A Good Month

Amidst problems and conflicts, a child life was saved in the past few weeks.  So, overall it was a very good month.

A girl of twelve, who always had a hoarse voice, presented with severe airway obstruction of two weeks duration.  The girl was disorientated and was not going to live through the night.  At surgery, papillomas were grossly removed from her larynx enabling her to breath and thus to survive.  The papillomas were caused by a viral infection that was obtained from her mother during childbirth. These papillomas will recur since they cannot be removed totally and there is no cure.  She may need a tracheostomy.

I am presently home in the US enjoying my family and the holidays until January 19^th. I have gained six pounds in ten days - so difficult to stay slim in our affluent environment.

A little boy saved

This week we saved the life of a seven-week old boy with severe respiratory obstruction from an infected congenital cyst of the neck and larynx (branchial cleft cyst, type III).  Yesterday the child had the strength to smile for the first time in a week.  The patients are so sick I do not have the heart to delay their care by taking pictures, but this handsome boy should have his photo taken.

There are pictures of a cattle truck, similar to the accident truck described in the 24 September blog, and of our burned pediatric bronchoscopes and esophagoscopes, which occurred when water stopped entering the sterilization machine.  Now two light carriers give irregular illumination, but hopefully they are still bright enough to remove foreign bodies from a child’s trachea and esophagus. These telescopic bronchoscopes and esophagoscopes are the only ones in all Ghana and they are used to save many children. 

A little boy and his toy.

While waiting to have a haircut I enjoyed seeing a contented, little boy who walked by pulling his home made car.  It was an ingenious toy, made by some loving person.  He agreed to have his photo taken and afterwards his observing playmates could not be denied to have their photo taken as well.

A little boy and his toy.

Going to the Mother of the Chief's Funeral

Last Saturday, a cattle truck was filled to the brim transporting a hundred Savelagu villagers to the mother of the chief's funeral.  In Tamale, funerals are accompanied by traditional dancing and music and they are both a diversion for the people and an important social event.  As the truck was attempting to pass another vehicle, it tilted causing some passengers to fall off.  The truck then fell into a deep cement gutter resulting in the immediate death of 15 or 20.  The dead, body parts and sixty others were brought to our hospital twenty minutes away.  The emergency room was chaotic with blood, patients, family and staff.   I triaged - directing the young doctors and nurses to care for the seriously injured and for the administrators and orderlies to move the walking wounded to a nearby location.  A dozen patients were sent to the operating room where four had abdominal operations for internal bleeding, eight had chest tubes inserted for collapsed lungs, two had limb amputations and many had suturing of open fractured skulls, multiple facial and head lacerations.  One experienced nurse suggested where to place the dead and these were laid out adjacent to the emergency room.   Twice the patients were checked hoping to find some life.  There were twenty-five dead patients laid side by side and head to foot.  Two thirds of them may have arrived dead.  Their families were twenty feet away anxiously watching the doctors and nurses work.  It resembled a war scene.  A photo did not seem appropriate but newsmen and others were taking pictures.  The death toll three days later is thirty-one.  Twenty-hour work days resulted but we saved many who would have died.

Today is a a national holiday, the birthday of Kwame Nkrumah, the first president of Ghana and it is allowing the staff to catch up.  Order has returned although life will never be the same for some families.   A man with an amputated arm, whose face and nose I sutured and with whom I cannot communicate, thanks me in his distress for caring for him.  It touches me.  Universally we are all the same.

Terrible twos

Terrible Twos

A referring doctor from Bolgatanga Hospital telephoned asking if he could send a two year old child in respiratory distress from a coin stuck in his esophagus. The boy arrived in Tamale alive after a three hour trip. He had had a cough for one month, was repeatedly treated at a local clinic without improvement and finally at the Bolgatanga hospital, an x-ray was taken showing the coin. The parents had no knowledge that the child had ingested it. With some difficulty, the coin was removed from the boy’s esophagus with equipment donated by Robert J. Fieldman, MD and partners and the Karl Storz Company. In the recovery room, the child had severe upper airway obstruction for two hours before returning to normal. The respiratory difficulty may have been caused by irritation from the halothane anesthetic gas which was used. Subsequently, he did well and was discharged. No time to get a photo as the cattle truck accident victims began arriving.
In the midst of the chaos resulting from the cattle truck accident, a little girl presented with a twelve inch wire sticking out her mouth. No one seemed to know how the toddler came to have such an object stuck inside of her but Mr. Mamonie, the senior nurse anesthetist believes this was an example of witchcraft as only the father brought the child in. The mother was not present. Under sedation, the long wire was removed from the toddler’s soft palate and anterior tonsillar pillar and she was sent home. Because I was overwhelmed caring for the numerous accident victims, a history was not obtained. I just removed the wire and returned to the critical patients.

Terrible Twos

A referring doctor from Bolgatanga Hospital telephoned asking if he could send a two year old child in respiratory distress from a coin stuck in his esophagus. The boy arrived in Tamale alive after a three hour trip. He had had a cough for one month, was repeatedly treated at a local clinic without improvement and finally at the Bolgatanga hospital, an x-ray was taken showing the coin. The parents had no knowledge that the child had ingested it. With some difficulty, the coin was removed from the boy’s esophagus with equipment donated by Robert J. Fieldman, MD and partners and the Karl Storz Company. In the recovery room, the child had severe upper airway obstruction for two hours before returning to normal. The respiratory difficulty may have been caused by irritation from the halothane anesthetic gas which was used. Subsequently, he did well and was discharged. No time to get a photo as the cattle truck accident victims began arriving.
In the midst of the chaos resulting from the cattle truck accident, a little girl presented with a twelve inch wire sticking out her mouth. No one seemed to know how the toddler came to have such an object stuck inside of her but Mr. Mamonie, the senior nurse anesthetist believes this was an example of witchcraft as only the father brought the child in. The mother was not present. Under sedation, the long wire was removed from the toddler’s soft palate and anterior tonsillar pillar and the she was sent home. Because I was overwhelmed caring for the numerous accident victims, a history was not obtained. I just removed the wire and returned to the critical patients.

Learning to work with limited resources

Learning to work with limited resources.

The patients come to the hospital so sick. Besides the medical problem at hand, they usually have malaria and malnutrition and in this condition their diseases overwhelm them. Even after entering the hospital, the laboratory and radiology capabilities are limited.
For example, a twenty-seven year old female student presented to a local clinic and then a hospital where she was treated for malaria, which is the knee jerk therapy as everyone has malaria. However, she had more than malaria. When her symptoms progressed, she presented to Tamale Teaching Hospital where I missed the diagnosis for a week because of an incomplete history and physical examination, the difficulty with language and communication, and the lack of laboratory and radiology capability. Since Tamale Teaching Hospital does not have a CAT scan she has to go by ambulance four hundred miles to rule out a brain abscess. She had a middle ear infection which spread into the neck and medially along her temporal bone and possible into her brain.
Poverty is a huge problem. A twenty year old young man, an orphan with no family, has a parotid tumor. He refused the advice of the village elders to go to the traditional healer and came to our hospital instead. His ten dollars is short of the forty dollars necessary for the biopsy and there is no government program to help financially. I will pay with donated money for the biopsy. Another example of poverty is a seventy-five year old woman who has thyroid cancer and hyperthyroidism and was placed on anti-thyroid medication to reduce her rapid heart rate prior to a thyroidectomy. Although she started on the medication she did not continue because she does not have money for more.
The new hospital construction is underway and the ground floor has now been completed. Dedicated doctors and technicians are here and working hard.

Medical Aid For Northern Ghana, Inc.

Access to health care is not as accessible to the people in the Northern Region of Ghana because the greater number of physicians are located in the southern part of the country. For that reason, I have chosen to work in this geographical area and have recently established a tax exempt foundation called "Medical Aid For Northern Ghana, Inc." through which significant medical needs can be addressed.
Corporations may wish to donate specific medical equipment while individuals may choose to make a financial contribution. It has been advised that checks should be made payable to "Medical Aid For Northern Ghana, Inc." and mailed to my address in the US where a member of my family will acknowledge its receipt and deposit the funds directly into the foundation's account.
Providing medical care allows me to experience the deep appreciation felt by the recipients and I personally thank you in advance for your generosity.
James P. Murphy, MD
Otolaryngology Consultant
Tamale Teaching Hospital
Tamale, Northern Region
Ghana, West Africa

A working holiday

Kola Nut


Doctors Joel Dickens and Andy Norman


The Gambaga Escarpment


A Female Pet Baboon

Last weekend, I visited the Gambaga Escarpment at Nakpanduri and stayed at the well respected Nalerigu Baptist Hospital. At the hospital, the doctors presented a young man who had a kola nut wedged into his throat for eight days and for which they did not have the equipment to remove it. Examination of the patient revealed air in his neck indicating that the kola nut had perforated through the esophagus. His history revealed that because his girlfriend had left him, he sought the advice of a traditional medicine healer who advised him to swallow the biggest kola nut he could find. This, the young man was told, would result in bringing his girlfriend back. The patient was transferred to Tamale Teaching Hospital where the nut was removed endoscopically and a neck drain and nasogastric tube were inserted. He is doing well several days after surgery.
For the past three weeks, Dr. Andy Norman of Vanderbilt University has been in Ghana performing vesicovaginal fistula repair on several women who developed complications from giving birth. If a woman has prolonged labor, the baby’s head can constantly pound on the urinary bladder and this may cause a permanent, open tract between the vagina and urinary bladder. When this occurs, urine leaks continuously out of the patient’s vagina causing the woman to stink of urine and to be ostracized from her family and village. The complication is rare in the developed countries where obstetrical care is available during labor but here, there are far too many women who are not as fortunate.

Thanks for the medical donations which are necessary in caring for the patients

Post operative photo.

Preoperative photo.


The endoscopic equipment, so generously donated by Karl Storz Corporation, is ready for the next child presenting with an aspirated foreign body. Recent donations of drill equipment by Anspach, microscope light bulbs and drapes by Karl Zeiss and tracheostomy tubes by Smiths Medical are greatly appreciated and are so necessary in caring for patients.
With the help of a visiting maxillofacial surgeon from Kusmasi, a neck tumor (teratoma) which was causing airway obstruction was removed from a five pound, four-month old girl. Post-surgery, the child’s breathing improved remarkably.

The child seen above is alive through the generosity of Mrs. Karl Storz and the Storz Corporate family. Karl Storz Company’s large donation of pediatric endoscopic instruments had just arrived when this three year old presented with a coin lodged in his esophagus. The child refused to swallow even breast milk and had a cough and fever with an aspiration pneumonia. With the newly arrived finely crafted telescopes and optical hard foreign body removal forceps, the coin was successfully removed from an esophagus that was edematous and inflamed.
The generosity of many companies such as Karl Storz, Carl Zeiss Meditec, Anspach, Surgitel, Smiths Medical, Covidien, Boston Medical Products, Dale, Westone Labs, Widex, Jedmed, Starkey, ArthroCare, Stryker, Grace Medical and KayPentax is heart-warming. When I am tired and discouraged, a request for needed medical supplies to save lives is granted and makes one realize how much good there is in the world. Businesses and corporations sometime receive bad press, but their contribution to this family is immeasurable. They have a living child and are eternally grateful.
Like many of our patients, this rural indigent family did not have Ghana National Health Insurance and were unable to pay for medical care. I am sure the Storz family is even more delighted that their instruments were used to save a child whose people are among the forgotten in the world.

An eventful week.

Doing well after surgery.

One week later he is doing well after surgery.

The child as he presented in the operating room.

Sitting lower than the chief who actively works for peace in the region.

Lower resistance allowed a tooth infection to spread to the neck obstructing her breathing.

A congenital lymphatic malformation became infected resulting in septicemia. Prior to drainage.

***

“What exciting thing is going to happen today?” This statement was certainly proven true during the past week.
A young man, riding his five-year old brother to school on a motorcycle, ducked to avoid a long steel pipe protruding from the back of another vehicle as he tried to pass it. The pipe, however, struck the little boy sitting behind him, penetrating the forehead, and pushing the skull into his brain. Now, several days after removing the displaced skull fragments, the child is doing well. Another man presented in septic shock from an infected neck cyst. A liter of exudates was drained and he responded well to antibiotics. Surgery to remove this lymphatic malformation will be performed after the inflammation subsides. A woman came in with difficulty breathing from a swollen, infected neck (Ludwig’s angina), caused by an infected tooth. She has purple skin discolorations, Kaposi sarcoma, and has adult immune deficiency syndrome, AIDS. Her husband died two years ago and her prognosis is poor. Her mother sits besides her bed and she will leave a nine year old son.
Our 110 volt electrocautery machine, kindly donated through Project Cure and transported by the Rotarians, exploded and burned when it was incorrectly plugged into a 220 volt outlet by a member of the nursing staff. The loss of this machine is heartbreaking as it takes months to replace and the cost will be high. Hopefully, the one available backup will continue to function.
Karl Storz’s large donation of endoscopic equipment arrived today. These telescopic endoscopes and forceps will enable us to remove the foreign bodies which many one to five-year olds swallow and aspirate into their lungs.
Many corporations have been extremely generous in supplying the finely crafted tools which have saved the lives of the patients described above. I, and the poor people of Northern Ghana, sincerely thank each and every one of the persons responsible for such an important contribution. I met with the Tamale chief and his elders who work to keep peace in the region.

Pursuing the Impossible Dream

X-ray of infant who aspirated an earring into her right lung which was successfully removed with modern bronchoscopic telescopic equipment.

After two and one half years has a modern ear, nose and throat department been established at Tamale Teaching Hospital? No. Some days we have moved backwards. The light at the end of the tunnel is seen, but the end is never reached. All things considered, however, our clinic now has equipment which is not available anywhere else in the country.
A modern, “state of the art” ear, nose and throat clinic cannot be established in a developing environment in one’s lifetime. It would necessitate all surrounding structures to be modern and functioning well. This does not exist. Examples of how outside conditions, over which we have no control, interfere with the goal of a modern ear, nose and throat department are an unreliable supply of water and electricity. The lack of water prevents sterilization of surgical instruments and the washing of surgical scrub suits resulting in surgery being cancelled. Electricity fails daily and the returning power surges destroy electrical equipment.
Why continue the uphill, difficult, strenuous struggle for a state of the art department? Because such a department, with modern equipment and technique, saves and improves lives. The modern pediatric bronchoscopes, telescopic optical forceps and magnified image on a monitor enable the removal of aspirated foreign bodies from the lungs of small infants saving their lives.
Sometimes I think I benefit the most from these efforts. There is peace and satisfaction in doing something worthwhile and good. The others who benefit are the poor in the northern region of Ghana. If the equipment were not here and we did not care for these patients, they would not have the money or means to travel four hundred miles to the capital of Accra to seek treatment.

Toothaches and malnutrition in the developing world

I was saddened by the death of a twenty-two year old young man from septic shock which resulted from a toothache. The young man started with a toothache one month ago and sought local village treatment. One week later he developed swelling of the jaw, face and neck, confusion and became irrational. His family continued with the local treatment. Cultural belief has it that swellings are not to be drained or injected. Eventually, he was brought to the hospital and I was called to possibly do a tracheotomy. However, this previously healthy young man was already in septic shock with the whole side of his face and neck filled with exudates; he was feverish, anureic, hypotensive and tachypneic. The abscesses were drained of thick brown pus, but the boy stopped breathing later that evening never responding to fluids and antibiotics. Many families do not bring their sick to the hospital because of cost. The hospital visit fee is $4 while they earn $2 daily. Cost for admission and surgery is between $200 and $300 which is well beyond their financial means. Many patients are brought in moribund and many die on the way. Of those admitted, fifty percent die within the first twenty-four hours, not giving us enough time to treat them.
Hopefully, a better outcome will occur with a 16 month old boy who was recently referred from a hundred miles away because of runny nose and upper respiratory infections of four months duration. The child was examined for nasal foreign bodies, syphilis and aids, all being negative. Because of his poor condition, he was referred to our excellent pediatrician, who questioned why a child with a runny nose was being referred from an ear, nose and throat doctor. After I explained the results of my work-up, he said he would get back to me and returned later stating the child had malnutrition, being less than one percent of normal weight, with multiple lymph nodes probably due to tuberculosis. He admitted the child to the hospital to be fed and treated. Although TB, pneumonia and diarrhea are listed as the cause of childhood deaths, the real cause sixty percent of the time is underlying malnutrition which makes the children more susceptible and results in fatal outcomes because their resistance is so low.
It is a joy to work with the young, intelligent, dedicated Ghanaian physicians and to see the improvement in the care of the patients.

Tamale Teaching Hospital is a good hospital

Tamale Teaching Hospital is a good hospital. Newly appointed and recently trained physicians, pharmacists, laboratory technicians and administrative professionals have improved patient care. The new graduates are dedicated, knowledgeable and hard working. They are capable of working in the most sophisticated medical settings with the proper orientation and training. Their lectures at the hospital clinical meeting are excellent. Medications and bandages are available through the persistent efforts of the new caring, hard working and honest administrators. However, the staff is limited by the lack of equipment. In the hospital there is one electrocardiographic machine, three ward oximeters, no vaporizers or intravenous infusions pumps. Our otolaryngology clinic is lacking a pediatric nasopharyngoscope and bronchoscopes, laser, rigid telescopes for sinus surgery and suction debriders for nasal polypectomies. “One looks for what is needed and then one uses what is found” and “We are managing” are the appropriate practical Ghanaian sayings in response to this lack of equipment. Six Columbia St.Lukes/Roosevelt ultrasound physicians and public health professionals, under a General Electric grant, gave an excellent two day ultrasound workshop. Ultrasoundography is inexpensive, non-invasive and without complications. Two ultrasound machines were donated, which are appreciated, but thirty are needed along with maintenance for the five millions patients in northern Ghana. All is not Utopia. Human nature is universal and there are those who do not work when necessary, saying they are underpaid. But, we are managing.