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.
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.