Wednesday, December 4, 2013

The finale

My time in Ghana was amazing. I am so blessed and grateful to have had this experience. I felt like I was really able to leave an impression on the people I worked with and they undoubtedly left a lasting impression on me. 

My first week was an eye opener. I have done mission trips before, but nothing like this. As a medical student, I went to mission trips to Dominican Republic, Jamaica, and Haiti. I went on each trip bright eyed and bushy-tailed, ready to make a difference in the world. Haiti was the best experience of my life; I have plans to return there.

But Ghana was different. I spent almost three weeks here learning. Learning the culture, the food, the people, the perspective, the hospital, the healthcare system. Witnessing (and relearning) how important the physical exam and clinical impression is; especially when it may be the only information you have to go off of and make pertinent life effective decisions. And also gaining a new fond appreciation for my training at NYU and access to labs, imaging, blood products, pumps, amazing nursing, ICU beds, etc. Each of these items have its own story.

This experience brought me back to my glory days; reminded me with very blatant examples of why I became a doctor in the first place. To fix the injustices of healthcare. The disparities I witnessed moved me to my core. In my almost four years of residency, we have had two maternal mortalities; one of which I was directly involved in. In Ghana, a maternal mortality was presented almost daily. In one day (my last Monday duty, aka 24hr call), I personally witnessed two. One arrived pretty much DOA and the second was a young 26yo P2 who I watched die right before my eyes. It was an excruciating experience. I felt helpless. 

She was admitted over the weekend, 2-weeks postpartum with a working diagnosis of pneumonia vs DKA. Her admission pulse was 150 with no O2-saturation documented. She had no labs sent, not even a UA or Udip to look for ketones. She has a CXR done which only one person on the team even knew about, and it was only reviewed just before she crashed. Pulmonary embolism was not written in any of the notes as a consideration for a differential diagnosis. The patient was only receiving prophylactic anticoagulation. When I met the patient, she was tachycardic, hypoxic and c/o chest pain. She was critical but in a bed on the wards. Thats when I learned there were only four ICU beds for the entire humongous hospital. As the patient rapidly fell into respiratory distress, a house-staff (an intern) and I ran her across the hospital to the OB recovery room where we could get her on a monitor, bag her, and get anesthesia assistance for intubation. She was pronounced dead approx one hour later. She was young and healthy with two children and she died. She didn't have to die...we should of been able to prevent this maternal mortality. But she was dead.

I sat down with the junior residents and we discussed the case, their working diagnosis when the patient was admitted, the differential, the missed events during her admission, the obstacles they ran into in delivery her care, why they thought she died. In summary, they thought she died because "we mis-managed her." We talked about how to learn from this experience, how to think about the likely diagnosis, and how to never forget the diagnosis they may kill the patient. She was dead and I can only pray to God we learned something.

The rest of the week was light. I had a wrap up meeting with the chairman. We talked about my experiences in and out of the hospital, my trip to cape coast, and a project I started with Dr. Oppong (reviewing charts of maternal mortalities related to PIH). The residents and fellow all gave me hugs and well wishes. They told me that they felt like I had been here for months because I integrated so well. That was the best thing they could of ever told me. 

I made some great friends here, professionally and personally. I learned about another culture and how to practice medicine within that culture. I felt so welcomed. Upon meeting Ghanaians, they would say..."welcome home." I was even given a Ghanaian name..."Ama" (Saturday born). And on my trip to Cape Coast where I returned from "the door of no return," I was adopted by a Ghanaian family who called me "Nana Hemaa" (Mother Queen). It was a humbling experience.

I feel like I have evolved to another level as a human and a physician that will allow me to deliver medicine on a higher level. I felt like I discovered another home away from home. I have some unfinished business there...I cannot live with the maternal mortality rate...and I will return there one day.

See you in 2015 Ghana...I will return home.

Sunday, November 24, 2013

Day 4

"How do I say this," he hesitated and thought really hard about his follow-up, "what are you Dr. Bennett?" he asked. Then he clarified, "I don't want to offend you, but what are you? African-American?"

Before coming to Ghana...I was wondering how I would be perceived here. Would there be opportunities for people to feel like they could disrespect me because I was a woman or because they thought I was African-American and not the typical "Obruni" that they have called my white colleagues who came before me.

My first day (which was really two days given the 24hr call situation) was a very pleasant experience. I felt welcomed by the team and was even treated like a senior resident by the juniors. Thank God for the great framework that Jenna and Katie left before me, because I sort of started meshing well with the residents from day 1. The junior residents would come up to me and run cases by me, even ask me to perform ultrasounds with them as they admit they are not that great at ultrasounds. I was asked my opinion a lot and at times asked "what would you do differently in America?"

I will admit...I bonded more quickly with the male residents than the two female residents on the team. One of the female residents (junior to me) even asked me to draw blood on our call shift. I overheard the senior resident asking her why I was drawing the blood, if it was because it was a difficult stick. But I knew she was just giving me a little hazing...its all good...I drew the blood with pleasure. We became fast friends after that.

This morning was day 4 but really my second full day with the residents. I was going to have breakfast with one of the junior residents who was really just escorting me because I had no idea where to go. On our walk, he started this conversation with me about what is my nationality, ethnicity, whatever.

I informed him that I was born in Jamaica but raised in the US. That I considered myself to be Jamaican, American, Black...whatever. Does it make a difference I asked him. And he responded in a very similar way that I have heard some caribbean people respond to African (Black) Americans. In short, he told me that African Americans are lazy in general and that they glorify playing basketball and sports and don't aspire to work hard and become physicians. He told me I was different because I was born in Jamaica and is like a first degree American because my parents were raised in Jamaica. He told me that people born in America with immigrant parents were also different. That they had a drive to do better and to take advantage of the opportunities in America and become doctors and lawyers etc.

He told me that African Americans were mad at Africans for selling them into slavery. He reflected on this time when he was doing an externship in Virginia and an African American throw something at him in the street and shouted something about "you sold us."

I quickly began to tell him that I didn't agree with this sentiment, though I understood where he was coming from because I have heard this sentiment before. I said, "I was raised in America and I'm a doctor." But he said I was different given my Jamaican heritage. I then began to tell him of all the amazing people that I knew that were straight up African Americans and were lawyers and doctors and not athletes. He looked at me with a little know that look that says I don't think you're a liar but I don't really believe you either.

I tried to convince him that his point of view was stereotypical and anecdotal at best. That there is another truth that he should seek to understand. I apologized for that person who threw something at him in the streets and tried to convince him that most Black people in America don't hate Africans because of slavery. He tried to understand my point of view. But this one conversation would not change his entire mind. But maybe it created a small peep hole...

I left this conversation too asking myself..."what are you Dr. Bennett?" I am a proud Jamaican and I love and cherish my Jamaican roots. But sometimes even Jamaicans say...ohh u left Jamaica when you were three...your American. So I also love and cherish my experienced being raised in America and call myself African-American too. You see...I dont get caught up into these categorization that we humans like to place on ourselves in order to perpetuate separation and discrimination. I AM BLACK. That's it.

When I got home that evening, I found two of my close friends online and quickly began to gchat this subject matter with them. Dominique is an American born, Bahamian heritage Lawyer; and Noelle is a American born, Jamaican heritage Educator/Administrator. I needed fellow Jamaican born, American raised partner in crime.

Lets just say it was a very interesting day...

The introduction

The word Ghana means "Warrior King." How befitting...since it is said that the maroons of Jamaica are descendants of these great people. were the slaves. There has always been a part of me that speculated that my people are of Ghanaian when the opportunity for me to visit the motherland came forth…I was Ghana bound!

I must admit…I was a little scared. I would be traveling to a different continent…by myself (my mother didn't realize that until after I was already here, given that I have always done mission trips with a team, but that's another story).  The people who know me best, know that I can sometimes get really nervous and frantic even…for about 5-minutes…then I pull myself together and give Terri-Ann Bennett (all day).

So I will admit…I was a little scared, but mostly curious!?!?

What would it be like to step foot on western Africa, potentially the land of my ancestors? Deep!

How would I be perceived…as a Woman…as an American…as a Jamaican…as a Black Jamaican American Woman? As a resident physician?
In the states…I am the chief resident of my team. In Ghana, I will be an outsider…joining a new department (temporarily) and working with a new team of residents where I would not be in charge and where my role is not clearly defined. I will absorb it all…I’m not off to change the world (not this time anyway)…but I am off to have the world change me…Lets see how this goes…

My travels were smooth…I slept the entire flight…thanks Bellevue night float. My journey through the airport was the smoothest it has ever been. My Ghanaian friend in the states made it his personal responsibility to ensure my time in his country was nothing short of amazing. His colleagues escorted me to a VIP lounge and got me through customs etc quite easy. It’s nice to have good friends. 

On my first day, I met with the chairman of the department who gave me a quick summary of their weekly schedule in reference to the daily morning report, rounds, and journal clubs. He knew I was interested in Maternal Fetal Medicine. He told me there were no sub-specialty departments here but there would be lots of high risk patients on the wards. He asked me what my interests were. I told him about my global health interest and that I mainly wanted to learn about Ghanaian medicine, especially in reference to “Pregnancy Induced Hypertension” (as they call it here) and maternal mortality. He seemed assured I would learn a lot about that and shared with me a thesis recently written by a resident/fellow on PIH in Korle Bu Teaching Hospital.

I met my team and learned my schedule…and oh yeah…we were on a 24hr call that night…just how I like to hit the ground…running. Korle Bu is a very busy hospital. The OB department has its own building. They deliver over 10,000 babies a year here; with a maternal mortality of 772/100,000 (per in house hospital records).
For a frame of reference: the documented MMR (maternal mortality ratio) of Ghana is 350/100,000 compared to 21/100,000 of the US and 5/100,000 in Greece.

Day one was quite interesting. In antenatal clinic I learned about Malaria in pregnancy and how every patient is treated with prophylaxis once during each trimester. I learned how to use a “trumpet” to listen to fetal heart tones…ps…it is hard to listen to fetal heart tones with a trumpet in a noisy open clinic space with loud fans. Lets just say I didn't pick it up very easily. “I wish I had a daptone,” I kept thinking.

Being on call that night was by far the most eye opening. The labor ward is much different than what I am used to in the states. It’s pretty much an open space with metal beds and few partitions. There were no husbands or family members permitted under these settings, rather the women labored together. At first I was uncomfortable with how exposed they were. But most (if not all) had some form of African fabric with them that they used to cover themselves. However, most of the time, in the midst of those labor pains (under no epidural), that fabric was somewhere at the edge of the bed and that woman’s perineum was in full view of the entire room. I was the only one phased by this, so obviously this was the culture on the labor ward and this was a community for these women.

I had lots of inquiries this night in order to understand this system. Another interesting observation was that there were no Magnesium drips running on the patients with severe preeclampsia. I asked about how they management preeclampsia on the floor. They told me there were no pumps and that magnesium was given as a loading dose of 4g IV and 5g IM x2 followed by 5g IM every four hours. And the family members had to go out and buy the patient medications and labs, including the emergency IV antihypertensives.

I was expecting differences in our health care systems but I was perplexed but how they handled emergencies (like imminent eclamptics) if the medications were not readily available. The senior resident informed me that sometimes they would have a few vials on the floor, but sometimes the pharmacy didn't even have any IV antihypertensives. That blew my mind.

There was a severe preeclamptic on floor that night; she had severe blood pressures all night. None of the residents were aware and no one was making a big deal about the fact that she hadn’t gotten IV-antihypertensives. “We wrote the pharmacy for it hours ago,” they said. “But she still hasn't gotten it,” I responded, “now what do we do.” No one had any ideas at this time. The senior resident then made a suggestion that maybe they will start to pre-purchase these meds and save a supply for the team that they can use in these instances. “But what about now,” I politely insisted. He then called over a house-staff (aka an intern) and asked him to figure something out. To everyone’s surprise, the intern later returned with a vial of labetalol.

Also that night, there was a sickle cell patient in the RR who was POD1 (s/p CS) who was concerning for a pulmonary embolism. The nurse came looking for a resident, everyone was dead sleeping. I was the only one who woke up. I woke up the fellow and we went to examine the patient together. I learned in this scenario that all postop patients are placed on prophylactic SQH. This patient was written for this standard protocol but had not received any of her doses. I didn't understand why, was it a pharmacy thing or was it a payment thing or both. The fellow also had no explanation and urged the nurse to call pharmacy for the meds. I asked him how concerned he was that this patient may have a pulmonary embolism and he said he thought it was probably. He asked me what would I do…I told him I was unsure because I was unclear on what things they could get accomplished at this time of night (it was like 4am). I told him I would start the patient on therapeutic anticoagulation and he agreed and wrote her for such. But this patient could not get a 12-lead EKG to look for right heart strain, she could not get a spiral CT, and she could not get stat labs. I was really worried about this patient. When we informed the residents of her clinical state, one responded…"I hope she makes it."

The operating rooms were also an interesting experience. In short, our facilities and techniques are different. There was a limit to air conditioning, a limit to suture (and thus instrument ties were standard), there was no scrub nurse to assist, and sterility was sub-optimal. Every patient received antibiotics postop due to “our sterility issues” the residents explained. I still don't understand how the intruments are cleaned as the one alcove I saw was broken. More to learn…

The morning came quick and we headed to 8am report where the residents had their daily conference, sort of like a daily morbidity and mortality report.

Day one/two/three (post call) quickly came to an end. What an introduction…

Monday, November 18, 2013

Day 8

Its another Monday morning...beginning with morning report at 8am (another mortality discussed), followed by Antenatal clinic, to be later followed by "being on duty" (aka a 24hr call). One thing I have really grown fond of is my daily discussion about medicine in Ghana with my attendings and co-residents.

My Monday "tradition" is going to the canteen with the senior resident for breakfast. He never allows me to today...I was intent on buying him breakfast. I informed him that Dr. Oppong had a project he wanted me to work on and so I would spend next week doing that. He asked about the project and my interest which I informed him was maternal mortality with a special interest in preeclampsia. This lead us to one of our many discussions about the differences in Ghanaian and American medicine.

I asked him what he considered to be the biggest factor of maternal mortality as it related to preeclampsia (which is the #1 reason for maternal mortality at Korle Bu). He made it very clear that it was about access to antihypertensives in the emergency setting, but that he believed the #1 reason was due to the lack of appropriate management from physicians and clinics/hospitals in "the periphery." He described to me that "the periphery" was basically made up of doctors doing their own thing and transferring patients to Korle Bu at times when it is too late and the patient shows up ecclamptic. I asked about access to Magnesium and if patients were loaded on their transfer and he said NO. At times, pt even transport themselves via taxi or personal vehicles and there is always a delay given traffic.

We brainstormed on interventions he believed could tackle this problem. He made a valid point about instituting workshops to help standardize (but really to teach) management of preeclampsia, especially at its onset; with special emphasis on when to recognize the early signs. He also informed me that magnesium was readily available at these peripheral clinics/hospitals but that many times the medical staff (physicians included) did not know who to administer the medication.

Just to give you a frame of reference: In Korle Bu, there are no pumps used in OB. Thus, Magnesium is given as a loading dose of 14 (4 IV and 5 IM x2).

We continued our brainstorm about how to institute workshops in our community and researching possible grants to assist in the access of IV antihypertensives in the pharmacy (as he made clear that quite frankly they have gone weeks without these medications at times). We finished our breakfast and headed to clinic.

I was seeing OB clinic patients by myself with my senior in our small clinic room (with one bed) that was set-up for two physicians at a time. He was seeing patients across from me. A junior resident comes in to inform him of a very sick patient. My senior resident goes to assist another resident. I head over to figure out what is going on. I turn the corner to a very narrow hallway (that leads to a small room that is the OB ER) and find a pregnant woman whom was more or less naked with another resident listening to her chest. I asked..."what is wrong with her" as I walked up to the junior resident; and he makes hand gestures suggesting that she is sleeping. I get closer and the other resident is listening to the patient's chest and pronouncing her dead.

"What happened?" I asked in a calm shock. "Probably a stroke," they responded, "she was a transfer." "What about the baby?" I asked in a shy manner. "Dead," they responded.

I eagerly grabbed the patient's chart looking for an explanation as the nurses started screaming that the patient was a DOA (dead on arrival), explaining how she fainted right outside and they lifted her and brought her to the OB ER. The patient BPs at this outside clinic/hospital was 200s/110s; no magnesium was initiated. She was only a 34yo primip. Upon further review I noted that just one week ago this patient had a mild range BP and was noted to be "well" in the chart and sent home.

My breathe was taken away, I was numb. I asked if they have ever seen a postmortem CS here and they said no. I remained numb; sadness filled me quickly.  I covered her with the traditional African cloth that was at her bedside.

I went to find the senior resident to inform him of what had just occurred. "It's exactly the same thing we discussed this morning," I said to him. He nodded his head in agreement and disgust. He continued working, everyone continued on to finish the clinic. I felt tears warming my eyes...I pushed them back where they belonged and went back to work.

"I am sad," I said to him. And we continued working...