No surgery today as we prepare to leave. We made rounds on our patients, and said goodbye to them and the staff, and took pictures. A number of people went out of their way to thank us for coming, and to express the hope that we will return. In our travels this morning, we went over to the XRay corridor to try to find Justin Byrd to give him the key to his supply closet in the OR, where we have left all of our supplies. Seated there was Augustine, the young boy with the leg mass whom we had seen in clinic, and whom I think has lymphoma. We had been worried that he would be lost in the system, but he had been admitted to pediatrics. I don’t know that there is anything that can be done for him, but I was happy that at least he was being evaluated to the extent possible.
Dewalt (actually Agent David Dewalt of SSS) took us and our baggage to the downtown Brussels Airlines office. Apparently it is a lot easier to check ones luggage in downtown rather than at the airport before the flight. When we go out of Dewalt’s Nissan Patrol (donated to Madame President by Muamar Ghaddafi, by the way), there was a crowd of men trying to help us with our bags, but I don’t believe they were airline employees LOL When we came out from the office, they wanted money, insisting that they had all helped. I realized then why we hadn’t ventured downtown more often !
From there we drove to a commercial area to visit an African Art shop which had carvings, etc. I bought a couple of wooden things. Then we walked around for a while among the street vendors before coming back to the Guest House for a last time.
Not knowing what to expect, or what was possible before we arrived, I feel that we have accomplished more than I had expected we would. I think we helped a number of specific patients by tackling their particular problems which others had been reluctant to do. I think the OR Staff and Anesthesia were pleased with our work. The Surgical Housestaff saw our 2 weeks as the opportunity to take it easy for a time, but that wasn’t a bad thing; I think they needed it. There is no 80 hour work week for them. I think they all look forward to future surgical visits by us, or others.
I also think it was good for us to be here with the rest of the HEARTT team : ER doctors, Internal Medicine, and Pediatrics. We all benefited from the presence of others who understood the way we approach problems, and who can commiserate about the uncertainties of diagnosis and treatment in Liberia.
Update: We are in Brussels waiting for the flight to JFK. See you all soon !
Friday, March 19, 2010
Thursday, March 18, 2010
Day 12
I think this will be our last day of operating, as we hope to go to an art market tomorrow before we leave.
Colleen and I started this morning with the 4 year old boy who had a large lipoma on his back. It was a 10+ cm mass which we removed through a 5 cm incision, so that was cool. Kinda like delivering a baby ! He was moving some during the surgery, but then afterwards he didn’t wake up for nearly an hour. Finally, he did, but it brought to the fore once again my concerns about anesthesia, and the anesthesia providers, here. I think they do an ok job, but it seems like supervision of the student nurse anesthetists is quite lax. They monitor O2 saturation, but not end-tidal CO2. There are also no CO2 absorbers that I can see; I will have to ask about that when I get home.
The next case was a young woman who had a criminal abortion in January, in which they perforated her uterus in 3 places as well as her sigmoid colon, so she had a hysterectomy at the MSF Hospital, and then was transferred here where she had a Hartmann’s by Dr. Konneh. When he heard that we had brought 2 EEA staplers with us, he was begging us to do this woman, and so we agreed. Dr. Konneh is an interesting fellow who is very enthusiastic and perhaps more aggressive than warranted, but he has been quite helpful to us. So Robert was doing a lipoma in the other room, and he and I did this woman. I was surprised and pleased with his abilities ! We did the whole case, and I let him go down below to do the stapling; I think and hope it all worked well!
My experience with him today has reaffirmed an idea I had last night, which I talked to Adaman about and he liked the idea. I want to come back here in the fall maybe, with no residents, and just work with the house staff here. I think they have done a remarkably good job of learning surgery under the circumstances they find themselves in, but they really need to work with someone to improve their technique and give them some stimulation. I think that would be an interesting 2 weeks for me, and I think it would be useful for them. Dr. Konneh thought it was a great idea!
Robert was doing bilateral inguinal hernias next, so Colleen and I did a takedown of a colostomy and handsewn reanastomosis in a 26 year old woman. She had been through 3 days of obstructed labor, delivered a dead baby, and was then found to have a rectovaginal fistula. So She had 2 attempts at repair: the first without a colostomy, and the second after a colostomy. The second one worked. SO now she was ready to be decommissioned. It went well, but they could certainly use more and better instruments. Their bowel clamps are what we put rubber shods on; they don’t have any actual bowel clamps as we know them. They also don’t have retractors, though in honesty we have done ok with them, probably because the people are thin.
While we were doing that, Robert came in to tell us that his hernia patient had coded, but had been resuscitated. He then developed what appeared to be flash pulmonary edema. Right now they have him in the ICU, and apparently they were able to find the guy who has the key for the ventilator, so he is on it. Once again, my concerns about anesthesia at JFK. They either don’t know, or don’t think it is important to know, what level of anesthesia their patients are under. Waking up and bucking during a case is more the rule than the exception. I know that can happen anywhere, but it seems that too often I look up to announce to the head of the table that a patient is bucking, and it is a student who seems to have little clue what to do.
We just heard that Robert’s patient died. It is terribly frustrating that we really have no idea what happened, and I have the feeling that no one will ever know. It will not be discussed among the participants, and no one will learn anything from it. Very sad.
We have a 4 year old with an acute abdomen to do, but his mother just fed him, and now we have to wait till 9 PM tonight. Oh well.
Colleen and I started this morning with the 4 year old boy who had a large lipoma on his back. It was a 10+ cm mass which we removed through a 5 cm incision, so that was cool. Kinda like delivering a baby ! He was moving some during the surgery, but then afterwards he didn’t wake up for nearly an hour. Finally, he did, but it brought to the fore once again my concerns about anesthesia, and the anesthesia providers, here. I think they do an ok job, but it seems like supervision of the student nurse anesthetists is quite lax. They monitor O2 saturation, but not end-tidal CO2. There are also no CO2 absorbers that I can see; I will have to ask about that when I get home.
The next case was a young woman who had a criminal abortion in January, in which they perforated her uterus in 3 places as well as her sigmoid colon, so she had a hysterectomy at the MSF Hospital, and then was transferred here where she had a Hartmann’s by Dr. Konneh. When he heard that we had brought 2 EEA staplers with us, he was begging us to do this woman, and so we agreed. Dr. Konneh is an interesting fellow who is very enthusiastic and perhaps more aggressive than warranted, but he has been quite helpful to us. So Robert was doing a lipoma in the other room, and he and I did this woman. I was surprised and pleased with his abilities ! We did the whole case, and I let him go down below to do the stapling; I think and hope it all worked well!
My experience with him today has reaffirmed an idea I had last night, which I talked to Adaman about and he liked the idea. I want to come back here in the fall maybe, with no residents, and just work with the house staff here. I think they have done a remarkably good job of learning surgery under the circumstances they find themselves in, but they really need to work with someone to improve their technique and give them some stimulation. I think that would be an interesting 2 weeks for me, and I think it would be useful for them. Dr. Konneh thought it was a great idea!
Robert was doing bilateral inguinal hernias next, so Colleen and I did a takedown of a colostomy and handsewn reanastomosis in a 26 year old woman. She had been through 3 days of obstructed labor, delivered a dead baby, and was then found to have a rectovaginal fistula. So She had 2 attempts at repair: the first without a colostomy, and the second after a colostomy. The second one worked. SO now she was ready to be decommissioned. It went well, but they could certainly use more and better instruments. Their bowel clamps are what we put rubber shods on; they don’t have any actual bowel clamps as we know them. They also don’t have retractors, though in honesty we have done ok with them, probably because the people are thin.
While we were doing that, Robert came in to tell us that his hernia patient had coded, but had been resuscitated. He then developed what appeared to be flash pulmonary edema. Right now they have him in the ICU, and apparently they were able to find the guy who has the key for the ventilator, so he is on it. Once again, my concerns about anesthesia at JFK. They either don’t know, or don’t think it is important to know, what level of anesthesia their patients are under. Waking up and bucking during a case is more the rule than the exception. I know that can happen anywhere, but it seems that too often I look up to announce to the head of the table that a patient is bucking, and it is a student who seems to have little clue what to do.
We just heard that Robert’s patient died. It is terribly frustrating that we really have no idea what happened, and I have the feeling that no one will ever know. It will not be discussed among the participants, and no one will learn anything from it. Very sad.
We have a 4 year old with an acute abdomen to do, but his mother just fed him, and now we have to wait till 9 PM tonight. Oh well.
Since they apparently don’t celebrate St. Patrick’s Day in Liberia, we have been working today. Colleen and I did an inguinal hernia, and then we had a 9 year old girl from the ER with perforated appendicitis and gross peritonitis. We had a bit of a dust-up before surgery, as she apparently had not paid the surgical fee. Senora came with some nursing staff, and pointed out that there is no surgeon’s fee charged since we are doing the surgery for free. Anyway, after a while, apparently the anesthesiologist was convinced that it was ok for us to go ahead so we did. Following that, Robert and I repaired a huge recurrent inguinal hernia with mesh.
There is a 3 year old boy with a large lipoma on his back which we are supposed to remove. His mother is an assistant to The President, so we have been asked to take care of this as a special favor to The President. I thought we were doing him today, but no one knew where he was. It turns out that he was admitted yesterday, but got lost in the system. Not hard to understand, since “the system” here is pieces of paper in random order with no evidence of an overall plan.
We are trying to schedule our last two days, but there isn’t enough time to do all that they want us to do. There are two fistula women ready to have there colostomies decommissioned; we will take some hernias off the schedule for tomorrow and do the decommissionings instead. We are hoping to run 2 rooms tomorrow in order to get these things done, but there is resistance from anesthesia. I have called Adaman to see if he can talk to Dr. McDonald and straighten things out.
Now we have a 2 year old from the ER with a large perirectal abscess extending into his scrotum. It looks terribly painful, and not appropriate for drainage in the ER. Getting the OR staff to do anything in the afternoon is a difficult process to say the least. They drag their feet over everything. The good news is that I now feel well-enough established here so that I am comfortable pressuring them to get moving.
The guy with the incisional hernia which Robert and Colleen repaired the other day has a big superficial hematoma, so Robert wants to bring him back to open it up and clean it out. I guess that will be next.
It turns out the Dr.Moses, the senior surgical house officer here, has seen a surgical atlas just once. He has had very little in the way of mentoring because there are no attending surgeons here now, and I suppose it is a testament to his abilities that he has learned as much as he has by reading whatever he has. This morning, during our hernia operation, he was in the corner with Dr. Konneh and the Chinese doctor was showing both of them how to tie knots. It occurred to me that when we did the bowel resection together, he did mostly instrument ties to save suture length, and maybe that is why his manual dexterity with knot tying isn’t all that great. It’s interesting that sometimes the reason for a sub-par performance can be due to many factors, not the least of which is the socio-economic milieu. At the same time, I think it is hard for people to strive for perfection when they know that they have barely adequate tools. The way I was taught surgery involves the constant pursuit of perfection(while of course recognizing that perfection is the enemy of good); if something doesn’t turn out the way we hoped it would, we are generally quite self-critical. This process of self-criticism (not only in Morbidity and Mortality Conference, but in daily life) is critically important in the further development of surgical skills. Here I see glimpses of an almost defeatist attitude: that it doesn’t matter whether one’s surgical skills are good, because there are woefully inadequate resources to care for a population with far too many problems. Even if you have great surgical skills, so much else involved in the optimal care of a patient is not available that it isn’t worth expending the extra effort to be the best you can be. Maybe I am over-reading the situation, but this is the way it seems.
The problems seem overwhelming here, but I constantly remind myself about the value, and the reality, of taking little steps instead of giant leaps. On a short 2 week mission such as ours, we cannot reasonably expect to change much except the lives of some of the people we have operated on. I think we have accomplished that for a number of them: Mr. Two continually expresses his gratitude for removing the mass from his neck; the 2 mastectomy ladies are very happy; and the woman who had her splenectomy yesterday is very pleased. A woman came to the clinic yesterday with a small thyroid nodule that bothered her because she thinks everyone can see it. Dr. Konneh told her that she should come back to the clinic in 3 months to have it checked; she turned to me and said : “Will you be here?” There have been other indications that our presence has been viewed positively, so I guess that is a good thing.
They cleaned out the hematoma while I was writing some of this, and now we will go see some patients. Then we will go back to the dorm, so I can sign online and send this out to my millions of readers !! OK, maybe not millions…
We’ll see if this can be exported to my blog. It’s a pic of us with President Sirleaf at her reception on Sunday night. And one of me and herself…
There is a 3 year old boy with a large lipoma on his back which we are supposed to remove. His mother is an assistant to The President, so we have been asked to take care of this as a special favor to The President. I thought we were doing him today, but no one knew where he was. It turns out that he was admitted yesterday, but got lost in the system. Not hard to understand, since “the system” here is pieces of paper in random order with no evidence of an overall plan.
We are trying to schedule our last two days, but there isn’t enough time to do all that they want us to do. There are two fistula women ready to have there colostomies decommissioned; we will take some hernias off the schedule for tomorrow and do the decommissionings instead. We are hoping to run 2 rooms tomorrow in order to get these things done, but there is resistance from anesthesia. I have called Adaman to see if he can talk to Dr. McDonald and straighten things out.
Now we have a 2 year old from the ER with a large perirectal abscess extending into his scrotum. It looks terribly painful, and not appropriate for drainage in the ER. Getting the OR staff to do anything in the afternoon is a difficult process to say the least. They drag their feet over everything. The good news is that I now feel well-enough established here so that I am comfortable pressuring them to get moving.
The guy with the incisional hernia which Robert and Colleen repaired the other day has a big superficial hematoma, so Robert wants to bring him back to open it up and clean it out. I guess that will be next.
It turns out the Dr.Moses, the senior surgical house officer here, has seen a surgical atlas just once. He has had very little in the way of mentoring because there are no attending surgeons here now, and I suppose it is a testament to his abilities that he has learned as much as he has by reading whatever he has. This morning, during our hernia operation, he was in the corner with Dr. Konneh and the Chinese doctor was showing both of them how to tie knots. It occurred to me that when we did the bowel resection together, he did mostly instrument ties to save suture length, and maybe that is why his manual dexterity with knot tying isn’t all that great. It’s interesting that sometimes the reason for a sub-par performance can be due to many factors, not the least of which is the socio-economic milieu. At the same time, I think it is hard for people to strive for perfection when they know that they have barely adequate tools. The way I was taught surgery involves the constant pursuit of perfection(while of course recognizing that perfection is the enemy of good); if something doesn’t turn out the way we hoped it would, we are generally quite self-critical. This process of self-criticism (not only in Morbidity and Mortality Conference, but in daily life) is critically important in the further development of surgical skills. Here I see glimpses of an almost defeatist attitude: that it doesn’t matter whether one’s surgical skills are good, because there are woefully inadequate resources to care for a population with far too many problems. Even if you have great surgical skills, so much else involved in the optimal care of a patient is not available that it isn’t worth expending the extra effort to be the best you can be. Maybe I am over-reading the situation, but this is the way it seems.
The problems seem overwhelming here, but I constantly remind myself about the value, and the reality, of taking little steps instead of giant leaps. On a short 2 week mission such as ours, we cannot reasonably expect to change much except the lives of some of the people we have operated on. I think we have accomplished that for a number of them: Mr. Two continually expresses his gratitude for removing the mass from his neck; the 2 mastectomy ladies are very happy; and the woman who had her splenectomy yesterday is very pleased. A woman came to the clinic yesterday with a small thyroid nodule that bothered her because she thinks everyone can see it. Dr. Konneh told her that she should come back to the clinic in 3 months to have it checked; she turned to me and said : “Will you be here?” There have been other indications that our presence has been viewed positively, so I guess that is a good thing.
They cleaned out the hematoma while I was writing some of this, and now we will go see some patients. Then we will go back to the dorm, so I can sign online and send this out to my millions of readers !! OK, maybe not millions…
We’ll see if this can be exported to my blog. It’s a pic of us with President Sirleaf at her reception on Sunday night. And one of me and herself…
I think this is day 10, but maybe it's 9 ?
Today is Outpatient Clinic day, but we are operating. First case was one of the Operating Theater porters, known as “The General”, who had a huge hernia that he wanted us to fix. Robert and I did it, and it was quite difficult because, as Moses said, it was an “African” hernia…a slider into the scrotum, etc. We did accomplish the repair, and he was ready to go home later in the afternoon, which is remarkable by JFK standards.
Robert has gone to the US Embassy to get his visa renewed so he can return to the USA. Colleen and I went to the Outpatient Clinic and saw several patients. The most depressing was Augustine, and 11 year old boy with a 10 cm mass in his proximal left thigh, palpable nodes above it, gross lymphedema of the leg, and palpable nodes in his right axilla. This is most suggestive of lymphoma, probably high grade as the mass first appeared only a few months ago. Some form of soft tissue sarcoma is another possibility, though the diffuse lymphadenopathy would seem to make lymphoma more likely. We ordered a CBC, and hope that he can be seen by pediatrics. It’s an interesting situation, in that they apparently could admit him and give him some cytotoxic treatment, but would be doing so without a tissue diagnosis, since there is no pathologist here to render one.
Now we are waiting to do a splenectomy on a 53 year old woman with an enlarged spleen for a year, and no response to the usual medical therapies for malaria and typhoid. She is anemic with a Hb of 10 and a platelet count of 66,000. The holdup has been arranging for blood. Prior to surgery, the patients need to either have a family member donate blood for them, or they need to buy blood from the blood bank. This woman’s husband bought 2 units, but the anesthetist wants 3 available. I’m not sure it is entirely necessary, but I also don’t want to be the bad guy if the patient were to bleed to death on the table. Apparently the husband has been contacted, and he is on the way to get money and then bring it back here to buy another unit of blood. Makes you think they should have an ATM machine at the blood bank, except that ATMs are just emerging technology here.
Update : The husband came and paid for a third unit of blood. Then the anesthetist said she would prefer to have the platelet count over 100K; I told her that 66K was fine, and I had done splenectomies at that platelet level before. Then the patient had been sent back to her floor. Someone was sent to get her, but returned saying that the patient had eaten. Colleen and I went down to the patient’s floor, and discovered that she had not eaten. So I went back up and told the anesthetists, and they said “oh, it’s already 1 PM…why don’t you do it tomorrow?” With that, I lost and rather forcefully exclaimed :”No, we are doing it today ! “ It seems that they respond better to force, since they responded to my outburst, and within about 10 minutes the patient was in the OR. Colleen and I did the splenectomy, and lost maybe 100 cc of blood. She received the 3 units of blood anyway, since they had been paid for already…Go figure ! We also did it with a rather modest collection of instruments by USA standards, which perhaps reaffirms Colleen’s original impression after our first day that “We are spoiled”.
Shortly after that I was interviewed by someone, and it was filmed, but I don’t really know if it was radio or TV. It was fun talking about what we are doing, and HEARTT, and the surgical needs of JFK Hospital. My feeling is that the first thing needed is a reliable electrical system so that they can have decent lights, and bring in new equipment as indicated. Apparently the hospital is not grounded, and it will cost $10,000 to do that; sounds to me like it would be a worthwhile investment! I am told that the hospital does have generators for use during power outages, but they do not go on automatically, and are only turned on if the outage is expected to be prolonged. Who determines that and how appears to be unknowable. Here’s an interesting story: about a month ago an Indian government minister came to visit Liberia to discover what they could do to help with healthcare. Unfortunately, that minister was in a car accident on the way into Monrovia from the airport, and he suffered a serious head injury. He was stabilized at JFK, and then flown to Ghana by UN helicopter for a CAT scan and treatment; apparently he has recovered well. So now the Indian government wants to give Liberia a CAT scanner for JFK Hospital. My first reaction is that they really need to solve the electrical situation first, since CAT scanners really don’t like voltage surges and power outages. Of course I don’t know the details, or whether anyone has mentioned that there are a lot of other things which are needed much more…but this is a common problem in the developing world, I believe. People in the USA and elsewhere donate with the best of intentions, but if they don’t know the needs or capabilities on the ground, much of that donation will go to waste. I am told that JFK Hospital has crates of equipment donated by Hospitals for Hope over the past 2 years, but it is all stored in a warehouse and not even catalogued yet. I believe that they have hired someone to catalog it, so who knows what will be found.
Tonight we had dinner at the Guest House with Senora, Robert, Colleen, James, and Venay, a pediatrician from Children’s in Boston who will be staying there to do a pediatric heme-onc fellowship starting in July. She has been here several times, and is currently here for 4 months as an attending for the Liberian and US residents. We had a great discussion about medicine here, and the changes we see are necessary, and how those changes can be encouraged. One of the main problems, as I see it, is a lack of accountability by doctors, nurses, and many others. They are so used to living and working under impossible conditions that in some ways many appear to be resigned to the idea that there is nothing they can do. So if the hospital is out of a drug which has been ordered, they just don’t give it, rather than probing or asking if there is an alternative which could be used. We mostly see death as a personal failure (“there must have been something that I didn’t think of or didn’t do which would have saved that person”). I think they see death as just another life lost , and treat it rather impersonally rather than the way we take it personally. Maybe this is part of their culture, but I think their recent history and civil war has a lot to do with it also.
Robert has gone to the US Embassy to get his visa renewed so he can return to the USA. Colleen and I went to the Outpatient Clinic and saw several patients. The most depressing was Augustine, and 11 year old boy with a 10 cm mass in his proximal left thigh, palpable nodes above it, gross lymphedema of the leg, and palpable nodes in his right axilla. This is most suggestive of lymphoma, probably high grade as the mass first appeared only a few months ago. Some form of soft tissue sarcoma is another possibility, though the diffuse lymphadenopathy would seem to make lymphoma more likely. We ordered a CBC, and hope that he can be seen by pediatrics. It’s an interesting situation, in that they apparently could admit him and give him some cytotoxic treatment, but would be doing so without a tissue diagnosis, since there is no pathologist here to render one.
Now we are waiting to do a splenectomy on a 53 year old woman with an enlarged spleen for a year, and no response to the usual medical therapies for malaria and typhoid. She is anemic with a Hb of 10 and a platelet count of 66,000. The holdup has been arranging for blood. Prior to surgery, the patients need to either have a family member donate blood for them, or they need to buy blood from the blood bank. This woman’s husband bought 2 units, but the anesthetist wants 3 available. I’m not sure it is entirely necessary, but I also don’t want to be the bad guy if the patient were to bleed to death on the table. Apparently the husband has been contacted, and he is on the way to get money and then bring it back here to buy another unit of blood. Makes you think they should have an ATM machine at the blood bank, except that ATMs are just emerging technology here.
Update : The husband came and paid for a third unit of blood. Then the anesthetist said she would prefer to have the platelet count over 100K; I told her that 66K was fine, and I had done splenectomies at that platelet level before. Then the patient had been sent back to her floor. Someone was sent to get her, but returned saying that the patient had eaten. Colleen and I went down to the patient’s floor, and discovered that she had not eaten. So I went back up and told the anesthetists, and they said “oh, it’s already 1 PM…why don’t you do it tomorrow?” With that, I lost and rather forcefully exclaimed :”No, we are doing it today ! “ It seems that they respond better to force, since they responded to my outburst, and within about 10 minutes the patient was in the OR. Colleen and I did the splenectomy, and lost maybe 100 cc of blood. She received the 3 units of blood anyway, since they had been paid for already…Go figure ! We also did it with a rather modest collection of instruments by USA standards, which perhaps reaffirms Colleen’s original impression after our first day that “We are spoiled”.
Shortly after that I was interviewed by someone, and it was filmed, but I don’t really know if it was radio or TV. It was fun talking about what we are doing, and HEARTT, and the surgical needs of JFK Hospital. My feeling is that the first thing needed is a reliable electrical system so that they can have decent lights, and bring in new equipment as indicated. Apparently the hospital is not grounded, and it will cost $10,000 to do that; sounds to me like it would be a worthwhile investment! I am told that the hospital does have generators for use during power outages, but they do not go on automatically, and are only turned on if the outage is expected to be prolonged. Who determines that and how appears to be unknowable. Here’s an interesting story: about a month ago an Indian government minister came to visit Liberia to discover what they could do to help with healthcare. Unfortunately, that minister was in a car accident on the way into Monrovia from the airport, and he suffered a serious head injury. He was stabilized at JFK, and then flown to Ghana by UN helicopter for a CAT scan and treatment; apparently he has recovered well. So now the Indian government wants to give Liberia a CAT scanner for JFK Hospital. My first reaction is that they really need to solve the electrical situation first, since CAT scanners really don’t like voltage surges and power outages. Of course I don’t know the details, or whether anyone has mentioned that there are a lot of other things which are needed much more…but this is a common problem in the developing world, I believe. People in the USA and elsewhere donate with the best of intentions, but if they don’t know the needs or capabilities on the ground, much of that donation will go to waste. I am told that JFK Hospital has crates of equipment donated by Hospitals for Hope over the past 2 years, but it is all stored in a warehouse and not even catalogued yet. I believe that they have hired someone to catalog it, so who knows what will be found.
Tonight we had dinner at the Guest House with Senora, Robert, Colleen, James, and Venay, a pediatrician from Children’s in Boston who will be staying there to do a pediatric heme-onc fellowship starting in July. She has been here several times, and is currently here for 4 months as an attending for the Liberian and US residents. We had a great discussion about medicine here, and the changes we see are necessary, and how those changes can be encouraged. One of the main problems, as I see it, is a lack of accountability by doctors, nurses, and many others. They are so used to living and working under impossible conditions that in some ways many appear to be resigned to the idea that there is nothing they can do. So if the hospital is out of a drug which has been ordered, they just don’t give it, rather than probing or asking if there is an alternative which could be used. We mostly see death as a personal failure (“there must have been something that I didn’t think of or didn’t do which would have saved that person”). I think they see death as just another life lost , and treat it rather impersonally rather than the way we take it personally. Maybe this is part of their culture, but I think their recent history and civil war has a lot to do with it also.
Tuesday, March 16, 2010
Day 8
I was up at 8 this morning, but realized that I hadn’t made plans with Dewalt to be picked up. Today was another holiday (President’s Day), and I didn’t want to wake him early, so I walked from the Guest House to the hospital, which is about a mile I would guess. It’s a straight shot down Tubman Boulevard. I must say that I attracted a few stares as a white guy walking in scrubs on the busiest road in Monrovia ! After arriving at the OR for our 9 AM case, we were informed that there would be a delay because both of the elevators had broken again. The OR is on the top (4th) floor, so they would have no way of getting the patients up and down. We suggested that they could walk up, but walking down stairs after surgery wasn’t a likely option. It turns out that the best elevator repairman lived in Ghana, and he used to come fix there elevators, but he died a couple of months ago. So now they use someone of the Ivory Coast. However in this particular circumstance, since both elevators stopped at the same time, they are thinking it is an electrical/power supply problem rather than an elevator problem per se. In any case we made rounds, and then the word was that the elevators wouldn’t be fixed today, so we might as well cancel our 2 cases. We told the patients, and they were disappointed, as we expected. Then we were on the stairs to leave when we met Adaman, and we told him our story of woe. He basically said that’s bullshit, that you guys are here to help, and people should do everything they can. So he called the administrator Dr. McDonald, who suggested that the patients could walk up, and then stay in the recovery room until either the elevators were fixed or the patient could walk down;
So we ended up doing our 2 cases: an incisional hernia and another locally advanced breast cancer. By the time we had finished the breast, the elevators were fixed !! The mastectomy went better than the last, or at least there was less blood loss. It came out well, I think.
We had an amazing downpour yesterday evening as we were waiting to go out to dinner. It was a hard rain, made even more significant by the sound of the rain on the metal roofs ! We went for dinner at PA’s, a sports bar of sorts, and had a good time. Then I went back to the Guest House. Senora started showing me “Liberia : America’s Stepchild” which appears to be a PBS production, but I fell asleep on the couch. She woke me up, and I ended up going to bed at 9:30 PM and sleeping very well !
So we ended up doing our 2 cases: an incisional hernia and another locally advanced breast cancer. By the time we had finished the breast, the elevators were fixed !! The mastectomy went better than the last, or at least there was less blood loss. It came out well, I think.
We had an amazing downpour yesterday evening as we were waiting to go out to dinner. It was a hard rain, made even more significant by the sound of the rain on the metal roofs ! We went for dinner at PA’s, a sports bar of sorts, and had a good time. Then I went back to the Guest House. Senora started showing me “Liberia : America’s Stepchild” which appears to be a PBS production, but I fell asleep on the couch. She woke me up, and I ended up going to bed at 9:30 PM and sleeping very well !
Monday, March 15, 2010
Day 7
I was up at 8 to get ready for church. I was the only one of the HEARTT people to go, so at 9:45 Senora took me next door to wait for Uncle Jeff. He and I chatted for a while, as The President was having a meeting in the gazebo at the front of her house with about 20 people. At 10:15, she stood up to leave, and Jeff said it was time for us to get in the car to join the motorcade. The convoy consisted of The Presidential Escort vehicle in front, followed by a number of police and SSS (Special Security Services aka Secret Service) vehicles, a UN Land Rover with several troops, and us. I think there were about 10 vehicles in all. As we drove along, all other vehicles pulled to the side of the road, on both sides, when we went through. We went to the Trinity Cathedral on Broad St for Episcopal services honoring Mothering Day. The front pew was divided: Jeff and the President sat on one side, and I sat on the other. At some point in the service they made some announcements, and soon afterwards one of the deacons came to me and asked me to write down my name. He then went to the altar and made a special announcement recognizing me and my purpose for being in Liberia, and then had me stand and they all applauded. There were probably 200 people there. The service went on for quite some time (like 3 hours) and then we all left. The motorcade went up around Mamba Point and the American Embassy, and then down Broad St where she got out to inspect some project. Then we came home, arriving around 2:15 PM.
Senora was here, so we made some popcorn on the microwave and I had a few beers while we chatted.
After a short nap, we went next door to the President’s house for a reception. Madame President Ellen Johnson Surlief is a delightful woman. She expressed her deep appreciation for the work that HEARTT volunteers are doing for patients as well as for the nation of Liberia. We had drinks, and photos, and a light snack dinner, and the more time for conversation around the pool. I had a very pleasant conversation with her, and she signed my copy of her book. I told her that I had first seen her on The Daily Show; she told me that Adaman’s 10 year old son had coached her on what to expect, and that she needed to throw John Stewart some curve balls to keep him off balance ! She was so sweet and kind; I think Colleen talked to her for 20-30 min, and was beaming the whole time ! I also had interesting conversations with other such as Dr. Gooma, the anesthesiologist, and Dr. McDonald. They both expressed appreciation for our being here; I later heard from Dr. McDonald that Dr. Gooma said it was so nice to have surgeons who could do a hernia in less than an hour rather then the 2.5 hours they were used to ! I asked Dr. Gooma what was on her wishlist, and either a fiberoptic laryngoscope or a Glide Scope are top choices. We shall see. After that, many of us went out to the Palm Spring Hotel for a few drinks and more conversation.
Senora was here, so we made some popcorn on the microwave and I had a few beers while we chatted.
After a short nap, we went next door to the President’s house for a reception. Madame President Ellen Johnson Surlief is a delightful woman. She expressed her deep appreciation for the work that HEARTT volunteers are doing for patients as well as for the nation of Liberia. We had drinks, and photos, and a light snack dinner, and the more time for conversation around the pool. I had a very pleasant conversation with her, and she signed my copy of her book. I told her that I had first seen her on The Daily Show; she told me that Adaman’s 10 year old son had coached her on what to expect, and that she needed to throw John Stewart some curve balls to keep him off balance ! She was so sweet and kind; I think Colleen talked to her for 20-30 min, and was beaming the whole time ! I also had interesting conversations with other such as Dr. Gooma, the anesthesiologist, and Dr. McDonald. They both expressed appreciation for our being here; I later heard from Dr. McDonald that Dr. Gooma said it was so nice to have surgeons who could do a hernia in less than an hour rather then the 2.5 hours they were used to ! I asked Dr. Gooma what was on her wishlist, and either a fiberoptic laryngoscope or a Glide Scope are top choices. We shall see. After that, many of us went out to the Palm Spring Hotel for a few drinks and more conversation.
Day 6
It’s Saturday, but we are back in the OR trying to take care of our backlog of cases. First was a young girl (18 or 19) with a giant juvenile fibroadenoma measuring about 15 cm across in her left breast and several smaller 2-3 cm fiboadenomas in her right breast. Colleen and I did it and it came out quite well, I think. It occurred to me during her surgery that we generally consider excessive blood loss to often be due to poor surgical technique, but I don’t think the surgeons here have the same perspective. At the same time we did that, Robert and one of the interns did an appendectomy for acute appendicitis.
Our next case was a mastectomy for inflammatory breast cancer. I regretted having ever had bad thoughts about the way they tolerate blood loss. It was a very bloody mess !! In the end it came out alright, but during the case I remembered how much I dislike a lot of bleeding and poor lights ! It became a matter of survival surgery: hoping that we could get through the operation, accomplish our objectives, and have a viable patient at the end. We succeeded in doing that, and in fact after a while the bleeding calmed down, and we actually ended up with a decent result. I doubt that we have changed her prognosis significantly, but we have hopefully made her short term outlook a little brighter.
Then we did an incarcerated inguinal hernia under spinal. For the first time some of the surgical house staff came in to watch, and it was good that they were interested. They asked good questions, and made some good comments. Then we made rounds to sort out what we ar doing on Monday. Although it is a public holiday, apparently it is a working holiday, and after some discussion with the anesthesia staff, we have been given permission to do cases. So we will do another mastectomy for a fungating breast cancer, and incisional hernia repair, and an ileostomy decommissioning. As people are learning that we are here, there are all sorts of patients being referred for possible surgery, so that is a good thing…for us anyway !
Then there was another hernia, but that turned out to be a hydrocele, so we were done for the day. We went to the Administration Building to meet Adaman, Senora, Jonis, and Steve along with Dr. McDonald. While they finished up there meeting, we spent some time chatting with a delightful woman whose name I will get…but she was a Professor of Dentistry/Maxillo-facial in Philadelphia before she retired and moved to Liberia. Her family is from Togo originally I believe. Anyway, there are NO dentists in Liberia, so she is setting up programs at JFK and elsewhere, and is much busier in her retirement than she ever expected! She was delightful to talk to, and had so many interesting ideas.
Tonight we came back here for dinner and beers, and had a good time once again. Tomorrow is Sunday, so we will have a day of rest…though we have some plans scheduled. Adaman came back from a visit after dinner to say that any of us who are interested are invited to attend church with The President tomorrow. We have to be ready when the convoy departs at 9:30; I’m going ! And then tomorrow night she has invited all of the HEARTT participants to her house at 5 PM.
Our next case was a mastectomy for inflammatory breast cancer. I regretted having ever had bad thoughts about the way they tolerate blood loss. It was a very bloody mess !! In the end it came out alright, but during the case I remembered how much I dislike a lot of bleeding and poor lights ! It became a matter of survival surgery: hoping that we could get through the operation, accomplish our objectives, and have a viable patient at the end. We succeeded in doing that, and in fact after a while the bleeding calmed down, and we actually ended up with a decent result. I doubt that we have changed her prognosis significantly, but we have hopefully made her short term outlook a little brighter.
Then we did an incarcerated inguinal hernia under spinal. For the first time some of the surgical house staff came in to watch, and it was good that they were interested. They asked good questions, and made some good comments. Then we made rounds to sort out what we ar doing on Monday. Although it is a public holiday, apparently it is a working holiday, and after some discussion with the anesthesia staff, we have been given permission to do cases. So we will do another mastectomy for a fungating breast cancer, and incisional hernia repair, and an ileostomy decommissioning. As people are learning that we are here, there are all sorts of patients being referred for possible surgery, so that is a good thing…for us anyway !
Then there was another hernia, but that turned out to be a hydrocele, so we were done for the day. We went to the Administration Building to meet Adaman, Senora, Jonis, and Steve along with Dr. McDonald. While they finished up there meeting, we spent some time chatting with a delightful woman whose name I will get…but she was a Professor of Dentistry/Maxillo-facial in Philadelphia before she retired and moved to Liberia. Her family is from Togo originally I believe. Anyway, there are NO dentists in Liberia, so she is setting up programs at JFK and elsewhere, and is much busier in her retirement than she ever expected! She was delightful to talk to, and had so many interesting ideas.
Tonight we came back here for dinner and beers, and had a good time once again. Tomorrow is Sunday, so we will have a day of rest…though we have some plans scheduled. Adaman came back from a visit after dinner to say that any of us who are interested are invited to attend church with The President tomorrow. We have to be ready when the convoy departs at 9:30; I’m going ! And then tomorrow night she has invited all of the HEARTT participants to her house at 5 PM.
Friday, March 12, 2010
Day 4
I should apologize to the non-medical readers for putting in so much clinical detail on patients, but in addition to being something for you to read, this blog is going to serve as a resource for me in remembering the patients we have seen. So I need to put in the gory details!
Today was Outpatient Clinic day, so that is where we spent the morning seeing a remarkable variety of pathology. A surprising number of breast cases, including a middle aged woman with locally advanced cancer who is in pain and will have a mastectomy tomorrow for palliation. Afterwards, if she has the means, she can buy some oral chemotherapy and some tamoxifen, in the hope that the drugs to slow the progression of her cancer. It is an interesting, and perhaps bizarre, indication of the state of medicine in Liberia that all of this will be done without benefit of pathology, since there is no pathologist here. I know it is cancer, just from looking at it; nonetheless, my mind would prefer the certainty of a pathological diagnosis. We saw another younger woman in clinic who had a breast mass excised 2 years ago, and it was assumed to be benign; however she now has a mass in the area of the scar and palpable hard nodes in her axilla. This most likely represents recurrent breast cancer, but we don’t know for sure. She has the means to go to Ghana for further evaluation and treatment, and so that is what she will do.
On the wards today we saw two young patients in their early 30s with what appears to be squamous cell carcinoma of the anus. One is female, the other male, and both are far advanced. An attempt will be made to send them to Ghana for radiation therapy, but it is expensive and for each of them strictly palliative. The male has bilateral lower extremity edema and scrotal edema, most likely as a result of involvement of his inguinal nodes. His cancer has invaded the sphincter, so he is incontinent; the medicine residents are going to discuss the possibility of a diverting colostomy with him, just for hygiene and dignity purposes. They will also ask if he wants to make the trip to Ghana.
Other interesting patients in the clinic included a 7 year old girl with what looks like a hemangioma of her popliteal fossa; she will go to see Dr. Sherman at the Firestone Clinic; a couple of hernias; and a young girl about 19 with a large mass in her left breast and a couple of medium sized masses in her right breast. She had a left breast mass removed, but this has grown back. It is smooth like a giant juvenile fibroadenoma, but the recurrence makes me wonder about a phylloides tumor. Since we have no pathology, we will never know for sure, but if we can get her into the hospital for surgery before we leave, I will take many pictures of the whole and cut mass.
This afternoon we repaired an inguinal and an umbilical hernia is a 5 year old girl named Hannah. There is a Chinese pediatric surgeon here who watched the case and asked me a number of questions afterwards. I told him about Loupes, and he was quite excited !
This evening we saw a 7 year old boy in the ED who was moribund from dehydration when he came in; we were asked to see him because of a question of whether he could have a typhoid perforation. That seems unlikely, based on his softly distended abdomen. He was started on IV fluids, and his father was sent out to get ceftriaxone. That is the deal: patients or family are expected to supply any medicine which is needed, especially in the ED. There was no ceftriaxone in the hospital pharmacy, and at last report the father had been to 3 separate pharmacies attempting to purchase an adequate supply of the drug. The boy looks terribly undernourished in addition to being dehydrated; I wonder if there is something chronic going on in addition to whatever the acute process is. I suspect that tomorrow morning we will hear that he has died.
This evening James (Adaman) picked us up at the hospital and brought us back to the Guest House for dinner: Robert, Colleen, Senora, Dr. Steven Dahl, Georgette, and Adaman. We had a nice dinner : fish, vegetable and potatoes, and rice; Adaman told us stories of his life, and his mother’s life, when they were growing up. All four of her sons were in college in the USA when she was arrested following an unsuccessful attempt to overthrow President Doe in 1985. They were told that she had died, and did not learn until 6 months later that she was in fact still alive and in prison.
We have 5 cases to do tomorrow, so that should be interesting! Stay tuned for details !!
Today was Outpatient Clinic day, so that is where we spent the morning seeing a remarkable variety of pathology. A surprising number of breast cases, including a middle aged woman with locally advanced cancer who is in pain and will have a mastectomy tomorrow for palliation. Afterwards, if she has the means, she can buy some oral chemotherapy and some tamoxifen, in the hope that the drugs to slow the progression of her cancer. It is an interesting, and perhaps bizarre, indication of the state of medicine in Liberia that all of this will be done without benefit of pathology, since there is no pathologist here. I know it is cancer, just from looking at it; nonetheless, my mind would prefer the certainty of a pathological diagnosis. We saw another younger woman in clinic who had a breast mass excised 2 years ago, and it was assumed to be benign; however she now has a mass in the area of the scar and palpable hard nodes in her axilla. This most likely represents recurrent breast cancer, but we don’t know for sure. She has the means to go to Ghana for further evaluation and treatment, and so that is what she will do.
On the wards today we saw two young patients in their early 30s with what appears to be squamous cell carcinoma of the anus. One is female, the other male, and both are far advanced. An attempt will be made to send them to Ghana for radiation therapy, but it is expensive and for each of them strictly palliative. The male has bilateral lower extremity edema and scrotal edema, most likely as a result of involvement of his inguinal nodes. His cancer has invaded the sphincter, so he is incontinent; the medicine residents are going to discuss the possibility of a diverting colostomy with him, just for hygiene and dignity purposes. They will also ask if he wants to make the trip to Ghana.
Other interesting patients in the clinic included a 7 year old girl with what looks like a hemangioma of her popliteal fossa; she will go to see Dr. Sherman at the Firestone Clinic; a couple of hernias; and a young girl about 19 with a large mass in her left breast and a couple of medium sized masses in her right breast. She had a left breast mass removed, but this has grown back. It is smooth like a giant juvenile fibroadenoma, but the recurrence makes me wonder about a phylloides tumor. Since we have no pathology, we will never know for sure, but if we can get her into the hospital for surgery before we leave, I will take many pictures of the whole and cut mass.
This afternoon we repaired an inguinal and an umbilical hernia is a 5 year old girl named Hannah. There is a Chinese pediatric surgeon here who watched the case and asked me a number of questions afterwards. I told him about Loupes, and he was quite excited !
This evening we saw a 7 year old boy in the ED who was moribund from dehydration when he came in; we were asked to see him because of a question of whether he could have a typhoid perforation. That seems unlikely, based on his softly distended abdomen. He was started on IV fluids, and his father was sent out to get ceftriaxone. That is the deal: patients or family are expected to supply any medicine which is needed, especially in the ED. There was no ceftriaxone in the hospital pharmacy, and at last report the father had been to 3 separate pharmacies attempting to purchase an adequate supply of the drug. The boy looks terribly undernourished in addition to being dehydrated; I wonder if there is something chronic going on in addition to whatever the acute process is. I suspect that tomorrow morning we will hear that he has died.
This evening James (Adaman) picked us up at the hospital and brought us back to the Guest House for dinner: Robert, Colleen, Senora, Dr. Steven Dahl, Georgette, and Adaman. We had a nice dinner : fish, vegetable and potatoes, and rice; Adaman told us stories of his life, and his mother’s life, when they were growing up. All four of her sons were in college in the USA when she was arrested following an unsuccessful attempt to overthrow President Doe in 1985. They were told that she had died, and did not learn until 6 months later that she was in fact still alive and in prison.
We have 5 cases to do tomorrow, so that should be interesting! Stay tuned for details !!
Thursday, March 11, 2010
Day 3
I woke up early this morning, as we had planned for Dewall to pick me up at 8:30 so we could start our OR cases at 9. He arrived at 8:30, but said that we couldn’t leave yet as Adaman was next door visiting his mother. Robert called me at 8:45 to say that they had already moved our patients up to the OR suite so we could start at 9 as planned; this was a totally unexpected display of efficiency!! Then at 9 AM, Adaman came walking down and said there was a change of plan, and that we had been invited for breakfast with his mother. So I had to call Robert to tell him that we would be delayed since I would be having breakfast with the President; this was perhaps the best excuse I have ever heard for a surgeon being late for his first case ! Anyway, before breakfast Adaman took me across the street to meet the Mayor of Monrovia, Mary Brough, who is a firecracker ! She is doing a lot to try to clean up the city; one of the things she told me was “the time for awareness has passed…now it is time for enforcement !” She gave us some Tshirts as we left…she is a very cool woman !
We then went for breakfast with Madam President. Her house is quite unassuming, aside from the pillbox and the armed UN soldiers and Liberian Army guys milling around. We all sat at the table, and rose when she entered, and then had a nice breakfast. She is quiet and appears very contemplative; she asked interesting questions, and added her perspective. She is in her early 70s, and was carrying 3 cell phones : a Blackberry, a small one, and one other I couldn’t identify. Also at breakfast was Uncle Jerry, and Aunt Jennie, two of her most trusted colleagues.
Then we went to the hospital. Robert and Colleen did a 5 year old girl (Blessing is her name) with a left inguinal hernia, followed by a 19 year old man with a right inguinal hernia, both of which went well. Then we planned to do Saah Two, a 62 year old man with a large mass on his posterior neck which we think is a hemangioma, and which spontaneously at least partially thrombosed. Unfortunately anesthesia could not intubate him, so we cancelled the case. We could possibly do a tracheostomy, and then resect the mass, but I thought it made sense to think about it and plan it rather than starting that at 2:30 in the afternoon. I could imagine us getting into serious bleeding as the light started to fade, and that would have been a regrettable moment.
Apparently overnight a 4 year old boy came in with an intestinal perforation, probably due to typhoid. One of the surgical trainees took him to the OR and repaired it, but in the Recovery Room his abdomen became very distended and he was having difficulty breathing. They couldn’t get the surgeon to come back; apparently they bagged him for a while, but then got tired and stopped. The boy died. Robert was quite upset that no one called him or us to help; we will see if there is anything we can do to change that. But since we are here for only 2 weeks, it is hard to introduce any systematic changes. I was thinking about M&M, so at least maybe someone would learn something through the deaths. But I don’t think they are ready for personal accountability yet. Death is handled more easily than expected, in part because it is just a fact of life. Infant mortality is high; the average lifespan is in the 40s; and 80% of the population is under 25.
Since yesterday was a National Holiday (Decoration Day, aka Memorial Day), things were slow so we joined the others at a resort about 20 minutes drive from Monrovia on the sea. It was developed by Robert Johnson, owner of Jet Magazine and others, and is really quite a nice spot. We had some beers, and food, and then came back to town. Then Georgette (pediatrician from Portugal, Senora, Jonis, James and I went to Sam’s Barbecue for another beer before calling Dewall to bring us home for the night.
We then went for breakfast with Madam President. Her house is quite unassuming, aside from the pillbox and the armed UN soldiers and Liberian Army guys milling around. We all sat at the table, and rose when she entered, and then had a nice breakfast. She is quiet and appears very contemplative; she asked interesting questions, and added her perspective. She is in her early 70s, and was carrying 3 cell phones : a Blackberry, a small one, and one other I couldn’t identify. Also at breakfast was Uncle Jerry, and Aunt Jennie, two of her most trusted colleagues.
Then we went to the hospital. Robert and Colleen did a 5 year old girl (Blessing is her name) with a left inguinal hernia, followed by a 19 year old man with a right inguinal hernia, both of which went well. Then we planned to do Saah Two, a 62 year old man with a large mass on his posterior neck which we think is a hemangioma, and which spontaneously at least partially thrombosed. Unfortunately anesthesia could not intubate him, so we cancelled the case. We could possibly do a tracheostomy, and then resect the mass, but I thought it made sense to think about it and plan it rather than starting that at 2:30 in the afternoon. I could imagine us getting into serious bleeding as the light started to fade, and that would have been a regrettable moment.
Apparently overnight a 4 year old boy came in with an intestinal perforation, probably due to typhoid. One of the surgical trainees took him to the OR and repaired it, but in the Recovery Room his abdomen became very distended and he was having difficulty breathing. They couldn’t get the surgeon to come back; apparently they bagged him for a while, but then got tired and stopped. The boy died. Robert was quite upset that no one called him or us to help; we will see if there is anything we can do to change that. But since we are here for only 2 weeks, it is hard to introduce any systematic changes. I was thinking about M&M, so at least maybe someone would learn something through the deaths. But I don’t think they are ready for personal accountability yet. Death is handled more easily than expected, in part because it is just a fact of life. Infant mortality is high; the average lifespan is in the 40s; and 80% of the population is under 25.
Since yesterday was a National Holiday (Decoration Day, aka Memorial Day), things were slow so we joined the others at a resort about 20 minutes drive from Monrovia on the sea. It was developed by Robert Johnson, owner of Jet Magazine and others, and is really quite a nice spot. We had some beers, and food, and then came back to town. Then Georgette (pediatrician from Portugal, Senora, Jonis, James and I went to Sam’s Barbecue for another beer before calling Dewall to bring us home for the night.
Wednesday, March 10, 2010
day 2
We met Adaman pretty close to 9 AM, and he took us on a tour of the hospital. Oh my. Some areas of the hospital are quite new, and look very nice; other areas such as the ER and the Outpatient Clinics are witness to a teeming mass of humanity under the most difficult conditions imaginable.
Here is a common scenario: the patient is seen and needs surgery, but it doesn’t need to be done emergently. He or she is told to go home, and come back when they have enough money to pay up front for the operation; they are given an estimate of what it will cost. So then they come back for their surgery, and the cost exceeds what they have pre-paid. They are ready for discharge from a medical standpoint, but now they are held in the hospital until they can pay more money to cover the excess charges. Of course most of them don’t have the money, so eventually, after a month or so, the hospital gives up and lets them go home. In the meantime, the hospital charges for board, meals, and medicine have been piling up. It seems like a no win situation for all parties.
On our tour of the hospital this morning we saw a woman in her 20s, 4 months pregnant, who was having seizures. It wasn’t clear to anyone if it was pre-eclampsia, or possibly cerebral malaria. This afternoon when we went back to the ward, she was being wheeled out having just died. Then we went to the pediatric floor to talk to one of the pediatricians; they were trying to resuscitate a newborn baby whom they think had a congenital heart abnormality; the resuscitation was unsuccessful and the baby died.
On a brighter note, we met with Dr. Moses, who is the senior surgical trainee, and we discussed some patients who need surgery. One man has a large mass on the back of his neck, which is probably a hemangioma with has spontaneously thrombosed; we will operate on him tomorrow. We also have a pediatric hernia to do tomorrow. Several other cases are waiting in the wings, so I think we will be quite busy.
Two of the medical residents(one from San Francisco, and one from UCLA I think) asked us to see a 32 year old man with abdominal bloating and pain in his upper stomach, and a palpable epigastric mass. They did an ultrasound with a portable machine, and we repeated it. I think the mass is a hepatoma (liver cancer). They had talked to his family, who wanted to take him from the hospital to go see a local healer (aka witch doctor); they were convinced to keep him in the hospital until we had seen him. I told one of the medical residents that the witch doctor was probably his best option now. One of the interesting aspects of this is that we don’t have many of the clinical tools which we normally use. We talked about doing an exploratory laparotomy to biopsy the mass, but there isn’t much point since there is no pathologist to make a diagnosis. In the end, we are forced to make clinical decisions based on much more uncertainty than we are used to, and that can be rather uncomfortable. Maybe it will get easier after a while, but I’m not sure.
This afternoon a group of us went in a minivan to tour the city, and to go to the site of the Hotel Ducor overlooking Monrovia. It is quite near the American Embassy on Mamba Point. It was a 5 star hotel before the war; now it is a shell, lived in by squatters, and patrolled by UN troops. It still offers quite a view of Monrovia. From there you have a nice view down Broad Street to the bridge which was fought over for months during the civil war. That bridge is a key access point into Monrovia.
Tonight many of us had dinner here at the Guest House; Aunt Jennie made food for us, I think, and it was quite pleasant. Most of us were too tired to go out after dinner, so it was an early night. Tomorrow is a national holiday …”Decoration Day”…where people go out to decorate the graves of their loved ones. Even though it is a holiday, the Hospital Administrator (Dr. McDonald) and the Chief Medical Officer (Dr. Brisbane) have given us permission to do surgery, and have arranged accordingly for staff.
I should note that Internet access is sketchy. There is wi-fi in the dormitory, but the speed is pretty slow. Last night after dinner Ben came over; he is a friend of Adaman’s who runs the telephone company. I think he might bring a wireless router over here for us to use, which would be nice !
Here is a common scenario: the patient is seen and needs surgery, but it doesn’t need to be done emergently. He or she is told to go home, and come back when they have enough money to pay up front for the operation; they are given an estimate of what it will cost. So then they come back for their surgery, and the cost exceeds what they have pre-paid. They are ready for discharge from a medical standpoint, but now they are held in the hospital until they can pay more money to cover the excess charges. Of course most of them don’t have the money, so eventually, after a month or so, the hospital gives up and lets them go home. In the meantime, the hospital charges for board, meals, and medicine have been piling up. It seems like a no win situation for all parties.
On our tour of the hospital this morning we saw a woman in her 20s, 4 months pregnant, who was having seizures. It wasn’t clear to anyone if it was pre-eclampsia, or possibly cerebral malaria. This afternoon when we went back to the ward, she was being wheeled out having just died. Then we went to the pediatric floor to talk to one of the pediatricians; they were trying to resuscitate a newborn baby whom they think had a congenital heart abnormality; the resuscitation was unsuccessful and the baby died.
On a brighter note, we met with Dr. Moses, who is the senior surgical trainee, and we discussed some patients who need surgery. One man has a large mass on the back of his neck, which is probably a hemangioma with has spontaneously thrombosed; we will operate on him tomorrow. We also have a pediatric hernia to do tomorrow. Several other cases are waiting in the wings, so I think we will be quite busy.
Two of the medical residents(one from San Francisco, and one from UCLA I think) asked us to see a 32 year old man with abdominal bloating and pain in his upper stomach, and a palpable epigastric mass. They did an ultrasound with a portable machine, and we repeated it. I think the mass is a hepatoma (liver cancer). They had talked to his family, who wanted to take him from the hospital to go see a local healer (aka witch doctor); they were convinced to keep him in the hospital until we had seen him. I told one of the medical residents that the witch doctor was probably his best option now. One of the interesting aspects of this is that we don’t have many of the clinical tools which we normally use. We talked about doing an exploratory laparotomy to biopsy the mass, but there isn’t much point since there is no pathologist to make a diagnosis. In the end, we are forced to make clinical decisions based on much more uncertainty than we are used to, and that can be rather uncomfortable. Maybe it will get easier after a while, but I’m not sure.
This afternoon a group of us went in a minivan to tour the city, and to go to the site of the Hotel Ducor overlooking Monrovia. It is quite near the American Embassy on Mamba Point. It was a 5 star hotel before the war; now it is a shell, lived in by squatters, and patrolled by UN troops. It still offers quite a view of Monrovia. From there you have a nice view down Broad Street to the bridge which was fought over for months during the civil war. That bridge is a key access point into Monrovia.
Tonight many of us had dinner here at the Guest House; Aunt Jennie made food for us, I think, and it was quite pleasant. Most of us were too tired to go out after dinner, so it was an early night. Tomorrow is a national holiday …”Decoration Day”…where people go out to decorate the graves of their loved ones. Even though it is a holiday, the Hospital Administrator (Dr. McDonald) and the Chief Medical Officer (Dr. Brisbane) have given us permission to do surgery, and have arranged accordingly for staff.
I should note that Internet access is sketchy. There is wi-fi in the dormitory, but the speed is pretty slow. Last night after dinner Ben came over; he is a friend of Adaman’s who runs the telephone company. I think he might bring a wireless router over here for us to use, which would be nice !
Tuesday, March 9, 2010
Day 1
The flight from JFK to Brussels was fairly miserable because of the lack of legroom; the flight from Brussels to Monrovia…7 hours…was better because the plane wasn’t crowded so we all had the opportunity to spread out. I got some sleep which was nice. The cast of characters so far includes James Sirleaf, aka Adaman. Adaman is his middle name, and that is how he is known by his friends, so I am learning to call him that. He is quite pleasant, and charming, and genuinely nice to all of us as well as others. When we arrived in Monrovia, many of the workers at the airport recognized him and said hello. We were offered special expedited treatment, but Adaman felt that we should wait in line like everyone else; after a short time, however, given the heat, etc, he relented and we were shown through while someone worked on our passports. We then collected the 11 pieces of luggage for the 5 of us, and drove into Monrovia. Before I describe that, let me tell you about the others… Senora was an ER nurse in Bridgeport, and has come to Liberia a number of times with James. She is staying here in the Presidential Guest House with me. Dr. Dahl is a retired Ob-Gyn from Phoenix who decided to join us about 10 days ago; he met up with us in Brussels. His nephew is a urologist at MGH. Jonas is a ER doc from Wisconsin who has been here before; he brought James, an ER resident from Chicago with him, and they will be here for a month. He has organized a multi-institutional ER resident rotation here, which I think could be the model for other rotations such as surgery. He just took a position as Program Director for the ER residency at the University of Wisconsin; prior to that he was at the Univeristy of ChicagoWe drove into Monrovia from the airport (about a 40 min drive) to drop Colleen and Robert at the hospital dormitory. Here I learned the first surprise of the trip, which is that there are a lot of other American medical people here, all sponsored by HEARTT. A pediatrician from Boston, and about 5 pediatric residents from a variety of different places in the USA and elesewhere; the ER docs as noted; and Justin, an orthopedic surgeon from NY who has been here for 8 months. We have already started collaborating; the pediatrician told me about a baby with a suspected posterior urethral valve who needs his bladder decompressed tomorrow. Wee have some pediatric Foley catheters in the nearly 200 pounds of supplies we brought, so we will probably try that first before going to a suprapubic cystostomy.We all went out for dinner at the Royal Hotel, and it was fun. I can already see that there will be many interesting conversations and collaborations between the ER, peds, and us. They seem genuinely happy to have a surgical team available; we are equally happy to have them here. After a restful night at the Presidential Guest House, feeling secure in a compound is guarded by UN soldiers, I’m ready for whatever challenges the day may bring…and I have no doubt that there will be plenty of challenges!
But before we get to that, let me tell you about the Guest House. George and Laura Bush stayed here apparently; I guess if it is good enough for them then it will be alright for me !It is about a 10 minute drive down the main boulevard from the hospital. It is quite large with a number of bedrooms as well as a spacious living room and dining room area. From my bedroom on the second floor I can see the ocean; there is a damaged building between the Guest House and the ocean, and I just saw a UN vehicle come out from behind that building. Serona told me that the last time she stayed here, several years ago, this was a bombed out building, as I guess it was a target more than once during the civil war. Nice air conditioning, though I don’t think there in any Internet access here. They do have access at the dorm, so I will bring my laptop with me today and I can send my blog from there. As I write this at 7:30 AM, the electricity just went out; I believe this is a fact of life in Monrovia which is just another of the challenges of living here. It will be interesting to see how these unexpected blackouts work at the hospital ! We are supposed to meet Adaman (James) at the hospital at 9 AM, but I have to keep reminding myself that we are on West African time. I guess the time is an approximation of when we might get together, rather than anything set in stone !We will wait for Dewall to come pick us up; he is Adaman’s driver when he is in Liberia, and I think he is a government/protective services employee. In any case, he seems to be the “go-to” guy for any of our needs.
But before we get to that, let me tell you about the Guest House. George and Laura Bush stayed here apparently; I guess if it is good enough for them then it will be alright for me !It is about a 10 minute drive down the main boulevard from the hospital. It is quite large with a number of bedrooms as well as a spacious living room and dining room area. From my bedroom on the second floor I can see the ocean; there is a damaged building between the Guest House and the ocean, and I just saw a UN vehicle come out from behind that building. Serona told me that the last time she stayed here, several years ago, this was a bombed out building, as I guess it was a target more than once during the civil war. Nice air conditioning, though I don’t think there in any Internet access here. They do have access at the dorm, so I will bring my laptop with me today and I can send my blog from there. As I write this at 7:30 AM, the electricity just went out; I believe this is a fact of life in Monrovia which is just another of the challenges of living here. It will be interesting to see how these unexpected blackouts work at the hospital ! We are supposed to meet Adaman (James) at the hospital at 9 AM, but I have to keep reminding myself that we are on West African time. I guess the time is an approximation of when we might get together, rather than anything set in stone !We will wait for Dewall to come pick us up; he is Adaman’s driver when he is in Liberia, and I think he is a government/protective services employee. In any case, he seems to be the “go-to” guy for any of our needs.
Sunday, March 7, 2010
A hint of things to come?
Yesterday evening I was in Waterbury looking for something to bring to President Ellen Johnson-Sirleaf as a gift; alas I could find nothing suitable. Unfortunately for me, as I was getting out of my car, apparently my wallet slipped out of my pocket onto the street. I didn't know this until I had left the store and noticed that it was gone. I ran back in and looked all around the store, but I couldn't find it. I thought maybe I had left it at home, so I dashed home...but my wallet wasn't here.
Then I saw the message light blinking on my phone. I listened, and it was a woman in Waterbury who said that her husband had found my wallet, and I could come pick it up. I went over to their second floor apartment in what we might describe as not the nicest part of Waterbury, and I met her and her husband...and their 8 children ! He told me that he saw my wallet in the street, and quickly picked it up and put it in his pocket, looking around to see if anyone had seen him. Then he remembered a promise he had made to himself, that if he ever found a wallet and it had ID in it, he would get it back to the owner. He went home with my wallet (which had about $20 in it along with credit cards, my driver's license, and some medical IDs), and looked up my phone number on the Internet.
I thanked him for his kindness and his honesty, and I gave him a nice reward. I hope that his children learn the lesson that honesty pays. I know that through his actions, he has reaffirmed my belief that there are a lot of good souls in this world.
Then I saw the message light blinking on my phone. I listened, and it was a woman in Waterbury who said that her husband had found my wallet, and I could come pick it up. I went over to their second floor apartment in what we might describe as not the nicest part of Waterbury, and I met her and her husband...and their 8 children ! He told me that he saw my wallet in the street, and quickly picked it up and put it in his pocket, looking around to see if anyone had seen him. Then he remembered a promise he had made to himself, that if he ever found a wallet and it had ID in it, he would get it back to the owner. He went home with my wallet (which had about $20 in it along with credit cards, my driver's license, and some medical IDs), and looked up my phone number on the Internet.
I thanked him for his kindness and his honesty, and I gave him a nice reward. I hope that his children learn the lesson that honesty pays. I know that through his actions, he has reaffirmed my belief that there are a lot of good souls in this world.
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