Ding!

On Monday it was time for the two new pathologist volunteers to arrive. The next crew was made up of a resident and attending from Mcgill University in Montreal, Quebec, Canada. When they got to Kumasi I took them to the hospital cafeteria (better than the USA) and treated them to jollof rice and chicken. The next 24 hours I tried to ensure a smooth transition from one set of volunteers to the next. By the next morning I was packed up and ready to for the drive to Accra and they were in the gross room and autopsy suite working.

The drive to Accra was fun. As I trekked south, everyone on the radio was talking about the US election. The polling had just started and there was an almost universal pull for Obama on the radio.

The flight home was 10 hours and 16 minutes on a mostly functional Boeing 767-300ER

I had the pleasure of sitting in 21G near the wing. It provided a fantastic view outside, but placed me next to the faulty exit sign/speaker combo. Every 2-10 seconds the light would flash and I would be greeted by a nice “ding.” To get the full experience, play the following video 308 times.

About two hours into the flight I noticed the nice spray paint job on the right engine and the thousands of miles of water in the background.

Meh, it’s the inside that counts. . .

Volunteer exchange

The volunteers change every few weeks at the hospital. Each new person provides continuity for the pathology mission and gives the local staff a unique view on how to practice. Today is Dr. Wester’s last day and to celebrate we went out for dinner Abusua (a nice place a few kilometers from the house). We both decided to treat ourselves and ordered dinners without rice. The meal was fantastic and we were able to watch the Ghana womens soccer team tie North Korea. After dinner we tried to catch a cab back home, but being Friday night in Kumasi everybody was out on the town. We gave up and chose to get a drink at the first place we could find.

We settled in outside the Cadilac bar in the warm tropical night and were treated to two ice cold STAR Lagers for $2. Everything was perfect. Later that evening I went to the bathroom and noticed that the quality wasn’t quite up to the rest of the establishment. I include this section for our microbiologist fellow Dr. Burnham who is a stickler for clean restrooms and isn’t fond of natures insect friends.

The room had a lovely tile floor with yellow tile walls. The ceiling had a slight mold problem and the toilet needed some servicing. Toilet paper was provided.

Overall I would give this establishment a 7/10. It was nice, the service was friendly, the drinks were cold, and the price was great. Somehow I don’t think my wife would rate it as high?

Water time

Being in a foreign country is a wonderful experience. You get to see and experience things that you wouldn’t even think about back home. Today was no different. After a few days of intermittent water we were just about at the end of our reserves. Our reserve water consists of two plastic trash cans for the bathroom and two blue buckets worth for the kitchen. Drinking water is separate. Since most volunteers are soft westerners we buy bottled water and keep it in the fridge.

Most houses and businesses have a large few hundred gallon tank that they store water in outside. Ours is placed next door to the house on a platform. An hour after the call we had our water truck and a man was climbing up the slightly leaning tower with a hose. The kid in me was a little jealous. Maybe I will climb up the tour later today when nobody is looking.

Ahhh, My Fabroids!

It’s another warm day in Kumasi. After signing out a large number of uterine fibroids this rotation I found the following sign across the street from the hospital to be particularly amusing.

Cribs: Pathology Overseas Ghana Edition

I have been busy at the hospital this week and have neglected my faithful online pathology fans. I thought I would write a little post for the future pathology overseas volunteers to let them see how we live day to day. The hospital provides us with a nice place to live and a driver to take us to and from work. The house is located in a small three house complex a few miles from the hospital. Some other physicians and hospital staff live in the other houses and a few small apartment like buildings are on the grounds for staff.

The inside of the house is very nice. The floor plan is very open and a light breeze generally cools after dark. Tile floors are present throughout the establishment and a uniform cream color is featured on all the walls. Through the front door you enter the main sitting room. The room is filled with nice furniture, an air conditioner if necessary, and a television that gets four local stations (All currently showing the Ghana Presidential debate). The strange box on the wall and the box on the floor are power conditioners to protect the more expensive equipment. The outlet power is generally good, but surges and brown outs are common. As you can see in the pictures, some of the volunteers have added a little art to the walls during their stay and I will probably leave a picture or two to brighten up my bedroom. A dining room is to the right of the living room and provides plenty of space if you wish to entertain a few guests.

Off of the dining room is a small kitchen with stove, refrigerator, water filter, and pantry.

Through the left door of the living room is a hallway that leads to the bathroom, shower, laundry, and two bedrooms.

The first bedroom on the left contains two double beds, an air conditioner if necessary, reading light and plenty of cabinet space.

The second room is slightly larger and holds a double bed, reading light, desk, fan, air conditioner if necessary, and plenty of cabinet space. The end of the hall has a rest room and to the left of the rest room are the shower, bath tub, and laundry.

I have had a good time here and I consider it home. I would not hesitate to volunteer again if my schedule permits and I would strongly recommend the experience to other physicians. The hospital really goes the extra mile (1.6 kilometer outside the US) to make the volunteers comfortable.

Weekend Update

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.

On the way up we took a break and stopped at Kintampo waterfall. It’s a toasty humid walk into the jungle, but the view was well worth it.

Soon afterwards we were back on our way north. The last two hours were rough and I acquired a new respect for the Nissan truck that the hospital lent us. After a day of travel it was nice to see our destination.

We signed into the park and made our way to the Mole Motel. It’s a nice little place to stay in the park overlooking a watering hole for the animals. On checking in, we found the room to be secured by a trio of animals.


Dr. Wester asked if she could pet them. I recommended avoiding personal contact with the wild animals. The next morning we awoke and made our way to the walking safari. The tour was hot, but we were able to get close to a group of elephants and see some other animals. Our tour guide was a fantastic and knowledgeable individual who seemed to really enjoy his work.

At the end of the walk he allowed me to get a picture of him in front of the staff canteen. Don’t worry about the gun. It’s only there to protect against “overly aggressive animals.” That evening I sat on the small platform overlooking the wilderness, had a tasty cold beverage, and watched the sun go down on West Africa.

The next morning we awoke and began the journey home. On the way we stopped to see one of the oldest mosques in West Africa. A local group of villagers took us on the tour and allowed us to take some pictures. The structure was constructed in 1420 and is still in use for daily prayer.

On the way back to Kumasi we briefly stopped at a local village for a picture or two.

I even got to do some work. On the walking tour I meet a British 4th year medical student working at a clinic in Tamale. When she found out we were physicians she pulled out her digital camera and started getting curbside consults on some of her more unusual cases. It was a long car ride, but overall it was a great weekend. If you do get the opportunity to go to a foreign country make sure you get out and see some of the areas off the tourist map.

A work day and a field trip

The day started out routine enough. We had a few trays of cases. Some of the cases I remember off 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.

They agreed and I asked where the band saw was located. . . (a hush calm set over the room)
Do we have anyway of cutting bone? . . . (Continued silence)
Can you get me a hacksaw, You know, something a plumber would use to cut metal pipe?. . .
A half hour later I was given a hack saw by one of the facility maintenance personnel. He said I could borrow it on one condition: “Thou shalt not use my hacksaw on people!”. . . .(Nutts!)

I turned to Edward (Laboratory technologist) and asked if he knew where I could buy one. He said sure and we were off to Kenjetia market (Hmmmm, I still don’t have a toaster J). The market was really active today. Everything was open and there were people doing business everywhere.

We went through a maze of small shops and eventually found our way to the hardware department. After finding a few stores to be out of stock, we found a friendly merchant who was willing to part with one and an extra blade for $5. Edward and I were like kids at Christmas. Joy!

On our way back to the car we took a slightly different path and I soon found myself face to face with a extra large blue toaster. It was a large four slot industrial model. I briefly thought about it, but decided against it. We continued on, grabbed a bite to eat, and headed back to the hospital.

On arrival, I went directly to the gross room to finish my quest. Two cuts for pictures and a thin section or two for decal. The larger sections are below to help you with "guess what it is." Maybe one of the residents can dress up as it for Jim’s Anti-Halloween Party.

Work III

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).

Next door to the gross room is histology. The students that were not watching the grossing were learning how to process and embed tissue. Notice how the ceiling is white. The pathologists are spoiled.

The quality of the surgical resections are generally good. We do have some problems with fixation, but I hope those can be resolved soon. I took a few pictures of today’s interesting case. It’s a partial jaw resection. You get bonus points with Jim if you can guess the tumor. Hints: Teenager, Recurrent

Work II – “Anyone here ever done a FNA?”

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.

After a brief search, I was able to find the necessary sterile equipment and proceeded downstairs to a small room adjacent to the gross room. We set up our equipment and brought in the patients one at a time. Both patients were rural and did not speak English, but a translator was located. A few minutes later I was back upstairs waiting to see the results of my work. The first patient’s FNA was diagnostic for malignancy and the patient was able to get an appointment with the oncologist that afternoon. The second patient’s FNA was hypocellular, favor benign.

I believe that the pathology volunteers here and the local staff are working one patient at a time towards improving the lives of the people in central Ghana.

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.

Separating the Resident and Attending areas of the office is a nice porcelain white sink. The green concrete walls, old sink in the corner and small window give the slightest hint of an Alcatraz prison cell.

The attending section of the room is truly posh. Bookshelf with glass doors, luxurious draperies, air conditioner, local telephone, and ready access to the library. Everything you could possibly want.

The whole room is very nice overall. It’s a cool comfortable place to review cases and has served many a volunteer well. Soon the department will be moving to the new pathology building. I was given a sneak preview and have included some pictures below. The new facility is fantastic!

Center room

New gross room (1st door on right)

Histology/Processing (2nd door on right)

Offices (not seen, but on left next to conference room with projector/screen (not shown)

A Sunday Morning at Kenjetia Market

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.

We started our search at some of the inexpensive outlet malls. The shops had a plethora of goods, but not a toaster or batteries in sight.

We eventually decided to move on to the more high end boutique shops and see if we could accomplish our mission. A variety of cell phones, clothing, and fresh produce were available.

No Toasters or Batteries here. . .

Dr. Frus was constantly assessing the situation and looking for the prize.

We eventually discovered a local electronics dealer that had a few batteries. After a brief discussion with his colleague we ascertained that he had seen a toaster a few days ago and maybe he would have one in stock tomorrow.

. . .Partial Victory. . .

Now I am off to the local communications hub to check my e-mail.

Later we hope to welcome the next volunteer pathologist who will be relieving Dr. Frus tomorrow. Perhaps we shall go the Pyramid Restaurant / Spice bar?

Lake Bosumtwi

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).

The boat looked like it met the necessary safety requirements. (It floated) We negotiated a 15 minute tour up the lake to the next village and back and scrambled aboard.

The lake is a meteorite impact crater that has filled with fresh water. The circular lake is about 10 miles across and has no natural inlets (Good thing, No rivers/ No crocodiles).

Everyone in the village was very friendly and many of the local school kids were out for a swim.

We went on a day trip from Kumasi, but a local resort is available for $50 if you wish to spend the night.

It was a good day trip and I snapped a picture of myself on the crater rim with the lake in the background on my way home.