Great news this week! We finally test-ran our study in the Retro Clinic by recruiting Patient #1! We screened her for eligibility, collected informed consent, recorded her baseline information, tagged her chart for the future, and even escorted her to the laboratory to ensure that the phlebotomist knew exactly which labs we needed drawn, and how much blood we would require.
While I'm very excited to actually have the project off the ground, recruiting the first patient obviously showed us all the logistical hiccups we'll have to iron out over the initial weeks. Since Wednesday's clinic, I've already revised our data collection worksheet, poured over different database designs we could use for data storage and analysis, and put in the request for the money that I (just maybe) forgot to pre-approve to pay each participant.
Thankfully, these issues are all very easy to rectify, and hopefully in the next 1 or 2 weeks we'll be recruiting patients full force!
Friday, October 30, 2009
Wednesday, October 28, 2009
Fufu For Thought 1
As promised, this post will be the first of several covering the wonderful array of Ghanaian food. While I haven’t sampled every dish quite yet, rest assured that over the next 8 months I’ll cover most everything!
Ghanaian culinary habits are similar to those throughout West Africa. Most people take only one large meal at midday, supplemented with smaller snacks at breakfast and supper times. The basic structure of the large meal is a ‘Starch’ with a ‘Stew.’ I’ll focus on this type of meal today.
Starch: fried/steamed yucca or plantains, or one of several Ghanaian ‘specials,’ called Fufu, Banku, Kenke, or Omo Tuo. These are all made by pounding grains (cassava, wheat, rice, etc) into a paste, then letting it ferment, pounding it into a gooier paste, and finally serving it as a ball.
Stew (Ghanaians call this a soup, but trust me, it’s more stew-ish): usually a spicy tomato pepper sauce with chicken/fish/goat, but can also be peanut or palmnut based; all stews are palm-oil based, by which I mean they’re loaded with palm oil.
(pictured: typical combo--Banku with Goat Stew)
(sorry that it's sideways. my computer is acting odd....)
The meal is eaten by using a piece of gooey starch as a utensil to scoop the stew. Pretty convenient--you never needs forks or knives! On the other hand, your fingers get pretty dirty. An important tidbit is that only the right hand is acceptable for eating. The left hand is considered dirty, and it’s rude to even shake hands with it.
So far, I’ve only had the chance to sample Kenke. Kenke is left to ferment longer than the other starches, and is known for its slightly sour flavor. Imagine eating raw sourdough bread dough. I ate it with a tomato stew and chicken. Verdict? A bit too gooey for me. Has that stick-to-the-roof-of-your-mouth-peanut-butter feeling to it. But I'll stay optimistic for the other gooey starches ;)
One of the best things so far about Ghanaian stews is their liberal use of hot peppers. At most meals, rest assured that your mouth will be on Fire. I like to call my stews ‘lava sauce,’ which usually cracks my roommate up.
Before enjoying your lava sauce, it’s very important to “invite” others around you to your meal. This is very simple. Before eating, simply say “You’re invited.” I’ve had some trouble remembering this, but am slowly getting the hang of it. In my first week, I tried saying, “Would you like some?” or “You can have some!” thinking it was the same. But this apparently implies that someone is ogling your food like a beggar and it’s actually an insult! By inviting them, on the contrary, you acknowledge their presence and your friendship. I’m obviously still learning my table manners over here, but at least I keep my elbows off the table?
Ghanaian culinary habits are similar to those throughout West Africa. Most people take only one large meal at midday, supplemented with smaller snacks at breakfast and supper times. The basic structure of the large meal is a ‘Starch’ with a ‘Stew.’ I’ll focus on this type of meal today.
Starch: fried/steamed yucca or plantains, or one of several Ghanaian ‘specials,’ called Fufu, Banku, Kenke, or Omo Tuo. These are all made by pounding grains (cassava, wheat, rice, etc) into a paste, then letting it ferment, pounding it into a gooier paste, and finally serving it as a ball.
Stew (Ghanaians call this a soup, but trust me, it’s more stew-ish): usually a spicy tomato pepper sauce with chicken/fish/goat, but can also be peanut or palmnut based; all stews are palm-oil based, by which I mean they’re loaded with palm oil.
(pictured: typical combo--Banku with Goat Stew)
(sorry that it's sideways. my computer is acting odd....)
The meal is eaten by using a piece of gooey starch as a utensil to scoop the stew. Pretty convenient--you never needs forks or knives! On the other hand, your fingers get pretty dirty. An important tidbit is that only the right hand is acceptable for eating. The left hand is considered dirty, and it’s rude to even shake hands with it.
So far, I’ve only had the chance to sample Kenke. Kenke is left to ferment longer than the other starches, and is known for its slightly sour flavor. Imagine eating raw sourdough bread dough. I ate it with a tomato stew and chicken. Verdict? A bit too gooey for me. Has that stick-to-the-roof-of-your-mouth-peanut-butter feeling to it. But I'll stay optimistic for the other gooey starches ;)
One of the best things so far about Ghanaian stews is their liberal use of hot peppers. At most meals, rest assured that your mouth will be on Fire. I like to call my stews ‘lava sauce,’ which usually cracks my roommate up.
Before enjoying your lava sauce, it’s very important to “invite” others around you to your meal. This is very simple. Before eating, simply say “You’re invited.” I’ve had some trouble remembering this, but am slowly getting the hang of it. In my first week, I tried saying, “Would you like some?” or “You can have some!” thinking it was the same. But this apparently implies that someone is ogling your food like a beggar and it’s actually an insult! By inviting them, on the contrary, you acknowledge their presence and your friendship. I’m obviously still learning my table manners over here, but at least I keep my elbows off the table?
Monday, October 19, 2009
Elmina & Cape Coast
This weekend I went to Elmina, the site of the 1st West African Slave Trade Fort. Elmina was originally a fishing and salt-producing village, (pictured: the boats ready for sea!)
until the mid 15th century when the Portuguese arrived in search of gold. The Portuguese named the town after the gold mines they found there, which soon became “El Mina.” Gold is common in the area and formed an important part of the trade industry.
St. George's castle was originally built as a Franciscan church, and is one of the oldest European structures outside of
<---original Franciscan Church
Courtyard built around the Church---->
The castle was la
ter renovated and served as a slave fort for over 200 years under the Portuguese, Dutch, and finally the British. Slaves from all over West Africa were led in shackles to Elmina, where they were sorted and kept in dungeons for up to 3 months before the ships arrived. Millions of people were traded as slaves to the Americas in return for alcohol, guns, fabrics, and Bibles.
<----doorway into women's dungeon
"Cell of No Return" where rowdy slaves were left to die-->
Cape Coast's Castle Courtyard:
Me in the Courtyard!:
View from the castlefront:
Standing in the slave dungeons where literally thousands of Africans died en route to the Americas was definitely a profound tourist experience. Thankfully, the towns seemed to have done a wonderful job of recovering from their atrocious pasts. Elmina has even returned to its fishing roots. The traditional African lifestyle bustling right in the shadows of the slave fort is quite an interesting contrast, and stands as a reminder of the past as well as hope for a peaceful future.
Wednesday, October 14, 2009
Morning Rounds 3-- The Retro Clinic
On the walk home from clinic today, a pickup truck passed me with a BABOON sitting in the flatbed. Just hangin out. Wow. Working in
On a more clinical note, today was the weekly Retro Clinic at the Korle-Bu Children’s Health Block. While I’d like to say that Wednesdays are the day everyone whips out their bellbottoms and tye-dyed tshirts, unfortunately Retro in this case refers to HIV (a “retrovirus”).
For those of you who are interested (which I assume you are if you’re reading this blog), the following passage from my Handbook on Pediatric AIDS in Africa is very informative:
“At least 90% of the 2.1 million HIV+ children (<15 yrs. old) worldwide live in sub-Saharan
Accordingly, the Retro Clinic at Korle-Bu works closely with the Prevention-of-Mother-To-Child-Transmission (PMCT) counselors at the Maternity Ward. They recommend HIV screening of all pregnant women, which the counselor told me has been very successful at screening almost all the patients. Now the task is to recruit more pregnant patients to Korle-Bu!
Once an HIV+ pregnant patient is identified, she is (1) counseled on the pros/cons of Cesarean Sections, breastfeeding, and safe sexual practices, (2) offered antiretroviral medications in the perinatal window to prevent transmission to her child, and (3) recommended for followup at the Adult Retro Clinic. The counselor told me that this has been a very effective program with mothers who are fully compliant. Unfortunately, some pregnant patients forgo these treatment options because they are afraid of the social stigma associated with C-sections and nonbreastfeeding, or they are simply in denial. I saw one woman in counseling who was diagnosed with HIV several years ago, pregnant with her second child, and had never been treated at all. That was a difficult session to witness....
The Retro Clinic at the Children's Block is (sadly) a hoppin place. Almost 50 patients are seen every week in the span of roughly 4 hours. I'm sure I won't have trouble recruiting my study patients here, and as expected, there is lots to learn about medicine in resource-limited settings from an afternoon at the clinic:
Some things that have disturbed me at the Retro Clinic:
-There are 3 exam rooms, to which the doors are never closed. So everyone in the waiting room can see the patients’ interviews and exams.
-Two doctors see two patients at a time, in the same room.
-The nurse overseeing PMTCT (Prevention of Mother-To-Child Transmission) counseling advises her HIV+ patients to avoid breastfeeding if possible. My pediatric mentor, on the other hand, advises all patients to breastfeed, because malnutrition is a formidable foe here in
Some things that impress me at the Retro Clinic:
-The same nurse works the front desk every week. I think this consistency is great, because the nurse must have a level of proficiency in her work, and she may even get to know the patients. Familiar faces can be very comforting.
-The charts include a standard WHO progress booklet, in which the WHO staging system, clinical details, and a full history are included. This helps to coordinate care between the labs, physicians, and nurses. It will also hopefully help me in data collection!
Obviously some of these problems cross cultural barriers, and others are dealt with both in the US and in developing countries. Nonetheless, they are difficult each time I learn about them or encounter them firsthand.....
Saturday, October 10, 2009
The 2 Akosuas visit Kaneshie
Just to clear the air regarding my feelings toward Germany , I’m quite pleased to announce that I’ve found a wonderful new traveling companion in Kirsten, a visiting medical student from Berlin Accra by tro-tro (in the city traffic they can’t speed aha!) and visited both Labadi Beach
La Beach is typically entered through the Labadi Beach Hotel. However, my half-marathoning experience showed me an alternate entrance. Here's the site of the Marathon finish, as well as my new secret entrance. No entrance fee for us, mwahahaha!
Views to the left and right:
Unfortunately, some locals got a little frisky on us. Some guy actually got in Kirsten's face and started pulling on her bag (I had walked away quickly. Maybe I'm not the best companion in a scrap?) so we took our cue to leave and headed off to the market.....
Getting measured for dresses!
Posing with some kids who were amazed by our cameras...
Kaneshie was just amazing. It's known for its variety of foodstuffs, and although I couldn't get any pictures, I saw goat skins for sale, cow legs, GIANT snails (still alive), crabs (also still alive, but for a small fee the vendor would rip their heads off!), and well, anything else you can possibly imagine...
Thursday, October 8, 2009
University of Ghana
The University of Ghana is the country's premier university, and its main campus is in Legon, just on the outskirts of Accra. Students come from all over the country to study here, where they can get a 4-year degree or begin medical, law, nursing, or another professional course of study. My roommate Amma got her degree in Nutrition at "Legon" before entering medical school, and she encouraged me to visit. In fact, every alumnus of Legon that I've encountered at Korle-Bu has encouraged me to visit. They have a real nostalgia for the place! So I went off to see it for myself...
One of the main courtyards:
Courtyard in the middle of one of the largest dorms. Nice right?
Volta Hall, the all-female dorm:
(Note their motto, "Ladies with Vision and Style")
In contrast, check out the motto of the Male-Only Dorm:
(Note: my friend wouldn't let me go inside "Vandal City" because I was wearing a red shirt and according to him, "Red is their color. They'll go CRAZY if they see you in it!" hmmm......silly boys. Some things never change....)
Scenic spot at the top of campus where you can look over all of Accra. Students have been banned from this area because of some "nighttime revelry" here. Silly administration.....
Ah, hooray. This next picture from the food court area shows how Legon makes it easy for the socially awkward among us (*cough* me *cough*) and tells us point-blank where "nice people meet!"
Botanical gardens on the edge of campus:
One of the main courtyards:
Courtyard in the middle of one of the largest dorms. Nice right?
Volta Hall, the all-female dorm:
(Note their motto, "Ladies with Vision and Style")
In contrast, check out the motto of the Male-Only Dorm:
(Note: my friend wouldn't let me go inside "Vandal City" because I was wearing a red shirt and according to him, "Red is their color. They'll go CRAZY if they see you in it!" hmmm......silly boys. Some things never change....)
Scenic spot at the top of campus where you can look over all of Accra. Students have been banned from this area because of some "nighttime revelry" here. Silly administration.....
Ah, hooray. This next picture from the food court area shows how Legon makes it easy for the socially awkward among us (*cough* me *cough*) and tells us point-blank where "nice people meet!"
Botanical gardens on the edge of campus:
Monday, October 5, 2009
Escape From Accra
Friday afternoon I left Accra with three visiting American medical students for Wli Waterfalls in the eastern Volta region of Ghana, near the border with Togo. The waterfalls are the highest in Western Africa, so we were pretty excited! There were some lessons on travel in Africa to learn though...
FRIDAY
3pm: Board bus. (want to avoid the questionable “tro-tro’s” here. They crash too much!) Our guidebook said that the bustrip to Wli would take approximately 3-4 hours. Should get there in the early evening….
9pm: Typical Africa. Just reached HoHoe, still 20km from Wli. Dark. Need taxi. I’m a pretty intense bargainer. When I tell a potential taxi that, “Listen we can just walk if you won’t give a fair price,” I get a few funny looks from my companions. (Hey! I did finish a half marathon last weekend.) Drivers do not call my bluff. Tactics pay off and we get a ride for half the original (inflated) asking price.
10pm: “Roads” were more like mud moguls. Slow going. Arrive at hostel. Very nice hosts. Soft beds. Running water. Ahhhh.
SATURDAY
8am: Breakfast at hostel, hooray. Set off on hike to falls.
(Pictured: view from hostel, wow!)
8:30am: Asked to pay for “guide” to falls. Not sure how much we’re being ripped off, but willing to support the community. Pay 9 cedi each. Oof.
10am: Guide fails to mention that hike is a direct climb up the side of a mountain. 75 degree incline at least. Beautiful hike, but could use rappelling gear. Guide starts giving us dirty looks for being “too slow.”
11am: Guide snidely remarks that he’s part of a business, that he makes his money by taking “several” groups up the trail each day. We’re costing him money by being too slow.
12:30pm: Reach upper falls. Beautiful! Huge! Guide glaring at us. Begin descent to lower falls.
2:30pm: Lower falls! Beautiful! Swimming! Woo!
3pm: Guide has left us in a huff. We refused his demand of 2 cedi each for “tip.” We’re not going to be ripped off again, besides he glared at us all morning. Head back to hostel.
(Pictured: guide leaving in a huff.)
3pm-10pm: Chill at hostel. Arrange taxi for 3am to make 4am bus (the only one!) back to Accra.
SUNDAY
2:45am: Waiting for taxi.
3:20am: Still waiting. Guard at hostel tells us he’s the only staff available, and he’s sure taxi will come. Tells us not to worry.
3:45am: Still waiting. Very worried.
4am: No taxi. Miss bus. Return to bed frustrated. Wonder if we’ll be stranded at hostel until next bus (on Tuesday). Don’t have enough money for that...
8am: Reign in temper while discussing situation with hostel host. He seems apathetic. Doesn’t know why taxi didn’t come. Assures us that we can pay 200 cedi to hire a car back to city. Great--now hostel thinks we’re made of money too.
9am: Germans staying at hostel steal taxi from us when we’re not looking. Blast you Germans!
10am: Get taxi to HoHoe. Find kind driver willing to drive us all the way to Accra for reasonable price (no where near 200 cedi).
2pm: Home!!
Lessons learned:
-Ghanaians think travelers are made of money. We will be overcharged by about 300-500% for most anything unless we make some hardlined negotiations. But we should carry up to 50 cedi emergency funds on trips, in case we get stranded somewhere...
-Funerals in Ghana are the most happening parties around. Despite a dearth of fellow travelers and no “nightlife” to speak of in Wli, there was a funeral that sounded like a rave raging from Friday night when we arrived to at least Sunday morning, 24 hours a day.
-Ghana has a beautiful countryside.
-Hiring a car/driver may be the most efficient and ultimately cheapest way to get around.
-Beware German travelers!
FRIDAY
3pm: Board bus. (want to avoid the questionable “tro-tro’s” here. They crash too much!) Our guidebook said that the bustrip to Wli would take approximately 3-4 hours. Should get there in the early evening….
9pm: Typical Africa. Just reached HoHoe, still 20km from Wli. Dark. Need taxi. I’m a pretty intense bargainer. When I tell a potential taxi that, “Listen we can just walk if you won’t give a fair price,” I get a few funny looks from my companions. (Hey! I did finish a half marathon last weekend.) Drivers do not call my bluff. Tactics pay off and we get a ride for half the original (inflated) asking price.
10pm: “Roads” were more like mud moguls. Slow going. Arrive at hostel. Very nice hosts. Soft beds. Running water. Ahhhh.
SATURDAY
8am: Breakfast at hostel, hooray. Set off on hike to falls.
(Pictured: view from hostel, wow!)
8:30am: Asked to pay for “guide” to falls. Not sure how much we’re being ripped off, but willing to support the community. Pay 9 cedi each. Oof.
10am: Guide fails to mention that hike is a direct climb up the side of a mountain. 75 degree incline at least. Beautiful hike, but could use rappelling gear. Guide starts giving us dirty looks for being “too slow.”
11am: Guide snidely remarks that he’s part of a business, that he makes his money by taking “several” groups up the trail each day. We’re costing him money by being too slow.
12:30pm: Reach upper falls. Beautiful! Huge! Guide glaring at us. Begin descent to lower falls.
2:30pm: Lower falls! Beautiful! Swimming! Woo!
3pm: Guide has left us in a huff. We refused his demand of 2 cedi each for “tip.” We’re not going to be ripped off again, besides he glared at us all morning. Head back to hostel.
(Pictured: guide leaving in a huff.)
3pm-10pm: Chill at hostel. Arrange taxi for 3am to make 4am bus (the only one!) back to Accra.
SUNDAY
2:45am: Waiting for taxi.
3:20am: Still waiting. Guard at hostel tells us he’s the only staff available, and he’s sure taxi will come. Tells us not to worry.
3:45am: Still waiting. Very worried.
4am: No taxi. Miss bus. Return to bed frustrated. Wonder if we’ll be stranded at hostel until next bus (on Tuesday). Don’t have enough money for that...
8am: Reign in temper while discussing situation with hostel host. He seems apathetic. Doesn’t know why taxi didn’t come. Assures us that we can pay 200 cedi to hire a car back to city. Great--now hostel thinks we’re made of money too.
9am: Germans staying at hostel steal taxi from us when we’re not looking. Blast you Germans!
10am: Get taxi to HoHoe. Find kind driver willing to drive us all the way to Accra for reasonable price (no where near 200 cedi).
2pm: Home!!
Lessons learned:
-Ghanaians think travelers are made of money. We will be overcharged by about 300-500% for most anything unless we make some hardlined negotiations. But we should carry up to 50 cedi emergency funds on trips, in case we get stranded somewhere...
-Funerals in Ghana are the most happening parties around. Despite a dearth of fellow travelers and no “nightlife” to speak of in Wli, there was a funeral that sounded like a rave raging from Friday night when we arrived to at least Sunday morning, 24 hours a day.
-Ghana has a beautiful countryside.
-Hiring a car/driver may be the most efficient and ultimately cheapest way to get around.
-Beware German travelers!
Thursday, October 1, 2009
Morning Rounds 2
The patient is a 6 year-old male brought in by his grandmother for respiratory distress. Grandmother notes that he has been cyanotic since around 6 months of age, with repeated bouts of similar respiratory distress, but was seen only by traditional tribal medicine practitioners in the Northern Region of Ghana. He was never seen in a hospital before now. She brought him in because his distress is worse than it had been in the past.
She states that he never actually stops breathing, just that he seems to work very hard breathing. She has also witnessed “collapsing” episodes since age 1, and notes that he squats when he’s tired or exerted. She denies noticing any recent cough, wheezing, fever, or drooling. Denies any gastrointestinal symptoms like diarrhea or vomiting. Denies recent illnesses. Denies asthma or known allergies.
The patient was born via NSVD, with a “good” weight and nothing abnormal, but he has had poor weight gain his whole life despite a full diet. He lives at home with the grandmother. He started sitting/walking/talking/socializing at appropriate ages. Both parents died in their thirties of unknown causes. He has no siblings. He has never received any vaccinations. No surgical or medication history.
On exam, the patient appears acutely ill and in severe respiratory distress on O2. He is pale, cyanotic and prefers not to speak.
Vital signs: RR 28/min HR 98/min Sp02 95% on O2
He is normocephalic, no thyromegaly or lymphadenopathy. + conjunctival injection, + nasal flaring, + white scalloped areas on tongue, dentition intact, no swelling of the tongue; His lungs are clear bilaterally; a holosystolic murmur is loudest over the right subclavicular region and the left sternal border, with a gurgling quality, no sternal heave, no chest abnormalities on inspection. Abdomen is soft and nontender; Fingers and toes are clubbed and cyanotic; no skin rashes or lesions noted.
OK for you detectives…..what is it?
Based on all of this, I had a pretty clear idea of what was going on. The squatting spells really nailed the diagnosis of Tetralogy of Fallot for me. Nonmedical readers: ToF is a heart defect patients are born with where the heart vessels to the lungs and to the body don’t form correctly. Causes de-oxygenated (blue) blood to go out to the body. This leads to lots of complications…..Not good.
One of the most interesting things to review was his chest X-ray. I was looking at it thinking, “Hmm, big heart! Looks like an egg? No…more like a little boot. Aha! Boot-shaped heart!” Very fun when textbook descriptions jump out at you…..
I was still interested in the labs though, and will include them for you interested readers:
HgB 21.2 wow! Quite a compensatory mechanism here…..
Plt 159
WBC 5.1
ESR 2
Na+ 145 *
K+ 5.3 *
BUN 12.9
Cr 0.7
An echo confirmed the diagnosis, showing an overriding aorta and turbulent pulmonary artery flow. The boy was started on propanolol, antibiotics, and fluids, and referred for urgent cardiac surgery. Now I just hope he can afford it…..
(Pictured: a pilfered Google image of a bootshaped heart. My patient's heart was bigger than this, but it gives you the idea....)
She states that he never actually stops breathing, just that he seems to work very hard breathing. She has also witnessed “collapsing” episodes since age 1, and notes that he squats when he’s tired or exerted. She denies noticing any recent cough, wheezing, fever, or drooling. Denies any gastrointestinal symptoms like diarrhea or vomiting. Denies recent illnesses. Denies asthma or known allergies.
The patient was born via NSVD, with a “good” weight and nothing abnormal, but he has had poor weight gain his whole life despite a full diet. He lives at home with the grandmother. He started sitting/walking/talking/socializing at appropriate ages. Both parents died in their thirties of unknown causes. He has no siblings. He has never received any vaccinations. No surgical or medication history.
On exam, the patient appears acutely ill and in severe respiratory distress on O2. He is pale, cyanotic and prefers not to speak.
Vital signs: RR 28/min HR 98/min Sp02 95% on O2
He is normocephalic, no thyromegaly or lymphadenopathy. + conjunctival injection, + nasal flaring, + white scalloped areas on tongue, dentition intact, no swelling of the tongue; His lungs are clear bilaterally; a holosystolic murmur is loudest over the right subclavicular region and the left sternal border, with a gurgling quality, no sternal heave, no chest abnormalities on inspection. Abdomen is soft and nontender; Fingers and toes are clubbed and cyanotic; no skin rashes or lesions noted.
OK for you detectives…..what is it?
Based on all of this, I had a pretty clear idea of what was going on. The squatting spells really nailed the diagnosis of Tetralogy of Fallot for me. Nonmedical readers: ToF is a heart defect patients are born with where the heart vessels to the lungs and to the body don’t form correctly. Causes de-oxygenated (blue) blood to go out to the body. This leads to lots of complications…..Not good.
One of the most interesting things to review was his chest X-ray. I was looking at it thinking, “Hmm, big heart! Looks like an egg? No…more like a little boot. Aha! Boot-shaped heart!” Very fun when textbook descriptions jump out at you…..
I was still interested in the labs though, and will include them for you interested readers:
HgB 21.2 wow! Quite a compensatory mechanism here…..
Plt 159
WBC 5.1
ESR 2
Na+ 145 *
K+ 5.3 *
BUN 12.9
Cr 0.7
An echo confirmed the diagnosis, showing an overriding aorta and turbulent pulmonary artery flow. The boy was started on propanolol, antibiotics, and fluids, and referred for urgent cardiac surgery. Now I just hope he can afford it…..
(Pictured: a pilfered Google image of a bootshaped heart. My patient's heart was bigger than this, but it gives you the idea....)
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