bush, or greeting or eating with the left hand (the left hand is for use in the toilet and for other jobs thought to be unclean).
Relieving oneself is widely done in public, albeit with some discretion. Some men think they will become sterile if they urinate in a toilet which may have been previously used by a menstruating woman. Perhaps that helps to explain why there are no working toilets in the 300 bed hospital. No need to make repairs if people are afraid to use them. While other Ghanaian facilities and many homes do have functioning toilets which are indeed utilized, people of a different mind-set cannot see the logic of urinating or defecating into a hole which is actually inside one's home.
When a family member gets sick, the first person consulted is often a Diviner (usually a male). The Diviner is believed to have special powers which allows him to communicate with the deceased ancestors and to advise what sacrifices are needed to appease them. I recently visited such a Diviner and was impressed with his sincerity. He didn't, however, recommend going to a hospital. The hospital is considered when all else fails and because people are brought there in a moribund condition, it is a place associated with dying.
I have a lot to learn but it is good being here. Although the challenges are many, contributing to a great need is very satisfying.

Clinical patients recently presented with a swallowed needle, ruptured eardrums, a Guinea worm abcess of the forehead, and hearing loss and tinnitus from chloroquin treated malaria. The Karl Storz telescopes were helpful in treating the seamstress who swallowed the needle. Several surgeries were successful but the lack of monitors caused post-operative concern about hypoxia and hypotension. Tyco-Nellcor and Respironics pulse oximeters will be put to good use. Electrical failures are frequent and I should have listened to Dr. Chang's suggestion of accepting Surgitel's battery powered headlight. Road accident deaths are numerous; it is foolish to be on the road a night.
I found the hospital to be full of broken medical equipment which was previously donated without provisions for maintenance. Today, 80 % of this old otolaryngology equipment had to be discarded because it was beyond repair. A section of the roof has been leaking and because of the recent heavy rains, the audiology suite was flooded. During the roof's repair, the hospital's main electrical cables were found to be rotten - a potential fire hazard and possible hospital closure. An electrician is due to evaluate.
I have bee bringing in new equipment gradually from an off-site warehouse. Now that the ear, nose and throat departmetn has more space, we can bring in additional supplies once security is assured.

Tamale Regional Teaching Hospital

Tamle Regional Teaching Hospital consists of eight separate wards and laboratory buildings, ten physicians, and 500 employees for Tamale's 350,00 and the Northern Region's 2 million inhabitants. The hospital's electrical power and water supply (which requires electricity) are intermittent. Operations have to be terminated when the electrical power fails. Voltage surges destroy electrical equipment and voltage regulators will have to be purchased. In contrast to the spartan hospital facilities, the Chinese under Ghanaian contract, built a new 50,000 seat football (soccer) stadium for the upcoming 2008 Pan African Cup!
This past week, three patients with profound hearing loss (typical candidates for cochlear implants), a ten year-old with bilateral complete stenosis of the ear canals causing deafness, and an accident victim with loss of skin to the anterior neck, requiring a skin graft were seen. The child with the canal stenosis and the accident victim will be scheduled for surgery. Cochlear implants are not available.
A presentation will be made on August 15 to the Tamale Rotarians for their support with "Project C.U.R.E." in sending medical supplies to the hospital. This effort will be in conjunction with the Rotary Club of Kearny, NJ in the U.S.
It has been pleasant and rewarding to work with a 70% Muslim population, experience the torrential downpours, and learn "Dagbani," the language of the Dagomba. Not so pleasant has been recovering from food poisoning and trying to transfer funds to the local Barclays Bank and/or SG-SSB bank without ensuing their 2.5% charge. And last night's particular experience: after just lathering up my entire body with soap & shampoo in the shower, the water failed. Had to resort to toweling off all the soap & felt like a Roman of the first century who depended on oils to cleanse himself. Hoped Cyndy would appreciate the sweet smell but she was already fast asleep.
Your blog comments and emails to our gmail account are much appreciated!

Successful Arrival of Container

The 40 ft container of medical equipment having successfully arived intact one week ago is now secuely warehoused nearby. Little by little, distribution & utilization of the equipment should be accomplished and hospital security measures put in place. Tamale Regional Teaching Hospital has problems with intermittent electrical & water supply. Dr. Seth Wange, the Ghanaian ophthalmologist, had to finish four cataract operations with a flashlight when the electrical power unexpectedly failed. There is only intermittent running water in the ear, nose & throat clinic & the entire hospital is in need of painting.
Once every two weeks, four tonsillectomies are performed by a visiting physician who has had 18 months of otolaryngology training. He does a good tonsillectomy without available cautery. The nurse anesthetist is impressive in his technique & concern for the patient. Sterilization is with boiling water.
Patients with profound hearing loss, absence of speech, delayed speech, Bell's facial paralysis & many cases of external otitis & allergic rhino-pharyngitis were seen in the past two days at the ENT clinic. Mr. Kadiri, the ENT nurse, does a good job. Three schools for the deaf have over 1,000 children overall.
There is certainly a need for an otolaryngology specialist here in the Northern Region. The hospital staff are warm, receptive, helpful, & eager to learn and the patients are very appreciative.

All Beginnings Are Difficult

The 40 ft medical container supposed left Tema yesterday but still no sign of it. Hopefully, it will come intact. The Ghana drug department confiscated one carton of eye drops which they said had expired. I've been introducing myself at the hospital and everyone has been quite receptive. Interestingly, of the twelve doctors on staff, only four are Ghanaian; the rest are Egyptian or Cuban. The hospital housing that we were shown was sub-standard and we may have to obtain private housing to find clean, acceptable living conditions. We're in the rainy season now which brings on the mosquitoes and malaria. Around the hospital grounds, I've been seeing a few men with goiters which should be evaluated. There is an Ear, Nose and Throat Clinic run by an ENT nurse, seeing non-referred walk-in patients daily. However, the patients do not come in until very sick. With what little time I've spent there so far, I've seen significant pathology. The next few days I should be very busy unloading, securing, and organizing the otolaryngology equipment from the container. As we are now in temporary quarters, it is difficult to add to this blog at the present time.

Accra,Ghana

We arrived Wednesday, July 11, via KLM at Accra's Kotoka National Airport at 6pm to find two medical suitcases missing. By nine o'clock the missing pieces showed up, we cleared customs ( no problem) and were met by a driver of the Good Shepherd Home in Abeka/Accra. The accommodations are great and we slept soundly. We had spent the six hour layover in Amsterdam seeing the canals. Friday, Cyndy and I were shown the ear, nose and throat department at Korle-Bu Hospital, Accra by Dr. Kitcher, department head, who has done a lot of work and has an excellent facility. Later we visited the Director General of the Ghana Health Service, Dr. Elias Sory,who warmly greeted us and also made us feel welcome. The department has a Zeiss microscope in the clinic, but one optic is opaque and they can use only one eye. The department does not have loops, telescopes for laryngeal or sinus surgery. The physicians do a sub-labile approach to the pituitary using the microscope. There are no prosthesises for stapedectomies or cochlear implants. Korle-Bu Hospital, with the Ghana Medical School, is the premiere institution in the country. Sunday we are sightseeing "Osu Street", the popular nightclub street of Accra. The container with medical equipment seems to be clearing the port and customs and we will depart for Tamale perhaps tomorrow.

Two Days Until Departure: Good-Byes and To-Dos

I still have to pack, send several emails, observe surgery and arrange for a wire transfer of funds before departure. It was nice today having all our four children visit. We will also see them tomorrow night before departure. My concern is clearing customs and safely getting through the airport. The airport always has some shady characters and it is a hurdle to pass.

Here is a picture of our family at my youngest son, Stephen's Loyola-Marymount University graduation. I hope they all visit Cyndy and me.

Teaching an Old Dog... How to Blog

Two days until the long-awaited departure! I've just helped my dad set up this blog to document my parents' adventures while in Ghana. They leave for Accra out of Newark Liberty Airport on Tuesday afternoon, July 10th. They'll stay in Accra for a few days until they can guarantee that the 40-ft container filled with all of their medical supplies has passed customs and will continue on safely to Tamale. This move has been a long time coming (retiring to Ghana is a bit different than retiring to Boca) and we are excited that they're finally on their way. Excited, but sad, too. Mom and Dad, we'll be thinking of you! Safe travels, and all our love to you both.

-- Beth Murphy, 24, New York, NY