Returning to Tamale, Ghana, West Africa

August 29. 2022 The pain resulting from my left leg fracture has ceased and I will return to Tamale Teaching Hospital this October and remain there until December, 2022. Decline of my vision, hearing and memory, mainly due to aging, has forced me to submit my resignation. The young otolaryngology doctors will take over and do a good job. Three times a year, I can visit to bring equipment and offer advice. All my goals were not accomplished, but some good things resulted and many lives were saved or helped. Now, my wife and I will be able to enjoy ourselves in a more relaxed way. To equal the happiness and satisfaction I had in Tamale will be difficult. Our emergency departure from Tamale due to my fracture has left many things to clear up: bank account, water/electric bills, housing. Ghana has had few cases of Covid 19 compared to the developed world. The reasons given are speculative, but to eventually find out why may help the world. This September, at the American Academy of Otolaryngology - Head and Neck Surgery meeting in Philadelphia, I will try to encourage healthcare workers to work in the developing world. It is an honor to have been accepted as a speaker. There, I will also have the opportunity to request donations of medical equipment from various medical manufacturers. Prior to the pandemic, the manufacturers were generous, but donations during Covid 19 have diminished.

My new grandson, JR
Hello, I am new here.

The Surgeon as the Patient

Dinko ready to lift me onto the plane.

Dinko and Peter, Tamale Teaching Hospital nurse and doctor, took me to Accra. It was Dinko first flight.

My sons,Jim and John, helping me into our house on arrival home.

Cast after the second operation.

Sorry to say it has been an exciting few months. After returning to Tamale Teaching Hospital in January, 2022, I fractured my right leg by falling into an unprotected construction pit as I was walking home after finishing ear surgery at 7 pm on March 1st. My colleagues operated on me the next day, but they were not totally happy with the alignment. Since I was already scheduled to accompany my wife back to the USA in a few days, we thought it best to obtain a second opinion. The return trip home was difficult. The safety officer for Africa World Airlines was not going to allow me to board the small aircraft to Accra until my colleague, Dr. Adjeso, who conveniently happened to be his relative, persuaded him. Upon our arrival in Accra, the next leg for our Delta flight to New York was delayed overnight, but we finally arrived safely in the U.S. on March 6th. The orthopedic surgeon in New York agreed that the alignment should be improved upon and the reconstructive surgery was performed on March 14th. I am participating in daily physical therapy and now able to walk using a cane. The wound has healed and the pain is much reduced. My return to Tamale depends on the ability to heal further. My wife’s friend told her to break my other leg in order to keep me home, but the desire to get back to work is strong.

                                          

My fractured left tibia and fibula with titanium rod.

Iddi visiting me in Tamale Teaching Hospital. He pulled me out of the unprotected, construction hole.

Effective Medical Help in the Developing World

To be effective in providing medical help in the developing world, it is necessary to be on-site full time. Even though I had already come to this realization from working on-site full time in Ghana for the past fourteen years, it was further demonstrated when I returned from an absence of two years due to the COVID pandemic. Among the clutter and general disorganization of equipment and supplies, I found three fiber optic endoscopes destroyed by not sterilizing with 2% formaldehyde, but instead using parasol after being clearly instructed that this would do harm, two non-operative ear drill handles, a malfunctioning camera and flashlights, otoscopes and pulse oximeters not being used due to lack of batteries. On a personal level, our rented house was dirty even though a cleaning woman was paid monthly during our absence and water pumps, toilets and lights all needed repair.

An ongoing presence is essential to resolve problems as they arise and to ensure a consistency of an effective and well run medical facility.

Home With A Guilty Conscience

I returned home to the U.S. in March, 2020, when my concerned daughter purchased an airplane ticket for me, but I felt guilty leaving when there would be an increased need for a doctor during a pandemic. Since I was scheduled for a vacation and knew my family wanted me home, I thought I would take my vacation and then return. The border closed the day after I left and just recently opened. My colleagues at the hospital report that the people are healthy even though they are testing positive for COVID-19. There have been 50 deaths country wide among the 45,000 infected persons. If I returned and became sick, I would be a burden. There is only one working ventilator in our hospital. 

While home, I have been ordering medical equipment and we have just finished painting our house. I am getting to better know our two daughters-in-law and our four grandchildren, all under the age of six. Several family members have health problems which I also may be able to help. Returning might be possible early in 2021 after being vaccinated.

Encouragement to work in the developing world

As an American ear, nose and throat doctor practicing in West Africa since 2007, I encourage you to work in the developing world.The death rates for victims of accidents and women giving birth are fourteen times higher than in the developed world. Because there are few dentists to provide primary care, we have patients who die from septic shock caused by tooth infections. When we operate on our indigent patients, we often have to purchase medications for them.The hospitals in the poor regions of the developing world lack necessary funds, specialists, equipment, bandages, tracheostomy tubes, foley catheters and medications along with a consistent supply of water and electricity.

The developed world has so much while our brothers, sisters and children in the developing world lack medical care, sanitation, housing and transportation. Unable to afford a car, families rely on a motorcycle to bring their children to school. Accidents are frequent. I recall a five year old child who lost his arm when perhaps it could have been saved if there was a vascular surgeon on staff.

If you decide to work in the developing world, visit before going. You will learn what equipment you must bring. These rural facilities cannot afford to buy what you need, no matter what they promise. During discussions, they will tell you what you want to hear. Support is crucial - family, equipment, finances, maintenance, administration, assistance with customs and on and on. There are organizations and corporations who help, but it takes time and effort to locate and correspond with them. I am busy clinically, yet half of my time is devoted to repairing and requesting equipment.

The rewards are plentiful - experiencing a new language and culture, advancing in your chosen field and becoming friends with hard working, talented people.

The Difference Of An Ear, Nose and Throat Practice in New Jersey and Rural Ghana

My ear, nose and throat practice in a teaching hospital in northern rural Ghana is different than when I practiced in community hospitals in New Jersey, USA. My patients now are younger. The 2019 median age here is 21 years, in USA, it is 38 years. Weekly we remove tracheal and esophageal foreign bodies and see caustic ingestions and stridor in children. 

Another difference is how poverty influences patient presentation and treatment.  Because of their concern about expenses, the patients or their parents first attend a local villager who has a reputation for health knowledge and only after worsening of the sickness and obtaining permission from the village elders, do they come to our hospital in late stages of diseases and in septic shock. Resuscitation is necessary before definitive treatment can be done. There are three dentist in northern Ghana and septic shock and deep neck abscesses from molar infections is common. We now have a maxillofacial surgeon who will extract the carious teeth which we previously struggled at doing. Frequently the patients and the hospital cannot afford their antibiotics and we buy their antibiotics using donated funds.

Somewhat similar to the USA practice is the trauma caused from road traffic accidents, which here is the leading cause of adult deaths. The motorcycles and old imported cars along with inexperienced, risk taking, fast driving teenagers result in many deaths and injuries. The police have to do a much better job.

What are the benefits for a Board Certified American doctor
to work full time for twelve years in the developing world?
When I first came to the Northern Region of Ghana, I did
not foresee the numerous benefits.

Living in a different culture continues to be the biggest reward.
The people are polite, kind, thoughtful, religious and show
great respect for their dead. Like any society there are
exceptions, but they are few. Learning a new language has
been fun although it requires a lifelong attempt to master.
The food, rich in vegetables and fruit, includes dishes very
different from those experienced in the U.S.

As a doctor, I have grown and have been humbled by being
the only specialist for two million inhabitants when I first arrived.
Many patients present with illnesses that are already well
advanced. In addition to practicing my particular specialty of
otolaryngology, I must care for a variety of medical conditions
because of the lack of other specialists. A doctor in the
developing world has to be his/her own secretary, fundraiser,
purchaser, custom clearer and repairman.

Our medical visitors are a joy, even if I am left to care for the
complications their patients may have afterwards. On my trips
home, I have enjoyed Istanbul, Amsterdam, Lisbon, Cairo,
Rome and soon Cape Town.

Once in town a boy came over to say hello, his way of
thanking me. Many appreciate my work and I am content
in doing this needed healthcare.

  Ear, Nose and Throat Nursing Students

Child who had a groundnut (peanut) in the trachea 

is better after removal yesterday

New Hearing and Vertigo Clinic

We have started a weekly hearing and vertigo clinic. Although the supply of material and prostheses needed for ear surgery are still being obtained, we were not able to wait when a 24 year old girl presented in coma from an invading cholesteatoma of her left non hearing ear. Her pars flacida cholesteatoma extended anterior to the malleus, deep into the petrous bone, destroying the malleus, incus and horizontal canal. A radical mastoidectomy was performed and left open, because our patients frequently do not return and we do not have an MRI to observe for residual cholesteatoma. Two days ago we saw her in the clinic and she is doing well, without headache. Another successful ear case this week included a seven year old girl from whom we removed a stone from her middle ear. She was referred from another hospital where they had tried to remove the stone. When we removed her stone at surgery, we found the girl had a total eardrum perforation, dislocation of the malleus and the stone in her middle ear. With a microscope and good equipment, stones can be removed without anesthesia and without complications. Finally we were asked to see a patient who developed sudden profound bilateral hearing loss. He had become paralyzed from tuberculosis of the lumbar vertebrae and simultaneously lost his hearing. We now have to check if he received any ototoxic drugs prior to being transferred or if he has tubercular meningitis.

A Twenty Five Day Struggle To Save An African Infant's Life

A nine month old girl was transferred to our hospital in respiratory distress after being fed hot porridge by her mother. Was the respiratory distress due to a burn of her larynx or did the porridge enter her lungs? Examination of the larynx revealed a swollen, reddened larynx obstructing her breathing and an endotracheal tube was passed relieving her airway obstruction. In order to prevent the child from removing her life supporting endotracheal tube, she was sedated; a feeding tube was also passed. She developed pneumonia, malaria, diarrhea, abdominal distention and her endotracheal breathing tube came out on the eighth day. At that time, the swelling of her larynx had subsided and she was able to breath. Finally on the twenty-fifth day, after her mother had been educated on feeding, she was well enough to be sent home.

 Examining the infant girl prior to discharge.

 Burned, swollen larynx with endotracheal tube passed through her vocal cords.

                                                             
  Ready to go home.

Medical Cases from Africa

A four year old presented who aspirated a tamarind seed two weeks before. Every time we tried to remove the large, swollen seed through the vocal cords it would fall off the forceps. Breaking the hard seed into smaller pieces to allow passage was also unsuccessful. Even by paralyzing the patient we could not extract the seed. Keeping the patient sufficiently oxygenated was a problem. An incision was made in his trachea and the seed was removed directly from the wider trachea. The child was discharged healthy in four days.

A 60 year old man presented septic, with a deep neck abscess. He had had a tooth removed six years ago. His x-ray showed a dense object in his peritonsillar region and examination of the oral cavity showed a partially visible object. His neck was drained of 150 milliliters of exudate and removal of the object revealed it to be a round piece of wood with a ceramic base. It looked like a prosthetic crown or the broken end of an oral clamp. The patient denies having had a prosthetic crown put in after his tooth removal; however, it will be shown to the maxillary surgeon for further clarification.

                                          Tamarind Seed

The Advantages of Practicing Otolaryngology in Ghana by an American Otolaryngologist

Practicing otolaryngology for twelve years, the majority of the time as the only otolaryngologist without other specialists in an area of over two million people, has required studying, reading, consulting physicians, accessing Hinari and Youtube. Caring for many sick patients has been the best teacher of all. Helping to restore the health of others resulted in increased confidence and the personal satisfaction of contributing to society.

Living, working and sometimes disagreeing with the Dagomba of northern Ghana resulted in appreciating another culture, religion and race. It taught me the common human feelings shared by all men. The Dagombas welcome strangers believing we are enriched by each another. One of their proverbs states that a stranger can do no wrong. They forgive my many mistakes and truly appreciate the little help I have given.

Ways to Improve Our African Hospital

For eleven years I have worked in a four hundred bed Sub-Sahara hospital where needed improvements can only come about through outside funding. The developing country in which the hospital is located cannot afford the cost for these basic improvements. Three main problems are lack of water, lack of oxygen and the cost to the patients for treatment.

The hospital does not have a consistent water supply which causes the inability to sterilize instruments and wash gowns, thereby shutting down surgery. Lack of water prevents laundering of sheets and towels making it impossible to treat patients with diarrhea and prevents patients from bathing and using the toilets, all of which break and are rarely repaired.

Oxygen supply is irregular. After weekends, during which many accident cases occur, oxygen is never available. Surgical cases, even life threatening emergencies, are cancelled. I have bought my own tank of oxygen which I keep to use when needed.

Many times the hospital does not have medications or the patient does not have insurance and the patient’s family has to go to town to purchase the drugs. X-rays, ultrasounds, lab tests, Foley catheters and plates for fracture stabilization must be paid for prior to a procedure being done. Frequently family members contact their village for money which takes critical time and results in delay of care.

This emergency patient had a possible injury to his blood vessels. Because his family could afford to pay for a computer tomography x-ray which did not reveal any injury he was able to avoid surgery.

Muslim custom unfortunate liability with the use of motorcycles.

Having been here ten years in a referral hospital, many interesting cases come to us. Sadly, several are in the late stages of their diseases and only palliation can be provided. The patients are poor and they first try to obtain a cure from a local healer. Only when in their final stages do they come to the hospital.

 A malnourished child was brought in with his left cheek and jaw necrotic. After being fed he looked and acted stronger. However, he needs the dead cheek and jaw to be removed and his rehabilitation will be far from perfect.

The traditional Muslim custom of the woman wearing a long scarf can become an unfortunate liability with the use of motorcycles. We are seeing accidents in which the scarf gets caught in the wheel and results in strangulation. Such a case presented recently in a woman with a total transection of her trachea from her larynx. Only an emergency tracheostomy saved her life. Her trachea was sewn back to her larynx and now she has a fair air passage. However, both vocal cords are not moving and her nerves may have also been transected with her injury. We are hoping at least one vocal cord will recover.

Because there is minimal dental care, we continue to see many cases of deep neck abscesses from infected teeth.

The custom of drying out groundnuts and corn (maize) on the compound floor allows crawling infants to swallow such items and these young children present choking with food stuck in their trachea.

 We have used our donated facial reconstruction plates on several patients with multiple rib fractures and they did well.

Malnourished child with necrosis of left cheek and jaw.

New form of Transportation

Tamale Teaching Hospital Doctors traveling for Awards

Poor, recovered child whose care was paid for by her doctors

Reflections and Recommendations After Eleven Years as an Otolaryngologist in Northern Ghana

After eleven years of working in the Northern Region of Ghana, a poor and largely rural area, I ask myself if the experience has been worth it? For the patients whose lives were helped and saved, yes. For my family enduring long separations, each of those members would have to comment. Personally, I have gained immeasurably in appreciating a different culture, enjoying other countries on home visits and improving immensely my surgical skills and medical knowledge.

While strongly encouraging foreign healthcare workers to live and practice in northern Ghana, the following  recommendations may improve upon one’s goals. If worthwhile things are to be accomplished, come with strong financial and administrative support to allow you to remain on site for many years. My days are spent with clinical cases, administration and teaching - all of which require more time than exists.  I spend a good portion of my time  purchasing supplies, clearing items through customs and repairing equipment. This is not what these people need from a medical surgical specialist. Too often after surgery, the physician, himself,  has to supply the antibiotics needed to keep his patient alive and this requires funds. A developing country can truly benefit from a specialist who will come for several years with modern equipment and teach the in country physicians new techniques. Medical training in Ghana lacks the availability of such tools and often does not include the instruction of more current methodology. As a result, Ghanaian doctors continue to do surgical procedures which could be better performed if the proper instruments were available.

The value of short-term visiting teams is questionable. One group came to teach a week-long course on middle ear surgery which requires certain microscopes and drills. However, if the visiting team does not leave the equipment necessary to do what they are teaching, little is accomplished because those instruments are not available here. The visiting cleft lip and palate teams come to correct patients’ deformities, but they do not allow the Ghanaian physicians to do the procedures under their supervision. Surgeons do not learn how to do an operation by observing.

Neck trauma causing a collapsed lung and airway obstruction.
This patient's life was saved.

Mosquito net. The mosquito bites are the most annoyance.

The Rewards Of Being A Surgeon Northern Ghana

Top: The privilege of learning from bright, young doctors. Above: Local smocks given as gifts.

One receives much more than one gives in performing surgery in northern Ghana. Saving one life a week is more satisfaction than any other I can imagine. Sometimes saving patients lives is possible because they are young and their sickness is the result of trauma, infection, aspirating or ingesting coins, groundnuts or maize. A health worker has the feeling of contributing, of being worthwhile and the gratitude from the patients, staff and population is heartwarming.

A few days ago a woman thanked me for saving her life four years ago. Her chest was mostly scarred from the skin grafts which were used to cover her open wound after a deep chest abscess from an infected molar tooth. There are many examples of patients’ appreciation: an illiterate father returning with ten yams, an old, poor farmer giving me a guinea fowl, the boy who stopped his bicycle to say hi, the young woman with a baby on her back who kept smiling at me in the taxi and whom I later learned was the mother of the now healthy child we had saved the year before, the girl with the reconstructed nose who stuck her head in the door to say hi. These expressions of thanks make our day.

Working here has made me appreciate the goodness in all people. Generous donations given to me with no strings attached are truly appreciated and put to good use. Finally, there is the joy of learning that human nature is the same regardless of religion, dress or language. Sorrow over a loved one’s illness or death is universal. Interesting layovers over the years in Lisbon, Istanbul, Frankfurt and Manchester when going home for a family visit would have been compensation enough. I never dreamed of the many rewards which I do not earn or deserve.

Disease in Africa

The child with the congenital lymphatic malformation and the child with the scars from previous local medical man treatment.

Tamale Teaching Hospital serves the two million people of northern Ghana. Because of poverty and cultural beliefs, our patients come to the hospital late in their illness after being treated by the local medicine man. Last week, a child in severe respiratory obstruction was brought in by her step-mother. The step-mother said the child lived with the grandmother and had been sick for two weeks. However, the healed scars on the child’s abdomen signified a longer course of disease. The child’s respiration was obstructed by viral laryngeal papilloma which were partially removed allowing the child to breath. Unfortunately, viral papilloma will return as there is currently no effective treatment other than periodical surgical removal when breathing becomes obstructed.

Children with congenital abnormalities here do not have surgery because there is no specialist to perform the procedure. We currently have a backload of otolaryngology-head and neck cases which need surgery. One patient is in his sixties and has been bothered all his life with a condition which he has had since birth. Yesterday, we removed such a congenital neck cystic lymphatic malformation in a two year old in a five-hour operation. The case went well except for injury to the eleventh cranial nerve which rotates the head and elevates the shoulder on that side.  Another method of treating this condition, which we did not have available, is to inject a sclerotic drug into the cyst. We do our best and are saddened by any complication. The families are appreciative and thankful that we are caring for them..

Working In A Poor African Hospital is Challenging

Working in a financially deprived region has the reward of saving lives. The infected young or road traffic patients are able to respond to care, antibiotics and blood transfusions; however, not all survive. Patients are admitted in septic shock with deep neck abscesses from carious molar teeth. Recently, four have died from sepsis or hemorrhage. There are only three dentists in northern Ghana for two million people. There are four road traffic accident patients currently on the ward who have lost their scalp or face; one an 18 month-old child, another a 19 year-old boy whose injury also includes a facial paralysis and hearing loss. The young, risk-taking, helmet-less motorcyclists observe few traffic rules and the police do not have the capability of enforcing laws. Police are not in vehicles, seen only on foot. Road traffic accidents will soon be the major cause of death in the developing world, exceeding malaria. It is sad to see so many bright young people die needlessly.

Working in a poor hospital is difficult. It is often necessary to collect medications from discharged patients in order to supply new patients who cannot afford them or when the hospital does not have the needed drugs on hand. For the last two days, there has been no oxygen or water. Therefore, there is no sterilization of instruments, no bandages, no washing of linens and gowns and no surgery. The hospital is not functioning well.

Road Traffic Infant After Skin Grafting To His Scalp

Providing health care in a poor region in Africa

Providing health care in rural Ghana is challenging. Many of our sick patients cannot afford the CT scans, antibiotics, analgesics and Foley catheters necessary for their care. The hospital cannot afford to buy these supplies and does not have them available. The families, if they have the money, must seek out pharmacies in town to purchase the items. All this takes critical time in an emergency. I save medications which were not used on former patients for these poor patients. It occupies much of my time and effort to keep a supply. When the patients are admitted at midnight or on the weekend, when all the pharmacies are closed, I hope I have enough medications to keep them alive until the morning.

A 19 year-old boy needs urgent reconstructive surgery in Lubeck, Germany. Two months ago, a German Professor/surgeon removed his mandibular tumor, but the young man needs reconstructive surgery to prevent lifelong disfigurement and feeding problems. When the patient applied for a passport, the machine was broken. The former head of the passport department was removed for accepting bribes for passports. The family has finally obtained the passport; now the Embassy states he must apply in person for the visa. Many calls and emails to the embassy explaining the patient’s condition have not resulted in any response.

Progress is slow and difficult, but with much effort lives can be saved.

Having my wife here is good; with her doing the marketing, cooking, paying household bills, etc., it enables me to better cope with frustrations, freeing me to study and care for my patients.

Poverty prevents appropriate medical care and a happier life

Three weeks ago a twenty year old male had his tumorous mandible/jaw removed by a visiting professor of surgery. The large defect, from angle to angle, was reconstructed by using the fibula bone from his lower leg. However, the grafted bone did not take and it will need to be removed. This good looking young man will no longer be handsome without a jaw. His tongue will fall back, causing life long eating difficulty. He cried when told the graft has to be removed. The original surgeon, who has returned to his university, believes a second attempt could only be successful if done where better facilities exist. We are urgently trying to arrange this, but finances and insurance policies make it a one in a million chance of happening. I have come to like and respect this young man and feel saddened for his future. This is the poverty I see daily.

Our patient at the finish of the removal of his tumorous mandible/jaw; unfortunately the fibula graft which was used for reconstruction did not take and needs to be removed.

A traditional healer is chosen by my watchman.

Shortly after going on leave to greet Scarlett,our first grandchild, my watchman, Abdulai, fractured his leg and chose to be treated by a traditional healer.  On my return, I visited him, meeting the traditional healer.  Abdulai asked that his pay be continued during his illness.  I agreed, but requested he be examined by the hospital’s orthopedic surgeon. The orthopedic surgeon put him in a more stable cast and in two months he should have a good strong union. The total cost for the traditional healer’s services is twenty-five percent of Abdulai's monthly salary, while the hospital’s total cost is one hundred seventy- five percent.