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.

The day after Christmas

Saturday, 26 December 2009
This day off found me rising at the usual 5:30 AM, breakfasting on yams and onions, muffins, fresh orange juice and a pau pau, which I purchased with haggling yesterday. I studied Dagbani for an hour by listening to conversations that I had recorded while in taxis traveling to and from work. It is fun to use the small hand-held recorder I recently purchased as some passengers are not familiar with recorders nor have they ever heard their own recorded voice. They also roar over my atrocious pronunciation. I laugh too when I listen. Just this month I have been able to have a simple conversation with a familiar topic. It gives me a thrill as language learning is difficult with my moderate hearing loss. Afterward, I placed cuttings from flowering bushes in water and compost soil and following that, I spent an hour studying a patient’s disease. Today, the disease was hydrocephalus and Arnold-Chiari malformation, because I lost a three-month old Wednesday with this condition. The child had a progressively enlarging head and dyspnea from bilateral vocal cord paralysis when he presented with cerebral malaria, seizures and died. A pediatric fiberoptic nasopharyngoscope was needed to examine this sick infant’s larynx. The adult scope was too wide to pass through her nose.
Lunch today consisted of a yam, string bean and carrot stew, diluted orange juice and a Christmas present of cashew nuts which Cyndy gave me yesterday. Then another gardening break. This time planting pau pau trees in the dry cement-like soil. Each side of the house now has a row of ten pau pau trees; the symmetry is pleasing. Time to treat myself to whatever I choose. This blog posting is being written because my friend and former medical school roommate mentioned on a call yesterday that there were no blog entries since November. Next on my agenda: taking an interactive aviation course online or looking up sites for my birthday-family vacation this March in Egypt. Hopefully the hospital will not call to disturb this Type A personality. I described my day after reading "Narrative of the Life of Frederick Douglas, an American Slave, Written by Himself." It is an excellent book and he could certainly give me a few lessons in writing. P.S. Corrective comments are appreciated.

Steady but slow progress

Workload and problems with electricity and computer have caused a delay in any additional blog postings. The twelve-year old with a crushed larynx pictured in the previous blog could not adequately breathe or phonate; further surgery removed obstructing granulation tissue and a keel was placed between the vocal cords to improve her voice.
Yesterday, a two-month old with shortness of breath, severe chest retractions and normal cry was referred and may have a congenital double aortic arch compressing his trachea. Laryngoscopy and bronchoscopy may help diagnose the cause of the child’s dyspnea. Hopefully the obstruction is due to a cyst of the larynx which I may be able to remove. If it is a vascular malformation, the cardiothoracic unit at Korli Bu in Accra may be able to correct it. However, a big problem is the family’s inability to pay the expenses of traveling and staying in Accra for the duration of the child’s treatment. Most families cannot afford these costs and the child will be brought back to the village to die.
With our Egyptian pathologist having returned home, proper patient care has deteriorated. A biopsy of a patient with laryngeal cancer was sent to another institution four weeks ago and still there is no report. His cancer is now inoperable. In the future, I will send the patient to have the biopsy and treatment at the other hospital until we have a working system here.

An exhausting, but successful week.

Twelve year old girl hit hit by a broken machine belt crushing her larynx and lacerating her pharynx.

Three year old whose house wall fell on him causing a concussion, swollen tongue and upper airway obstruction.

This week was exhausting, but successful. Three patients presented with severe upper airway obstruction requiring emergency tracheostomies. The first patient had complete upper airway obstruction from a carcinoma of the larynx. Following his tracheostomy, his tracheostomy tube obstructed twice due to lack of humidity, suctioning and the use of too small a suction catheter. The second patient, a three-year boy had the wall of his house collapse on him during a heavy rain causing a concussion, orbital fracture and swollen tongue, which required an emergency tracheostomy. The third, a twelve-year old girl, had a crushed larynx caused when a machine belt broke hitting her flush in the anterior neck causing a thyroid cartilage fracture, separation of the true and false cords from the arytenoids and retropharyngeal air. Intubation was impossible and a cricothyrotomy was performed. The following morning the tracheostomy was properly repositioned and the larynx was sutured and stented back into its proper position. Sunday afternoon I slept five hours exhausted. I am in need of tracheostomy tubes of all sizes (as my own supply has dwindled), suction catheters, laryngeal stents and suction machines.