Ghana Day 8, 8/10/14

Our second day of clinic was completely awesome! I had a really great time the entire day, which I spent first in doctor consultation and second in the dental station. During lunch, I got to speak a little bit to the head of community development for Global Brigades about the state of reproductive and sexual health in the Ekumfi district where we have been working for the past week.

In the doctor consultation station, I was working with Dr. Cornelius, the head of the medical brigade community. Working with him really was as awesome as the other interns had been saying because he truly understood that we were students and very interested in the medical details of the consultations. He would explain each of his decisions and encourage us to take in as much as possible so that we could eventually be the ones that were diagnosing the patients based on their symptoms.

He gave Sam (my partner) and me some really great advice, starting off with, “Treat the patient, not the disease.” This refers, of course, to the fact that patients are individuals that have their own opinions and the right to make some important informed decisions, but he also was referring to the fact that doctors makes money and business based on their ability to take away pain. He said that if a cancer patient came to one doctor that said that she could take the cancer away vs. another doctor that said that they could take the patient’s pain away, the patient would likely choose to see the second doctor because the way that the patient feels after their treatment is oftentimes more important than the way that the disease progression is actually going. To treat a patient, in other words, is to first take care of their pain (or other symptoms) and then worry about the disease. It’s not the first time I’ve heard this said from a physician, but it was the first time I had the privilege of seeing the principle in action.

Dr. Cornelius also told us not to always trust the patient’s words because they can lie either to get more medications than they need at the time or be afraid of judgment. The patient’s vital signs, on the other hand, can be much more reliable and telling. In general, if the patients look to be functional and can answer basic questions about their name, what they did this morning, etc., low numbers should be fine. High numbers, especially for a mobile clinic, are the ones to really worry about.

A couple of medical facts that he told us: malaria is more likely in travelers than Ghanaian natives because we have lower tolerance to the parasite; women are more likely to be anemic due to menstruation; chills means feeling cold; rigors are caused by extreme chills to the point of shaking; bacterial conjunctivitis is discharge from the eyes in the morning. Dr. Cornelius told us to think about the physiology of the cardiovascular and respiratory systems when taking into account the heart rate and breathing patterns; something like anemia may be accounted for with a high respiration rate.

There were several patients that we saw who had talked about symptoms they experienced weeks before because they know that brigades come and provide them with medications. It was a reminder that medical brigades are the sole discipline that does not quite fit into the sustainable development model. However, we come to treat just the symptoms that patients are feeling at the moment because we don’t have the resources to continually stock them with all kinds of drugs.

One of the best patients that we saw was a pregnant woman who claimed to be 7 months into her pregnancy (cyesis in medical-speak). We needed to make sure to be mindful of the medications we prescribe to her, but she seemed to be pretty healthy overall. He took us to the OB/GYN station to show us a little more about the baby. When babies form, they have their head at the top of the woman’s torso. Starting at about 6-7 months, the head starts to move towards the cervix. Based on this observation, you can tell about how long a woman has been pregnant if you can feel the baby. Because we lack much of the technology to be able to see the baby or figure out its health, we have to use feeling. The coolest thing that we were able to do is use an instrument called a fetalscope, which looks a little bit like a thin Erlenmeyer flask with a wider top and made of metal, to hear the baby’s heartbeat. You can place it on the woman’s stomach and lean on one side of the fetalscope to hear an extremely faint but very fast heartbeat, which was completely awesome.

Near the end of the doctor consultation station, the Dr. Appa, the other doctor, had a patient who came in with a child who had Down syndrome. He specifically called Sam and me over to take a look because the knowledge of Down syndrome in Ghana is very limited. He had us talk to the mother as if we were the doctors, and encouraged us to not be shy about asking (that didn’t make it any easier, especially when dealing with a mother who is clearly concerned about taking good care of her child). When I asked whether she knew that her daughter was sick, she nodded. When I asked whether she knew what it was, she shook her head no. Her daughter looked to be at least 3 or 4 years old, potentially older, but her mother told us that the symptoms started only when she started going to school, saying that her daughter would often have trouble focusing during class. It was a really interesting case because Down syndrome is used as a medical example in middle and high school science textbooks over and over. I don’t think that it would be exaggerating to say that almost everyone who has been to school in the United States knows about Down syndrome, and it’s definitely not exaggeration to say that a child who is checked up on and born in any hospital in the US can and will be checked for conditions like Down syndrome. However, the misconceptions that she had about her daughter’s condition ran deep and impacted her fundamental understanding of her health, which was further explained to us by Dr. Appa. Although we were soon called away to lunch, I very much valued the interaction and the opportunity to see how information that is so prevalent in the US is so significantly misunderstood without the education that we are so privileged to receive. 

I also think that it was very valuable to see how the medications we worked with yesterday were prescribed, and I think that my background information from the pharmacy was very useful in consultation. I had a better understanding of how pharmacists and doctors work together in the clinical setting.

The little bit of education background that I got was that it takes 7 years of training out of high school to be a generalized physician. After graduation, doctors are required to spend two years in an internship (this was the stage that Dr. Cornelius is currently in) before they can choose a specialization. Dr. Cornelius said that he wants to go into public health because he really enjoys working with community members the way that he is able to during brigades. He is applying to really great schools in the US, including Columbia in New York, Johns Hopkins, and Harvard. Wow. That definitely makes sense though, considering that he believes that if someone can get into these schools, why shouldn’t it be him? His mindset that if there is one person that should represent a group of 1000, it should be him seems to serve him very well, considering how talented he is in interacting with patients and medical students alike, and the fact that he is so knowledgeable about his profession. I also don’t get the impression that he thinks he is too good for anything or anyone, especially because he comes from a rural community himself. He seems to understand that life and culture and is very passionate about his work.

During lunch, my interview group had the impromptu opportunity to talk to Maame Afua, who is the Director for Community Development of Global Brigades Ghana. We had several questions to ask her about sexual and reproductive health knowledge and practices in the Central Region in Ghana. I’ll post my notes from the interview in another post, but I really had a great time being able to speak to her and hear about these issues.

One thing that she pointed out was some of the posters that were lining the walls of the classrooms, which were part of the “Alert & Proud” campaign sponsored by UNICEF. They showed education about AIDS awareness, but they were worn and looked like they had been there for years, potentially decades. I’m very glad that students are made aware of these issues as early as they are, but the fact that the posters only say “AIDS is bad” and quotes like it without explaining how it was transmitted or what it is, and the fact that many were partially torn and looked to have water damage makes me wonder how much impact the education actually has. I wonder how many of the students know what AIDS is, and how many of them even recognize the posters.

After our lunch break, I was at the dental station. The dentist, Dr. Elijah, was playing one of those driving games that are pretty common on his tablet as I walked in (just like the other doctor was playing Temple Run earlier in the day). I talked to him a little bit about travel to get to know him first, and he said that he has really enjoyed all the time that he spent in the US. One of the biggest differences that he noticed was the availability of a really wide variety of goods and services even in really small cities so that Americans living in rural areas only have to go to the nearest city to find most resources they need. By contrast, Ghanaians living in rural communities can’t always get what they are looking for in the city nearest them and have to travel to the major cities, which can be hours farther away. It’s inconvenient for them, and though they can take public transportation to these cities, they can’t always afford frequent the longer trips. When I asked whether Ghanaians had anything akin to the tooth fairy, he laughed and told me that they don’t much care for teeth.

Throughout the afternoon, I saw a total of four patients, each of which had one tooth extracted. Dr. Elijah shared with me that adult teeth can start to wobble if there are deficiencies in just one of the four types of dental tissue in the mouth. Additionally, many illnesses can manifest in the mouth, so any time you see patterns of tooth decay or something of the like, you can bet that the patient should be checked out for a chronic disease.

One lady that I think was in her 60s that wanted a tooth extracted opened her mouth for Dr. Elijah and we saw that she was missing all her back teeth (on the top and bottom of her mouth) except one, which she claimed to be paining her. When he started to get ready to extract it, he still had many of the materials that dentists in the United States have. He used Novocain and I finally had the opportunity to see where it is injected after having so many injected in my mouth over the years. He waited a couple minutes for the Novocain to take effect and numb the mouth, and then took a little wrench, tugged on the tooth, and pulled it out. The lady winced a little bit, but other than that, she just closed her mouth on the cotton swab we gave her continued through the stations. It was a small trauma to see and hear the tooth being ripped out of the gums because I could hear it (it sounded like what I would imagine ripping flesh would sound like) as I saw it happening. Because she had lost most of her bottom teeth a long time ago, we could see how far her gums had receded, and Dr. Elijah explained to me that it happens when there are no teeth for the gums to hold in place. By the time we saw her last tooth, we could see much of the root part because of how far the gums and bone in the mouth had receded. Dr. Elijah told her to make sure she is checked for diabetes and other chronic diseases because they can be the cause of the unhealthy teeth, rather than just poor dental hygiene alone.

When we saw another patient who wanted a tooth extracted, I was able to see just how deep the roots of teeth can reach (and subsequently, how much blood can be involved in an extraction).

The third patient that we saw was an 8-year old girl that wanted her baby tooth extracted. When Dr. Elijah injected the Novocain, he didn’t let her see the needle at all, hiding it until he asked her to keep her eyes closed. When he wanted to put the pliers into her mouth, he first covered it with gauze and told her that he was just going to clean her teeth to prevent her from backing out before the operation was finished. The most impressive thing about her extraction was that she winced a little bit and cried out when her tooth was being pulled, but she didn’t shed a single tear and seemed extremely brave. It was a stark contrast to what I would imagine in the United States, where children would not hesitate to cry their lungs out at the thought of even having to sit in a chair in front of the dentist.

I admired the work that Dr. Elijah was able to do with such a primitive and basic clinic, with sterilization and materials to only pull out teeth that were bothering his patients. I had a hard time watching him because I’m not a big fan of hearing teeth being pulled from gums, but I’m really glad I got to glimpse his work.

The last thing I learned from working with Dr. Elijah was that Africans have wider jaws than most Americans because they are used to eating hard foods and chewing bone, which expands the capacity of the jawbone. As a result, their adult teeth grow in straight and sometimes with gaps between them, and wisdom teeth don’t cause them pain when they grow in. Most people have a full set of teeth and don’t need braces, whereas Americans often need braces and have their wisdom teeth pulled as a preventative measure. It’s one of the procedures that really benefit dentists financially in the US, but is almost unheard of the rural Ghana.

On our drive back, we tried to do a small wave with everyone in the van, and I think it turned out pretty well considering that there was only 12 people to do it. After our night meeting, Deanna kept telling us that we are free to get condoms if we might be able to put them to good use. Okay. That’s not sketchy at all. She’s definitely an interesting one.