IHDN will be having a fundraising event on March 23rd, 2012 to raise funds for the construction of the new inpatient ward at the IHDN Mission Hospital. Please consider joining us or making a contribution.
For more information, please contact:
June Agamah at jcagamah@aol.com or Tana Elder at tltanalorraine@hotmail.com
Twice a year IHDN publishes and distributes a newsletter that documents the latest happenings at the hospital and reviews recent and future mission trips. If you didn’t find one in your mailbox, check it out below.
Pictures for December 2011 Newsletter
Happy Holidays!
-Ben
Since opening in the summer of 2007, the IHDN Mission Hospital has become a major provider of health care in Agbozume, Weta, and their surrounding villages. As more patients require inpatient care, the original wards for women, children, and men have quickly been outgrown. Despite continued financial struggles due to National Health Insurance payment delays, IHDN has forged ahead to provide quality health care in the region and expand the hospital. This previous summer, ground was broke for the first phase of inpatient wards. Located directly behind the outpatient building, the wards will be able to accommodate ~80 patients.
Picture 1: Ward foundation under construction June 2011 (above)
Picture 2: Ward with ongoing mason work as of November 2011 (above)
In addition to wards, a canteen and staff quarters have been constructed and are near completion. You can see the staff quarters in the background of picture 2. It is exciting to see the growth of the hospital and I can’t wait to return and see the completed project.
A fundraising event to raise funds to support completion of the wards is being planned for March. More information will be posted as it becomes available.
I made a short photo slide show that displays a bit about what we did. It can be found here:
Sorry, no music. Just choose your own and enjoy! The original soundtrack is:
1) Matiskahu – One Day
2) Ben Harper – Better Way
3) K’naan – Wavin’ Flag
I just wanted to invite everyone a presentation/meeting that will summarize our trip to Ghana this past summer.
Here is the info:
Where: Hope Church, 3000 Lenhart Rd., Springfield, IL
When: October 23rd, 1:00-3:00pm
Who: Those interested in medical missions
Lunch will be provided, RSVP to jcagamah@aol.com
This is a great opportunity to see what we did this past summer, learn more about IHDN and its mission in Ghana, and meet other members of the mission team. If you are considering participating in a future trip this would be a great chance to learn a bit about what it entails. Please feel free to invite anyone you think may be interested.
Thanks to everyone for their continued support!
-Ben
Anyone who knows me knows that I like food—eating it, cooking it, talking about it—so it’s only appropriate that I do a post about the food we ate in Ghana, especially since I promised such a post months ago. While the ladies in the kitchen often tried to Westernize things for us, we had the chance to try a good variety.
Breakfast
Ben’s not a big breakfast person, but Auntie Aloko made sure we both started the day out with a good meal. Porridge was the standard fare, but the primary grain could also have been oats (my favorite), ground corn, or white rice. White sugar and full-cream evaporated milk were the common condiments, though I also provided raisins for the first couple of weeks. We had eggs that were hard-boiled, fried, or made into thin omelets with tomato, bell pepper, and onion. Ben and I attempted to make a fried egg with a runny yolk (over-easy), but the yolk cooks much faster in the eggs here than at home. Ghanaians typically do not have this full of a breakfast; when the accountants from Accra were at the compound, they usually had about four slices of toast and tea. When more Americans came and another cook, Sister Grace from Accra, joined Auntie Aloko and Rose in the kitchen, we had quite the breakfast buffet (see below). Though I pretty much continued to eat the same things, I did enjoy sprucing up my porridge/oatmeal for the last couple of weeks with peanut butter and bananas!
Lunch/Dinner
One of my favorite Ghanaian lunches was red-red (I think that’s what it’s called) and fried plaintains. Red-red was cooked black-eyed peas or red beans mixed with palm kernel oil, which is also red, and onions. To add some crunch to the beans, we add gari, dried and ground-up cassava root that looks something like coarsely ground bread crumbs. (In Springfield, you can actually buy gari at the Little World Market on Macarthur…just FYI!) Fried plaintains accompany the beans, and to add a little punch to the whole meal, we use the condiment shitor, a spicy paste made of hot peppers, tomato paste, spices, and fish. Shitor, gari, and dried coconut are commonly carried in small packages by school children to be added to any dish they may have for lunch. I love the shitor especially, and I brought some home to share with friends and family. Another lunch was a slaw sandwich. Auntie took shredded cabbage and carrots and mixed it with leftover fish and some other spices, then pressed the sandwich to warm it. One time, we had them for breakfast, and I added a hard-boiled egg to mine, and it was delicious! Occasionally, watse (wa-chay), a mixture of rice and beans, was served as a light lunch.
One of the real staples of Ghanaian food is steamed dough. Depending on the ratio of corn flour to cassava flour and the potential addition of plaintains, the dish is called something different—akple, abolo, banku, or fufu. Mills do a good business in Agbozume as everyone eats these different doughs and needs their corn or cassava to be ground. In general, the flour is mixed with water over heat, either on the gas stovetop in the kitchen or sitting on a charcoal stove (see picture above). Auntie holds the pot steady while she stirs by bracing her feet on two poles that hook into the handles of the pot. We watched Auntie make akple one night, and it was easy to see how she has developed such strong arms since she stirred and kneaded vigorously with a large wooden spoon almost constantly for 30-45 minutes. Fufu is different in that it is pounded with a huge mallet and mixed with cassava (see picture below). The dough is then wrapped in plastic or, in the case of abolo, in banana leaves and steamed. Pre-made and wrapped abolo can be purchased in the market for those ladies who do not make their own. To eat it, you tear off pieces with your fingers and dip it into whatever soup/stew/sauce is being served with the dough—light soup (a spicy broth with chicken or goat), okra stew (a snotty mess with spinach or other greens), ground nut soup (a peanut soup that we didn’t have the opportunity to try) or pepper sauce are some examples.
Beyond these options, we had pretty much the same menu for lunch and dinner—pan-fried chicken or fish, rice or spaghetti topped with tomato sauce, and salad. When we had fish, it was fresh that day in the market. Without refrigeration or freezers in people’s homes, a lot of fish is smoked as a preservation technique and then sold in the market. The smell of the smoked fish is a bit putrid to me, so I didn’t try it. A lady at the Denu market did spit some at me, but that’s a story for a different day.
Fresh fruit was served for dessert, and I have never eaten so many mangoes. The Agamah family has a mango farm that Uncle Elorm manages, so our supply was never-ending. Buying another mango in the U.S. is probably not even worth it after the amazing deliciousness of those in Ghana. We also had fresh pineapple, coconut, oranges, watermelon, and bananas—all fresh and fantastic!
Snacks & Treats
While out in the markets, we usually stayed at our posts for several hours without a break. On occasion, Mark or Daniel would go get snacks for us all to share, and in an effort to prevent GI distress for Ben and me, we’d sample some of the imported packaged foods that is sold in the market. Most of the products come from China, India, or the UAE—cream or onion crackers (the former are like sweet Ritz crackers), glucose biscuits, a whole variety of candies, including “Big Olivary” gum balls. For those of you in medical school, you’ll understand why I found this amusing because all I could think about was that I would be chewing olivary nuclei. One of my favorite treats, which we had while working at Akatsi Junction, was a sachet of FanMilk, a soft-serve vanilla ice cream eaten GoGurt-style. Other local snacks that I preferred to the imported stuff included popcorn, boiled or roasted ground nuts (i.e. peanuts), and plaintain chips. Mixed popcorn and shelled, roasted ground nuts—think Cracker Jack without the caramel—were sold in empty water bottles, one of the many items/containers I saw reused and repurposed in Ghana. Drinks were usually sodas, fruit-flavored in orange, lemon, and fruit cocktail. Malt drinks are also really popular, but not being a huge soda drinker in general, I never tried one.
At the Denu market, I had the good fortune of being the recipient of some thank-you gifts from local sellers. Even though they were helping us out by participating in our research, they were grateful that we were providing them with some information about their health at no cost to them besides their time. One lady gave me a small bag with shriveled, brown, pea-sized seeds. I had no idea what they were, and she simply described them as “sweet.” Foods that would be mildly sweet if at all to Americans are very sweet to Ghanaians, it seemed, which probably speaks to the little to no sugar they add to their foods. Anyway, it turned out that the little seeds were dried taga nuts, something I’ve never heard of before, but they reminded me of sweet soy nuts. I enjoyed them and actually saw the same woman selling them on another market day in Agbozume. Another treat I received at Denu was a couple of fried dough balls, denser than your average doughnut hole in the U.S. and, again, less sweet, but very delicious. I bought a painting at the art market in Accra that shows a woman carrying a case of these on her head, if you’d like to see what it kind of looks like. Both of these treats were made even more special by the fact that I consumed both and didn’t have any diarrhea 
Well, I could go on and on, but I think that’s plenty of information on this topic. If you want to try some fried plaintains and shitor, just let me know!
We arrived safely back in Springfield on Thursday night. It was sad to have to leave everyone in Ghana, especially knowing that a return trip won’t be for several years. After many goodbyes we were off on a 7 hour flight to London. After a relatively quick 5 hour layover, 8+ hour flight to Chicago, and 3.5 hour drive, we were finally home. The flight was uneventful and everything kept to schedule.
I am quickly readjusting to western living, though I am still hesitating when I use water. After only periodic cold showers, it has been nice to have hot showers on consecutive days. Also, to take a shower and not immediately have to put insect repellant on has been refreshing.
I plan to update the blog as I start to analyze the research data and begin submitting abstracts and such, so keep an eye out. Thanks to everyone for all the support!
Today was our last day working at the clinic before we leave tomorrow for Accra and then home on Wednesday. While Sarah’s last post touched on some of the more emotional cases that we have seen in the last week, I thought I would share a bit more about our general daily activities at the hospital. It really has been an amazing learning experience, and we have been exposed to a spectrum of medical practices, ranging from physical diagnosis and patient counseling to wound dressing and suturing. Our experiences have provided a glimpse into the many roles a physician can play and should greatly aide us in our future studies.
Each morning patients fill the reception area of the hospital and patiently wait to be seen by the doctor. Some are returning patients while many our first time customers. Patients check in at the records office and their card (chart) is pulled or created. They then go to the screening room to get their vitals checked by a nurse before siting in the final line and waiting for a doctor to see them. Unlike in the US, where patients are placed in exam rooms and the doctor floats between rooms, here, the doctors remains in a single room and the patients enter one by one to be seen. This likely is due to the limited supplies that are available; by using this method, only a single exam room needs to be functional. In the past week, however, we have created three fully functioning exam rooms, each outfitted with an oto/opthalmoscope, sphygmomanometer, and exam table. This has allowed Dr. Amoateng (current IHDN physician), Dr. Agamah, and Dr. Bussing each to have a room to examine patients.
The number of patients that Dr. Amoateng sees in a few hours amazes me. Today, for example, I saw 12 patients, Dr. Bussing saw 15 patients, and Dr. Amoateng saw 65. Totally ridiculous, but necessary in a country where the number of doctors are limited and the need is great. Dr. Amoateng says that they must learn to work quickly because, otherwise, many people won’t get seen. At his home hospital, he rounds on 60 patients in the morning, then sees maybe 80 patients in the outpatient clinic during the afternoon.
L->R: Marcellinus (Nurse Anesthetist), Dr. Amoateng, Godwin (Nurse)
I have spent a fair amount of time shadowing both Dr. Agamah and Dr. Bussing. Each has their own style, and I have learned much from them. Dr. Agamah speaks Ewe, so he talks to the patient, conveys the gist of what the patient has told him to me, and then I postulate a diagnosis. This has given me the opportunity to think about and learn how to distill a constellation of symptoms to a differential diagnosis. Dr. Bussing works through an interpreter, which has really helped me to learn the important questions that are asked in association to a specific symptom. With each, I have had to opportunity to practice the few basic physical exam skills I know and also learn many more. I have auscultated the crackles and rales of a lung plagued by pneumonia, felt the chest wall thrill of severe aortic stenosis, and palpated a grossly distended bladder due to prostate enlargement. These experiences have driven home the importance of thorough physical exam as some patients’ primary complaints weren’t even associated with their larger gross findings.
The most prevalent diagnoses that we have been making are malaria, typhoid fever (enteric fever), osteoarthritis, and hypertension. Malaria plagues everyone, from those living in squalid poverty to the upper tiers of society. Most suffer a bout of malaria 2-4 times a year. This is often a blessing in disguise as some partial immunity is afforded by repeat infections and allows the disease to be less severe. Patients present with general body pains, fever, chill, bitter taste in the mouth, and sweats. All fevers are considered malaria till proven otherwise. Fortunately, when diagnosed early, a regimen of artemether/lumefantrine combination pills for 3 days resolves the patient’s symptoms. Children are more vulnerable as their acquired immunity is less robust. They often present with many of the symptoms mentioned above plus listlessness and anemia. We can give them a rapid malaria test to assess for Plasmodium falciparum, the most deadly form of malaria, and then look at a Gemsia stained blood smear to quantitate the extent of the parasitemia. Anemia is assessed clinically by looking for paleness of the conjunctiva and confirmed by a blood count. These children are always admitted and given a quinine injection and combination pill regimen along with IV rehydration. Typhoid or enteric fever is also quite common. Patients present with similar symptoms as malaria but also have gastritis, diarrhea, and pain in the lower right quadrant of the abdomen over the terminal ileum. Cipro is the treatment of choice for typhoid.
I have also glimpsed the struggles of poverty. Above Dr. Agamah sits with a child that suffers for kwashikor. Notice the burnt red color of her hair, a classic sign of malnutrition and protein deficiency. This child’s mother was counseled on what foods are most nutritious, and the child was given multivitamins and treatment for worms and malaria.
It has been a great week in the clinic, and both Sarah and I have too many great cases and stories to share here. Ask me about the coconut guy sometime.
This week, we have been working long days at the IHDN Mission Hospital. Ben and I have seen many patients under the supervision of Dr. Agamah, Dr. Bussing, and Dr. Amoeteng, and the lessons I have learned are innumerable.
A couple of cases struck an emotional chord for me, as I’m sure they would for anyone, because they involved the end of lives. The first case was a patient seen by Ben and Dr. Agamah on Wednesday. A very elderly chief of a traditional tribe, probably in his 100s, came to the hospital suffering from pulmonary tuberculosis and congestive heart failure. He looked absolutely skeletal. With some treatment, he eventually was able to sit up on his own, was eating, and appeared well enough to discharge with orders to go to another hospital with more capabilities. Later the same day, however, he deteriorated and was struggling to breathe. It became apparent that there wasn’t really anything left to do. His daughter decided that they didn’t want to take him to another hospital but would rather take him home to die with his family. His status among his tribe also made dying in the hospital an undesirable option. Under Dr. Agamah’s guidance, the patient was given a last dose of Lasix, in the hopes that his heart would be relieved enough to get him back to his home and to allow a short time for family to gather. I watched two young men carry him out to the taxi, wrapped in his cloth, and he was propped up between two people in the back. Each breath was gasped and labored; his expression registered no emotion. I pray that he made it home in time to take in his surroundings before his spirit left his body.
Another patient came in struggling to breathe. This man is 49 years old and served as the professional photographer at the church celebration we attended last Sunday. He shared with us his diagnosis of congestive heart failure (CHF) and brought along an x-ray that showed an enlarged heart. Our physical exam quickly confirmed the diagnosis: extreme orthopnea, crackles in his right lung, hepatomegaly. He had gone to another hospital, and they gave him a painkiller (paracetamol) and an antibiotic (azithromycin), i.e. nothing to really help his CHF. Dr. Agamah admitted him and got him started on Lasix. Ben saw him again and said he was looking much better. I find it so hard to watch someone struggle to breathe. Perhaps the ability to help someone regain their breath played into my dad’s decision to become a pulmonologist; what a powerful thing to do.
Yesterday, I spent the day in the supply room, organizing and doing inventory of the loads of donations that have been spent from Illinois. Just before we left for the evening, Kim Dunnington, a nurse from Springfield who came with Team B, came in and asked if I had come across any baby bottles. I hadn’t found any, and not surprisingly, the hospital didn’t have any in stock. It’s commonplace for mothers to breastfeed openly in public as long as their children are taking milk, so the need for bottles is minimal to non-existent for most people. In this case, however, there was an extremely dehydrated baby who had just been admitted and was biting his mother. All attempts to get an IV in had failed; the nurse anesthetist on staff tried every possible part of the child’s body, including turning him upside down to try to get a scalp vein. All I could offer were some 3cc oral syringes.
I finally went down to see him, and I’ll probably never forget how he looked. Dressed in a pink Lacoste polo shirt and shorts, he was being held by his mother, eyes sunken in and hands and feet looking shriveled. His breaths were shallow, his limbs cold to the touch. It turned out that the boy was 18 months old and had been “failure to thrive” from the beginning, maybe due to a complication of labor…who knows. When I walked in the mom was trying to feed him a starchy soup, and while some went down, you could hear it sticking in his throat as he breathed. Kim came up with the idea of combing some 50% dextrose solution with normal saline to try and get some electrolytes and fluids back into him. His ability to swallow was obviously compromised, so our final effort was to administer fluids by hypodermoclysis, a rehydration technique used to rehydrate elderly patients whose peripheral vasculature is constricted. Dr. Bussing, an internist from Springfield who has been a great teacher for us this past week, knew of this technique. This involves inserting an IV catheter straight into the subcutaneous tissue, running in an isotonic solution, then stopping the drip and allowing osmotic pressure to redistribute the fluids into the vessels. According to UpToDate, this method is ~50% successful in rehydrating mild to moderately dehydrated adults compared to ~80% when intravenous rehydration is attempted.
Unfortunately, this was severe dehydration. Dr. Agamah came in to see the patient, and a quick exam indicated to him that the little boy was too far gone. His distal pulses were faintly palpable to experienced fingers, not at all to mine. His eyes, which had been open when I entered the ward, were half-closed and his pupils were non-reactive. Without any blood pumping out into his limbs, the ability of the venous system to return was probably nil. While this prognosis was not necessarily surprising, it still wasn’t what anyone wanted to hear. I called his mom back into the ward, and Dr. Agamah briefly explained his opinion. The nurse, Frank, disconnected the IV he had put in, and as Kim and June (Dr. Agamah’s wife) prayed with the mom, I wrapped the baby in his cloth and carried him from the bed to his mother’s arms. Even as I handed him over, I noticed his breathing was becoming fainter. Part of me wanted to stay with her until he was gone, but I left. Soon after, I was standing in the hallway, and she waved good-bye to me as she headed out of the hospital. Her baby was wrapped on her back, in the way all moms carry their kids here, and she had covered his head with another cloth. I can only assume he was gone or nearly gone.
Sometimes I question my choice to become a physician. It’s not a question of if I can handle the rigorous training, the long hours, the all-consuming nature of medicine. No problem. It’s a question of if I can handle it emotionally. We’re told time and time again at Rush how important it is to develop rapport with patients, to see beyond the disease to the human being, to sense the needs of the emotional mind in addition to the needs of the body. The importance of this is obviously a significant part of being a successful physician, especially in the primary care setting in which I plan to work, but it’s a treacherous path to walk if you haven’t found a balance between empathy and emotional self-preservation. Add that to my to-do list.
While we spend most days working, out collecting data for the research project or now in the hospital seeing patients, we do find time to enjoy ourselves with a bit of relaxation. Our adventures are limited to where we can go by foot, but we have been able to explore Agbozume quite a bit over that last four weeks. To name a few places, we have been all over the market, purchasing little but enjoying the sights and sounds, to the hospital supply warehouse where we picked coconuts and indulged in their pulp and water, and past the village Chief’s palace, a gated mansion (at least relative to its surrounding homes). Just two nights ago, we stumbled upon a futbol/soccer game. While the field was patchy and in bad need of a mowing, the game was much like we would watch at home. Fans lined the sidelines, coaches yelled for their players to position themselves, and players neatly dressed in uniform.
At home, we spend a fair amount of time reading—both of us finished the novel Cutting for Stone by Abraham Verghese but have spent more time reviewing some relevant tropical medicine topic—and learning from the women that care for us about Ghanaian culture and food. After some explanation, we were able to convey what playing cards were and found them in the market (you would think we would remember to bring this). After playing much solitaire, we were getting a bit bored, so in true Henkle fashion, we decided to make a cribbage board (see below). It is made from a piece of cardboard and has matchstick pegs. A Sharpie marker added a bit of color. Sarah is leading our ongoing winning tally, but I have the lone skunk. We also found popcorn kernels in the market and have been enjoying a bit of freshly popped popcorn as an evening snack.
The Ghana boys also have joined in the cards. Above, Issac, an accountant from Accra that was auditing the IHDN books, and Mark, the IHDN administrator play cards Ghana style. I don’t really understand how they play, but they only use about half of the deck, do a weird shuffle, cut the deck a few ways, and deal three cards at a time. They go back and forth, and the highest card by suit gets points. It is quite a showy game with cards being thrown down with authority, constant bragging, and lots of laughing.
Long days at the hospital, both seeing patients and doing various other administrative tasks, have reduced our leisure time this week, but on Sunday, the team will head to Denu Beach for a little R&R.
