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programme

25 Jul

We all slept well last night thanks to continuous rain throughout the night (and the cool breeze that comes with it).  Missing our morning runs in Ghana, we decided to exercise this morning, using a yoga video and yoga mat (brought by Rachel).  It felt so good to move and stretch, but we also realized how far we have to go once we get home to get into half-marathon shape by December (we are running the Dallas White Rock Half with Rachel’s sister, Jen).  It also spurred conversations about how our home on the ocean is going to need a fitness room, as running during the rainy season would be a complete joke (it POURS here, and has pretty much all day today).  We had oatmeal again for breakfast with fresh mango on the side.  We weren’t sure what the “programme” for the day would be since we had not talked with anyone since church yesterday.  But this is Africa.  And of course, there were 6 African pastors on our doorstep around 11 a.m., asking us what our “programme” for the day should be.

At our request, they took us to see the largest of two government hospitals in Conakry – Hopital National Donka.

We were able to see the pediatric ward and met with two pediatricians (Dr. Moustapha and Dr. Emmanuel) that work at the hospital who were kind enough to stop seeing patients in the middle of their morning to answer our questions.  They explained how the healthcare system is set up in Guinea and how the educational system works, and then answered our questions until Pastor Elijah graciously recommended that we allow them to continue their work (none of the pastors were quite as excited to be there discussing medicine as we were).  We learned that there are three levels of care in Conakry: primary, or large hospitals with the highest level of care available, such as Hopital National Donka; secondary, which seems to include smaller hospitals and clinics that would be equivalent to small private hospitals in the U.S.; and tertiary, or community clinics that refer patients to secondary or primary centers if needed.  Patients are admitted through the emergency room typically, but can also be directly admitted if they accidentally skip the E.R. and show up on the wards.  There are 70 beds in the pediatric ward alone – the entire hospital is very large and composed of several buildings, each housing different wards, labs, and imaging rooms.  Within the pediatric ward, they have a nutrition center and have recently opened a room dedicated to diabetic patients.  Dr. Moustapha trained in endocrinology in France and heads up the diabetes room.  He explained to us that Novo-Nordisk (a company that produces insulin to treat diabetes) started a program in 7 countries in Africa, including Guinea, that donates free insulin, glucometers, and supplies to patients with diabetes.  It is supposed to continue for 5 years.  Dr. Moustapha has been treating cases through the hospital since April of this year with the help of this program, and travels to villages around Conakry to identify new patients who need treatment.  He has also started giving seminars to hospital staff to educate them on the diagnosis and treatment of diabetes, specifically coma due to DKA (a serious complication of type 1 diabetes).  They are also airing commercials on the radio to educate the public about signs and symptoms of diabetes.  It was so exciting to talk with him about what he is doing at the hospital and to see how motivated they are to improve the care provided to patients here.  Both pediatricians discussed how they recognize the flaws and limitations of Hopital Donka, but that they are working toward improvements as best they can.

the building that includes the pediatrics ward.

the pediatrics ward.

We learned that the education of physicians is quite different than in the U.S.  Students who pass the national exam after 12th grade (see previous post about school system) can apply for medical school.  Those accepted study for 6 years and have at least some clinical experience scattered throughout that time.  They then must pass an exam to be considered “general practitioners.”  Some then go on to specialize in one of several areas, including internal medicine, pediatrics, OB-Gyn, surgery – pediatric or general, urology, neurology, and others.  This process takes an additional 4 years.  For those who wish to sub-specialize, such as in pediatric cardiology or gastroenterology, it is rare to have the opportunity.  They must either snag a spot in a program in France, or find someone who has been trained in a particular field in France and returned to Guinea to work.  For example, Dr. Moustapha happened upon an opening for pediatric endocrinology in France and travelled there for his studies.  Now that he is back in Guinea, he is going to train Dr. Emmanuel in the same field.  When we asked how difficult it is to get a chance to go to France to train, they almost laughed and said it is “by chance or luck.”

We then toured the laboratories and were impressed by the wide variety of tests available.  They have all basic labs in addition to cultures (identification and susceptibilities), viral serology, and even viral load for HIV patients.  The facilities are dirty and run down, but the lab appeared professional and organized, and the staff were clearly well trained.

our tour guide, the lab director (on the left).

the biochemistry lab.

rachel scoping out the microbiology lab.

Overall, the hospital appears to be “worse than a condemned project” (in Adam’s words), but we are excited by the opportunities that exist here.  In Ghana, we were often frustrated by the fact that the hospital was so limited and we were left guessing about many of our patients.  Here, because we are in a big city, it seems that we would have access to many of the same labs we use in the U.S. (even at the government hospitals – we haven’t seen the private hospital yet), which would allow us to practice good medicine and have the satisfaction of knowing what was happening in most of our patients.  Of course, there is A LOT of room for improvements, but that’s the whole reason to come.  And it is refreshing to see that the Guinean doctors are as excited about change as we are.

This trip has really been perfect.  We got to see a functioning hospital in Ghana and see what it would be like to work in that type of setting.  We felt rewarded by our work, and yet were not completely fulfilled.  We enjoy learning and teaching so much that we want to be in a setting with more opportunity for advancement.  Today, God reminded us that He has a plan for us, and likely in a larger city such as Conakry.  It’s exciting.

Thank you again for all of your prayers for us – God is clearly listening and working.

– Courtney & Rachel

last day in the ward

19 Jul

Today was our last day to round on our patients in the pediatrics ward.  The ward was beyond full with 59 patients (remember, only 37 beds).  Moms and children were sleeping on the floor in the middle of the room and between beds, and there were two children per bed along one side of the ward.  IV poles were everywhere with fluids and blood transfusions hanging.

The nurses lined up the kids in the middle of the room who weren’t connected to an IV pole for us to start seeing.  We essentially start at opposite ends and the moms carry their children down the line of stools until they get to us to be seen.  We then round on the children with IV’s connected – they stay in their beds and we come to them – though the ward has been so busy lately that Dr. Hewitt, Dr. Wilson, and Dr. Dickens usually make it through the rest of the hospital before we finish and come to help us with the kids.

We were able to send many home today – a lot of the admissions from last night just needed some extra fluids or a transfusion.  It’s crazy how much our concept of an acceptable hematocrit has changed since being here in the middle of malaria season – we pretty much only transfuse for hematocrits below 19% (in the U.S., we typically transfuse for anything below 24%, sometimes higher).  We have also become experts at feeling large spleens and livers in kids when examining them – a skill we were excited to master.  We feel ready to be senior residents in charge of many patients, and are not as scared to be the one to run a code in the hospital when we get back home.  It has been such an amazing experience.

Rachel’s translator for today is named Ralph.  He is a fabulous translator and is so interested in learning – he always asks questions and does such a good job explaining things to the moms of our patients.  He told Rachel at the end of rounds that if he had the power, he would give her an award for the hard work she has done here.  He said that it “is better” with us in the pediatrics ward and he wishes we could stay longer.  All of the nurses have been telling us how sad it is we have to leave and that we must return some day.  It has been so encouraging to hear these words from them.

This afternoon, we held an in-service for some of the nurses on treatment of seizures (see previous post, “all for good”).  We discussed the physiology of seizures, the potential complications of having seizures, the mechanisms and indications for valium and phenobarbital, and the proper doses of each.  We were surprised by their enthusiasm to learn – they participated actively and asked great questions throughout the presentation.  We went over several cases at the end to illustrate the concepts we covered and they had clearly been listening as they were able to answer all of our questions correctly.  We then spent some time answering their questions and discussing some scenarios they had seen on the wards.  It was encouraging to see how interested they were in learning and how appreciative they were for the in-service.  Unfortunately, the pediatrics ward was so busy that none of the pediatrics nurses could come.  However, those that attended agreed to teach others and we are planning to type up our presentation and provide it as a handout for all the wards to review.  We have also re-designed the protocol of standing orders for the pediatrics ward – it will be hung in the pediatrics ward.  You can see the new protocol under the documents section on our blog.

We then distributed all the left over supplies to various wards – blankets, onesies, diapers, and bulb syringes to the maternity ward, surgical supplies to the theater, medications to the pharmacy, and band-aids, medications, medication syringes, pediatric nasal cannula, and the glucometer to the pediatrics ward.  The nurses in the maternity ward were so sweet – they thanked us and expressed their sadness that we were leaving “just as we were getting to know each other.”  Everyone was appreciative and wished their blessings on us – it was like Christmas.  So fun.

Tonight, we are apparently having pizza for dinner – they must have read our minds!  We are then going to the Nyhus’ house for dessert (ice cream sandwiches made with chocolate chip cookies!!  so excited) before heading to the village streets to pass out glow bracelets and necklaces as our last hoorah with the kids.  We leave at 3 a.m. tomorrow to drive back to Tamale to catch our flight into Accra.  We are sad to be leaving, but so thankful to have gotten to come.  We have been so deeply blessed by the people here – by their hospitality, bravery, sense of community and willingness to accept us into it, joy, and faith.  Our God is so, so good.

– Courtney & Rachel

de-swa (describes a person who was sick and now is better)

18 Jul

Yesterday, we all went to the escarpment with the Wilson and Hewitt families.  The escarpment is the one tourist attraction in this part of Ghana and was definitely worth the 45 minute bumpy drive in the crowded van.  It is a large cliff that overlooks a valley – you can see into neighboring countries from the cliff and it is just breathtaking.  To get to the cliff, you have to “hike” for about 15 minutes down a dirt path and over rocks through what seems like the jungle of Africa– very authentic.

Once at the top, there are two rocky cliffs to climb up and around.  The views are amazing and it was so nice to be outside in the fresh air.  We were glad we got the chance to see Ghana in this way.

The drive itself was also beautiful and interesting.  We passed through several villages with lots of waving children, huts, crops, goats, donkeys, etc.  We stopped in a few villages for snacks (cookies, peanuts, and dried dates) and sodas.  It was so fun to see a glimpse of the daily life of the people in the villages, sitting around selling harvested goods and enjoying each other’s company.

Today, we rounded on the peds ward in the morning after getting an amazing night’s rest due to a big rainfall with cool winds.  We finished early and had time for a short break before heading to clinic where we saw just under 100 pediatric patients.  Most were malaria or viral respiratory illnesses, and of course the rashes we still can’t diagnose with certainty.  We also had the joy of seeing follow-up patients from recent admission or clinic last week – most were doing much better with smiles on their faces.  We decided we should have had all of our patients come for follow-up so we could have seen then well and acting like children again.  Of course, that would mean seeing 200 patients in clinic, so probably not a good idea!  We’ll just be happy knowing that the majority of our patients go home and stay home, because they are well again.

Just an update – our two premature babies we have been taking care of are doing very well as of today.  One of them is 9 days old and the other is 5 days old (and feisty as can be).  The moms are so sweet and are doing such a great job of using the oversized diapers and clothing to keep their babies warm like we asked them to.  They are also trying to breastfeed them so the babies can learn how to, then cup feeding them so they can get the calories.  Both are on aminophylline (a medicine that helps them remember to breathe) and the younger is still completing a course of antibiotics (a measure taken here for all premature babies to give them the best chance).  We feel like we have finally gotten into the groove of taking care of these tiny babies in such a foreign way.  Because there are no labs or respiratory support or cultures, etc, we’ve decided they do best when you let the mom’s try to feed as best as they can and provided minimal support (a little IV fluids, antibiotics and aminophylline).  And so far, it seems to be working.  They still have a ways to go, so continue to pray for them and the moms, but we are happy with the progress they are making.  We took pictures of them side by side today and with their moms.  Adorable!

We had a term baby who had neonatal seizures and respiratory distress that we treated for pneumonia.  We were also concerned about brain injury during birth because she wasn’t feeding well and had abnormal muscle tone.  She got to go home yesterday after being weaned off oxygen, seizure free and starting to breastfeed.

Over the last couple of days, we have started to say good-bye to some of the people we have worked with.  We are sad to be leaving and feel like the time has passed by much too quickly, but have gained so much knowledge and understanding that will be priceless as we start to plan our future work overseas.

– Courtney & Rachel

the gift of blood

16 Jul

At dinner one evening, Courtney mentioned that she wished she knew someone with B positive blood. I turned and looked her square in the eyes and said, “Lovey! I’m B positive.” She then informed me that there was a patient with tuberculosis in the isolation ward that needed B positive blood and asked me to donate.

Since I am pretty much a champion at third world blood donation (see my donation from a couple years ago: red cross), I got up from the dinner table and went straight to the hospital. I walked right up to the laboratory and told them that I have B positive blood and was ready to donate. They took me in, sat me down, stuck a needle in my arm, and started drawing blood. There was no machine to help mix up the blood, so the lab tech simply patted the bag with his hand every 30 seconds or so. There was no scale to determine how much blood I had given, so the lab tech just guesstimated and stopped when the bag looked full. Again, no cookie, no juice, no t-shirt.

 

When I had finished donating, the lab tech asked me and Adam if we wanted to see the malaria parasite under the microscope.

The science teacher in me was pretty excited.

The son of a microbiologist in me was questioning, ‘Can the malaria parasite pass into an open wound in a lab with numerous slides of malaria?’

The scientist reassured me, ‘No, I think the parasite needs a vector.’

The son of a microbiologist: ‘Who is this random old lady who just wandered through the front door of the lab with a slip of paper in her hand?’

Me: ‘This is Africa.’

Anyways, we took a look at the tiny parasite, and then headed home.

Marie (another volunteer here) and Courtney both donated their O positive blood to a patient as well. Marie told a story of how the lab tech asked if she was a good kisser about half way through her donation, which made for an awkward situation. Courtney had to be stuck four different times, twice in each arm, and said that this was one of the most painful experiences that she has ever been through. Despite their setbacks, they were able to save a life through their giving of blood.

The connection here is pretty straightforward, because after donation you simply walk your bag of blood over to the patient in need of blood. You can even watch the nurses hook up the blood to the patient.

Although we all came out healthy (we hope) in the end, giving blood in a developing country feels a bit more intense than it does when we give in the States. Even while they obtain the blood in a sterile fashion, there’s always a doubt in our minds — is this safe? Will I get a disease after doing this? Then, there’s the one, two, or four sticks with a very large needle… and then moving the needle when the blood stops flowing to try and get that needle back in the vein.

Yet it was our weaknesses he carried; it was our sorrows that weighed him down.  And we through his troubles were a punishment from God for his own sins!  But he was wounded and crushed for our sins.  He was beaten that we might have peace.  He was whipped, and we were healed!  Isaiah 53:4-6

– Aaron

all for good…

16 Jul

Once again, God is showing us his faithfulness, even through hard times.  We talked about the little boy who died after receiving large doses of seizure medications in our blog a few days ago (from the 13th).  We have spent the last several days discussing what we think led to his death and what needs to be changed in order to prevent this from occurring in the future.  To summarize briefly… Most children are admitted by M.A.’s (medical assistants) who work during all hours of the day, including during clinic hours.  The rest are admitted by us from clinic.  We have noticed that all children who come in with a history of convulsions gets an order for valium (a short-acting seizure medication) every 4 hours as needed.  Those that come in and are seizing at the time of admission get an order for both valium and phenobarbital (a longer acting seizure medication) STAT, in addition to the valium every 4 hours as needed.  On top of this, there is a standing protocol in the pediatrics ward that allows the nurses to give valium and phenobarbital to children who are seizing without a physician’s order.  There are several big issues with this system.  First of all, the doses of valium ordered by the M.A.’s and those allowed by the protocol are big doses, usually the maximum recommended (for the medical people, 0.3 mg/kg IV at a minimum is what we’ve seen).  The phenobarbital dose ordered is usually 10 mg/kg, which is not huge, but a significant dose given that it is given in conjunction with the valium.  Secondly, the nurses and M.A.’s like to give the medications no matter how long the seizure lasts, which often means that the kids get the medication either BEFORE the seizure has even lasted a minute or AFTER the seizure has already ended.  Finally, the way the orders are written allows the nurses to give far beyond the recommended amount of valium per 24 hour period because there are no limits set.

To make this a little more clear (hopefully) for the non-medical people… The management of a child with a seizure in theU.S.is very different from what is described above.  Valium is only given for seizures as they are happening, because its purpose is to stop the seizure from going on for a prolonged time.  It is rarely given in the first 5 minutes of a seizure, because the seizure itself does not pose significant harm to the child unless it is very prolonged.  Phenobarbital is a medication to prevent future seizures, and it can also be used in large doses to stop seizures when valium does not work.

So let’s say a child comes in with a seizure.  We would usually give 0.1 mg/kg of valium.  If the seizure stopped, great, no more meds.  If it didn’t, we would maybe give another dose of valium or move on to phenobarbital.  We would give what’s called a loading dose of phenobarbital (20 mg/kg) – a large dose meant to get good levels of the drug in the bloodstream quickly – and then consider starting a maintenance dose depending on the child’s condition.  After this, you can still give valium for breakthrough seizures, but still the smaller dose and only when the child is actively seizing.

So what happened to our boy?  He got 0.3 mg/kg valium plus 10 mg/kg phenobarbital upon admission, even though he was no longer actively seizing, but had had a seizure in the M.A.’s office.  He then got two more doses of valium over the next several hours for seizures that lasted less than a minute (both given after the seizure had subsided).  When he had his next seizure, he was given phenobarbital 10 mg/kg again per the “standing protocol” in the peds ward, despite orders NOT to give any more.  About 3-4 hours after this dose, he stopped breathing.

So now to the point of this whole post.  We were talking with Dr. Hewitt about our frustrations the other night and he agreed with our assessment of the situation.  He suggested that we give an in-service (teaching session) to the nurses who work on the peds ward on Tuesday afternoon regarding appropriate seizure management.  We are also going to modify the current protocol for the peds ward that dictates what the nurses give should there be no order on the chart for seizure medications.  We are so excited to have this opportunity.  We feel like it gives a chance to make a good, lasting change here that will keep kids as safe as possible.  In some ways, it helps to cope with the loss of one life – we hope to be able to prevent the loss of future lives in some small way.

“And we know that in all things God works for the good of those who love him, who have been called according to his purpose.” (Romans 8:28)

– Courtney & Rachel

oh happy day!

13 Jul

We want to thank everyone for their prayers and words of encouragement in response to our blog yesterday.  It means everything to us to read your comments and keeps our spirits up every day.  And we hope you are as blessed as we are to know that God is hearing all your requests, because we had such a wonderful day today.  I think He knew we were getting close to our limit and needed a little happiness.

We went for a run this morning – a little farther than before down toward the river, which was refreshing.  We then went to the wards for rounds, which went surprisingly efficiently.  We got to send so many children home today, and we saw tons of smiles – a rare occasion with our patients.  One in particular made our day.  He is a little 2 year old with cerebral malaria who was super sick last week with seizures that were difficult to control followed by a coma that had persisted for about 5 days.  Today, however, he was sitting up on his mother’s lap taking food by mouth from a spoon with his eyes open.  His mother had a huge smile on her face when talking about how much better he is doing.  He will likely get to go home soon – praise the Lord for his healing power!  Rachel also took care of a new admission that came in unresponsive during rounds after suffering from a seizure this morning.  She examined her quickly and then thought to take her glucose, which read as “Lo” on the glucometer.  Rachel gave dextrose (essentially sugar water) through her IV using a syringe and about half way through, the girl opened her eyes and starting looking around.  It felt so good to fix someone!  So glad we went ahead and bought that glucometer to bring with us.

We then went to clinic and saw lots of malaria again, but more “well” children than earlier this week.  We handed out toys to many and actually got several smiles and laughs in return… what a sweet sound.  Courtney saw a seven month-old girl who was referred from Public Health for neck muscle weakness.  Sure enough, as she sat in her mother’s lap, it was apparent that she had very poor head control.  Her mom told us that she had never developed good strength, since birth; she cannot sit up, roll over, or lift her head.  Unfortunately, it was obvious that we were not going to be able to fix her problem, knowing that it was likely a permanent condition.  We consulted with Dr. Hewitt, who noticed that she had some subtle features suggesting Down Syndrome.  We are going to look into whether there is a place that she could go for physical therapy.  Yet, even with a diagnosis for which we have no treatment, she brought us so much joy today.  Among all the kids who are scared and crying, she had a huge smile and the sweetest giggles you’ve ever heard.  Every time we would look at her and smile, she’d grin right back and give a big laugh.  We gave her one of the plush flowers that Rachel’s mom sent along… could she be any cuter?!

– Courtney & Rachel

 

 

the terrible, horrible, no good, very bad day (x2)…

12 Jul

to sum up our day, all we could talk about on our walk away from the peds ward at the end of today was how badly we wanted a pizza, a tub of blue bell ice cream, and a bottle of wine.  we keep thinking we might have one day while we’re here that could inspire a happy, up beat blog post… but unfortunately, we have yet another tear-jerker for you tonight.  however, even as we tell these sad stories, god has been faithful to remind us of his grace and power.  this morning, we went to devotional (held at 7 a.m. every morning at the front of the hospital and led by one of the chaplains) and the choir from first baptist church of nalerigu was singing.  they sang a few ghanian songs, and then began singing “because he lives.”

because he lives, i can face tomorrow

because he lives, all fear is gone

and i know, oh yes i know, he holds the future

and life is worth the living just because he lives

the words of this song, and the hope we have in god’s power to overcome death is so much more obvious and relevant to us here.  in the midst of suffering and hard times, it is so much easier to understand songs like this and to actually look forward to the day when he returns.

in the last two days, we have signed a total of 8 death certificates.  while each was difficult in its own way, we will tell the story of only one tonight.

he was an 18 month old boy who came in with malaria and seizures yesterday afternoon from clinic.  he continued to have seizures last night and so received valium and phenobarb (both seizure medications) and was then very sleepy.  rachel saw him and wrote in her orders not to give any more seizure medications overnight, as both could cause him to get sleepier and possibly stop breathing.  however, by the time we made it to the wards this morning, he had received two more doses of valium and a large dose of phenobarbital despite our orders.  he was difficult to wake up during courtney’s exam, but was breathing ok.  unfortunately, a few minutes later, one of the student volunteers noticed his breathing had changed.  courtney checked his oxygen saturations and found them to be decreasing quickly as he stopped breathing altogether.  he then lost a pulse.  courtney started compressions and called rachel over to start bagging (providing breaths with a bag-mask).  his pulse returned quickly and we got his saturations up to 95%.  but then we were in a bit of a pickle… he clearly had no respiratory drive due to the seizure medications, and we didn’t expect a speedy improvement, but yet we have no ventilator here to support him as we waited for the medicine to wear off.  so we kept bagging.  for 4 hours, taking shifts with the nursing staff and the student volunteers.  at that point, we enlisted the help of one of the anesthesiologists to find an intubation tube and blade to make the work a little easier for everyone, as the number of nurses had dropped to 2 after shift change and the ward was filling with new admissions already.  intubation was successful and we continued bagging via the tube for another 4 hours, again taking shifts.  all we had to monitor our patient was a pulse ox.  around 5:30 p.m., we checked his pupils and found them to be fixed and dilated, indicating a very poor prognosis and an unlikely recovery no matter how long we continued to bag.  we called the chaplain and made the decision to withdraw respiratory support.  the only request the mother had was to take a picture of her son, but unfortunately, there was no way to get it to her (no printer, no email address, etc).  it was heart breaking and defeating.

we were struck today by the fact that despite our ability to intervene here, there is no way of monitoring the intervention like we do at home.  in other words, there are no monitors, labs, blood gases, etc to help us adjust our interventions and ensure the patient remains safe.  it’s frustrating when we can’t do what we know needs to be done – we knew the patient needed to be intubated and ventilated this morning.  but there is no ventilator available (not even for patients under general anesthesia in the operating room), and even if there was, there are no blood gases to guide ventilator settings.  and truth be told, the patient would have been considered in “critical condition” even at home.  so it’s hard to know where to draw the line of what is helpful and what is only prolonging the suffering.

we were so thankful, though, for one of the peds nurses, who told us that we had done “such good work” today.  she said that even though we had lost a life, we had worked hard and that was appreciated.  it made us feel some peace knowing that even with a language barrier, the nurses and parents can see that we care.  and we can continue loving because he loves us and asked us to serve him in this way.

because he lives, i can face tomorrow.

– courtney & rachel