Ghana day 6

As horrible as it sounds, today has been the first day of working in Ghana which I've enjoyed. The BBQ last night really cheered me up, and I went to Kwasimintim this morning with enthusiasm (and a slight hangover). A labouring woman came in and Ellyn and I looked after her. Her baby's heartbeat was a bit slow, and staff were willing to cannulate and start IV fluids. Short of starting a CTG (certainly not available at Kwasimintim!) their management of the situation was exactly as I would have done in the UK. Whether that's a positive reflection on them or a negative one on me is for you to decide. The baby came far quicker than any of us anticipated, and as I was the only one wearing gloves I delivered (#48, if you were wondering). As the baby came so quickly the woman had quite a nasty tear. Watching this being repaired was horrible - especially as it was being done with no anaesthetic. I could see a 10ml vial of 1% lidocaine, and tactfully suggested we used it. "Okay" said the midwife, "get me 1ml". Ordinarily I'd use 10ml, so I didn't expect this 1ml to go far. She infiltrated half of it, and commenced suturing again. Unsurprisingly 0.5ml of local didn't really touch the sides, and I persuaded the midwife to give the other half as it had already been drawn up, and couldn't be used on another patient. As awful as this was to watch, I knew it didn't happen because any member of staff was being deliberately cruel: it happened because that 10ml of lidocaine had to last for many other women too. Today, I felt everyone tried their hardest with the available resources - for the first time since I've been here. 

The lack of effort and care in Ghanaian healthcare terrified me on a personal level. I was diagnosed with transverse myelitis in November 2014, and assumed cold British weather worsened my symptoms. As they improved as the weather became warmer I took this as causation and not correlation. Having been in Ghana for a while I've learned extremes of temperature - be it hot or cold - trigger pain. I hadn't expected to be needing analgesia stronger than codeine whilst I was out here, and got quite worried at the thought of needing morphine: from what I've seen of African hospitals so far, I'd rather return to the UK to get it. I mentioned this to Joe, our project manager, and he told me not to worry because there is a local hospital which will only treat ex-pats. Hearing this completely confirmed my opinion of Ghanaian healthcare: this is the place where staff sleep in front of patients, staff collect vague 'fees' at outpatient clinics which are then pocketed, and every ward has a staff television but can't provide bedding for patients. 

I think the biggest lesson I can take from Ghana to my own midwifery practice is how not to do things.

Love Emily x

Ghana day 5

Today has been my third day at a Ghanaian hospital, and it's been as head-bangingly frustrating as the others. Ellyn and I arrived at 8:25 (Ophelia, our housekeeper served breakfast at 7:45 instead of 7:15) but no-one had noticed, never mind cared! I am now accepting this as 'the Ghanaian way'. As soon as we arrived we saw there were no labouring women. With Work the World's advice of being proactive in our minds, we went to theatre to ask if there was an elective caesarean list running that day. "No", we were told, "but there will be an emergency case soon". We legged it back to the staff room to put our theatre kit on, and went back to theatre hoping we hadn't missed it. The doctor (who is awesome) told us to wait in the corridor and we'd be told when the woman was brought over. We waited for an hour, and again thought "this is just the Ghanian way". After another half an hour I asked a nurse when the woman was coming. "We've just had a phone call", she said (bollocks; we didn't hear a phone ringing) "we'll do it tomorrow". How big an emergency was it?!

Another biting-tongue moment came later on in the day when a para 4 (woman giving birth to her 5th baby, for the civvies!) came in, and Ellyn and I suggested she stood up to use gravity to help her baby descend. The midwife in question replied "no, we don't allow that because when the baby is born they'll hit their head on the floor". We mentioned that in the UK we have 1:1 care in established labour, to which the response was "we don't have the resources for that". I tactfully replied that there were presently 5 midwives staring at this poor woman (2 of which had previously been kipping on patient beds), and perhaps we could deviate from their normal practice on this occasion. They were fairly insistent I VE-d (vaginally examined) this poor woman, and couldn't accept that just because she wasn't fully dilated at the last examination doesn't mean we might not be now, and no, it's not okay to shove your fingers in on an ad hoc basis with no warning or consent.

After the day at work and a big debrief a group of us braved Takoradi's circle market. If there are any GoT watchers reading this: think Flea Bottom. For everyone else, try to imagine the smell of rotting fish being a welcome distraction from the stench of the open sewers running alongside each pavement, and rats. Lots of rats. The people living in the inner-city had no issues with grabbing us and steering us towards their stall. Children were grasping us and shouting "abruni!" and "osei!". The passageways were so narrow we were walking single file, and even that was too hard at times. Walking through that market was the closest I've come to feeling unsafe here: the residents could see we were the only white people for quite a way, were trying all tactics to get us to buy from them, and got fairly irate when that didn't happen.

Patient and marketplace assault aside, I think I'm getting the hang of other aspects of Ghanian life. I've woken up to find I've been sharing my bed with a lizard. I've become an expert at negotiating prices for EVERYTHING. I've managed with no running water for 2 days. I've chosen fabrics and am having them made into custom clothing. I've stopped bracing each time a taxi swerves off the road to avoid hitting a goat. I now dance slightly less like a white woman.

After we all returned from work we had a house BBQ with lots of alcohol and dancing. The stereotypes unfortunately turned out to be true; the black men were dancing like pros and us white girls were sort of shuffling 2 beats behind.

This weekend a group of us are heading to Cape Coast to do the canopy walk at Kakum forest, stroke some crocodiles and stay at a hotel with running water, and hot running water at that!

I can't wait.

Love Emily x

Ghana day 4

On Wednesday a group of us took part in a medical outreach programme, which meant we went to a village called Lower Dixcove and screened the residents for diabetes, hypertension and dental problems. I've never seen a systolic blood pressure reading of >200, even in the most severely (pre-)eclamptic women I've looked after, but it this village it was not an uncommon finding. As with many aspects of Ghanaian healthcare, the point of undertaking medical screenings and examinations is undermined by the reluctance to act on any abnormal findings, but hey, it was a great opportunity to practice speaking Fante.

In this region of Ghana it is customary for visitors to meet the village chief, and take him a bottle of gin. I made several enquires about securing this position for myself, but I just got laughed at for being a white girl (and a ginger one, at that) trying to speak Fante. Joseph (the Ghana Work the World  manager) and 3 of us students went to meet the village chief, which was a surreal experience. I don't know if any of you readers have ever watched Prison Break, but Lower Dixcove really reminded me of Sona: similar shades of mud and dust, people not living but just killing time and, especially, an upper-floor grand room occupied by the 'elite' which seemed an impossible contrast to the poverty below it. As the chief entered the 4 of us had to stand and introduce ourselves in Fante. We were then asked what day we were born - "er... Sunday?" seemed to be the correct answer, and the chief cheered and shouted "essi Emily" which translates as "Emily, born on Sunday". Walking from the chief's house back to the village hall took us through lots of back alleys full of roaming chickens, goats, and children. The children kept stroking my skin, shouting "osei" ("ginger"), "abruni" ("white person") and asking us to take photos of them. They were also huge fans of inflated gloves (+/- a drawn on face).

After finishing the clinic we went to Fort Metal Cross; a fort used for the detainment and exchange of slaves. The 'Metal Cross' part of the name derives from the shape of the instrument used to brand slaves upon arrival. We had a lovely (although questionably appropriate) Ghanian lunch on top of a wall overlooking the sea. A football got produced, a dish of chicken went overboard, and we left shortly after.

To cheer things up a bit we went to Busca beach. Even though it was a pretty overcast day you could still appreciate the beauty of the place, and how untouched it is by western tourists. A nearby bar sold beer for 4 cedi a bottle (approx. £1), so we swam in the sea, played football, and knocked ourselves out!

Update: this post was written on the ride back from the beach. We got pulled over by the police, and the minibus driver didn't have a license.

Ghana day 3

There's a huge lag in posts - sorry! I tend to write them at the end of each day, but by that point we either get a power cut or the internet crumbles so they get published the next day. When I wrote this it was my 3rd day in Ghana (Tuesday). I feel like I'm starting to find my feet, but I don't think I'll ever get used to it!

The driving is crazy. I'm a shit driver, but in Takoradi I'd be up there with the safest! I took a taxi today and it had no wing or rear view mirrors. In the UK this would concern me, but in Ghana no-one uses them anyway so I guess it's fine. I've never seen an indicator used. Taxis are identifiable by random yellow panels on their car, meaning every other vehicle looks like an Inbetweeners car in reverse. Ellyn and I commented on this to a nurse at the hospital, and she laughed and said you don't need a licence to drive in Ghana. Whilst this would explain the awful standards of motoring we were shocked so we probed a bit more. It eventually turned out you DO need a driving licence, but there isn't an organisation to enforce this. If you get pulled over by the police you tell them you've forgotten your licence, slip them 20 cedi, and drive off.

Being an extremely Christian country there are images of Jesus and references to God EVERYWHERE. The Work the World minibus has Jesus on the bonnet and "Messiah!!" plastered across the rear window. There are roadside shops called  "Jesus Chop House", "Worship God Computers" and "Believers Shoes". Hospital staff have no issue with asking me if I go to church. Initially I was stupid enough to answer truthfully, and an hour and a half later internally vowed never to repeat this mistake. "Are you married?" seems to be as good a conversation starter as "hello", and as soon as they find out I'm single they try to get me to marry their brother. I'm seriously considering buying a ring to put an end to this - I've already been told I'm going to hell for fornicating (some of the other girls have been called "white devils") so I might as well chuck a few lies onto my sin list!

Takoradi is far less developed than I thought it would be. Only the main dual carriageway going through the city has tarmac; everything else is rubble or mud. I think seeing the Work the World house before I left gave me an expectation that the rest of Takoradi would be of a similar standard. It is not. We are definitely the elite rich in this city. From the house (which is comfortable, but still doesn't have hot water) I can see hundreds/thousands of huts made from iron sheets, wood or - if you can afford it - bricks. These are where the majority of Takoradi's residents live. Children and goats roam aimlessly. Giving that the people here have so little it's really jarring to see Shell garages, Vodafone shops and Cadburys adverts. Even the hospital direction signs are sponsored by Lucozade!

First day Working in Ghana

Today has been my first day working as a midwife in Ghana. I expected it to be under-resourced. I expected there to be education limitations. I knew mortality rates are far higher for both mothers and babies. What I wasn't expecting, though, was a complete "so what?" mindset.

I'm working with another final year student (can I say newly qualified yet...?) called Ellyn, from Manchester. I'm so glad I had her there for support, and I don't think I'd be able to do it alone. Our first day was extremely surreal... we spent the morning observing staff doing their tasks: vaginal examinations with no consent or warning, listening to fetal heartbeats when they could be bothered and when the Sonicaid had battery and ignoring women in pain. I'm not sure what I expected the hospital to be like, but whatever vision I had was very far from the reality. There is one 12 bedded ward; 8 beds for labouring women and 4 postnatal. There are curtains around the labouring beds, but hey are only occasionally used to give these women some privacy. Males are not allowed. There is a bucket by each bed - this is used for vomit and urine. Once women are fully dilated (or, usually, at staff's discretion) they are moved to a delivery room. This is where our day took a turn for the worse.

(This is the delivery room - I stood as far back in the corner of the room as I could to take this photo, which highlights the cramped conditions here)

It says a lot about Ghanaian midwifery that I don't know the name of this woman. Ellyn and I only planned to observe the delivery, but felt we had to intervene. Initially the delivering midwife was using her hands as forceps to bring the baby down, and didn't ease off as the head was crowning. She continued after the head was born, but there was no further progress. At this point alarm bells were ringing for Ellyn and I, as we both shouted "shoulders!". The delivering midwife was still tugging on the baby's neck and hadn't even considered McRoberts (for the civilians: a manoeuvre where the woman lays on her back and brings her knees as far as she can to her chest, to maximise the space in her pelvis), so we stepped in to do it. The midwife was still tugging on the head, and telling the woman to "chim, chim" (push, push). We tried to stop he woman from pushing (in a shoulder dystocia the baby's shoulder is stuck against their mother's symphysis pubis, so pushing it futile and may increase injury to mum and baby), and started supra-public pressure (trying to push the shoulders downwards through the mother's abdomen), and that didn't work either. The midwife was twisting the baby's head to try to get it out, but that didn't work either. I moved to the bottom of the bed to enter the vagina, and at this point the baby was born. 

No two ways about it, this little lad wasn't born in good condition at all. He was as pale as me (which is extremely bad news if you're Ghanaian), not breathing, and the only good thing about him was he had a heartbeat... just. Ellyn and I took him over to a flat surface and did what we could with no equipment. None of the hospital staff seemed willing to do anything beyond stimulating this baby with a towel, and I was the only person in the room with a stethoscope to confirm this baby was still alive. Finding this out didn't seem to alter anyone's perspective of the situation, so Ellyn asked for a bag/valve mask. One was found (after the staff had debated whether or not they had one), and the 'lead midwife' gave the crappest inflation breaths I've ever seen whilst I performed a double jaw thrust. Ellyn tried to persuade her to slow down the maximise the benefit of the puffs she was giving, and I told her I was feeling air on my thumbs so the seal around the baby's nose and mouth wasn't working. Eventually this baby started breathing for himself, but I'm convinced that was spontaneous effort and not a result of the half arsed ventilation he'd been having. After this, I turned around to face the woman again, just in time to see the placenta be delivered. Her blood loss was fine, but the midwife performed a bi-manual compression (inserting a fist into the uterus via the vagina, and using the other hand to abdominally compress the uterus onto the internal hand), did no perineal inspection whatsoever, and then inserted an entire sanitary pad (complete with the paper strip which covers the adhesive side) into her vagina.

After the baby had developed some muscle tone I noticed his right arm remained completely limp. I mentioned to the midwife that I was concerned about a clavicle fracture or brachial plexus injury. She picked up his arm and dropped it 3 times, and agreed with me. And then she did... nothing. At this point I had definitely seen enough, but the final straw came when we saw a bottle of surgical spirit and a pair of scissors making their way to the baby. Ellyn and I left the room to digest the situation we'd found ourselves in, and heard the little boy's first cry as his foreskin was cut off. 

Ellyn - being a far nicer person than I am - was worried we might have offended the hospital staff by intervening and taking charge of the situation. I, however, am happy to take resentment of people I will only know for two weeks over the long-term guilt of not doing all I could to save a life. After we took a breather we went back to the unit and had a chat with the staff. They seemed grateful for our help, and one even tried to persuade me to marry her brother! Ellyn and I got a photo of the baby we helped to save, and also of some of the staff.

 

(This is Sharon. Before this photo was taken she said "I can't believe I'm sitting in between two white people"!)

Our afternoon was far better. Our Work the World manager took us on a tour of Takoradi. Unfortunately it was bad weather, but we were shown some beautiful beaches - and bars which back onto them! We stopped at one for a drink, and then headed to a supermarket. The prices of things here are baffling. 70cl of 40% gin costs ~10 cedi (around £2) but a box of Coco Pops (a staple food in my diet) costs 48 cedi!!

I'm starting to get my head around this no hot water business now, and the general Ghanaean culture. Everyone is so friendly, and they've even taught me the word for redhead (ohse). I'm learning to roll with whatever hospital staff is the best option, and starting to let go of my germophobia. 

Love Emily x

Ghana day 1

So. I have arrived in Africa. At the time of writing this I'd been here for an hour, and it's already been a huge culture shock. Getting here was relatively trouble free - getting out of Heathrow was the tricky bit! Firstly I checked in, received my boarding pass, and said emotional (for Megan...) goodbyes at the security gate. I was re-united with my parents approximately 93 seconds later because my boarding pass wouldn't scan. I marched straight back to the check-in desk to replace it with a functional one (earning lots of dirty looks from other passengers), re-said the emotional goodbyes, scanned it at the gate again, and it worked. I gave my parents a wave - confident the drama had resolved - and headed through to security. Now, I don't know if any of you have used a TENS machine. I've been trying it recently to help with transverse myelitis pain, and it's worked wonders. I now have a thorough appreciation of how it appears through a body scanner: fairly similar to an explosive vest, really. This meant I qualified for a suitcase search (it's amazing how quickly they're able to find your luggage when they want to!), and at that point 32 matching underwear sets, 2 skipping ropes and a shitload of nipple cream becomes extremely difficult to explain. I eventually managed to, and it was agreed I'd done nothing illegal, but I still felt like a terrorist whore.

Since landing, I have witnessed 10 people inside a Mini (father and 1 child on the drivers seat, mother and 2 children on the passenger seat, and 4 others squished into the back) which then had to be jump started, and after getting it moving the guy pushing it jumped into the boot. Traffic lights are seen as an optional guide. Roundabouts operate on a give way to the bigger vehicle system. I've seen a goat roaming a dual carriageway. If you want to overtake you just accelerate in whichever lane has least traffic. The Work the World rep said a prayer for us before we set off. I've seen a family drive truck laden with piles of clothes, a fridge, and three children. It's definitely a country where you just roll with whatever happens, and I can completely get on board with that!

Arriving at the Work the World house was another eye opener. Everying is clean and comfortable, but is a stark contrast to the dusty road, roaming goats and huts we see from our windows. Everyone is so friendly, and it's been really interesting hearing other students stories. I start working tomorrow, and I'm excited and nervous in equal measures.

I did a stock take of what I brought out with me for the orphanage - you guys are awesome!

Thank you all for all of your support and encouragement which made this amazing adventure possible.

Love Emily x

Sunny Hunny

Last weekend my dad organised a scooter ride to Hunstanton (aka Run to the Hun): a great weekend with great weather.

Now academic work is a thing of the past I've been filling my spare time with HCA shifts. I recently worked on an intensive care unit and was amazed at the closure this brought. I booked the shift because I thought it'd be an interesting place to work, and it didn't occur to me that it would affect me on a personal level.

Whilst there, I came across a leaflet which is given to patients when they step down from intensive care, and when they finally go home. It outlined PTSD, but also went into detail about why this can occur. Perhaps the most helpful part was it didn't once mention the phrase "at least you made it out of here", or anything similar.

It explained that your mind makes links with things when you're ill, which you're often too ill to be aware of. It used the example of feeling unwell, in pain and frightened whilst being in hospital, and then associating these feelings with the beeping sound of machinery surrounding you. This is something so simple which I hadn't considered before. Understanding this made me realise why - in December, January and February - I was terrified by most aspects of daily life. I'd associated bleeping with pain, despair and fear and these emotions were re-triggered every time I heard a beep - from a phone, a doorbell, a microwave, an oven, or even an e-mail. It explained why I found it impossible to sleep in a normal bed without some fairly hefty sedation, because I was used to being semi-recumbent on a hospital air mattress with opiates being pumped directly into a central vein. It also described how the relative silence of 'home' becomes an unfamiliar, and therefore unsettling, sound.

Who knew one shift could achieve so much?

Love Emily x