Ghana January 4th & 5th 2010

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.