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…