I was planning to put up one final post about my recent trip to Ghana at some point. I was going to say something more about how I spent my free time in Ghana. For now, suffice it to say that I spent one of my free weekends on a beach in Ada Foah, a slip of sand where the Volta River reaches the Ocean, and you can escape for a weekend to sleep in huts and relax.
That trip seemed quite far away yesterday, given that I spent about 15 minutes cracking a half inch thick layer of ice off off my car to be able to drive home from the hospital.
As you may know, I arrived back in the US on Monday evening. I gave myself Tuesday to rest and reorient, and began work again on Wednesday. I was on call on Wednesday, starting work at 7am, and leaving the hospital Thursday at 1pm, having had a chance only to doze for about 30 minutes. As you can imagine, I wanted nothing more than to sleep, but I had a few errands to run first.
Unfortunately for my new roommate, Neville, my central heating system had been malfunctioning throughout the month of January (while I was sweating in Accra). The system was constantly flipping the circuit breaker and eventually he gave up on using it, bought a space heater and cocooned himself in his bedroom. After a process which took over a month, I finally was told that the malfunction was likely due to a defective breaker, and could easily fixed by replacing the breaker. That was my chore for Thursday afternoon before I could sleep. I was successful, and my heat now works. It was very exciting.
Almost as exciting as sleeping after being awake for 34 hours. I was ready for bed. In fact, I was walking to bed when I noticed that my toe was a bit sore. I had noticed the same thing about a week before, and saw that there was a little duskiness beneath the toenail of my right 2nd toe. I thought I had kicked something and bruised it, and had paid it no mind.
I was surprised to notice yesterday afternoon, however, that it seemed to have gotten slightly worse, rather than better. I needed to take a closer look. When I looked under the toenail, I saw this:
Just a tiny dot below the toenail. But it was more than a dot. It seemed to be a small whole with something dark inside. The answer was obvious - I had some crazy tropical parasitic bug living under my toenail. These things happen. And the solution was obvious - I had to cut it out. As you can see from the bleach in the above picture, I had already begun to prepare a surgical field (my bathroom sink). My instruments were, admittedly, limited, but never let it be said that there is anything you can't accomplish with persistence and a good Leatherman.
So I began.
I began by cutting back the toenail, and then extending the opening in the skin.
It didn't hurt that much. Some parasites secrete a kind of local anesthetic around their bodies so as to make their hosts less aware of their presence. I wondered whether that might be the case here. As I continued to expose more of my little stow-away, however, I was surprised to find that it was not as little as I had expected.
In fact, as I exposed more and more, it seemed to be about pea-sized.
It was a bit hard to see exactly how deep it went. I was hesitant to be too aggressive, as I wanted to remove it intact. I wanted to remove it whole, both because it would be cool to have an intact specimen, and because there are some parasites (see section on Complications) that, when you rupture their cyst or body, release ill humours that can cause inflammatory responses and spread of the infestation. I didn't really think that anything that bad would happen if I did break it, but I figured it was reasonable to avoid that possibility.
I continued.
But I got to the point where I had dissected around circumferentially as much as I could, and I felt that I might have to go deeper. Hmmmmmm. I looked at my available facilities.
I looked at my toe.
And I thought: maybe I should go somewhere with sterile instruments.
If there is one benefit to being a resident, it's that you know a lot of doctors with access to sterile instruments. At this point, I also took a moment to surf the internet and look at my parasitology text, and quickly diagnosed myself with Tungiasis -- an infection caused by the sand flea Tunga Penetrans.
I called the pediatric ER. The peds ER is a bit of a smaller, calmer place than the adult ER, and there was a higher chance that I knew someone working there. It turned out that one of the Attendings (supervising doctors) who was working that afternoon was one of the heads of the Pediatric Global Health Track (who had just sponsored my trip to get this parasite). I figured that she had at least partial responsibility, so I headed in.
It is safe to say that everyone was impressed with degree to which I was willing to dissect my own toe prior to seeking (non self-) medical care. She also thought that the extraction best be left to the experts, and provided me with the phone number to a podiatrist, who she knew could see me in the morning.
As you can imagine, I wasn't all that satisfied with this solution. Now I had this huge wound in my toe and this exposed parasite hanging out. I didn't really want to go home and pretend to ignore it. I though about checking myself into the adult ER as an actual patient, but it wasn't really an emergency, and more importantly, I now hadn't slept in about 36 hours, and it would have likely been a long process.
I was walking out of the hospital when I remembered that, at that very moment, there was a Tropical Medicine lecture going on upstairs. The Tropical Medicine course is sponsored by the medicine department, and has lectures every few weeks on topics that you don't otherwise learn too much about practicing in the US. I figured that, even if I couldn't find someone to take this damned thing out, at least there would be a lot of interested people.
The lecture was on Trypanosomiasis, and was actually being given by a friend of mine in the med-peds program, Jeff. I restlessly sat in the back of the room until the lecture was over, and immediately jumped on Dr. Majid Sadigh, the professor of medicine who runs the Tropical Medicine course, and our resident expert on Tropical Diseases. I showed him one picture (the second one, above) and he immediately said -- "oh, sand flea. Very common." I also solicited his advice on removal. He laughed: Just pop it and scoop it out. It doesn't matter if you rupture it.
Just what I had been hoping to hear! So, Jeff ran to a supply closet for some gauze, and I went for it.
Success! It turns out it was more disc shaped than spherical, and hadn't been nearly as deep as I thought. I had actually mostly excavated it already. When I squeezed, it came right out.
So here it is:
And here is the divot left in my toe.
As I dissected I tried to leave the cuticle intact, so hopefully my toenail will grow back.
Some antibiotic ointment, some band-aids and a few days and I'll be good as new.
To my knowledge that is the first parasite I've had, though it certainly makes you wonder...
Who says you can't bring your work home?
So. Things at the hospital have been going well.
Today I gave a presentation to the Peds Department on electronic medical knowledge resources. Ostensibly, this was the purpose of my trip -- to come and do a brief project with the aim of improving access to and familiarity with available resources.
Physicians who work in major US hospitals, in addition to having (relatively) unlimited resources with which to practice clinical medicine, also have free access to a huge variety of online medical information, including journals, reviews, systematic databases, decision-support tools and so forth. Just ask any resident you know how often they use UpToDate. These resources, however, are not cheap, and are therefore not widely used in the developing world. There has been movement in recent years, however, to bully the major medical publishers into providing free access for free to those practicing in the developing world. HINARI is a program from the WHO which makes this access possible.
So, with the help and guidance of one of the Medical Librarians at the Yale Medical Library, I undertook it upon myself to find, catalog, and consolidate resources like HINARI in a way which made them easily accessible to the house staff here at Korle Bu Hospital. I did this by making a simple HTML page with one-click access to the major points of interest. The purpose of my presentation this morning was to review the available resources, distribute and explain the HTML access page, and give some tips on how best to navigate these resources.
The presentation was well-received, and was undoubtedly the first time that many of the staff present come into contact with some of these resources. Still, it takes far more than mere presentation of new information to affect clinical practice. Habit is a powerful thing. The integration of electronic medical resources into regular clinical practice requires personal interest and motivation, not to mention a certain baseline technical knowledge and infrastructure. Just ask the aging generation of physicians in the US, many of whom continues to struggle with some of these requirements.
Regardless, one must start somewhere. So consider it started here.
While having a coherent project plan (as above) was necessary to arrange an international elective, my personal interests were equally in clinical work and learning my way around the wards, which is how I have spent the remainder of my time. As with much of life, it has been educational, in that once again, I have learned how much I still have to learn.
There is this idea that a Western Doctor can show up in the developing world (even to a hospital well staffed with locally trained physicians) and be expected to provide better care than the local staff. Perhaps this is an obvious fallacy to some, but I doubt that it is to everyone. So let me put it this way:
Do you think it's easier to practice medicine in a resource rich or a resource poor environment?
Is it easier to practice medicine in a familiar environment or an unfamiliar one?
Is it easier to treat patients with illnesses that you see often or illnesses that you rarely see?
Exactly. Or how about this one:
If I am still very much a student of medicine at my home institution, will I be less of a student here?
So the initial idea is a bit off.
What, then, do I and my cohort of do-good Westerners have to offer? Not necessarily that much, initially. Still, there is a reason that the rigors of a US medical education are prized. The reason is not simply what you learn -- which in a foreign situation may be of little relevance -- but how you learn. Or more appropriately: how you learn to think. How to approach a problem and manage it's solution. This is a lesson that always serves you well. But form without content won't get you far in the hospital. You still need to fill in the blanks - the specifics of diseases, languages, treatments, and the politics of life and work in THIS place.
So, as always, there is still a lot to learn!
But who doesn't like learning?
This is a child who was running around the pediatric ward this morning. In case you can't quite read the caption: There is Nothing to Fear but Chuck Himself.
Hey All.
I'm back in Ghana. As per tradition, rather than updating via mass email, I will try to occasionally post a few thoughts here. Don't miss the links embedded below...
I'll only be here for the month of January. I am lucky enough to have gotten sponsorship from the new Yale Pediatric Global Health Track to do a quick project at Korle Bu hospital - the major teaching hospital here in the capital, Accra. In addition to spending time on the wards, I'm doing a quick project with the pediatric housestaff to improve access to and familiarity with available electronic medical knowledge resources. Basically, there are a variety of resources, such as electronic journals, databases, and decision support services which are can be obtained for free if you are a practitioner in the developing world. You just need to know how to jump through a few hoops to access them. Luckily, with the help of the Yale Medical Library, I have learned how to jump, and I plan to teach these skills. But more on that some other time.
First, because I believe that appropriate orientation is important for truly understanding your environment, I have put together a little google map with a few of the sites important to my life in Accra. Enjoy.
Here is the textual update.
Living situation:
There aren't a lot of places that rent rooms by the month here. As such I've ended up in a little apartment complex owned by a large Ghanaian woman named Auntie C, and occupied variously by her extended family, and a variety of Obroni. The expats here are an interesting bunch, working variously for the Korean embassy (he's Korean), a carpet business (he's Pakistani), the Goethe Institute (one guess...), a company that runs toll booths (he's also Pakistani), an NGO focused on fostering a transparent democratic process (also German), and their own start-up film-making business (brits). It's a nice little social spot, where not infrequently someone takes it upon themself to cook a big dinner and the crew sits together on the porch for dinner and a chat.
The hospital:
There will be more on this in later posts, so suffice it to say that Korle-Bu is the largest teaching institution in one of the most developed (though still very much developing) countries in West Africa. As such, it is characterized by the contrast between advanced pathology, scarce resources and leapfrogging technology (malnourished children with advanced cancers, payment required prior to lab work, sparse facilities for provider hand hygiene, Wifi access in part of the Pediatric Block, and a broken (but present) hospital MRI machine). As for interesting pathology there is plenty. Have you ever heard of Cancrum Oris? Neither had I. I was in the Emergency Room today -- which is, in fact, a room -- and I was impressed by the rather gory wound on the face of a wholly calm 2 year old. He had lost the majority of the soft tissue overlying his right jaw, with the exception of a twisted, blackened bit of lower lip, which exposed his lower arch of teeth and mandible. My first thought was electrical burn, given the charred appearance of the remaining lip. The resident with whom I was working found this to be a novel idea. It was, in fact, Noma - necrotizing stomatitis, not seen in the US or western Europe since Auschwitz. It was impressive. If you have a strong stomach, consider searching google images for "Noma". As the resident said - 'We see that here.'
Other tidbits:
I have to say -- the experiences that one has walking and running through various corners of the world never fail to entertain. For instance, you might think that I would have remembered past lessons prior to going running down the beach along the southeastern edge of Accra. Alas, I have been reminded.
Something one could never wholly prepare for, however, are the hilarious variety of reactions that one gets as a white man in Africa. Once, jogging down a farmer's path in the humid, hilly and verdant central Ghanaian Ashanti region, I so confused a local woman that she grabbed her small child and sprinted terrified off the path into the forest (I hope she found her way back). At other times, I've run with crowds of merry Tanzanian school children in tow. I've heard many a cat-call , and when my hair is long not infrequently been likened to Jesus. I was even once called Osama bin Laden - I have to assume it had to do with the long beard, although--let's be honest--the beard was bright red and attached to a really white guy.
But regardless, the media-fueled power of racially-based free-association never ceases to amaze, and I have perhaps never been as amused as yesterday when, walking the few blocks home from the local Tro-Tro stop, I heard the unmistakable, half-comical, gritty tone used to yell random things at foreigners, as a Ghanaian man called me:
Chuck Norris.
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