Tungiasis - WARNING - Graphic Content

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?

Thinking...

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?

More Chuck

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.

I'm Back

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.

A Few Pictures.

Here's what you missed:

Uganda: Jump off of me.

Lake Nakuru, Kenya

To clarify -- This is a Rock Hyrax.

But they're so cute....

And I probably don't have rabies.

Orient yourself. You're still in Kenya.

And enjoy the view.

Chase a Giraffe into the forest on foot.

Don't scare the flamingo.


And move on to Ethiopia...
Lake Tana and its monasteries...

You heard what the sign said!

9 century old bibles hand written on goat skin, displayed by adorable monks abound...


Gondor, Ethiopia -- The Camelot of Africa, as they say.

The Simien Mountains.

Ethiopian Angels.

Lalibela, Ethiopia and it's rock hewn churches...
These churches were carved directly out of bare rock. Ground level is at the top of the picture.

Yup. Carved out of a hillside.

The church interiors are carved from the same single stone.


Look for the people at the left side of the picture for scale.


This nun paints Ethiopian Christian religious imagery on small patches of goat hide from her monastery atop this mountain...


Feeding the hyenas in Harar, Ethiopia. Because I probably didn't have rabies yet.

Malawi.

Northern Mozambique


Rwanda. Gorillas and Genocide...

It's kind of how you picture The Jungle. Right Max?


Yup. We're that close. That's a silverback.

Please take a moment to appreciate the relaxed attitude of the baby on the left. It's good to be king of the Jungle...

Elsewhere....

Church Genocide site.


The near sign marks the place where French soldiers played volleyball while 50,000 bodies were thrown into mass graves (marked by the further sign).

Spain.
Meanwhile, at the Alhambra, in Granada, there hasn't been a genocide since ... the Inquisition.

Take a look at that white wall in the foreground. Closer...

Closer....

Close enough. Now remember that.




and now?

A New World.

Want to hear something frightening? Someone in a bank -- who seemed to know what they were talking about -- told me today that I was pre-approved for a $160,000 mortgage. Seriously -- someone is foolhardy enough to front me a hundred and sixty large. Kind of a sea change from African street hustlers trying to bilk me out of an extra 13 cents.

So yeah -- things change fast when you hop a few intercontinental flights, and get a diploma that says MD.

I'm afraid that I became rather delinquent in my blog updates during the last month of my trip. Now, sitting in one of my future co-resident's living rooms, a few days into my search for a new home in New Haven, Connecticut, the adventures seem rather distant.

I still haven't gotten the cable out of storage that can connect my camera to my computer, so you'll have to wait a bit longer on pictures, but here is what you missed in the rest of East Africa. For details, give me a call, my number hasn't changed:

Scuba-diving in northern Mozambique -- real fun.
Being qualified to rent scuba equipment, and head out in a boat with a buddy -- real foolish.
Having to eat a raw egg, including shell, as part of an awkward PADI-Scuba initiation ritual -- real not fun.
Hopping a flight from Northern Mozambique straight to Dar es Salaam, Tanzania in order to skip 5 days of arduous overland travel -- real smart.
Finally getting rid of the body lice infestation of questionable origin that you picked up a month prior in a hotel in Ethiopia, and which proved resistant to the "All-Natural Lice Shampoo" that you found in Nampula, as well as the pungeunt homemade disinfectant mixture with which you later washed everything that you owned, including your body in Pemba, but was susceptible to the 'Not-Natural' (read: effective) Lindane lotion which you bought in Dar es Salaam and applied in Arusha, in the shadows of Mt. Meru -- real satisfying.
Laughing at Max when he finally lotioned himself 2 denial-frought weeks later -- also satisfying.
Being back in Tanzania -- homey.
Taking a bus directly from Arusha, Kenya to Kampala, Uganda -- really long; improved by overnight self-medicating; worsened waking up and finding that your headlamp was stolen while you were deep in a medicated sleep somewhere near the Kenya-Uganda border.
Kampala -- bustling.
Deciding to go to Rwanda to see some of the few remaining Mountain Gorillas -- smart.
Rwanda -- good infrastructure, easy to travel, and oddly pleasant for a country only 15 years out of a genocide.
Seeing 35 year old Rwandan men on the street and wondering: what were you doing when you were 20 -- disconcerting.
Going Mountain Gorilla tracking and being touched by a Silverback -- real real naughty. (that's a good thing, mom.)
A variety of Rwandan Genocide memorials containing everything from polished informational exibits, to gnawed, abandoned clothes covering the pews of a once-church-refuge, to the twisted bodies of adults and infants, exumed from shallow mass graves, covered in lime powder, and pkaced in room after room after room of a once-school once-site of 50,000 killed, set upon a hilltop surrounded by lush tropical hillsides and a view as incongruously beautiful as the smell of the memorial was memorable -- difficult to fathom.
The trip back to Nairobi and a farewell to Africa for a while -- bittersweet.
Waking up in Nairobi and going to sleep in Madrid -- stisfying, especially if the first thing you do is buy a bunch of wine and bread and cheese (which we did).
Couchsurfing -- always an adventure.
The Alhambra -- not too shabby.
Two weeks in Spain -- exceedingly pleasant.
NYC, Gradutation, relocation and residency -- the capital of the world, fine, ongoing and we'll see.

Pictures soon...

mulanje to pemba: a variety of transportation - Guest blog by Max

Hello! Inasmuch as I've fallen far behind on all my electronic responsibilities, and I started traveling with my roommate Max two weeks ago in Malawi, the following blog entry is brough to you by Max. I'm still working on the entry about Ethiopia (the prior few weeks), so forgive the out-of-chronological orderness. Anyway, the trip has been Ethiopia, meet Max in Malawi, overland northern Mozambique, and now in Dar es Salaam, Tanzania. My old stomping grounds. More soon... Now, from Max:

________________

ben and i arrived at mulanje, a border town on the malawi/mozambique border on tuesday morning, april 7th following an overnight trip from blantyre. the date is easy to remember because it's our new favorite holiday- women's day in mozambique. at the border we were welcomed by rowdy, boisterous, and saucy women drunk at 11:30AM. they implored us to come back to one of their homes to have lunch and we accepted. it turns out that that woman runs a restaurant out of her home- whoops. sumptuous lunch and and too many beers in, i cut myself off from the barley hops at 3; dancing all afternoon was the complementary remedy. dinner was served, and we were fast asleep on a mattress by 8.

430am out the door to walk into town and head to mocuba by public transport (this was a small lorrie, but we were offered the cab). bumpy road, one short break down and 6 hours later we arrived. at the bus station we inquired about transport to nampula- this was the long leg on the journey to the indian ocean. in the manner of minutes we found a group of guys, in a huge lorrie, who could take us. after using our spanish as broke-ass portugese to understand destination and price, we agreed- this time in the bed of the truck. after filling the bed will other passangers on the way out of town, we were on our way.

and then it started raining. hard. and the roads were horrific. about, i'd say, 10 minutes into the trip, we were soaked to the bone and our packs were water-logged seat cushions. the conditions were pretty nasty. rotten fish was the dominant scent whenever we slowed down. sometimes the group haphazardly pulled a grimey tarp over us, creating a hot, wet, fetid atmosphere underneath. about 4 hours later we stopped at a town to fill the bed with bags of corn- human and agriculture transport now. 2 hours, 2 beers, and a fiasco trying to dislodge the truck from the mud, we were back on the road. now it was dark. the rain had diminished, but the threat loomed and a chill sunk in. one silver lining was a beautiful tropical savvanah countryside illuminated by a full moon.4 more hours and then we arrived at another town. we quickly filled our stomaches and heard that there was now one spot in the cab. we looked at each other- rock paper scissors? the loser was gonna be PISSED. so, we inately implemented the sad puppy dog guilt-trip technique. layed it on real thick. next think we knew ben was on my lap in the cab. PA-REESH. 4 hours later we pulled into nampula at 3AM. good lord. 14 frickin hours. 14 hours. we were in a state of hazy distortion- fatigue, lack of shelter, damp nastiness. thank god the hotel we found was nice.

after head to ilha de mozambique the next day, we had transportation paradise from there to pemba. ridiculous. by complete dumb luck, an opportunity for a pricey (by our standards) by not unreasonable private van fell upon us. after some back and forth with the driver and hastily assembling our packs we were on the road. feet up on seats that faced each other, the only two in the entire back seat of the van with and ipod to dj with. hehe, this was a beautiful, beautiful thing. gorgeous, expansive country side, our music, a book, lounging in padded seats. oh yea, there was a sunroof! paradise really, especially after the nastiness that had proceeded it.

k, off to the beach.

word.

max