Morning Rounds 4

I hope you all didn't think I'd forgotten about Morning Rounds (posting about cool cases) because I haven't! Just been (obviously) busy with other stuff and wanna make sure to keep you interested. Sooooo...with that said.....let me tell you about the patients I saw today!

A team from Cincinatti Children's Hospital came to Korle-Bu this week for a whirlwind surgical mission of pediatric colorectal cases. The patients were already prescreened and prepped by the Ghanaian team so that the Americans could maximize their time here and complete as many cases as possible. I got wind of this mission and requested to tag along for a day. Thankfully, they were very gracious and welcomed me with open arms.

The first case I saw was a colonic resection for Hirschprungs Disease. Hirschprungs Disease occurs when neural crest cells don't migrate properly to the colon during the embryonic period. In layman's terms, this means that the developed child doesn't have the proper nerves in the rectum, and they can't poop! This can become seriously problematic as the stool remains in the colon over time, causing bacterial infection and distension. Eventually, the child will die. So correction (removing the part of the colon without nerves) is essential. The patient was only 18 months old, but Hirschprungs is something you ideally correct as soon as possible (even right after birth). The surgeons were able to do the entire procedure transanally, as opposed to doing it through the abdomen. This means an easier recovery period and less pain for the patient. I haven't seen this procedure before, and it was absolutely amazing to see the surgeons pull (just pull!) the colon out of the anus. Just trust me on this one.

The Hirschprungs-affected colon looks totally different from normal healthy intestine. It had a 'stretched-out,' leathery appearance, whereas the normal parts looked smooth, pink, and glossy. Now, usually during this procedure, the surgeons will pull out all the Hirschprungs colon, and then do frozen pathology sections to make sure that they've reached the margin of diseased v. normal tissue. But here in Ghana they can't do frozen sections intraoperatively, so the surgeons had to just send tissue to the pathologist and rely on a gross visual analysis to make sure they'd resected enough colon. For all the medical students out there, the pediatric surgical fellow asked me what the pathologist would be looking for at the margin of diseased v. nondiseased tissue. I'll put the answer at the bottom of this post.

The other procedures I was able to see and learn about were fistula corrections. Female babies can be born with a variety of congenital fistulas that connect the urethra, vagina, anus, or any combination therein. This can mean, in some cases, that they only have one opening for all three organs! Incredibly, some of these disorders remain undiagnosed in Ghana, and the surgeon had even done a congenital fistula repair on an 18-year old woman. I was particularly impressed at how quickly he could work: He repaired a rectovestibular fistula in just 1 hour, right before my eyes!

I had never really considered Colorectal Surgery as a career before, but seeing this team at work really intrigued me. The quality of life of these patients (and in cases like the Hirschprung's patient, the life expectancy) will be dramatically improved after just one surgery. That's pretty amazing.

For those interested, the pathologist analyzing the Hirschprung's patient's tissue will be looking for 3 signs that indicate diseased tissue:
1) aganglionosis
2) hypertrophied nerve fibers
3) abstainment of Acetylcholinesterase

If all 3 of these signs are absent, the tissue can be considered healthy.

Earthquake Hoax

KNOCK KNOCK KNOCK.

Frantic knocking. Check my watch. It’s 4am. Stumble out of bed to the door, and find a stranger standing there, already knocking on my neighbor’s door.

“There’s going to be an earthquake. You have to get out of the building.”

Ama and I walk outside together, confused, a little scared. Outside I see all 80 or so students who live in the ISH, milling about in their pajamas. The especially studious ones are hunkered down with flashlights reading microbiology (there’s an exam at 9am, and yes they are that intense), while the rest just mirror my own dazed look. I look around for the night porter who woke us, expecting some sort of announcement. He’s nowhere to be found. I realize that if there is an earthquake, we are missing people. Do we attempt to find them now? Do the porters have a roster for the dorm? Who is leading this safety effort?

The questions could go on and on. And if GoogleEarth had passed over Accra (or southern Ghana) between 2am and 5am Monday morning, it would have captured the entire population milling about worriedly in the streets. The rumors were:

“It’s going to be a 9.6!”

“It’s an after effect of the earthquake in Haiti.”

“The BBC ran the story this morning and the radio is carrying it now.”

Ghana is an area known to have mild earthquakes, so no one could be sure if these rumors were totally true or false. And unfortunately, no one was actually providing any data. We didn’t have access to televisions or internet outside. The radios I heard out of some cars weren’t confirming or denying the rumors. Everyone was just passing on the story they heard via cellphone from “a friend” or “my family.” I started to doubt the whole thing when I heard the followup rumors that "Cosmic rays are going to hit Earth from Mars!" and got really upset that the person who felt the need to wake 80 students didn’t have the leadership to actually inform us of his sources, his information, or any school-wide evacuation plans. I work at a hospital here, and I thought there would be more disaster-preparedness within a medical organization….

Around 5am, we finally decided that everyone was just spreading rumors rather than fact, and went back to bed. Apparently around the same time, a government official came on the local radio to assure the general public that no earthquakes had been identified in the local region. The next morning, everyone was pretty jovial about the whole thing. Laughing at the way rumors can spread.

Still, I never found the situation funny at all. It showed me how quickly a situation can escalate due to lack of information, confusion/panic, and rumors. I’m relieved that no one was actually hurt in this massive evacuation, and amazed that cell phone rumors can carry quite so far. The whole experience showed me how disaster management can become, well, a disaster. This ‘earthquake drill’ also demonstrated just how wonderful certain things are:

(1) fire drills

(2) 911

(3) Check, Call Care!/CPR

(4) Stop, Drop, and Roll

(5) Only YOU can stop forest fires!

A little infrastructure, a little preparedness, can go a long way. I mean, the chances of me being set on fire are pretty slim, but I still know what to do: Stop, Drop, and Roll! (phew!) I hope that here in Ghana, we all take a few moments to think about how we will react better the next time a real, or imagined, disaster comes our way.

(And now to provide sources I wish someone had provided Monday morning...)

Articles on the Earthquake Hoax:

http://news.bbc.co.uk/2/hi/africa/8465619.stm

http://news.myjoyonline.com/news/201001/40680.asp

Mt. Kilimanjaro!

I love warm weather, the beach, etc. But as some of you may have already heard, the Ghanaian heat and humidity is nothing to joke about. I’m still getting accustomed to sweating 24-7, and chug at least 3L of water daily. Good for the skin right? But as the holidays approached I decided it’d be nice to have a White Christmas, or at least a Cool Christmas. Taking inspiration from Toto, I decided there was no better getaway than 6,000m above the Serengeti: climbing Kilimanjaro!

Mount Kilimanjaro is in northern Tanzania, and at 5,895m (19,340ft) it stands as the highest mountain in Africa. Also the highest free-standing mountain in the world, if that means anything to you. Most importantly, it is the only one of the seven summits that a hiker can climb by simply walking up the mountain. No technical skills or ice gear required. I signed up with ZaraTours, an operator out of Moshi, Tanzania, and asked to be placed in a group on one of their 5-day Marangu Route hiking expeditions (the shortest and cheapest climbs available). Then I joked with my family that I’d either end up joining a group of burly German mountaineers or camera-toting Japanese tourists. Little did I know…

I arrived December 24^th in Moshi, Tanzania, the tour operator’s base and met my group. And almost burst out laughing. Japanese Tourists!

(pictured: Keen, Megumi, Me, Mayuko, Toshi; not pictured: Quian, Tara, Ryan)

Day 1: climbing to Mandara Huts (2,720m)

(me, all set to go!)

We set off towards Kilimanjaro on Christmas morning, for an 8 kilometer hike through rainforest to the first camp. Hiking with us was a crew of approximately 20 people: 3 guides, 15 porters, and 2 cooks. This is pretty standard for how most tour groups. Our guide started off on the trail with us and immediately taught us the meaning of “Pole Pole,” the Swahili slogan of Mount Kilimanjaro.

Pole Pole means “Slowly, Slowly.” Climbing to over 19,000 feet is no joke, and doing it too quickly can cause Acute Mountain Sickness (AMS). Because it’s an accessible mountain, and tourists tend to undertake it without adequate preparation, hiking Mt. Kilimanjaro account for 50% of AMS worldwide. Pretty scary. Complications of AMS include pulmonary edema, cerebral edema, and death. In fact, comments I heard in the days leading up to my trip included:

“Please don’t get cerebral edema and DIE.” –my mother

“I made it halfway and then threw up blood, so they made me descend.” –girl at busstop outside park

“Only 4 in my group of 8 made it to the peak. One guy got stretchered down.” – tourist at the border

Needless to say, these comments made me a little nervous. But hiking behind the guide “Pole Pole” style alleviated most of my fears the first day. We were literally hiking in slow motion. Picture a three-toed sloth. Or a turtle. Now imagine it in slow motion. That’s Pole Pole.

(me and our main guide, Abdi)

Day 2: Hiking to Horombo Huts (3,720m)

We woke up the day after Christmas and had a hearty breakfast to fuel our 12k hike to Horombo Huts. The Japanese tourists made the morning extra cheery by whipping out their iPod and portable speakers to play Christmas carols on the trail. So funny. Some hikers coming down the mountain were even wearing Santa hats. A very good morning.

This extra holiday cheer was pretty helpful, because the hike to Horombo Huts was not only long, but it poured cats and dogs the entire way. I had been warned about hiking during the rainy season, but whew! I was getting the desired winter vacation!

(me in the rain with some cool vegetation)

I also spent the day marveling at the porters. These men carried loads of up to 30kg, mostly on their heads, and literally ran up the trail ahead of all the tour groups. Some NGOs in East Africa are actually focused on protecting the health and wellbeing of porters, because the physical strain of the job is so intense. I absolutely could not believe their strength, and urge anyone looking to get in insane physical shape to take up a porter job in Tanzania…..

We finished the day at Horombo Huts, 3,720m above sea level, which is pretty high. Some people in my group started to feel the effects of altitude, getting headaches and feeling nauseous. Thankfully, I felt fine.

(me and Quian)

Day 3: Up to Kibo Huts (4,700m)

Day 3 promised to be the most intense of the trip, because we not only had to hike 9k to Kibo during the day, but we would set off for the summit at midnight. We were nervous!

We hiked through Alpine Desert, large expanses of red sand with sparse dry bushes. Combining the scenery with lightheadedness from the altitude and it kind of felt like walking on the moon. This would have been really neat if (1) it weren’t pouring, pouring rain the entire time; (2) I hadn’t been so focused on conserving energy for the summit. I guess you could say I was really getting in the zone; and (3) Our group was too tired to talk at all. No using the iPod in the rain…. Combining the effects of these extra factors, I like to refer to Day 3’s hike as “The Trail of Tears.” Please don’t misinterpret the sentiment. I was having an awesome time. Just in a Trail of Tears kind of way. Maybe you had to be there....

Happily, when we arrived at Kibo, it was SNOWING! White Christmas Woo!!!

(arrival at Kibo)

(me and Kitentia, another of our guides)

(getting ready for the summit)

Night 3: UP TO THE SUMMIT

We left Kibo at 12 midnight for Uhuru Peak, the TOP of Kilimanjaro. Hikers leave in the middle of the night like this because it assures that the mountainside will be frozen and easy to walk on. It was still snowing, and yes I was still elated. I never knew I was such a closet winter weather fan!

We started the ascent with all 8 hikers in our group, but unfortunately, only 30 minutes later we lost one person. Mayuko started vomiting from the altitude and a guide escorted her back down the mountain. After that the 7 of us continued on. Hiking in the frozen night was so different from anything I’ve done before. We needed to wear headlamps to light the way, and when I looked up, all I saw was the black night and twinkling stars. The incline was so steep that sometimes I mistook hikers’ headlamps ahead for stars. (After some thought I decided not to look up too much; hiking toward the stars seems kind of demoralizing.) We carried our water in our jackets because the night was so cold that anything in our backpacks froze. And we intentionally panted every few minutes to make sure we got enough oxygen. Our guide sang us Tanzanian songs in Swahili to keep us energized. Amazing.

At 7am (somehow I hiked for seven hours and barely realized the passage of time), we reached Gilman’s Point. This appears from all angles to be the top of the mountain, and from here we watched the sun rise.

Not to be distracted, however, I had my eyes on a ridge to the southwest: Uhuru.

Our group was starting to falter, however. Two people didn’t feel they had the energy to continue on across the ridge, and we had to buckle down and Pole Pole together.

(the group walking across the ridge to Uhuru. That's Tara in blue getting some support from our guides.)

8am: UHURU PEAK! The Roof of Africa!

Day 4/5: "Oh Yea, We Have to Go Down..."

Climbing Kilimanjaro was amazing, one of my absolute favorite activities so far in Africa. If anyone's interested in going back to do it on a different route, count me in! Just remember, however, that after climbing for 3.5 days, your guides expect you to descend the mountain in 1.5. This means that after hiking for almost 24 hours to reach Uhuru, we had to essentially run down 42 kilometers. Fast. Unfortunately, we lost another group member doing this. Toshi needed a stretcher to reach Mandara. But the hike down did give me the opportunity to see all the beautiful scenery again. Let me emphasize this: Tanzania is bee-yoo-tee-ful.

(rainforest trails by Mandara Huts)

(exiting the park

And if you can't climb Kilimanjaro, you can always drink it!

And that’s it! 1 summit down. 6 to go. Everest anyone?