Another day at the hospital.....

Becky and I experienced another heartwrenching story this morning........A father showed up at the emergency check-in area with his 10 year daughter looking very, very ill. He had been out of town several days apparently and arrived home to find his daughter sick. The girl's name was "Rachael"........she had a seizure while they were checking her in to be seen by the medical staff. Apparently she had been seen by a local clinic in Gambaga just 3 days ago for similar symptoms but we were unclear as to what treatment had been rendered. She was lethargic, not eating, and very weak by the father's report. She was rushed down to the Theatre area where we all hang out on Tuesdays and Thursdays. She looked very ill, curled up in a ball on the cart, foaming from her mouth, wimpering. Becky and I looked her over and Dr. Faile wanted us to proceed with a lumbar puncture to rule out meningitis. After what we have seen over and over here, we were apprehensive to say the least. With the help of the tech and father, we rolled her to her side and Becky was able to get a very cloudy, slightly bloody spinal fluid from her back. Initially the fluid came quickly, the it slowed. We sent it for immediate gram stain and cell count and took her to the isolation ward. Becky ordered stat antibiotics, labs, treated her for seizures, and started IV fluids. Things were not looking so good as the next few minutes passed. When I gazed over where her father stood at the end of the bed, Rachael started to have agonal breathing - a labored breathing pattern that can mean herniation of the brain and increased pressure on the brain. Becky and I watched over the next several minutes, and we knew in our hearts it was going to be over soon - Rachael would need a miracle to survive the infection we believed she had. We called for the chaplain, and then met with the father to tell him of the impending death of his 10 year old daughter. Our hearts just sank, as we sat and watched her for the next 45 minutes succumb to her overwhelming infection of the brain. Throughout our time with Rachal, the father stood at the end of the bed, coming in and out of the ward, never once holding his daughter, touching her or speaking to her......a woman came in shortly later, we assumed it was her mother, but we didn't know for sure....she also stood at the end of the bed, watching patiently to see what was going to happen. The father then picked up a small metal basin, filled it with cool water and sponged his daughter to try and cool her. Her temperature was well over 104 degrees.......as he sponged her so gently, with the mother standing at the end of the bed, Rachael took her last breath. The woman cried for just an instant........Becky listened and could hear no heart beat.....her battle was over................it's overwhelming at times to see all this......a few hours later we checked on her spinal fluid results. She had Neisseria Meningititis on gram stain in large amounts. Despite our efforts, Rachael was going to die......even in the US children and adults may not survive an infection of this magnitude. And I say again, this happens all over this hospital and others like it in Africa all day long.......

There are many miracles here at BMC too......many that we do save with meningitis, and in fact the woman who was in the bed next to Rachael, had severe mengititis on admission and is doing great and will go home soon........she sat and watched, as did all the other patients and families in the isolation ward, as we did our best to care for Rachael.........

Good night from Ghana........we leave at 4:30 am for Tamale then onto Accra for some rest and relaxation. We should have wireless in the hotel to keep blogging for everybody. This experience has changed us all - I can't speak for all the others, but I don't think any of us will leave the same person that we came......a better appreciation for life and death, and how others live in this world. So long from BMC. All is well as we pack for our trip home.

Last day at BMC.....

We all can't believe our last day has come and gone. We did rounds, then procedures, then OR and everybody is back packing up their belongings now. The heat has let up some and we are all feeling good, but ready for some site-seeing and beach time in Elmina. We will be at the Coconut Beach Resort for 2 nights and 3 days. We have a driver hired to take us there from Accra when we fly down early tomorrow morning. We leave BMC at 4:30 am - the drive is about 2 hours and our flight about 8 am. We will eat dinner around 6 tonight and head to the weekly Station meeting at Jayne's house, the pharmacist. I have posted the pics of the "high-powered vacuum" procedure that Becky did yesterday. You can see her here holding the tube in place and I am showing the contraption that removed the fluid in record time. We did it again today but the vacuum machine ran out of power - we're not even sure how it is powered actually. So today we just kept pulling fluid with a large syringe to remove her fluid. She is in pretty significant heart failure....we hope this makes her feel a little better. Enjoy

Pound Cake and more.....

Today was a really good day at BMC. We had a nice, even pace in clinic and actually finished up early....we got down to the Theatre early to start on the procedures of the day. We did what I would call a "High-powered Vacuum" thoracentesis of the lung on an elderly patient in pretty significant heart failure. Her left lung was almost full to the top with fluid and the right about one-third of the way up. We don't have the usual vacu-tainers that we drain fluid into in the US. Normally you put the needle in, hook up the tubing and pop it into the suction container where you take off 3-4 liters over an hour. Here we do it quite differently. Becky put the needle in perfectly (on the third try - she'll be a pro before she gets back to the States though), she got a flash of the yellow colored fluid into her syringe. She pulled out the metal needle leaving the plasitc angiocath inside the patient where the fluid was. At this point, the tech handed Becky the large tubing that is connected to an electric-powered vacuum device that is normally used in the OR to suck up blood during a case. She put the tubing on the catheter and the tech flipped the power switch and what happened next was quite amazing to see !! All the fluid in her lung was instantly, and I mean instantly removed from her lung - like a vacuum cleaner would do. For a moment we were all scared the patient may crash. A liter was sucked out of her body in a matter of seconds and we repeated it several more times. She breathed better in the end and could lie a little flatter in bed now without becoming short of breath......we just do it differently over here but in the end the outcomes all appear to be the same !! So there you have it - the "high-powered vacuum" thoracentesis. I guess it beats an hour - we were done in seconds !!

After the day ended we went to the Hewitt's house for a movie and pound cake with fresh strawberries - just for a moment we felt like we were back in the USA. It was delicious and the movie was the "Illusionist" which was quite good. Mary Ann and I are on call tonight so we'll see what comes in tonight. We leave for Tamale and Accra on Friday morning at 4:30 a.m.

That's all for tonight - good night all and I hope you enjoy the stories - I have a picture of this I will try to post tomorrow.....

Pics of "one large knee"....

Here it is - I will let everyone know if we do an amputation today - it is so heavy and he is so thin he can barely move around - i think you get the "real" picture now on this one.

One large knee.........

Sorry I don't have the picture yet but I will post it tomorrow. We have a boy that is around 20 years old - presented to clinic with a massive right knee - like he has a pumpkin there. It is incredible really - he can barely walk because of it. Just picture a tiny upper and lower leg and in the middle a large pumpkin. It is extremely painful to even light touch. Now the bad news - likely an osteogenic sarcoma - a fatal cancer at this point. His CXR showed some pulmonary nodules so already metastatic. For palliative care and comfort we will most likely do an amputation above the tumor tomorrow. Unfortunately, he has been febrile all day so this makes surgery a little more risky. He is so great, and so thankful to all of us and he speaks pretty good english for a change. The outcome will not be good but we hope to make his last few months a little more liveable......pic coming soon - if we do the amputation we may have a before and after shot for everybody.

All of us are doing really good - the students have been awesome and working hard !! And we are all healthy, well-fed and showered everyday !! I thought the parents would like to know this. We head to Accra then Elmina Coast for a little R and R this Friday - well deserved for everybody ! Take care a good night from Ghana - thanks to everybody who has emailed support and posted comments on the blog - we appreciate everybody's kind words.......

Experiencing death in Africa

On Saturday, Kavara and I were assigned to call. We had several admissions that we were called to evaluate and work-up. When Kavara and I got there we started to work up the first patient. He was a small 10 month old baby boy that looked pretty sick - he had a high temp, vomiting, and diarrhea for 3 days as well as a cough. On exam, he was irritable, eyes rolling around in his head, painful belly, and chest exam showed diffuse ronchi throughout. With the fever and how bad he was doing, we did a lumbar puncture on him. It went beautiful - Kavara had attempted only one other time, but she got this one on the first stick. Here they don't use spinal needles on kids - just a regular old needle. The fluid was clear and we sent it for a VERY basic analysis - WBC's or not. I ran down to the OR suite to get something for a brief minute and then the nurse came running down saying the medical student needed me right away. I ran back up the hallway and turned into the peds ward. Across the room I saw Kavara giving chest compressions and mouth - to -mouth rescuscitation on the baby. I ran over - no pulse, no breathing - the mother stood quietly at the end of the bed, saying nothing. The families of other patients all sat and watched - the nurses watched us.....the baby coughed only once in this entire thing but blurped up some phlegm into Kavara's mouth. None the less we kept on, but knowing in our hearts it was over. After a couple of more minutes - it seemed like an eternity, the mother waived her hand at us to stop. She had seen enough, and we weren't making any progress. We had not been told what to do should an infant or adult patient code. Our instinct in the US is to save - here it is to let die. I broke down in tears and put my head down on the cart and gazed into the childs blank stare - Kavara got teary eyed - then we got up and walked back to the work station. The mother cried for just an instant, patted the baby briefly and walked out of the ward. The death certificate came up and three men that were obviously part of the family, came in, wrapped up the baby in african cloth and left. I have never been part of anything like this.......they just see death differently than we all do in the US you know. Dying is just part of living, and is accepted as part of illness. A similar event occurred the following night as well. This time however, the baby stopped breathing a little later after the LP was completed. Our team let this baby go........no code, no CPR.....just let the family be with the baby......and be together to say goodbye......what I describe above, happens everyday in this hospital.....adults and children alike. It's so different from how we practice back home........it really opens your eyes and you learn so much from these special people we are taking care of everyday.

Two more pics

For those of you who like to see more pictures - two more. One is the Nalerigu Market that we went to on Saturday afternoon. The other is Colleen, Becky and I on the hike up to the rocky overpass ! Enjoy !