Going Global

The Going Global blog is an opportunity for emergency physicians to share their experiences practicing and teaching outside the United States. Submit an article about your experience to EMN at emn@lww.com. Be sure to include a brief biography and photographs of the authors. Photos taken during time spent abroad are also welcome, and should be 300 dpi and in jpg, tif, or gif format.

This blog was started by the emergency medicine residents of Palmetto Health Richland in Columbia, SC, who travel the globe on medical missions. The program is under the direction of Thomas Cook, MD, who oversees one of more than 40 academic departments of emergency medicine that sponsors Global International Emergency Medicine Fellowships.

Thursday, May 16, 2013

A Step Back in Time
By Nathan Ramsey, MD
I traveled to Ghana, West Africa, during the fall of 2010 with the sidHARTe program (www.sidharte.org) sponsored by the Joseph L. Mailman School of Public Health of Columbia University. I spent six weeks at a district hospital participating in an educational program, the goal of which was to develop a curriculum and to focus on training midlevel providers in the basics of emergency medicine. Emergency medicine is a developing specialty in Ghana. Most emergency care is provided in ill-equipped casualty units in district hospitals. The units are rarely staffed by physicians and the first-line providers are nurses and medical assistants (equivalent to physician assistants or nurse practitioners). Most of the nurses have not even been trained in the basics of emergency care.
This trip was a totally new experience for me and proved to be invaluable because its primary focus was not direct health care delivery but educating and training local practitioners. It was my first opportunity to switch modes from a resident focused on learning emergency medicine to a teacher passing on what I have learned. I was stationed in a 100-bed district hospital located in the medium-sized city of Mampong in the Ashanti region of Ghana. There was one staff physician for the entire hospital and, for the most part, I functioned independently during my time at the hospital. I worked as an attending doing daily teaching rounds as well as giving weekly lectures, leading small group sessions, and running mock patient simulation.
This was a very rewarding experience because the time I spent in Ghana would have an impact even after I left. By training local practitioners we can make a difference that lasts long after the brief time spent in their country. There is potential to affect the care of countless patients that one will never meet.

Day 2
I arrived in Accra, Ghana. An airport worker let me skip customs, and then expected a bribe. I gave him $20. An aggressive taxi driver tried to get me out of the airport before my ride and additional travel arrangements could be made. I found my real ride to the hotel.
I exchanged US dollars for Ghana cedis on the street. All the money changing offices are closed on Sunday. The guy I changed money with was remarkably accurate and honest. I felt a little like a gangster to trade over $800 on a sidewalk. ₵1100 cedis is a huge wad of cash.

Day 3
I arrived in Kumasi, and had to wait two-and-a-half hours to be picked up at the airport. My unofficial orientation was interrupted by a crash between a police officer and a man on a motor bike. The biker was a multitrauma with positive FAST scan (blood in the abdomen) and hypotensive (in shock). I did the best impression of ATLS I could, and we sent him off to the larger hospital that had a surgeon. It was an hour ambulance ride away. The policeman had a dislocated shoulder. This was the first time I have had an AK-47 in the trauma bay.
Today, I saw my first cases of malaria ever. I realize this is going to be a totally different experience than I have ever had in my life.
Day 7
One of the patients I cared for yesterday died overnight. The family of a baby we had been treating for meningitis decided to take the child home against medical advice. She was in the process of dying this morning despite our best efforts. A second family of a baby under a year old decided to take their child home as well. He had cerebral malaria, and was neurologically devastated. He likely will die with or without treatment.

Day 14
I was able to diagnose a young man with a perforated ulcer. This was the first time I have successfully used a flat and upright abdominal x-ray to find free air in the abdomen. I looked at the films, and there it was as plain as could be — a free air bubble under the right diaphragm. I suspected perforation but had only seen those x-ray findings in textbooks.
Medicine here is like taking a step back in time. This must have been what it was like practicing medicine in the years following World War II. You have to depend on your brain, history, and exam findings more than sophisticated diagnostic testing.

Day 16
Tonight a man came into casualty seizing. We quickly determined he was a diabetic with very low blood sugar. The entire hospital was out of dextrose 50% solution, the indicated treatment, but we improvised by giving him a rapid infusion of 1.5 liters of dextrose 5% solution. This was successful in resolving the seizures. We then realized the hospital was out of oral glucose. I ran back to the house and dumped a whole box of sugar cubes (including some ants) into a cup. I then added just enough water to dissolve the sugar into a gel. I rubbed this into the patient’s mouth. He eventually recovered enough to be able to drink the rest of the solution. When I left for the night, he was talking and alert.
I learned today the hospital is out of D50, insulin, IV pain medication, urine test strips, and I’m sure countless other vital medications and equipment. After regular hours, the x-ray technician turns off his phone so x-rays are only available from 9 am to about 3 pm.
Day 21
Today was one of the hardest days yet. I worked at least eight hours in the casualty unit today. When I walked in this morning, it looked like a battlefield hospital. There had been a serious vehicle crash involving 15 people. Six of them were present in our unit, including two critical trauma patients. This was a hard task for me and one nurse, and she was not a casualty nurse. She was filling in from the women’s and children’s ward. Every bed was full including hallways. The power was out for at least four hours, and unfortunately the backup generator was out of gas. No labs were available during this time, and I was not able to read the mornings x-rays until 6 pm.
This was a true mass casualty incident for our small hospital. The casualty ward is usually only staffed by one nurse. We eventually transferred three patients to the Komfo Anokye Teaching Hospital (KATH). No one died under my care today. That was a real blessing.
Day 26
I accidently stood on an ant colony, and was bitten several times by African ants.
We intubated our first child in the casualty unit today. He was a 1-year-old having status seizures. We had to give him so much medication to stop them that he needed ventilator support. I went with him in the ambulance to KATH in Kumasi. I had to use an ambu-bag to ventilate him en route. We went lights-and-sirens all the way, which is about an hour drive. The ambulance driver was amazing. He dodged in and out of traffic, coming within inches to other cars. At one point, we went the wrong way down a major four-lane road, weaving in between on-coming cars. This may have been the most dangerous thing I’ve done in my life. I still feel a little car sick from my ambulance ride.
Day 28
We left for Mole Park today. We made it all the way by the grace of God. The roads were the worst I have ever traveled. There was a three-hour stretch spanning 90 kilometers that was more like off-road conditions. Our driver’s name was Badu. He was very skilled, and we only got stuck in the mud one time. We were able to get out relatively easily. We were driving in a taxi, and saw no other cars attempting the trek. We encountered only SUVs and trucks. I was very nervous that we might break an axle or get stranded in the mud. Our trip took about nine hours total.
We went to a local monkey sanctuary. The monkeys were so friendly we could feed them from our hands. The locals treat all the monkeys as pets. They believe that it will bring a curse on them and that someone in the village will die if they harm a monkey. They even bury the monkeys when they die. The monkeys come into the village to participate in breakfast, lunch, and dinner on a daily basis. We fed bread to no fewer than 20 monkeys as we walked along the trail.
The rural villages are very poor. They mostly consist of crumbling mud huts. We spent the night in an old guest house located in Larabanga, which is just outside the park. We tried to sleep on the roof, but a rainstorm drove us inside.
Day 31
I had fufu with light soup for the first time today. I learned that the one of the ingredients is a root that is poisonous if it is not cooked and prepared properly. It was good, but I like rice ball better.
We had a man come in today with a devastating hand injury from a homemade shotgun that misfired. It basically destroyed half of his hand.
Today was very busy with traumatic injuries. We transferred three patients to KATH, and had one man come in with a devastating head injury that we are managing with comfort care.
Day 36
Today we took our first solo trip to Kumasi for some touring and shopping. Everybody in Kumasi knows my name. They yell Obruni whenever I walk by. Obruni means white man.
Kumasi is a disorganized city with a mass of humanity and activity. We spent a good portion of the time lost wandering around the streets. We ate lunch at Big Baboo’s, a restaurant that serves food more like I was used to. It was nice to get a little taste of home. We toured the palace of the king of the Ashanti Empire, and learned about the culture and history of the region.
Day 41
Today was my last day working in Ghana. It is very sad to leave all the friends I have made here. I spent the day saying a lot of goodbyes.
I packed this evening. My bags are much lighter going home than when I arrived. I left all of my slacks, most of my scrubs, and threw away all my socks because of the mud.
I’m sure it will take a few days to get adjusted once back in the United States. I’m looking forward to some American food and a hot shower once I get home.
Dr. Ramsey visited Ghana in 2010 while an emergency medicine resident at Palmetto Health Richland in Columbia, SC.