Monthly Archives: December 2013

LITTLE PEOPLE!!!

Children! I love them. Really, what is there not to love? They generally love me too. The reason for the mutual ‘amor’? Well, I guess the kids can just sense that am not like the other big people. You know, putting a cap on all things fun, and such.

ImageWant to talk about imaginary friends?  Well, my imaginary twin was the best. I could go on and on about her. Let’s! If you want to play, please, let’s! I love playing. Children are very interesting people. They have so much to say, somehow the ‘big people’ think they don’t usually make sense, but they do. You just have to patiently follow their train of thought to realize how profound some of their statements are. Anyways, I had such a great time at the department of paediatrics I am seriously considering a carrier in paediatric haematology. I think I’ll have the most job satisfaction spending my days around children.

Let me just say, y’all need to start paying attention to the children. For one, they are not simply miniature adults. They are people. Actual humans, with the entire spectrum of emotions you and I feel. We can start by showing them a little respect and not considering them as ‘little people’ that are not smart enough to have a say in anything. What is that we say about life beginning at 40? Hell, by this, I ain’t even born yet, I guess that makes me one of the little people then. We the children would like to be heard, if that is not asking too much.

Anyways, while at the department of medicine I really thought there were too many sickle cell patients on the wards. Within the period, we saw sickle cell patients from about 20 to 65 years with conditions from pneumonia to infective endocarditis to HIVAN, etc. I also heard about sickle cell patients on other wards  in the department. Their current admissions may or may not have been directly related to sickle cell, but I was just uncomfortable with how many there were at any given time. I felt like sickle cell was following me everywhere I went.

Oh, but nothing could prepare me for my experience at the department of paediatrics. There were just too many children in crisis on the wards, it was simply traumatic. There were those who came in vaso-occlusive crises, VOC. They would spend a few days on the ward and be out, feeling absolutely well.  Almost always there was the characteristic ‘gi-normous’ well-used folder. Been there, done that! It really is not a pleasant feeling, spending a lot of time on admission and being jabbed constantly to get your pain meds and IV fluids.

At a point, one of the kids, absolutely terrified of needles threw such a tantrum when it came time to receive his pain meds, I really felt sorry for him. The child was screaming, on top of his lungs. He just kept shouting, “I’ll bite you, I’ll bite you, leave me alone.” I guess that was the most violent thing his young mind could think up to harm his ‘assailant’. Suffice it to say, he got his meds anyway and slept like a baby after. If only that was the most violent thing in the world, won’t it be such a peaceful place? Ok, some smart a** will probably produce a biological weapon transmissible through saliva, but still. Just think of the US sending a group of marines to Iraq to bite suspected enemy combatants. Won’t that be something?

Staying on topic. The constant admissions and how much school we miss really takes it toll. One of the kids I clerked presented with severe back pain. Another VOC. The child was in pain, yet would not cry. Brave kid! He kind of reminded me of…me! He was wincing, doing stuff I’ll generally do when I am trying to act all macho. Well, I noticed and checked his folder.  He was two hours behind on one of his pain meds. I prompted the nurse who attended to him immediately and he was pain-free and asleep in no time. That made two happy kids, yes, I was happy too.

So I returned to the ward the next morning and my friend was crying. Had been for quite a while. First thought, these people have delayed his meds again. So I asked, turns out he was fine. Very fine, actually too fine. He wanted to go home. That was the reason for the tears. You see, my new friend ranked 10th out of 34 in his class in the previous term and was two weeks away from exams. Simply he did not have time to be sick and on admission. He wanted to go back to school. Now, that is my kind of kid. You know the whole drink loads of water advice for persons living with sickle cell, I asked if he drinks his water and in the cutest voice ever he replies, “I drink plenty water so that my sickness will go away”. Tell me, this is not the best kid ever. Very determined, again, like myself. I hope he came out tops in class this term. He simply ain’t got time to be sick.

The second most common presentation of the children with sickle cell disease I saw was the jaundice and dark coloured urine combination. This one kid had very remarkable jaundice. I saw those eyes, and just had to find out more. After a few questions I found out he was SS. Thing is, he was 11 years. I don’t think he had any biceps or triceps to speak off. So I decided to measure his mid upper arm circumference, which we generally do not do for children of his age. It was less than 11. That is just to give you an idea of the severity of his malnutrition. Weirdest thing though, he had the most beautiful silky black hair. Malnutrition causes silky hair, (think kwashiorkor) but his was black. Whatever happened to the characteristic browning of hair?  Damn! I’ll pay to have his hair. There was no way this was due to malnutrition, but actually, it was!  By the way he was in class 1. Which is a class for 6 year old children, he is actually 5 years behind in his education. Turns out, he spends most of his time in the hospital instead of school.

Another child who had been on the ward for quite a while, presented with what was thought to be a vaso-occlusive crises. Later, treated for septicaemia, he spent about a month on the ward.  He was sick, he really wasn’t going anywhere. The whole time, his mom was at his bed side daily. Lord only knows the effect this had on her employment. X-ray findings later showed osteomyelitis (bone infection) which by the way is very common in children with sickle cell disease. Oh this kid was absolutely terrified of needles too. I think you would too after about a month of constant jabs. The plan, surgical management of the affected limb, which entails more hospitalization, more absence from school for him and work for mom, more health costs and so much more.

Stroke. Oh yeah, you read right. This child was about 10 years and had already suffered his second stroke. Young person! Stroke! Think sickle cell, you won’t be too far off.  ( Throw in other hypervicosity states into the mix for differentials). Thing with this child, cheerful boy, I must say, he had suffered a complication. Expressive aphasia. Simply, he couldn’t speak. He could hear and understand us but had lost the ability to communicate with us. I really have no idea what the long term plan for management is with this child, maybe some form of speech therapy would come in handy.

These are but a few of the wonderful children I met during my paediatrics rotation. I always made time to play, even once pushing one of the kids on his little car thingy along the corridors. When you have been on admission so often you really appreciate the little gestures.

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It was also sad, seeing so many sick children daily. Anywhere but the hospital! Children should be out playing, running around in school, yet, these children spend so much of their childhood in hospitals and my question is why? Simply, why?

Why are children still being born with a preventable disease? Why are children still being subjected to so much pain and illness? Is it lack of information or do we just not care about what the children we bear go through?

I keep harping on this point. It starts with you. Know your Haemoglobin genotype, and then that of your partner. Then you need to get us much information as you possibly can to help you make an informed decision.

What are the odds of you two having a child with sickle cell disease? Is that a risk you are willing to take? Can you afford to prevent it, maybe IVF with genetic selection. Is a bone marrow transplant affordable and accessible to you?

Or maybe you will have that child, because missing several days of work sitting by your sick child on admission will not adversely affect your finances. Maybe you can afford extra tutors so they don’t fall behind in school. You can afford all the medications, test and procedures to keep your child healthy. You can give that child a good life. Well, fine by me. As I always say it is a personal decision.

Ensure that you have considered everything before you make a decision. I am glad to be alive. I have a pretty good life, I can’t say same for others. Really, can you afford this? More importantly, can you live with seeing your child in distress?

In making that informed decision, remember, there are always variables that we cannot control such as a child with sickle cell disease having two strokes before the age of 10. You can afford it, but should you? Just consider this carefully and make an informed life choice.

Love,

Sefakor_Enam.

GOING RED!!!

Visiting the Korle-bu teaching hospital for the first time, one is met with the curious sight of young doctors walking briskly with ice chests in hand. Could they be selling ice-cream, or is it just their packed lunch?  Valid questions, after all, we have all gone through the ‘lunch box’ stage at one time or another in our lives. Well, far from that, they are actually on their usual ‘blood products run’ that has come to be characteristic of being a house-officer in the country’s premier teaching hospital.

It is an essential service. Doctors move to and from the blood bank all day, securing much needed blood products for their patients. I have not as yet gone on one of those runs, thus have no experience of the intricacies of securing blood for patients. I have however, heard the stories. Doctors begging, literally, to get blood for their patients. All departments in the hospital are competing for these products which are always in short supply. What determines which patient gets it as opposed to the other? It is even worse, if the patient happens to have a rare blood group. The chances of securing your blood products are even slimmer.

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ACCRA GOES RED!!! Blood donation exercise.

Venue:Indafa Park Korle-bu.

Please come donate blood to help save lives.

The process, a patient’s blood is taken for grouping and later cross matching when a transfusion is required. Forms are filled and the request sent to the blood bank. Now, the blood bank being ‘virtually anaemic’ itself then provides the blood products needed by the patient. Demand certainly outstrips supply. Patients relatives our thus required to replace blood products.  That pretty much starts world war III.

For one thing, patients assume they pay for the blood, thus should not be required to replace it. Well, blood is not sold, not in Korle-bu Teaching Hospital. What patients pay for is the processing of the blood. Let’s consider this, the blood bank goes through several processes to get its products. Blood donation exercises, such as Accra goes Red are key. Voluntary blood donation is not common practice in Ghana, thus blood donation exercises are a means of obtaining the products. Then there is the process of ensuring its safety. You don’t want to be transfused with blood infected with HIV, hepatits B, or whatever other infection the donor may have. That is a costly process. I could go on to talk about storage, and everything else that is done to ensure safety of the blood patients are transfused with. This is actually, what you pay for. Curiously, if the blood is not replaced how are we expected to provide for others?

Now, blood! Oh bloody hell! There is so much apprehension with its usage. For religious reasons of course, some persons do not accept blood transfusions. I absolutely respect that. I may not agree, but, we all have the right to whatever religious belief we identify with. Then, there is sheer ignorance. It beats me how people can be so sorely mistaken about something and yet so passionately apprehensive of it. Last weekend, I was involved in a blood donation exercise, I have to say, I learnt a lot. It was a good experience.

ImageThere were a number of people, voluntary donors (the safest type there are) who actually came to the donation site, because they have decided to give blood to help save lives. There were a few people who came to attend to their own business at the mall, but on minimal interaction were convinced and willing to help. One guy was actually quite surprised that he had been convinced to donate. He was like; ‘I better go to heaven for this.’ And am like ‘mannn, you need Jesus for that!’ Cool guy, we had quite an interesting conversation. There were a few who were knowledgeable about the process, and  will straight up say, I donated recently, I can’t safely donate now, or I have been unwell I have malaria. I even had a guy say, I can’t donate, I have hepatitis B. A good number said, I partied a lot last night. I had a lot of alcohol. I loved that some people were aware of reasons why they were not qualified to donate. At least, there is some education out there even though a lot more needs to be done.

On the opposite end of the spectrum however, there were a few misinformed people. For one, fear of the blood being tested for HIV was an absolute put off. He will much rather not know. You can live a relatively healthy life with HIV if you are aware of it and get treatment early. Anyways, to clarify, HIV testing requires extensive counselling before you tell anyone their status. So, no, you won’t get called and told you are HIV positive even though in reality, that would inure to your own benefit. Of course the blood will be discarded. There were also a few people who just felt like they did not have enough blood to give. Again, by way of information, the screening process ensures that you healthy enough to donate blood safely. An Hb less than 12 for a female, or 13 for a male, weight less than 50kg and age less than 17 or above 60 are some reasons why a person, after  the screening process may not be allowed to donate. Simply, there are quantitative ways of determining whether your blood is ‘enough’ thus, subjective assumptions of low volumes of blood, which by the way will leave you in shock and unable to go shopping, just don’t hold water.

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My favourite, however was a guy, who claimed to be a pharmacist. To him blood transfusions are bad. Apparently, it is lazy doctors who resort to transfusion, instead of going with more appropriate therapy. Of what therapy he was speaking, I have no idea. Supposedly, there is a lot of research backing his claim, he just could not cite any. For one, you have to do better than that when you want to debate me on anything. For a pharmacist, I was disappointed at his line of thought. His argument was simply fleeting between the laziness of doctors and religious reasons why transfusions are inappropriate. Of course I wasn’t going to debate him. Maybe if he had a sound argument I just might have indulged him.

Now, the argument about haematinics ( blood tonics) is quite common. If I may, blood products are used in every field of medicine. Let us start with obstetrics and gynaecology. The foetus obtains its iron(and everything else) from mom’s blood, then there is the possibility of intra and post-partum haemorrhage (bleeding). In paediatrics, that neonate ( less than 28 days old) may be severely jaundiced, requiring an exchange blood transfusion. Yes, we do take out aliquots of the baby’s blood and replace with our blood products to treat the underlying condition. Shall we move on to surgery? Well, for one thing the anaesthetist will not touch the patient  if the Hb is low. The surgery just doesn’t happen, until all parameters are within normal range. Unless of course you will much rather have your surgery without anaesthesia

Accident centre/trauma unit, now if you ever happen to be involved in an accident and  lose a lot blood, by all means, allow me to scoop some Kontomire stew into  your mouth. After all, the green vegetables help the body to produce blood. In these situations, lost blood needs to be replaced immediately, else the patient will exsanguinate. Oh sorry, that is the option for the lazy doctor. When a pregnant woman is bleeding or someone’s cancer has a high probability of  spreading to other organs without immediate surgery, let’s just pour in the haematinic and wait for the body to go through its natural blood producing process. Shall we? Haematinics and other therapy have their place, and are used. After all, the blood bank barely ever has enough blood. I fail to comprehend how it can be assumed that blood products will be used for patients who don’t need them, just because doctors are lazy. Blood products like all other therapy, are only used when indicated and if there is no available alternative.

ImageNow, haematology. For persons with haemophilia, deficient in clotting factors, and who can pretty much bleed into their joint and anywhere else till it is destroyed. What is a doctor to do?  Freeze-dry factors? Well, they are prepared from blood too, shall we at this point shift the goal post, after all, it is not blood?  Anyways, we barely have that here, thus, make do with fresh frozen plasma (FFP), which is one of the products obtained from donated blood to help these patients, whose blood just won’t clot, to stop bleeding .

Of course sickle cell and thalassemia. There is a reason Hb genotype SS, is actually called sickle cell anaemia. Your red blood cell last 120 days on average, but in some persons living with the disease, it may be as low as 10 days, and in thalassaemia, not enough red cells are even produced to start with.  Again, what is a doctor to do? These persons need routine transfusion, to stay alive. Or we could just watch the sickle cells destroy every organ in the body and eventually kill them. There are several other indications for blood transfusion in a sickle cell patient, such as, in the acute management of a stroke.

That is not for everyone. Most of us do okay with daily haematinics, but a smart doctor always gives the best therapy to his/her patient. If blood products are indicated, certainly they must be used. Well, till our pharmacists come up with alternatives that are of course affordable enough for the average sickle cell patient in a lower-middle-income country like Ghana.

Till then, I suggest we just keep calm, read up and get accurate information, then make informed decisions about blood donation and transfusion.

ACCRA GOES RED. Currently ongoing at the new southern area blood bank. Indafa park Korlebu. Please pass by and give this precious gift to help save lives. The blood bank is always open to you to donate. Alternatively, pass by the Accra mall on the last Saturday of each month. (There is a mobile team stationed there)  Please spread the word, share this, educate a friend about blood products and their essential role in the field of medicine.Image

Regards,

Sefakor-Enam.