Sunday, November 24, 2013

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…

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