I had some hang-ups on the trip home.  Let me review: My departure from Accra was 4 hours late.  The flight was smooth and I had pleasant neighbors, and there was even an episode of The Office shown toward the end of the flight.  But about an hour from JFK it was announced that the airport was closed and that we had enough gas to wait for about 40 minutes, then we would have to land or make the decision to divert to another airport.  We landed at JFK and met the chaos of frustration at the jammed baggage claim and long lines of people waiting to find out how they were going to get home.  By midnight I had my 7am connecting flight to Salt Lake reserved.  I should have been sleeping in a Salt Lake hotel room, but instead I hauled my 3 bags all the way to a terminal where I could sit and eat without going through security.  I slept for an hour with my head on a table and went back to my terminal to check in at 4:30am.  I sat down at gate 10…then it was changed to gate 29…so I walked some more.  I was relieved to get to my seat on the plane…then my window was leaking on me.  Salt Lake was good to me.  It was a relaxing afternoon of touring Temple Square and resting at the airport.  I had milk for the first time at The Lion House, a moment I had been anticipating during my stay in Africa.  I was on the verge of losing my voice throughout the day, but I took advantage of a working cell phone anyway.

Sunday my family fixed a meal for me and a Cardinal game was on TV.  I got to give my niece the matching dresses I had Joyce make for her and her American Girl doll.  I let my nephew know that I remembered that he is 5 now.  He said it’s alright if I wait until I feel better to take him to the store for a birthday present.

There have been a few memorable cases throughout the week.  Last Friday I was given a patient’s card in clinic that said, “bitten by mad dog 1 week ago”.  That was the first time I ordered a rabies vaccination series.  His dog had started biting other dogs and then bit him before he was able to kill it.  I saw a case of tetanus for the first time as well.  The man had lockjaw and very tense arms.  He was sent to the isolation room within the isolation ward because part of the management of tetanus is to limit the amount of stimulation from light and noise.

Carpet vipers were fiesty the other night.  I had to get 4 viles of ASV to the wards in just one evening.  I was handed a chart that I expected to be a routine case, but when I got to the bed it was a 7 year-old boy and he had blood all over his face and ankles.  I hadn’t seen a snakebite victim who was actively bleeding, which is the outcome we treat to prevent.  Unfortunately, the boy’s tribal markings were placed the day before he was bit and the anticoagulant venom was causing them to bleed.

One new admission on my last call was a very weak 14-month old boy whose belly was distended.  I got Dr. Faile and he pointed out that the outline of loops of bowel could be seen on the tight abdominal skin.  We took him to the operating room late that night and found that the bowel was inflated like a balloon and there was an intussusception in the ileum.  It reduced well and I left feeling great that I had the opportunity to see an intussusception case from the time it presented through the operation.  I was not expecting to get a knock on the door at 2am to come see the child.  I guess he was just too weak before the surgery and didn’t survive through the morning.

Saturday I went to the market to find fabric for Joyce to make me a dress.  That night, she and Yisah invited Julie and I to dinner in their home.  Yisah handed us the 2-foot tall broom you have to bend over to use, and the dust pan, and told me, “Janie, you are going to work in a traditional African home today.”  So Julie and I swept the courtyard where the cooking would be done.  She had a few ingredients brought from the market to make banku.  I stirred the fermented corn which would become large balls of a playdough-like substance that we would pour a spicy stew over.  In Africa, eating is done with the right hand.  So we passed around the bowl of water to wash our right hands before eating the banku.  It’s not something I would want to eat again, but Julie and I kept putting another bite to our mouths because we were so appreciative of them inviting us over and taking the time to teach us a few things about their cooking.

This will be my last post before leaving Nalerigu.  I’ll spend one night in Tamale before leaving early the next morning to fly to Accra.  The next couple days will be a frenzy of picture-taking and getting all the information I need to stay in touch with people here.  You’ll hear from me in Accra, and I’ll add pictures to all of these posts when I get home.

Market is every 3 days, and I decided to go after rounds on Thursday.  Julie had already been there and went with me.  There were lots of waves from just about every child on our way there.  I heard them yell, “Silaminga!” to their buddies or to get my attention.  Silaminga is “white woman” in Mampruli.  I respond to it well by now.  The market had a lot of food and clothing, but my only purchase was a few packets of laundry detergent.  The markets in this part of the country have mostly things that are needed by the people.  The markets I saw in Accra were geared to tourism, and they bothered me to look at their things a lot more.

There have been a lot of new faces at the BMC this week.  A group of doctors arrived Wednesday from Massachusetts and will relieve Dr. Faile while he’s in the states for a couple weeks.  They have all been here before and knew what to expect.  The larger staff was no match for the patients who came to clinic on Friday, however, as it lasted from 10am to 9pm.  Before then, I had only admitted one clinic patient out of all the clinic days.  I admitted 4 on Friday.  I wanted Vince, one of the visiting doctors, to give me some direction on one of them, and as I waited I just had to wonder if the patient would make to one of the beds alive.  He ended up having surgery that night.  The findings were a typhoid perforation that likely happened days ago and pockets of pus throughout his abdomen.  The most shocking sight was a very severe case of paraphymosis.  I had never seen a case before, but the look on Vince’s face when I had him see the patient was telling of how severe it was.  Since we’re usually out of clinic by 6pm, I could tell that the translators were a little disappointed that we were still there so late.  I tried to kill some time as we waited for more patient charts by asking them how to spell their names and writing them in my notebook.  Agnes told me to write, “Agnes is #1″, and Lamisi wanted to give me her address, too, so that I could send her some gold when I get back to the states.  We laughed, and they laughed harder when I told them that we were doing pretty well to be so happy when we’re in clinic at 8:30pm.

Today was rounds as usual and then one procedure after another.  There was a malaria baby with a hematocrit of 13% that had no family members with matching blood types.  I was a match and I went to the lab to give blood after lunch.  I was hoping they would just trust that I knew my blood type, but instead the lab tech jabbed by finger with a primitive-looking lancet to type my blood.  I cringed as I sat up on the donation table.  It was nice to see how thankful the family was, and they were able to express it without a single word.

We all took a break in the afternoon and changed into our Mamprusi-appropriate clothing to go to the Nayiri’s palace to greet him.  The palace is a small compound with about 10 huts attached to the courtyard.  Each of his wives had her own hut and his area was 2 rooms that were also connected to the courtyard.  I was given a few pieces of advice by the others in the group before I walked into the greeting room.  I was told not to make eye contact with the chief and to keep my heels pointed away from him.  There was also a hand maneuver we were supposed to do at certain times when the men clapped.  It involved flicking the pinky finger on one hand with the index finger of the other.  We walked into a room that had about 4 couches lining 2 sides of the room and the chief was at the front sitting on a platform.  A lower-level chief translated his message to us, which I was told later was a series of proverbs.  He talked a lot about how great the BMC is to his people and how they are willing to give more of their land to the hospital.  When he finished his message it was announced that we had permission to take pictures of him and the palace.  We walked around in the courtyard for a while and watched all of the kids playing and begging to have their picture taken.

When we got back from that intense experience, Vince guided me through a pleural aspiration procedure.  I got 10cc of pus and then they placed a chest tube.  There are a lot of opportunities for experience in procedures here, and I’ve been able to do things in the last few weeks that I thought I may never get to do as a medical student.

I was in the operating room a few times last week.  I watched Dr. Faile repair a cleft lip on Thursday.  Then I assisted on an above-the-knee amputation of an older woman’s gangrenous leg.  He let me do the sawing.  When I tried sawing on the next amputation case, which was a young man, I didn’t get very far through the bone before I had to have Dr. Faile finish.  Another case was a seven year-old girl who had a surgery several days back because her bowel perforated from a typhoid infection.  When she came back for a dressing change, her wound had dehisced and her intestines were coming through the open wound.  We suctioned little pockets of pus and reapproximated her fascia and skin.

On Monday, Wednesday, and Friday I was given my own clinic office to see patients.  I saw 149 throughout the week.  At registration their complaints are written on their chart, which is like a little stack of large index cards stapled together.  Some cases are straightforward.  Some completely stump me until my translator gives me hints, such as for a man on Friday who was telling me about his abdominal pain and other unrelated things.  I kept asking questions, but finally the interpreter told me that he wasn’t really having pain.  He just believed local witches cast a spell for him to get this pain and he wanted something for when the pain would come.  Tylenol it was.

Dr. Faile’s office is adjacent to the one I’ve been using.  Usually at least once during a clinic day he will walk in and ask if I’d like to see something interesting.  On Friday he walked in and asked if I’d ever seen someone who had been struck by lightning.  I walked around the corner and a woman was writhing with purposeless movements on a stretcher.  She had a 2-inch hole through the flesh on the very top of her head.  The bone was visible and the area looked singed.  Dr. Faile admitted her because she had stopped taking food at home and was slipping mentally.

I left a note on my door saying I was at 2nd Baptist Church this morning.  If there’s an emergency, the nurses can ride their motos to the churches to find the person on call.  The kids in the village that I’m familiar with found me before 10am and walked me along a thin dirt trail that winds through all of the mud huts.  There are goats and pigs in some of the yards, and tiny patches of corn here and there.  I get lots of waves wherever I go.  The kids are trying to teach me some Mampruli greetings, but I haven’t picked it up yet.  Church was in a one-room building that had 3 sections of plastic lawn chairs.  Men sat on the left, most women in the middle, and children with some other women on the right.  Yisah was there and told me to sit in the middle.  I was impressed by the music.  It was a lot of rhythm for one room.  Isaaku, the man who drove me from Tamale to Nalerigu and changed the flat tire, was a deacon there.  At one point when he was speaking, everyone turned to me and the few other white women sitting near me.  Yisah told us we were supposed to stand up and introduce ourselves.  We then got a big round of applause.  Everyone turned to us and laughed at one point in the sermon, but I’ll never know what that was about because most of it was in Mampruli.

 I didn’t think afternoon rounds would take as long as they did, and I was stuck at the hospital without a flashlight this evening.  There are no phones to reach the people I know in the guest houses, so I had to brave the dark to make it back home.  I stood in one spot for a few seconds hoping my eyes would adjust, but the trees are low and branch wide, covering the trail from the moonlight.  The whole experience was enhanced by the bats that fly low through the trees in the early evening.  I just took it slowly and made it by feeling whether it was grassy under my feet or smooth like the clay trail.  Lesson learned.

After rounds Saturday morning I was able to get away with a group that was going to the town of Nakpanduri to spend time at the Gambaga Escarpment. We took a trail about a quarter mile from the road and found the large rocks that are high above the plain. I needed some help getting up there because of the height, but it was worth conquering my fear because the view was amazing. We sat there for 40 minutes or so and left when we heard thunder. I have seen the rain here twice, and it is a downpour every time.

Sunday I split call with Heather, the family practice resident who is staying in House 7 with me. We finished late rounds through all the wards about 9pm and came back to the house. If there is anything urgent, a nurse will ride a motorbike to our house to get us. Or if there’s a routine admission that just needs orders signed, we can take care of it without having to walk the trails in the dark. At about 10:30, just as I shut off the shower, I heard a frantic-sounding nurse say to Heather, “Car accident. 20 people.” We grabbed our flashlights and got another resident and student to go with us to the hospital. There were 3 patients on stretchers in the hallway by the procedure rooms that had gashes on their faces and knees that we ended up stitching that night. Several had broken wrists. One had a dislocated hip. Just beyond the doors leading to the wards was a lady that had died. I had another student run with me to get Dr. Faile from his house, and we also got a visiting OB-Gyn doctor to come help. There was a row of patients with minor injuries in the hallway when we got back.  While we were putting stitches in one lady, Elisabeth Faile stood by her side and translated for us. We learned that they were all market women who had been to the Nakpanduri market that day.

I was asleep by 1:30am, on the couch so I could hear the nurses knock. The only knock came at 3am. She needed an order for anti-venom and clot time and for me to get an ASV vile for her since the pharmacy is closed at night. I followed the trail to House 6 and got a vile from their fridge.  It’s very convenient to have it close by.

Monday was clinic day. My first patient had an eyebrow laceration from a bike accident. So the first hour of clinic I spent stitching him up in the procedure room. The rest of the day I saw a total of 43 patients and left the hospital at 6:45pm.

On Tuesday morning our driver picked us up from the guest house in Accra and drove us the 2.5 hours up the coastline to the city of Cape Coast and the castle where the British headquarters of the transatlantic slave trade were. Our guide took us in the male and female slave chambers, punishment rooms, cells, and the chambers where governors stayed. The view from the castle is beautiful and you hear waves crashing on the beach throughout the tour. After seeing the castle, we drove north to Kakum National Park and did the canopy walk through part of the rainforest. The walkways are mostly made of rope with boards covering metal ladder-type structures to walk on. They were very, very high. Unfortunately I was so focused on holding on and getting to the next platform that it was difficult to enjoy the scenery. One boy thought it would be funny to walk right behind me and shake the ropes until we got to the next platform. That was pleasant. The long drives have been my favorite part of the experience so far because everything I see is so different and interesting. Every few miles there’s a village next to the highway that consists of 10-20 small wooden huts with several people in the yard doing their daily work. There are schools along the highways, too, where hundreds of children will be playing outside, all in the same uniform.

On Wednesday morning, Fusheni picked us up and drove us to the airport at 5am to catch our flight north to Tamale. We just took a seat and Fusheni checked us in. We didn’t have to show passports or anything. The flight took an hour, and the real adventure began in Tamale. The two men sent by the BMC to pick us up put our things in the van and we were on our way north. Ten miles out of Tamale our back tire was completely flat. I looked back at Heather and we had a mutual fear that there was no spare tire. There was a spare, however, and the men got it changed quickly. I saw several women walk by, carrying their goods to market on their heads, while I stood on the side of the road as they changed the tire. We stopped about 100km later in Walewale to have the tire patched. I got a picture of the thatch-roofed tire shop. When I got out of the van, a gentleman offered me a seat on the big pile of tires under the thatch roof. I can’t understand the languages, but some of the people know just enough English to communicate simple things.

The road to Nalerigu from Walewale was a really rough clay road that had potholes and areas that had been washed out by the rainy season. The land was the most beautiful I have seen so far. Instead of wooden huts that I had seen near Accra, all of the homes in the small villages along the road were made of mud. The clay road went on 56km to Nalerigu. We pulled into the town and went through the gates of the BMC. As we pulled in, we could see the front of the hospital was covered with people lined up to be seen in clinic. I was a little overwhelmed by the site of so many people waiting to be seen. It was also market day which makes the clinic busier. Our driver then took us to House 7 to unload and settle in.

The rest of the afternoon I got an introduction to clinics from Dr. Faile and Kate, a visiting OB-Gyn resident. I saw infertility patients with her until 6:30pm. I probably did 15 bimanual exams in my first few hours at the hospital. I never would have guessed my first task would be to examine and advise women here on how to improve their fertility. The last two days I have been rounding with the doctors to learn how to manage some of the common things.  Today I worked with the family practice resident I’m staying with, and we saw 83 patients from 10am to 5pm. One of the last ones of the day was a snake bite, and the guy brought the dead snake in a plastic bag for us to see. It doesn’t really matter whether it’s a carpet viper, which has an anticoagulant venom, or a cobra, which has a neurotoxin venom, because our anti-snake venom is multi-valent and covers all the common bites. Dr. Hewitt told me that most bites are from carpet vipers because they are a very aggressive snake and will strike people who sleep on the ground outside when the hut becomes too warm. Cobras are less aggressive and only strike when threatened, like when boys reach in a hole hoping to pull out a rat for dinner, but instead get a cobra bite. Besides snake bites, other common presentations are malaria and typhoid. There are a lot of I&Ds and debridements of wounds to be done. I’ve only seen a couple procedures so far, but I’m impressed with how much tolerance patients have for pain. We only have local anesthetic injections or ketamine to give for some things that would be done under general anesthesia in the states.

The hospital is a little less than a quarter mile from the house I’m in. I have to take a flashlight to clinic every afternoon because it is completely dark by 6:30 and impossible to see the trail back home, not to mention that the snakes that are nearly the same color as the dirt trail. All I’ve seen so far are large frogs … and the gecko that was on the interior side of our door when we came home from dinner last night. I check under my bed, between my sheets, and behind my curtains for critters every night before going to bed.

I’ll be on call Sunday with a resident and hopefully start taking call alone one night next week. Call means making afternoon and evening rounds in all the wards on patients that had lab work to be reported by the nurses as well as signing the orders on any new admits overnight. Sometimes there will be a serious case they want us to come look at, but most often the nurses will walk to the house of the person on call and let us sign paper work without walking back to the hospital. The pediatric ward is full of malaria patients, and once I have the protocol down I hope to relieve the doctors of some work and handle as much as I can by myself.

It’s going to be a busy 5 weeks! I can’t imagine what it will feel like to be in NYC and Salt Lake on my way back home. A few medical students will be leaving next week, which is sad because they are very nice people and I have thoroughly enjoyed their British and Swedish accents.

After leaving my things at the guest house, I had a great opportunity to see the city of Accra with a couple other people who will also be heading to Nalerigu on Wednesday. Johnny was our driver and an excellent tour guide. His family is Ashanti but he was born in Accra. He did the bargaining for us at the markets and took us to the Kwame Nkrumah museum and Independence Square. It was a pleasant surprise to hear George Straight singing “Somewhere Down in Texas” on the radio in the car. I assumed I wouldn’t be hearing any American music for 6 weeks.

The guest house has a lot of conveniences. I just had a fried chicken dinner with the 6 other people who are staying here tonight. There was a bottle of filtered water in the bathroom so I don’t have to use the tap to brush my teeth. And there’s even a little hot water heater I can turn on for my showers if I want to. It’s also nice that the office here can exchange US dollars for Ghana cedis so that I didn’t have to search for a currency exchange in the city.

I think Johnny is going to take us to Cape Coast tomorrow. I’ll try to post again before heading north.