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.