Keough, Elaine: January 2010 Archives

By Valerie King

Today is my first day at Margret Marquat Hospital.  For those that know me this is not my area of expertise.  I am a community based nurse. I am much more comfortable going from hut to hut than to try to serve a purpose in an acute care hospital.  I had hinted at my desire to stay at the outpatient health center but Maura thought my assessment of the nursing care at the hospital would be helpful. 

We have been asked by the new medical director, Dr. Lucy, to do an evaluation of our experience at the hospital.  She wants to make some changes so our input is solicited.  We are treated very kindly by the nurses but there are significant deficiencies in the nursing care that goes against everything that we have been taught as an American Nurse.  The contents of our report are too lengthy to go into in this Blog but suffice to say patient safety, infection control and issues related to competent and compassionate nursing care were some of our biggest observations. 

Later on this evening I created with Maura and the students, a 4 page document that we will use to present our findings to Dr. Lucy.  I am reminded of the comments of my teacher and friend Dr. Geoff McEnany-Phillips when he taught me about evaluation.  It is important to be truthful but we have to be mindful of the stakeholders in this situation and try to present our findings in a thoughtful and professional manner. We create the document over a bottle of wine and with very insightful comments from the students.  I am not sure how Dr. Lucy will use the information but we felt it was our duty to be advocates for the patient but also to help promote professional development of the nurses in Ghana.

To help with our goal of professional development I gave a 2 hour lecture today at the Kpando Health Center on a few topics.  I presented a lecture on the assessment of the geriatric patient and also diabetes mellitus.  The audience of mostly nurses but some other staff seemed to be very much engaged with the lecture.  I had to slow my rate of talking and to try to use appropriate and understandable terminology.  I tried to lose my New England accent. 

The time flew by and I was encouraged by the thoughtful questions that were asked by the participants.  I have truly come to respect these Ghanaian nurses.  They work with such limited resources but have such potential for improved care if only they are given the education.   Throughout my lecture I keep repeating that they have incredible power as nurses to make a difference in their patient’s lives.  I think the nurses could play a larger role in the care of the patients but am limited in their knowledge and sense of responsibility when it comes to patient outcomes.  I pretty much told them that they are much more important than the doctors (my apologies to my physician colleagues).  I think there is a vast difference in the way that Ghanaian nurses and American nurses are educated based on my observations.  

I would like to see these nurses claim their autonomy and professionalism.  Change comes slowly.  I think having the UML nurses work with them opens the door to comparisons, questions and emulation of behaviors.  We have witnessed an obvious change in the demeanor of the patients when the UML nurses address them with respect, touch them and provide the level of compassionate care that is the trademark of the American nurse. I have such personal pride in the accomplishments of the student nurses from UML.  We have had many thoughtful conversations at night about the comparisons of the two countries and their ideas for improvement.  I am proud to be a graduate of UML and I am equally proud to be a nurse educator who will have a role in creating the future American nurses.  I will end now on that positive note.  There are still many more stories to tell but again I am burning the midnight oil and tomorrow is another busy day. 

"Tears, Smiles and Tears"

By Valerie King

Today we are scheduled to go to the Hohoe Christian Children’s Home. Before we leave Kpando we have become aware of another acute public health problem. We drive a very short distance behind the health center and we are in a small village.  We depart from our Tro Tro (which appears to be held together by not much more than duct tape and rust).  We are visiting a watering hole. We trek into the woods about ¼ mile along a rutted path and we meet many people, mostly children, coming out of the woods with various water containers on their heads. It is amazing that these people have to walk such lengths to get their water. 

Our true shock comes when we come upon the watering hole.  There are actually 3 holes. The first one can only be described in one word. DISGUSTING.  It is a large hole in the ground filled with putrid green water.  We do not see people collecting water from this hole but we are told that people do use it if the other holes are low. We come to the second hole.  I have to tell you that the next part is pretty gross.  If any of you have the seen the movie The Ring you will recall that there was a deep well that a little girl was drowned in.  Well this “hole” is exactly like that movie and the saddest part of all is that over the last year six children have fallen in and drowned and only one body was recovered.  The other 5 bodies have sunken to the bottom of that well and supposedly not retrieved.  These families have to continue to draw their water from this well.  Part of me doubts this story but if it is true I can only imagine the anguish a mother must feel as she has to draw water for the rest of her children from the very well that took the life of her other child.  The third hole is quite active today and surrounded by about 20 people who are drawing up the water using buckets and ropes.  You can see how a small child could fall into these wells and if no one was around there is no way to climb out.  It is a pure vertical cylinder of old stone. The village has been trying to get some funds to dig a bore hole but the government is not listening to their request.  They have asked for our help in this project.  We are unsure what we can do to help them but we will be visiting them on Saturday for a demonstration about boiling the water that they are pulling out of the holes before consumption.  We will see what the costs are for a bore hole.  This is a perfect project for our engineering students at UML and I hope to bring this to their attention.

After our walk out of the woods we load back into the Tro Tro.  We are like little sardines squeezed into a small tin can. Hohoe is about a 30 minute drive down bumpy roads.  We arrive at the orphanage to be greeted by the loving arms and hugs of 30+ children. They are all so happy and affectionate and give freely of their hugs.  One of the Community Projects is implemented today with the orphans. 

The UML students are presenting a dental health program today.  They have donated samples of toothbrushes and paste and have developed a whole program that is flawlessly implemented for the attentive audience of children ages 3-15.  It is interesting to note that even the older children are interested in the coloring pages that are given out. They do not consider them to be juvenile and my impression is that they are sweetly naïve to all the usual American teenage angst.  I am joined at the hip by my new “son” Francis.  He has stayed with me all day today and at our previous visit.  The founder, Nicholas is married to an Australian woman who is back in her country for a Christmas visit.  She is a white woman and I think the children are missing their white mother.  I am missing my own children so it is a nice way for me to give and receive affection.

There is a cute little three year old girl named Lee and she has a very obvious bald spot on one side of her head that appears to be a healed burn.  We ask for her story and it is the most tragic story I have heard yet.  She is from the region of Tamale and has only been in the orphanage for about a month.  She used to live in a village that was very superstitious.  Her parents died, of causes unknown to me, but her grandparents believed that this little girl is a witch and she is to blame for her parent’s death. They chained her and starved her and burned her head with some type of hot metal to get rid of the witch. She was found by a census worker who rescued the child and gave her to a Peace Corp volunteer who in turn brought her to the orphanage.  You can see the fragile bones of this dear child who appears to be thriving in this caring environment but one wonders about post traumatic stress disorder and what type of psychological issues will arise for her in the future.  She is affectionate and loves the clothes and underwear that we have brought with us.  This horrific story has me near tears.

The young boys seem to gravitate to Maura and me probably because we are mothers.  They want to tell us about themselves and share their colored pages with us.  My buddy, Francis is staying close to me and insists on carrying one of my bags. We take multiple pictures and I cannot wait to load them onto the BLOG site.  Our Tro Tro arrives and the children hover around us. Francis is holding tight to me and crying into my shirt.  It breaks my heart to leave him but I am not in a position to take him with me.  I would like to continue to communicate with the director and hopefully Francis will write to me as he has promised he would.  There are so many children here who need a home.

My day ends on a bright note.  I have been able to use my own laptop in the internet café and the access seems a bit quicker.  I have been feeling a bit lost without communication from friends and family and I hope it will improve a bit.  It is now about 11:30 pm and tomorrow will start early so I will go to bed now.

“Sunday is a day of rest”

By Valerie King

After our lack of sleep last night we are a bit sleepy today and I think many of us could use the rest.  We wanted to go and visit the Fesi Pottery and the Lourdes Grotto today but there was some confusion in our schedule and it never happened. We had also hoped to see the children drummers from the local church but that also did not happen.  I did some administrative work for NSWB and around 2 pm we walked to the local carver, Papa Bones and Billy the Tailor.  The students are buying and ordering some wood carvings and also getting some fabric for dresses to be made. The day is quickly passing and after a brief session at our meeting spot across the street we make the 1+mile hike to Shine and Bernard’s house.  We have been invited to supper.  The students are amazed that Maura and I made that walk every night in the dark.  It is treacherous in the beginning due to the auto traffic and treacherous at the end due to incredibly uneven terrain.  I am again amazed at the air quality here. It is such a poor quality due to burning and engine emissions.  We are all feeling in our lungs and most of us have a dry cough.  Our clothes and hair seem to absorb these smells and there is a huge drying effect upon our hair and skin.

 We have a great meal of Pasta and Sausages which reminded me more of a spicy Pad Thai and fried Kielbasa.  We are all very weary due to poor sleep last night.   We leave and journey back home.  I try to take some of the walking time to get to know some of the UML students a bit better.  They are all lovely so far and I am enjoying my time with them.  We walk past the dim and dirty shack where Hannah (age 6) Michael (age 10) and their mother Edith.  We have gifts for them and we bring them to their home.  They are so appreciative. Edith wants us to take pictures of her officially receiving the gifts.  She is also talking about a plan that she would like us to set up a school in her village which is further away.  We are constantly overwhelmed by needs that this country has but we tell her that we do not have the resources to start a school. 

As I near our guest house I have one last stop.  I must meet with my new friend Foster Dominics, who is trying to enroll at UML in the nursing program.  I have given him some admission information and he has to wait now to take the SAT and TOEFL test. That will not happen until December 2010.  Until then he plans on working and saving money for his dream to get a US education.  I told him I can assist him with making connections in the US but I cannot be a financial sponsor of his education.   He is a gentle young man that appears to have the intellect and desire for a nursing education.  He has a twin sister, Fostine and his mother died about a year ago.  I told him I will do whatever I can to help him with this processs.

As I type this my eyes are very tired from lack of sleep and also the effects of the smoke in the air.  I am going to bed.  Tomorrow is our first day in the clinic.

By Valerie King

We do not have any clinics planned today.  We are going to make our first visit to the Christian Children’s Home in Hohoe. This is a very well run orphanage we visited last year and I am excited to return.  We have to rent a tro- tro to get us there.  The cost is 10 cedis per student (under $10).  We will be using that transportation to go to the Wli Water Falls also.  

A tro-tro is a larger passenger van that accommodates anywhere from 12-16 passengers legally but there are many instances where there are many more people jammed into these vehicles.  Occasionally you can see a goat tied to the top of the vehicle along with multiple boxes and parcels that the passengers are carrying.  Some of the larger transport vehicles will have 10-15 feet high of parcels and boxes.  It seems top- heavy to me and that it would not take much to topple the vehicle over.  The condition of the Tro Tros can vary from bad to very bad to very, very bad.   Usually they are very dirty with ripped or taped seating and dirty and slightly rust interiors.  We are all very glad that our tetanus is up to date.  Because of my motion sickness I am usually sitting beside the driver on the raised seat in the middle.  That is an advantage in that I can see out the front window.  It is a disadvantage because my bottom is sitting directly above the engine and it is literally the “hot seat”.  Seatbelts do not seem apparent except for the driver.  It is a manual transmission so I must move my leg whenever he has to shift the tro-tro.  It is very loud due to engine noise and all the windows are open.  There is no air conditioning and the open windows let in all the dust from the roads.  I am struck again by the air quality.  It is now the beginning of “burning season” and the farmers have begun to burn their fields in preparation for the next growing season.  The cars and other vehicles would never pass any emission test in the US.  They are frequently seen with a trail of black exhaust.  I do not know the incidence of respiratory diseases here in Ghana but I am sure it must be an emerging problem.

We arrive at the Children’s Home and are again greeted by a throng of happy children.  They sign some songs for us and I have captured some of video and will try to post on this BLOG.  They are all extremely affectionate and run over to hug me and the girls and grab our hands.  One little boy, Francis offers to carry my bag.  I am a bit leery but then I am reassured when he carries my bag but also does not let go of my hand.  We are buddies for the morning.  He gleefully shows me his schoolroom and dormitory.  The conditions are very spartan but there is an attempt at cleanliness and orderliness that I did not witness at other orphanages. I hug the twins that I met last year and I am told that they are being adopted and will move to a family in Texas.  There are about 40 children and 15 of them are awaiting adoption.  My heart wants to take them all home with me but I know that is not realistic.  I do want to contribute to their welfare and will use some of the money that has been donated to me by my church for this very worthy orphanage.  Today is a preliminary meeting for the children and the UML students.  We will return next week with some of our supplies (toys, clothes, medicine) and also will conduct a dental health teaching clinic.  We have received many donations of toothbrushes and toothpaste and one of my Community Project groups will be doing 2 dental health clinics at this and the orphanage in Peki.   It is time to leave these children but we have left them some coloring books and crayons and we will return.

                We have negotiated for a lunch at a nearby restaurant.  Everything here is about negotiation.  I have agreed to a certain price for our plates of food and we are served the food which is jolloff rice (spicy red rice) and chicken and vegetables. It is a clean restaurant and all is going well until the proprietor comes with the bill.  She has increased the price per plate, AFTER WE HAVE EATEN ALL THE FOOD, and now expects us to pay the increased fee.  I am livid and I tell her that is unacceptable and that we had negotiated the price prior with her? husband or father.  She states he did that without consulting her and he did not know the prices.   Part of me wants to just lay down the agreed amount and walk away but I am hesitant to offend this establishment as they are somehow connected to one of our escorts and he has been very kind to us.  It makes me angry and resentful of some of the Ghanaian people who assume that Americans are all wealthy and we can afford this price gouging.  I again express my displeasure and state for all to hear that I am very unhappy with this treatment and it makes me want to take my volunteers (and our donation of time and supplies) to a place that we will not be gouged.  Our escorts are somewhat embarrassed that we are treated like this but let me take the lead.  My vow is to be much more aggressive with any expenditures of money.  This is not the first instance of the “price changing” that has happened.  I realize that these people are only trying to survive but the whole premise of gouging has me angry and hurt.

                We return to our tro-tro for a 30 minute drive to the Wli waterfalls.  We are told that it is a very busy day here due to the holiday (January 2).  I am not sure what holiday that is but the prediction is correct.  We trek 45 minutes into the deeply wooded terrain and come upon the Wli waterfalls. They are magnificent and only pictures can describe.  I will try to post some pictures.  What amazes me on this trip is that there must be at least 300-400 people there. Mostly young men and women are in various stages of inebriation and celebration. There is much drumming, singing and dancing.  We are the only white people there.  We attract some attention but not as much as I would have thought.  The air is charged with all this energy and I am slightly uncomfortable and feel the need to watch the UML students and our belongings very carefully.  Most of the girls decide to go in for a quick dip under the cold waterfalls.  They do attract some attention as they walk to the water in their bathing suits and I feel tense as I watch for any signs of inappropriate contact.  They are accompanied by Kwadwo and Mawuli and I think that helps.  After they return to our little pile of clothes and bags they are now approached by some of the Ghanaian men for their contact information.  I ramp up to “mother –mode” and gather them close and tell the med that they cannot share the information.   He is not buying that.  I then tell him that I am their teacher and if they give out any information they will flunk out of school.  That carries a bit more weight and the men eventually leave.  We decide to leave and I am a bit relieved.  It has been a fun trip to the waterfalls but last year was more relaxing for me.

                It is starting to get dark as we leave and we have a long journey back home.  The road conditions alternate between smooth pavement and deeply rutted dirt roads.  We are jostled in the tro tro and try to rest a bit but it is difficult. On the way we drive through many villages with young people gathering for today’s holiday.  It is busy and loud and the tro tro must move slowly through the crowd but then our driver speeds up on the smooth roads so it is a very chaotic drive home. 

                We arrive back at our guest house find out that there is some type of event happening in our courtyard.  There are chairs and later on it becomes a very loud ceremony/gathering of some sort.  The PA system they use is scratchy and I cannot understand what they are saying although I believe it is in English.  There is loud music.  Now I hear a competing sound, on another scratchy PA system.  It is hard to tell where it is coming from and I don’t really want to leave my room to explore.   Unbeknownst to me it is beginning of a very long and loud gathering that will go on ALL NIGHT LONG.  There is drumming and a repetitive chanting and ? singing that is not melodic to my ears.  At midnight I hope it will end, it does not.  At 3 am I hope it will end, it does not.  At 6 am I hope it will end, it does not. Finally the roosters start crowing around 6:30 and the music seems to end but then the village awakens, the son is in my eyes and there is not much sleep to be had.  We had hoped for a good rest last night but we did not get it.  It is now January 3.  We have been here for less than a week and so much has happened.  We have 2+ weeks left and many more activities.


By Valerie King

I stayed up until midnight to go and sit with the students for the New Year countdown.  No big ball falling from New York City but the tiny glow of a cell phone and wrist watch that tell us the New Year has arrived.  The students are happy and mellow, having spent a few hours relaxing at the Friendly Spot but we all return back to our room because we know we have a clinic to do tomorrow at Torkor. My sleep is interrupted last night by the local singing and dancing that is occurring into the very wee hours of the morning.  The residents have returned from their church services and are ready to have a party.

After a breakfast of Crystal Light and peanut and butter crackers.  I pack up my bag and medications and get ready for another clinic.  We negotiate for a taxi ride (50 pesuas per person which is about 50 cents).  The car is something that you see in our worse junkyards.  Half way to Torkor the car stalls and the driver lifts up the hood and ties a plastic bag around some type of tubing under the hood.   I hope it is not for the brake fluid. 

We arrive in Torkor and it is much less crowded from yesterday.  There are very few market vendors and it appears that half the town is sleeping.  I think that is the case because we don’t have many patients the first few hours except for the small children. 

They are fascinated with the student nurses and are very anxious to have the nurse, "touch them.”  We have been able to do some pediatric assessments.  It is difficult because many of the young mothers do not speak English.  It seems to me that in the poorer communities the young men seem to have some command of the English language but the young women not as much.  We do not have as many interpreters today so some of the young men help us out with instructions to the patients.  

The children appear healthy but we again are seeing the increased frequency of umbilical hernias.  I do not know the reason for that.  We have such limited tools.  I do prescribe some penicillin for a young child who has some type of skin infection.  I am able to demonstrate to the UML students how to do a scoliosis screening.  At one point in the day the UML students engage the children in a clapping and singing game.  It is a moment we catch on video.  The children are always at first hesitant to come to the nurses but after a few moments they relax and are fascinated with the young girls and their cameras.

We see another “Ya-vou” which means white person.  We mimic what the residents have been doing to us when they see us walking down the street. A UML student yells “Ya-vou” and this young white man immediately turns and comes to greet us.  I cannot recall his name but I am going to call him “cute guy from Spain” and his friend Courage who is a resident of Kpando but attends the University of Madrid with Cute Guy.  They are in a PhD program and they study microbiology.  They are touring Torkor today just out of interest but tomorrow they leave for the northern regions of the country (Tamale) to gather some samples for their research.  They are collecting human and animal feces samples and will bring them back to their lab in Spain to research antimicrobial resistance and certain aspects of the microbes.   We invite them back to the Friendly Spot tonight.

We have now been working for about 3 hours and it has been a steady but not crazy flow of patients.  It appears that more people are coming now and I suspect that these are the people who are probably just awakening from their celebrations of the night before.  We try to examine more patients for about an hour but we are starting to get tired and hungry.  We close the clinic at 3 pm and we have to promise to return for another clinic.  

This village is so poor and these residents are happy to have some access to free care.  They need so much and we are only equipped to deal with a few health problems.  Yesterday Alison, a UML student, took one of my big picture books that I use in my clinical practice at home and went out to the waiting crowd to show them pictures of the human body and where the organs are and specifically the organs affected by hypertension. 

This is a totally unscripted educational program and I admire her for her ingenuity and ability to recognize that she had a teachable moment.  She is knowledgeable and this is not the first time I have seen her jump right in and begin teaching the patients.  She recognizes the value of educating the people here and wants to leave them with knowledge about their health.   I find all the UML students very inquisitive and willing to learn something new.  We have had some impromptu teaching sessions about various topics. Often these topics arise because of something we have witnessed.  I am enjoying the process of helping them to consolidate some of their book learning into real life community-based nursing.  I am very honest with them about my in inadequate skills in an acute care setting but I feel that I can help them so much with their community-based care.

We pack up our “clinic” which is contained in a cardboard box and my Barnes and Noble book bag and off we go to get our Taxi back to Kpando.  We become victim to a little price gouging when we try to arrange our taxi home.  We were told it was 3 cedis each way per taxi but now they know that we are trapped in Torkor and they can up the price because we have no other options.  We are now told it will cost 5.9 cedis to get home.  I agree to the increase and I leave in my cab with ½ of the group.  The other half balked at the price and were ejected from their cab to go and negotiate a rate with another taxi.   We are a bit upset that these people would take advantage of us after we have just given them 4 hours of free medical care.  Everyone in this country is struggling to survive and the “ya-vous” represent a revenue stream for them.   This is the part of the trip I do not like.

After returning home we rest for a few hours.  Maura is arriving today.  Maura is the other “Mama” who traveled with us last year and she decided at the last minute to join us in Ghana.  I am thrilled to have a buddy and another RN who will assist me during this trip.  We have arranged a meal of chicken and Yam chips (like French fries).  Our cost is $5 for the meal.  This food expense is something that was not built into the trip cost because we had no way of estimating it.  It is a chore to decide on a menu and arrange to have it prepared by a local woman, Patience.  She is a wonderful cook and I am very glad to help her with our money but for me it is tiring to be the “menu” organizer and I hope to share that duty with the students. 

Maura and I decide to walk to Shine and Bernard’s house (our hosts from last year).  This is about a mile long walk which entails going thru the busy part of Kpando where the walking is treacherous due to auto and people traffic.  We then turn onto a very dark and rutted road to continue our journey (about another ½ mile) down into a residential section.  The road and path conditions seem a bit worse this year and we rely heavily on our flashlight to guide our steps.

We meet with Bernard, Shine, 3 of their visiting friends, Mildred who is Bernard’s 4 year daughter and Maria, the medical student from Puerto Rico, who is staying with Shine for 2 weeks.  We have a wonderful conversation about various things and we share our gifts to them.   This is another aspect of our packing that I did not have last year.   Last year I brought a hostess gift to Shine and I had some cheap t-shirts for Bernard and others.  This year we return knowing so many more people that we feel obliged to bring gifts.  My suitcase weighed so much but 1/3 was food, 1/3 was gifts and 1/3 was clothes.  I am looking forward to a lighter suitcase upon my return home.  

It is getting late and we are tired so we begin our journey home.  Shine and Bernard accompany us ½ way.  The busy street has turned into a mob scene very similar to a Mardi gras atmosphere.  There are hundreds of people in the street, loud music playing in local bars that spill onto the street and many, many people walking.  We follow a walking street band for a while and get a photo of the group.   We are a bit nervous in this crowd and Maura and I walk arm in arm down the street protecting our pockets.  We are happy to return to the safety of Cedes Guest house.

The students are having their own little party over at the Friendly Spot with our new friends from the University of Madrid.   I am introduced to Dominic who had contacted me via the internet a few weeks ago. He is very much interested in attending UML and studying nursing.  He has brought his teacher from high school (who is Courage the student from U of Madrid) who wants to discuss Dominic’s credentials with me. I have come prepared with some admission material and I give that to a very enthusiastic Dominic.  I do not know much about International student admission but I can connect him to the right persons. 

It is getting late and I am totally exhausted.  Maura and I chat for a while in our room and we quickly go to sleep.  We are giggling a bit because our families have such a hard time comprehending the fact that we sleep together in one bed.  The living conditions are so different here.  We are not at the Hilton.  I am thrilled to have a comfortable bed, a flush toilet, electricity and the best of all air conditioning.   I go to sleep in my sheet snug sack I brought with me and the blanket I “borrowed” from British Airways.   Tomorrow is a full day and we need to get some rest.

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This page is a archive of recent entries written by Keough, Elaine in January 2010.

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