A Happy Day

We just finished removing paper from the nose of a child, when a four year old boy came in vomiting and dyspneic (difficulty breathing). He was salivating profusely and vomiting every ten seconds. Perhaps he was poisoned. The brother said he saw a blue pen top in the child’s mouth before the vomiting began. When he was examined, I saw a large blue pen top in the back of his mouth. The child was turned upside down and as the pen top moved superiorly, his breathing improved and his clearing of his throat subsided. The child was taken to the operating room, sedated and the large pen top removed with difficulty. The child did well and was sent home at 4PM. One life saved, charges 19 GHc ($19).

This girl had a nice happy smile on discharge

Week of 18.04.08
A seriously sick otolaryngology patient arrives every week. The patients present late in their disease after attending a diviner and the failure of local treatment; some patients are brought in dead and 40% of those who die in the hospital expire within their first 24 hours of admission.
This week an eleven year girl arrived with a peritonsillar abscess, Ludwig’s angina and a marginal airway of four days duration. She needed drainage of the abscess, but the mother was reluctant, because the Dagoma people believe death will occur if an injection is given when the patient has a swelling. This is the correct observation of the sequence of events when the patient presents moribund, an intravenous line is started and the patient subsequently expires. Mr. Kadre, our excellent senior ear, nose and throat nurse, explained that the procedure would be a withdrawal and not an injection. The mother agreed and 10 mls of thick, green exudate were aspirated from the peritonsillar abscess. Because of her obstructed airway and the possibility of total obstruction and septic shock, the child was admitted. The otolaryngology nurses spontaneously volunteered to periodically check that the child’s antibiotic, clindamycin, would be given correctly and at the right times. In spite of this, the child still received one dose instead two as ordered, but the next day she was better. I just received a call, now two days later, Sunday, that there is no clindamycin available and the child is sixty percent improved.
Earlier in the week I complained to the matron that a patient received the wrong medication and when the correct medication was given, it was given twice in twenty four hours when it was ordered every six hours. The following day the patient did not receive any antibiotic and I stormed out of her office. Although this incidence was not the matron’s fault, she has been the administrator for years and the system functions poorly with no quality control. On Friday I was appointed "coordinator of clinical affairs" without an explanation of the duties it entails, and was seated with the administrators during a conference. I felt uncomfortable sitting with the administrators as this hospital is run poorly by Ghanaian standards. But, for improvement to occur, it is important to be active in the hospital’s management. With a better system, many lives could be saved. Anyone who wishes to help is encouraged to do so, as a team can do so much more than an individual.
The medical school invited me to evaluate their second year students as they examined the heart, elicited lower extremity reflexes, drew blood on a mannequin and applied bandages. Luckily for the students, their anatomy professor, also an orthopedic surgeon, was examining with me. After the students nervously floundered in front of six observers, he did an excellent job teaching the reflexes and a fair job teaching the cardiac exam. While there I met Dr. Geydare, the new dean, with whom I worked in 1978-79 when we were young like these students and we enjoyed reminiscing after thirty years. Dr. Geydare mentioned that Daniel Buror, a student who lived with us for two years in New Jersey, was working in Sunyani. Our family had grieved when we heard some time ago that Daniel had died in Nigeria, so it was happy news to hear that he is alive and we look forward to seeing him again.

This blog should come before the following blog

Every Week, Interesting and Unexpected

My sixty three year old Dagomba watchman, who protects me and my house with his bow and arrows, had a persistent, hacking, morning cough and a sputum smear showed the Tuberculosis bacillus. Because patients stop their anti-tuberculosis medication when stomach discomfort occurs, his pill, containing four medications, will be taken daily under my direct observation. He has not appeared in two days either due to miscommunication or he is seeking a diviner, for the Dagombas believe sickness results from offending the ancestors and the ancestor must be appeased with sacrifices to again gain their protection from disease. A diviner will recommend the appropriate sacrifices. He will also take his medicine, because there is no harm in playing both ends.
Last Friday, a cadaver dissection of the facial nerve was done with the medical students. Even though they were off this week, they requested another demonstration and sixty students arrived for a dissection of the carotid and jugular vessels, cranial nerves V, X, XI, XII, ansa cervicalis, cervical plexus, strap muscles, thyroid and parathyroid glands. In their final dissection the vessels, brachial plexus, larynx, trachea and esophagus will be demonstrated.
We do not have a pediatric endoscope or a pediatric anesthesiologist, so it was safer to examine the larynx of a floppy, eleven month old girl with noisy breathing using an adult nasopharyngoscope passed orally. Her bite was weak and a finger in her mouth protected the fragile endoscope. Her larynx was normal.

Two Step Forwards, One Step Backwards

A fifteen month old child, with an abscess originating in his left mastoid and extending to his right eye, presented late Thursday afternoon. He was prepared for incision and drainage over the objections of the nurses who wished to wait until morning. When requested to give anesthesia at six PM, the nurse anesthetist refused and came only after the chief administrator sent a car for him. One hundred milliliters of exudates were drained. Clindamycin was ordered every six hours, but the antibiotic was given twice daily and no explanation for the discrepancy could be obtained. The child improved and with antibiotics his mastoiditis should resolve and his eardrum perforation may close.
In gross anatomy class, the skull and larynx were demonstrated to appreciative Ghanaian medical students. The course may continue and more detailed demonstrations well be given. Finding time to study the anatomy myself and prepare the dissections is difficult.
Our good, hard working Egyptian general surgeon will stay a fifth year if Tamale Teaching Hospital will continue to pay his former Egyptian salary. Cuban and Egyptian doctors here are paid by their countries to work two and four years respectively in Ghana. The United States needs a program whereby salaried physicians work in developing countries.

An Advancement not planned, but occurring because one is here

Because there is no pediatric endoscope or pediatric anesthesiologist, an adult fiber optic nasopharyngoscope was passed orally on a floppy, eleven month old girl with strider (noise obstructed breathing) to examine her larynx. Her general weakness caused a weak bite and a finger in her mouth protected the endoscope. Her larynx was normal.
Last Friday, the medical students and I did a cadaver dissection of the facial nerve. Even though they were off this week, they requested another demonstration and sixty arrived for a dissection of the carotid and jugular vessels, cranial nerves V, X, XI, XII, ansa cervicalis, cervical plexus, strap muscles, thyroid and parathyroid glands. In their final dissection next Friday the vessels, brachial plexus, larynx, trachea and esophagus will be demonstrated. The colon and pelvis will be demonstrated by a visiting British surgeon, who will also lecture on “Perianal Disease” at our weekly clinical conference. “Medical Practices Among the Dagombas” was discussed last week by an anthropologist who studied this local tribe for fifteen years.
My coughing, sixty three year old Dagomba watchman, who protects me and my house with his bow and arrows, has tuberculosis. Because patients stop their medication when stomach discomfort occurs, he will take his single pill, containing four medications, daily under direct observation. Due to miscommunication, or because he is attending a diviner and offering sacrifices, he has not appeared in two days.

A few photoes

The pathology laboratory does not have a microscope. The X-ray equipment is outdated. This is the only basinette for the delivery room.

Will we be correct in our decision next time?

A successful choice of therapy, but the next time will we be this lucky?

An obese woman with her airway obstructed from abscesses of her tongue, floor of the mouth (Ludwig Angina) and neck, caused by sharp molar teeth cutting her tongue, was the sickest patient this week. The woman was febrile, weak, and unable to speak or swallow her saliva. A tracheostomy was indicated to relieve her airway obstruction, or as a safety to prevent her sudden death if her airway obstruction worsened. The tracheostomy would have been difficult, because of her obesity, goiter and edema; oral intubation was impossible and nasotracheal fiberoptic intubation dangerous. Since there are no oxygen or suction machines on the ward, it was decided that the safer course was to give antibiotics, clindamycin (900mg every 8 hours) and ceftazidime, and then reevaluate her. Before leaving that night a check on the patient showed she would have received only one dose of clindamycin over the next 24 hours instead of the three doses ordered and the wrong cephalosporin. This was corrected. I spent a concerned night and was happy to see the patient alive the next morning. Each day misinterpretations of the orders were corrected with the nurses. She still has a swollen tongue, but now her floor of the mouth, neck and breathing are normal; she is afebrile and able to swallow liquids. The patient had diarrhea today and the clindamycin was reduced to 600 mg three times a day. The dentist will smooth her sharp molars before she is discharged to prevent a recurrence. We were lucky this time, but a tracheostomy is the standard, safer treatment choice to prevent sudden death in these airway obstructed patients.

The vice president of Sales for Zeiss Corporation kindly and promptly offered to find a transformer for the broken microscope which would enable us to do ear surgery. Light bulbs and sterile drapes for the microscope are needed, but these are obtainable.

Perhaps a future Einstein died needlessly

A one year old child, who swallowed a large bottle cap which obstructed his airway, died ten minutes after I unsuccessfully attempted to remove the cap. Because of his obstructed breathing, intubation of the trachea was attempted without paralyzing the child. Several attempts of inserting the endotracheal tube on this swallowing child were unsuccessful. The larynx may have been displaced anteriorly from the large cap lodged posterior to the larynx at the entrance of the esophagus. The esophageal entrance was hemorrhagic and edematous, but the foreign body could not be seen. The child had an apneic spell and the procedure was terminated. His oxygen saturation was 95% when moved from the operating room. Ten minutes later, he had a cardiopulmonary arrest and could not be resuscitated. Regretfully I did not accompany the child from the operating room and he was being observed by students. After being told of the death of his son and crying, the father thanked me for my efforts. These poor people are kind and give me encouragement to continue caring for them. This child should not have died. We have saved other obstructed airway patients. It would be easy to give up, but I am the only one here and the need is great. God willing, I will do better next time.

Many Help in the Care of the Numerous Sick Patients

Many children present with swallowed coins, caps, mango seeds and hair clips or inserted stones, seeds and pen ends in their ears and noses. Most of these foreign bodies can be removed painlessly in the clinic with the microscope, sometimes immobilizing the child in a papoose, similar to a straight jacket. Uncooperative, older, stronger children, and those patients where the removal would cause pain, require general anesthesia. Frequently the foreign bodies pass through harmlessly. Patients with draining ears and perforated eardrums are common and 80 are listed to have tympanoplasties, eardrum surgery, as soon as the operating microscope is repaired. Patients with prolonged upper airway obstruction from epiglottitis, tuberculosis or cancer of the larynx and pharyngeal abscesses, (from bones lodged in their throats), require emergency tracheostomies. Immediately following the tracheostomies, copious, frothy, mucous pours out their mouths and their oxygen saturation falls to 50% when they breath on their own, i.e. pulmonary edema. Since the wards have neither respirators nor oxygen, these patients must be stabilized and this requires three hours of diuretics, steroids and positive pressure ventilation with 100% oxygen. Most cases survive, but one mother of six died two days after her tracheostomy immediately after which she had a cardiac arrest with a flat EKG and another elderly woman now refuses a curative laryngectomy, because she believes she will not survive. Surprisingly this woman never smoked nor used tobacco.

My biggest concern is an inoperative Zeiss microscope preventing me from performing ear surgery. When the microscope, which was still set to 110 volts, was plugged into the 220-volt outlet, its transformer was ruined. A new transformer, from 220 volts, 50 cycles to 6 volts, 30 watts is needed to power its light bulb. Supposedly Zeiss does not supply this transformer anymore. They may have a conversion kit to a fiberoptic lighting system. I have one working microscope in the clinic, but it would be foolhardy to frequently transport this microscope up two flights to the operating room for surgery, as it will quickly break. It is a necessity to have one microscope in the operating room and one in the clinic. Any help in quickly fixing this problem in order to perform ear surgery would be appreciated.

Surprisingly, two unplanned accomplishments have been the organization of a physician’s Wednesday scientific Clinical Conference and the shipment of two forty foot containers with medical equipment and supplies. At the hospital there were no medical meetings, little communication among the physicians and hard feeling between the physicians and the administration. The rapport was less than low. Now, with the Clinical Conferences, there are discussions on improving patient care, lunches with the administration and excellent exchange of knowledge. Even Ghana’s governing medical body, the Ghana Council of Medicine and Dentistry, has applauded the quality of our Clinical Conferences. The other accomplishment involved countless kind hearted, hard working Rotarians contributing $15, 000 to pay the expense of shipping two forty foot containers of medical supplies and equipment supplied by project CURE, value 800,000, to Tamale Teaching hospital. Every hospital physician listed their urgent needs and project CURE will try to comply. The poor patients of northern Ghana sincerely thank everyone; the relief of suffering and the cures these efforts will produce are immeasurable. Because this blog is public, names are not mentioned, but the praise and appreciation is great.