Heading Home

Today is bitter sweet. We are leaving our new friends and heading home to our respective countries - Denmark, Italy and the USA. We sincerely hope that the MOH will procure 2 additional ultrasounds so that all 5 Government Hospitals in Kumasi will have their own and that all the Trainees will have an opportunity to continue improving their ultrasound skills. Ghana means "Warrior King" and to me these Trainees are truly warriors fighting to reduce maternal and infant mortality. I salute them and hope the newly formed Kumasi Scanning Club will be a productive forum for learning and ultimately helping their patients. I look forward to our return in 6-8 months!

And of course it is the weekend of 9/11. A day of remembrance of all those innocent who lost their lives in 2001. My heart goes out to all the families who lost a loved one.

Hopefully this Outreach has helped build a small bridge that leads not only to improved maternal and child outcomes in Ghana but to long lasting friendships, better understanding of each others cultures and a more peaceful world.

Peace.

Lisbet

Last day of Outreach in Ghana, Friday Sep 9, 2010

What an awesome day! (borrowing Sharon's favorite word, but it just fits so well!) The entire class showed up for the last day even though it's a national Ghanaian holiday. That speaks for itself I think.

We started with Post Tests of First and Second Trimester and Gynecology. The tests were in actuality the same as the Pretests and included multiple choice as well as ultrasound images. Ann graded them and presented the fantastic results later in the day: a significant improvement on all 3 tests across the board!The class was delighted as were we. There were a lot of cheers and applause.

But before we got to that I gave a short review of adnexal masses, benign vs malignant and then after a short break of donuts and Fanta the scanning began. Some of the NMWs were so good they could complete the entire OB exam in < 15 minutes. Remember, some of them had never seen an ultrasound before! That is remarkable. Truly!

Today we actually saw a normal uterus without fibroids (myomas). It was a bit comical at first because the Trainees were so used to easily identifying the uterus because of the high prevalence of fibroids. This one tilted to the right and was slightly retroverted so the Trainee struggled to find it; an experienced ultrasonographer would have also. The patient had had surgery several years ago but she wasn't sure what procedure she had had done. Her complaint was primary infertility and absence of menses at the age of 36. It was a mystery that needed solving. Dario helped locate the uterus and ovaries which were small and inactive in appearance. The most likely diagnosis was premature menopause, unfortunately for the patient. Soon thereafter we scanned a patient with acute abdominal pain and a moderate amount of fluid in her pelvis. Having just had the lecture on ovarian masses the Trainee successfully demonstrated the "ring of fire" in the left ovary representing the vascular flow around the corpus luteum formed after ovulation. Talk about great timing! Fortunately this patient had a good prognosis- her pain was related to ovulation and would not require surgical intervention.  We scanned many others and saw twins again. The Trainees have had plenty of practice learning how to assign measurements to the appropriate twin durng an ultrasound scan. I think all in all we scanned 20 patients.

Lunch break was late around 1:30 PM. Dario, Barbara and I enjoyed "fufu with light soup." Fufu is a soft doughy substance of plantain and cassava pounded and mixed together. One eats with one hands here in Ghana so washing of the hands before the meal is a  must. Then one grabs a little bit of the fufu and dips it into the soup which is spicy and contains either vegetables alone or fish, chicken or meat. It is quite filling and delicious. Another Ghanaian food I have enjoyed is "red red" - a spicy mixture of fried plantains and rice.

 At 3 PM Abeena, the coordinator with MCI arrived and the scanning stopped. The room was cleaned and set up for the closing ceremony. Abeena demanded the group to be on their best behavior. Before the official ceremony started ISUOG Course Instructors were given an opportunity to say a little something to the participants, thanking them for the opportunity to be with them, complimenting them on their dedication and enthusiasm and expressing thanks to the Partners including MCI, Physicians for Peace and Siemans.

Several physicians from the Ministry of Health and the Press arrived at 3:30. The official Closing Ceramonies started with a prayer, proceeded with introduction of the Master of Ceremony and then all the Officials including the Chairman, the Ghanaian course leaders, ISUOG's Outreach leader and several others spoke. The diplomas were handed out with a handshake and photo session and gifts were presented. We received some beautiful Ghanaian clothes that had been carefully chosen to fit the individual in size and personality. It was quite touching. Because our schedules had been so full I had not been able to purchase any fabrics which is what this area is known for so I was delighted with these very thoughtful gifts as were the others. Ann and Alfred presented Abeena and Dr Apoko-Adusei with our gifts - a lovely glass bowl from Copenhagen and a handsome mantele clock with an inscription. Then it was time for the official handing over of the 3 Sequoia ultrasound machines to the MOH by Barbara. Channel 3 News recorded it all. There were a lot of shaking of hands (Ghanaians love to shake hands!) and posing for photos galore, exchange of contact information, hugs all around and laughter. A great day indeed!

2010-09-09 A large pelvic mass arising from the cervix – possible a sarcoma, two sets of twins, one undiagnosed and already well into the second trimester, a 37 week breech > 3700 gms, fibroids galore, a patient with classic PCOS, a 13 year old pregnant child weighing no more than 85 lbs and many other patients with healthy pregnancies were scanned today. The course participants have all made great strides. I really am so impressed by them. Their ability to measure CRL and differentiate between a good and not so good BPD was impressive. Femur lengths and ovaries on endovaginal scan were the challenges today and we cautioned them not to be impatient but to practice, practice, practice!
 During our break Barbara and I walked through the hospital and out of the front gates to explore the surrounding area. Street vendors selling corn on the cob from a hot grill, textiles, soaps, bananas and household necessitites were set up beautifully in small stalls and manned by friendly Ghanians. Chickens and goats mingled within the busy small market area. A private Ultrasound clinic looked quiet about a block from the hospital. No clients today. We went into a small pharmacy where prescriptions are available as recommended by the local pharmacist, no physician's prescription necessary. Everyone wanted to talk to us. “Where are you from?” “First time Ghana?” “You must stay longer!” I can see how it would be easy to be seduced to stay a little longer than planned! At the end of the day we asked our 2 drivers who have been so faithful at picking us up and returning us safely every day if we could go by the Ghanaian Cultural Arts Center on the way home. Drs Opoku-Adusei and Asante Mante graciously came along as well to make sure we got to see everything. The handcrafts were so beautiful and inexpensive. Ann liked the hand woven baskets in particular. I admired the Ashanti beads, wood carvings and ceramics being fired in a large kiln the size of a small house. We learned from a young earnest woman while touring a museum set up as a typical Ghanaian home all about the Ashanti people and their king who still governs over land disputes.
Then it was ack to our Royal Park Hotel, another fine dinner at the Chinese Restaurant. We had a good discussion about how the schedule for Friday, our last day, would be structured, the closing ceremonies, the distribution of certificates and plans to return again in 6-8 months. It was a great day.

Wednesday

Wednesday was a day of scanning. Again the group was split into 2 groups. The physicians and ultrasonographer worked together seeing a mix of GYN and OB while the NMWs concentrated on OB. About 20 patients were sccanned. An unexpected intrauterine fetal demise in the mid trimester, twins, oligohydramnios, healthy pregnancies, low lieing placentas and multiple uterine fibroids causing pain and infertility were diagnosed. Today the students also learned how to write up reports summarizing what they found and we started checking them off on the competency check list. This is a list of the basic items we expect the course participants to be able to do on a scan: the presentation, biparietal diameter, abdominal circumference, femur length, placental location, amniotic fluid level and presence or absence of a heart beat.
During lunch Abeena took Ann and Dario on a tour of the other government hospitals. There are 5 government hospitals in the city plus a teaching hospital. There are about 3,000 deliveries a year at Suntreso per Dr Opoku- Adusei, 30,000 per year if count all 5 government hospitals and the teaching hospital together. Prenatal care insurance is provided by the government for free so most women get prenatal care and deliver at the hospital and home deliveries are not the norm. But there are many health issues including sickle cell anemia, malaria, TB, HIV, hypertension, diabetes and preterm delivery. The majority of the deliveries are performed by the NMWs. A group of 15 work at Suntreso in shifts covering the hospital 24/7. There are 4 full time physicians at Suntreso Hospital and 2 part time hired physicians. Their days start at 6:30 AM and end late.
After the last patient had been scanned Ann introduced the participants to the ISUOG web site were they can access lectures and educational resources on women's health issues. Dr Annie Opoku gave Ann a hug and expressed her gratefulness for the tools this collaborative effort had provided her. These Ghanaians are now the newest members of the ISUOG family!
In the evening we all met at a lovely new Indian restaurant where we enjoyed a wonderful meal, comraderie and several speeches. We shared stories about ourselves and our families. It was memorable. I know we have made some good friends for life!

Tuesday

2010-09-07 We ate in the Chinese restaurant here in the hotel for the third night in a row. There are not many other restaurant choices close by and a recommended Lebanese Restaurant with a good reputation recently closed. So we had asked Jeffery, the hotel owner if we could have a steak or something different than the usual Chinese menu. He graciously served us tuna fish sandwiches on toasted bread with lettuce, sliced tomatoes and French fries. After a review of the day’s events we discussed plans for the following day and then retired to our row of rooms in the “ISUOG Wing” to Skype with family and update lecture slides.

Other than the damaged Sequioa machine which Barbara and her entourage of Ghanaian engineers have worked on tirelessly, things have gone very smoothly. Our class size ranges from about 15 to 18 students from 6 hospitals and 2 private clinics. Some have had exposure to ultrasounds in their training, one or two do ultrasound on an irregular basis and for some it is the very first time seeing an ultrasound image or using a key board. We have two rooms for scanning. The physicians scan patients in one room and the NMWs scan in the other. Today we scanned about 35 patients, 10 GYN patients and 25 mostly healthy obstetrical patients. We found many fibroids in every size and location, one blighted ovum, 1 dermoid, one 17cm cystadenoma, an 8 cm posterior cystic uterine mass one year after myomectomy, one breech and one transverse lie fetus. A woman with a 19 week gestation looked perfectly fine. We asked how many babies she had. “Only one living,” was her sad reply. 3 pregnancies had been lost at 22 weeks. A decision based on this story was the made to do a transvaginal ultrasound. It showed funneling of the internal os of the cervix and a short cervix < 2 cm, both warning signs of cervical incompetence contributing to pretem delivery and possible death of the infant. The patient was admitted to the hospital for cerclage placement tomorrow. Hopefully the stitch in her cervix will help her maintain this pregnancy until viability.



After the day was over Dr Opoku, the Suntreso Hospital Director and a fellow obstetrician- gynecologist gave us a tour of the Suntreso Hospital. His tour was repeatedly interrupted by screams from the near by labor room. No epidurals here! Then there was finally silence and about 15 minutes later a young woman looking about 15 years old was lead by a nurse from the delivery room to the post partum ward. NMW do the majority of the deliveries. Physicians perform the cesareans and “difficult” deliveries. There are approximately 3,000 deliveries/year at Suntreso Hospital. Most patients stay only 24 hours before heading home. Unfortunately the hospital cannot provide food for their patients so family must bring some in. But care is free through the government health insurance plan. The open ward the new young mother was brought to was fully occupied. Earlier in the day even mattresses on the floor were occupied by other patients that had since been discharged. One large TV was on in the postpartum ward. I think the program was “Who Will Be America’s Next Top Model.”

Dr Opoku and Abeena, who is with the Millennium Cities Initiative (MCI), proudly displayed the very new and clean Mother Baby Unit on the oher side of the hospital.. Preemies and very ill babies are kept here. This is another large open ward currently only occupied by 4 mothers and their newborns who were receiving IV antibiotics for neonatal sepsis.. We subsequently toured the small library and large lab which was quite impressive. It even has a designated refrigerator for blood but with no blood available, chemical reagents are stored there for now. Suntreso Hospital has one operating theatre but it is far from L&D and awkward to get to in an emergency. Dr Opoku is hoping to raise funds to finish a half built theatre that was abandoned about 10 yrs ago and is strategically located right next to L&D. I wish him great success. Last but not least we saw the big generator and water purification system, all very critical components and necessary infrastructure for a successful hospital.

Being a Hospital Director in Ghana requires big shoulders and a wardrobe of many hats!

Ashanti beads

2010-09-07 So who knows what Ashanti beads are? I was having a difficult time pulling the young pregnant lady’s clothes down to expose the abdomen in preparation for an abdominal ultrasound. It was as if she had a belt around her undergarments and no matter how I tugged her clothes would not slide down very far. I soon learned that traditional Ashanti beads are worn as decoration much like a necklace except down around the hips. They signify her arrival to womanhood and are also handy at keeping western undergarments up! They also create a little of an indentation creating a smooth curvaceous shape, appealing to the opposite sex. Well Ashanti beads are lovely and come in all colors but they get in the way of the ultrasound so next time I quickly asked the patient to loosen her beads so we could proceed with the ultrasound. I’m learning!

First Day

2010-09-06 I was up late trying to rid my computer of a virus. Finally successful by midnight, after a few hours of sleep and then a light breakfast of toast, omelet and powdered Nescafe, we were off to Suntreso Hospital for our first day of teaching. After a slight delay as conference rooms were changed the red plastic chairs were set out, the projector was plugged in and Abeena with MCI and Ann made the introductions. A malfunction causing smoke to rise from the extension cord to one of the ultrasound machines was quickly taken care of and then Barbara introduced Siemens' Acuson Sequia ultrasound machine with all its bells and whistles. A pretest was given and the lectures launched: Alfred and Ann introduced First Trimester US discussing physiology and embryology correlating them with ultrasound findings. Alfred gave a lecture on ectopic pregnancies. Dario gave a detailed lecture on ultrasound in the Second Trimester after a pretest on the same. A live video scan of two obstetrical patients followed. Some of the students got a chance to practice and it was thrilling to see their enthusiasm and excitement. Then it was on to pretest in Gynecology. I spoke on ultrasound of the uterus and Ann finished with and extensive talk on ultrasound of the ovary. Somewhere in the there we had a lovely snack of meat pie and Fanta. Later lunch was delivered to the conference room consisting of fish, plantains, cold slaw and rice. We were scheduled to start at 8:30 AM and finish by 5 PM and I must say we did a good job staying on time despite the slight delay in the beginning! The students were extremely attentive, some never moving from their chairs except to participate in the live demo. I saw them nodding yes that they understood and when prodded responded to questions. 2 or 3 timidly asked questions but they are clearly interested and eager for this opportunity to learn a new skill!

Our flights

2010-09-04
Despite Hurricane Earl’s best effort to delay our flights we were on schedule and everything went smoothly. Our rendezvous in Washington with Barbara was seamless. We are now at 31,000 ft heading towards Accra, Ghana.




2010-09-05
After a 10 hr flight we arrived right on time in Accra. Our luggage made it too. We transferred to the Domestic Airport and met Ann and Dario who had arrived the day before and spent the night at a local hotel. A 45 minutes long flight and we landed in Kumasi, the second largest city in Ghana. We were met by one of the physicians enrolled to take the ISUOG Basic OBGYN Ultrasound course. 3 cars transported us and our entire luggage to the Park Royal Hotel through this large city of 2.6 million people. Traffic was busy as a local soccer game had just ended at the Stadium. The roads are paved and there are traffic lights which most seem to obey but the traffic circles were rather chaotic! Laundry hanging from balconies, shoes for sale hanging on display from cement walls, street vendors cooking a quick meal of rice and chicken were everywhere. Some wore traditional Ashanti floor length gowns. Muslims, although a minority in Ghana (15%) were seen mingling in the crowds. A hot shower, a Chinese meal at the hotel restaurant and a few Ghanaian beers later and I am ready for bed!

Preparing for the trip

2010-09-01 Our second conference call in preparation for our trip to Ghana was at 7 AM today. We reviewed travel plans, the training schedule and discussed proper attire for work and possible social events. I can sense the excitement and perhaps a slight nervousness about the unknown amongst the travellers. Simon's packet was comprehensive including information on ISUOG's partners (the Minister of Health, Physicians for Peace, Millenium Cities Initiative and Siemans), the 5 day schedule, important contact information and the names of the 18 Ghanian students: 4 Gynecologists, 3 Medical Officers, 9 Nursemidwives, 1 Nurse Anesthetist and 1 biomedical officer. Only 3 of them have had exposure to ultrasounds in the past. I am very curious about them and anxious to meet them! I am also anxious to re meet the Training Team. While I have worked with Alfred and Sharon before in Haiti, I have only met Ann, Dario and Barbara at the ISUOG meeting in Hamburg. I am hoping this will not only be an exciting  two way learning  experience for Trainers and Students but an opportunity to meet and make new friends who share my passion in Women's Health!