The hardest cases for me have been ones in which we could not do anything to save the patient.  There are simply not enough resources here for us to be able to give the gold standard in treatment to everyone, and that has been so hard for me to deal with.  There have been a few stroke patients who are brought in by there family and there is nothing we can do; we can’t even give aspirin because there is no way to tell if it is ischemic or hemorrhagic.  If they can not go to a larger hospital in the capital Accra, where all 3 CT scanners in the country are located, they can not get treatment.  Originally I was frustrated because I thought that no one here had any sense of urgency, I thought that they did not understand how urgent these problems were; but then I realized that they know there is nothing that can be done here and they have accepted that.

Along the same lines as the unavailability of technology, if a patient does not have money they can not get treatment.  The care until recently was ‘cash and carry’ , the medication (even IV fluids) must be paid for before it can be administered.   Just recently government insurance has become available, they have to pay for it so not everyone has it, and it is really really crappy.  They pay for some basic medications and primary care visits, and that is about it.  Patients have to pay for all imaging, most lab tests, all referrals, surgeries, even cancer treatment (except breast cancer for some reason).  I had a patient with the biggest thyroid I have ever seen/felt, it wrapped 75% of the way around her neck.  She had apparently had that for some time, but when I saw her we found an abdominal mass, and she had lung mets on chest Xray.  She could not get a CT because it is too expensive, so it is impossible to tell where the cancer originated, but if caught early the spread could have likely been prevented.  But she could not afford surgery, or even to see a surgeon, so there is nothing we can do.  I just can not get over the fact that life-saving surgeries can not be preformed because a patient can not pay for it up front.

Many diagnoses here carry a huge stigma that I was not aware of.  They have special numerical codes for HIV status, they write 279 or 280 depending of if the test is positive or negative.  They have to do this because if a family member or anyone in the community finds out that person can be shunned and their life is virtually over.  I just learned today that they do not even tell patients that they are being tested because if they find out they will refuse it.  If they are found to be positive they go to counseling where they are not told their diagnosis until after 2 sessions of education!!  I had a really hard time with-holding information like this from a patient, but a doctor explained to me that the patient would likely stop coming and not get treated if we told them the truth.  This is still hard for me to swallow, I am used to being extremely open with patients and telling them exactly what we are thinking about their disease process.  Other diseases that carries this stigma  are TB and cancer.  Apparently mentioning these as a possible diagnosis makes the patient feel that they have no hope.  Like HIV, TB can result in being shunned by friends, family, and neighbors.  Doctors say ‘C. A.’ instead of the word cancer when talking to me in front of the patients ; even the lady with cancer everywhere that I talked about before didn’t know exactly what was growing inside her body. Even after 4 weeks I still do not fully understand why some things are with-held from patients here, but I think it is because of the lack of education of the general public.  In more developed countries everyone knows that there is treatment for cancer, TB, and HIV, but some people here have heard terrible things about these diseases and think they have received a death sentence; so  without properly educating a patient on their illness they will not pursue treatment.

I only gave one opoid pain medicine over the whole month, and it was oral morphine to a lady with acute coronary syndrome.  In the states we over-use pain medicine so much.  It seems like every week in my clinic there is at least one ‘pain-seeker’ wanting narcotic pain meds, and they usually get them.  I don’t know if the people here don’t complain as much or the doctors just don’t offer them, but there is not handing out of Vicodin or Percocet like we do back home.

The youngest pregnant lady I saw was 20.  The youngest one I have seen in Kansas City was 13.  Most Ghanians really value family and marriage, and most are Christians and very religious.  This is such a huge difference from what I saw on my OB/Gyn rotation.  I don’t know if they teen/single pregnancies here do not seek treatment or if they are really not as prevalent, but 98% of the pregnant ladies I saw were married.

On the flip side, abortion is illegal and I did see a few partial abortions.  Girls can get some medications from the drug store to try to abort their pregnancy but it usually does not work fully so they present with infections and continued bleeding.  This is sad because these girls get pretty sick, and end up with huge medical bills.  One girl had to have surgery to remove the remaining fetus and she was basically held hostage in the hospital until she paid her bill.  She was there for over a week after being released because she could not pay and they would not let her leave until she did.  I know abortion is a touchy subject, but if these girls had access to the proper procedures they would be able to avoid trying to ‘fix’ it themselves and then getting really sick.

Doctors are so highly respected by everyone, I feel like I got spoiled by just being a medical student!  Every day a nurse assistant brings the doctors a freshly-baked snack, a soda, and a bottle of water during their clinic duty.  The nurses never second-guess medical decisions or ask why we ask them to do a task, they just do it; the orders are not merely suggestions.  Elders are also highly respected.  When someone important, a guest, or an elder comes in to the office or the mission house they are greeted with a tray of snacks and drinks and are always called sir or madam.

I will miss seeing the moms carrying babies on their backs.  It is so cute, and the kids always look so happy.  I have to admit I was nervous at first that they would easily slip out of the wrap around the mom’s bust/waist but they are pretty secure…at least I never saw one fall out!

I am sad that I just discovered red red in the last week that I was here.  It is this dish that is plantains fried in red palm oil served with beans, sounds simple but it is the best food I ate here by far!  I just had some earlier today, Ruth was nice enough to make me some since she found out that I loved it so much!!  All of the other food was good too, I mostly ate rice, yam or plantain with some sort of tomato and onion based sauce with fish or chicken in it.  I am thankful that Ruth and Eban stayed in the mission house after their wedding; they were like a second family to me and Ruth cooked us dinner every night:)

I do not know how to sum up my trip but there are definitely things that I will take and keep with me forever.  I am ready to come home, but ready to  come back sometime again.

Last Saturday I went shopping in Accra.  It was really fun!  Maakporye took me to Osu street first.  This is a busy street that is lined with market-style shops on the sides of the street and small indoor shops as well.  We were dropped off across the street and walked down to the main area.  I had a list of things that I was looking for because I tend to impulse-buy so we were on a mission!  I tried to just look at first so I could get an idea of what they had and how much I should be paying.  I was looking for a dress and some jewelery for myself, a wooden mask that hangs on the wall, a shirt for my mom from when Obama came to Ghana last month (it really hurt me to spend money on that!!),  and something for my sister.  When I saw the huge array of goods out for sale I knew this would be a challenge!  There were many shops selling dresses and fabrics (they make custom dresses too), a lot of wooden art–masks, bowls, clocks, scenes of women carrying babies on their backs and/or stuff on their head, and a lot of people selling jewelery.  There were also some shops with bags, shoes, soccer jerseys, watches, etc.  Even with all of the distractions I found everything on my list and managed to still have some money left over!  I got good at bargaining by the end, but realized that I got ripped off by one of my first purchases.  A man was selling necklaces and bracelets made from these really pretty stone and glass bead, he did not have a proper shop he was just walking down the street so I stopped to look.  I got 2 necklaces and a bracelet for 35 cedis (maybe $20) which I thought was a pretty good deal, then toward the end of the street there were the same necklaces for 3-5 cedis!!!  I could have gotten the same stuff there for like 10 cedis!  Other than that everything went well.  We even stopped to have ice cream at a place called Freddy’s that reminded me of being home.

After Osu we took a tro tro to the center of Accra to go to Makala market.  This ended up being a place that was geared more toward locals.   They had more practical things like cleaning supplies, toiletries, everyday clothes, bags, fabric, and they were not as aggressive in getting me to purchase things like the people at Osu were.  I took a picture down the row of shops, which I had been doing all day at various places, and a lady who owned a facbic store came out to yell at me.  I’m not sure what she was saying but it didn’t sound good, luckily Maakporye was there to calm her down, so we said sorry and quickly went on our way.  I did not buy anything here and we didn’t stay long because I had already gotten most of the things I was looking for so we just headed back to Manna.

It was a fun day and shopping made me think of being back home.  I can’t wait to give everyone their gifts and share all of my pictures!

The city of Cape was like nothing I have ever seen before.  I thought that the streets here in Teshie were crowded with vendors but this was incredible.  There were blocks and blocks of tiny shops selling anything you can imagine, and I think that there was an inner part that we did not even enter.  This is a fishing community so there were women carrying huge wooden trays of smoked fish on their heads, along with women and children carrying the usual baskets of water, bread, clothes, biscuits on their heads as well.  We ate lunch here before heading to Kakum.  We stopped at this vendor’s stations that was a table with several pots and pans spread across it that were full of home cooked Ghanian food which she spooned out onto a reusable plate (I poured some bottled water over mine before she put the food on) and grabbed the piece of chicken with her bare hands.  Without a doubt the most unsanitary meal I have ever eaten, and that is saying a lot, but I lived.  There was an old table behind the food station where we sat and ate with bugs buzzing around and live chickens walking around our feet. There are lots of bugs because the city is so unsanitary; I am not trying to be rude, I talked about this with the Ghanians who were with me.  There are open ditches/gutters along all of the streets that are filled with trash and urine.  People literally pee everywhere, it is not an offense to pee on the side of the street in broad daylight. It is my worst fear to fall in one of these gutters, needless to say why

So we hopped a tro tro the 30min to Kakum for another dollar.  Kakum is a rain forrest reserve and national park, and the main attraction there is this canopy walk in the trees (will explain later).  The drive there was nice because I got to see some really small villages, the kind that most people probably think of, with mud-walled huts with leaves for roofs (not all of the houses were like this but a lot were).  When we were dropped at the entrance we had to pay 10 cents to enter then walked up a big driveway to the main building.  Here we purchased tickets to the canopy walk for just under $2 and found some actual toilets with tp!!  Our group was set to leave for the canopy walk at 1 so we waited in line for about 15 min then made the hike up a hill with rock steps for about a mile, and up 200+ feet.  Then we waited for 2hrs in line for the canopy walk, but it was so worth it!  While waiting in line the tour guide would point out some trees and stuff but we didn’t see any animals bc they are nocturnal.  The coolest part about the wait was the rain; it rained but we didn’t get wet because the trees of the canopy were so big and full.  It is hard to describe because you could see the rain through the gaps in the branches but it seemed like it just didn’t come through, it was really awesome.  So we finally got to the canopy walk.  It is a series of 7 rope bridges suspended between really huge trees.  There are two cables along the top of the bridges with roped hanging down from them and making a sling.  Then there is netting from about waist to armpit high on both sides.  The part you walk on is the middle of this sling and it is literally made of layed out metal ladders with wooden boards laying up the middle on the rungs. The lady right in front of us took 5 steps and started screaming and bawling so everyone behind her had to walk back so she could get off, this mad it a little scary but it was really funny bc this was like a 40-something lady, not a kid.  So needless to say this is super wobbly but once I was walking on it, it feels pretty stable.  I will post pictures when I get home, but the view was just indescribable.  In every direction all you could see was rain forrest, no city, no buildings just huge trees poking out of all the other trees.  Some of the bridges had to be 200 feet off the ground, but this was hard to judge because you couldn’t see the ground just more trees and plants.  So we took a lot of pictures and got to the end.  Then it was a muddy walk down hill back to the base where we started.

Tro tro back to Cape Coast to go to the Cape Coast castle, it was the hub of the West African slave trade in the 1800s and is now a historical site and tourist attraction.  I honestly wasn’t really excited about this but I felt like I had to do it for my grandpa, who always makes us go to every historical site anywhere we ever vacation (seriously, I mean detours to museums and memorials on the way to the beach) but I am so glad that we went!  It was a short tour, maybe 45min but really interesting and a little sad.  There were these tiny dungeons where they crammed hundreds of slaves, and the guide told stories of all of the terrible things associated with it.  The castle itself if more like a fort.  It has tall white walls with an interior courtyard protected by cannons facing the water.  The view from here is amazing; it is right on the beach but the part directly in front is a shoreline of rough rock.  The water slammed against the rock and it was so breezy and beautiful (I promise pictures when I get home!).  Right after the female dungeon there is the famous “door of no return” this is the door that the slaves exited before going out to the boats to sail to Britain and the US and be sold.  The door is actually labeled door of no return, it was so sad and cruel.  Outside the door there was a patio, just past the patio there were local fishermen coming in for the day.  They were bringing in their nets and it smelled so pungently of fish, but it was a cool site to see.

Just outside the castle there are a few shops with carved art and jewelry and stuff so I bought a few gifts then we went to the resturant to eat.  On the inside, you would have never know it was Africa; it looked like a beach-side resturant in any costal city, playing ragae music, and overlooking the water.  I could tell that this was a big tourist site because over half of the people were white, I think most of them were Eueopean and most of the ones in Kakum were as well.  Before last weekend I had literally seen 4 white people in 2 weeks, this does not bother me at all, but it explains why so many kids are either scared of me or come up and touch my skin!  Anyway, I had my fill of Ghanian food for the day from the street cart so I ordered a cheeseburger, I know really boring but it sounded amazing.  It was a little burned but it reminded me of home for a few minutes

Our long day ended with a taxi drive to the bus station and a 2hour ride in the dark back to Accra, then a final tro tro to Teshie, and a short taxi drive to the mission.  Whew…it was a long day but so much fun and it was nice to get out and explore other parts of Ghana.

I am excited to go to Accra next Saturday for shopping!!  I saved that trip for the last weekend so I wouldn’t spend all of my money

 So I did the best I could to get ready then met Maakporye in front of the church where we boarded a bus full of Manna Mission Church members and headed the 30min drive to Tema for the ceremony.  It was a lively drive; most of the people on the bus were around my age so it was fun to socialize with some peers, and the streets we drove on were busy with shops and vendors so there was plenty to look at.  Near the end of the drive we drove along the ocean; the water was very rough with tall choppy waves and the beach was pretty dirty.  Maakporye told me that there were nicer areas and places to swim where the resorts were a few miles away.

 When we arrived at the wedding it was aroung 1:30, which was when it was scheduled to start, but we were some of the first there.  The ceremony didn’t actually start until almost 2:30, I was informed that this is common practice in Ghana, and have noticed that everyone is always late!  So, I thought Catholic weddings were long but this was the longest wedding ever!  A total of 2 1/2 hours!  It was full of singing, dancing, a sermon, 2 offerings (1 for the chruch, 1 for the couple), traditional Christian vows, and a really beautiful blessing at the end.  I will just give you the highlights.  So there was a lot a singing before the bride even entered, which was different.  Then when the wedding party came down the isle the brides family followed her, there were about 15-20 family members after the bride.  The weirdest, and most annoying, part of the wedding was that people from the crowd would just get up and walk in the middle of the ceremony, or isle, and right in front of everyone to take photos!  I couldn’t even see the exchanging of the vows or the kissing of the bride bc there was literally a crowd of people in the front of the church.  Apparently this is the norm, but I found it very distracting and I couldn’t see a thing.  Another unique thing was the presence of at least 10 pastors.  There were a few from the church where the ceremony was held, about 7 from Manna and Manna’s other locations around Ghana, and a few from the couple’s church in London.   But only one did the ceremony, and other than being introduced individually, the others did nothing but sit on the stage.  At the end the couple kneeled and all of the pastors huddled around them and prayed to bless them and their marriage; I thought this was really cool and powerful and it was a really great moment.   The bride and ceremony were beautiful but after over 3hrs in the church I was ready to go to the reception.

The reception was at a nearby Rotary Club, I didn’t know they were international but obviously they are.  So we sat at a table with one of the pastors from Manna and his wife.  It took forever to get food bc they went table by table to go through the line but we finally got to eat around 7.  It was traditional Ghanian dishes — 2 kinds of rice with spicy sauce, chicken legs, fish (with the skin and bones), noodles (kind of like thai noodles) and vegetable salad.  There was soda in little cans to drink; it is interesting that there is nothing diet here yet not many people are fat, no diet pop or sugar free anything.  Anyway as soon as we sat down to eat the bus arrived so we had to eat quickly and leave.  I was kind of bummed bc I didn’t get to see any dancing or have any cake :(  but all of the people I knew were on the bus so it wasn’t that big of deal.

The next day was church.  The Manna Mission Church is directly across from the hospital, which is probably 300 yards down a dirt road from the Mission house where I am staying.  As soon as I exited the house, I could hear the music from the church!  The church is still being finished, but basically it is a building made of cinder blocks with a 2 tiered roof that is open to the outside between the tiers.  There are plastic chairs set in rows for the congregation and an area for the band at the front left.  The servcice was like any Baptist church service but with more powerful singing and praise than I have ever experienced.  It is really cool how everyone sings at the top of their lungs and gets so excited, it was very loud but so great.  After a few songs, about half in Ga and half in English, there was a sermon by Rev. Dr. Ablorh then more singing, and an offering.  Maakporye had mentioned that Dr. Ablorh usually introduces visiting students and missionaries to the congregation but he never did, so I thought that I had gotten out of it but instead another pastor called me up at the end.  It wasn’t too bad, I just said my name and what it is that I am doing here and took my seat.  Then there was Sunday school, which is actually like school, complete with a test at the end of the year!  It was just like my old Sunday school, with a memory verse and lesson, but all ages were mixed rather than seperating by age.  After Sunday school there is another service but I went with the girls from the office to help set up for the post-wedding brunch.

 We arrived at Dr. Ablorh’s house to set up and got everything ready before all of the guests arrived.  His home was extremely nice, but the party was in the lush backyard.  There were a few huge palm trees in the middle that gave lots of shade and a canopy with some vines growing all over it that gave more shade.  It was a beautiful sunny day, just warm enough with a great breeze.  There was more Ghanian food — rice, chicken, fish, noodles, full-sugar soda.  I really had a lot of fun at the brunch; it was not rushed like the reception.  I got to play with some kids, who were a little scared of the ‘Okiere’ (white person) at first, but then were a blast to play with!  I also got to talk to a few interesting people, a man from London (that is where the couple live) who spent some time in the states, and Maakporye’s pastor who had lots of good advice for us.  The thing that made this different than an American wedding brunch (other than the clothes and the fact that there was only 1 American there) was at the end the extended family of the bride and groom gathered in a circle and introduced themselves and just talked for about an hour.  I don’t really know what they were saying bc it was mostly in Ga but it sounded pretty intense at time, but I think it was all good things.  Anyway it was a pretty cool tradition that really got around all the small talk that dominates the intra-family conversations in the states. 

In the end, religious ceremonies are just similar enough to be familiar, but at the same time are so different.  Maybe I will take some of these practices back with me, but regardless I will always remember them.

 So, in this herd of women there was one that required an ‘emergent’ c-section (emergent takes ~9hrs to happen).  She was a new onset pre-eclamptic with anasarca (swelling everywhere).  At first she did not want it, and Auntie finally convinced her by saying (in Ga) that they brought over a special white doctor just for her, then they looked at me and laughed and told me what they said.  So she stayed, I went home to change into scrubs while the anesthesthitist came in.  When I came back to the hospital it was around 5, the anesthesthitist arrived around 7 and the surgeon at 8.  Anyhow we proceded in a fashion that would make every ID doc go nuts, if the absence of handwashing didn’t do it!  I put on the shoe covers which were made of cloth, and would later act as a great mop for amniotic fluid and blood, then I ’scrubbed’ by washing my hands with iodine soap, no brush, then had to turn off the faucet with my elbow.  The nurse put a sterilized reuseable gown on me that was kind of like windbreaker/raincoat material (that made me sweat profusely!) then gloves.  They are so short on supplies that they only had 3 sizes of surgical gloves, so I chose a size too big on bottom with a size too small on top.  At the table I realized that I did not have eye protection, and neither didi anyone else!  So I asked a nurse if she could put some on me, and everyone thought I was crazy because they do not use it, but I asked nicely and they finally found me a scratche up pair of glasses in a cabinet.   Although the technique was not what I am used to the surgery went relatively well and mom and baby are doing fine today.

 Today was another usual day in clinic, but I started seeing a few on my own.  There are 2 major problems with this: 1 they will act like they know what I am saying but really have no idea, and 2 they use the British system of drugs so I am totally unfamiliar with about half of the trade names and doses.  This makes it hard on the resident that I check out patients to but she is very nice and understanding that I am trying to learn.  I have only been seeing patients for 3 days here but I have come to appreciate the art of physical exam.  There are no stat CTs (there are only 3 CT machines in all of Ghana!!), no radiologists (we read our own plain films), and no way to get electrolytes here.  The lab does CBC (no dif), UA, blood smear for malaria and sickle cell, pregnancy test, and that’s about it.  The doctors have to rely on history and physical exam which is a dying art in modern technology.  Anyway I have enjoyed my time so far and can’t wait to learn more.

 I am very excited that I am going to a Ghanian wedding tomorrow!!  As some of you know I love weddings and I am missing Adam’s brother’s wedding this weekend so I was really excited to be invited to Dr. Ablorh’s brother’s wedding.  I will surely write about that soon!

So Joseph was the driver who took me the 40min to Manna Mission.  The drive was uneventful but unlike anything I have ever experienced.  The streets were so hectic; there were really no traffic laws, and there were vendors lining the streets selling what seemed to be the most random items–apples, plantain chips, toilet paper, and super glue.  Anyway after getting out of the busy Accra traffic things quited down until we got to Teshie.  In Teshie the streets are lined by tiny store-front shops that look like a strong wind would blow them right over.  The streets were very crowded and loud, and people seemed to do a double-take when they say a white girl riding by. 

The staff here is so kind and welcoming.  Diana, the housekeeper, brought me some fruit, water, and a bottle of soda when I got there and then I met Maakporye.  She is in charge of the missionaries (this is what they refer to me as) and has been such a great help in introducing me to everyone and giving me advice on what to do.  I am staying in the mission house, which is a large 2 story house with many rooms, a kitchen, laundry, and 2 bathrooms.  My room has 2 beds, a rack for clothes and a bookcase; but the best part is airconditioning!  This seems to be a luxury because only the bedrooms and staff offices have it.  I must admit it was a little scary to be there alone on the first night, but today everything is a lot less intimidating in the daylight!  There is one person staying with me, Ebaneza (?spelling) he is Dr. Ablorh’s (the physician in charge and minister of the church) brother and is getting married Saturday.

 The first day at the hospital was pretty laid back.  I met with Dr. Ablorh and a few of the staff physicians.  I would call the staff physicians equivalent to residents in the US; they are relatively young, and are working here to repay the government for their medical school.  The ‘resident’ I worked with today finished her med school 3 yrs ago, worked around the country as an intern for 2yrs to repay for her education, then got ‘posted’ here.  She is starting a heme/onc residency next month.  Other than meeting everyone and looking around the hospital nothing too exciting happened today, but tomorrow I start actually working so we will see!