Central Regional Hospital
So a few days ago it looked like Miranda had malaria. Headache, chills, fever (although low grade), joint pain; fairly close to classic malaria. She was on doxycyclene for prophylaxis (against malaria), but it’s not 100%. We headed to the chemist Dom introduced us to, she thought malaria as well, and gave Miranda ACT (which is the remedy I would have sought myself, so I was happy). It’s a 3 day therapy so you get well pretty quickly. Malaria falciparum replicates on a 3 day cycle generally, which is also why so many chronic malaria sufferers go through cycles of thinking they are getting better, and then they get worse, then better, then worse. Still, ACT has a 96% cure rate or something like this, so I was pretty confident. And although as many as 25% (or something along these lines, the numbers get blurry depending on where you are) of drugs in Africa can be fakes, we got ours from a respected and knowledgeable pharmacist which significantly militates in our favor.
Miranda finished her last dosage two nights ago, and that same night her headache was back. Hmm. Could just be dehydration. The next day it was still around, and even more intense, with some nausea to boot. Unfortunately that was a Saturday. We stopped by the pharmacist, but her shop was closed. We tried two more places, both of which were significantly less professional or proficient in English, and wanted to de-worm her (both times they tried to give me mebendazole, which is for hookworm). Although there aren’t too many downsides to mebendezole or albendezole, there’s no way Miranda has hookworm, and none of her other symptoms seemed like a roundworm or similar infection to me.
We decided to wait the night out and see how she felt Sunday. There was literally nowhere to go, other than the central regional hospital, which we could always do Sunday. Sunday we woke up and the hospital appeared to still be on our agenda, since her headache hadn’t abated at all.
We caught a cab to the hospital and I got us into their ER intake. $7CEDI (around $5USD) to be seen. Here you pay up front for everything. If you’re used to USA cash pay (that is: if you have no insurance), it’s not that dissimilar. I looked down while reaching into my pocket, some dots of fresh blood on the floor.
“Is that yours?” I asked Miranda. Nope. The image of a Ghanaian, dripping blood, trying to pay his seven Cedi flashed into my mind. Again, not all that unlike the US.
We were given a chart and vaguely told to deposit it in the next room. We shuffled passed two dozen or so waiting people. A crying girl with a bloody rag around her foot was ushered through the door and onto a stretcher.
We stood for five or so minutes, looking confused, hoping someone would say “here let me take your chart,” or “please wait over there.” Eventually another woman, waiting with her listless infant, indicated to me to drop it on a desk with a stack of others. I thanked her in Twi and did so. Miranda found a seat and we waited. And waited.
Again, depending on whether you’ve used the US emergency room system you might be familiar with the next few hours of our lives. It was basically like the US (wait, a lot, and see a lot of people who are worse off than you).
Mostly I did see medical staff following BSI (body-substance isolation) precautions … but the occasional lapses still caught me off-guard. When I am teaching classes I try to drill into my students the need for BSI, for protecting your own safety first before trying to help your patient.
In my mind afterward I am I thinking about the random spatters of blood on the floor. About the discarded bloody cotton ball languishing on the tile. The one restroom, co-ed, its solitary sink clogged with vomit and blood (photo here, if you really want to see). And as I imagine these I am trying to decide if that’s better or worse than the US. When we were at Harborview last year we definitely saw a guy bleed everywhere in the intake area, and now I’m straining to remember how long it took for it to be cleaned up.
There was also a wasp’s nest inside the emergency ward, see if you can spot it in this photo. That was a bit of a surprise, although people here don’t seem to have much concern about wasps.
I saw the man who would later be our doctor begin to tell a woman, “I am the only one here, and you’ll need to take a seat and wait.” After a minute or her protesting he asked what was wrong with her child, and she answered he had swallowed a nail. To the doctor’s credit, after some more discussion as to the swallowing incident, he wrote something on a slip of paper and sent her off, I assume to x-ray.
So I guess my only significant complaints were that the idea of hygienic precautions seems to be a little less than I might like, as well as there is no triage system (although the States are not really better here, either). You come in, deposit your chart, and wait. If you have arterial bleeding, I imagine they will see you ahead of time. Or if you collapse. But if you’ve swallowed a nail, and just look like everyone else sitting alongside you, you will be waiting a while.
Eventually another doctor came on staff, noticed us in the hall (amongst a dozen or so Ghanaians also waiting for service — the first time in Ghana we’ve felt invisible, for hours no less!), and asked why we were at the hospital, why we were in Ghana, and where Miranda’s chart was. It took him a while to find it. A good while. If we hadn’t been Obruni and caught his attention I’m not sure how long we would have waited. I’d checked about half an hour before this and our chart was no longer on the desk where I’d left it (but the other charts were). So basically if someone hadn’t specifically gone looking for it, I’m not sure we’d have ever been called, as it had been moved to some mystery location by a third party who had no idea to whom it belonged.
Anyway, the doctor saw Miranda, listened to her complaints (for a significant amount of time — way longer than in a US emergency room, so score one for Ghana in this department), and then with Malaria ruled out, he went to the next diagnosis we’d expected: typhoid. He ordered a Wedel test for her and me (although if she or we are in our first week of typhoid it will be negative) and prescribed her Cipro.
I made up my mind to wait until we saw the phlebotomy lab before deciding if I’d consent to the blood tests. The lab was air conditioned, had professional equipment, and needles were individually vacuum packed (I could see a package of them on the counter near where we were told to sit). Seeing this, I decided I was willing to get poked. We had a brief moment of pause when our phlebotamist ended up producing a needle from a different place than I’d thought he would (it came from a box, and was not individually shrinkwrapped), but he verified for me it was new and originally capped (as best I could tell, anyway) and we had our blood drawn. When drawing Miranda’s blood he did drop her needle afterwards and it landed on his foot. His flip-flop-clad foot.
A friend of mine who taught physics at a prestigious school in LA used to hang up a photo of Jesus and ask her students “in what way is Jesus not dressed for lab?” Well, open toed sandals are not good for lab, fyi.
When it comes to the needles, I don’t mean to come off as overly paranoid about Africa, by the way. I feel like I should stress my paranoia isn’t because “this is Africa.” At one point Jay and I were talking about corruption in government making funds “disappear” in Zambia, and she reminded me that many African governments are no more corrupt than the US gov’t. My reply was, “exactly!”
My paranoia about needle safety is because I see an underfunded institution — I’d be just as paranoid within the United States with an underfunded institution that is pressed to cut corners. A clinic not far from where I used to live was caught reusing syringes for years and exposing tens of thousands to HIV and Hep C, so I consider myself pragmatic, not paranoid, when I want to physically see that the item I am being jabbed with is brand new. We brought suture kits (thanks, Steve!), irrigation syringes, and nitrile gloves on our trip for just this purpose — if one of us sustains a wound requiring suturing I will have sterile supplies.
Our two vials of blood were labeled and we were told to come back tomorrow for the results. The Wedel test will likely be negative since I don’t think either of us could be in our second week of typhoid, and I am unsure what other tests the doc ordered. I guess we’ll see tomorrow! (Update: my test is conclusively negative, Miranda’s looks borderline, but Wedel tests are largely worthless from what I have read, and the Cipro is making Miranda feel a whole lot better, which is all I care about)
I don’t know that Miranda has typhoid (or I — if I did I’d be asymptomatic, 
although my prior sickness, which occurred coincident to hers, fits some of the symptoms), but whatever she has, if it’s bacterial (other than gonorrhea or TB) it ought to succumb to Cipro.
Oddly he gave her a low dosage for typhoid (not so low I am worried, but lower than American doctors would use, and lower than the instructions within the Cipro box say to use for S Typhi). He also told her to take Tylenol, despite her near inability to walk/stand due to pain.
I just finished reading a book on medicine & culture (going by, perhaps predictably, the same name), and American doctors are best known for their ‘aggressive’ stance. Where mastectomies are common in the US they are more rare in France because self-image and mental well being are both given more weight than in the US. So perhaps it is not surprising that vicodin or percocet weren’t on the menu today, but it was still interesting to see this in action, as I was sure she’d at least get codeine. I was also surprised he didn’t want to do anything about her blood pressure (90/60); the same book talked about how Europeans are much more concerned with low blood pressure, with digitalis and adrenaline frequently prescribed in Germany. (and I am pretty sure her low blood sugar is associated with her headache)
Overall I found the Ghanaian healthcare system eerily parallel to the US system. Our bill for admission and bloodwork was around 7 days of average (which is also very close to minimum) wage*. It’s hard to say, but I can easily imagine an ER visit with lab tests in the US coming to a week’s pay for a minimum wage employee as well, not to mention possible ambulance ride costs.
I think the conditions we saw at CRH might be marginally better in the US (as far as random blood and vomit and such), but I stress the word “marginally” as Harborview is often called ‘Harborzoo’ and I have seen plenty of people bleed on the floor there too (although it does get cleaned up fairly promptly that I recall). We also waited only 3-4hrs today, compared to the 9hrs we waited when Miranda broke her foot last summer and we went to Harborview.
Also, a quick update, we went Monday to pick up her test results and I walked in to find a gloved nurse wiping a gurney down with alcohol, as well as previous blood smear on the floor was gone, so those are both positive indicators. There were also more doctors on staff on Monday, so perhaps we just caught them on a bad day.
*minimum wage is $2.65CEDI per day in Ghana
