Day 16 & 17: The End

On my last day, Tuesday, I followed my usual routine. In the morning meeting, Dr. Mahmud led a presentation on epidural steroid injections for back pain. He detailed their history, rationale for usage, and indications and contraindications (when to use them and when not to use them). The bulk of the discussion focused on comparing injection approaches and the importance of fluoroscopy and contrast to correctly guide the needle.

I spent the rest of the day my favorite way- teaching and playing with the children. Since it was my last day, Auntie Pat and I decided to break out the chalk so the kids could play hopscotch (modified for their backs), practice their writing, and draw. We led activities at both FOCOS and JB House so that all patients got to participate. At the end of the day I did my final walking traction with the children, as our friend Edmond told me that I was lying about leaving and even if I wasn't the plane would stop by to pick him up tomorrow too. As I hugged all of the children goodbye and promised them I would return, they were all so gracious and thanked me "so much" for coming. It felt funny having the patients thank me, when really I should be thanking them. The children I have met have opened my eyes by sharing their stories and showing their incredible resilience, passion, and gratitude. Saying goodbye to the staff, I thought about how lucky I was to have learned so much. Unlike other jobs and volunteer opportunities that have centered around pure observation or following a repetitive, set plan, my time at FOCOS allowed me to gain such valuable knowledge on everything from specific spinal terminology to how to run a non-profit organization.

During my travels home, I had a lot of time to reflect. What struck me the most about FOCOS and the unbelievable work they do was their complete implementation of sustainable development. At school I am a member of Global Medical Brigades, a wonderful organization that works in developing nations to provide healthcare, with other branches of Global Brigades working towards legal rights, housing, clean water, etc. This organization prides itself on its sustainable development model, which means that brigades go into villages not just to provide care, but also to teach the people there how to do the same. This system works so that eventually these places are able to provide for themselves, and although it takes time, it is the most effective form of aid. Last May I went on a trip with Global Medical Brigade to a village in Honduras, and the implementation of sustainable development was still very much in works; patients traveled hours in order to see our clinic, and most received the only healthcare they had and would have in a while. On the other hand, the FOCOS Hospital is a rare example of completely implemented sustainable development. The hospital has an abundant staff of healthcare workers and administrative professionals almost all from Ghana. Unlike the FOCOS medical trips years ago, the organization no longer utilizes outside resources. Everything the patients need is there, and on the off chance that a patient presents with an additional non-orthopedic problem requiring help beyond general medicine, the hospital has great relationships with specialists in the area. Prof has done a remarkable job educating the staff, especially the medical team, and the progression of this sustainability can be seen in the Ghanaian medical students and residents who learn at FOCOS.

In fact, old students of Prof and Hospital for Special Surgery medical professionals come to Accra to learn the intricacies of extreme spinal deformity from FOCOS. This is where the biggest misunderstanding lies. Foreigners may come to FOCOS as "volunteers" in the sense that they paid for their travels and living arrangements and are unpaid during their time there, but really they are students. I was not a volunteer, I was an intern. I did not make personal sacrifices to give to others, I was honored that others donated their time and resources to teach me. I was a student and I am forever grateful for all of the knowledge that my friends shared with me.

Thank you so much to my family and friends for their support during this journey, and even more thanks to the FOCOS team and patients for allowing me to be a part of their world. I'll be back soon!

 

Day 15: Coming to A Close

Days 15: Coming to A Close

*The pictures in this post are of the specific children being discussed. I think there is value in being able to put faces to their names when you are learning more about their stories

Morning Meeting

Prof arrived back from his trip to Ethiopia on Sunday, where he performed nineteen surgeries and saw 127 pre-op patients and 50 post-op patients in just three days! Monday’s morning meeting discussed many of the post-op cases I’ve been sharing frequently here.

Eshetu, the nineteen-year-old girl who had a severely myelopathic spine (spinal cord was very compressed), is now six days post-op. She is feeling sensation in her lower limbs, although they have no voluntary movement motor power. This may change with time and is due to the previous and prolonged condition her spinal cord was in. She is currently in physical therapy and can withdraw her legs from painful stimuli. She is being closely monitored.

Esther, the younger girl who had the first of two operations almost two weeks ago, will undergo her second procedure tomorrow. She had an anterior (side approach) release twelve days ago to increase spinal flexibility, and will now undergo a posterior spinal fusion. She, along with many of the other post-op patients in the ward, had malaria last week and was treated. This is extremely common here, as the blood used for transfusions typically carries malaria because of how widespread it is. Because malaria is treatable with medication and there would not be enough donated blood if malaria positivity was an eliminating factor, all patients receive blood transfusions and are then tested for malaria and treated accordingly. Esther’s hemoglobin levels are higher than ever, but she still may receive a unit of blood pre-operatively to be cautious.

Mengistu is six days post-op and was also treated for malaria this weekend. His alignment looks great and his current obstacle is an abnormal gait (walking movement) on his left side.

This week Rediet, a sweet nine-year-old female that I’ve gotten to spend a lot of time with, will undergo a posterior spinal fusion and vertebral column resection for her very high risk posterior kyphosis. She was in a halo for around four months, which reduced her kyphosis from 138 to 114 degrees. She is extremely skeletally immature, so the procedure will inhibit some of her growth.

Another pre-op case for the week is Haliya, who is also a nine-year-old Ethiopian girl. Haliya is a fascinating casse. She arrived with a severe neurofibromatosis (spinal tumor) and congenital kyphosis that had inhibited her from walking for four months prior to her visit. Her bowel movements are controlled, as is her urinary system now that she has taken medication, which is important in determining her risk of paralysis. After putting her in halo traction, Haliya became able to walk during walking traction. I witness this when I accompany the children on their walks, as Haliya’s friends always help push her because she has a more difficult time in walking traction than others. She is a very quiet girl who is extremely polite and will warm up to you after a few funny faces. Her vertebral body has been dislocated, so she has two vertebrae side by side instead of stacked up and down. Much of her surgical plan will be determined when she is opened and they can assess the severity of the situation.

An additional pre-op that I found interesting is Agnes, a fifty-eight-year-old Ghanaian female in need of a double knee replacement. Her more severe knee will be operated on first. Agnes’s knees are in such bad condition at a relatively young age because of her weight. She is obese with a BMI of 40.5. Activity level, or fitness, is often more important than weight in patient outcome. To optimize Agnes’s post-op outcome, the doctors want her to engage in some type of activity, which is difficult given her weight and two bad knees. Some ideas included walking, walking in water, and stationary biking.

Emanuel, a three-year-old Ghanaian boy, will be operated on this week for the same condition that another three-year-old whom I previously discussed, Franklin, had: arthrogryposis. Emanuel’s condition is in his arms, unlike Franklin’s, which was in his legs. This causes Emanuel’s elbows to be frozen so that both of his arms are stuck extended. He will have bilateral radius and ulna shortenings.

Clinic

I then shadowed Prof in clinic at the Out Patient Department for the majority of the day, which was an incredible experience. We saw many patients whom I have become familiar with, as they are pre-op or post-op cases staying at FOCOS. However, many new and old patients traveled far just to have an appointment with Prof. Some of the patients we met had come from Nigeria, Sierra Leone, and parts of Ghana far from Accra. My favorite appointments to shadow were post-op patients coming in for their six month or one year check-up. It was so incredible to see how these patients, mostly children, were flourishing and resuming daily life. Looking at their pre-op and post-op x-rays side by side, all while being able to see them standing tall in person, was truly an incredible experience. We even saw one Ghanaian adolescent patient who was being seen because her scoliosis curve was observed early and being monitored. She is nearly done growing and has a 26 degree curve, so she will likely never need treatment. It is mind-blowing that this type of appointment is the norm in the US, yet it is the first of its kind that I have observed here at FOCOS.

One of the patients we saw was Abraham, an enthusiastic and intelligent young boy living at JB House that I have taught often. Abraham had surgery exactly one month ago, but his deformity is more visible than ever. Before his operation, Abraham had severe kyphosis. From the side, his spine looked like a lowercase "r" with the top vertebrae not even creating a curved hunchback, but rather a completely horizontal hunchback. This severe deformity needed to be corrected immediately, so Abraham had a spinal fusion. However, because of his young age and small size, which prohibits the doctors from using stronger, larger implants even though his spine is persistently growing, he has developed kyphosis below his fusion. This means that his spine is now forming a hunchback under the implant in a location lower than the original problem. Prof debated whether he should extend Abraham's instrumentation now or let him go home to Ethiopia and observe him until a second procedure becomes absolutely necessary. The reasoning for the latter idea is that it would give Abraham more time to grow; he is still very young and short, and any part of the spine that is fixated with instrumentation will stop growing. Because Abraham's rod is very close to his skin due to the new curvature, Prof decided to keep him at JB House and reevaluate in six weeks. 

I spent what time remained in the day hanging out with the children and enjoying some music-making and dancing before walking traction. I cannot believe that my time here is coming to a close and am so grateful that I was able to learn more inspiring stories in clinic. 

 

Day 10, 11, & 12

I've been so busy lately that I decided to recap my past few days in one big post...enjoy!

Days 10 & 11

On Wednesday morning, Prof and a small team left for Ethiopia to visit partner organization American Jewish Joint Distribution Committee. There he will perform easier procedures at the local hospital that the organization uses, as well as refer more severe cases to return to FOCOS for complete treatment. More complex cases need to follow Prof back to Ghana so that they can utilize halo traction for a few months before going into surgery, followed by recovery and rehabilitation. Eshetu and Mengistu, whose procedures I observed on Tuesday, are recovering well. Eshetu is unable to undergo a motor assessment at this time, but likely will by the beginning of next week. They are unsure if it is because she is tired and not wanting to exert herself just yet, or if her motor function has not improved post-operatively compared to her previous state, which is a possibility that I discussed previously. Both patients have been moved out of the ICU and into the wards, and I will have more details on their cases on Monday. On Thursday I visited Eshetu, Mengistu, and Mubarak, an Ethiopian boy who had surgery on Wednesday, in the wards. All of them were in high spirits for their physical states, and the young boys were excited to receive their own crayons, pictures, and activities to occupy them while they're primarily bedridden.

The new book shelf at JB

The new book shelf at JB

Every Wednesday all of the children at JB House come to the hospital for weekly height and weight measurements and halo screw tightenings. It's so rewarding to see the patients grow taller and put on much needed weight as their treatment progresses. After their routine was completed, I headed over to JB House with Auntie Pat to organize the new bookshelf installed there. We discarded completely destroyed books and organized the rest into educational workbooks and reading books by level. Many of the books so generously donated are advanced novels for a typical American teenager or adult. Every child here is learning English as a second language, likely for the first time in their life, and many can only listen to others read. Thus, story books and simple picture books are greatly appreciated. You can contact FOCOS to send old books to the New York office so that they can be used here in Ghana. Later we did some reading and, of course, coloring.

On Thursday I had a great time hosting a spelling bee for the kids. We had the patients from JB come over so that everyone could take part in the fun. Abilities ranged from those unable to understand English to those at "Level 3" here, which is around a mid-elementary school level in the US. The spelling bee was conducted in an untraditional format to cater to the children's learning abilities. Each student was given a word at their level and asked to spell it. They were given multiple tries and helpful hints. If the student could not spell the word, others were allowed to quietly raise their hand and give it a try. I would choose another child of the same level and keep going like this until someone spelled it right. We went around in a circle three or four times with almost every child present, so the game lasted a few hours! Each time a child spelt a word correctly, they got a point. Quickly after the game started and our first word was spelled, all of the children did a special clap that Auntie Pat has taught them. I've seen the kids do it before when they're quieting down, but it was so amazing to see how supportive they are of one another. Though the patients got competitive and were eager to try to spell, they always made sure to do their special clap for every peer after they spelled a word right. It was heartwarming to feel the support for every patient, from those who could only spell "no" or "dog", to those who took on tricky words like "tomorrow" and "kitchen". Every child got a box of crayons, a tattoo, a pencil, and a lollipop for participating. The first, second, and third place winners got a little bit extra. I was very impressed by one boy in his young teens, Shepherd. Shepherd learned some English at his school at home, but was noticeably ahead of all of the children, spelling words like "strawberry". When I asked Shepherd where he learned to spell and speak English so fluently, he told me that his Canadian sponsor has been extremely involved and helped him tremendously with his English. He was so happy that he succeeded at the spelling bee, and I was so happy that his sponsor made such an impact on his life in addition to their generous contributions to his treatment.

The spelling bee

The spelling bee

After lunch, we played a spelling bee of sorts with pictures for those who struggle greatly with English. The children were shown a picture and had to say what the image was in English. Then they would try to spell it, and if they could not a peer would help them. After that, we played word bingo. I would show a card with an object and its name on it and read it aloud. The students would then put a chip on their card if they had the object. After we exhausted all of the options and every student had filled their entire card (this isn't your traditional bingo), one by one they'd spell all of the words on their card. First they'd spell the words while reading them, and then they'd cover the object names and spell them again. The children got such a thrill out of yelling "Bingo!" every time they connected a line and it was a useful exercise for all, from those who are working on identifying words with images to those progressing in spelling.

Edmond stealing the camera to take a series of selfies

Edmond stealing the camera to take a series of selfies

Another child who has struck me is Edmond, the six-year-old Ghanaian boy with a kyphosis-causing spinal tumor whom I originally described as "a little shy". I have come to learn that Edmond is anything but shy once he opens up to you. Edmond was previously having a difficult time adjusting to the hospital, as he is one of the only Ghanaian children and cannot speak any English, so nobody understands his dialect. In addition, he is younger in comparison to most of the children currently at FOCOS and has just started his traction and living full-time at the hospital. Earlier this week, the nurses brought Edmond to me in tears while I was teaching in the wards. He had been crying in his bed all day and this was his first time interacting with the other children. After helping him color and exchanging a few stickers, Edmond warmed up to me and showed me his mischievous humor and bright personality. Now Edmond greets me every morning, participates in the learning activities though he cannot understand (yet), and hangs out with the other children. I have helped convince him to eat more and practice his walking traction, and he has taught me to trust a six-year-old boy with nothing! I am fascinated by how a child that cannot verbally understand you can connect with you so quickly. There are many ways to communicate besides written and spoken language. Showing someone that you care about them is easier than it seems and makes a huge difference. Being compassionate and showing love is the strongest language, and I know this is true by how the children both treat me and respond to me.

Day 12

On Friday I traveled to Cape Coast, a fishing port city in southern Ghana. I first visited Kakum National Park, a tropical rainforest with monkeys, antelopes, elephants, and many diverse birds and butterflies. There I hiked and walked the famous canopy walkway, an elevated hanging path that stretches for 1,150 feet, showing you the park from above. Then  I stopped by a crocodile pond to pet one, which was as scary as it sounds. Afterwards I enjoyed a beautiful lunch on the beach before I headed to Cape Coast Castle. The castle is over 540 years old and was once a major slave castle where Africans were brutally abused and held captive before being sent to the new world via ships arriving in Cape Coast's ports. The castle tour was filled with heartbreaking stories and extensive information about the slave trade, as well as other purposes that the castle has fulfilled before it was taken over by Ghana and became a World Heritage Site. It was so special for me to explore this country outside of the hospital to see its culturally relevant wonders. I learned so much yesterday and was yet again taken aback by the beauty of this nation, both in the geographical context and in reference to its inhabitants. I am so grateful for all that I have seen thus far, medical and non-medical, and all of those who have been so kind to me on this journey.

 

 

Day 9: OR

Morning Meeting

We began our discussion on the issue of staging surgeries, or correcting a patient in multiple successive procedures. Many of the patients here have staged surgeries to avoid extreme stress, but improperly staging operations can create further damage too. Prof said that it is ideal to have the second surgery one to three days after the first, though in certain cases (like one that will soon be discussed) that time period isn’t possible. When the surgeon waits over three days to perform the second operation, the patient is weak because they haven’t had an appetite post-operatively. Their body is also in stress, which is apparent in their hemoglobin levels and other factors. In the United States, a patient requiring two consecutive procedures avoids this dilemma by receiving total parenteral nutrition (TPN), or intravenous nutrition, in between surgeries. If this is not done, the patient waits six weeks for their final procedure, which is not realistic with the cases and resources at FOCOS. Esther, a post-op patient that I’ve been discussing, is waiting two weeks to have her second surgery because of the conditions of both her recovering body  and her deformity. In the mean time, she is on increased nutritional supplements, aggressively using an incentive spirometer to improve her respiratory function, and having a total protein profile performed to ensure that she is healthy enough. Despite her progress, she has fluid consolidating in one of her lungs and needs to attend chest physical therapy and use her spirometer more. Her first procedure was an anterior (from the side of the body through the ribs) release to increase flexibility in her spine, and her upcoming procedure will be a posterior (from the back) spinal fusion.

We then reviewed two patients who I was fortunate enough to observe the surgeries of in the OR later on. The first was Eshetu, a nineteen-year-old Ethiopian female with congenital kyphosis so severe that she has high risk spinal cord compression, or myelopathy. This has caused a partial loss of motor function, so she walks with a stick. Pre-op, Eshetu’s kyphosis measured 93 degrees and her lordosis 73 degrees. Her lungs are very compromised and she needs room in the front of her spine for her spinal cord. This is a lot more difficult than patients who need room in the back of their spine for the cord, as that can be corrected by a laminectomy and is fitting to the posterior approach; surgeons open from the back of the spine, so it’s a lot easier for them to make room for the cord there than it is from the front where there’s no incision. It is unclear if she’ll regain motor function and if so how much.

The second patient was Mengistu, a delightful nine-year-old Ethiopian boy that I spent a lot of time with on Monday. He is constantly smiling and very intelligent. He was one of the first to finish his drawings with his name well-printed and politely asked if he could color some more. Mengistu had two previous operations: one to correct his curvature and another later to remove an infected, exposed implant from that procedure. This complication resulted from his small size and stubborn spine, which I touched on in yesterday’s blog. Mengistu is short and very underweight, with a BMI of 13 with his arm span (more accurate) and 14.9 with his height. He has been on the antibiotic augmentin for some time, and will continue on his six week course post-operatively. His procedure will be re-instrumenting his spine from his T2 to L4 vertebrae to prevent deformity where the old hardware was removed. Prof noted that he will have to be mindful of the patient’s small size and weak skin and soft tissue.

Operating Room

It was such an incredible opportunity to shadow Prof in the OR. The rules, conduct, and timeline of each procedure were very similar to what I have observed in the US. However, the procedures were much longer and more high risk. Eshetu’s procedure was around five hours. Due to her compromised motor function, her MEPs and SSEPs were abnormal. I will go into greater detail about this when we formally review her post-op case. Secondly, the forward nature of her spinal cord compression required operating on the front of the spine to make room (the part of the spine you’d first encounter if you cut through the patient’s chest area, which is not possible). This required Prof to maneuver from his posterior incision in her back essentially around and under the spine to manipulate the front of it. This is extremely dangerous, but her operation went as planned without further complications. Mengistu’s procedure was much shorter and offered more visibility, though spinal surgery is difficult to see and is aided by cameras hooked up to screens. Both cases were fascinating and I look forward to telling you more about them when their details are discussed at the next morning meeting. Thursday will be filled with more patient interactions, and I hope to go in depth about certain children that I’ve formed special bonds with.

 

Day 8: A Day With The Patients

Morning Meeting

After a relaxing weekend exploring Ghana and its culture, I started Monday with the usual morning meeting. These meetings are not only a great way for me to learn the details of complex cases, but also for me to track patients’ progress as I observe many of them from pre-op to post-op. Some upcoming surgeries include Eshetu, a nineteen-year-old woman from Ethiopia that I know from teaching. She has congenital kyphosis of 93 degrees that has visibly thinned her spinal cord. Her condition is so severe that she currently walks with a stick. Another is Mengistu, a nine-year-old Ethiopian boy who was previously treated here for post-tuberculosis kyphosis with spinal fusion and vertebral column resection (VCR). After his original surgery, he underwent another procedure to remove an exposed and infected implant, in addition to rounds of antibiotics. After six weeks of traction, the patient is ready for his third procedure, which will re-add hardware. Unfortunately, these situations are often unpreventable because such small patients need small instrumentation, but at the same time the hardware must be strong enough to not become misplaced. We also reviewed post-ops, and I wanted to share how well Bai (the buckled spine) is recovering. He is now five days post-op from a posterior spinal fusion, VCR, and cage implementation for kyphosis. His surgery was four and a half hours long, and today his drain is removed and he is walking! Bai took part in many of the activities I did throughout the day and had a hearty appetite at lunch. Esther is also doing well, experiencing less pain, and enjoying coloring!

Physiotherapy (Physical Therapy, PT)

n the morning I observed physical therapy with the patients from JB House whom I had taught before. PT is so important in orthopedics, as patients must relearn how to use and restrengthen parts of their body necessary for activities of daily living. However, spinal surgery requires a lot more because of the extreme nature of the surgery and the spine’s control over nearly every part of the body (not just your back). PT is crucial in pediatrics so that patients are not sentenced to being forever physically inhibited by their previous challenges. The children have such strong relationships with their therapists, whether it’s being motivated to work harder or confiding in them about personal feelings. One little girl is upset that her friends are progressively leaving while she’s still in recovery, and she openly talks to her physical therapist about this and receives words of support and inspiration in return. The patients know their routines and begin their ankle weight exercises as soon as they begin, which include separately lifting their legs both straightened and bent while seated. After a certain number of sets, they add in raised arms. Other exercises include walking up and down stairs with ankle weights, doing single-leg kneels both on the mat and while putting down and picking up markers in a line, using arm-strengthening bands, and balancing on their toes. Some of the children practice walking normally, as they previously bent their necks and hollowed their chests into their shoulders in a hunchback-type posture. The therapists also stretch out the children, especially in their necks which are still supported by braces. 

Hanging With the Pediatric Patients

I spent the rest of the day following the daily routine of the many pediatric patients who stay at the hospital. The children already had breakfast before physical therapy, and after PT came learning with Auntie Patty. Patricia has emphasized to me that while teaching the patients is important and occurs daily, it is very difficult because of the varying education levels, ages, and languages. However, her main goal is to use educational activities like reading, writing, and mathematics to cheer them up amidst all that they are experiencing. Our first activity was coloring. In order to get a sticker prize, the students had to color their picture to the best of their abilities and write their name. The children who are unable to write in English practiced by having their name written for them so that they could try to copy it below. The patients were so thankful that I brought new coloring books, and drawings from Dora and Frozen were a hit among boys and girls. I then went to lunch with the children. Here they are closely monitored to ensure that they eat everything. As in many activities, the older patients led the way by listening and eating quickly.

After lunch I read a book to the kids, which involved a lot more than reading. After every sentence or two, Auntie Patty and I stopped to ask the children what had happened. Sometimes a handful of children understood and explained it to the others. On the other hand, Patricia and I often reexplained the sentence in multiple terms, using images and gestures frequently. We then asked the kids follow-up questions about the sentence read to ensure that they understood it and we could move on. After the story, the children read their own books because June is Reading Month and they are in a competition to see who can record the most pages in their reading log. Many of the children can read in English at an elementary level, but those who cannot use books in their own language.

When teaching was over, each of the patients got some more little toys and lollipops for their participation. I then accompanied the patients on their traction walk. The traction walk takes place twice a day, once in the morning and once in the late afternoon. The children’s halos are disconnected from the equipment on their wheelchairs and attached to the same apparatus on standing frames so that they can move their legs. Post-op patients who were either walking without halos full-time or unfortunately wheelchair-bound participated, encouraging their peers. This type of group spirit can be seen throughout the day and is constantly inspiring me. I’ll be spending a lot more time with the kids this week, so stay tuned!

Day 5: Warriors of the Week

I cannot believe that I only arrived on Monday. My first week at work has quickly transitioned me to feel at home at the hospital with both the staff and the patients. The hospital is set up so that all of the buildings are interconnected by outdoors sidewalks with roofing and railing. Words cannot describe the happiness I feel when I am walking outside and the children yell at me from across the hospital to say hello (all wearing their new sunglasses, of course). I feel so welcomed at FOCOS and in Ghana, and already envision future experiences here.

Rounds with Prof

Rounds with Prof

I began my Friday rounding with Prof. It was so exciting when we arrived at the ICU only to find out that both Esther and Bai were stable and had been moved to the wards. Esther, though in pain, is working hard on her breathing exercises with her incentive spirometer. This is a device that measures the amount of air the patient expels to keep their lungs clear, active, and regaining strength after surgery (Cleveland Clinic). We then checked up on Bai, and I was so taken aback when he greeted us with total calmness and a sweet smile. After all that Bai has undergone mentally and physically, he is so content to be alive and one step closer to standing tall. Prof estimates that Bai has grown five inches from his procedures. During our rounds we also saw Franklin, the three-year-old I introduced yesterday who underwent an arthrogryposis repair. Franklin was in visible pain, due to the nature of his surgery and more so his age. He was fortunate to have his family at his bedside, and his recovery was going smoothly. Eunice, who had a below-the-knee amputation, was also recovering nicely. All of the patients we saw were so thankful for Prof and the FOCOS team. I am so inspired by not only the work that FOCOS does, but also how thankful the patients (especially the children) are. It is very difficult for pediatric patients, especially those far away from home and without family, to understand why they are surrounded by unfamiliar faces and experiencing such severe pain. I am moved by how the kids are able to put age-expected feelings aside to express gratitude for their second chance at life.

I spent the rest of the day with Gifty in the procurement department, which is responsible for the acquisition of all items needed by the hospital. In one year alone, the FOCOS Hospital spends well over $1 million on consumables. Consumables are all purchases except for fixed costs such as electricity or water treatment. There are many stages of approval for each purchase, first traveling up the procurement chain before they are brought to the head of finance. A purchase approval is just the beginning, as multiple quotes then need to be compared to find the best price and potential discounts. All procurement matters are logged into the hospital’s digital system, HIS, and recorded in writing as well. Most purchases are made based on timing; Gifty knows how often they use each item and how much of it has to be ordered when they hit low stock. However, there are also emergency purchases, which usually occur when a unique patient needs a new medication. Though many purchases come from Ghana, a bulk of the medications and medical supplies are only sold internationally. Gifty makes usual purchases from South Africa, Israel, France, Germany, and the United States. The US purchases are compiled and sent by sea in a massive container two times a year. In the interim, a warehouse in New York receives the items purchased. Fortunately there are some donors, like the Hospital for Special Surgery and medical supplies companies (either those that produce one product and thus can donate some, or those that donate their surplus).

The most frequently used items are gloves, lap sponges, and syringes. The most expensive purchases are lab reagents. Other common pricey purchases include OR equipment, nutrition requests, and bracing material at $142 a sheet. A huge source of expense is one-time-use products, which are abundant in medicine. Though some OR items can be sterilized using the autoclave, plenty have to be discarded after used in a surgery. Selection of OR items largely depends on the doctors’ preferences, and the price must be paid to make sure that the surgeons are doing their complex procedures with tools they feel comfortable with.

Gifty toured me around the warehouse and I was in awe of its magnitude. The large warehouse is packed with various items, and it has distinct employees responsible for logging, storing, and delivering the items there. A new warehouse was just created to store items requiring colder temperatures, and those products will be moved over by next week. It is so interesting to learn about all that goes into operating a foundation-based hospital, and I have gained newfound appreciation for all the moving parts that make this organization run.

 

Day 4: Practice and Presents

Rounds and Morning Meeting

I began my Thursday shadowing Prof on his morning rounds in the Intensive Care Unit (ICU), where patients who have just undergone major procedures are constantly cared for until it is safe for them to move to a ward. We also checked in on the patients staying at the wards. Before entering the ICU, we had to put on special shoes only worn there, cover our clothing with long jackets, and put our hair in nets or scrub caps. There were two brave children in the ICU this morning, and I will describe what I learned about them from both rounds and the morning meeting to explain their complex cases:

  • Esther: Esther is a twelve-year-old female who underwent an anterior thoracotomy (enter from side), including disectomies (removing herniated disc material) from her T6 to T10 vertebrae and spinal fusion for her scoliosis from T6 to T11. She had just been extubated in the ICU, so she can begin consuming fluids. This surgery was the first of two for Esther. The anterior approach made her spine more flexible, and now she is ready for a posterior procedure that will ensure her spine doesn’t rotate around the hardware.

  • Bai: Bai is the seventeen-year-old male from Sierra Leone that I had written about a few days ago. Just a quick refresher: his kyphosis began at 211 degrees and was so severe that the top of his spine had essentially buckled over the lower half, requiring a posterior-only approach due to high risk. FOCOS has only treated fifteen patients like this. Bai’s surgery was successful, but the procedure was shortened and he will have to undergo the second part soon because of his mysterious “paralysis”. Some terminology before things get confusing…throughout surgery, the patient’s SSEPs and MEPs are measured. SSEPs, or somatosensory evoked potentials, are electrical stimulations to the afferent (sensory) nerve fibers to ensure the somatosensory pathways are functioning. MEPs, or motor evoked potentials, are electrical stimulations to the efferent (motor) nerve fibers and motor cortex to ensure the motor system is intact (Medscape) During the first surgery’s baseline measurements, Bai did not have MEPs. During the procedure, motor signals were not transmitting to his legs or arms, and eventually he had a transient loss of SSEPs. The first procedure was cut short because of Prof’s fear of quadriplegia, as well as Bai’s blood loss of nearly half his total blood volume. However, Bai came out of his first procedure fully functioning. During the second procedure to put a cage in front of his spine and pack bone around it, Bai temporarily lost movement in his arms. Though still sedated and intubated Thursday morning, Bai is able to move all of his limbs, and Prof thinks the mysterious readings were due to how damaged his cord was from such stress over time. Bai had instrumentation and four rods placed through the majority of this thoracic and lumbar spine. His curve is now at 39 degrees! Material found during his surgery suggests that his deformity was not congenital, but rather post-tuberculosis.

I was so taken aback by how brave these children were, away from home with no family with them, in extreme pain post-major spinal procedures. I remember my sister enduring extreme pain for weeks after her spinal surgery, which was nothing (sorry Jordan) compared to these, and how my mom or dad slept in her room every night and she was never unattended.

Thelma rocking her new shades. 

Thelma rocking her new shades. 

During ward rounds I saw our girl Thelma, and she is becoming more tolerant of her nightly feeds! I also met Franklin, a three-year-old boy who has arthrogryposis, which means he was “born with joint contractures” where his “joints don’t move as much as normal or may even be stuck in one position” (Seattle Children’s). His procedure will include a soft tissue release for the extra tissue that has grown around his contractures, as well as a fixation of his right femur and club foot.

The meeting also discussed two middle-aged women with sickle cell anemia, one who underwent a hip replacement and another who had bone grafting. There is little information on joint replacement in patients with sickle cell anemia, and the doctors discussed starting a prospective study on the topic. A pre-op case I found interesting was Eunice, an eight-year-old female with a BMI of 16.2 (extremely underweight). Eunice has a fibrotic, infected, non-functioning, and painful right foot that essentially looks like a deformed toeless foot with only some of a big toe emerging. Eunice will undergo a below-the-knee amputation and will be fitted for a prosthesis when her stump has healed.

Shadowing Family Physician Dr. Otori-Amantuan

Why does an orthopedic hospital have a family medicine practice? 

Dr. Otori-Amantuan joined FOCOS six months ago as their first family physician. He explained how his position is necessary to treat orthopedic patients’ comorbidities, as most patients’ pre-operative visit is their first check-up ever, and many underlying issues are discovered. The most common are diabetes, cardiovascular disease and related parts like hypertension and dyslipidemia (high cholesterol), asthma, and sometimes even chronic kidney failure. Locals rarely seek medicine immediately when they fall ill; instead they go to chemists at pharmacies like the ones Emma described or take herbs. Dr. Otori-Amantuan also takes care of the medical concerns of the staff, ensuring the patients are cared for only by those in great health.

What’s a normal day like in his clinic?

The doctor saw both potential FOCOS employees and patients when I shadowed him. An older woman spent a long time asking him questions about her medication, as she is on statins to lower her cholesterol and is very apprehensive about their potential harms. Another interesting patient was a young man applying for a job here. Dr. Otori-Amantuan was very thorough while reviewing the man’s medical history, asking the patient multiple times about past issues and family members’ health whenever he seemed hesitant. The patient’s blood work came back positive for Hepatitis B antigens, though the patient was unaware that he had ever had the infection. Since his assay tested positive for the antigens, he will have to undergo a Hepatitis B profile to see if he is an asymptomatic carrier (had the infection and mounted resistance, now fine but should inform spouse, not give blood, etc.) or actively has the infection (needs to see a specialist and take medications).

What are some of the difficulties of treating Hepatitis B in Ghana?

Dr. Otori-Amantuan said that people sometimes faint when they hear that they have Hepatitis B. Radio stations have widely commented on how expensive treatment is, and people are often fooled to use vitamins instead. Though medical officials have worked hard to explain otherwise, traditional healers oppose them and there is little funding for public health. Practices aren’t allowed to advertise their services, so they have to find other ways to gain public attention, like sharing patient success stories on local radio or television.

What other infectious diseases are common and what are their public health implications? 

Hepatitis A is usually only seen in indigenous populations or people who consume water from a very bad source. Hepatitis C is the most difficult to address, and efforts are currently being made to reduce the extreme treatment costs.

Learning how to read chest X-rays with Dr. Otori-Amantuan

Learning how to read chest X-rays with Dr. Otori-Amantuan

FOCOS screens patients for tuberculosis (TB) but does not treat them here. Fortunately, there are successful  TB treatment centers set up by organizations like USAID and The Global Fund. The Global Fund has also been instrumental in making medication for malaria available here. The US has mass distributed nets and insecticides, and Ghana is fortunate to not have abundant drug-resistant mosquitoes like elsewhere.

A recent yellow fever outbreak occurred during the ebola epidemic, and many thought that it was ebola. However, Ghana was untouched by ebola, and Dr. Otori-Amantuan was actually involved in a workshop at NYU discussing Ghana and other nations’ preparations for potential ebola outbreaks (Read the article here: “Preparing for Ebola Virus Disease in West African countries not yet affected”). He feels that Ghana got lucky, as there were major flaws in ebola preparation spanning from the health system to the government and immigration. Around the same time there was a cholera epidemic in Accra, and “things spiraled out of control”. Multiple regions were sick for months, and over 20,000 people had cholera.

Typhoid is prevalent but many people in Accra buy their food, which helps unless regulations are not enforced. Those who do not know how to properly cook or store their food are most affected, so typhoid manifests among the poor. FOCOS is fortunate to have their own water treatment plant to avoid typhoid and other infections.

What is the perception of HIV/AIDS here? 

HIV treatment here is free, and most of those infected during its peak have passed away. One problem is that people on treatment feel so well that they think they’re cured and do not need to disclose their status to their partner(s). Poorer patients do not comply with their meds and may sell them for money. The stigma of HIV/AIDS is still prominent, with even married couples sometimes not exchanging their status. Polygamy is also common, which can cause a web-like spread of the infection.

What are some other public health issues on the rise?

7.7% of secondary school and university students smoke cigarettes, which traditionally was not a problem here. Dr. Otori-Amantuan explained that there are no regulations on cigarette smoking in Ghana like there are in the US, so tobacco companies can make packages look glamorous and taxes are not raised to hinder purchases. The drinking age is 18, though unenforced. Wealthier youth is becoming more involved in psychoactive drugs due to “cross-cultural fertilization”, as well.

Visiting Patients

Hanging out at JB house

Hanging out at JB house

After my in-depth discussion with Dr. Otori-Amantuan, I visited children in the wards with social worker Paschalina and teacher Auntie Patty. Each child got to pick toys and candy, and they went crazy over their new sunglasses! It was so interesting to see how the children open up to Paschalina about their struggles, like missing home. The patients were so thankful towards me and I was so thankful that I could brighten their days. I then headed to JB House, where I distributed the same goodies and gave temporary tattoos to all of the children. Once they got the hang of it, their arms were covered.

Our favorite tattoos were Spongebob, Dora, spiderman and peace signs. 

Our favorite tattoos were Spongebob, Dora, spiderman and peace signs. 

I am extremely fortunate to be learning so much. Today was another inspiring day filled with smiles, and I can’t wait for the next!

 

Day 3: Meetings, Meds, Meals, and More!

June 8, 2016 is a day I’ll never forget.

Morning Meeting: Diabetes

I started my day at 8 am at the morning conference. Today’s conference did not discuss patients, as all relevant cases were discussed the day before. Instead, a doctor led a presentation on perioperative care of patients with diabetes. He discussed the rise of type 2 patients, and most doctors shared that they had never treated a type 1 diabetic here. Some have seen patients with LADA, or latent autoimmune diabetes in adults. LADA is often seen in adults who have been mistreated for type 2 diabetes with oral medication, when really they need insulin. 18% of orthopedic patients receiving total hip or knee arthroplasty are diabetic, which can cause post-operative complications. At FOCOS, diabetics undergo glycemic control and cardiac risk assessments before their surgeries. The staff here agrees that insulin is the best treatment option because of how easily it’s manipulated. If a diabetic is on non-insulin medications, the staff will switch their meds to insulin for the perioperative period. The bulk of the conversation focused on how surgery is a period of “increased hormonal stress”, and thus proper diabetic care is crucial during this time.

Pharmacy

After breakfast, I headed over to the pharmacy to learn more from Emma, the FOCOS Pharmacy’s licensed pharmacist. Emma is assisted by two technicians. Emma was extremely helpful and let me shadow her, in addition to explaining topics ranging from pharmacy basics to FOCOS specifics.

  • Licensing: The FOCOS Pharmacy is licensed as a community pharmacy, as opposed to a hospital pharmacy. This allows people who are not FOCOS patients to fill their prescriptions here.

  • Costs and Payments: Discounts are arranged with vendors, which are directly taken off patients’ costs. It is cheapest for the pharmacy to buy medications from Ghanaian importers. The pharmacy does not accept most insurances, as they involve poor payments. However, FOCOS has the lowest drug mark-ups compared to outside pharmacies. The  pharmacy receives some donations, as well. Emma commented that many of the patients have the mentality that drugs are expensive and inconvenient, so FOCOS services like free medication delivery and refill reminder calls encourage upkeep.

  • Patient Interaction: It is crucial to thoroughly explain medications to patients. Many patients are on opioids or other medications with strong side effects, or on multiple medications at once. The pharmacists make sure to carefully explain medication timing and spacing in the language the patient best understands, even if that requires a colleague outside of the department translating.

  • Drugs: The pharmacy has everything, from medications for the common cold to secured narcotics. The antibiotics sold are first generation, meaning that they are best at targeting both gram-positive and gram-negative bacteria. Commonly sold medications target infections, hypertension, diabetes, high cholesterol, and pain. Although many medications are from different manufacturers not distributed in the US, they are made by the same pharmaceutical companies, like Pfizer. I saw plenty of familiar medications too, like Lyrica, morphine, propofol, Prozac, Centrum vitamins, augmentin, amoxicillin, Dulcolax, and Zithromax.

  • Rules and Regulations: Community pharmacies are licensed to treat minor ailments, like headaches and malaria, with over-the-counter medications. In Ghana, it is common for pharmacies to illegally sell prescription medications to patients who have not seen a doctor. Similarly, chemical shops (drugstores, like CVS) are supposed to only sell over-the-counter medications, but often distribute prescription drugs. Emma commented on how the regulations are improving, but their enforcement is not. A policy enacted this year allows only one pharmacist to be licensed to one pharmacy, as previously pharmacists could work multiple jobs while leaving technicians unattended at one of the pharmacies. Emma stresses to patients the importance of seeing a doctor and getting a prescription to fill at a legitimate pharmacy.

  • Ordering: Major drug orders are placed every two weeks, though some are purchased so frequently that they’re refilled weekly. Ideally, Emma would like to place orders every few months, so that she could order in bulk to avoid constantly rising prices. This would in turn help the customers save money. However, the FOCOS Pharmacy needs more funding to be financially comfortable enough to place such large orders at once.

Nutrition and Dietetics

Then I headed over to Nutrition and Dietetics, where I met with Melinda, the Assistant Dietician. There is also a Senior Dietician and clinical students. All of the patients at FOCOS must undergo a nutritional assessment. The vast majority of children are treated for being underweight, while many adults’ plans work at minimizing their comorbidities and/or losing weight. The overweight or obese adults of greatest concern are those receiving joint replacements, as their weight can put excess pressure on the hardware. The initial nutritional assessment factors in blood work, body mass indexes, body composition (if over 18), weight, height, arm span, and arm circumference (if under 18). There are two types of BMIs taken; one measurement is calculated from height and weight, and the other is calculated from arm span and weight because spinal patients’ heights will be compromised. The arm span-weight BMI often shows how little the patient weighs in comparison to what their height would be like without their deformity. Arm circumference is larger due to muscle mass on patients with adequate protein intake. Underweight patients’ deficiencies are most evident at their clavicles, ribs,  and buttocks.

The nutritionist sets two or three targets for each patient to meet. With underweight patients, a large concern is the lack of appetite post-operatively that requires them to have energy stores ahead of time. Children working to gain weight eat three meals a day and two or three snacks. All post-op patients must have three meals and three snacks. The snacks are high in calories and energy dense. One of the most common deficiencies is iron, which also dips after surgery. High levels of vitamin C and iron are put into the diet in the form of fruits, vegetables, and protein sources to help with this. Many patients have infections, which calls for high vitamin C and protein, as well. Some patients have GI issues like gastritis or diet-limiting diseases like Hepatitis B, so special meals are planned for them. Patients from outside of Ghana may need to adjust to typical meals, and poorer children may have never had common foods like eggs, fish, or milk. When these children consume certain products for the first time, it may expose novel GI issues. The underweight patients eat plenty of injera, a carbohydrate-loaded flatbread found throughout Africa.

When I asked Melinda about one of her most difficult cases, she brought up our friend Thelma from the other day. Thelma is extremely sick, and you can help sponsor her surgeries here: Help Thelma. Thelma underwent surgery two weeks ago to get a percutaneous endoscopic gastrostomy (PEG) tube, which is inserted in the abdominal wall and passed through the stomach. While some children here use nasogastric (NG) tubes for a few days during their perioperative periods, Thelma is the first to need a PEG tube for long-term feeding. Thelma came here weighing six pounds at almost three-years-old. Before her PEG tube surgery, she was up to almost 18 pounds. She had difficulty with that procedure, having apnea while being woken, meaning her breathing temporarily stopped.

Last Friday Thelma peaked at nearly 20 pounds, but she has since been struggling to keep on weight. Thelma’s compromised pulmonary function causes her to hyperventilate, which expends excess energy. She is given feeds through her PEG tube for multiple hours every night, but she vomits up the majority of her feeds in the mornings. She’s currently 19 pounds. Thelma has delayed gastric emptying and cannot handle protein, so her diet relies on lipids (fats) for energy. For Thelma to undergo her first surgery, she must weigh at least 26.5 pounds for a better chance of survival.

Melinda explained that her job is not only to plan meals and diets, but also to inform patients of the reasoning behind their nutritional needs. She says that most patients are very compliant, and unfortunately their malnutrition is due to circumstance. Poor patients do not eat enough at home, and when they do it’s staples like plantains, rice and oil with pepper sauce, yams, and cassavas. Melinda is most saddened when she sees patients requiring multiple procedures succeed at gaining weight here, only to return extremely thin later on. Weight gain is crucial for the children, as a few patients who could not wait any longer for their surgeries did not survive their procedures because they were unable to put on weight.

Teaching at JB House

In the afternoon, I went on my first visit to JB House, FOCOS’s home down the road for foreign patients staying for prolonged periods of time. There are currently post-op patients from Ethiopia and Tanzania there. I went with the full-time teacher, Patricia, or as she is affectionately called by many, Auntie Patty. My time with the children included reading with English lessons, coloring, practicing addition and subtraction, and eating juicy mango. It was so interesting to say how the children interact and teach one another. Each nation speaks their own main language, in addition to a plethora of tribal dialects. One child who had learned some English previously and at FOCOS was able to understand enough through basic reading and listening to translate to his same-speaking peers. On the other end of the spectrum, a nine-year-old girl had never been to school and was first learning her ABCs. These barriers were a lot less obvious when it came time for math, the universal language. It saddened me observing how intelligent many of the children were, as I know they either do not go to school at home or receive a low-quality education that will not continue as they age and progress. As I led a handful of children through carrying numbers in double-digit subtraction, I felt so fortunate for the education I am receiving. I feel foolish reflecting on assignments I’ve complained about and teachers I’ve “hated”, as these young patients were so eager to learn after major spinal surgeries, and unfortunately this opportunity is a rarity for them.

I apologize for the length of this post, but today was an incredible day filled with lessons and love. Tomorrow I will be shadowing clinic, hanging with patients, and visiting my friends at JB House again, so stay tuned.

 

Day 2: Close-Up With Clinic

I started off the morning shadowing Prof (Dr. B) on his 7 am rounds. Here are the cases that I found most interesting:

Edmond before his halo fitting 

Edmond before his halo fitting 

  • Edmond: Edmond is a six-year-old boy whom a surgeon has kindly decided to sponsor. He has a spinal neurofibroma, or a nerve sheath tumor (“soft mass”), accompanied by kyphosis. Kyphosis is an “exaggerated rounding of the back” that is frequently treated here (Mayo Clinic). His curvatures measure 88 and 80 degrees in his high thoracic spine. Today Edmond was fitted for a halo to put him in gravity traction. Traction uses a weighted halo around the head attached to an upward string-type to lessen severe curvatures by decompressing the spine while the child spends time in a wheelchair fitted with the contraption. I got to hang out with Edmond later, and with the help of a bilingual nurse (many of the children speak English but he cannot), I learned that the energetic boy is a little shy, but likes to play soccer and run around.
  • Thelma: Thelma is a delightful and very tiny three-year-old girl from Ghana. Thelma’s parents do not make enough money to afford the extensive treatment she needs and you can sponsor her surgeries here: Support ThelmaThelma came to FOCOS with such severe congenital kyphoscoliosis that her pulmonary function was extremely compromised and she could barely breathe. Although Thelma still faces many obstacles, Prof is confident that they have made progress in her treatment through traction (her curve has already reduced from 160 to 70 degrees) and that they have saved Thelma’s life with this process. Prof admitted that if Thelma was admitted any later, she likely would have died. I learned a lot about the difficulty of traction treatment in small children by observing Thelma’s case. Thelma’s halo started around 9.2 kilos and is now up to 10 kilos, but Prof wants to see her work up to about 13 kilos. In addition to the need to increase halo weight, Thelma cannot undergo her first of multiple growing rod surgeries until she gains weight. She is currently using a GI tube and working with the nutrition department to “just eat all day”.
  • Another patient that we saw was a seventeen-year-old male from Sierra Leone, who also underwent surgery later on. The patient had such severe kyphosis (211 degrees) that his thoracic spine had cross over the lumbar spine, looking like an S from his right side where the top “C” half of the S had curved outward so much so that parts of it were below where the normal lower half of the spine was once alone. This extreme condition caused destruction at the apex and required a dangerous procedure involving resecting the spine just posteriorly, as the risk would be too extreme adding in an anterior approach.

Next I joined the doctors and research staff for their morning conference, where each member presents their respective cases complete with blood levels, x-rays, MRIs, SRS-22 Patient Questionnaires and FOCOS Risk Scores, and treatment plans. The cases were fascinating. First we discussed the patient from Sierra Leone that I detailed above, as his surgery was just a few hours later. His doctor shared x-rays and curvature measurements from each month of traction. At the 5 month traction mark, the patient’s progress plateaued at 116 degrees, which is an astounding improvement from his original 211 degree kyphosis.

One of the wards for pre-op, post-op, and extended stay patients

One of the wards for pre-op, post-op, and extended stay patients

I also learned more about the case of a thirteen-year-old Tanzanian male with early onset scoliosis, who I had seen earlier and was also scheduled for surgery. The patient had previously been unsuccessfully treated for Pott’s Disease (spinal tuberculosis), as well as braced with no success. After six weeks in halo traction (of a total of eight), this patient’s largest curvature (he has three) decreased from 96 to 61 degrees. The surgeons discussed that it was safest to do the procedure just posteriorly, but that the limiting approach would require them to really affix the apex with multiple screws to prevent rotation. Prof detailed making “the spine so rigid that it cannot turn”. It is rare for a spine to be able to re-curve against so many pedicle screws at multiple fixation points. The doctors also discussed potentially using wires in the procedure for further stability. This patient’s procedure will only require one rod, because his 57 degree kyphosis is “not so bad”, or at least in comparison to what is typically seen at the FOCOS Hospital.

The discussion then moved to discharged patients, and it was truly incredible to see the progress that they had made. One patient was a young female with early onset scoliosis who had a growing rod implanted through her entire thoracic and the majority of her lumbar spine. The patient’s curvature was reduced from 109 to 19 degrees! Next up was a seven-year-old female with early onset scoliosis who had a Shilla growth-guided procedure modified by the FOCOS Hospital known as FBGM, or FOCOS Bidirectional Growth Modulation. Her spinal hardware included a hook and reduced her curvature from 60 to 24 degrees. Adult patients discharged included two laminectomies for lumbar canal stenosis, a left total knee replacement, and a procedure for bilateral knee osteoarthritis.

The OPD

The OPD

In the afternoon, I met with Justice, the Manager of the Outpatient Department (OPD). The clinic is open five days a week by appointment only, and each day has specific specialists. Some days are for orthopedic surgery, some are specifically for pediatric orthopedic surgery, and others are for neurosurgery. Some of the doctors are permanent FOCOS employees, while others are visiting doctors that come on certain days each week and receive a portion of what their patients pay. Permanent staff includes specialists in neurosurgery, orthopedic surgery, and general and family practice, as well as residents from a nearby medical school. The clinic also includes anesthesia clearance for pre-op patients. Justice handles all of the billing; each patient undergoes a financial assessment to see what they can afford. People are only charged reasonable amounts that they can pay (some appointments are “virtually free”), and Justice takes care of patients in severe financial situations by finding them sponsors (Click here! Anything helps!). In Ghana, few people have insurance, and there is no system equivalent to US Medicaid and Medicare. Many patients come from outside of Ghana through partner organizations and other sponsors. Justice talked about how severe some of the cases from Sierra Leone are, especially because of how financially troubled the nation is. Ethiopian patients are also brought here often through the American Jewish Joint Distribution Committee. Prof will actually go to Ethiopia next week, as less acute care is needed for this trip and the medical professionals there will be able to handle post-op care.

Hanging in Justice's office, filled with lots of surveys and even more bills. 

Hanging in Justice's office, filled with lots of surveys and even more bills. 

What I found so amazing was how hard the doctors work with patients with existing diseases to allow them to be safe for surgery. Many patients come in with conditions like diabetes or hypertension, but the doctors work with their patients and the pharmacy to track their progress until they are healthy enough to have their orthopedic deformities fixed. Only two surgeries have had to be cancelled in all of FOCOS history due to health, and the patients had severe cardiac disease and a cancerous lesion. FOCOS distributes and analyzes surveys every quarter given to patients regarding the quality of the clinic (wait time, doctor’s performance, cleanliness, etc.). I was so blown away that this organization, which takes incredible measures for those in need, cares so much about their patient experience. No doctor in the US would ever ask me if I minded my wait time! As Justice and I discussed the clinic’s quality, I couldn’t help but notice that on top of everything, Spongebob was on for the children in the waiting room. The hospital has two ambulances, which are mainly used to transport severely disabled patients. As per protocol, the ambulances stay at the FOCOS Hospital on surgery days in case of emergency, though they’ve never been used for this purpose.

Today was incredibly moving and informative. I am excited to spend more time with the exceptional doctors and brave children and cannot wait for what the rest of this journey has in store. Thanks for reading, and please stop by FOCOS’s Sponsor A Patient Page!

 

Day 1: Planning and Preparing

After a ten hour flight, I landed at Kotoka International Airport earlier than anticipated around 7:45 am Monday morning. After collecting one large duffle and two even larger cardboard boxes of supplies from baggage claim, I navigated my way to the exit, receiving some assistance from lovely airport personnel after my belongings flew off the cart mid-downward slope. Once I got outside, I was greeted by the friendliest FOCOS driver who helped me cram everything into the car and shared interesting tidbits about his homeland on the way to the hospital.

Once at the FOCOS Orthopedic Hospital, I met up with Chief Administrative Officer Leticia and other administrators to fill out some paperwork and get my mandatory badge. I then received an orientation packet, in addition to listening to a presentation more specific to volunteering at FOCOS. The presentation focused on the organization’s mission, staff values, expectations, and, most importantly, why FOCOS’s work is so important. I was previously aware that Ghana had a low physician density (or fewer doctors than needed based on the size of its population), but did you know that as of the most recent report, Ghana has roughly one doctor per 10,000 people? And that’s with rounding up. Needless to say, specialties like orthopedics are often forgotten and there are only twenty-something orthopedists in the entire nation. This is shocking and heartbreaking due to the abundance of extremely severe orthopedic deformities in Ghana. Just waiting to get my blood work and chest x-ray done today (before being cleared to shadow and interact with patients), I saw spinal deformities beyond anything I had ever witnessed in person before. Many of these spinal abnormalities are due to tuberculosis, a bacterial infection that typically affects the lungs but “can attack any part of the body such as the kidney, spine, and brain.” (Centers for Disease Control and Prevention). My first day also included sitting in on a monthly meeting with all the department heads, checking out the cafeteria, itemizing the donations I transported, and planning an exciting itinerary for the next few weeks.

All of my potential fears have been completely lifted with my first taste of Ghana. The hospital staff is so thoughtful, respectful, and best of all, friendly. On just my first day I felt welcomed and already at home. My accommodations are superb and most definitely will allow me to get a good night’s sleep before tomorrow’s 7 am start. Until tomorrow!

 

T-minus 24 hours until Accra

As I sit on my floor, simultaneously curating my first Ghana-themed Instagram and struggling to write this blog post (I’ve never done this before so bear with me), I look up at my clock only to realize that at this time tomorrow I’ll be boarding my flight to Accra, Ghana…I realize that I shouldn’t have said that because my flight will now undoubtedly be delayed. Anyways, I’d like to use my first blog post to explain my internship and what I’ll be doing in Ghana during my two and a half week stay.

Me and my brace, which is now used at the FOCOS Hospital

Me and my brace, which is now used at the FOCOS Hospital

If you knew me at all between the ages of nine and sixteen years old, you likely recall a lanky and jubilant Lara always enwrapped in or close to her scoliosis brace. My experience with adolescent idiopathic scoliosis is one that I am ever grateful for. My spinal curvature and its extensive treatment taught me many important lessons, like the insignificance of appearance and the value of discipline (wearing a piece of plastic around you for 20 hours a day ain’t easy). But most importantly, my scoliosis was my introduction to the world of medicine. Every minute in my back brace was worth it, as my struggle with scoliosis allowed me to uncover my love for medicine, especially orthopedics.

My doctor, Dr. Oheneba Boachie-Adjei, who at the time was the Chief of the Scoliosis Service at the world-renowned Hospital for Special Surgery, is the most humble and inspiring man I have ever had the honor of working with. Not only did Dr. B successfully treat my scoliosis, he mentored me in scoliosis research, which helped me decide to pursue pediatric orthopedic surgery (we’re talking long-term here, as I’m currently glaring at a stack of MCAT books). I am so fortunate that Dr. B introduced me to his organization, the Foundation of Orthopedics and Complex Spine (FOCOS). Through working with FOCOS and other similar organizations, I have decided to pursue a Master of Public Health in addition to medicine. Dr. B founded FOCOS after his own struggle with illness as a child in Ghana, and I encourage you to read more about his inspiring story and all that the foundation does here: FOCOS’s mission Great video about Dr. B’s story. There are more details on this blog’s “About FOCOS” page, as well.

Massive box of medical supplies I will be bringing with me.

Massive box of medical supplies I will be bringing with me.

FOCOS now owns and operates a comprehensive non-profit orthopedic hospital in Accra, the capital of Ghana. Patients from all over the world travel here to undergo extreme spinal and other orthopedic procedures, in addition to rehabilitation. These past two weeks I have interned at the FOCOS office in New York, learning about all that goes into building such a phenomenal organization, from raising funds to delivering supplies. However, I am most excited for the latter half of my internship that lies ahead. My 17 days in Ghana will involve shadowing surgeries, helping to prepare patients for surgery and rehabilitate them afterwards, and sharing special moments with the many children who live at the hospital for prolonged periods of time without any family. I am most excited to be immersed in the Ghanaian culture, teach and play with the pediatric patients, and study the many rare diseases and disabilities that Dr. B and his staff encounter. I will update this blog as often as possible with the unique stories and emotions that my time at the FOCOS Orthopedic Hospital will bring. And until my next post, nanteyie! (That means “bye” in Twi).

Treats for the children

Treats for the children

Meet 2016 FOCOS Emissary Lara Cohen

The YLF Emissary Program is proud to announce the 2016 emissary interning in the FOCOS office and traveling to Ghana this summer is Lara Cohen.  For those of you just tuning in or new to FOCOS, the Emissary Program was established in 2014 to offer young professionals the opportunity to volunteer in the FOCOS Orthopedic Hospital.  Lara will be in Ghana for two weeks, starting this week, and will keep a blog of her experiences to share with all of you.  Interested in being the 2017 Emissary? Click here to learn more on how to apply: http://bit.ly/1YLFFOCOS

Meet the Emissary:

My name is Lara Cohen and I am a pre-medical student at Boston University working towards a Bachelor of Science in Human Physiology and a Master of Public Health. I am extremely honored and excited to be a part of the Young Leaders of FOCOS Emissary Internship! I have been interested in medicine and specifically orthopedics for as long as I can remember. Growing up, I was fortunate enough to be treated by Dr. Boachie-Adjei for scoliosis. He has inspired me immensely as I have matured and decided to pursue global medicine. For the past year I have been working as a Research Coordinator in the Orthopedics and Sports Medicine departments at Boston Children's Hospital, where I just finished working on a study developing outcome measures for pediatric shoulder and elbow injuries. I have previously worked with the Scoliosis Service at HSS and FOCOS, in addition to Orthopaedic and Neurosurgery Specialists (ONS) at Greenwich Hospital with Yale New Haven Health. I am grateful to see FOCOS's sustainable development model in action in Ghana by observing the training and education that occurs at the hospital. I am looking forward to learning more about the rare conditions that FOCOS specializes in as well, and hope to shadow some surgeries while there. I am most excited to interact with the patients and learn more about them as we interact through activities like art, learning, and just playing around.