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Last summer I was asked to substitute for a Peruvian surgical pathologist, Dr. Arturo Heredia, at a public hospital in Peru in a city named Pucallpa. Dr. Heredia was doing 6 months in a surgical pathology sabbatical in Los Angeles, CA, courtesy of the LA Society of Pathologists. Pucallpa is located in the middle of the Peruvian Amazon jungle. It is a city of 200,000 but services almost 600,000 people, with 70% of its citizens living below the poverty level.

The children here all want their picture taken. The adults not so much. Not at all really. Still the kids will holler "hello" at you and give you a huge smile hoping for a spot in your digital library. These boys were playing in the water of the marina.

We were invited by some Utah residents here (emergency medicine and anesthesia) to join them on a weeked trip down to the coast and, of course, could not refuse the offer. The eight of us piled into a van with a driver provided by the hospital and after a few bumps and many accelerations we were there. Highlights of our weekend in Cape Coast included the following: a guided tour of the Cape Coast castle (with even more information provided by our excellent driver/tour guide, Sammy), a rainforest canopy walk in Kakum National Park (with a suspension system loose enough to make you want to hold on but secure enough to feel safe), crocodile watching (and petting by one member of our group) at Hans Cottage Botel, some walks along the beach, a quick dip in the Coconut Grove Beach Resort swimming pool, microbiology studying (by Justin), ice cream eating (this was only a highlight for me, a real addict), and lastly some elegant palm wine, finely tasted and carefully selected for us by Sammy. We arrived back in Kumasi by Sunday afternoon and then headed to the nice, new stadium to attend a soccer game. Although our cash flow was a little limited by this point, we were all able to afford VIP tickets for 5 cedis (about US $3.50). The major perk of being a VIP is a shaded seat. It is hot here! We witnessed a superb goal made by a bicycle kick backwards into the goal, ate some stadium Ghanaian donuts (like beignets without powdered sugar) and cheered Kumasi on to victory. We topped of the weekend with a delicious Indian feast at Moti Mahal. We are now dreaming up our adventures for next weekend.

Last summer I was asked to substitute for a Peruvian surgical pathologist, Dr. Arturo Heredia, at a public hospital in Peru in a city named Pucallpa. Dr. Heredia was doing 6 months in a surgical pathology sabbatical in Los Angeles, CA, courtesy of the LA Society of Pathologists. Pucallpa is located in the middle of the Peruvian Amazon jungle. It is a city of 200,000 but services almost 600,000 people, with 70% of its citizens living below the poverty level.

We are wrapping things up here but still have a lot to do. The third week had some ups and downs but overall was quite good. Some technical issues delayed some slides earlier in the week but we were getting plenty of cases by the end of the week. On Friday I finally broke the cycle of Angela getting all the slides and got numerous trays of slides. Some interesting cases too, including an alveolar rhabdomyosarcoma (i think).

End of Week 2 and Week 3 update as follows...
We traveled to Lake Bosumtwi last weekend for a little rest and relaxation. As a native Minnesotan, I appreciated the palm trees on the lake shore and slighty mountainous surrounding terrain, aesthetic features that I am not accustomed to in the "land of 10,000". We enjoyed watching the fisherman paddle their paduas (boats that may be likened to floating logs or plywood) and check their fishing nets. Swimming was an option although we all still had the schistosomiasis case in the back of our minds so we did not partake.

End of Week 2 and Week 3 update as follows...
We traveled to Lake Bosumtwi last weekend for a little rest and relaxation. As a native Minnesotan, I appreciated the palm trees on the lake shore and slighty mountainous surrounding terrain, aesthetic features that I am not accustomed to in the "land of 10,000". We enjoyed watching the fisherman paddle their paduas (boats that may be likened to floating logs or plywood) and check their fishing nets. Swimming was an option although we all still had the schistosomiasis case in the back of our minds so we did not partake.

After the great weekend we got right back into signing out cases on Tuesday. Well sort of...Angela and I rotate signing out cases with Dr. Peterson on one day and supervising and helping to improve the grossing (or as the Ghanaians call it, 'cut-ups'). on the next day. Angela always seems to get the sign-out days where there are lots of cases while I get the days where there is some mysterious delay in making slides.

The remainder of the first week produced numerous adventures. Fortunately, new glass slides arrived on Tuesday so we were back in business and signing out 30 cases a day for the rest of the week. Highlights included a mycetoma (Madura foot), some accral-type melanomas, and a nice case of schistosomiasis in the bladder (this produced a yawn by one of the Ghanaian path residents who probably gets shown schisto every month by us wide-eyed volunteer pathologists). The residents were around early in the week to look at cases with us and got some instruction. The Easter holiday, however, disrupted the work week a bit with a generous 4 day weekend. No problem. We took advantage and headed out of town to see the sites (see next entry by Angela). My favorite part of the week, however, was the Tumor Board conference on Tuesday afternoon. The format consists of a resident who presents the patient(s), the patient who is available for examination if necessary, and then a lively discussion amongst the clinicians about the treatment course. These discussions, while never angry, frequently got heated and lively. At one point a number of the clinicians were standing up and shouting their opinions about a patient with an anal/rectal mass complicated by a fistula. Some of the clinicians wanted to radiate the mass first while others wanted to give the patient a colostomy to try and heal the fistula. The conversation then turned to a discussion about the availability of colostomy bags in Ghana (currently available) and the ethics of giving someone a colostomy without being able to guarantee a supply of bags. It was fascinating. Overall, the conference seriously underscored the need for a more comprehensive surgical pathology service at the hospital. In all the cases discussed, none had a definitive pathological diagnosis. For some patients, it was not known if the tumor was a lymphoma, carcinoma or sarcoma. The need for basic but easily available immunohistochemistry was also evident. One male patient presented had an anterior chest wall mass of which 1/2 of the clinicians thought it was a breast cancer invading the chest wall while the other 1/2 thought it was some thoracic/pleural tumor invading the breast. A biopsy of the mass revealed a probable carcinoma with a papillary architecture but a more definitive origin could not be given by H+E alone. It must be extraordinarily difficult for these clinicians to make treatment decisions for patients like this one where the potential for gross over-, under-, or mistreatment is so high,

Hello, to our first introductory blog for the April 2009 volunteers! We all arrived over the course of last week without incident. The hospital was very good about picking us up in Accra and taking us to Kumasi. Dr. Lawrence Peterson and his wife Carol and Dr. Angela Bohlke, a resident from Tulane University, arrived earlier in the week and I arrived on Friday morning. Over the weekend, we got used to our new home which is in a very spacious group of houses on the outskirts of town. So far everything has worked there well with only one short loss of water.

The day started out routine enough. We had a few trays of cases. Some of the cases I remember of hand: Kaposi Sarcoma on the big toe, mixed cellularity Hodgkins, leiomyoma, fibroadenoma, complete mole, invasive ductal carcinoma, unremarkable duodenum, gastric perforation with serositis, and some lesions I have never seen in the United States (17cm sacrococcygeal teratoma from a 5 month old child). After we had finished I headed to the gross room. I asked about the jaw tumor from yesterday and I was told they had placed it in decalcifying solution (Excellent). I opened the container and found it to still be in one piece (Bogus). I went to Isaac’s office (pathology resident) with one of the histotechnologists and suggested that we could improve the histology, fixation, and speed of decalcification if we cut the jaw instead.

One of the advantages of doing an elective overseas is that on your days off there are new unique opportunities available. This weekend Dr Wester and I decided to make the 7 hour trek north to Ghana’s Mole National Park. Joe from the hospital volunteered to be our driver for the weekend and we asked him if he wanted to bring his oldest son Carlos along. Carlos is a teenager and Joe had to ask to be sure (Hey you want to go to a national park with two strange American doctors and your dad?). I’m not sure exactly how Joe phrased it, but Carlos came along. The trip up is five hours on the main north south road. Then two hours on a gravel road that has a large number of surface deficiencies.

When there are no more slides to read I head outside and downstairs to the gross room and histology. The gross room and histology are more closets than rooms. They are decorated with the same light green concrete walls but blue ceilings to make you think you are outside. There is a nice exhaust fan and a fume hood that can be used for grossing. The only grossing station is in the corner under the fan and consists of a sink half covered with a sheet of wood. It’s not fancy, but it works. The last few days have been special as we have a room full of laboratory technical students with us. The students are eager to learn and I think they enjoyed me talking a bit about each specimen we received. There is no dictation system so all gross descriptions are written on the back of the requisition form by the technologist. While I dissected the tissues, I explained some of the pathology, normal anatomy, what sections I took, why I took those sections, and how I would like them embedded. To the right is a picture Isaac in blue with a group of students. When Isaac is using the sink I use the hood and gross “cleaner” specimen on newspaper or a scrap of cardboard. (cardboard for today in image 1)

Sorry, no pictures today. I was spending Tuesday afternoon reviewing cases with the attending (now Dr. Wester) when we were asked if either one of us could do a FNA. The local pathologist said that there were two women who were sent from the hospital to pathology for breast FNA. The two senior pathologists had not done the procedure recently and both deferred to me. I did quite a few needle aspirations as a medical student and a few more in residency. I said I was uncomfortable reviewing the microscopic without assistance as I have not seen many breast FNA slides. Both pathologists said they were comfortable signing out the sample if I would acquire it for them. Since one of the goals of pathology overseas is to set up a functioning cytology service in Kumasi, I agreed.

Sorry, no pictures today. I was spending Tuesday afternoon reviewing cases with the attending (now Dr. Wester) when we were asked if either one of us could do a FNA. The local pathologist said that there were two women who were sent from the hospital to pathology for breast FNA. The two senior pathologists had not done the procedure recently and both deferred to me. I did quite a few needle aspirations as a medical student and a few more in residency. I said I was uncomfortable reviewing the microscopic without assistance as I have not seen many breast FNA slides. Both pathologists said they were comfortable signing out the sample if I would acquire it for them. Since one of the goals of pathology overseas is to set up a functioning cytology service in Kumasi, I agreed.

Work I

I thought many of you would like to see what was behind door #2 at the KATH Department of Pathology. I have put together a small picture tour of the current pathology overseas office. As you can see the first picture is the resident half of the office. It is decorated with a wonderful concrete wall with a lovely shade of green. The department directory is posted in the upper left hand corner and is slightly askew. The desk is constructed from a sturdy wood and does the job well. My two favorite references so far are placed near my scope on the left. Rosai is for images while the Washington Manual of Surgical Pathology is a good source of staging and grading. Pending cases are at the upper left with notes (BONUS DIAGNOSIS: 5 year old, distal colon resection, one end is dilated, no ganglion cells identified, waiting on additional sections from proximal end). The scope does the job, but I do wish I had my nice familiar Olympus.

After a few days at the house it became evident that we needed to go shopping for a few things. I brought a box of pop-tarts for breakfast, and Dr. Frus liked to have toast. The only problem was we didn’t have a toaster. In addition, the AC in the house is mounted in the ceiling and has to be accessed with a remote. I found the remote, but it lacked AAA batteries. We hailed a cab and went on our way to the market. The cab driver told us most “stores” were closed on Sunday, but we might get lucky.

After my first week of pathology I decided to get out and see some of the area around Kumasi. Saturday’s trip was a short 30km (one hour) drive out to Lake Bosumtwi. We packed light, but had all the necessities.

If you forget anything a local Super Mall is available on the way for your shopping convenience.

We arrived at a small lake town and were promply greeted by a man who said he is the local tour guide. He gave a brief history of the lake and town and offered to take us on a boat ride if we wished. (~$1 per minute)

After a good 14 hour ‘nap’ I was met by the driver and we made our way to the hospital. The trip was a few miles and it took 20 minutes (ants again).

I arrived at the old pathology building and found the facility different but strangely familiar. Everyone in the department is extremely friendly and helpful. They showed me around and I soon found myself settled in behind my microscope with my cases. The first office on the left is for the department head (Dr. Quason). The pathology overseas volunteers share the middle office and the end of the hall is an office for the administrative staff. The two doors across the hall are the morgue and the bathroom.

After asking Dr. Green many questions and getting the go ahead from my wife I have finally arrived in Ghana. The trip over from St. Louis was long, but it wasn’t too bad. On the flight over I sat next to a Canadian(French) who has worked in Accra for three years and she helped me out with a few tips. You have to understand that I am a novice traveler. I have only been out of the United States once, and that was to Germany. I made good time thanks to a tailwind and we were going to get into Accra an hour early. When asked what I would do for an hour while waiting for the driver I naively suggested I would get a coffee at the airport and have a seat. My brief Canadian(still French) guide turned to me and said with a blank stare, ‘you have never been to Kotoka Airport.’

....So the tiny plane landed in the dusty little town called Timbuctu...
Nope. that does not sound romantic at all. Timbuctu is a place where one
should make long and hard treks, over dangerous terrains, not a quick
airplane trip. Though, to be truthful, the plane ride was quite difficult to
arrange, expensive, on again off again, unpredictable and long and bumpy.
So, in a way, I did pay my dues...

Like most of you, I too have been watching the Olympic games on TV with my
Ghanaian friends. I noticed a tremendous solidarity amongst all african
nations and recognition of a pan-african, transcontinental identity- an 'us
vs them' mentality - almost like 'we brothers have to band together, the
non africans don't understand our problems and blame us for all things...'
In TV, they will talk about 'africa's' medal count, not individual

...the other day I was explaining to my resident that a lesion made up of
polymorphous population of cells (inflammatory, epithelial, stromal etc) is
usually benign, non neoplastic, whereas a monomorphous monoclonal population
of cells usually means a neoplasia. My resident brightly said, "I get it. A
village market filled with men, women, children, rich, poor, buyers,
sellers--that is safe, and good. But a troop of uniformed soldiers--that is

Disease wise, malaria is THE commonest, with TB being #2. Among parasites,
Oncocerca seems to be the commonest, next to GI worms. HIV-AIDS is
surprisingly low 7%, compared to rest of africa. Amongst cancers, breast
cancer has overtaken cervix in women. In men, aggressive prostate ca seems
the commonest, next being hepatomas due to hep B,C etc. Very surprisingly,
lung cancer is quite rare!. Smoking is not common, in fact I have not seen a