The Circle of Life

Howdy from the sweaty streets of Donkorkrom. Just as a word of warning before I get going, most of this post is medical and some of it is a bit rugged - reader discretion advised.

Life is falling into a pleasant routine here in Donkorkrom. I get up around 7am and get ready for the day. Then I head down to the hospital, stopping on the street for something to eat - some bananas, an omlette, some bread, then I arrive at the Children's/Female Ward and I do rounds with Dr. O. Then some days we go 'to theatre' (the operating room) or to the outpatient clinic.

However, today things were a bit different as Dr. O had to make a trip to Accra (a 3 day undertaking essentially...one day to get there, a day of business, a day to come back). We met at 6am for rounds and then he disappeared, I walked back to my accomodations and had another bit of sleep :-) Then I returned about 8:30 and did rounds in the ER/Male Wards with Dr. B.

Saw some interesting cases - a 25 year old with Rheumatic Heart Disease and congestive heart failure - he is edematous (pitting to mid-shin, ascites), in respiratory distress, has a large tender liver, large spleen, and a heart murmur. All in all, not a healthy guy, especially for a 25 year old. The next patient had an indwelling suprapubic catheter that was being discharged. He has a urethral stricture from some unknown cause (potentially repeated urethritis) and as a result has urinary retention...thus a suprapubic catheter because you can't get one up the ureter. Another man had presented with lockjaw and received thousands of units of anti-serum which had soaked up the toxin produced by the microbe and he was recovering. Next there was a patient in kidney and liver failure with full blown encephalopathy. Rather exciting for me (in a morbid way) was the fact that he had asterixis - this is a finding where the patient cannot control the movement of the hands when they are held out in front of them as if they were stopping a bus; instead they flop uncontrollably - I don't think this patients prognosis is very good at all. When I asked about management 'hope' seemed to provide a significant part of the treatment. His condition is exacerbated by his chronic alcohol intake (likely a cirrhotic liver) as well as the fact that he took traditional remedies before coming to the hospital and these remedies are most often toxic to the liver.

The next patient was a shocker...this patient presented to the hospital and was ambulatory. Upon admission they did a measurement of his hemoglobin. Hemoglobin is what determines the ability of your blood to carry oxygen. The normal range for hemoglobin in a man is between 130-180...in a woman the normal range is more like 120-160. Here in Donkorkrom I have seen many low hemoglobins in the 48, 55, 62, 75 kind of range. If a child comes in and has a hemoglobin below 60 usually they receive a blood transfusion...depending on their clinical picture. However this man presented with a hemoglobin of 18!!! This is ridiculously low and after a blood transfusion he was up to 32. I was astounded - it is amazing what the human body can adapt to. This man's hemoglobin has just crept lower and lower and his body as adapted. He has severe pitting edema all the way up his legs (his legs look like tree trunks as they are so swollen and he has folds of skin holding fluid at his ankles) to his abdomen where there is fluid in the peritoneal cavity but he appears relatively well and with proper nutrition should recover I understand.

I have been made very aware of the circle of life the past few days. On Monday I watched a cesearean section and witnessed the first cries of a new born baby as it entered the world - it was a powerful, amazing, awesome moment...I don't know what the child's life will be but for me to be there when it made those first sounds was incredible. Today in clinic I saw multiple children who could melt your heart with their little smiles - yes, I'm truly a softy for the kids.

However, I've also witnessed the flip side of this coin. One patient who was operated on never came off anesthesia and she passed away, thus her little child is now motherless. Yesterday Dr. O performed two ultrasounds which I watched on preganant women. The foetuses in both cases were no longer viable...basically the babies were dead. One woman was about 24 weeks and will have to be induced to get the foetus out. This is a particularly terrible case as the woman is sick as well. She has a significant patch on her pendulous breasts that the skin has sloughed off of. The patch is close to 6"x4" in area and the rest of the skin on the breast is not healthy either; the other breast shows peau d'orange (the skin looks somewhat like an orange peel) and I'm not sure what is going to happen with it.

This is all bad enough but then this morning I went with Dr. B to perform a Donkorkrom Post Mortem/Inquest into a hit and run death of a 5 year old girl. I didn't know what to expect as I've read some stories about post-mortems (PM), morgues, etc but this was pretty bad. The refrigeration system in their morgue here no longer works so the bodies are embalmed immedeately on arrival, thus this PM wasn't quite what you read about in the Scarlatti and other novels about medical examiners. Lets just say it was pretty terrible. Death is ugly. I'm going to spare you the details as there is no need for them to roam the internet but it lacked any sense of serenity, dignity, or sterility. The little girl's father and perhaps uncles/immam/community elders were there to claim the body and they watched the examination which was quite basic - the doctor only examined the exterior to determine cause of death. I'm not sure I'd want to be a medical examiner after today. It was a place that sucked the energy out of you simply by being there.

After the PM we went to the clinic and I had some of my own patients again which was quite exciting. Then I've had a few hours off this afternoon in which I've read up on a few drugs and had an awesome sleep. I'm on my way back to the hospital for evening rounds and that will be a day in my life.

I hope that all of you are well and enjoying glorious summer weather.