Farewell To Donkorkrom

This will be my last post from the Afram Plains. Today was busy with the quarterly Mortality Conference, a busy out patient day, and then last minute errands and goodbyes. I have to say I was somewhat surprised at the difficulty of saying goodbye. I am looking forward to going home but after 5 weeks here I have got close to these people.

The past few days have turned out to be rather hectic. Almost immediately after I got my last post uploaded we were called to the Casualty because of a Road Traffic Collision. Dr. Brown arrived a few minutes before I did. When I walked in I'm not sure it was even controlled chaos. There were three men sprawled on the floor of the very small casualty ward, there was also a sick child and her mother on one of the beds and a sick woman on another bed. Envision the following scene - a room approximately 5m by 6m square. There are four large old fashioned hospital beds, a wardrobe, a small sink and table, a cabinet on the wall, and a trolley with various equipment on it. There are two doors, one to the outside, and one to a small triage room. As well as the three men on the floor there was a doctor, three nurses, two orderlies, several onlookers, an anesthetist, and myself. There was also various staff members coming and going. Lets just say it was chaos. To compound the difficulties the most severely injured patient was lying in the swing radius of the door going to the triage room. Thus, anytime someone needed to go to this room for supplies, charting, etc, they had to step over and squeeze through the door.

When I arrived the nurses had me put a line into one of the men and then we began fluid resuscitation. When the patients were stabilized - at least as much as you can tell when you have only portable blood pressure cuffs and your clinical acumen for tools a secondary survey was performed. The one of the patients was pretty badly injured but stable, the second had a compound fracture of the tibia and fibula, and the third was only shocked with muscle strain and bruising. The severely injured patient was sent to X-Ray to try and figure out for sure what was going on. On the way back they noticed that he had a small arterial bleed on his leg so that had to be tied off. The X-rays showed that he'd been pretty beat up - four broken ribs, an avulsion fracture to the right ilium, fractures on both sides of the left pubic ramus, closed fracture of the left radius and ulna, and a dislocated right patella. This isn't considering the soft tissue damage that was underneath all the bloody dressings. However, with the patients stabilized we called it a night.

Saturday morning after rounds Natalie and I went to Casualty to see what was going on with the patients. The severe patient - from here on in Bob - had dressings on his feet, right lower leg, left knee region, and also on his face where his lip had been sliced through. As the dressings were removed the extent of the damage to his legs was revealed. There were deep lacerations on the lateral side of the left knee, the 'meat' of his left heel was literally hanging by a few strands and part of the bone had also been cut off. Then we unwrapped his right leg. The collision or getting out of the vehicle had sliced his shin from top to bottom, essentially peeling the skin layer off, splitting the fascia, and revealing the muscle below. His right heel was also lacerated deeply. We began by suturing the lacerations on the left leg, and reattaching the heel. Unfortunately the lacerations at the knee had severed the nerves and Bob had no motor control or sensation from the knee down as best we could tell. After quite a few sutures the heel was reattached and the two lacerations around the knee closed we began on the other leg. First the wound was washed to remove all the gravel from it, then it was sutured closed, as high as possible. The problem was that the accumulation of fluid in the muscle had caused the tissue to swell so that the skin could not stretch enough to cover it. Thus the wound would require secondary suturing. With that the patients were done. The Bob and his friend Bill with the compound fracture were referred to one of the teaching hospitals with orthopedic surgeons while the third patient was discharged and that was another day.

Sunday we were looking forward to a day of rest. However, one of the Doctors was opening a new clinic in a small community about 1 hour away from Donkorkrom and requested we come. After a truly marvelous example of 'African Time' (e.g. Instructed time of arrival - 8am, instructors time of arrival - 8:40am; time of departure - 10am; time of arrival at clinic - 11am; time of first doing something 1pm) we began seeing patients in a free screening/advertising set up at the local market. About 80 patients later (40 each) we headed back to the clinic for a bite to eat and some relaxing. So by the time we got back to Donkorkrom our Sunday was gone.

Monday proved to be especially hectic in the Out Patient Department. Some of the staff that usually help are on leave and as a result there was a massive line up of people speaking at least three different languages with a variety of complaints. After an exhausting day we finished and started getting a few things lined up for our departure. For lunch one of the ladies here in Donkorkrom invited us for a delicious Ghanian meal. She prepared Red-Red. The closest Canadian food would be a chili except with a bit of fish instead of ground beef. It is served with fried ripe plantain and is very delicious. It was cool to eat some more traditional food as opposed to the rice and fish we have been eating.

Our final day was topped off by a delicious meal prepared by another of the ladies who works at the hospital. We had rice balls and two kinds of soup - ground nut soup with goat and light soup (tomato base and fish). It was a gorgeous African evening with the frogs croaking, good food, and good company. A splendid way to say goodbye.

Tomorrow we will travel to the town of Cape Coast via Accra where we will drop our luggage. I'm sure that there will be more adventures but this is goodbye from the Afram Plains and will likely be my last post from Africa.

Farewell

Wrapping Up

Well, the time here in Donkorkrom is wrapping up. I'll be departing Wednesday morning which means I have only three days of work left at the hospital. The time has absolutely flown by. I've done some of the things on my 'to do list' and missed some. This past week has gone by very quickly but nothing with a major 'gross' or 'exciting' factor has occurred. We have kept busy with the inpatients and then the outpatients which is always busy at the end of the week because people come to the market days (Wed, Thurs) from the outlying communities.

I thought I'd just upload a couple pic

tures to give you a bit of a taste of my life the last

couple weeks.

The little school kids in the first picture watched me wait for my breakfast one morning. I would get an omelet and wait while the fellow cooked it on a little charcoal grill. They were very happy to have their picture taken.

I ordered 'formal' Ghanian wear and had it made up this week. According to all the Ghanians who have seen me in my outfit I look just smashing.

The waterfall below is the Wli (pronounced

something like 'Vlee') where I went last weekend.

This is just the lower falls, there is

another fall above.

On the way to the

falls we passed a sort of cocoa plantation - the cocoa trees were just mixed in with the forest. Then as we got closer to the falls we'd occasionally see cocoa trees, wild I think that were growing wild. The cocoa seeds are in the pods you can see growing along the trunk of the tree.

The shot below shows the falls from the village where we spent the night. The quality of the photo is lower to get it uploaded but you can sort of make out the waterfall. There was a beautiful little guest house run by a Ghanian couple who have traveled extensively. The proprietors were friendly, the food excellent, and the rooms very comfortable. These little mud huts are ubiquitous throughout rural Ghana.

This final pictures hows us in the consulting room after a long day of seeing patients with one of our translators, Evelyn.

I hope you enjoy the pics. Sorry for the rather disorganized state of them - CL

Chapter 9

Chapter 9 – In Which Phileas Fogg Clinton Lewis and Passepartout Natalie charter a leaky boat, spend the night with monkeys, find themselves three on a motorbike, and bathe under waterfalls, and find the bag running rather short on bank notes.

For those of you of a literary bent you may be familiar with Jules Vern 1873 novel Around the World in 80 Days. It is one of the novels I brought with me on audiobook and I very much enjoyed listening to it. Thus, I thought I would pay it homage in my title, placing myself of course in the role of the inestimable, indefatigable, and ever English gentleman, Phileas Fogg.

This weekend proved to be a series of most excellent adventure, providing both myself and Natalie with many memories.

We began our excursion on Friday afternoon. The hospital kindly provided us with a vehicle and driver which took us the 30 minutes on gravel roads of varying quality (mediocre to terrible) to a little village by the lake. Here the driver informed us that there were no public boats going across the lake to Kpando our immediate destination. Thus, our only option was to charter a boat to take us across. After hailing an appropriate young man a price of sixty-five cedi for the journey was agreed upon, down from one hundred cedi. The boat upon first examination appeared to be quite serviceable - about a twenty-five foot aluminum fishing boat for the journey of some thirty kilometres. After the young captain carried the 40 horsepower outboard motor down to the boat, on his head the boat was placed in the water, the motor affixed, monies paid, and we boarded our vessel. As we pushed off through the shallow and wonderfully warm waters of the shore of Lake Volta there were certain cold fingers of trepidation caressing my spine as I considered the distance to be traveled and the in rushing of water from the multiple cracks, holes, and other assorted leaks in the aluminum. Of most significance was perhaps the fact that it was possible to see daylight through one of the holes in the bow. There was also a constant spraying at the bottom of the bow where two cracks, one on either side provided a rather merry little fountain display of water coming in. The right side of the bow, approximately half way up also had a 30cm or so long crack. Each time we would come over one of the waves (about 2 feet high but smooth and rolling) in the middle of the lake we would crash down and the water would spurt through this long crack like blood spurting from an artery. The purpose of the extra men in the boat (there were three guys as well as Natalie and myself) became apparent - one to drive, one to bail, and one to assist. From my description it may sound like this were rather dire. Much to the contrary they were absolutely marvelous! The day was warm (and overcast), the breeze was warm and the water was significantly warmer than any shower I've had in recent times. About an hour after we departed we landed at the little port on the eastern side of the lake (which has a most horrendous stench of fish) and walked up to procure a taxi into the town of Kpando proper.

Our enterprising taxi driver offered to take us to our final destination about 15km from the town of Kpando which was a small village with a Monkey Sanctuary where live several groups of sacred Mona monkeys. We set off in an Opel station wagon with the windows down along a road that was being reconstructed. The result was a smooth ride for a time and the taxi was absolutely filled with fine red dust that seeped into each crack, orifice, and seam. By the time we arrived at Tafi Atome my white shirt was sort of reddish pink and my mouth tasted like the road. Tafi Atome was a tiny village and they have developed the monkey sanctuary as a community development/ecotourism project. For a very small fee we got our supper, accommodations for the night, a tour of the monkeys in the morning, and our breakfast, all in all quite a good deal. However, once again the maxim "You get what you pay for" came rather forcefully to mind as we were shown to our rooms. My room had a fan which came to a height of about 6'3" which meant it was significantly dangerous to stand up straight. The room smelled rather musty and I must say it was one of the most uncomfortable beds I have slept upon in my twenty-three years here on the planet. The bed was composed of approximately five 1x4s and a 6" foam mattress. The boards were arranged rather unevenly and I kept finding my backside or hip falling into a rather large crevasse. Thus, it was not the best sleep I have had.

We were up and ready to go at 6am when our guide arrived to take us to see the monkeys, some of which were already playing in the trees over the building our rooms were in. We wandered to the area where another tribe lived and as we stood there and waited, and the guide called they soon came swinging out of the trees and watched us to see if we would feed them bananas. The guide had brought a few which if we held still the monkeys would come and eat out of our hands. After a walk through the bush and observing another group of monkeys we returned the house in the community where we had taken our supper (boiled eggs in tomato sauce with rice) for a light breakfast of bread and porridge. After showering in the ablution block and packing our bags up the next stage of our adventure continued.

This stage was the journey to Tafi Abuipe a village where everyone is a weaver. It was about a 10km trip which we conducted on a motorbike...three of us on a motorbike, a driver, Natalie, and myself. It was certainly cozy and the rack at the back of the bike does not provide significant amounts of padding but we made good time and soon arrived in the next village. One of the Ghanian cultural artifacts is Kente Cloth. This cloth is made by weavers in strips approximately 6" wide. These strips are then sewn together to make cloaks, etc that are used only for ceremonial or special occasions as the traditional cloth is all woven by hand. We visited this village and observed people from children of about 10 up to older adults weaving on fascinating looms that are set up in little sheds constructed from bamboo (with thatched roofs) as well as in a large shed funded by the government. After touring through the village where the sound of the wooden shuttles click clacking filled the still air we got on another motorbike which took us the 5km to the main highway. After being unceremoniously dumped on the roadside we wandered into the nearest town and waited for transport north towards our next destination Hohoe. We waited only about five minutes before a car (maybe a taxi, maybe not) pulled over and took us part way to our destination. Then we hopped in another taxi and soon found ourselves in Hohoe.

Hohoe is a rather quite town and after finding some lunch in a relatively 'western' restaurant (I had a club sandwhich - the closest western comparison would be a chicken salad sandwich) we looked for a taxi to our final destination. Our afternoon destination was the Wli waterfalls, purportedly the highest in West Africa. After making our way to the Lorry Station and finding a taxi we waited about 25 minutes until it filled up with passengers. Then we got underway. In order to maximize the profits the driver managed to pack 6 adults, himself, and a child into the taxi. Suffice to say it was very cozy with four adults in the back seat. I have become quite close to Natalie in the past weeks as we have traveled, as well as to a number of African individuals. The child, about 18 months old was a bit grumpy so her mother sort of reached under my arm, around her child, pulled a breast out, and the child began to feed. However, the angle wasn't really ideal for the child so she pushed off against my legs to try and readjust - thus one travels in Ghana. However, the journey was not long and within 30 minutes we had arrived at Wli.

I think that the Eastern Region of Ghana is my favorite so far. It is magnificent mountainous country with misty mountains on the horizon that offer immense opportunity for imagination. Wli is in a mountainous valley less than 1 km from the Togo border. We procured accommodation in a very pleasant guest about 150m from the entrance to the waterfall visitor centre. After dropping our bags we set off with vigor to see the falls. We paid our fees, were assigned a guide and launched forth up the trail. On the trail I got to 'check' one of my 'goal boxes' for my time in Ghana. We saw cocoa growing partly in the wild and partly in a rough plantation! The cocoa grows in large pods on the trunks of the trees and I was most excited to see it. I find it fascinating how few chocolate products I have seen thus far in Ghana although in the past it has been one of its most significant products.

We charged up the track, gaining some elevation but nothing too extreme, crossing small bridges over streams and then we heard the squeaking. There are thousands of bats that roost on the rock cliffs around the waterfall and you can hear their sound from some distance. We soon reached the absolutely beautiful falls. They plunge from a significant height into a pool of cool clear water in a clearing at the base of large cliffs. After some time there we set back down the track to our guest house. After a shower we had one of our better meals in Ghana. I enjoyed a tomato and cucumber salad with macaroni and cheese and roasted chicken - it tasted marvelous.

After a very restful evening we began our return this morning. Thinking that our previous days taxi load of 8 had been impressive we found another share taxi only to have our previous conceptions dashed to dust. In the Opel station wagon we found ourselves sharing the taxi with not 8 but 11 people, 10 adults and 1 child of about 10. It was very cozy and it seemed almost necessary to synchronize breathing, however, several people soon got out and a more realistic number of people (eight) were left in the taxi. Due to our inability to find a functioning ATM in Hohoe on our journey to the falls our funds were becoming rather scarce. However, after asking around we found that there was one bank in Hohoe with a functional ATM where we could top up our bank notes. This can be a real challenge in this country as the economy is almost completely based on cash. Debit cards are useless and credit cards almost equally so. Thus, it requires the carrying of significant amounts of cash after one finds access to international funds. Our banking accomplished we caught a tro-tro to Kpando and then another to the port. We found ourselves there much earlier than necessary but we decided we could not afford chartering a boat again so it was necessary to ensure we did not miss the ferry.

After some hours resting in the shade we boarded our ferry. This 'ferry' was in fact a large pirogue some 50' long and 6' wide. There were about 30 people, 10 chickens, several bicycles, and various other assorted luggage. One and a half hours after we set off in the blazing sun we arrived at the other side where there was one tro-tro and a taxi or two waiting. We made sure to get to the tro in good time and got ourselves squashed in. As we departed we counted 20 people inside of the 16 person van, along with backpacks, suitcases, chickens, roosters, and fish. Then the 21st person hopped upon the roof with some of the luggage. About 40 minutes later we arrived safely at home in Donkorkrom.

I've enjoyed a quiet afternoon, getting some laundry done and preparing for the week. It is hard to believe but I'm in my last full week here in Donkorkrom. I believe I will be staying and working this weekend here at the hospital and then the plan is to leave the Afram Plains next Wednesday. It is difficult to believe how rapidly the time has passed and the many adventures with it.

Of Eyeballs, Stretching, and Hamburgers

It has been some time since I posted and there has been much happening. Last week Natalie arrived from Tanzania. She is a medical student from the UK and it has been great to have another obruni to talk and now travel with. We decided to go traveling last weekend. On the spur of the moment we decided to travel to Kumasi on Friday instead of Saturday.

Kumasi is the second largest city in Ghana and the centre of the old Ashanti (one of the major tribes here) kingdom. Thus,

it is a bit of a tourist centre for historical purposes. The distance from Donkorkrom to Kumasi is maybe 250km in terms of actual driving distance. However, the journey took a bit longer than that. Natali

e and I decided to leave Friday afternoon a bit early if possible. When I mentioned this to one of my preceptors you would have thought I'd lit a fire under his backside. They rapidly got us on our way and by 2:30 we were on our way. We began our journey in a very dilapidated Daewoo share taxi. Share taxis go when you fill them up. This little car (technically a 5 seater if you are all 5' tall and weight 110lbs) is designed to carry six in Ghana at least. The seats had nice covers on them which was fortunate as I'm quite confident there wasn't much seat underneath. After getting into the back seat (which is supposed to fit 3 people) Natalie and I decided to buy the empty seats (they were only 2.5 cedi) and carry on our merry way. The driver asked for our money which we gave him and then he went and bough fuel so we could make our journey to the river. He returned with a 20L bucket filled with fuel and a funnel after which he filled up the car and we set off. The roads I have described before - they were marvelous as anticipated and we made good time to the ferry.

At the ferry crossing a little bit wiser than on my arrival we chartered a small boat. I think it might technically be called a pirogue. I'm not 100% sure on this but I believe that is what they called - they are long and skin

ny made out of slabs of wood and plywood. The hulls are made of plywood and have a flat bottom at the back and then a bit of a bow that comes up about 6' if it were sitting on the flat. We boarded our pirogue and I felt instantly at home. The slow seepage in the bottom reminded me of man

y a river trip (however, I was nice and warm so this detracted from the river trip feeling). Then to top off the marvelous feeling of being back at home the outboard motor of questionable provenance lacked a recoil. The ingenious fellows (reminding of a certain paternalistic figure in my life) had rigged up a rope attached to a little piece of wood that could be wrapped around the flywheel (I think, my mechanical knowledge is rather slim...) after 14 or 15 pulls as we drifted in the choppy waters of Lake Volta we were off...only to be hailed by the organizer of our little cruise who had found another passenger. This passenger also happened to have a street motor bike. After much grunting, groaning, a bit of splashing, a heave and a ho the bike was on board as was our new passenger and we zoomed across the lake (after only a few more wraps and pulls on the recoilless motor).

On the other side of the lake we walked up from the little 'port' area to the area where we could get another taxi. On our way once again we zipped up and down the hills, through little towns, across the Kwahu escarpment to Nkawkaw. Unfortunately the tro to Kumasi had only one seat remaining so we had to wait for a second tro to fill up before we could depart in the dark and rain. At this point in the adventure we realized we had failed to secure lodgings for the evening which was now upon us. Let it be kn

own that attempting to secure two rooms via cell phone with questionable connections, a language barrier, and in a tro tro filled with people, the radio blaring, and the driver and mate both shouting at the top of their lungs trying to fill up the vehicle is a bit challenging. However, with some effort and perseverance Natalie succeeded - I managed to successfully evade the difficulties and instead offered moral support.

The journey seemed to be interminable. The Ghanian authorities in their infinite wisdom saw fit to place a multitude of speed bumps of various types on the main motorway between the countries two major urban centres, Kumasi and Accra. While I'm sure that in a soft bureaucratic chair with sufficient coccyx padding this is a superior example of engineering and design from coccyxes less we

ll padded they made a long journey seem to last an eternity. However, in due time and the pouring rain we reached the 'last stop' where the mate informed us it was necessary to depart the tro. Unfortunately for us we had only the vaguest of ideas where we actually were, no landmarks, etc. As the rains descended and the floods came we managed to flag down a taxi and after some deliberations, gesticulations, and commiserations we began the next stage of our journey to our hotel...which turned out to be about 3 blocks from where the tro had dropped us off.

The Hotel de Kingsway is described in the guide books as 'having rather prison like corridors' and a friendly little night doorman who seems to think it is 'the place' to be. I can now attest that both the former and latter are true. After ensuring that we had secured lodging for the evening the next step on our weekend adventure was to secure varying victuals to satiate appetites which had been subsisting upon rice and chicken or rice and fish with the occasional meal of chicken and rice or fish and rice tossed in on the side. Vic Baboo's turned out to be our port in the storm. Conveniently located just across the street from the Hotel de Kingsway, Vic's offers a large variety of western and Non-Ghanian foods. The proprietress is Indian I believe and while one part of my brain insisted the food was decent the part of my brain which has been in Ghana for almost 4 weeks was in heaven.

Natalie and I began with our customary Fanta (for her) and Coke (f0r me). Then we had SALADS...real lettuce with s

hredded carrots and tomato in an 'Italian' dressing. The lettuce was a bit warm and slightly greasy because it had been well washed then dipped in warm salt water in an attempt to remove amoeba, bacteria, and parasites which lead to gargantuan gastrenteric problems or worse. Then we both had pizza. In a failure to appreciate the shrunken states of our stomachs we each ordered a personal pizza. I managed to get through half of mine but that was all I could do and even that much was

an effort. After chatting with the grinning night manager (who would make a great used car salesman) we retired to our beds.

The next morning after deciding that we didn't want to spend 2 nights in a prison we packed our bags, and set out to explore the city a bit. Our first stop was a 'supermarket'. This store certainly had the expected accoutrement's of a supermarket but the execution thereof demonstrated once again that we were not in the Western World. We discovered much to our pleasure a packaged, processed, no refrigeration required Chocolate Filled Croissants - they are quite delicious warmed up just a little bit and remind me of something you'd buy from a convenience store at home. They made an excellent breakfast and we carried on our way to a Methodist Guest House/Hotel where we procured accommodations for our second night. Then we set off again into one of Kumasi's main attraction - its central market. This market is thought to be one of the largest in W

est Africa at somewhere around 12 hectares. It is truly massive and you can buy most things there. One thing that intrigued me was to see the cobblers at work making sandals. They cut out the leather, plastic, and other various components then nail, sew, pound, and glue them together with the result being relatively classy sandals. We also found live chickens in baskets, plastic rugs

, aluminum cookware, fabric, seamstresses, bead stringers, live snails larger than my fist, assorted candy, row upon row of dried, roasted, salted, or fresh fish, and so on and so forth. After wandering for about two hours we decided to rest and then retired to Vic's for another western meal.

Vic provided us with hamburgers and fries (sold separately for almost half the price of the burger) and then we carried on our way to the National Cultural Centre. Here we saw the sticks that the betrothed of the Ashanti Kings were given so that no other man would look at them, the war vests (that supposedly stop bullets), replicas of the stools upon which Ashanti kings sit, and other paraphernalia. We also observed artisans making drums by hollowing out chunks of wood. After observing and then playing some drums both Natalie and I were sufficiently enticed to purchase a drum for ourselves which we have been attempting (rather unsuccessfully) to learn to play a little this past week.

The planned evening meal was to be Chinese food at a new restaurant which turned out to be a mistake. We should have entrusted our final meal in Kumasi to the faithful cooks at Vic Baboo's. The City View Restaurant offered a selection of Chinese fare, including noodles. However, after ordering a noodle dish we were informed there were no noodles and it would be at very minimum 1 hour before noodles could be fetched and then cooked so noodles were out. Natalie compromised by ordering a spring roll. To her horror and disgust upon biting into one of six which arrived on a plate they had been made with a fish based filling. She persevered trying several more but alas they all proved to contain fish. My visions of lightly stir fried broccoli, crisp fried shrimp, and sweet spicy ginger beef were dashed upon the rocks of Ghanian reality. Instead I was confronted by a bowl of glop...chunks of chicken (i.e. take chicken, cut off head, remove feathers, feet, and guts; cut into chunks, cook, place in Clinton's bowl) although there were not that many chunks of chicken surrounded by a brown glop of limp cabbage, the occasional carrot, and stray piece of sweet pepper. I was sadly disappointed and we returned to our rooms somewhat mournfully.

The next morning slept in and then gathered our belongings and headed to duplicate our journey in reverse as we were uncertain of

our ability to secure transit on a Sunday when things slow down a bit in this country. We secured a more comfortable tro which we changed half way to Nkawkaw as the driver stopped and told us to get into a different tro. I enjoyed seeing the countryside in the day and the land around Nkawkaw is particularly beautiful with massive, rugged hills rising up out of the greenery and rolling hills. From Nkawkaw we secured a taxi and as the ferry was departing as we arrived we took passage on 'the pontoon' as the locals call it - although if time had been a concern I'm quite certain that we would have been faster to secure a pirogue. The ferry moves at quite a glacial pace.

In Eshe, the Afram Plains side of Lake Volta we ran into minor transport difficulties. The only available transportation appeared to be a big old Mercedes tro/bus - a picture should appear somewhere. To our untrained and western eyes this vehicle appeared to be stuffed to the very gills with men, women, children and luggage but fortunately for us this was only an optical illusion. There was certainly room for two obrunis with backpacks and drums (which we were now forced to carry with us after the

ir purchase on the previous day). As we rolled out of the town I enjoyed reflecting on what constitutes a vehicular necessity based upon our travels. It would appear that African society is very minimalistic when it comes to transportation - it is not at all about the 'frills' of western vehicles. For example having power steering is very much over rated, even if you have to dodge 562 potholes between Donkorkrom and Eshe; having good brakes is not really needed even if you do swerve left around a pothole instead of right and then come to the edge of a potchasm and which to stop before you plummet to your coccyx's agony below; another thing that is optional is a relatively clear windshield - I'm not talking about dust but rather the 65 cracks which radiate in all directions from various foci of cracking. An effective park break is also unnecessary - that is part of the role of the mate - whenever you stop he simply places a chock under the tires to prevent the bus full of passengers from rolling away. Much cheaper than maintenance costs on breaks! However, there is one essential item which I observed, namely the Fire Extinguisher. As a passenger I must admit that I felt much more comfortable

knowing that there was a fire extinguisher in the vehicle. Also, in the defence of these vehicles I must admit that in general they are lovingly cleaned with regularity (especially on the outside), although the red dust of the Afram plains makes short work of a good scrubbing.

Our bus lacked power steering or good breaks and had a load on the roof (goods not people), and a load inside. I'm estimating there were about 45 people packed cheek to jowl in this bus. I was sitting at the front (fortunately) as it meant my knees could protrude into the space between the mate's seat, the gear shifter, and the driver's seat. I sat on a seat that folded down into the aisle. To my right were two African women, to my left two African men and a boy about 7 or 8. Thus, we were very cozy. As the journey commenced people got on and off but the total number remained constant and even increased to the point where I was sitting in the front with the mate and I had to dismount the bus, so we could lift up the seat anytime anyone wanted off. However, in good time (only about 2 hours) we arrived in Donkorkrom, ready for a week of medicine before our next adventure.

This week things have been busy at the hospital. This is in part because both of the physicians, one of the Gha

nian student doctors, and about 75% of the many patients coming through the door have been sick with malaria. Because they are locals and have some immune exposure to malaria it hasn't been severe (in the case of the doctors) but it means they are tired and don't feel well. Thus the Out Patient Department/Clinic has been especially busy. There is a constant stream of patients wanting to be seen, complaining of a cough, headache, waist pains, fever, general malaise which in this location is essentially the diagnostic criteria for malaria. However, it hasn't been all humdrum malaria. This week I've seen and done a few new things medically.

Yesterday the lovely Gladys, one of the nurses here, and I sutured up a scalp laceration...thus, I did my first stitches in a real patient which was quite exciting. I must admit I was surprised at how tough the skin actually is. Intellectually I have known that the skin is strong but until you are trying to drive a needle through it you don't actually appreciate it. Earlier in the week I had another big first

- I witnessed a normal vaginal delivery of a bouncing little baby girl. I guess I've always appreciated on an intellectual level that labour and delivery was a messy painful process but watching a delivery certainly made the painful, energetic entry of a being into the world real on a much more experiential/emotional level. I must admit that once again I was amazed at the amazing properties of skin (in this case elasticity) and again I was thankful for the contribution of the Y chromosome in my own genetic experience. Finally I got to scrub in on what at home would likely have been plastic surgery.

Last evening a woman presented to the Casualty Department (ER) with over 10 lacerations on her scalp, face, and hand. She had been attacked by her husband who had taken poison following the attack and was dead. She was stable but the wounds were filthy and bleeding a bit. After ensuring she was stabilized it was decided to wait to do the repairs until today when family members could have come in and donated blood so she could be transfused prior to surgery. This morning I scrubbed in for the repair - the next paragraph is somewhat graphic, consider yourself warned.

We began by cleansing the hardened blood from the face and shaving most of the woman's hair. When blood congeals in these people's hair it is virtually impossible to remove so the hair is shaved off. Then we opened one eye which had been swollen shut and realized that the machete blade had actually cut and destroyed one eye. Thus one doctor closed the cut at the bridge of the nose/cheek (about 15-20cm long, cutting into the bone of the nose) and then another laceration above the eye, and multiple lacerations on the skull, and even one ear was cut almost in half. Then the other doctor came and removed the damaged eyeball (with an eyeball removing spoon, scalpel, and scissors if you are wondering). After the eye had been packed and dressed the first doctor began repairing the hand.

Anyone who has been to Body Worlds, or looked at pictures/models of the muscles and tendon's of the hand will have some idea of the complexity of the hand. Consider the multitude of actions we can perform with our hands - play a violin, stroke a loved one's face, write a letter, type a blog post, paint a Madonna, or wield a machete in rage upon another human being. Thus, the slices on the back of the hand were problematic because they had severed at the very least four tendons, at most seven or eight. The wounds could not simply be closed but the tendons had to be repaired if possible so t

he woman would have at least some function in her right hand. This turned out to be relatively easy for most of the tendons although the final tendon was difficult to find and I have no idea how effective the healing of the tendons will be. Likely this woman will be blind in the right eye and permanently disabled in her right hand...but she will live. I have no idea what kind of scars her psyche will bear but I'm sure they will be deep as well.

That was the lion's share of my day.This afternoon I assisted in the ultrasound scan of a woman who is pregnant with her 9th child. Then this evening one of the doctors had to go in to perform a Cesarean section to remove a dead baby from the womb. The mother was pregnant with twins and delivered the first twin at home dead. The second had not yet come so she came to hospital and it was removed. It sounds like the operation was difficult and gruesome so I'm not particularly sorry that I didn't assist in it.

Life is not particularly kind to some people and for the people living in this region life is difficult. They lack access to a multitude of things we take for granted and have no conception I'm sure of many things we could not imagine living without. However, they still smile when you smile at them and the children are exceptionally cute.

I hope this finds you all well, if you've made it to the end of the post you likely deserve an award as it was a bit of an epistle. I hope it wasn't too painful for you.

CL

The Days March On

Greetings from noisy Donkorkrom - not noisy with cars, motorbikes, music, or anything else. It is the sound of nature - some massive sounding frogs, a few ducks, the occasionally baaing of a goat. I've never really thought much about goats before but kids (baby goats) are exceptionally cute. They run around all over the place here. As I understand it in this society goats are your wealth. The more goats you have, the wealthier you are. Several Sundays ago I went to a Ghanian church service (4 hours worth). Part of the service involved the giving of a goat and a massive bowl of cassava (a kind of starchy tuber) to one of the ministers to celebrate his ordination. I'm sure that there must be some way to know which goat belongs to which person but for the casual onlooker they appear to roam at will around the town, in the gutters, eating whatever they come across.

Things are going quite well for me. I recently got my Course 4 marks (the exam I wrote the 2 days before I departed for Ghana) and I passed with a healthy margin so I was very excited about that. My living accommodations have also been modified. I had been staying at a 'hotel'/guest house about a 15 minute walk from the hospital. However, one of the doctors here has arranged for me to stay at his house which is fabulous. It is good for several reasons, one of the biggest is that it means I'm close to the hospital if something happens so I don't have to walk 30 minutes to get here and back, I'm now a 5 minute walk, if that to any part of the hospital.

The days flow by quite peacefully. Things are relaxed here. The doctors never really are off call but they also make sure to take some personal time, they just might have someone bang on their door while they are relaxing. The person will be clutching a patient folder and need some information - perhaps about dosing, a concern about a patient's status, lab results just became available, etc...but within 5 or 10 minutes the docs are back to their relaxing. I think it is a very equitable arrangement as these doctors have fairly significant responsibilities.

Yesterday afternoon I went and visited the orphanage here in town. It was a cool experience and I intend to go back. There are 21 children and 3 caregivers - a huge job I'm sure. The kids were eating supper in various states of undress while I was there but they were very cute and definitely warm the cockles of one's heart. The oldest appeared to be 10 or 11 so I'm not sure if perhaps the older children go to boarding school but it should be fun to get to know the children there.

Today I observed the most disgusting thing I've seen yet. A woman with severe mastitis had a very large necrotic area on one of her breasts. Today we debrided the breast. An piece of necrotic skin the size of my hand (with fingers together) was removed - for those of you that don't know me...I have pretty big hands. I think the worst part of it was the smell. Necrotic fatty tissue doesn't smell very good, and it doesn't look very good either. Today I also observed 2 hernia repairs. I think I'm about ready to assist on one as I've watched a few now. I don't think that the tradition of 'watch one', 'do one', 'teach one' quite holds true but I'm starting to feel like I'd have at least a better idea of what to do all scrubbed in and across from the surgeon.

This evening another medical student arrived. She is from the UK and will be here until I leave. I think it is going to be nice to have another 'obruni' (white person) around to talk to and bounce ideas off of so it will be cool to get to know her better. She has spent the last few weeks in East Africa so it will be interesting to hear how medicine in Ghana is different from other parts of the world.

I hope all is well in your respective parts. Thank you everyone who has posted comments and also to those who have sent me personal emails - I appreciate your thoughts and care.

Take care

The Circle of Life

Howdy from the sweaty streets of Donkorkrom. Just as a word of warning before I get going, most of this post is medical and some of it is a bit rugged - reader discretion advised.

Life is falling into a pleasant routine here in Donkorkrom. I get up around 7am and get ready for the day. Then I head down to the hospital, stopping on the street for something to eat - some bananas, an omlette, some bread, then I arrive at the Children's/Female Ward and I do rounds with Dr. O. Then some days we go 'to theatre' (the operating room) or to the outpatient clinic.

However, today things were a bit different as Dr. O had to make a trip to Accra (a 3 day undertaking essentially...one day to get there, a day of business, a day to come back). We met at 6am for rounds and then he disappeared, I walked back to my accomodations and had another bit of sleep :-) Then I returned about 8:30 and did rounds in the ER/Male Wards with Dr. B.

Saw some interesting cases - a 25 year old with Rheumatic Heart Disease and congestive heart failure - he is edematous (pitting to mid-shin, ascites), in respiratory distress, has a large tender liver, large spleen, and a heart murmur. All in all, not a healthy guy, especially for a 25 year old. The next patient had an indwelling suprapubic catheter that was being discharged. He has a urethral stricture from some unknown cause (potentially repeated urethritis) and as a result has urinary retention...thus a suprapubic catheter because you can't get one up the ureter. Another man had presented with lockjaw and received thousands of units of anti-serum which had soaked up the toxin produced by the microbe and he was recovering. Next there was a patient in kidney and liver failure with full blown encephalopathy. Rather exciting for me (in a morbid way) was the fact that he had asterixis - this is a finding where the patient cannot control the movement of the hands when they are held out in front of them as if they were stopping a bus; instead they flop uncontrollably - I don't think this patients prognosis is very good at all. When I asked about management 'hope' seemed to provide a significant part of the treatment. His condition is exacerbated by his chronic alcohol intake (likely a cirrhotic liver) as well as the fact that he took traditional remedies before coming to the hospital and these remedies are most often toxic to the liver.

The next patient was a shocker...this patient presented to the hospital and was ambulatory. Upon admission they did a measurement of his hemoglobin. Hemoglobin is what determines the ability of your blood to carry oxygen. The normal range for hemoglobin in a man is between 130-180...in a woman the normal range is more like 120-160. Here in Donkorkrom I have seen many low hemoglobins in the 48, 55, 62, 75 kind of range. If a child comes in and has a hemoglobin below 60 usually they receive a blood transfusion...depending on their clinical picture. However this man presented with a hemoglobin of 18!!! This is ridiculously low and after a blood transfusion he was up to 32. I was astounded - it is amazing what the human body can adapt to. This man's hemoglobin has just crept lower and lower and his body as adapted. He has severe pitting edema all the way up his legs (his legs look like tree trunks as they are so swollen and he has folds of skin holding fluid at his ankles) to his abdomen where there is fluid in the peritoneal cavity but he appears relatively well and with proper nutrition should recover I understand.

I have been made very aware of the circle of life the past few days. On Monday I watched a cesearean section and witnessed the first cries of a new born baby as it entered the world - it was a powerful, amazing, awesome moment...I don't know what the child's life will be but for me to be there when it made those first sounds was incredible. Today in clinic I saw multiple children who could melt your heart with their little smiles - yes, I'm truly a softy for the kids.

However, I've also witnessed the flip side of this coin. One patient who was operated on never came off anesthesia and she passed away, thus her little child is now motherless. Yesterday Dr. O performed two ultrasounds which I watched on preganant women. The foetuses in both cases were no longer viable...basically the babies were dead. One woman was about 24 weeks and will have to be induced to get the foetus out. This is a particularly terrible case as the woman is sick as well. She has a significant patch on her pendulous breasts that the skin has sloughed off of. The patch is close to 6"x4" in area and the rest of the skin on the breast is not healthy either; the other breast shows peau d'orange (the skin looks somewhat like an orange peel) and I'm not sure what is going to happen with it.

This is all bad enough but then this morning I went with Dr. B to perform a Donkorkrom Post Mortem/Inquest into a hit and run death of a 5 year old girl. I didn't know what to expect as I've read some stories about post-mortems (PM), morgues, etc but this was pretty bad. The refrigeration system in their morgue here no longer works so the bodies are embalmed immedeately on arrival, thus this PM wasn't quite what you read about in the Scarlatti and other novels about medical examiners. Lets just say it was pretty terrible. Death is ugly. I'm going to spare you the details as there is no need for them to roam the internet but it lacked any sense of serenity, dignity, or sterility. The little girl's father and perhaps uncles/immam/community elders were there to claim the body and they watched the examination which was quite basic - the doctor only examined the exterior to determine cause of death. I'm not sure I'd want to be a medical examiner after today. It was a place that sucked the energy out of you simply by being there.

After the PM we went to the clinic and I had some of my own patients again which was quite exciting. Then I've had a few hours off this afternoon in which I've read up on a few drugs and had an awesome sleep. I'm on my way back to the hospital for evening rounds and that will be a day in my life.

I hope that all of you are well and enjoying glorious summer weather.

One Week Gone

It was my intent to send this post on Saturday but the internet conspired against me and thus it is coming to you on Monday. I hope all is well in your corners. A brief update on today...Dr. O was busy today so I worked for part of the day with one of the Medical Assistants in the outpatient clinic...I saw my own patients, communicated with them as best I could and then wrote up their orders [for drugs or admissions] and sent them on their way, conferring with the MA when necessary so I've jumped right in with both feet. Tonight I'm heading back to the hospital to see some patients in the Maternity Ward with Dr. O...I guess there are some issues that need seen to but he wanted to go home for supper, thus I get to go home for supper. I'm enjoying things immensely. It rains almost every day but it is warm and when I'm in the clinic I get to enjoy the air conditioning which is BLISS. It is very humid as a result of the rain and it makes it a bit tough to get your clothes dry but can't complain too much.

Enjoy my post from Saturday ~ CL

I realize that I've been swamping my blog with new posts but time has permitted so I thought I'd make use of it whilst I could.

Today I'm enjoying a relatively relaxing Saturday. I arrived at the hospital at 8:30 this morning and we rounded on the woman's/kid's ward. Then we went and did a couple minor procedures - removed a peanut (called ground nuts here) from a child's nose and sutured a boys foot. The top of the foot had been lacerated some time ago and the parents waited too long before bringing him in. Because of this the laceration (about 4cm long, at least 1 cm deep at one point) couldn't be closed when they'd first brought the child in. It was starting to heal a bit but was too deep to heal on its own. Thus, today we debrided the wound - it had stretched into an oval shape with pointed ends and was probably 1.5cm between the skin edges - then loosened the skin up on either side and sutured it together. This means that instead of taking up a bed in the ward the child can go home. Then we came back to Doctor O's house (my preceptor) where we had some lunch - boiled plantain and a spicy tomato/onion mix with a bit of fish in it which his wife had prepared. He has let me use his computer and his internet so I'm taking this chance to do another post.

Donkorkrom is a small town although compared to the surrounding villages it is a booming metropolis. It is composed largely of mud brick buildings where the vast majority of the people live. The rest of the structures are primarily cinder block and some of the little stores are made of containers that have been . The town itself runs mainly along the main road running east-west between the two ferry ports. The Afram Plains are essentially an island - although they are not surrounded by water on all sides there is virtually no access to the west via road and then there is water to the north, east, and south. There is maybe 2km of 'town' on either side of the road with a central area with a market and a place where the trucks park. In Donkorkrom it is perfectly acceptable to drive your tractor to town although there aren't actually that many of them and they are mainly old. I live on a secondary road that runs south of the main road and the guesthouse where I am staying is at the edge of town, across from a church and the primary school. Judging by the number of churches and pastors that preach at the hospital certain days of the month the Ghanians are quite religious.

The guesthouse where I'm staying is quite nice - I have a double bed, a fan, TV (with 3 channels that work sometimes), an attached bathroom with cold water shower, flush toilet, and sink. All in all it is quite sufficient. Thus far my meals have been a bit helter skelter. The 'restaurants' in town - there are 3 but they are not particularly well marked and I've only just figured out where they all are. I've eaten at the street stalls - fried bread, buns, ground nut paste (raw peanut butter), fried chicken one night, etc. Yesterday I tried a grilled chicken gizzard - the flavour was quite good but the texture left quite a bit to be desired...there were significantly unchewable components. After we finished rounds and surgery yesterday Dr. O took me out for lunch at one of the restaurants. We had steamed fish with rice and a tomato paste/chili sauce, it was good and perhaps the first 'proper' meal I've had since I've arrived. I'm quite certain that I'm going to be eating a LOT of salad when I get home - I'm already craving fresh veggies and it is only the first week.

Last night I ran into 3 other white people...it was quite exciting to speak English with someone who I understood clearly. They were Peace Corps volunteers. A man and his wife have been teaching here at the high school for the last 2 years - they return to the Midwestern U.S. in 2 weeks. They are definitely having mixed feelings but one thing they are definitely looking forward too is the food. The third individual was a girl who has only done one of her 2 years of service. She is living at an even smaller village about an hour out of Donkorkrom doing an Agricultural program of some description. I suspect I'll be meeting up with them again as it is nice to hang out with people whose accents I understand without difficulty.

It is pounding down with rain again but nothing unexpected and it will stop within the hour, it rarely rains for long here and when it finishes I'm going to head home and do some laundry.

Let the Medicine Begin

Before I log off for the night I thought I should let you know that I've also started my 'medical elective' part of things. I need to go soon but will give you a taste. I arrived at 8:00 and we began with ward rounds - things are very relaxed and nothing like Canada but I'm learning heaps. To give you an idea of things that I've seen I will list them. On the first day I saw (with the doctor - I'm basically shadowing at the moment, participating in some of the history taking):
- Malaria, almost everyone has malaria
- Diabetes (multiple people with diabetic ulcers, diabetic foot, amputations)
- A woman with 7 perforations of the terminal ileum due to Typhoid (enteric) fever
- A family with schistosomiasis
- Amoebic Dysentery
- A necrotizing snake bite - the doctore debrided and area about 15cm square on the back of this boys hand.
- Multiple cases of septic arthritis
- Hypertension
- Saw a woman who was expecting (that had malaria)
- Several cases of ring worm (tinea capitis for the medical nerds out there)
- The doctor drained an abscess of several mililitres of purulent green pus and blood in the arm of a 2 year old.
- Saw a woman who hasn't been taking her AIDS medications properly
- A woman and child with SEVERE burns that are now healing and the dressings were being changed.

Today we did round and three minor surgeries and saw:
- Malaria like you wouldn't believe (kids have febrile convulsions because of the malaria sometimes)
- Conjunctival haemorrhage due to excessive coughing.
- A girl wil full sickle trait (homozygous) with a sickling crisis
- An infant with an infected cord
- Another necrotizing snake bite

Then for the surgeries - the doctor repaired a small epigastric hernia, did one side of a bilateral inguinal hernia, and removed a 1cm sessamoid bone from the medial side of the proximal phalanx of the middle digit - all in a days work.

Then we went for lunch and watched a football (soccer game). Speaking of soccer - the score is still 0-0 but this is perhaps one of the more significant cultural events while I'm here and I don't want to miss it. I hope all is well in your respective corners and will write more as time allows.

The Adventure Continues - The Trip to Donkorkrom

Wednesday at 8:30AM I began my trip to the middle of nowhere Ghana - also known as Donkorkrom. In fact it is in the middle of a large fertile (but uncultivated) plain called the Afram Plains. This region is covered in jungle/bush, is sparsely populated and poorly developed. Accra is, I suspect simliar to any large urban centre in a developing country - a noisy, busy, relatively western hodge-podge of affluence and poverty, deelopment and subsitence, construction and abandoned construction, old and new. The Afram Plains is most definitely a different picture.

Sefa the elective coordinator met me and we took a taxi to the bus station wher we caught a minibus to Nkawkaw. Minibusses (full sized vans) were not desigend for the 6'5" tall male or the 40+" wide female - suffice to say I have spent 3 hours traveling in greater comfort at previous times in my life. They are doing some major road works on the road but instead of making a proper/effective detour, traffic just plows through on the roughest path of least resistance. The drivers avoid as many potholes as possible both for their passengers and undercarriages. The enet effect of this ends up being a van packed full of people careening down a dirt path like a drunken camel.

In the interest of time our driver decided to by-pass the detour, construction, traffic and roads in general. We meandered around what could be called back alleys (if you are being particularly generous), through yards, over streams, through mud holes, etc and we only bottomed out 7 or 8 times. Eventually we reached more or less continuous 'highway' and made our way towards Nkawkaw. The land as we got closer was increasingly rugged with massive outcrops of rock proturding from the verdant jungle.

At Nkawkaw I got on a 'coach' (more like a city bus) and we headed for Donkorkrom. The second leg of my journey began with gorgeous scenery as we climed up a serios of wicked switchbacks surrounded by jungle on both sides except of the occasional break when we could see out. After we reached the top of the Kwahu escarpment we careened up and down rolling hills and through several villages. On this bus we were quite cozy as well. About the length and wideth of a standard Greyhound bus, this bus had 70 passengers seated adn some standing. The seats provided about 18 inches of width per backside and lateral expansion was curtailed by a solid bar at the aisle. My seat mate was a lovely lady who was an orthodontist's dream and spoke no English. Unlike Magalena Haggalina both of this lady's hips had decided to come on this trip. Thus, with her prominent poisterio and my not insignificant rear were were well and truly wedged into our 36 inches. I also pondered another measurement that the bus planners on multiple continents have clearly disregarded the 'kneetock' or 'femass' or 'femum' or 'kneebottom' were a few proposals I came up with. In essence, the distance between the end of the femur/knee and the back when one is seated. Ah, the joys of being tall.

We arrived at the ferry port of Adowso on Lake Volta and were most delighted to disembark. After a Coke I boarded the ferry to cross the lake. It was a magnificant afternoon - roasting hot, clear, and a light reeze off the lake. From the number of floats it appears that fishing is a significant industry on Lake Volta (I've since enjoyed some of the aforementioned fish). After the crossing (about 30min) we rewedged ourselves onto the bus for the 3rd and final leg of the journey to Donkorkrom.

I have a message for all the readers of the children's story "Go Dogs Go" - in the book, if my memory serves me correctly the dogs relax in a marvelous tree with a long trunk and then a relatively full but flat crown. Well, today I saw those trees growing wild. Not in the fertil plains of an illustrators imagination but in the fertile soil of the Kwahu escarpment. I must admit I was delighted inside by the variety of flora I've observed on my travels. The uniqe plants reinforce again the fact that I'm in Africa - that and the fact I haven't seen another white face since I said goodbye to Leah.

I started the third leg of my journey feeling quite hopeful as the road seemed very good. However, we soon got to a more rural "National Geographic" style Africa - mud huts, as well as goats, chickens, and children all providing a significant hazard on the road. I had significant difficulty deciding if there were more road than pot holes or more pot holes than road. The asphalt and pot holes eventually turned into dirt and pot holes. I have heard that the roads become insane in the rainy season and I believe it!

About 6pm we arrived in Donkorkrom. After the mud huts of the villages along the road I was feelign a bit sceptical. However, it was reassuring to find a quiet provincial administrative centre with electricity, and buildings not made out of mud (although there are certainly a significant number of those as well). I found my lodgings which are more than adeuate and got settled in. Then I wandered down to hospital (a 10 minute walk) and checked things out. After buying some waer I returned to the guest house and got ready for bed. I supped on some trail mix, bananas, and candy and called it a night - I had made it to Donkorkrom.

Hello from Donkorkrom

Good Evening from the depths of Ghana...my apologies for the long silence but this is the first time I've had internet access since I arrived. I have been keeping a journal so thought I'd just use that as my blog post with a few deletions. It will make for a long post but I'll arrange it in a couple sections for your ease of reading. Before I start, I'm writing this in the middle of a tropical thunderstorm, the rain is absolutely pouring down and I can hardly hear over anything over the sound of the rain on the corrugated tin roof. However, it makes it gloriously cool. I'll have to update you on my day today at a later point if I don't get time tonight as I'm going back to the hospital in about an hour.

Entry 1: 28 June
This finds me under the awning at the Oyortey's home in the suburb of Dansoman, Accra. Leah, Esther and myself have just finished laundry. I only had a bit to do but Leah had left hers and had 2.5 'loads' to do. Laundry here is a bit different...several 5 gallon tubs and ajar of washing poweder and of course some good old fashioned muscle power. I suspect I will be doing all my laundry like this for the next 6 weeks. It certainly will make me appreciate the amenities of home.

So back to the beginning. I left home about 5:3Oam on Saturday and picked up Glenda who dropped me off at the airport. I flew via Denver and Washington DC. the flights were uneventful. I had the window seat between Denver and Dulls which was not a good thing. The guy in the middle seat was my height and probably weighed more than 3oolbs...suffice to say, we were certainly cozy. After a 4 hour layover in DC I boarded the plane for Africa, Ghana to be precise. It was a 1o hour flight and I was glad I'd broken down and paid the extra for extra leg room. After my early start combined with a week of little sleep I was able to sleep some on the plane which was fortunate. However, as the map showed us getting close to Africa I found it difficult to sleep.

I'd like all of my readers out there to do two favours for me: firstly if you read my post just say hi in the comments section at the bottom to let me know how you are, secondly, I'd like everyone to make a comment with the first three things they think of when you hear the word Africa.

I hope reading this won't spoil the thought exercise for you but perhaps the first 3 for me were black, exotic, poor...and of course the place where I am for my elective! I found it a very interesting exercise when I consider the size of Africa and the number of people who live here, hundreds of tribes, peoples, cities and so forth. Yet, in my mind and I suspect the minds of others it is difficult not to just clump Africa into a bit 'away' place in our minds.

Kotoka International Airport is where we landed in Accra. It was very relaxed and quite small. I collected my bags, changed some money and wet out to meet Leah and Philip who were waiting for me. We flagged down a taxi (I believe the driver was a rally car driver in a past life] and we made our way to Dansoman where the Oyortey's live. Lunch of white rice and fish in a spicey red sauce was being served as we arrived. The cook had kindly made a little 'less spicy' port for us soft Canadians. After lunch it was time for a catch up with Leah and a much needed siesta. The workers Florence and Lorpu had a gospel meeting at the house at 7pm so it was nice to get in on that.

Entry 2: 3o June, 2o1o
I'm writing this post in Donkorkrom but I'll take you back to where I left off.

Monday morning Leah and I went on an adventure by ourselves. Leah has been around enough that they were comfortable with her being my tour guide. Philip had school so it was just the two 'obrunis' (white people] out on their own.*Sorry about the square brackets and lack of hyphens, neither of those keys work on this keyboard* We set off by taxi to the sister's bach where we had a drink and chat. Then Lorpu saw us on our way.

A word on motorized conveyance in the Greater Accra area. There is no word to describe the chaos of traffic and vehicles in the developing world. To begin with there is no visible enforcement of any law if the law even exists in the first place. The result is Mercedes minibuses circa 198o pouring out clouds of smoke overtaking a little Kia car that should have hit the junk yard long ago as its door is held on by twine and rust and its exhaust pipe is dragging. Close on the tail of the minibus is a new model something; Hilux, Ranger, Land Rover, Audi with the windows down because one wouldn't want to use the air conditioning. You might get cold. The trotros, essentially hop on, hop off vans are even more shocking. Doors are optional. Yesterday one of our trotros had no ignition, just two wires sticking out of the dash. Also considered optional in the jampacked pot hole filled streets is power steering...fun and games ~ no wonder motor vehicle collisions are the largest source of trauma in the developing world by a large margin.

After the workers we wandered down the street until we eventually came to the trotro stop. On our way we had a 'bo froot' a deep fried ball of dough quite like Indian fry bread without the honey butter or icing sugar. It is a good snack and seems to be available everywhere. We got off our trotro at Circle, a large market around a larege roundabout. After browsing through the stalls we walked along hundreds of stalls of cell phones until we met up with Philip and did a bit of shopping. All of the gutters/sewers here are open so it makes for a rather pungent walk down the street. We returned home after a stop to get some FunIce. FunIce is quite simply fabulous icecream in a bag. It is very refreshing and very cheap which is a great combination.

Hello again - last night when I was attempting to get this posted there was an electrical storm which killed the power and the internet. Thus, I was unable to get it posted so I'll carry on now. Being on the internet right now is near to heresy in this country as Ghana plays Uruguay in the World Cup tonight in 15 minutes. It is a crucial match and if Ghana wins it is going to be truly EPIC! Football or soccer is king in this country. I'm pretty sure that I'll go and watch some of the game, along with the 22 million Ghanians all over the world.

Thursday morning after brekfastwe headed into Accra proper via trotro. At this point in my Ghana career I've had three different kinds of porridge - roasted corn, western (oats + another seed, sort of like Sunny Boy) and sour corn (dry corn that has been soaked for 3 days in water. I've got to admit I've found the corn based porridge a bit rough going. The consistency is that of gruel, it is even runnier than cream of wheat and the flavour is nothing to write home about. I've been glad for the bread and processed cheese which definitely slides down a bit better.

Downtown Accra was buysand hot. We went through the second hand market, walked past a multitude of vendors selling most things and even w alked through past the various hardware stalls selling everything from screws to rebar to door knobs. The city was a bit of sensory overload - everyone was smacking their lips in a kissing noise to get our attention, grabbing at your arm - not to mention the smells and other sounds. At any rate it was hot, loud, smelly, colourful, vibrant and most definitely not Canadian. I've since heard that Accra isn't 'true' Africa - however when I got to Kumasi in a couple of weeks I'll be getting a better taste of the 'real thing'. On our way home we stopped for a western snack, Ghana style - we had pizza. It was similar to Canadian pizza and was a nice break in the afternoon.

Tuesday I met up with Sefa, the man who coordinated my elective and made plans to meet up with him on Wednesday morning so that I could head up to Donkorkrom which I'll tell you all about in the next post.

Let the Adventure Begin

I'm typing this post with hands that smell like dead people. I've washed my hands 5 times now but the scent of formalin (the preservative) still permeates my skin. Alas, the joys of medical school.

The last few weeks have flown by, the longest day of the year is past, and June is almost over. This means two things. First of all it means that I have my Course 4 final examination on Thursday (peripatetic - 20%) and Friday (MCQ - 80%). Course 4 has been all about the kidneys and hormones. We've covered some really common (and a bit boring) things like Type 2 Diabetes -exercise, lose weight, control your diet, stop smoking and your risks of Type 2 Diabetes go down - it is a very good thing if your risk of T2D is down because T2D is bad (retinopathy, nephropathy, neuropathy, hypertension, CAD, etc). Then we also have other exciting topics like obesity, osteoporosis, vitamin D deficiency, thyroid disorders, and so forth. Some of our professors have used the analogy that most medicine is like horses - common, everywhere, unsurprising - but every so often you run into a zebra which is rare and presents you with something new and interesting. At this level of medicine we are learning all about the 'horses' although the 'zebras' (rare diseases) seem a bit more interesting and you certainly haveto be aware of.

However, the day when we get to focus on zebras will come soon enough, if we specialize. So for now, we are learning the bread and butter of family medicine.

Endocrinology has been pretty interesting because it has some fabulous 'zebra' disorders, as well as some pretty neat 'horse' disorders. An example is acromegaly - this is a disorder where you have too much growth hormone. Growth Hormone is what is responsible for making you grow as a child and teenager. However, when you get too much Growth Hormone (GH) it is bad, especially in an adult. It tells your bones to grow, but because your growth plates are fused when you end puberty your long bones (legs especially) can't grow any longer. The result is that you get bone growth in places like your face, hands, and feet. You also get some soft tissue changes - your tongue becomes massive, your lips get big, your neck gets larger, and you sweat a lot with a characteristically bad odour. This is a disorder that the trained eye (aka an Endocrinologist - a hormone doctor) can spot walking down the street, on the train, in an audience - so disorders like that are certainly interesting to learn about.

At present though the horses and zebras have been galloping through my eyes and into my brain (hopefully) at a great speed because I'm in full on cramming mode. I seem to function well this way, leaving a lot of my studying until just before the exam. It makes for a fairly stressful week or so prior to the exam but my life is quite relaxed other than that...and it has worked so far. Tonight I spent several hours in the anatomy lab with some of my friends going through the cadavers to learn the anatomy relevant to the renal and endocrine systems - thus the smelly hands. We also looked at pathology specimens - these are essentially body parts in jars which exhibit a certain disease (pathology). For example, tonight we looked at five different types of kidney tumours, prostate cancer, enlarged prostates, bladder stones, and kidneys of someone with severe hypertension (high blood pressure) so my mind is still full of nerves, vessels, and masses.

I like medicine and I'm enjoying medical school - at least that is what I tell myself after a full day of studying. Several weekends ago I spent a day in High River learning some new skills and reinforcing some other new skills. The day was designed to encourage us to consider 'rural' medicine as a career option and it was pretty exciting. The first reason was that I successfully inserted an IV for the first time. For some people (such as nurses) this is a bit of a non-event and they do it all the time, in fact, a lot of practicing physicians have very few reasons to put an IV in. However, for me as a student it is one of those things that makes me feel a bit more like I'm on the way to becoming a 'real' doctor. The other exciting thing was the three hour long sessions about labour and delivery. I don't think I want to be an obstetrician (care for pregnant women/deliver babies) but it was pretty interesting to learn about. I'm excited to deliver a baby (hopefully I'm still excited after it happens), and perhaps I'll get to watch/assist in a delivery in Ghana.

Speaking of Ghana - that is the second impending event. I depart for Accra, Ghana on June 26th, 2010 at 8:15am - that is this coming Saturday! I fly via the US traveling from Calgary to Denver, then Washington Dulles, and then on to Accra. I'll arrive about 12:30pm on Sunday and Leah Campbell, one of my friends from Calgary who is currently visiting Ghana will be picking me up at the airport. She has arranged for me to stay near or with one of the Ghanaian families that she knows for my first night which will be fabulous. On Monday I plan to meet up with the Elective Coordinator Sefa and likely head out to Donkorkrom.

This past week I spoke with the student from Class above me who went to the same hospital last year. He was able to fill me in on some of the details of my elective which were quite lacking prior to our conversation. There are still a lot of unknowns but it is going to be a grand adventure! Donkorkrom is the administrative centre for the Afram Plains District of Ghana which is one of the poorer regions in the country. To get to Donkorkrom will be about a 7 hour adventure in itself - or so I understand. First I'll be catching a bus from Accra to a smaller centre, then from there a tro-tro (minibus/van/truck) kind of transport to a ferry crossing the western arm of Lake Volta. After the ferry crossing it is about a 2 hour tro-tro trip on dirt/gravel roads. The student who went last year said that they got stuck during this segment of the trip and they all had to get out and push to get the tro-tro out of the pothole as it is rainy in Ghana at this time of year. I have no idea what my experience will be but I'm going to try to keep you updated

Once I arrive in Donkorkrom I'll likely be staying at a guest house a 10 minute walk from the hospital itself. It doesn't sound like much of a town from the guidebook and what the other student said but there are supposedly two internet cafes in Donkorkrom so I'll be able to update you on the exciting events of my elective.

The hospital has 74 beds and runs a busy outpatient clinic. On staff are two doctors, some nurses, some health care assistants, and various others. This means that the doctors are very busy but the fellow who went last year said they are excellent teachers which I'm quite excited for. If the style of elective is the same I'll likely spend mornings and some afternoons in the outpatient clinic dealing with patients with any number of complaints but malaria and typhoid are very common. In the other afternoons I'm hoping to assist with surgeries, work in the emergency room (casualty), or the maternity ward. However, I'll just have to wait and see how it goes.

Because I'm time restricted and only have six weeks (of which I'm supposed to work approximately 6) I'm hoping to travel on the weekends. If everything goes well I'll get to a national park where you can see elephants, perhaps some hippos, and other African wild life. I'm sure that I'll also enjoy the African life right in town as well.

I know that the next six weeks are going to be an incredible experience - I'm going to gain new perspective on life, medicine, and the world, but for now I need to catch some zzzz's so that I can pass my Course 4 exam and not have to rewrite it in February.

Da Vinci and the Countdown

Well, I spent my first time in the OR today - we watched a radical prostatectomy and not only that, I leave for Ghana in 19 days - WOW time flies.

This morning we had our Urology Clinical Correlation - due to uncertainty regarding traffic we arrived at the hospital significantly sooner than necessary. After changing into scrubs, booties, caps, and masks we could potentially have looked like we knew what we were doing if it weren't for the somewhat aimless wandering and the periodic looks of fear anointing our visages. However after waiting some time our preceptor arrived and then we walked with him to his office doing a little prostatectomy quiz. Calgary has a funky robotic platform called a Da Vinci for performing laparoscopic prostatectomies. It is actually pretty cool. It is a big machine with articulating arms that are hooked up to various instruments that have been inserted into the patient. Then the surgeon sits at a console and controls four different instruments using his hands and feet. It is sort of like a combination of playing the organ and crocheting - at least from what it looked like. We clustered around the various monitors which showed what the surgeon could see. We were seeing it in 2D on flat screens. However, one cool feature of this machine is that the surgeon sees everything in 3D which is a boon for precise manipulation. Everything was hugely magnified so it was amazing once we got oriented (we finally saw the pubic symphysis which allowed us to get our bearings a litte) and we could see the various organs, vessels, and nerves that had to be dissected through or around in order to remove the prostate. Things didn't go especially well this morning in terms of speed from what we were expecting but after 3.5 hours the prostate was gone, the bladder had be anastamosed to the urethra (and tested to make sure it held water) and we were on our way. It didn't make me want to be a urologist and do lap prostatectomies several days a week. It was cool to watch for a while and I recognized the skill involved but it didn't really pique my interest but it was pretty amazing to watch the surgeon manipulate the needle drivers and suture to sew up the bladder.

Today is the 7th of June. I leave for Ghana on June 26th which is 19 days by my calculation - this is not very long at all! Between now and then we write our Renal/Endocrine exam. According to rumours floating around the class this is one of the most difficult systems exams that we will have...so it seems like the wise thing to do would be to initiate serious study effective immediately. However, we'll see how it goes.

This week I also have pre-elective departure briefings. We are going to have several sessions about ethics and different issues that will face students going overseas for their elective. In the past month I have also been vaccinated against a whole range of diseases including Yellow Fever, meningitis, Typhoid, and so on. I have a ticket, and I'm waiting for my visa so things are certainly getting exciting for my next adventure.

Considering the predicted difficulty of the exam I ought to pay attention. The lectures we've had recently are mainly on endocrine topics and have been very interesting so paying attention isn't actually that difficult...so now its time to learn more about the action sites of Testosterone.

Glomerular Proteinuria

It has been a long time since my last post but considering I'm struggling to pay attention to our lecture on protein in urine (one cause of which is glomerular proteinuria) I thought I would share some more of my med school adventure.

I successfully survived Course 3 - Cardiovascular and Respirology and finished my first year of medical school. We completed our exams in March and then had a two week holiday which was very much enjoyed but a bit on the short side. When we started back in April we began Course 4 which is Renal (kidneys) and Endocrine (hormones). Since then we have been ploughing through the material. We've talked about hypertension, diabetes, low sodium, high sodium, and the list goes on. Our knowledge base is growing significantly and it is less than a year (only 9.5 months) until we begin our clerkship.

Because we are in a three year program here at UofC we technically finished our first year in March. This is actually quite comparable to an academic year at a normal university. However, when things changed was when we started back on the 5th of April to begin our second year. Our 'second' year will be 11 months long (less Christmas vacation). Fortunately we have six weeks of elective during the summer which will break up the monotony of 11 months of lecture.

Speaking of summer electives - I'M GOING TO GHANA. The 'A' on the map above is where I'm headed. I have most of my shots, I have a ticket, and I'm in the process of getting a visa. I depart June 26 and will be spending six weeks at Donkorkrom Presbyterian hospital. This is a 74 bed hospital in a poor and relatively remote region of Ghana and I'm very excited. I don't know precisely what I'll be doing. I'm hoping to rotate through the various departments at the hospital getting heaps of awesome experiences. I am also hoping to go to some community clinics or do health promotions work if it is feasible. However, there will definitely be more on this later. For now what I know is that I will be staying on site in a guest house, I'm the only student going from UofC, and it is going to be an adventure. I'm anticipating learning a lot about malaria and other tropical diseases and hopefully some of my clinical skills will be a lot better when I get back compared to when I left.

However, I need to get learning about the kidneys so I'll be less useless when I leave for Ghana in 38 days.

Hearts, Lungs, and Summer

Our Cardiovascular and Respirology course has been proceeding at great speed with massive volumes of information being dumped into our brains. In this course, due to the massive amount of material we have a midterm exam that actually counts. So, next Monday we have an exam for Healthy Populations. HPOP as it is known is generally disliked by the vast majority of students and is probably contains the most skipped lectures in Medical School. The topics covered are basic medical statistics (which have been most unpleasantly reminiscent of my despised days in undergraduate Statistics from 8:30-10:00 Tuesday and Thursday for two semesters with Dr. Wilson Lu - it made a big impression), determinants of health (education, childhood health, gender, biological endowment, etc), and epidemiology. The topics might sound interesting but the lecturers managed to make most of the lectures exceptionally boring. Since the holidays we have been focusing on more at specific populations with various health risks. These have included patient presentations from individuals who are homeless, transgendered, etc. and have been quite interesting. However, the final examination in this course is coming up so this week should contain a significant amount of study...but we will see how it goes.

The following week we have our Course III midterm exam so there is a lot of material to try and synthesize for that as well. We have covered Acute Coronary Syndrome (heart attacks), COPD (what you get if you smoke), asthma, Pulmonary Embolism, Diffuse Interstitial Lung Disease (i.e. pneumonia and a couple other things). So when you take the anatomy, physiology, pathophysiology, pharmacology, clinical presentations, physical exam, radiology, and treatments associated with all those things there is a fair bit to cover. However, we'll get there...it might just require a few late nights - or some serious and dedicated planning and pre-night before the test studying.

The other event of note that has been occurring is preparation for our Summer Electives. This year UofC has changed the schedule a little bit compared to last years. In previous years students had a period of 8 weeks in the summer during which they had to do 6 weeks of clinical elective and then had 2 weeks of holidays. This year the Administration has decided we need a break in March so we will have a 2 week Spring Break at the end of March. Then we will have 6 weeks in the summer during which we have to complete 6 weeks of clinical elective. UofC is a strong supporter of doing International Electives during this period of time so I'm quite excited. I'm in the process of setting an international elective which means I'm going to spend at least six weeks overseas this summer. After some careful consideration of a number of different issues I have decided to try and set up an elective in Ghana. Ghana is a relatively stable country in West Africa. Its biggest advantage is that English is the official language of the country. While tribal languages are spoken many people also speak English which will facilitate my learning experience. So, I'm sort of excited. Things are still quite early in the planning stage but if all goes as planned that is where I'll be this summer for six weeks. This is definitely a topic that will be getting more blog space but thought I'd update you on this bit of excitement.

It is time to go and book a session for our Physical Exam practice exam which is coming up next week. We are becoming more adept at taking blood pressures, examining the abdomen, checking peripheral pulses, and listening to heart sounds. Now the time has come to show an examiner that we are getting better at it.

Breaking the Silence

So it has been well over a fortnight since I last made a foray into the blogosphere to comment on the status of my life and studies.

I completed and passed (although with a less than comfortable cushion) Course Two prior to the Christmas Holidays. Having completed 1.5 weeks of Course Three I'm going to go out on a limb and say that MSK/Derm (Course Two) was my least favorite course. I found the organization lacking, the material not especially interesting (especially Rheumatology), and the course as a whole was rushed. Dermatology was quite interesting but I wouldn't have minded spending another week on Dermatology to cement some of the topics in my brain.

I was very ready for and enjoyed a restful and relaxing Christmas break with some of it spent in Southern Alberta and some of it spent in Northern Alberta. It was classic Canadian Christmas weather - decent amounts of snow and not too cold (other than the -36C at High Prairie) which made outside activities very enjoyable. Cross country skiing, tobogganing, snow mobiling, and sitting in front of crackling fires with large amounts of chocolate and other Christmas goodies were very much appreciated.

I was not ready to return to the information infusion that is Med School but I'm slowly getting into the swing of things again. Course Three is an eleven week course which is almost as large as Course 1 (12 weeks). The topics we are covering are the cardiovascular system (heart and blood vessels) and respirology (all about the lungs). Thus, I have christened it 'Beating and Breathing' to follow Blood and Guts, Skin and Bones, and now Beating and Breathing. We have begun with cardiology although there are components of respirology integrated as the two disciplines are very closely integrated - neither the heart nor lungs can fulfill their function without the other so it is a very logical integration. Tomorrow we will be heading to the hospital for a couple hours for our first cardiac clinical correlation session. This should be quite exciting because we may have another opportunity to use our stethoscopes for their original purpose - to listen to heart sounds. Beating and Breathing is one of the most crucial units simply because so many things that go wrong with its components cause death very rapidly. Thus, physicians in virtually any specialty need to be familiar with the various pathologies that can occur. Heart disease is still the number one killer in Canada so it is something that we need to learn about as future physicians.

One of the most complicated tasks we are coming up against so far is the interpretation of ECGs. An ECG aka EKG aka electrocardiogram is a recording of the electrical activity of the heart which gives the trained interpreter very large amounts of information...however, at this point in time I'm having a difficult time telling what a normal ECG looks like; it still primarily resembles a bunch of squiggles to me.

A while back a request was made for me to outline a 'normal' day at med school so I thought I'd give you an idea what a day at the UofC looks like. To give a bit of background first; med school for us here at UofC doesn't involve much 'assigned' work. We don't have worksheets, essays, quizzes, etc to complete for the most part. Our primary 'assignment' is to assimilate and integrate massive volumes of material that we will need to recall at some point in the future. Thus, we have scheduled 'Independent Study Time' for some of us this translates into 'time to deal with the necessities of life' i.e. catching up on sleep, getting groceries, and occasionally some studying. Thus, we usually have one morning and one or two afternoons a week that are not scheduled with lectures. Often we do Physical Exam sessions or Clinical Correlation sessions in this time. However, when nothing is scheduled they are ours to use as we please.

Monday

8:30-12:30 - Healthy Populations - 2, 3, or 4 lectures about topics in epidemiology, social determinants of health, understanding underserved populations, etc.

- This time block is sometimes used for other kinds of lectures such as course related material (Breathing and Beating) or other longitudinal courses such as Global Health.

1:30-3:30 - Main course material lectures - anatomy, physiology, pathology, treatments, disease processes, patient presentations, etc.

3:30 -5:30 - Case Studies

- We have case studies at various times but they are often in this time slot. Case Studies are almost always 2 hours long.

Friday

8:30- 12:30 - Main course material lectures - surgery, radiology, etc

- Anatomy small groups (time in the labs with cadavers, etc) are also slotted in at various times like this.

12:30 - 5:30 - Independent study time.

* This is just a sample but gives an idea of how our day goes.

To conclude this large post I thought I'd discuss History of Medicine. I choose in the late summer to sign up for an elective course called History of Medicine. For medical students this is an elective course that falls outside of regular lecture times (Monday 12:30-1:30, and Thursday 5:30-7:30). I'm not certain if I would sign up for this course if I were doing my first year again but there have been some interesting lectures. This past Monday I presented a 50 minute talk regarding Artistic Responses to the Black Death. I did some research and then prepared a presentation. Combined with a presentation I completed in December it fulfilled my requirements for the course and if all goes as planned there will be a letter in my official file that I completed this elective course and fulfilled the requirements. This information will be included in the file that is sent to Residency Directors when I'm applying for Residency and hopefully be a useful component in allowing me to settle and do my residency at my school of choice.

The time has come for me to return to the world of valves, bronchi, septa, percutaneous coronary interventions, ischemic cascades, and flash oedema, but hopefully my future posts will be more regular than they have been in the last month and a half.