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 The X-ray equipment is outdated.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.

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

Right brancheal cleft cyst and left brancheal sinus

Lafort Fractures