January 2010 Archives

Home at Last

     I know I fell behind on posting toward the end of the trip, but Professor King did a marvelous job of keeping everyone up-to-date on our travels. The Cape Coast castles, Kakum National Park and the Canopy Walk, celebrating my birthday, and our last few days in Ghana spent swimming and visiting the beach were a relaxing way to wind down our very emotional and work focused journey in Ghana. Now, I'm home. The first thing I did was drink a large Dunkin' Donuts coffee (thanks to Geoff.) I enjoyed the luxury of riding home in a car built for 5, carrying only two, and equipped with seatbelts. I made a b-line for a piping hot shower, before crawling into a warm (ant free) soft pillowed bed for a nice long nap.

     Since my return I have eaten a plethora of cheeses, enjoyed many glasses of milk, devoured a large burrito complete with copious amounts of sour cream, and not worried about the source of water used to make the ice cubes in my drinks. I am, once again, brushing my teeth with tap water. I was able to wash (and dry) my clothes in a machine, rather than by hand, and utilize toilets without the need to byotp (bring my on toilet paper) or hand sanitizer. When I go to work, I'm going to go into our OR and hugging the anesthesia machine. I have a much better sense of what I have in my life, and am so very grateful for all of it.

Continuing the Work

     Ghana was a once-in-a-lifetime, eye-opening, and overall incredible experience. It has reaffirmed my calling to nursing. My heart broke almost daily when I observed the conditions Ghanaians live in; the quality of their air, the amount of litter on their streets/in their water, the lack of access to healthcare, the lack of resources nurses and doctors have to work with, the minimal exposure to even simple technology (washers and driers, dishwashers) that I take for granted daily...it was simply overwhelming.

     I met up for drinks with some of the NSWB members last night, and they echoed my exhaustion, both mental and physical. We are all feeling emotional now, and I think it's because at some point we had to hold back/turn off emotionally while we were away. There was homesickness eating at all o f us, poor nutrition and sleep deprivation, and on top of all this we witnessed so much need. In order to get through each day, we had to face our patient's problems one at a time and accept the fact that there was only so much we could do in that moment. Now that I am home, I feel I am faced with an even greater responsibility than I had while I was in Ghana.
     We have assessed, first hand, the needs of the people, the clinics, the hospitals, the nurses. We are well equipped to help next year's group fund raise with the stories people have shared with us, the pictures we have taken, and the contacts we have made. Our work as NSWB members has only just begun, and I am looking forward to the work ahead this upcoming semester.
     I now recognize that educating the nurses of Ghana is more important than any blood pressure clinic, or day spent working in a hospital setting. While this interventions were important, it was in teaching our patients and colleagues that I think we made the greatest impact. With this in mind, next year's Annual National Nurse's Conference should be a priority, and it could easily be twice as big if it is better advertised than this year's was. Supply donations could be better organized now that specific needs have been identified, such as the need for alcohol swabs and a flip-flop drive. Money can be raised toward specific needs as well: anesthesia machines, blood bank refrigerators, maternity beds, bore holes for clean water, etc. It is going to be a very big year for NSWB.

THANK YOU

     Thank you to everyone who donated supplies and money to our cause. Thank you to my co-workers at Emerson Hospital for understanding that I needed this time off, and for covering shifts for me. Thank you to my family, friends, and boyfriend for your financial and emotional support. Thank you to my classmates for your encouragement and emails you sent while we were away. Thank you to the readers of this blog. Blogging was new for me, but rewarding. I hope I didn't bore you with too many details. :-)

     Lastly, thank you to my fellow NSWB members. I am so proud to be a part of this group. I think we all worked incredibly well together. I look forward to working closely with new members as our semester begins on Monday. 

Sincerely,
  Jody Roper, Supply Coordinator and Secretary for NSWB 2009-2010

        Day 14: January 11, 2010

       Today we returned to Nkonya to conduct my Community Project group's intervention: HIV/AIDS Prevention Education. We had slightly over 50 participants from age 12 to 18. There were a few in the male group who were even a little older than 18 (early 20s) but we let them participate regardless.
        Our program was designed to target adolescents from age 12 to 15 years of age, because we had identified the highest risk group for HIV infection being those aged 15 to 24 years old. We wanted to be able to educate the younger population, so when they reached the higher risk age groups they would be better prepared to protect themselves from HIV infection. Our original goal was to conduct this program in Kpando, but when we arrived we learned that HIV (while a problem in Kpando) was an even larger concern in Nkonya. The area is very poor and has minimal access to healthcare; there is a maternal clinic in the village, but the nearest full service clinic and hospitals are located in Kpando over 30 minutes away by car. Given the poverty in the area, education above a primary level is not common in the village, and many girls leave town for bigger cities (such as Accra) to make money for their families as prostitutes. Once they become sick, commonly infected with HIV, they return home.
        I believe that our program was really successful in this setting. The participants were all voluntary and eager to learn about the topic. Our pretest indicated a huge need for further education. Many participants were unclear on what HIV even was, how it would impact their health, and even more had a very poor understanding of how HIV was transmitted. We handed out index cards so that individuals could submit questions they had about HIV, sex, etc. and because this activity gave the person anonymity we got numerous questions on each card. I worked with the female group, but when we regrouped later in the day to review how each group did I found that all of the questions the adolescents asked were intriguing:

    -If I have sex with an HIV infected girl and she does not orgasm, can I get HIV?
    -If I wear two condoms, am I better protected against HIV?
    -Can I get HIV from a mosquito bite?
    -If someone with HIV cooks for me, can I get HIV?
    -Can I get HIV from deep kissing?
    -If I am a student and I have sex, am I still at risk of getting HIV?
    -Where does a condom go, how do I use it?
    -Can a boy use a condom more than once if you do it more than once with him?

        We reviewed all these questions at the end of the program, and I know that at least the girls were 100% when we conducted our post-test with them. They had a hard time choosing their favorite part, and did not offer us any cool feedback when we informed them that we were just trying to improve the program for the next group. I felt really, really good about what we did today. The girls were waiting to get their soda and biscuits during the break we provided to ask me individual questions. We had 5 immediate volunteers when I completed a condom demonstration and opened up the floor for others to try.
        The only negative part of the day, for me, was HIV testing that was conducted following our education session. First off, I think those 15 to 25 should have been prioritized for testing because they are at greater risk of being infected, but the testing was opened up first to participants in our group. My other problem was that those being tested were being told that we had a test "for diseases of the blood" that they could participant in if they chose. The NSWB members were instructed not to tell people we were conducting HIV testing. Our guides and advisors at Africed said people will not willingly go for HIV testing in this area, and many areas of Ghana, because of the huge stigma surrounding HIV. That is why they said we needed to keep what we were testing for a secret.
        I am a firm believer in patients' rights. I think women have the right to choose whether or not they want to terminate a pregnancy, I think a patient's end of life decisions should be respected (DNR or Full Code, etc.) and I firmly believe that informed consent should be given before someone is subjected to any kind of invasive procedure or test. I chose to opt out of the testing, because those being tested did not know we were looking for HIV or not. Also, at the end, if they were negative we were simply to tell them that they were "free from any diseases we tested for today." That is misleading and, especially given the language barriers we have encountered here, can confuse people into believing they are healthy when they are merely HIV negative. They could still have some other STI, or malaria, or TB, etc. But, now that a "white nurse" has told them they are disease free they may think they are free and clear.
        The argument made for testing was this: HIV antiretrovirals are available to those who are HIV+ even if they don't have money. People are refusing to find out their status by getting tested. There is huge stigma surrounding HIV, and people would rather be ignorant than have their "life be over" when friends and family and coworkers learn that they are HIV+. In the meantime, the spread of HIV continues and is a huge problem in the area. It was a greater good for a greater number. Positive members would be counseled by local healthcare workers trained to deal with this kind of life changing news.
        I can see both sides of the argument, but that was my ethical dilemma of the day, and I am glad I chose not to participate. At the end, when everyone turned out negative I reminded those gathered that just because they tested negative today for a disease didn't mean their actions tomorrow couldn't cause them to be sick. I also reiterated that we did not test them for every disease out there, so if they had a rash or a fever or some other symptom of illness they still needed to report to a clinic or hospital to be evaluated. I hope everyone there heard that part of the message.

    Day 15:  January 12, 2010

        Today we went to Anfoega to donate to Anfoega Catholic Hospital. Lt. Holly, who met us at immigration at the beginning of our trip, is receiving a special honor in this village. They wish, in the "near future" to make him a paramount chief (or maybe it was one below this, I don't fully understand the chief structure here.) He thought it would be nice for us to see the area, and we were delighted to see him again and thank him for being our Knight in Shining Armor when we first arrived, tired and nervous, two weeks prior. Before we arrived in Anfoega we were under the impression that we would be conducting our HIV education program again. After learning that the hospital was Catholic however, this plan was axed since condom use is promoted by our program and that is not in line with Catholic ideology.
        We received an extensive tour of the hospital, which was the cleanest I've seen since we arrived in Ghana. However, they are lacking vital resources which is a problem we've encountered throughout the region.
        -The hospital is located about an hour from Kpando, but that is the only ambulance they have access to.
        -There is no anesthesia machine in their "theatre" or operating room, so surgery, including c-sections, are conducted under conscious sedation!
        -There is no blood bank refrigerator, so the hospital does not have blood banked for an emergency
        -The lab had to conduct all its blood work without the assistance of a machine (that means manual counts on CBCs, etc under a microscope!) until a week before our arrival, when the new doctor (only doctor) at the hospital made sure a machine was purchased.
       
        I give so much credit to the healthcare providers here in Ghana. They are asked to do so very much, with so little. I want to make it clear that some of the poor practice we have witnessed (not utilizing alcohol swabs before starting IVs) is not the fault of the nurse but the system (not having alcohol swabs.)
        In Anfoega, specifically, Dr. Alex Ackon has done incredible work. He has been stationed here for only 6 months and he has revamped their Pharmacy system, begun updating the Laboratory, ensured a more cleanly environment, and is working hard to get an X-Ray machine and updating the OR. He came from a teaching hospital in Accra, and is amazed with how little this area has. Yet, he is hopeful that they will get help and make the hospital (which takes cares of 10 surrounding villages) is better equipped to provide safe and effective patient care.

    Day 16: January 13, 2010     National Nurse's Conference

        Today we hosted the first (annual) National Nurse's Conference at Chances Conference Center in Ho (the capital of the Volta Region.) There were approximately 35 nurses from the Volta Region (HoHoe, Kpando, Ho, etc.) in attendance. Some we recognized (Edith, a midwife from Marquat; Peter, the surgical ward RN; Sister Magdeline, the CNO from Marquat; Senna, an RN from the Kpando clinic) and many were new faces. Funding for this educational day came from Sigma Theta Tau, Valerie King's parish, Maura Norton and Valerie King's own wallets, and was co-hosted by Africed (the organization our guides work for, though I am not sure if they assisted in its financing.)
        The day started off bumpy. Our bus arrived at quarter of 9 when we were up and waiting outside Cedes Guest House for its arrival at 7am. The conference was scheduled to begin at 9am, and we had an hour and a half drive ahead of us. Luckily, Zanele and Allison had gone ahead with Nicholas (the representative from the Ministry of Education we had been working with) and Mawuli (one of our escorts who works for Africed.) When we arrived, embarrassingly late, Allison was completing her talk on Pediatric Rehydration Therapy. Then we were informed that some important politicians were arriving with the media, so we had to put the conference on hold until they arrived. Politics is very big in Ghana. It is my impression that many groups and organizations have seized on the opportunity to promote themselves when we go places to conduct our interventions. When the important Ministry people arrived, they stayed long enough to make speeches for the media and then left; they didn't stay to see a single lecture. This sort of behavior frustrates me, but I will never understand politics (even in America.) From here on in, I think the conference went well. I think next year's group should view the Second Annual National Nurse's Conference as an incredibly important intervention. Continuing education for nurses in Ghana is practically non-existent and it is certainly not mandated like it is in the United States. The nurses gathered together today came from far away and were very eager to hear us speak, to ask questions, to participate in their learning. Topics that were covered included (I don't have their official titles):
    Pediatric Rehydration Therapy-Allison Geissert
    Hypertension Diagnosis/Prevention/Treatment-Elizabeth Long   
    Stroke Prevention Education-Jody Roper and Lauren O'Keefe
    Diabetes-Valerie King (she is a very engaging speaker for anyone who has her for Community Project this Spring!)
    Congestive Heart Failure Definition/Treatment/Pharmacology-Renee Glennon and Stephanie Whippen
    Breast Self-Exam-Zanele Denaro

        At the conclusion of the lecture portion of the program we opened the floor up for more questions, and then every nurse was called forward to receive a BP Cuff (we had 18) or Stethoscope (35) and all were provided with a marker, highlighter, pen, and t-shirt we had made for the conference. The BP cuffs went first which is not surprising, given that oftentimes a clinic only has one (and it's mercury.) Everyone was very grateful and excited about continuing this tradition next year, but with even more participants.

Peki
    After the conference we began the ride to Peki (Mawuli's hometown.) We were greeted with an elaborate, traditional welcoming ceremony. I have never experienced anything like it. When we arrived, the area was packed with people of all ages- there was some drumming and dancing already underway. As we got off the bus, children swarmed around us. They cheered and jumped and shrieked in delight whenever we took a picture; everyone wanted the opportunity to see their "photo."
    We joined the dancing briefly and then were seated under a canopy of palm tree branches/leaves. Across the dance floor (an open dirt patch) sat the chief and his linguist as well as male elders of the community. All of them had robes of various African clothes wrapped around their waists and thrown over their left shoulder. To the chief's left sat the Queen Mother, her linguist, and drummers.
    Our guides spopke to the chief on our behalf and presented him with a gift of Schnapps. They explained our mission in Ghana. The chief received the Schnapps, which symbolized him receiving us and recognizing our mission as good and our relationship to the community as friendly. After a time, the chief and some of the elders approached to let us know we were welcome, and then entertainment was provided in our honor.
    First a group of 12 young people danced and sang for us (in their native tongue, Ewe.) The group had boys and girls of varying ages; they had cloth wrapped around their middle fingers that they twirled and utilized as they danced to an upbeat, hip swaying, rythym. Then young boys took their turns performing. Their routines involved sticks that were cut to look like small swords or spears. They made menacing faces; puffed out their cheeks, rolled their eyes upward until only the whites were visible, and bared their teeth. They spun and crawled and ran around, interacting with the entire circle of people; at times grabbing at or leaping toward the small children on the outer rim. Their "dance" incorporated defensive and aggressive moves, and seemed to be inspired by battle/swordplay/fighting.
    Next up was a group of women in matching skirts and tops who sang a few songs; the first in their own language and then some religious (Christian) ones in English. The last piece of entertainment involved the Queen Mother and her linguist dancing around the circle. They pulled NSWB members forward to join them. It felt like she was showing us to the people. Those who were pulled from the safety of the canopy were: Whip (Stephanie), Myself (the Queen Mother told me I was "very good"), the Mamas (Val and Maura), as well as Jocelyn and Zanele. I've got pictures. They aren't as good as some others, as the dust and sand kicking up during the dancing came out as spots when our cameras would flash.
    The entire affair was quite an event to witness. After all the entertainment concluded, our formal acceptance into the community began. The chief called each member forward and gave them their African names and two bracelets made of long strands of some kind of dried grass cinched by two traditional painted clay beads. These bracelets, we were told, represented our membership into the community as children of the Chief and Queen Mother (the word Royal was thrown around too.) Our African name is our first name, the day of the week we were born (in Ewe), and then our last name. Mine is Jody "Akousa" Roper, because I was born on a Sunday (my mom will have to correct me if I'm wrong.)
    Maura Norton (being the eldest) received an even greater honor during the ceremony. She was crowned as a Queen Mama; as the community views her as "Mama" to our group. She received more beaded bracelets, a crown of woven/braided cloth, and special sandals. She sat on a stool beside the true Queen Mother, wrapped in a robe of Kenti cloth for the rest of the evening.
    The dance floor was opened up to all participants at this time; so we danced. The welcoming session concluded with our group being offered palm wine, which was shared around our circle in a gourd bowl; you drink and then pour a small amount on the ground (I believe for your ancestors.) I have a phobia about sharing drinks, so I hung back a bit with the little girls I'd been dancing with and was passed over in the dark. I was told the drink was warm and bitter.
    We loaded back on the bus, exhausted. We'd all been up since 6am and the ceremony had lasted three hours. There was one more stop to make; Mawuli's uncle's house. On the well lit front porch a brand new bottle of chilled palm wine was opened for us. Many gourds were offered around our circle. I received a fresh "glass." It was fizzy and cool and delicious; though my tastes may have been influenced by the fact that I'd danced and sweat and been without drink for over three hours. It was a very unique flavor though, so I can't think of anything to compare it with at the moment.

      

Day 10:

                We returned to the Christian Children’s Orphanage in HoHoe with our donation bins of clothing, toes, vitamins, soap, shampoo, flip-flops, coloring books, pencils, notebooks, books, etc. The community health project group that I am not a member of conducted their Dental Hygiene program with the residents.

                The girls doing tooth care with the children did an amazing job. The kids loved coloring their dental related pictures at the end, they were eager to participate in the activity about foods that are healthy for teeth (I’m sure the stickers had something to do with that), and the song the girls taught them was great. The Ghanaian culture is all about music. People blare their radios and sound systems from 7 in the morning well into the night. In school music is utilized to teach moral lessons, about community, about history, etc. The children learned that song very fast (to the tune of Row-Row-Row-Your Boat) and sang it in a round; they won’t forget the dental hygiene message anytime soon.

                One interesting thing to report back about here too, not a single student raised their hands to affirm that they had ever been to a dentist. When the girls pried further and asked if anyone knew what a dentist was, again not one hand went up. Personally, I have a total phobia about going to the dentist, but I carry dental insurance and can go whenever I have to. I’ve had numerous cavities filled, but never needed braces. I cannot imagine not knowing what a dentist is, let alone having never been to a dentist. I definitely need to get over my own hang-ups and schedule myself a cleaning when I get home, because I have the luxury to utilize this service.

                I also wanted to take a brief moment here to thank Dr Auffinger, who donated almost all of our dental supplies. The children were ecstatic about receiving their own tube of toothpaste and a brand new toothbrush (with Disney Princesses, Winnie the Pooh, snazzy neon colors, Power Rangers, etc.) To all our supply donors….know that the resources you sent us with are equally valuable and being utilized well and graciously received by the different communities here in Ghana.

Day 11: 

                Today I went to the Margaret Marquat Hospital and, shockingly, chose to go to Maternity. I hope some other students are taking the opportunity to blog so those of you more interested in Surgical, Pediatric, or Medical concerns are getting some insights into how Ghana operates in other specialties.

                There was one patient in Labor. Male family members (partners, fathers) are not present during the laboring process here. No female support person comes with the woman either, which I was surprised to hear. The patient today was actually being induced (with Oxytocin) because she was postdates (the midwife reported her as “40 plus.) The induction did not bring contractions the entire time I was on the unit, and the oxytocin drip was increased once during my stay. The patient remained alone in her room, except for the three or four visits I made with the midwife, and she has to stay on the small metal table, she could not walk around or sit up because of her IV. She had no pillow, no TV to pass the time, no radio.

                In the labor room there are three metal beds with a tri-fold divide for privacy. There is no such thing as a call bell here. I asked the midwife in charge of the induction how the woman could get in touch with us if she did start contracting, her water broke, she had pain, etc. She was very perplexed by my questions, and I had to rephrase it several times. In the end she laughed and said, “Oh no, we just check on her to see what she needs.”

                How often did we check on her? Well, I was told that when the oxytocin is running the midwife is supposed to listen to the Fetal Heart Rate every 30 minutes. I was on the ward for three hours and she listened to the fetal heart with the Doppler once, the metal cone I’d seen at the clinic another time, and that was it. Each time we left the office and crossed to the building where the laboring primip (first time delivery) was, I usually asked about her rather than the midwife suggesting a visit. It was a slow day on the unit, with many post-partum patients having been discharged the day before. There were 5 midwives chatting in the office, so I don’t know if this is their usual practice or if I caught them on an off day. I don’t know if I am spoiled by the way the nurse’s I work with practice, but I was expecting a more caring environment. I was expecting support people; I was expecting the patient to not be so restricted/confined to her room/bed. I was expecting small talk between the midwife and the patient. Again I was struck by how little interaction there really was between staff members and patients (as in the clinic.)

                In any case, it was all a very shocking experience to me. I know many people who hope for natural labor, or hold woman in Africa up as an ideal way to labor and deliver. Given what I saw today, I know that we (in the States) have a very romanticized view of how woman in Africa labor. The bedside metal table was rusted, the paint on the cement walls of the building cracked, the bed shorter than the woman laying on it and (as I said) minus a pillow and linens. Also, some labor without pain medication or epidurals because they have no other option; it is not a conscious decision/choice. I spoke to several women on post-partum who asked if it was true that Americans can give birth without pain, and one midwife said we should bring that pain relief with us to give it to the women of Africa…very interesting things.

Day 12: 

                We started off the day presenting gifts at both the hospital and the clinic. At the clinic some of the people who came out to receive the items (gloves, bulb syringes, cord clamps, prenatal vitamins, betadine, alcohol swabs, bars of soap, Purrell, gauze, disinfecting wipes, Band-Aids, cotton balls, etc) I found myself having to explain what some of the items were. The clinic does not use alcohol swabs, only dry cotton balls. I never witnessed anyone wiping down a surface either, and did have to explain what the disinfectant wipes were. Shine, a nurse at the clinic and friend to our group, was also helping explain some things to people gathered round. It was good to know that some of the staff has this knowledge to share with their colleagues, but pretty shocking that such education is required. None of the items we donated were high tech.

                After our donation rounds were over, I returned to the hospital and shadowed a very conscientious nurse named Peter. He works in the surgical ward. The lack of empathy and personal communication I’d witnessed in many clinical areas in Ghana did not apply in this nurse’s case. He said he enjoys the day shift because he gets to really know his patients, change their dressings, and feel like he has done something positive for them. I missed his brief tour of the patients on the unit, but was informed by my colleagues who were also shadowing him, that he knew everything about each patient (medications, dressing changes, diagnosis, length of stay, etc.)

                Even here, with such a kind, compassionate, seemingly educated nurse, I saw things one would never (or hope to never) see in an American hospital. The oxygen had “finished” (run out) that morning, so one patient was hooked up to a nasal cannula but was getting no O2. They had no pulse oximetry available (Peter said they never have them) to check the patient’s O2 saturation, but he was sitting in the tripod position and using accessory muscles to breath; clearly in distress. Peter drew blood without gloves on, utilizing a syringe to take a sample of blood. While he was in the vein, he paused to answer his cell phone before he finished drawing the lab! As with the clinic, only a cotton ball was used before insertion of the needle…no alcohol. Sharps bins here, as with the clinic, were cardboard boxes and the needles the staff has access to are not safety needles. Single rooms are unheard of anywhere in the hospital, the patients are separated by gender and beds line two sides of the room, about half an arm’s length from one another. There is no privacy, no HIPPA here. On most of the beds, patients were sprawled out atop bare mattresses, and the rooms were semi-dark sweat boxes. Again, no A/C or fans (as far as I saw.)

                When we went to the lab to bring a patient’s CBC (of full blood count) and BF (malaria smear) Peter asked if we’d like to donate blood. That felt awkward. I know blood is scarce anywhere one works in healthcare; I know it gives life, but I just couldn’t bring myself to expose myself to the tools and techniques this nursing staff has available to them. Sterile technique that I have witnessed is sloppy or just plain wrong, and there are not even alcohol swabs to start IVs. I said no. There are so many problems here that I can witness but do little to change, which can be frustrating.

Day 13:

                Today we went to Nkonya to advertise our HIV/AIDS Prevention Education program, which we will be hosting tomorrow (Sunday) with my Community Project group. We split up into four groups and followed interpreters into different corners of the village. Each team was armed with one stethoscope, a blood pressure cuff, and a handful of useful donations to distribute to villagers: soap, shampoo, mouthwash, lotion, etc.

                My group (Michelle, Whip, and our interpreter Vivienne) met a girl who has what sounds like epilepsy. She had "an episode" 2 weeks prior; resulting in severe burns to the left side of her body (she fell into a fire!)

I saw a woman who claimed to be 11 months pregnant, but didn't have money for the cab ride to Kpando to get her "picture" (ultrasound) that the clinic in Nkonya
recommended. She claimed to have already felt the baby move/kick 3x
today, and it was her fourth pregnancy. She had had no pains, bleeding, fever, etc. Still, it didn't seem like the head was engaged in the pelvis (breech? I thought I felt a head closer to her fundus.) I had no measuring tape to do a fundal height but she looked near term, if not term. I just hope she was wrong about the dates. She is
coming to the clinic tomorrow when we go back, and we plan to ask people for money to get her to U/S. We saw several blind individuals (Val thinks it was the River Blindness.)

Again, we encountered some outrageous blood pressures. We saw a 10 year old boy who appeared to have something like psoriasis. His mother reported he's had it for 7 years and that it itched. It was over his joints. It's so hard. We didn't have Val or any meds with us, so they are coming to the free clinic tomorrow, though all we have is cortisone cream and pain med...and there is no physician readily available to him for any kind of treatment.

Another little girl had some kind of rash...it goes on and on. The people need to very much. I had Tylenol in my first aid kit for the group which I administered to a woman in her young twenties who was drenched in sweat from fever. She confirmed a bitter taste in her mouth, that the fever comes and goes, and cough...malaria. She can't afford the medication though. All we could do was talk to her about drinking water, adding sugar and salt to her fluids (she wasn't taking in any food) and stressed going to the clinic or getting someone in her family to help her pay for the medicine. We also told her to come tomorrow as Val may be able to access the appropriate medication if she talks to our guide.

Day 8: Monday, January 4^th, 2010

                Today we split up into two groups. My group went with Val to spend the day at Kpando Health Center, and the other half accompanied Maura Norton (Brianna’s mother) to the Margret Marquat Catholic Hospital.

                At the Health Center I spent the first half of the day in maternity with the midwives seeing patients for prenatal visits. I know I talk a lot about maternity, but I am a scrub tech in L&D back at home and it’s something I have a firm point of reference on within the healthcare field and it’s a clinical area I am extremely passionate about.

                All day patients were weighed on a bathroom scale that wasn’t zeroed; it was probably about 2 to 3 kg off. However, if all the women weigh in on the same scale each time, I suppose that isn’t a huge concern. There was a sink in the room with a small bar of soap and even a hand sanitizer dispenser that was about one fourth full. I saw the head midwife wash her hands in the sink twice, and utilize the sanitizer once. Her colleague never washed her hands in my presence. The linen on the exam table, along with the privacy sheet, were not changed between patients. The blood pressure cuff was mercury, and not every patient had a BP taken. The same was true with FHR, and even when the babies heart rate was assessed it was for but a moment…not to obtain an actual rate. The tool they utilized for this intervention was a metal funnel with a round flat base with a hole in it. They would ascertain the position of the infant and then press the widest point of the funnel against the mother’s stomach, placing their ear on the round circular part. I was amazed when I was given the opportunity to listen for myself. You could hear the infant’s heart beat fairly clearly. I asked what would be utilized in labor and the midwife showed me a Doppler but reported that it was broken, and a replacement was nowhere in sight. This appears to be a common problem in Ghana, clinics everywhere are lacking funds and supplies.

When medicating patients with a PO med, women were filling water from the tap with a brown plastic cup or, worse, scooping water from a teal bin that sat by my side all day. This cup was reused numerous times and no more than rinsed to clean it. However, I’m sure disposable cups or a bubbler of fresh water would be out of the clinic’s budget. That may, in part, be the reason for reusing the same linens all day. I don’t think everything is done out of ignorance, because Mary, the midwife, did offer me and my classmate some hand sanitizer after we checked a fundal height and infant position, so they have some idea that hand washing matters. If they know this, they must know re-using linen and cups is not an ideal situation.

I then asked what would happen if the midwife was able to hear the rate and knew the infant was having decelerations or in distress. The mother, I was told, would then be referred to “Marquat Hospital.” “By ambulance?” I asked, as I’d seen one parked in front of the hospital on our ride back from Wli Waterfalls. “No, in a taxi,” she said. That blew me away. When things go wrong in labor, they go wrong fast, and Mary Marquat is over a 30 minute walk across town, and there is no taxi stand outside of the health clinic, so I’m presuming one would have to be fetched before the journey to the hospital could begin. Considering that they routinely allow known breech patients to labor here, have twins deliver here, and one of the patients seen while I was there was a known TOLAC (trial of labor after cesarean) I am sure the need for that taxi ride presents itself in this setting.

The one intervention I witnessed that I don’t see in the States with our patients was prophylactic malaria medication. Along with prenatal vitamins, patients are routinely prescribed a course of antimalarial treatment. They take three pills at 16 weeks, take another 3 a month later, and the last dose of three a month after that. I would later learn at the hospital that, despite these precautions, Malaria is still the number one cause of stillbirth.

The entire conversation/history was conducted in Ewe (the native tongue of the Volta Region) so I did not know exactly what was being said all the time. One of the midwives (Sister Mary) was very good about translating, but the other was not so much. Still, privacy in the clinical setting is very different from the States, and I also observed a much less compassionate and friendly approach in the nurse-client interaction. A patient would come and sit, hand over her maternal record, and the midwife would often not look up or address the patient. She would transcribe from the record to her book and then order the patient on the scale, or to hold out her arm for a BP reading, or to get up on the table for a fundal height check. There did not seem to be much back and forth, or chatting about the day/the pregnancy/concerns, etc. Later in the day, while doing intakes with a few different women, I got this same impression from those other nurses I worked with.

 I don’t think the three year nursing program here emphasizes compassion and communication skills. There is a lot of staring at paperwork and asking short questions. There is little follow-up, minimal eye contact, no smiles exchanged. I don’t think it would be unwelcomed by the patients, making kindness a culturally irrelevant means of practicing nursing. I spoke with one little boy about his thumb, while his father answered the nurse’s inquiries about his injury. At first he was timid, in part I’m sure because of my odd color, but then he was smiling and explaining that he fell and it hurt a little. The father turned to me and smiled, and he said thank you later when they left for the consulting room to get patched up. 

Kwado, our guide, reported during debriefing that nurses in Ghana are not held in the same esteem as they are in America. Many people believe women and men become nurses to have a stable job and to make money, that they are not truly called to the profession. I find this very sad, but am beginning g to see where this picture of nursing comes from.

Day 9: Tuesday, January 5^th, 2009

                Happy Birthday Allison G, NSWB Treasurer! I spent the day at the clinic again. My morning was with Maria, a third year medical student from Puerto Rico (whom I believe I’ve mentioned before.) She was a wonderful teacher, taking the time to review important medical concepts with us, discussing diagnosing patients from symptoms (as the clinic is not equipped to run many labs), the challenges of treating patients with a limited regiment of medications, and the frustration of having to refer patients to the hospital when she knows they do not have the transportation to get there but the clinic does not have the necessary resources to provide appropriate treatment.

                The most common illness seen here at the clinic is malaria. Of the 60 patients that were seen the previous day, I counted 35 as being diagnosed with Malaria when I worked on intakes. Today we also say septic arthritis, this young man did not even speak Ewe, he had just come to town for market and to see a doctor. His complaint was joint pain and a cough for over a month. His elbows and knees were extremely hot to the touch, so Maria decided to start him on oral antibiotics for 21 days. She doesn’t have access to IV antibiotics at the clinic and he said he could not afford to go to the hospital. She was going to “detain” (admit him) for the day to be sure he got his prescription filled and received the first dose. These are the kind of decisions she says she has to make every day when treating patients in this area.

                Also interesting to note is that Maria is only volunteering here for 2 weeks, and she is considered senior staff and is one of only two doctors (the other holds a more administrative position and was not present on either day I was at the clinic.)

The Market

                After work we all headed out to play, including Maria and her host (Shine) who is a nurse that housed both Val and Maura during their stay last year. The market was jam-packed full of vendors, goods, people and animals. I know I have not done a very good job at describing what it looks like here, and (I’ll say it again) can’t wait to post pictures, but I’ll try.

Women carry their infants on their backs with long colorful cloth, they are often are attired in dresses or skirts with a top. The men are often in cache, jeans, or black pants, and button-up shirts are more popular than t-shirts. Nearly everyone where’s flip-flops, if they have shoes on. It is more common to see barefooted children than adults. Children, of all ages and sizes, can be found on the streets during the day and night. They run around in packs or small groupings, and are rarely accompanied by an adult as far as I can see. Everyone carries items on their heads. Vendors will have metal bowls full of bags (not bottles) or water or macaroni or plantain chips, etc. Sometimes they have wooden boxes with clear side panels full of meat pies or pre-cut pineapple wedges, or stew in a bowl with cups. It’s not uncommon to see women selling eggs even, balanced on round trays and stacked, god only knows how.

At the market there were permanent looking structures with cover/roofs. There were also makeshift stands as far as the eye could see. The colors and smells and amount of people were overwhelming; as were many of the smells (some good and some not so good.) There was fabric for sale, tomatoes, hot peppers, gold jewelry, sandals, bread, traditional beads, carvings, etc. If you can imagine it, you could probably find it for sale on market day. I ended up buying fabric that I took to Billy the dressmaker later that day to have custom dress made for me before I leave. Maria and Shine were good at bartering, but I just traveled from front to front until I liked the price (and the fabric.) I found two yards for 4 cedis, which is what Billy informed us it would take to make a dress. He only charges 7 cedis for his work, so I feel like this will be an amazing and memorable souvenir for me.

There is so much more I could report, but need to work on packaging boxes of supplies to present at the Children’s Home tomorrow. I just want to note that everyday I miss my family, friends, coworkers, and (of course) my boyfriend. Still, I am over the major hump of the culture shock. I’m used to the sights, smells, language, etc. I know that I am still living a privileged lifestyle even while I live in Ghana. I do not have to carry my water, I have a toilet at Cedes Guest House that flushes, a working shower; I have A/C and a fan, and I have electricity. I have money to eat out at restaurants, and to purchase filtered, clean water. I’m more appreciative with each day for all the amenities my life in the United States affords me.

Day 2: Monday, December 28, 2009
       The flight from Heathrow to Accra was pushed back by an hour. The wait was fairly uneventful, aside from Stephanie’s entire carry-on bag being rifled through by security; they thought her international electric plug adapter was a bomb or something.
       I spent much of the layover trying not to think about being thirsty, given that the unfavorable exchange rate of dollars ($1.77) to pounds (1) made bottled water nearly $8.00. I tried unsuccessfully to catch a vertical nap on a seat and, when the noise and excitement of the day made that impossible, I journaled for a moment before delving into a Rachel Cohn book recommended by my Aunt Nancy; librarians are great people to know.

Our Arrival in Accra
       The reception in Ghana was tremendous. A representative of the United States Army helped usher us through immigration and customs. Our guide/escort Kwado met us at baggage claim. We loaded up 22 boxes of supplies, 22 carry-ons, 10 checked items, 10 Nursing Students, and a faculty advisor into a 25 seater van. Our driver, Solomon, is one impressive motor vehicle operator- he could get that enormous van parked most anywhere. Oh, and I almost forgot, it was over 80 degrees when we landed.

Our First Meal in Ghana
       It was very late at night when we arrived in Accra, but Kwado, his wife Sylvia, and our other guide (Mawuli) took us out for toasted cheese (grilled cheese) at Frankie’s before we checked into The Samartine Hotel; owned by Sam and his wife Martine (a native of Belgium.) Both the owners were extremely welcoming and hospitable. We were delighted to find our bathrooms contained toilet paper! The first night I had no water to shower by, but this was remedied on the second night of our stay.

Day 3: Tuesday, December 29, 2009
       Breakfast: instant coffee or Lipton Tea; mango or orange juice; an order of “eggs” got you scrambled eggs with red pepper and onion; toast (a sweet bread); fat spread (margarine); sugar; creamer

       This morning was my first introduction to Ghanaian time. We were all up at 7 am, due to leave for our tour of Accra and the University of Ghana at 8 am sharp…we didn’t depart until 9:25 am. My boyfriend would absolutely love Ghanaian time.
       We were honored on this day to be joined by Director Eugene Armani from the Ministry of Education. After our bus tour it was arranged for us to meet a representative of the Minister of Education where we discussed our itinerary and the kind of programs we hoped to implement. He, in turn, offered us some insights into the history and plight of Ghana, and offered us some excellent advice.
       “Find out how they [Ghanaian people] live; do not shy away from difference [and] if [the clinic] has no waiting room, no drugs, find out why; evaluate challenges [so] you can help advice, guide, and serve as advocates.” –Mr. P.K. Daneau (sp?)
       We also learned in this meeting that 40% of Ghana’s population lives below the poverty line. Though education for all is priority of the Ministry of Education and there are enough teachers in Ghana, deploying these teachers to remote, poor communities is a problem; meaning quality education is not accessible to all.

Touring
       Stay tuned for pictures. Describing my impressions of the people, the roadways, and the building structures just won’t do justice to what you can see from the pictures I’ve taken. I will say, though we have plenty to complain about with the Big Dig, it’s nothing compared to the roadways here-most often dirt/clay, full of potholes (even those that are paved), with large drop offs on either side where the sewers are. There are no speed limits, no sidewalks, and vehicles claiming the right of way!

Day 4: Wednesday, December 30th, 2009
       Another early morning wake-up call but delayed departure. We repacked the van and headed for Ada, a poor community of approximately 15,000, on our way to Kpando.
       In Ada we were given a tour of the Kasseh Health Clinic. It was absolutely eye opening. Their “nursery” housed a sink and a metal crib with no mattress. The labor room was two metal tables an arm’s length reach from one another that weren’t even long enough for someone to lay flat. The Post-Partum Unit (the “Laying In” room) is where women go after delivery for six hours before being sent home with their newborn. This area housed four frames with mattresses hemorrhaging stuffing at all four corners, and lacking any kind of plastic or protective covering. I work in Labor and Delivery, so this touched a very sensitive cord for me. Thanks for the tissue Renee; that experience was overwhelming. New mattresses could be purchased for 80 cedis ($55.50 American) but this expense is far too great to be affordable to the clinic. Again, I feel like words are not enough and look forward to when I can post pictures for all to see.
       I stayed in Ada for a blood pressure clinic with Zanele, Whip (Stephanie), Lauren, and Renee. The other half of the group loaded up into the van to go to a nearby village.
       At our BP Clinic we could not prescribe meds because Val was with the other group, so we worked with the clinic and referred people over to their consulting room when we found extreme BPs. I was shocked by some of our findings.
       Male, aged 60, 200/90
       Male, aged 47, 248/148
       Female, aged 40, 210/94
       Male, aged 37, 158/100

       Many of these people had been on medication for their blood pressure but reported that it was “finished.” They did not understand that blood pressure medication is something you need to be on for life. Through our translators, Prof and Sylvia, we worked with these clients to explain the complications of high blood pressure, lifestyle changes that help improve BP, and the importance of getting on and staying on medicine.
       The hardest thing about this interaction was the patients who sat before us for a BP screening but who really had some other medical problem they hoped someone could treat for free, because they could not afford the clinic.
       Female, 75, c/o foul smelling urine, question UTI
       Female, 23, severely jaundiced, question TB or Hepatitis
       Female, 53, c/o right sided pain radiating to her back, possible kidney stone

       We had no antibiotics to give these women, no means of testing for hepatitis or TB. Our possible kidney stone was in tears, but we didn’t even have strong pain medicine to offer her relief. It was depressing, but really drew a vivid picture of just how much these people need, because we were offering such a small service and they were still so thankful to be seen by white “nurses.”

Our First Supply Donation
       Though we did not have as much to give as we would have liked the donations we offered the clinic at Ada probably doubled the resources that we had seen during our tour. They were all gratefully received by the nurses and other staff members there.

Day 5: Thursday, December 31, 2009
       We are staying in Kpando at Cedes Guest House. The girls last year became familiar with this location because they would eat at Cedes Restaurant, which is closed for the time being. The internet café is located directly across the street, but the owner Eyram informed us that the internet was down for the day and he wouldn’t be open on the holiday, New Year’s Day.

The Ministry of Health
       I’ve been amazed at how welcoming important government officials have been to us. Twice now we’ve been invited into Ministry buildings to speak with very important people. Today we spoke to representatives for the Ministry of Health and the Director of Health, a Doctor, for the Volta Region. With them we negotiated how our time would be spent during our stay in this region (through January 12th.)

BP Clinic in Torkor
       We saw well over 250 patients on this, market day, in Torkor (a fishing village along the Volta Lake.) People waited in the hot sun, many standing, to have their blood pressure taken at one of our four stations. We also set up two other students with BP cuffs who circulated through the crowd taking BPs. Many were sky high, stroke material, blood pressures. We kept Val very busy calling her over to consult about a patient. It was hard to tear ourselves away at the end of the day, but we had dinner arrangements waiting for us on the other end of the day.

Day 6: January, 1st, 2010
       Happy New Year! We spent the day in Torkor again. Lauren, Zanele, Jocelyn, and Mawuli walked through the village with a speakerphone to inform people of our location in the market place. Lauren videotaped a good portion of her journey on foot and had some amazing storied to share about life in the village. If there is ever an opportunity to raise awareness about our presence, I will certainly jump at the chance. One man approached the group asking that they come see his ill mother, too sick to travel to the market. The girls saw a hawk with no wings, being kept as a pet. They reported huts upon huts upon huts corded together. And, as we have found to be the case everywhere, they encountered gratitude that we had come.
       Back at the clinic…we had quite an influx of children on Day 2, compared to day one. We listened to heart and lung sounds, checking their mouths and discussed dental care, several went home with antibiotics for ringworm-more than I would have anticipated seemingly had umbilical hernias so parents had to be referred to a doctor for surgery.
       The adults waited in line for two stations and, again, we found some very high blood pressures requiring amlodopine prescriptions from Val and clinic referrals. We are very lucky to have an NP with us who had access to prescription medications and the knowledge base to prescribe it appropriately. We also saw ringworm, a large venous ulcer on the calf (that was dressed,) vision problems, bilateral leg edema, etc.

Financial Argument
       On our way out of the village, there was an argument over our agreed on cab fair (50 cents a person.) It’s the first time I felt somewhat unsafe in Ghana. The vast majority of people are very welcoming and friendly. The people of Ghana are typically friendly, truthful, and thankful. Many young children do call us out as we walk down the street (Yovo: white person) but it all feels welcoming. Adults frequently greet us with a “you are welcome to Ghana.”
       Our escorts were speaking rapidly in Ewe to the driver, trunks were opening and slamming shut, one man put a hand to another’s chest- it may have been less frightening had the whole argument been in English, but even though this it the “national language” I have been surprised by how many citizens (outside the cities) do not speak English. Most, even who know English, speak in their native tongue amongst themselves.
       In any case, we piled (literally as there were 5 of us girls in the cab) our and jumped in another Taxi. Mawuliu has been an incredible advocate and guide for us. I was extremely thankful he negotiated us out of that tense situation. The root of the problem we encountered in this instance is poverty. When some people here see a white face, they see an opportunity to bargain for a higher price. There is this idea that all Americans are extremely rich. Compared to Ghanaians, we are, so I can see where they are coming from. In reality, however, the NSWB’s funds are limited, so we rely on the help of our escorts to keep extra costs reasonable.

Day 7: January 2, 2009
       We spent the day visiting the Christian Children’s Home in HoHoe and touring the Wli Waterfalls. Today was the first time I saw an actual chicken pen; most chickens roam around the streets. The children were absolutely adorable. They eagerly greeted our Trotro, carrying 15 of us, and sang songs I recognized…The Lion King, and songs I didn’t, but that appeared to be the kind of children’s songs that have hand movements that go along with the words.
       We got a tour of the facility from one of its leaders, Nicholas. There is a girl’s dormitory and boy’s dormitory, three classrooms that are broken up by age, a kitchen, a sleeping area for the volunteers, washrooms for volunteers, and the chicken coop previously mentioned that houses poultry to provide protein sources to the children. Outside the facility is also a playground with an area utilized as a soccer field, swing sets, and some other metal jungle gym type equipment.
       It was heartbreaking to see how little these children had. One little girl grabbed my hand and dragged me from room to room, before pulling me into her dormitory, over to her bed. There she dragged a black trash bag out of a cubby and dumped its meager contents on the bed, two plastic horses, a kaleidoscope, a stuffed bunny, a coloring book, and four broken bits of crayon. These were all her worldly possession and she was so proud to hand me her bunny and show me pictures she’d done in her coloring book. Than she gave me her most complete crayon, purple, pointed to a page and said “You draw!” She gave the best of what she had, and shared. It was touching.
       Later, before we left, we gave all the children a page from a coloring book and one crayon. We didn’t have enough, at that time, for two per child. However, we have tons of chalk and crayons that will be given to Nicholas, the director, to distribute. Still, I watched the children share colors or come up to trade for a different color. It was certainly nearly a riot to get their hands on the initial round of stuff, but than they were all very kind and civilized…not remotely whiney or selfish as sometimes children in those age brackets can be. Truly, truly impressive…it makes me appreciate so much all that I have and that my parents were able to provide for me.

            I have not been able to access the blog due to lack of internet café availability, internet outages, and rolling blackouts (no electricity), etc. However, I apologize for having kept people in suspense for so many days. Believe me, I found it equally frustrating. In any case, welcome to my blog! J

 

Day 1: Sunday, December 27, 2009

            Our flight was delayed-instead of meeting at the airport at 4 pm and taking off at 8:20 pm, our flight departed Logan at 11:05 pm. I think we all appreciated the postponement of our journey though, as it shortened our layover in Heathrow and bought us an extra couple hours with our loved ones.

            British Airways was very accommodating and allowed us to start checking in our baggage a little earlier than anticipated. A few of our 22 boxes of supplies were slightly over the 51 lb weight limit, but we weren’t charged extra.

            On the first leg of our journey most of us watched a movie, I watched The Hangover (hilarious) and my seatmates chose The Time Traveler’s Wife (slow, but the book is supposed to be really good.) We all did our best to sleep after the films concluded. I was woken to a breakfast snack at 9:15 am London time, so I reset my watch (reading 4:15 am Boston time) and tried not to focus on or lament over lost sleep.