First Day at Work

October 9, 2012
Kasoa Home Base
We have lost power again. It is so hot I want to undress myself. It should be okay, I am alone in the room and no one else comes here.  I don’t mind losing power at night. Dinners are always more intimate with candlelight. Conversations are easy. And the air is always more still. I looked up at the sky tonight as I was hanging my newly washed clothes. It was beautiful. Dark and dotted with stars that always to me, look ethereal and quieting. All three of us here are readers, so after dinner we always lie down on the sofa and read books— and tonight was no exception. They both had flashlights, and I had my Kindle (I love it). Reading non-medical books is for me a real luxury, and I am savoring every word I read.
This morning was quite fun and unusual. I got all the girls (including our helpers) to work out with me using the Insanity videos I brought along. It was hilarious how we all struggled toward the 3rd round of the 3rd set of crazy and insane exercises (and decided to fast-forward the video to the end). But oh boy did it feel sooo good. I was sweating so much you’d think I ran 10K on a 90-degree weather. It felt like it. I thought with the morning African heat seeping into the living room combined with our sweat, doing hot yoga here might not be so far-fetched an idea after all. We have a reasonably big front yard and I told L that if she sees me running around the perimeter it means I have gotten bored with the videos. Which I doubt, because I also brought P90X with me. I am crazy active this way.
Ok so I have taken off my shirt already. Oh my god I hope we have power soon. I don’t think I can be more naked than naked.
Anyway, today was my first day at work at Ga South Municipal Hospital. We (W and I) reached the vicinity at around 10 am, after a 45-minute tro-tro ride. Then it was a short (5 mins) walk to the hospital itself. The compound was more like a set of one-storey clinic buildings than one big hospital building. I met with the head of the whole hospital who gave me a draft of my schedule for the month. I asked if I could change it according to my needs, she said she did not think it was a problem. Next I met the Medical Superintendent (a doctor too) who also said the same thing. Then I was led to the HIV counselor, whom I will call G.  She was in a small room at the corner in one of the buildings. At that time she was counseling a patient (whom they call here ‘client’) and I thought it was notable that people here do not mind walking into a room even when there’s obviously some business currently being transacted among persons inside it.
The next 4 hours were spent counseling patients who were there for testing (either as a walk-in or as a referral from a physician) and for follow up. Most of them were women, interestingly. I watched G swab the oral mucosa (more specifically, the upper and lower gums) of a patient. Apparently this is the way they confirm a positive ‘First Response’ result. Today however she used it for initial screening because they have run out of the First Response kits (akin to a pregnancy kit). If the kit has a positive (two red lines as opposed to only one red line for a negative result) result, they do a confirmatory HIV antibody test by doing the oral swab or a blood test. Then depending on the result they undergo further testing and treatment or not.
While I was there G was called by another nurse to please run a rapid test on a sick patient in the Male Recovery Ward. I went with her and found a real sick-looking man in his (maybe) 60s lying on his yafunu (stomach). I asked G why he was here for and she said because his chest hurts. I instantly became worried. He looked really ill. A doctor has already seen him and has already requested tests and medicines for him, which his relatives are already in the process of buying in the pharmacy nearby.  I walked away feeling helpless and real uneasy. An hour or so after, I took a peek in the ward and saw that his bed was empty. I hoped he just transferred beds.
Every bed in the Male Recovery Ward today was filled, but not with men. Men occupied two of the six beds. 3 women and 1 child occupied the other beds. The Female and Children Recovery Ward also had I think 6 or 7 beds. All but one was filled. A nurse was trying to insert an IV into a child’s vein and I almost volunteered but I have been without practice for such a long time and I didn’t want to waste precious IV needles. Also there was my fear of having a needle stick injury.
Apparently there are always more women than men who are either admitted to the hospital or being tested and treated for HIV/AIDS. G said it may be because they have more women in Ghana (not unique to Ghana, I thought), and may also be because men are less inclined to seek consult. I said because they are macho. She chuckled at this. She thought so too.
She brought out a list of their ‘Defaulters’ or in our language, those lost to follow up. If the records are accurate then I must say it isn’t too bad. They have 73 recorded defaulters from January to June 2012. Some of them were even wrongly recorded as defaulters because they have followed up. G, who I thought was dedicated and sincerely caring, said that she wanted to get the defaulters back into the loop but she didn’t know how to start and she didn’t have the budget as well. I did the math for her and made the observation that if we calculated it out, 73 defaulters would mean around 12 defaulters per month, which I said was a doable number if we further divide the 12 into 4 weeks. I said you could certainly reach out to 3 patients in a week. She lightened up and agreed that this was indeed more attainable than she thought.
I suggested that she should not have to do everything on her own. Hiring public health or community nurses to do the leg walk would decentralize responsibility, which was especially paramount because she was absolutely needed in the clinic.
She agreed and said that she would include this in the proposal she is in the process of writing up.
The physical infrastructure of the HIV unit leaves much to be desired, but I was rather impressed with how they organize their patient files. Each patient that comes into the HIV unit has one folder and in it contains two big notebooks issues by the Ministry of Health. One notebook was dedicated to HIV/AIDS initial and follow-up care, and the other notebook a record of all other visits with each page basically dedicated for a SOAP format. I thought this was pretty neat. It isn’t EMR, but it was better than loose papers or even none.
G said that one of the biggest barriers to adherence is still the stigma to HIV and AIDS and all the misconceptions on how it is transmitted. She told me of one woman who only told her husband of her HIV after almost one year of treatment for HIV, and after an ultimatum from G (bring your husband or else I will stop giving you medicines). Most people think that you get HIV just by physical proximity, by using the same cup, using the same spoon. And yet, and yet— men don’t use condoms. It breaks my heart.
Tomorrow I will be back. I cannot wait. There is much to learn.  Along the way today G introduced me to different people and introduced me as Dr? I always chime Baua. I thought two syllables would be easy enough to know, but apparently not (after all in the States I am Dr Bau, Dr Bauer, Dr B, and oh yeah—RosBagh).
It seems they also have a difficult time understanding what Med-Peds is. They say so you’re a pediatrician. I say yes but also an internist. A what? I say a doctor for adults too. Oh, so you’re also a physician! I think about correcting the term and clarifying that a pediatrician was also a physician, but decided to agree that yes—you’re right I am a physician and a pediatrician. I think I chose a specialty that is not universally widely understood.
Before I left, G and I came into the uncomfortable topic of religion (a topic that Ghanaians do not mind discussing with you). She asked if I had a Bible and a devotional guide. I said yes (I only recently received the guide from one of my patients in Geisinger). She asked if I read it. Honestly I said no. And that’s when she went on trying to explain to me how reading the Bible is important. Though I am not opposed to reading the Bible (in fact on occasions I have read it and have found solace in it), I do not appreciate people proselytizing me. The way to my heart is by example. Luckily W gave me a call and I stood up and excused myself. I said sorry I need to go W is here, it was real nice working with you today and thank you very much.
I am pretty sure the Lord loves me as I am. And in this I find my peace and solace.

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