We returned to the airport around an hour before boarding.  The small suit case that I had intended for a carry on was too large, but with a little smiling, the guard let me take it to the side of the plane to check instead of having me to go back to the front and pay for it as a third checked bag. 

The flight was long, about 12 hours.  I got a fair amount of “Three Cups of Tea” read and snoozed on and off.  I sat next to an American Ghanaian who had never visited the northern area of Ghana.  It seems to be a common theme with those from Accra.  The flight arrived late at JFK and we missed our connection to Detroit.  Delta put us up in a hotel and scheduled an early flight to Detroit the following moring. 

It was a short night of sleep, but the hotel beds were the most comfortable place I’d slept in for the past month.  A hot shower felt amazing after the ”cold” flight, and I was excited to rinse my toothbrush in tap water from the sink.  The alarm went off far too soon and we headed back to the airport. 

The flight from JFK to Detroit was much shorter, and we worked on our presentation for the residency program during the five hour layover.  It made the time go by faster and we got the presentation about half done.  It will be challenging to work on it together since I’ll be in Des Moines for the next month, and Jill will work nights. 

The flight from Detroit to Cedar Rapids was even shorter.  The beautiful green grass and trees, fresh air, and cool breeze made me instantly feel at home.  It was a stark contrast from the red, dusty fields, mud huts, dirt roads, and blazing sun of northern Ghana.  Jill’s husband, Joe, picked us up at the airport and dropped me off at home.  Curt arrived from his most recent conference a few hours later. 

It was a wonderful month of learning tropical medicine hands on, serving by treating patients as best as I could and allowing the permenant staff a little time off by taking calls, meeting new friends, and learning about a different culture and language.  It is also good to be home.

The alarm went off at 3:40am and we quickly got ready for the day. Greg and Essa, our driver, arrived with a truck and we loaded the suitcases, trunks, and cooler. Greg prayed for a safe trip and that Essa may avoid hitting goats and donkeys on the way. It was still dark when we pulled out of the BMC gates and into the streets of Nalerigu. Sleeping goats were scattered over the red dirt road, and some awoke to move out of our way. We zigzagged around the ones that did not get up. Two other passengers rode with us to Tamale. We dozed on and off while Essa drove. As the sun came up, we could see that the fields that had been nothing but dry, red dirt dotted with black plastic bags when we arrive a month ago had now turned moist and green with the rains.

Essa dropped us off at the airport and we got assistance lugging our baggage to the line. No one checked IDs, asked names, or questioned the PB&J sandwiches Wendy sent with us or the multi-drug resistant TB sputum sample we were carrying. The flight was very smooth and a driver was waiting to take us to the guest house. On the way, he took us to the University of Ghana to drop off the sputum sample. He drove through the university grounds, pointed out the dorms, and let us follow him into the laboratory. It was quiet due to the break.

We stopped at an ATM on the way back and asked where we could find chocolate for Anna. We stopped at a grocery store, but they did not carry Ghanaian chocolate. He said he would go to market for us and arrange for a box.  Later on, he found us and said that he was unsuccessful at locating the chocolate, but not for lack of trying.  During the day, we napped, blogged, and took a walk to the Global Momma’s shop in the Osu district.  It was a cute store with lots of clothes, placemats, and scarfs made by women in villages all over Ghana.  Most things were made from botique fabric and items were sold for fair trade.  We ate supper at the guest house and met a number of Americans spending time in Arfica for various reasons: such as peace corp, fish and snail farming, and medical work.

I miss Nalerigu, but now that we have made the first leg of the trip, I am even more eager to get home and see my Curt.

There was one other patient to be seen, a man with a snake bite who was admitted the day before. His third clotting time was normal yesterday afternoon, but the nurses had forgotten to show me the patient. He was to be discharge the previous afternoon, so I wrote discharge orders at 5am and he would leave when the morning arrived.

I went home and tried to sleep until the alarm, but thoughts of the 17 year old pregnant girl kept me awake. I had just fallen asleep when it went off and we prepared for our last day at the hospital.

Jill and I rounded on the pediatrics ward. Most of the kids were doing well. I changed antibiotics on a child with bloody diarrhea, and talked with a mother of twins about attempting to nurse the second, smaller twin prior to offering expressed breast milk. My little Rasida was smiling and acting well except for the abscess incisions that were still draining. Her fevers and cough had improved, but there were two new abscesses that were nearly big enough to I&D. I helped one of the newly arrived medical students attempt to drain one, but no puss came out. We left the second alone. Her mother let me take a picture and I said good bye. I hope and pray that she is able to heal.

Susanna, Jill, and I hurried back to the houses to meet the rest of the ladies for our outing to the witches’ village. The “witches” live at a shelter for women who have been labeled as “witches” by the community and ostracized. Some years ago, a Peace Corps worker found out about the “witches” and donated beads and taught them how to make jewelry. She took the necklaces and bracelets they made and sold them in the States. Recently, she sent the money from the sales to Mona to return to the “witches” so they could purchase more supplies. There are around 90 “witches” who live together with their children and apart from the rest of society for their own protection. Accusations about being a witch can be based on anything or nothing, and once labeled, it is very difficult for one to prove one’s self not a witch. Besides jewelry, they also make soap to sell and they have an electric mill to grind millet and corn for the community. Mona presented the money to the group and Wendy spoke about the unity of women and our need for love and respect. She encouraged the “witches” saying that God provides the love and security that all women desire even when other people do not offer love. We prayed together and the “witches” seemed appreciative that we had come. There were not many necklaces or bracelets available for sale since a group had come in the day before and bought much of the completed work. Each of us was able to find something to buy to take home.

We arrive back at the BMC and headed back to the hospital for clinic. Most of the children had already been seen my Nelson, one of the medical assistants, so Jill and I saw mostly adults for the rest of the day. A newborn came in with an undescended testicle. I referred him for ultrasound to look for the missing testicle and advised his mother that if it does not descend on its own, it should be repaired surgically when one of the visiting surgeons come. A seven year old came with a laceration in his armpit where he had been kicked by a donkey earlier in the day. A little girl had fallen from a tree and broke her proximal tibia a month ago. She was casted and was scheduled to come today for review. There was no cast on her leg and I asked the mother about it. Her leg had been hot and itchy, so the family soaked it and cut it off themselves three days ago. She had thickening of the bone where the fracture had been, and was walking without pain. I gave her bubbles and prescribed Tylenol and multivitamins.

After that, I saw adults who all had heart burn, generalized body pain, waist pain (aka lower back pain), and agreed to fevers when asked. It was a long afternoon, but everyone was seen.

In the theater, I sutured the seven year old’s armpit laceration. His father was very sweet and thanked me. We said good bye to the theater techs, and walked through the pediatrics ward one last time to give bubbles to the kids, gum and pens to the nurses, and say our good byes before walking home from the hospital one last time. Everyone asked if I wanted to come back, and I told them that I absolutely did, but next time with my husband.

Wendy made dinner and everyone gathered at the M4 house for potato soup, sweet bread from market, mango fruit salad with cinnamon, and cake. We gave our small gifts to the missionary families and chatted for a while. It was hard to say good bye went I felt like I was just starting to get to know them.

We finished packing around midnight. I stuffed all of my market treasures and gifts into my small suitcase and added a few of my clothes to Angela’s trunk. The rest of the things I brought had been eaten or given away. I agreed to take trunks back to the States for both Angela and Mona, along with a cooler containing a sputum sample from a patient with antibiotic resistant TB.  The pile sat by the door waiting for morning.

The time in Nalerigu has gone too fast!

We ate together as a group and I started packing.  My purchases just barely fit in my suitcase and I plan to leave most of my clothing here.  I rounded again at 2:30.  There were a few admissions, but nothing crazy.  I asked Dr. Dickens to cover for me for an hour and I joined the group of volunteers on a trip to meet the king of Nalerigu.

We drove in the back of the pickup to the entrance to the market where the king’s palace is located.  We waited outside for a while, playing with the group of children who gathered.  An official met us and Terry gave him the bag of nuts that they had bought at the market today for a gift at Dr. Hewitt’s recommendation.  He took us into the palace and many of the children followed us, likely the king’s grandchildren.  He asked us to remove our shoes and we entered a large, square room made of brick, not dirt.  There were large leather seats around the edges of the room and a platform in the front of the room.  An older man in a solid light blue jacket sat in the middle.  It took me a while to realize that he was the king.  A younger man spoke for him, asked us to sit, and told us to clap.  We did as he asked.  He asked Terry what was our mission for coming.  Terry told them that we wanted to greet him, bring him a gift, and learn more about Nalerigu.  The man said that we should have read books about Nalerigu before coming.  He asked if we take the beans/nuts that we brought as a gift.  (They are coco or cola beans and have some sort of effect on the body.)  Terry said he had never tried them and the man told him that we will keep it that way.  He went on to say that eating the nuts together is a sign of agreement, then changed the subject.  The king began to talk and his spokesman translated for us.  He said that the BMC has been very helpful for his people, that people who die do not die because a doctor is not there but because it is their turn to die, and that we should speak highly of Nalerigu when we return home so that others will come to work at the hospital.  He also wanted us to aid in the education the Ghanaian nurses and medical assistants who want to become doctors so they will be able to return and serve their own people.  Terry was the only one to speak at this point, and the spokesman told us that we could not take pictures until others had had a chance to share their ideas.  It sounded as if the king wanted advice, but none of us were ready to offer him any after being in town only one month.  We assured him that we would speak well of Nalerigu and he seemed pleased.  He allowed us to each come up on his stage one at a time and have our picture taken with him, then we all stood together for a group shot.  We were about to say good bye and leave when the spokes man told us to all sit back down for a while.  We did as we were told and he returned with two guinea hens.  He told us that it was not a good time (meaning supper was not ready) so he sent the hens home with us instead.  The children swarmed us again and we took pictures and gave high fives, which they seemed to love.  One of the men who might be an elder returned to our house with us in the truck, carrying the hens.  Chinny met him and squatted and clapped, which we found out was the proper way of greeting royalty.  He was wearing his usual scrubs and surgical eye protection as if they were sun glasses.  Chinny knew the man from church and was very excited about the hens.  He took them immediately to the backyard and Bowa, the cook, brought him a large knife.  He butchered them on the spot while we had sweet tea with the elder.  Two of the guys drove the elder home and we talked about the crazy experience for the rest of the evening.  Bowa had already prepared supper, so the hens will wait for tomorrow.  The elder told Terry that he would like to come to our house again tomorrow.

We met at the Wichita house after supper to exchange photos.  Caleb showed up on the door step with his guitar.  We gathered the volunteers and had another jam session.  My drum was packed already, but someone else brought one and Caleb played some fabulous rhythms along with songs he had never heard before.  Dr. Dickens and Greg joined us and Rachel and Lisa made brownies with ice cream.  It was another lovely evening.

Suzanna and Zion joined me on evening rounds.  We saw a newborn with asphyxia who had seizures earlier in the evening.  The man with tetanus had died.  A man with sickle cell crisis was still in pain, so we gave him more Demerol.  Labs were back on others and about a third of the BFs for malaria were positive.  A child with malaria and anemia was now having wheezing and chest pain, a NEB treatment did not help, so we gave Lasix and started Amoxicillin.

We made it to the school house by midnight to blog.  Tomorrow will be a clinic day and our last day at the BMC.  I will probably not have time to blog tomorrow, but will put something up when we arrive back in the States.  I am already looking forward to returning to the BMC.

Joyce, the head nurse in clinic, placed me with Neslon, one of the medical assistants, in the front pediatrics room. Most of the patients were less sick than usual. I only admitted one. It was a boy who returned from the lab with a positive blood film and a hematocrit of 14%. Dr. Hewitt called us into his room to see a girl with osteosarcoma of the distal femur. Her knee was almost the size of a volley ball and the rest of her was pencil thin. She had enlarged lymph nodes in her groin and there was not much that could be done for her.

After all the children were seen, I started to see adults and once again felt at a complete loss. An older woman came in with an enlarged right breast. It was four times the size of the left, hard, warm, and with the orange peel skin indicating malignancy. She also had enlarged lymph nodes. I took her to see Dr. Dickens since he told me the other day that he sometimes does mastectomies as palliative care.

A woman came in with lower abdominal pain and a missed period and was thrilled when her pregnancy test came back positive. Nelson told me that occasionally urine pregnancy tests can be done. It was nice to be able to give her a definitive answer since I was not able to diagnose a 6-8 week gestation based on uterus size in a slightly plump woman.

The last man I saw in clinic required help to walk in. He had a stiff neck, headaches, and fevers. I walked him to the theater, did an LP, and admitted him for concern for meningitis versus malaria.  Malaria is always the back up diagnosis here, and often is the culprit. 

I stayed in the theater for the next three hours helping with minor procedures including removing a ground nut from a three year old’s nose, I&Ding the abscess on my seven month old inpatient, and stitching up a split eye brow on a five year old who fell from a tree. I showed him my matching eye brow scar from when I was three.

After everyone else went home, a 12 year old boy came in with a degloved knee after falling on a tree. The story didn’t quite make since for the size of the injury. I scrubbed dirt and twigs out, snipped out sandy tissue, and stitched it up as best as I could. I took an after picture and wished I had taken a before picture.  I have the hardest time snapping photos when a kid is in pain. After I started washing his open wound, the theater tech came in and wanted to know if I had asked the family if they had insurance. I said no since I didn’t even speak enough to ask the boy to get on the table and roll on his back. She was adamant that they either have insurance or collect the money before I started stitching. If they could not produce either, the wound would be washed and bandaged, but not sewn. Thankfully, they had insurance. The boy laid still and watched me scrub and realign his opened knee without as much as wincing.

I made it home by 8pm, had a late supper, showered, and enjoyed my last pineapple Fanta before heading to the school house to blog.  It is hard to believe that we only have two days left at the BMC before flying home.  I will miss the patients who come in so sick and make phenomenal recoveries, the lack of coding terminal patients, the hospital staff, the freedom from computers, the fresh air blowing through the clinic windows, and the simplicity of life.  God willing, this will not be the last time I’m here, and next time, Curt will be with me.

After the first market, we went with Lisa’s friend to see her home.  She lives in one of the mud hut homes with many small rooms surrounding an inner courtyard.  The middle area had a concrete floor and was empty except for a dried grass shelter in one corner with a number of long wooden benches.  Three women were sitting there, drinking a cloudy liquid out of bowls made from dried gourds.  We sat down with them and our friend introduced one woman as her mother and a second as her sister.  She brought her children to show us and we talked for a while.  A dog wandered in and sat under one bench and a mango lady with a large plate of fruit on her head joined us off the street for a moment, then moved on.  Each room in the home had its own door into the court yard.  Lisa told us that last time her friend showed her the home, she took Lisa into her room.  There was a sleeping mat on the floor, a small stack of clothing, and a short dresser, which totaled all of her earthly belongings.  The men in the family were all living elsewhere and only came for occasional visits.  Lisa’s friend works at the hospital, so is not able to travel.

Today I slept in a little and the nurses teased us for coming to round late.  They said five minutes or one minute doesn’t matter, both are late.  Two of the children I discharge the other day were still there waiting for family to bring money to pay their hospital bill so they could go home.  It reminded me to be conscious of the cost of test, medications, and length of stay while still treating the kids. 

Only one child died over night – the five year old boy with an admission weight of 7.4kg.  He looked like death since his arrival, and I was not surprised, but I was sad.  Children anywhere should not have to diet just because there is no nutritious food for them when there is so much excess elsewhere in the world.  The rest of my kids showed slow by steady improvement.

In the procedure room, a man was wheeled in with a swollen, painful left knee.  He had been in a bus accident and had a number of scrapes.  Drew showed me where to stick the needle and I aspirated about 150mL of blood from the knee.  The swelling visibly decreased the longer I pulled off fluid.  He pain was slightly better afterwards.  If it reaccumulates, we’ll have to do it again.

We changed clothes and met at the Nyhaus’ to ride to church together.  We drove to the Fulani church and piled into the tiny building.  The pastor is a sweet man with a spark in his eyes.  Sallifu sat next to me and helped find the right songs in the hymnal.  He was the same boy who came up to me in the market yesterday and said, “Hi Jessie, do you remember my name?”  I didn’t, of course, although he looked familiar.  The pastor quizzed the congregation by asking for someone to summarize the sermon from last week for everyone.  Eventually, someone came up with it and he was satisfied enough to move on.  He talked about Jesus’ resurrection, switching back and forth from English to Fulani.  Partway through, a group of children came to the door to watch.  The pastor asked for a rug which was unrolled in front and he told the children to come in and sit or to go home.  They all came in and he handed an older girl a stick to poke anyone who spoke during the service.  The last song was “Blessed Assurance, Jesus is Mine” in Fulani.  We did our best to sing their words from the hymnal along with the familiar melody.  They did not have piano or drums, only beautiful voices that carry their song to the heavens.

We drove home in the back of the truck and had lunch as a group.  Our volunteer cohort is now small enough to all fit around one table and pray and eat together.

After lunch a few of us drove to town to stop at the tailor’s shop.  I came along to buy a ball of soap to scrub the red dirt out of my skirt.  It turns out that local soap works great to remove local dirt for local cloth. 

I spent the afternoon looking back through everyone’s pictures that we shared the other night, and Jill and I outlined our presentation for the residency program.  Since I’ll be in Des Moines next month and Jill will be on nights, we are going to try our best to finish the presentation before returning to the States.  Hopefully we’ll be able to rearrange seats on the plane and sit together on the trip home so we can continue to work on it.

A baseball game started and we went out to watch and catch fly balls.  Sukanya, the Nyhaus’ youngest daughter is six years old and a fireball.  She works hard and keeps pace with all the action, including climbing trees in a dress after church, playing baseball with all the guys, bouncing all over the back of the pickup while driving and parked, and begging her dad to toss her in the air.  She’s my kind of girl.

We ate supper together, then met at the Wichita house for a jam session in the evening.  Drew played piano, John played guitar, and the rest of us drummed and sang.  They brought binders of praise music and we all picked out favorites.  Many of the songs reminded me of Knollbrook and the ULC.  It was a great Sunday!

We went to market before lunch with Lisa and one of her Ghanaian friends whom she had met on her last trip to Nalerigu.  I drove everyone in the truck.  It was my first time driving outside of the BMC complex.  The pot holes and goats made quite an obstacle course.  At the market, I made friends with a little boy who was about three and wanted to hold hands and walk through the market together.  He would tap my hand and point when he saw something interesting, and refused to let go when we started heading back to the truck. 

We went home for lunch and a second group planned to go to market afterwards.  Jill and I joined them as well.  This time a teenage boy asked me out of the blue if I’d marry him and a 20-something man yelled that he loved me and asked if I loved him back.  Two in one day is a new record.  Bright found us and helped guide us through the market.  We were late meeting the rest of the group at the bus.  While they were waiting for us, a group of Ghanaian children swarmed the van.  The Sulaminga kids were overwhelmed with all of the attention and were glad when we arrived and we could leave.  I felt bad for holding everyone up.

We spent the afternoon catching up on blogging, and then had supper with the group.  For desert we met at the Dickens’ for games and snacks.  The kids were playing flashlight tag outside.   About half of us joined them and the other half went inside for homemade limeade.  Their version of tag is very similar to the Moonlight, Starlight that we used to play at Grandma Robin’s house.  I ran for a hiding spot since I joined the game late and had limited time, and tripped on a speed bump in the drive way in the dark and wiped out.  I hope that the red dirt will wash out of my new Ghanaian skirt.  After that, I hid with Abigail who is about three and has a cast on her leg.  We went at a much safer pace in the dark.  After a few rounds, we went inside and the girls beat the boys at a round of Cranium.

I did two or three I&Ds in the theater and Drew walked me through a D&C.  It seems like any tropical medicine doctor should be trained in obstetrics and gynecology, because pregnancy and it’s complications lead to so much of the morbidity and mortality here.  I also did an LP on a woman who was pregnant and was recently discharged after completing treatment for meningitis.  Her mental status has not yet returned to baseline.  The tap was clean, but she was admitted for observation overnight because the family felt more comfortable that way. 

After clinic, the procedure room was flooded with women needing ultrasounds, mostly for abnormal menstrual bleeding or concern about losing a pregnancy.  I did two and watched many others. 

Once all the patients in the theater had been seen, I walked through the wards again.  During clinic, about eight new pediatric patients had been admitted.  I checked their labs, looked at the sick kids, and adjusted medications and doses.  There were a few very sick children admitted, including a three year old boy who suddenly lost consciousness during the day.  His CSF was clear, but he was positive for malaria.  A five year old boy was the weight of a 2 year old.  His parents said he had been sick for a week, but he looked like he had been severely malnourished all of his life.  I discussed fluid resuscitation and refeeding with the nurses.   When the options for fluid rate include slow, medium, good, and fast, it is difficult to prevent flooding the patient’s lungs or inducing dehydration.   We do not check electrolytes, which in some ways makes it simpler.  In my opinion, as soon as the patient can drink, it is safest to stop the IV fluids.  There were two girls who were swollen, possibly due to kwashiorkor, but urinalysis results had not returned and renal dysfunction was also a possibility.  We don’t do BUNs or creatinines, either.  They had been started on milk feeds for protein replacement.

In the adult ward, I saw a young woman with an acute abdomen concerning for appendicitis.  A girl with sickle cell came in with severe abdominal pain, likely a sickle cell crisis, but I could not rule out a typhoid perforation versus other cause of an acute abdomen.  There were snake bite patients who needed their bleeding time results checked, and young and old women with abnormal vaginal bleeding. 

It grew dark outside and Terry drove the truck back up to the hospital to pick me up since I didn’t have my flash light with me.  I put him to work on some of the adults, then we headed back to the houses.  We stopped by Dr. Dickens’ house to tell him about the appendicitis and sickle cell patients, and he said he would head up after a bit.  Susana and Zion had saved some goat burger pizza for me and we all gathered at the Wichita house to watch reruns of the Office.  I hadn’t seen it before and it was pretty stupid, but funny in a way.

Zion and Susana wanted to come back to the hospital with me for night rounds.  The only patient who needed attention was a 20 year old woman who was 32 weeks pregnant.  She had taken a local medicine today to induce labor and it was working.  She was already dilating and having frequent contractions.  We started dexamethasone to mature the baby’s lungs, and antibiotics.  The nurse midwife sat with her for the rest of the night.  I didn’t get any more calls until the next morning.

At 5am, Jill woke me up because I had not heard the knock on the door.  The nurses wanted me to come to the hospital to see the woman who was in labor.  She had been uncooperative all night, was on the floor crawling around, and was refusing to have cervix checks.  The nurse midwife seemed frazzled and wanted me to call someone to do a C-section and get it over with.  I talked with John, who decided to wait so that she could complete the steroid doses prior to delivering the premature baby.  I was pleased since it would be better for the baby to have as much time as possible provided it continued to have good heart tones.

Dr. Dickens went during the night to do the appendectomy.  The woman’s appendix had ruptured and she had an abscess that was drained.   She will hopefully do very well.

We rounded on the inpatients. There were quite a few this morning. I saw the infant girl with multiple abscesses that were drained yesterday. She had three new ones today that I I&D’ed after rounds. She is one of the chubbier babies that I’ve seen, and is interactive and lovely. I wonder if she has an underlying immune problem predisposing her to so many skin infections. There is no testing that can be done here.

A man came in with an opened fracture on his lower leg. He had been in a van about two weeks ago with 13 other passengers. The van was in a crash and he was the only survivor. He had pins placed in his leg for stabilization at on outside hospital. The care seemed unsatisfactory to him and he transferred to the BMC. On arrival, his dressings were old, dirty, and saturated with pus, four pins were protruding from his leg without any external fixation device. Under the dressing, we found maggots in the wound. It was cleaned and redressed. His fracture had not healed and his lower leg could bend in the middle. When his leg was still, he was cheerful and talkative, but in obvious pain when the leg was moved.

During lunch, Jill and I presented our “Mini Grand Rounds” talks. No one fell asleep. After lunch, Steph, Hollynn, and I had one last drumming jam session. (The West Virginia crew leaves early tomorrow morning.) The boys were out on the front porch, so Steph took her drum out to see what they could do. They were quite impressive musicians. I hung out with them for a while, letting them take pictures on my camera of each other.

I returned to the procedure room to do a D&C. While we waited for the autoclaved instruments to cool, a man came in with feet lacerations from dropping a chain saw on himself while cutting down a tree. He was successful in bringing the tree down. Terry started working on the left foot which looked like the top layer had been through a shredder. I gloved to help get him stitched together quicker, and the lady arrived for her D&C while we were working, so I didn’t get to do it. There will be more opportunities for D&Cs in the next week. The foot came together nicely.

We met back at the house for an afternoon of socializing with some of the Ghanaian translators who are interested in going o medical school. We compared stories and ate mango cobbler. Jill got the recipe and promised to share it with me. I intent to hold her to it.

Supper was fufu with ground nut soup and chicken. Fufu is a sticky ball made of boiled, pounded yams. We watched them make it at the house with a big stick four pounding, and the cooks wife turning the dough in the bowl between thuds. The cooks made sure we ate it as soon as it was ready, and we were only allowed to eat with our hands (the right in particular). It was delicious!

Angela hosted station meeting tonight. We sang and John accompanied with his guitar. It was beautiful to hear voices raised in worship. Angela led the kids in a Bible drill and had Jill and I judge their speed. I was overwhelmed by the preparation they put into learning verses and references. We prayed as a group then shared snacks. A storm came up during the meeting. On the way home, I stood in the back of the pickup and enjoyed the cool breeze, gentle rain drops, and distant lightning as we drove through the night.

We exchanged pictures with the West Virginia group and said our good byes. Jill and I helped Steph pack her big drum into a plastic garbage can and tie down the lid. It will be nearly boring without them for the next week.

Interesting patients for today:

My four year old inpatient with a cough for the past year had his chest X-ray today (after waiting most of the day for the techs to come in).  It showed atelectasis versus consolidation of the upper right lung field with right shift of the trachea and heart.  There was not pneumothorax, but the lung fields looked hazy.  It may explain his cough and crackles, but I still don’t know what is causing it.  There are old bronchoscopes around and it would be interesting to scope him to see if there is a foreign body, anatomic anomaly, and obtain a sample for AFB testing.

A 10 year girl came in for pain with sitting.  She had a large abscess within her right buttock.  The cheek was visibly larger than the left, hard, warm, and tender.  She had eaten earlier in the day, so we could not use ketamine.  I gave her a little lidocaine and made a 2 cm incision, then Jill and I squeeze out about 2 cups of thick, yellow purulent material.  She said “why, why, why” which is the Ghanaian equivalent of “ow”, but never moved.  Once we were done, she stood up, dressed, and was as cheerful as could be.  The pain tolerance of the people here never ceases to amaze me.  She waved and grinned later and I walked passed her at the end of the day.

A 2 year old came to clinic who was the size of a 6 month old.  She had a mongoloid facies and was significantly developmentally delayed.  She could sit, but could not crawl, stand, or walk.  Her mother had been referred to the nutrition center and she came in for screening labs (blood film for malaria, Hct, and stool O&P) prior to admission.  I think she probably has Down Syndrome, but do not have testing available to prove it.  The specific diagnosis does not matter much in this situation.  I talked with her mother about how she will continue to develop slowly and will not be like her siblings, but how she can still lead a happy life with some extra care.  Right now, her main issue is malnutrition and hopefully she will be able to grow at the nutrition center.

A little boy came in with vesicles and crusts on his left cheek and ear, and an erythematous, vesicular rash on his left index finger.  I think he likely has a herpetic whitlow with secondary impetigo, and I treated the bacterial infection because acyclovir is not on our formulary.  I stopped by the pharmacy later and they dug out one box of acyclovir tablets.  When he return in 5 days, I will prescribe him acyclovir if his lesions have not improved.

A boy came in for follow up for a donkey bite on his upper arm.  The lesion was mostly healed, but one area had induration below a yellow ulcer.  His mother refused an I&D and I discharged him with a second course of antibiotics and instructions to return if it did not heal by the end of the course.

I was seeing a clinic patient when the triage nurse brought in a mother and her son who was in severe respiratory distress.  He was bumped to the front of the line and I pulled out admission orders before completing a history and physical exam.  He was moaning with each breath, febrile, had a distended abdomen, and stared off into space with glassy eyes.  As I finished the orders, Jill walked him to the pediatrics ward and told me his breathing was less noisy by the time he arrived.  A few minutes later, the nurse from the peds ward came to find me in the procedure room to tell me that the patient’s status had changed before any labs were drawn or medications were given.  I changed the orders to expired.

An elderly man was admitted with tetanus and locked jaw.  We stopped by to see him and read about tetanus treatment.  His prognosis is not good.

At the end of clinic, Joyce (head nurse in the clinic) taught us some more Mumpoole phrases including “do you have cough” and “he is my husband” which is used as a joke when talking about one’s young grandson or nephew.  After supper, we took group pictures with all of the baskets from Bolgatonga.  There was a sea of them.  I worked on my talk for our “grand rounds” tomorrow and blogged.  Terry requested the topics of fluids and electrolytes and neonatal resuscitation in a developing country.  Jill called NNR and I’m working to make fluids interesting.  After being here for three weeks and having only D5W, Normal Saline, and D2.5 1/2 Darrows available for the children, I was curious to do some calculations and figure out the best solutions to use.  I just hope the students will be just as excited about salt, sugar, and water tomorrow.

PS - I passed Step 3!!!