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.
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.
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.
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.
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!