Dear Ms. Ceesay

The following blog is in response to one of the comments posted to our blog yesterday. The author did not give her email address, so I am using the blog to reply to her.

Dear Ms. Ceesay,

I received your comment to the blog today, and immediately went to the medical ward to see your father. He was admitted yesterday about noon with a stroke, as you said. He as admitted by one of our team, Dr. Amelia Pousson. His condition is currently stable. After 30 hours here, his blood pressure is under control and his symptoms have not worsened, his stroke has not progressed. He is unable to speak, but he is able to swallow soft foods and drink. He has almost complete loss of motor function of the right leg and right arm, which is called hemiplegia, indicating that he likely had a stroke on the left side of his brain. It is most likely that he has had an ischemic stroke, which is when a blood vessel is blocked, and an area of brain tissue suffers damage from lack of blood flow and oxygen, rather than a hemorrhagic stroke, when bleeding occurs in the brain. Your father is on all the appropriate medications to manage his condition.

I spoke at length with your family at the bedside, answering their questions and explaining what I could. The definitive test to confirm a stroke is a CT scan, which we do not have here at SJGH. The only one is at RVTH in Banjul. At this point, a CT would really only provide additional information such as exactly what part of the brain in which the stroke occurred, and how much tissue is involved. This information can be important to help determine prognosis and expected length of recovery, as well as prevention of further strokes or other neurologic events. After much discussion with your family, and with the Cuban doctors who manage the medical wards, a decision was made that your father is now stable enough for transfer to RVTH in the morning for this CT scan and neurologist consultation. Discussion can be made there based on the results of the scan and his condition whether he would benefit from further rehabilitation outside of the country. My understanding is that there are no physical therapy or rehabilitation facilities in The Gambia.

I hope this information is helpful to you and easy to understand. Your father has suffered a significant injury, but he is awake and stable, and will likely continue to improve if he receives the proper attention and care. Predicting how much of the use of his right side and speech that he will recover is impossible to tell at this point in time. Your family was wonderful, and so many of them are at the bedside caring for your father and assisting the nurse with management. It is wonderful to see families come together like this for a loved one, as I am so used to American families that can be so small and spread out, and people live into their later years with no one around to help care for them. Your family says hello to you.

I hope you will keep me posted about your father’s progress, and he will be in all of our thoughts and prayers in the coming weeks. Please email our website if you have any further questions, or if we can be of further help. We leave The Gambia on Feb 3rd to return to the United States.

All the best,

Susan Thompson

The Longest Blog Ever!

 

Zeke celebrates his 30th birthday with dancing and singing!

Thursday, January 29, 2009.

 

What a week. Sorry it has been so long since we’ve written, but it has just been a very busy week, so many things happening, so many emotions, many ups and downs. Everyone is having a difficult time, and yet having a wonderful time as well. This will be a very long blog, but it is covering 6 days, so bear with me!

Sunday, January 25, 2009. Tonight, our relaxing evening was interrupted by a nurse coming to get us because of a gelly-gelly (bush taxi) accident. Eight patients had just presented to the OPD with various complaints after a gelly had been basically head-on’d by a large truck. The passenger in the front of the vehicle was the most injured, with facial lacerations and a right leg injury that we suspected was either a muscle rupture or a femur fracture; either way, a significant injury. The rest of the patients had various lacerations, contusions or abrasions, or mild head injury. We were able to triage everyone and get them all treated in a matter of 30 minutes, with a little extra time for a few of the lacerations. Jules did her plastic surgery magic on the complicated facial lacs, while Lonnie repaired an upper lip and the rest of us managed the other cases. Teamwork. ☺

Monday, January 26, 2009. Today was another trip to RVTH for me, alongside Adam and Amelia. Adam presented “Damage Control Surgery” to the surgical staff and medical students for Grand Rounds, and he was quite a hit. Following, one of the Cuban surgeons, Dr. Felix, took us to see the OR’s, the surgical ward, and to follow up on the patient that Amelia had transported to the A&E department the previous Friday. She was much improved, and had not required surgery. She was very happy to see Amelia again, as was her family. We had a lovely meal at a local restaurant while waiting for our ride back to Bwiam to arrive. We returned just in time to race to our evening clinical lecture, which was Jules presenting a summary of burn care. She used as a case study our patient from the other day who had suffered severe burns, and sadly passed away from his injuries during the night. It was not only a good review of burns and their treatment, but a stimulated discussion of the issues associated with care of a critically ill patient here at a facility with limited resources.

Tuesday, January 27, 2009. This was a wonderful day altogether. In the afternoon, after much hard work in the OPD and scanning, rounding, Adam doing surgeries, we all went to the local women’s group, the Kofa, which Lonnie has mentioned previously. They were making “tie and dye”, which is the process of dyeing fabrics in special patterns. It is very similar to what I call “Jerry Garcia tie dye” in America, but they don’t actually tie the fabric at all, they lie it out on the ground on canvas and twist it around into patterns with their fingers. Then they pour the various dye colors onto the fabric, rather than dunking the fabric into the liquid dye. The result looks nothing like what Jerry Garcia tie dye looks like; it is intricate and beautiful and amazing. We were invited to watch the women make this fabric, as we had seen samples of it and had let them know that we wanted to purchase some from them. What a lively group of women! Greeting went around and around, making sure all of us had Gambian names, and telling us which ones of them we were all related to, then shaking all of our hands and going through the various Jolla and Mandinka greetings over and over. We felt very welcome. The process of the tie and dye was fascinating, and what ended up looking like an absolute mess on the ground turned out to be beautiful and captivating once it was rinsed and hung up in the African sun! We were appropriately enthralled, and shelled out our Dalasi for the materials. These kinds of interactions are so special, and the vision of those women, all smiles, dressed in beautiful colors, will be with me forever.

Later in the evening, it was time for our clinical lecture. Adam had brought the equivalent of ATLS, Advanced Trauma Life Support course, which is the basic training for medical professionals in dealing with any patient that has a traumatic injury. Because there is a large amount of trauma here: traffic accidents, pedestrians struck, falls from height, animal-inflicted injuries, and sadly, teacher-inflicted injuries to children, of which we saw many and had a very difficult time dealing with, we felt it would be a great topic for the staff. We used our gelly accident patients as case examples. Halfway through the lecture, after most of Adam’s questions to the audience were answered incorrectly, he realized that perhaps the subject matter was a bit over everyone’s heads. So he asked someone to volunteer the definition of “trauma”. No one was able to answer correctly! Imagine that nurses caring for patients on their own would volunteer “unconscious” and the definition of what a trauma patient is… So Adam backtracked and started at the beginning, defining trauma and what constitutes a traumatic injury. It was another wake-up call to us about our lack of understanding about the staff’s breadth of knowledge. No one working here had ever learned about trauma or the care of the trauma patient. No wonder we see them doing all the wrong things, they haven’t learned the right things! Certainly their ability to provide exact care according to ATLS is limited given their environment and lack of equipment, however knowing what to do and not being able to do it is very different from not knowing that you’re not doing the right thing. This is all the more reason to continue to share our knowledge and training with those here. As the lecture concluded, we all felt that even though the subject matter was simple, it made a positive impact.

After the lecture concluded, we returned to the house to have a surprise party for Zeke, who is turning the big 3-0 today! We had arranged to have some local women led by Lonnie’s “Gambian mom” Gia, to come by, along with 2 drummers, one of which is Gia’s grandson, to play, sing and dance local music for Zeke’s party. They were wonderful, and we all sat on the back porch, clapping, singing and dancing with them until very late. Julie had brought party favors that made a loud squeaking sound when you blow in them, and the women could not get enough of the sound, blowing into them over and over while dancing around singing “Happy Birthday to You” to Zeke. Zeke was quite animated, joining in the African dance with skill befitting a true Gambian, and even taught the women some of his own moves! It was a very good time, and marvelous to be able to experience the local music and dancing with people like Gia and Seiku, her grandson, to whom we have become so close. Too many JulBrew’s now, time for bed.

Wednesday, January 28, 2009. This was a very busy day with some very sick patients. Julie admitted a 3 year-old boy with high fever, convulsions and coma. She suspected cerebral malaria, which was confirmed with a blood film showing 1+ parasites. Despite the appropriate medication, the baby had 2 further seizures throughout the day and did not improve much. It was difficult to watch him suffering so much while waiting to see if he would get better. Another patient, a woman with an abdominal hernia, unfortunately passed away today from complications of poor blood sugar control. None of our team were directly caring for her, however each of us were involved in her hospital course at some point, and all of us were very emotionally involved in her well-being. It was a somber group that had dinner together tonight after hearing of her outcome. One of the good things about being with a team, though, is the ability to talk through difficult situations such as this and gain perspective, to help everyone cope.

Another patient, a pregnant woman, about 34-35 weeks along she thought, her 10th pregnancy, had had her water break 2 days prior to today. She was having no contractions, but she was no longer feeling the baby moving. She had been admitted, and today Amelia and Dr. Spencer, the surgeon, had performed an ultrasound, showing a good heart rate for the baby, but the amount of amniotic fluid left inside was dangerously low, and the baby was not moving at all, even with stimulation. This is worrisome, for if labor does not progress after the amniotic fluid drains (the water breaks), there is a serious chance of infection to spread into the uterus, or the baby to lose adequate blood flow and oxygenation. A decision was made by Dr. Spencer to start the patient on Pitocin, a drug that stimulates uterine contractions and induces labor, even though the patient did not adequately meet criteria for the induction, and C-section was actually the appropriate course of action. There was no response to the medicine, and when we went back to check on the patient, she was eating a big bowl of rice! A full stomach is never a good idea when someone needs general anesthesia… In any case, the nurse came to get Adam to assist with the C-section that Dr. Spencer had just decided to perform. This was Adam’s first C-section, as in the United States obstetricians perform C-sections, rather than general surgeons. Amelia scrubbed in as well, and although the baby girl required a little resuscitation on her arrival into the world, she was healthy and intact, and currently mom and baby are both doing well. Everyone was very happy to hear the news, as we were all waiting anxiously outside of the OR, and had cancelled our evening clinical lecture due to the events of the day. Everyone needed a happy ending to this trying day, especially mom and baby girl, who will await her naming ceremony in 7 days, when we can all wish her a fruitful and happy life.

Thursday, January 30, 2009. Thursday was a slower day, as everyone was a little drained from the day before. We spent the morning rearranging flights, as our team’s time here at SJGH is coming to a close very soon. Amelia, Adam and Jason leave tomorrow, and the rest of us are slated to leave on this coming Tuesday.

Lonnie and I had the privilege of meeting two dignitaries today, both of whom stopped by the hospital to meet the team of American doctors who are currently volunteering at SJGH. The first was John Bojang, the Chairman of the Sulayman Jungkung General Hospital Board of Directors. He is a Gambian, who previously has served as Secretary of State, as well as the Gambian Ambassador to many countries. He talked to us for over 30 minutes, praising our work and our initiative to come here and bring a team to serve their community through the hospital. In light all of our difficulties here, it was helpful to hear some encouraging words, especially from a man of his experience. Later, we were invited back to Mr. Badgie’s office to meet the Secretary of State for Health, who had also come to meet us and view the new solar panel installation, as well as the Chairman of the Community Based Medical Program, the Cuban-run medical school that has 4 sites here in The Gambia, training Gambians to be physicians in the Cuban medical curriculum. SJGH is one of their sites, new in the last year. The Chairman and the SOS were very interested in speaking with us about a possible collaboration between DMAG and themselves and their medical students. We brainstormed about the best way in which to contribute, and are thinking about trying to assist them in acquiring textbooks and online study resources and journals for their curriculum. I think it would a great way to help, and would enable us to contribute to the education of the doctors that will be working here, so that problems like what happened the previous day may be avoided in the future. Something to think about.

In the evening, Lonnie and I gave our Education Committee lecture, “Infection Control Through Handwashing”. It was a spirited discussion of the most basic of necessities at any hospital: handwashing. Obviously in a facility without 24 hour running water this can be a difficult thing to enforce, however we feel that this change needs to happen in order to create an environment of health and cleanliness that will subsequently transfer our into the community, and really prevent the spread of disease. Often it is necessary to start way at the bottom. It was a bit delicate, trying to discuss the conditions here without offending anyone, as things we brought up to them, such as livestock roaming around campus littering feces and giving birth at all hours and places, dirt all over every surface, never being cleaned, linens being reused between patients, and dirty towels used to wipe hands, are sensitive subjects when dealing with differing cultures. We only know what we are used to, what we know the standards are at home, which we feel are absolutely necessary to prevent the spread of disease in a hospital setting. The audience was very receptive to the lecture, and asked many thoughtful questions, never appearing upset about the subject matter. They seemed just as frustrated as we about the conditions and their lack of materials with which to wash their hands properly. Lonnie and I are hopeful that DMAG’s project idea of starting a handwashing education program and raising funds for supplies such as hand sanitizer, paper towels or personal hand towels, and soap will be able to go forward. It seems as though we would have the support of the staff, as well as the support of the administration. I am sure that much planning is needed, however, and we will certainly have our work cut out for us in the coming months after our return.

Friday, January 30, 2009. Sadly, one of our ranks, Julie, is sick. Again. I’m not sure who you have to offend to get sick twice on one trip while others sailed through without even a sniffle, but Julie must have done it! Nothing life threatening, but we hooked her up to some IV fluids last night and she’s feeling better today. Thank goodness, she has suffered enough, what a trooper. (Julie says hi mom, and don’t worry, she’s feeling better! She’ll be home soon!)

Today we send Adam, Amelia and Jason off to the airport while Julie, Zeke, Lonnie and myself stayed back here in Bwiam to continue. We are sad to see half our team leave us, but happy that they are safely on their flight and taking off as I write this.

There may not be any further blogs for this trip, as we will depart Bwiam soon and there will be no more satellite modem to use for uploading. I hope that everyone who has been tuning in has been enjoying the blogs in some way, and thank you all for your support. We have enjoyed all the comments, thank you for those as well. We will see you on the other side of the pond very soon!

∼Sue
(I love you mom and Grace! Thanks for your support!)

Adam and Amelia performing a C-section

 

 

A Kafo women's group member making our tie and dye

A Severe Burn Case Presents More Than Just Medical Challenges

Josh, Julie, Adam and Sue working on a severely burned patient

Saturday, January 24, 2009. Today there was a knock on Lonnie’s door and a nurse asked her to come to the out patient clinic to assess a patient with a burn. The nurse motioned to his arm. She said ok, she’d be right there. “I can handle this”, she said to herself, assuming the patient only had a burn on his arm. She collected her medical bag and began to walk over. On the way she ran into Adam, the trauma surgeon here with us, and she asked “hey do you want to see a patient who has a burn in the OPD with me?”, thinking she would be wasting his time. Julie and Josh came along as well, and Sue joined the group when she heard the news. When we all arrived, to our horror the conscious and awake patient had extensive full-thickness burns over 90% of his body including inhalation burns. He had fallen asleep by a fire, warming himself in the morning, and his clothes had caught on fire, waking him, and he was unable to remove them. Family members were able to eventually put out the flames, and transported him to the Hospital from his village, 90 minutes/50 km away.

Many of us have never seen anything like this in our lives. Immediately Adam took the lead and we began our work. Given the fact that he was an 80 year-old man and we are in a country with limited resources, we were faced with many ethical issues. How far do we take his treatment? How much of the hospital supplies do we use? Do we transfer him to RVH in Banjul, which has more supplies than we, but 2 hours away on mostly dirt roads? They may not have any additional benefit to offer him there, and the transfer would be dangerous in his acutely ill state. His family may not be able to travel the 110km to be with him. This is a catastrophic injury, and even in the United States the mortality rate would be high, both early from respiratory injury, and later from renal failure or sepsis. This patient had obvious extensive airway involvement, however we had no means with which to artificially ventilate him for any prolonged period of time. We asked the hospital administrator for permission to turn on the generator in an emergency capacity so that we could administer oxygen to the patient, and we were granted permission. Unable to start peripheral IV lines, we were able to use a large IV to initiate a central line at which time we gave him fluids and morphine, and provided body wide burn care. After extensively cleaning his wounds and applying sterile dressings, we transferred him to the surgical ward here and his family was informed that he was critically ill. After handing the patient’s care off to the nurses on the surgical ward, we all gathered together to discuss all the complex ethical issues mentioned above. Included in the discussion was Lamin Ceesay the senior Gambian nurse of the surgical ward, who, even though he was off duty today, helped us understand the cultural aspects of caring for this patient. In the United States, family members are a huge part of the care of critically ill patients. Long discussions regarding prognosis, need for procedures, the wishes of the patient and the family regarding end of life issues are held, so that they are included in decisions about care, or even withdrawal of care. Here, we are unable to directly communicate with patients and family, as we cannot speak the language, and we are also likely ignorant of cultural practices that can influence care. Lamin helped us to understand that in The Gambia, being able to be with a family member at the end of life is very important, and It was decided that since the patient’s prognosis was very poor at best, we would not transfer him to RVH and we would keep him as comfortable as we could. Every member of the team shared his or her impressions, and we were all on the same page. I feel proud that we provided our Gambian colleagues with an excellent example of teamwork, and feel lucky that we could be a part of the care of this man. With hope our patient will spend the last hours of his life with his loved ones with him.

~Lonnie and Sue

Thank you, Drs. Ed and Gen

The whole DelMed Aid-Christiana Care Residency Team

Friday, January 23, 2009. Today I felt a bit frustrated and for me a bit of homesickness is setting in. I tend to be a very idealistic person and depending on the situation this can work for me or against me. I just never know when. DelMed has partnered with a health care setting in the third world and there are enormous problems. At times it seems overwhelming but I ask, why would anyone come here with the expectation of anything less in one of the poorest countries in all of Africa? The bottom line is I am very fond of Africa and the Gambian people. No matter how complex the issues are, DelMed has decided to face the many challenges found here and will attempt to deliver quality healthcare. We are committed to finding solutions. They may not be or perhaps should not be an Americanized formula but we will strive to find sustainable answers. Our fact-finding exploration including learning Gambian culture continues and we will do our best to work with the administration and staff at SJGH to develop projects to best serve the staff and community. The challenges are immense, but so is our commitment.

∼Lonnie

Also on Friday… Just a sad note about 2 of our number leaving us today… Ed and Gen Goldenberg, our father-daughter team, are heading back to the States. We have enjoyed immensely getting to know both of them in this setting, working closely, dealing with challenges and also just having fun. Ed really made an impact on the staff here, and many of them commented on how sad they were to see him go. I know that his presence here was appreciated, as there has never been a cardiologist at this hospital in its history, and he was able to convey information and skills that had heretofore been unseen. His positive attitude and laid-back approach put everyone at ease, and he seemed to have a smile on his face every time we would see him. He looks at obstacles as “opportunities”, and I really feel as though I have learned so much from him in the last 10 days. He taught me a great deal about cardiology during the 5 years that I was a resident at Christiana Care, and now that we are colleagues here in The Gambia, he has taught me a great deal about humanism. I can’t tell you, Ed, how much we appreciate your being here.

Everyone gathered for a quick group photo, even though the OPD was incredibly busy for a Friday, they spared us for a few minutes to say goodbye.

In the evening, Lonnie, Jason and I brought our friend Modou to the house to show him a treat… He is one of the good friends we made last year, and he is a devout Chelsea Football Club fan – and the country itself is football (soccer to Americans) crazed. Lonnie had downloaded a Chelsea v Fulham match, and we played it for Modou and his friend on the living room wall using the LCD projector. They were so excited, as this is quite a rarity for them, given that there is no electricity in their compounds, and they have only seen one or two games in the last few years when they have had the luck to travel to the city to an establishment that is showing the matches. It felt good to be able to given them that small pleasure. I didn’t let on that I was actually cheering for Fulham…. ☺

∼Sue

US docs + Cuban docs + Gambian Patients = International Medicine

Drs. Goldenberg and Thompson with Drs. Ezcurdia, Hernandez and Ruiz at the Royal Victoria Teaching Hospital, Banjul, The Gambia

Thursday, January 22, 2009. Caution non-medical readers! The following may be a bit dry, but hang in there till the end…

Case of the day: 37 year old female presents to the outpatient clinic at the Royal Victorian Teaching Hospital in Banjul, The Gambia complaining of shortness of breath on exertion and pleuritic chest pain that was gradual in onset and has been worsening gradually for 2 weeks. She has no past medical history. She is thin and somewhat underweight and in mild respiratory distress. Her vital signs show her to have an elevated heart rate of 110 and hypoxia of 87% on room air, blood pressure stable. Heart is hyperdynamic but regular with a systolic ejection murmur, early peaking and radiating to the carotids. Auscultation reveals almost no breath sounds on the right, while clear on the left. Mild neck vein distension, but trachea is midline. Abdomen is scaphoid, with exquisite tenderness in the right upper quadrant over a liver that is palpable 4cm below the costal margin. There is 2+ pitting edema of the feet and pretibial area and mild periorbital edema. The remainder of the exam is normal. Initial CXR is below. No follow up x-ray has been done, and no procedure was performed. An electrocardiogram shows sinus tachycardia without acute changes. Echocardiogram shows a round, homogeneous appearing mobile mass in the left ventricle at the apex. Valves and cavity sizes are normal. There is a moderate sized pericardial effusion, without evidence of RV collapse or paradoxical septal movement. She is treated initially with oxygen and diuretics while the echo is pending, and she improves. Her edema resolves, she is titrated off oxygen and she is in no distress. She continues to have mild pleuritic chest pain.

Diagnosis?

This is a patient on whom Dr. Ed Goldenberg and I were consulted by the ICU attending physicians at RVTH. We had traveled to Banjul for the day for Ed to give his Grand Rounds at the hospital, “Renin-Angiotensin System Blockers in Hypertension and Heart Failure”. We were met by Dr. Manuel Ezcurdia, the chairman of the Department of Medicine, and warmly welcomed into the offices of the medical school. The lecture hall was on the 2nd floor of the hospital, and although not the largest lecture hall I have seen, it packed in the 50 people who attended Ed’s lecture! It was an excellent talk, and attended by physicians, residents and medical students. I suppose the topic was possibly a bit specific for the setting, given that even here in the capital at the largest hospital in The Gambia, they have limited options for antihypertensives, however they were very enthusiastic about the data and information, and current guidelines in clinical practice are relevant regardless of whether or not you are able to practice them.

Following the lecture, Dr. Ezcurdia and Dr. Udi Hernandez asked us to come to the ICU to consult on the above patient. They admitted that they are a bit stumped, and wanted our input. Ed re-echo’d the patient and had to agree, there is a round, highly mobile mass in the apex of the LV that does not appear to have a pedicle, but is flapping so hard in the breeze and not going anywhere that we had to assume it was attached. The doctors were about to start the patient on anticoagulation, assuming it was thrombus. Going through the patient’s history with her again revealed nothing. We made a few recommendations. Anybody know the diagnosis?

I am returning to RVTH on Monday (sadly, without Ed, who leaves tomorrow….), but with Dr. Fox, who will be giving his Grand Rounds on that day, and we are anxious to follow up on this patient. Feel free to send comments with your ideas, or your questions. I’ll let you know what it is next week. Interesting case!

On returning from Banjul, (after running a number of errands including more vegetable and fruit purchasing, which somehow cost us a quarter of what the same amount cost us the first time… how’d that happen? I think I’m a better haggler than Jason and Zeke…) we found Amelia, Julie and Josh performing ultrasounds on a few in- and outpatients, as the power had come on at 7pm. We have been doing a great deal of scanning here, as we are very comfortable with it, and the machine is very good. (Paul, we’ll get you the specs.) Those patients whom we can’t fit in to scan between 10a and 2p during the daytime electricity, we have been asking to return to the hospital at 7p, when the evening electricity comes on. Inefficient, but do-able. Amelia and Jules have been scanning maniacs! They are really doing a wonderful job, and, I believe, contributing significantly to the care of many, many Gambians.

Tonight Zeke prepared a chili dinner from a recipe given to him by his new friend “Chief”, a man who also keeps the boys full and happy with attaya tea in the afternoons. And it has so much caffeine and sugar, it keeps them yapping all night!

Tonight was the first formal lecture of our evening clinical lecture series, which was “Heart Failure: A Case Study” given by Ed, involving a patient that he admitted here to SJGH and cared for with the nursing staff on the medical ward. It was well attended and had a lively question-and-answer session following. I know it was a long day for Ed, but we had to fit in all his lectures before he leaves us tomorrow!

Speaking of which, we are going to be very sad to see 2 of our group leave us tomorrow, Ed and his daughter Gen. I know they are sad to leave us as well, but likely not too sad about the long hot shower they’re going to have when they get home! Bucket baths leave something to be desired….

Until later.
∼Sue

X-Ray from RVTH ICU cardiology consult

The Koffa Club

The Women's Group Meeting

Wednesday, January 21, 2009. Yesterday morning (Tuesday) I traveled to Banjul to pick up two more DelMed volunteers from the airport…Adam Fox, MD and Josh Usen, MD. Ebraima (who works for SJGH security) was my driver for the day. He is married to Owa who works in the maternity ward and is a new nurse midwife graduate. They have three children, two of which are twins.

Not to brag to all of you back at home but the weather here is just beautiful…no humidity, blue skies, sunny and about 80 degrees. At night it’s breezy and cool, perfect sleeping weather! Peter Bakery the Peace Corp worker who lives next door, told me I don’t know the real Gambia as this short dry season (which is winter here), does not in anyway represent typical Gambian weather. He spoke of a two-week period this past summer where he just wanted to die. The temp here at it’s hottest can range from 38-40 Cº (100-104 Fº) with 100% humidity. I think January is a nice time to visit!

My drive to Banjul with Ebraima took about one hour and 10 minutes. Much faster than last year, due to improved road conditions. Along the way we listened to Senegal music and I watched various Gambian daily life scenes play out along the way. It was a bit surreal staring out the window watching kids walk along the road to school, women in their compounds pounding grain with their mortars and pestle, others cranking the well pump for water and passing many piles of produce and firewood for sale. As you speed by the villages with their corrugated metal roofed concrete homes that look desolate, one might quickly assume you’re passing one ghost town after another. But much is happening inside. Intricate lives exist here and interestingly we share some of the same hurdles. Gambians deal with the typical family dynamic issues we all do, including child rearing demands, and daily household duties. They want quality health care and education for their children. To exist here however is not easy. As much as our two worlds are drastically different in some ways they are the same.

Wednesday I was invited by Alex Tatum to attend the local women’s club called “the koffa”. The women gather weekly and each pay dues. They are an entrepreneurial group in additional to a social group…they manufacture and sell antibacterial soap and tie-dye fabric. It was so funny to see them bicker over the dues…who paid and who didn’t. I belong to a women’s club and we’ve bickered over the same thing! They gossiped, laughed and talked about all the usual things women do and it so much was like my own women’s group. I felt so welcome as we gathered in a circle under the beautiful mango tree. They even passed food; some sort of frozen slush treat that smelled like coconut, a women’s group meeting is not complete without sweets! I was honored to be a guest at their meeting.

~Lonnie

Reflections

Lonnie helping train some SJGH nurses

Monday, January 19, 2009. Let’s have an introspective moment. Today was a busy day as usual, but because it was Monday, the Out Patient Department (OPD) was teeming with patients all day. Gen, Julie and Amelia handled all the patients in the OPD with skill, while I joined Ebraima the nurse to see all the pediatric well visits. Well, schmell…! Many of them were little sickies! Poor things. We worked together to get them all seen, scanned, treated, or whatever they needed.

Despite the long day, I had some time to reflect on my own presence here in a larger sense. Sometimes I feel as though we are working harder than any of the staff, nurses or doctors who work here year round, by far. It is frustrating trying to think about making sustainable teaching and change, when as soon as we arrive, many staff members seem to expect us to just take over and do all the work for them. I am here seeing patients, treating the ill. I am trying to teach nurses how to better care for their patients. I am trying to learn from the staff how they care for their patients, how it is different from what I would do, and what is the best route to take. I am also supervising EM residents from my home program while they do the same, trying to contribute to their education, broaden their perspective, and to help understanding this place where we have all come, when I do not completely understand it myself. I am representing Power Up Gambia, as a member of its Board of Directors, and spend time trying to oversee the installation of the solar power panels that is currently in its final stages, as well as trying to identify the problems with the new water system and come up with solutions for the future. Finally, I am here as Chairperson of DelMed Aid for Gambia, through which we have brought multiple volunteers to also treat patients, teach, and get a new and different cultural experience and outlook on life and the practice of medicine. These are a lot of things to do, and lot of directions to focus my attention and time, and it can be a bit overwhelming.

I have been feeling a bit conflicted of late, knowing that I am here because of a passion I feel for the people whom I met last year, who were kind to me, who reached out to me, and who need care so badly, but also realizing that change, sustainable change, is slow and difficult anywhere, let alone a developing country, or the poorest country in Africa. I wouldn’t be here if I didn’t feel that there was something I can do, some way I can contribute. I am entering into this quest with my eyes open, however some days the obstacles seem insurmountable.

I am a runner, and when I am on a long run, I tell myself that there are highs and lows. Highs and lows. When I’m on a high, and feeling good, I tell myself to ride it out and make it last, because soon it will be over. When I’m in a low, I tell myself to hang in there, because another high is just around the corner. Another high always comes.

I’m trying to apply this concept to my time here in Bwiam, thinking of the mission and goals of DelMed Aid for Gambia. Each day we come up with ideas for how to improve healthcare delivery here at SJGH, and each day issues arise that make improvement seem incredibly difficult. Our big dreams of moving forward with new equipment, more wards, an ICU, seem like pipe dreams. How can a hospital have an ICU, if the staff doesn’t wash their hands? We need to start at the lowest level, it seems, such as projects for trash removal, animal containment, and handwashing. Basic infection control measures have become the focus of our attention, and Lonnie and I have decided that an ongoing project designed to facilitate and educate the staff here about these issues will be the current focus of DMAG. It will take a great deal of planning, encouragement, and help from our volunteers, and we’re hoping that others take up the cause with us, with optimism and a positive attitude. It may not be the most beautiful place on earth, it may not be shiny and look like the movies, and it may be that we’re doing most of the work trying to overcome the inertia that exists here, but if everyone gave up hope because things were difficult, nothing would ever improve. And that’s just not acceptable. The people who live here in Bwiam, in all of The Gambia, are just as deserving of the human dignity of medical care as all of us. Therefore, our goal remains to help this hospital and its staff, who work so hard under difficult circumstances, to implement sustainable improvements.

∼Sue

Sue and Modou Lamin Barrow, Pharmacy Staffperson, who is applying for nursing school in 2009

Accidents do happen

The Solar Panels that will soon be online.

Sunday, January 18, 2009.  “Trauma day”.  (Get comfy…this is a long one.)  It is a lovely day here in The Gambia, clear blue sky, warm sun, and cool breeze, peaceful.  It is Sunday; a day often called the day of rest, but there was no rest to be had today for the staff of SJGH.  We were on our way to Muhammad’s store in front of the hospital to buy sodas when we were called into the OPD.  Julie had already decided that the topic of one of the lectures she will be giving to the staff here during our stay was going to be “initial care of the trauma patient”.  Serendipitously, today we were able to give hands-on training to the staff on how to take care of injuries.

It seems a “gelly-gelly” had overturned on the road.  The bush taxis that take people up and down the main road running from the coast upcountry on the south bank are called gelly-gelly, apparently because of the sound they make.  “Gelly-gelly-gelly-gelly-gelly-gelly…” Picture a Volkswagen bus from the 60’s, but more modern and angular, yet more rickety, and with about 30 people crammed in.  This is the public transportation, and while it can seem like quite a scary ride to a fresh tubob, they are actually very functional.  That is, unless there is an accident, which is not uncommon.  Today a gelly-gelly had driven too far to the side of the road and hit a rut, and subsequently turned onto its side.  Glass was broken, people were thrown out, and people on the side of the road had had debris hit them.

Two of the many patients presenting from the accident were a 1 year old and her mother.  The mother complained of body wide pain, but had no obvious injury on exam.  The infant, however, had multiple complicated and deep lacerations to the scalp, with significant bleeding.  Julie and lead nurse Hassan worked together to repair the wounds.  Hassan is probably the most skilled and smartest nurse working here, and he was quick to learn from Julie’s technique and steady hand.  It was apparent pretty quickly that basic wound cleansing, anesthesia and closure techniques are an area for improvement, and for us to do a few clinics and lectures during our stay.

Julie and I repaired lacerations while Amelia opened and drained abscesses, (not from the gelly-gelly accident, but nevertheless just as graphic), and I splinted fractures and then referred those patients to the main hospital in Banjul, RVTH, for x-rays and an orthopedic consultation.

Amelia cleaned and debrided extensive burns on a 6 year-old girl’s legs and hands.  She had been warming herself by the fire a few days ago when her dress caught on fire, and she was unable to remove it quickly.  No local care had been done, and it is difficult to know why her family had not brought her in sooner.  The burns were filthy, and caked with carbonaceous material.  Amelia administered morphine to try to make her more comfortable through the painful and traumatic procedure.  Apparently anesthesia/analgesia is not a priority here, as most of the time patients seem to be quite stoic when undergoing minor procedures, which is such a change from home!  This case was the exception, however, as burns are so painful, and the patient was at just the right age to be young enough to be scared, too young to explain what you’re doing, but large enough to fight anyone who tried to hold her down.  We opted for the humane approach.  Amelia did a fantastic job cleaning her wounds, and admitted her to the surgical ward.

The last patient we saw today was unfortunately the saddest case.  A 25 year-old man, a boy really, had been climbing a tree.  He fell from height, we don’t know really how high, but he landed on his chest according to witnesses.  He was carried to his home, and a vehicle was fetched to bring him to SJGH.  He was placed on a stretcher and brought into the OPD; startling our attention up from the paperwork we were finishing on the bush taxi accident victims.  It was reported that the fall had happened approximately one hour before his arrival here.

Julie and I jumped up, and immediately began our primary trauma survey.  The patient was unconscious, not breathing, and had no pulse.  His pupils were non-reactive, and he had visible trauma to the face and chest.  We could feel the air crunching in his skin, a sign that he likely had broken ribs and collapsed a lung, possibly leading to his cardiac arrest.  There was nothing to do, it had been too long.  He was gone.  His family and friends were at the bedside, and Hasan told them the news.

This is the first traumatic death I have witnessed in The Gambia.  I know that it is common, however it does not make it easier to process.  I think about our EMS system in the States, and how differently the outcome could have been if this had happened there.  On-site immediate intervention is so important in trauma, however the resources required to put a system into place are significant, and I don’t think that this hospital is anywhere close to that goal yet.  The cultural standards are to get the patient to the hospital immediately, and no one is trained to do resuscitation in the field.  The hospital has only one ambulance, and when it is not being used to transport the staff and equipment to the trekking clinics 4 days per week, it is used to transport gear or patients back and forth from RVTH.  Even if the ambulance could be available to go out on the equivalent of “911 runs”, the catchment area is so large and the terrain so difficult, that the response times would be significant, leading to delay in treatment and transport.  Many more resources are needed in order to begin a project such as pre-hospital EMS, however we can only hope, and it is definitely a goal for the future.  I know this man’s family would want us to try.

Feeling rather low, we returned home to find the local children, our little friends, visiting us at the house, and they lifted our spirits significantly.  Watching them play soccer, singing and dancing, and posing for the many photos that Lonnie and Ed take with their big fancy cameras, I am encouraged to keep going and keep trying.  One step at a time.

∼Sue

Oh, and another delish dinner, this time courtesy of both Zeke and Ed.  Everyone seems to show up at our house for dinner, I wonder why that is…? ☺  We’re running out of food, however, and need to make a plan to somehow travel back east for supplies.  We have those two bikes…

Venturing outside the Hospital

Amelia and Julie at the local women's co-op.

Saturday, 1/17/09- This morning everyone slept in after a late night and busy day yesterday. Across the street Gen, Ed, Jules and Amelia discovered two surprise guests in the middle of the night occupying a room at the end of the hall…two Senegalese men who came to Bwiam to fix the broken generator. Amelia was quite startled in the middle of the night when she went to the shared bathroom at the end of the hall and said, “how long will you be here?” Apparently they like to stay up very late. Jason and Sue went to the Bintang Bolong river to paddle a canoe they had haggled to rent from a local fisherman, but returned later unsuccessful due to high winds and rough waters. Gen and Ed traveled to Serekunda to browse the local markets and had lunch at the LaBey Hotel on the beach.

Alex Tatum, Kennett Square, PA and Jeff DeFlavio, Boston, MA (two recent GWU college grads planning careers in medicine) who are living here for 9 months to work with Mr Badgie in administration, invited us to their cottage for lunch. We brought our left over pasta w/vegetables from dinner last night and a few JulBrew’s…the official beer of the Gambia. During lunch we (the girls) were admiring Alex’s skirt and she said she had it made right here in Bwiam by a local tailor. So after our lovely lunch, she kindly led the way to the general store that sells colorful fabric. Then it was off to the local tailor where we were measured to have wrap skirts made. I can’t wait to see the results!

The Women’s CAFO group is a group of women in the village who meet weekly and work on several entrepreneurial projects and volunteers projects for SJGH. The make and sell antibacterial soap, tie-dye fabric and volunteer cleaning services. Today they met on Mr. Badgie’s front porch to shell peanuts for the hospital kitchen. The peanuts are used to make Domoda sauce. Everyone was dressed in colorful traditional Gambian outfits. I wished my skirt were finished so I could put it on. I felt out of place in my western clothes! The group is very lively and there was much talking, laughing and joking. Even though much of it was in another language (some spoke English to help us) they involved us, made us feel very welcome and you could not help but laugh at all that was going on. It felt just like when I have lunch with my girlfriends at home.

Zeke and Jeff were hanging out today and Jeff got a call from his friends (Robert, Thomas and Chief) who run a local clothing shop selling western cloths here in Bwiam…the owners offered to make them Benechin, a popular local dish. Zeke said it was good but the neck meat was a little tough! They also enjoyed attaya tea, and Zeke was told it would make him a good strong man. This is the tea the men in The Gambia drink daily around 3PM and is very sweet and strong.

~Lonnie

Dr. Amelia Poussin with some new friends.

TGIF?

Dr. Gen Goldenberg examining a carpenter's swollen hand.

Friday, January 16, 2009. Today was unusually overcast, and subsequently there was no running water during the day, as the water depends on the daily dose of sunlight on the solar panels to fill the tanks. Nonetheless, it was a busy day on the wards and in the outpatient department, since the patients don’t stop coming just because it’s not sunny! Ed and Amelia made rounds on the medical and surgical wards in the morning, continuing care on the patients that remained from the previous few days, and following up with the patients that we admitted the previous day and evening. Jules and Gen worked in the OPD all morning, and by noon we were all there, seeing the many patients that were waiting as efficiently as we could, each with our own interpreter.

Gen saw a young male patient, about 20 years of age, who is a carpenter by trade. He presented with his left hand swollen and painful for the past week, a spontaneous thing, apparently non-traumatic. He had seen a local healer who had placed a poultice, which, when we removed it, appeared to be a thick paste of green herbs mixed with dirt. His hand was severely swollen and tender, focally over the palmar aspect of the base of the 3rd and 4th fingers, but the swelling extended distally through both fingers and proximally over the palm, and the back of the hand was very swollen as well. He had limited range of motion of the fingers due to pain. We were very concerned about a deep space infection of the hand, as well as possible tendon inflammation. We made a decision to admit the patient for intravenous antibiotics and a consult with Dr. Spencer, the surgeon. Unfortunately, the patient was unwilling to stay, and after much back and forth with the translator, stressing the possibility that if the infection worsens he could lose function of the hand or lose the hand altogether, we were no closer to convincing him to be admitted. We placed the patient on oral antibiotics, and Amelia was just about to perform an ultrasound to look for any possible collection that we could drain, when the power went off. The generator had broken down, and it was only noon. No more laboratory tests, no more ultrasound and no more functioning outpatient clinics. We sent our patient home after emphasizing that he needed to return in 24-48 hours for a reevaluation. I hope he returns. See, signing out AMA is not just an American thing, except there is no paperwork to fill out here!

The generator needed a new belt, and Njagga, the deputy chief nursing officer left for Kanali to acquire one. We continued to see many patients throughout the afternoon, despite the inability to perform any testing. A young child with pneumonia, a young man with malaria, a middle-aged woman with congestive heart failure. Ed Goldenberg is sharing an immeasurable amount of knowledge with the staff about the treatment of cardiac disease, however, it is quite satisfying to see him treating general medical walk-ins including pediatric patients, and asking our EM residents how to treat them!

By nightfall, the generator was not yet repaired, and we had sent many patients away without testing, asking them to return on Monday. The men are still working on the solar panels, and we are hoping they will be finished by next week. We had a candlelit dinner together, and then all retired for the night. We’re looking forward to perhaps exploring the local village over the weekend.

∼Sue

The Drs. Goldenberg side by side in the Out Patient Department