The Patients: Everyone is tougher here, yet they are somewhat terrified of receiving medical care. Patients come in with their leg torn open and don’t blink, but when you pull out a needle they grimace and squirm. Much like the US, men are bigger babies than the women and sometimes even the children. However, the look of angry betrayal kids shoot their mothers is impressive; and the brave face of a baby getting her burned arm cleaned is mature enough to break one’s heart. Medical care is oftentimes put off until people are more seriously ill; they wait until diarrhea and vomiting have been going on long enough to cause dizziness or even non-responsiveness (which is bad when it comes to the babies). This is partly due to living a more challenging lifestyle, which leads to greater acceptance of imperfect conditions. Although it is mostly because even paying for the trotro [van taxi] ride to the clinic, let alone the clinic and medicine fees, is difficult and sometimes not possible. As for age, I can count on one hand the amount of patients I’ve seen over 65; you see a much higher number of young people here as they deal with more recurrent, contagious diseases versus simply chronic or acute. There is always the exception, however. Today I cared for a ninety-five year old woman who looked like a Tolkien character and put me in awe of her existence.

The Doctor: The doctor runs the clinic with nurses and lab specialists working under him. I spent busy market day with him in his office as he sees an endless line of patients (there are two market days a week here and it’s generally when people from remote villages check in with the doctor). Patients are sent in one at a time by the triage nurse with a card containing their name, city, blood pressure (BP) and temperature. The doctor then draws their health story out of them in the local dialect twi (pronounced CHA-wee) generally checking their bottom eye lids to see if they are anemic and listening to their lung sounds if they complain of chest pain. He then sends them to get intravascular (IV) /intramuscular (IM) medication from the nurses, labs drawn, and/or to the pharmacy for medications to take home. If labs are drawn or medications with quick results are given, he will have them come back to him for further analysis/diagnoses. He does not have anything other than some simple lab tests to help him diagnostically so his years of experience and local knowledge are imperative along with his education. You do not want to: waste his valuable time, cut in line unless you are truly dying (a toe cut in half does not qualify), or cry in front of him (the tears of a woman with shingles were utterly baffling to him). Otherwise, he is very nice and even jokes with many patients. His handwriting is as illegible as American doctors…making things tricky for the foreignor already battling a moderate language barrier.

The Lab: The main lab tech is amusingly vain about small personal details, but extremely meticulous, kind, and helpful. The girl who does most of the blood draws is saving up for nursing school on the coast, and the other phlebotomist is a quite man with a quick but shy smile. They can run all the basic quick tests needed for diagnosing. Hemoglobin (hgb) stands alone as the test for anemia here, (it’s the main thing we look at back home but we get a million other tests to further fill in the details). White blood cell’s are counted but rarely broken down into types. Glucose tolerance tests and blood glucose levels (cbg) are tested for a diabetes diagnosis, but they don’t run A1C’s (a glucose test showing 3 months average rather than simply your glucose at a single given moment) instead they have the patient come back for rechecking over the next two weeks (which they may or may not be compliant with). Pregnancy tests are constantly run as everyone seems to be pregnant here. Malaria is tested for by staining and microanalysis. Typhoid is tested by swirling serum samples in two different dyes (the 2 dyes being for 2 of the several different strains) and examining them for sediment formation at set intervals; however, the doctor seems to take the results not diagnostically but rather as further evidence to be considered in conjunction with the clinical picture. Urinalysis (ua) includes strip testing and microanalysis but no cultures are gathered because patients are not around long enough for a culture to grow and often do not come back if told to (finances again come into play). However, they do have the necessary equipment (such as an incubator) so hopefully someday they can use it in order to prescribe more specific antibiotics and thus decrease the spread of antibiotic resistant microbes. Stool is analyzed for parasites etc. More advanced tests such as testing for the sickle cell gene and erythrocyte sedimentation rate are done but not often as they are expensive for patients and not often indicated. The average patient gets hgb, cbg, ua, malaria, and typhoid tested for 15 cedi (about $7.5 USD).

The Nurses: They are mostly young women, but some are older and some are men. The oldest man is my favorite as he is very detail oriented and exact, like me. He is also the best at placing difficult iv’s. One of the nurses is very sweet and I always go to her with questions, another is forever flirting and a spirited laugher. They administer a lot of IM meds and even give some IV meds using blood draw supplies if it is a single dose without IV fluids ordered. Otherwise they place iv’s and give meds and fluid per doctor’s orders, which is common as many patients are dehydrated (heat, humidity, diarrhea, and vomiting are not a good mix). Nurses also clean, stitch, and dress the many cooking burns, motorcycle accident wounds, and cuts. The nurses mostly wear stereotypical collared white dresses that zip up the front and fall just above the knee.

The nurses are not compassionate by American standards as they often appear annoyed with patients too sick to be quick or they laugh at patients who are scared of receiving care. However, the deal between patients and nurses here is simple. Patients just want to receive the ordered care and nurses provide it; no warm fuzzies guaranteed or expected. The nurses also are skilled at sleeping anywhere when there is a lull in patients. They will be dead asleep in the hallway benches, their chairs, or the unused bed for 30 minutes at a time. They work 32-60 hours a week with 6-10 hour shifts. They are mostly all government trained nurses at the clinic, but women who can’t afford government school do private school as it is a little cheaper up front. However, private school is equivalent to paying for unpaid internships, (read not very good training). Thus they end up saving their private nurse wages when they, hopefully, get a job to then afford government school. So if they could just have a little more to invest up front in order to go to government school it would cut their schooling and costs in half.

The Pharmacy: The inventory appears pathetically small and limited, yet they seem to make do. They predominantly give hypertension (htn) pills out and there is, as always, the issues of affordability and compliance.

The Miscellaneous: The front desk, record keeping girl is young and very nice. The records consist of a ledger of labs run/results/costs kept in the lab and complaints and treatment kept by the MD as well as a form with their city/name/bp/temp/MD’s notes on history and current situation as well as their prescribed treatment. This form is then shelved on one of the many walls covered top to bottom with countless forms disintegrating in the humidity. There is apparently an order to the madness, and the girl assures me she can find specific patients. There’s also the woman who runs a food stand on the front porch for patients needing food before being medicated, and the boy with mad machete twirling skills who sells coconuts on the road front. Construction workers noisily build new bathrooms as the current ones are getting near to full, (they are actually pretty good by the standards here with 4 wood walls around cement with a hole in it close to full with sewage, maggots, and with no toilet paper in sight.)

The Volunteer: Mostly they are women and mostly they are still students (MD, PA, RN, NP) The doctor assumed I was a PA due to my knowledge but the nurses are skeptical about whether or not I am officially trained. When I don’t do things exactly their way they assume I don’t know what I’m doing. However, being respectful, skilled, and putting my time in seems to be chipping away at this.