GHANA PROJECT GROUP

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.

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.

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.

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.

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

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

...flying in to accra from amsterdam, the airport lounge was absolutely
packed with returning ghanaians excitedly chattering in twi and lugging all
shapes and sizes of bags and bundles. I tried to edge into a seat and was
immediately assaulted with strong BO! A thing that I had almost forgotten to
prepare myself and something that no guidebook tells you about. Tired and
alone, and feeling a bit nauseated, I was almost feeling sorry for myself,

As I prepare to leave I reflect on my experiences here. Ghana is a very safe country, filled with people who are surprisingly helpful and kind. When i think of the people in Ghana I think of smiles. Smiles of friends meeting, smiles of children yelling "Obroni", and smiles in farewell. Farewell, Ghana.

Adrian and I went out with a few of the folks from the department as a farewell from Adrian to the staff of the department

Here are a few photos from the evening the first is of Samuel, Gilbert, Olivia (Emmanuel's wife) and Emmanuel. Samuel and Emmanuel are histotechnologists, and if you volunteer here they will soon become your "go-to" men. Gilbert is the person who types all of the reports, he is also very helpful.

The cases that we have been seeing here are really very interesting. Many of them are from children. Just this morning we signed out an osteosarcoma, a sinonasal undifferentiated carcinoma and a burkit lymphoma.

This is a picture of Dr. Issac Siaw, the local pathology resident, and I at the scope.

This coastal city is home to Elmira Castle which was the largest slave castle on the continent. It is 526 years old. Built by the Portuguese when they discovered gold in Elmina (the name comes from El mina "the mine") it was subsequently owned by the Dutch and then the British. Ghana has been independent now for 50 years and has owned it since that time

The town of Elmina is busy and full of life.

This canopy walk was built by 6 Ghaneans in conjunction with 2 Canadians. I have to admit I was just a bit scared but it was really very stable.

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.

I never thought i would hear the words "Is anyone here a doctor?" in real life.

Last night i did. A man sitting near me on the plane wasn't breathing, and his wife was calling out for help. 10 second later i was at his side. He had a pulse but he wouldn't wake up for us. Then he seized, the type of seizure that you see when someone's blood sugar is too low. I asked his wife and he was a diabetic on Metformin. We were surrounded by flight attendants and people shouting do CPR. I was shaking like a leaf. After he seized he was more alert but not much. We put some sugar in his cheek and he was able to drink some orange juice. by the time we found a glucometer his sugar was 167. His pulse came back strong, and his bp was stable. we checked him again in an hour and he was holding at 154, which thanks to Mitch Scott i know is within the standard error for the portable glucose meters. Still even though he was better and seemingly stable i was worried that the long acting Metformin was going to cause him to bottom out again. The next morning he was as if nothing had happened. What a relief.

If you know me then you know what an incredible klutz i can be. You have seen my "white" coat with coffee stains down the front.
if you knew me in medical school then you remember how I would come to class covered in coffee having spilled it all over myself in the car on the way in. And you will also remember that I didn't have a single syllabus that made it even a week without getting drenched in some hot drink.

You should see my room! Its a disaster, but by the end of the day I'll be packed and ready to leave for Accra in the morning.

Don't forget your toothbrush!