We had a few drinks at Rob's house along with the Minister of Defense and the Minister of Maritime Affairs; they were both quite interested. What we were doing, and interesting to talk to about Liberia. Rob and his wife Clare were also quite fun to chat with. Then we went out to the Red Lion where they had a live band. Eventually Ben arrived; we met a crew from CNN and they were interesting to talk to.
Now I have packed up and I am ready to leave. As it turns out, Madame President is on the same flight with us, as she is going to NYC for the Clinton Conference and then the opening of the UN General Assembly. I believe she will be speaking at the Clinton Conference. So a lot of her staff as well as Aunt Jenny are on the flight with us. Adamah talked to the Delta manager at the airport about upgrading me to Business; she came back and said it would be $2000+ to do so. He mentioned this to Aunt Jenny, and that he was pissed about it; she has spoken to someone so we will see what happens. In the meantime Adamah and I agreed that, at his insistence, we could switch in Accra...but when we boarded he insisted that I take 4F, so here I am. As it turns out, the purser on the flight is an ex-girlfriend of his ! So he is sitting in Business Class to Accra at least, and they are working on an upgrade to Atlanta. He says that he really doesn't mind flying in coach; I have to say that I really like the legroom and ability to sleep in the up front seats on long flights. So I am feeling less and less guilty about taking his seat !
I think this has been another useful and educational trip for me. There is a certain excitement which comes from being present in a country which is really just be beginning to recover from a horrible war. While the Liberians have every right to be angry with the world and their lot in it, and depressed, and feeling hopeless, they do not appear to feel that way at all. They appear optimistic for the most part, and eager to progress with rebuilding their devastated country. There is so much that needs to be done, and it will take a lot of time and money and patience; they certainly seem to have the will and determination to accomplish it. Personally, I don't that they would have made nearly as much progress as they have without the steady hand and vision of President Sirleaf. This 70+ year old woman could easily be living an easier life anywhere else in the world, but here she is working 12 to 15 hour days trying to make Liberia a better place. I doubt that any other Liberian politician would have had the success that she has had in convincing creditors to forgive Liberia's debt to the extent that they have.
In terms of the medical/surgical work, i think it was useful for me to come and do 38 cases with Moses and Konneh. I think there was mutual education, and I certainly have a better feel for what they are dealing with professionally. I am looking forward to coming back here in March with residents, and I think we can continue the mutual education process. If we were to pick one big area to concentrate on, perhaps it would be to introduce the concept of short stay surgery. There really is no need for a healthy, educated, motivated patient to stay in the hospital for 3 nights, including a pre-op night, for a hernia repair. Addressing this would free up some needed beds, potentially make it cheaper for the patient, and would really be moving in the direction they need to go. Clearly there are hurdles to cross: anesthesia and the bureaucracy are two which spring to mind immediately. But these are not insurmountable problems; we just need to find the Liberian solution to solving them.
Monday, September 20, 2010
Saturday September 18
Another fascinating day in Liberia ! And it's only half over ! This morning Laura, Jennifer, Adamah and I had breakfast with the President. Also there was Aunt Jenny, a female Superintendant from Bassa County, and Eric Werker, an Assistant Professor at Harvard Business School and Special Advisor to the President. As before, Madame President was her usual engaging, charming self going around the table asking each of us about our experience in Liberia etc. We all also particularly enjoyed talking to Eric, and having him explain to us as an economist how Liberia might start to get back on it's feet. A major step recently was the 97% "haircut" (the term used these days to describe the forgiving of national debt) recently agreed to by private debt holders...well all except one...such the Liberia no longer has debt that needs to be paid back. In terms of economic advise, he suggested that the way to move forward was the ascertain where the country wants to go, and then figure out what are the obstacles to accomplishing that, and then set about to remove those obstacles. Obviously it all takes time, and can be frustrating, but it makes sense. Along those lines is also figuring out ways to incentivize people to work harder, produce more, and grow the economy; he used e example of China figuring out that a farmer growing rice will produce more if he can keep a portion of what he grows to sell, thus putting money in his pocket which will be used to buy things, etc. Another point Eric made was that in attracting foreign investment and companies to mine, drill oil, etc. what is hoped is that at certain nodal points there will be opportunities for Liberians to become part of the process whether driving trucks, providing food, providing legal services, or whatever. Eric's wife is an ER doc, so it is possible that she will become part of the HEARTT team at some point. We remarked later that it was one of the unexpected benefits of these trips that we are able to meet such interesting and informative people !
Laura and Jennifer then went shopping while Adamah and I went to his late uncle's clinic in downtown Monrovia. Adamah still owns the property, and a clinic stills runs there staffed by a PA with occasional visits from a doctor. His uncle was a real general doctor who did surgery, delivered babies, and saw medical patients. He lived on the third floor; on the second floor was an Operating Room, a Delivery Room, and several patient rooms. In the OR we found some log books of nurses notes keeping daily track of patients: one entry indicated that there were 9 patients as inpatients at the clinic, including a couple of women who had just delivered babies and a man who had undergone an appendectomy. There was also a picture of Dr Sirleaf in his robes with a medallion, and Adamah tells me that he was once President of the West African College of Surgeons! I think it would be worth investigating whether the WACS would be interested in rebuilding Liberian surgery...
This evening we are all going for dinner at the house of Adamah's brother Rob, who is in charge of national security in Liberia. should be interesting !! According to the New York Times, he recently participated in a sting with the FBI in which a Columbian drug attempted to bribe him so that they could use Liberia as a shipping transit point for selling in Europe etc. They were subsequently arrested by the DEA here in Liberia; there is some concern that the cartel will seek revenge on Rob, so he is laying low.
Laura and Jennifer then went shopping while Adamah and I went to his late uncle's clinic in downtown Monrovia. Adamah still owns the property, and a clinic stills runs there staffed by a PA with occasional visits from a doctor. His uncle was a real general doctor who did surgery, delivered babies, and saw medical patients. He lived on the third floor; on the second floor was an Operating Room, a Delivery Room, and several patient rooms. In the OR we found some log books of nurses notes keeping daily track of patients: one entry indicated that there were 9 patients as inpatients at the clinic, including a couple of women who had just delivered babies and a man who had undergone an appendectomy. There was also a picture of Dr Sirleaf in his robes with a medallion, and Adamah tells me that he was once President of the West African College of Surgeons! I think it would be worth investigating whether the WACS would be interested in rebuilding Liberian surgery...
This evening we are all going for dinner at the house of Adamah's brother Rob, who is in charge of national security in Liberia. should be interesting !! According to the New York Times, he recently participated in a sting with the FBI in which a Columbian drug attempted to bribe him so that they could use Liberia as a shipping transit point for selling in Europe etc. They were subsequently arrested by the DEA here in Liberia; there is some concern that the cartel will seek revenge on Rob, so he is laying low.
Friday, September 17, 2010
Friday September 17
Final day of surgery at JFK for this trip. A couple of hernias, an esophageal dilation in a baby who swallowed some caustic substance a few months ago, an ileostomy decommissioning, and a huge groin lipoma. The decommissioning was in a young woman who had a typhoid perforation and severe peritonitis several months ago, so Moses did a loop ileostomy. For the decommissioning we took down the ileostomy, did the reanastomosis, and dropped it back in through the ostomy site. It worked well, and I was pleased that Moses felt comfortable avoiding a laparotomy.
Jennifer had come to the OR and was taking pictures, and after the lipoma we were taken for lunch at the home of George Saff, the Lebanese patient who had the hernia repair 9 days ago. He lives with his brother, who is a big deal in Monrovia. He has been here for most of his life, even during the war years, and has extensive investments in real estate, hotels, and the Lebanese restaurant where we ate last night, and which is next door to their house. He is President of the Chamber of Commerce, and appears to be very well connected in government circles. They put on a very nice lunch for us and Aunt Jennie, whom I saw as we arrived and she was leaving. George is thankfully doing well, walking upright, and just dealing with the scars of a painful first night after surgery !
Tonight we will have dinner at the house, and then go out to some clubs apparently. We might go up to Robertsport tomorrow if the weather is nice. And then we will leave on Sunday afternoon, arriving back in the USA on Monday morning.
It has been a good trip, but I have seen enough pathology and I am ready to return to a place where the diseases are not as obvious, the care can be given without concern for financial issues being in the forefront, and where the patients seek care soon enough so that the likelihood of a successful outcome is substantial. Jennifer and I had an interesting discussion this afternoon about attitudes to work by medical personnel in a setting such as this. I have mentioned before that the result of a high mortality rate for illness, combined with the horrors of living through civil wars(which really were not at all civil), results in people having a more detached attitude toward life than we are used to. It is only natural that they cannot invest a lot personally in the life of a patient because there is a significant likelihood that that patient, if severely ill, will not survive. But what we and others would like to accomplish is to develop a sense of professionalism among health care workers, such that they recognize the special bond of trust that exists between patients and caregivers. It will take a long time to move from here to there.
Jennifer had come to the OR and was taking pictures, and after the lipoma we were taken for lunch at the home of George Saff, the Lebanese patient who had the hernia repair 9 days ago. He lives with his brother, who is a big deal in Monrovia. He has been here for most of his life, even during the war years, and has extensive investments in real estate, hotels, and the Lebanese restaurant where we ate last night, and which is next door to their house. He is President of the Chamber of Commerce, and appears to be very well connected in government circles. They put on a very nice lunch for us and Aunt Jennie, whom I saw as we arrived and she was leaving. George is thankfully doing well, walking upright, and just dealing with the scars of a painful first night after surgery !
Tonight we will have dinner at the house, and then go out to some clubs apparently. We might go up to Robertsport tomorrow if the weather is nice. And then we will leave on Sunday afternoon, arriving back in the USA on Monday morning.
It has been a good trip, but I have seen enough pathology and I am ready to return to a place where the diseases are not as obvious, the care can be given without concern for financial issues being in the forefront, and where the patients seek care soon enough so that the likelihood of a successful outcome is substantial. Jennifer and I had an interesting discussion this afternoon about attitudes to work by medical personnel in a setting such as this. I have mentioned before that the result of a high mortality rate for illness, combined with the horrors of living through civil wars(which really were not at all civil), results in people having a more detached attitude toward life than we are used to. It is only natural that they cannot invest a lot personally in the life of a patient because there is a significant likelihood that that patient, if severely ill, will not survive. But what we and others would like to accomplish is to develop a sense of professionalism among health care workers, such that they recognize the special bond of trust that exists between patients and caregivers. It will take a long time to move from here to there.
THursday Septerber 16
The rest of the HEARTT team went on the chopper to Nimba today, but we had a lot of cases scheduled, including the 16 year old with the burn contracture, so I decided to not take the Nimba trip. Adamah had suggested that I could do the contracture on Friday instead, but I didn't think that would be right after a lot of people worked to get him admitted yesterday.
Before we did him, however, we did several cases including a 34 year old woman with locally advanced breast cancer. She had come to the doctor complaining of a "knot" in her right breast for the past year or two. Rumor has it that she went to either Ghana or the Cote d'Ivoire and had a biopsy done, which might account for the open wound in her upper outer breast. She also had palpable matted axillary nodes. Moses and I talked about how one deals with such cases; he said that if he had seen her in the clinic he would have recommended that she return to wherever the biopsy was done. However, since she was admitted to the hospital, he felt an obligation to give her her money's worth and go ahead with the mastectomy. Not an ideal situation at all.
Then we did the burned boy. We excised the keloid/contracture from mid chest up onto his face and chin. We also tried to fix his extropion. I hope we have improved things for him, but I'm not sure. Serious burn care with rehabilitation and everything else necessary is just not available in Liberia. This boy needs far more than we are able to give him, but perhaps we have made a first step.
The Nimba travelers are back. They went to see this hospital built by the Chinese in a relatively remote area of Liberia. The facilities are beautiful, but whether it can function as a hospital remains to be seen. Hospitals require a lot more than just a building; it is not clear where the people in charge think they are going to get either the money or the staff to run it. For instance, they have 3 diesel generators to supply power to the facility, but it is estimated that it will cost in the range of $250,000 a year for the fuel. To say nothing of the fact that it is a 9 hour drive from the port of Monrovia where diesel comes in, and the roads are virtually all dirt. Oh, and the government is suggesting a budget of $500,000 a year for the hospital. No, the economics make no sense.
Before we did him, however, we did several cases including a 34 year old woman with locally advanced breast cancer. She had come to the doctor complaining of a "knot" in her right breast for the past year or two. Rumor has it that she went to either Ghana or the Cote d'Ivoire and had a biopsy done, which might account for the open wound in her upper outer breast. She also had palpable matted axillary nodes. Moses and I talked about how one deals with such cases; he said that if he had seen her in the clinic he would have recommended that she return to wherever the biopsy was done. However, since she was admitted to the hospital, he felt an obligation to give her her money's worth and go ahead with the mastectomy. Not an ideal situation at all.
Then we did the burned boy. We excised the keloid/contracture from mid chest up onto his face and chin. We also tried to fix his extropion. I hope we have improved things for him, but I'm not sure. Serious burn care with rehabilitation and everything else necessary is just not available in Liberia. This boy needs far more than we are able to give him, but perhaps we have made a first step.
The Nimba travelers are back. They went to see this hospital built by the Chinese in a relatively remote area of Liberia. The facilities are beautiful, but whether it can function as a hospital remains to be seen. Hospitals require a lot more than just a building; it is not clear where the people in charge think they are going to get either the money or the staff to run it. For instance, they have 3 diesel generators to supply power to the facility, but it is estimated that it will cost in the range of $250,000 a year for the fuel. To say nothing of the fact that it is a 9 hour drive from the port of Monrovia where diesel comes in, and the roads are virtually all dirt. Oh, and the government is suggesting a budget of $500,000 a year for the hospital. No, the economics make no sense.
Wednesday, September 15, 2010
Wednesday September 15
Apparently there was no helicopter available to fly us to Nimba today, so we tried to do a few cases instead. One of them was going to be a nurse of the Outpatient Clinic, but her hemoglobin was low so Anesthesia declared her unfit for surgery. We tried to dilate the esophagus of a 4 year old boy who ingested lye a couple of months ago, but his cervical esophagus is completely strictured. This makes sense since apparently he is unable to swallow his own saliva. He has a gastrostomy tube, but still looks woefully malnourished. His longterm prognosis is grim.
Moses, Konneh, Barbor (one of the interns) and I then had an interesting discussion about the future of surgery in Liberia. The problems are immense, and it is hard to know where to start. Barbor feels that the interns are treated poorly by JFK and he has a point. They are paid $265 a month, and out of that they must pay for rent, transportation, meals, and even their phone. He noted that they are expected to have a phone to call consultants, etc. but this is not reimbursed by the hospital. According to him, other places pay much better, and provide reimbursement for telephones, gas, etc as well as providing meals to those on call. Other problems in Liberia include the fact that the medical school is not accredited, so it is very difficult/impossible for Liberian graduates to go elsewhere for training. To develop a homegrown training system will require overcoming huge obstacles, but a start needs to be made. Konneh suggested what I have thought of, which would be to have a program of visiting surgeons coming for 2 weeks every month for instance, and to have a pre-planned surgical curriculum which everyone could follow. I wonder if perhaps the West African College of Surgeons could be enticed to show some interest in their neighbor also. The whole issue of finances is clearly a major obstacle in the Liberian health care system, and I have no idea how to solve that. Moses also pointed out that there is a severe manpower shortage, such that for January thru May there will be no interns on surgery. He is trying to get the hospital to hire some PAs, but I guess that they are not easy to find.
We then attempted to dilate the urethra of a 30 year old man who has had a supra pubic tube placed because it had gotten so bad. Moses tried for a while, and then called in the Chinese doctor who has helped him with these before. The Chinese doctor used sounds etc for what seems to me to be obstruction at the level of his prostate, but they were unable to pass a Foley. So now they are going to open him thru his bladder and try to pass retrograde and antegrade. I will go back in shortly to watch....ok they were successful and have finished. This points out the need for a urologist here, as well as a plastic surgeon, and an orthopedic surgeon, as well as a pathologist !
Konneh told me that he has to go to court tomorrow over a personal property issue. Apparently he bought some property and built on it, but now someone is claiming that they owned it and then person who sold it to him had no right to do so. This is a common problem in Liberia currently for several reasons. Record keeping isn't very good to start with, and the war only made all of that worse. In addition, many people left the country drug the war, and others consider that they abandoned their property, and therefor it was open to claim. My guess is that title insurance, if it exists, would be prohibitively expensive !
Moses, Konneh, Barbor (one of the interns) and I then had an interesting discussion about the future of surgery in Liberia. The problems are immense, and it is hard to know where to start. Barbor feels that the interns are treated poorly by JFK and he has a point. They are paid $265 a month, and out of that they must pay for rent, transportation, meals, and even their phone. He noted that they are expected to have a phone to call consultants, etc. but this is not reimbursed by the hospital. According to him, other places pay much better, and provide reimbursement for telephones, gas, etc as well as providing meals to those on call. Other problems in Liberia include the fact that the medical school is not accredited, so it is very difficult/impossible for Liberian graduates to go elsewhere for training. To develop a homegrown training system will require overcoming huge obstacles, but a start needs to be made. Konneh suggested what I have thought of, which would be to have a program of visiting surgeons coming for 2 weeks every month for instance, and to have a pre-planned surgical curriculum which everyone could follow. I wonder if perhaps the West African College of Surgeons could be enticed to show some interest in their neighbor also. The whole issue of finances is clearly a major obstacle in the Liberian health care system, and I have no idea how to solve that. Moses also pointed out that there is a severe manpower shortage, such that for January thru May there will be no interns on surgery. He is trying to get the hospital to hire some PAs, but I guess that they are not easy to find.
We then attempted to dilate the urethra of a 30 year old man who has had a supra pubic tube placed because it had gotten so bad. Moses tried for a while, and then called in the Chinese doctor who has helped him with these before. The Chinese doctor used sounds etc for what seems to me to be obstruction at the level of his prostate, but they were unable to pass a Foley. So now they are going to open him thru his bladder and try to pass retrograde and antegrade. I will go back in shortly to watch....ok they were successful and have finished. This points out the need for a urologist here, as well as a plastic surgeon, and an orthopedic surgeon, as well as a pathologist !
Konneh told me that he has to go to court tomorrow over a personal property issue. Apparently he bought some property and built on it, but now someone is claiming that they owned it and then person who sold it to him had no right to do so. This is a common problem in Liberia currently for several reasons. Record keeping isn't very good to start with, and the war only made all of that worse. In addition, many people left the country drug the war, and others consider that they abandoned their property, and therefor it was open to claim. My guess is that title insurance, if it exists, would be prohibitively expensive !
Tuesday, September 14, 2010
Tuesday September 14
The girl from yesterday is doing alright; we will just hope she keeps it up. We had 5 cases scheduled for today, but 3 were cancelled/postponed for a variety of reasons. So Moses and I repaired an incisional hernia in a large woman, and then bilateral inguinal hernias and an umbilical hernia in a 9 year old.
Then we went to the Outpatient Clinic and saw the usual wide variety of interesting and amazing pathology, in addition to a gazillion hernias in all ages. One notable patient is a 16 year old boy who had acid thrown on his face 5 months ago. It mostly struck the right side, so he has lost most of his right ear, and has a severe extropion from scar contracture; he says he can still see out of his right eye. In addition, and the area where I think we can help, the right side of his chin and mouth are essentially fused to his neck by contracture. He walks around with a towel covering his head and face.
After first seeing him, I asked Konneh what we could do. He appropriately said that the boy needs a plastic surgeon, but there aren't any in Liberia. So I suggested that we could and should at least try to help by releasing his neck contracture. He agreed, and then we spent a little time figuring out how we can get him admitted and done before I leave. I called Adamah, and he said that if it was something I wanted to do, then he would take care of surmounting the financial hurdles, which he did. So the hospital waived the usual fees for admission and surgery, and he will be admitted today for surgery either tomorrow or Thursday. Obviously this a just the first in a series of operations for this unfortunate man; I hope that we can eventually get him to the point where he doesn't feel the need to cover his head and face, but I know I am being wildly optimistic. After him we saw a woman with a bloody nipple discharge who needs a duct excision, and then another older woman with an advanced, fungating breast cancer. We will try to do both of those surgeries on Friday.
I am still waiting to hear if we will be going to Nimba tomorrow. This is the town and county where Adamah grew up, and by some remarkable circumstance it is where the Chinese have built a new hospital, complete with CT scan, to serve that area of Liberia. The Ministry of Health would like HEARTT to expand to that hospital, so Adamah wants to go up to see it. It is an 8 or 9 hour drive there from Monrovia, so using a few connections, he has been trying to get a UN helicopter to fly us there. I think they have agreed in principle, so now the only question is which day. If it is tomorrow I can do it, but if it is Thursday or Friday I won't be able to go as I have too much surgery to do before I leave on Sunday.
Then we went to the Outpatient Clinic and saw the usual wide variety of interesting and amazing pathology, in addition to a gazillion hernias in all ages. One notable patient is a 16 year old boy who had acid thrown on his face 5 months ago. It mostly struck the right side, so he has lost most of his right ear, and has a severe extropion from scar contracture; he says he can still see out of his right eye. In addition, and the area where I think we can help, the right side of his chin and mouth are essentially fused to his neck by contracture. He walks around with a towel covering his head and face.
After first seeing him, I asked Konneh what we could do. He appropriately said that the boy needs a plastic surgeon, but there aren't any in Liberia. So I suggested that we could and should at least try to help by releasing his neck contracture. He agreed, and then we spent a little time figuring out how we can get him admitted and done before I leave. I called Adamah, and he said that if it was something I wanted to do, then he would take care of surmounting the financial hurdles, which he did. So the hospital waived the usual fees for admission and surgery, and he will be admitted today for surgery either tomorrow or Thursday. Obviously this a just the first in a series of operations for this unfortunate man; I hope that we can eventually get him to the point where he doesn't feel the need to cover his head and face, but I know I am being wildly optimistic. After him we saw a woman with a bloody nipple discharge who needs a duct excision, and then another older woman with an advanced, fungating breast cancer. We will try to do both of those surgeries on Friday.
I am still waiting to hear if we will be going to Nimba tomorrow. This is the town and county where Adamah grew up, and by some remarkable circumstance it is where the Chinese have built a new hospital, complete with CT scan, to serve that area of Liberia. The Ministry of Health would like HEARTT to expand to that hospital, so Adamah wants to go up to see it. It is an 8 or 9 hour drive there from Monrovia, so using a few connections, he has been trying to get a UN helicopter to fly us there. I think they have agreed in principle, so now the only question is which day. If it is tomorrow I can do it, but if it is Thursday or Friday I won't be able to go as I have too much surgery to do before I leave on Sunday.
Monday September 13
Made ED Rounds with Adamah and others this morning. Saw a woman with probable Stevens-Johnson syndrome probably the result of an allergic reaction to a drug, but since show doesn't know the names of the antibiotics she has taken. Another man who apparently collapsed at home last night, but his wife had no means to get him to the hospital so she waited till morning when a relative with a car was available. He is febrile, comatose, and having seizures; there is no good way to make a diagnosis other than to treat him for the major possibilities, and then see what transpires over time. It really is medicine by the seat of your pants !
We then attended Grand Rounds on glaucoma presented by the ophthalmologist. It was quite interesting, and reminded me that I need an eye appointment when I get home !
Our cases today included 3 hernias, and an appendectomy. It is difficult to criticize surgical technique given the equipment they and, the conditions under which they work ( dim lighting), and without knowing their results over time. I think that follow-up is an issue, as the system works against it. Moses says that when he tells patients to come to the outpatient clinic following discharge after surgery, he tells them not to register, as it is tedious, time-consuming, and costly. They just come to his clinic office directly to have their sutures removed etc. Of course that means there is no documentation in the chart, but so it goes.
They have had us bouncing between 2 rooms today, which has clearly made everything go faster. They also use MAD ( Minimal Anesthesia Dosing) as a standard technique. I don't think it has been written up, but clearly having the patient awake halfway through the operation allows them to get the patient off the table faster at the end of the case ! It is pretty much routine to have patients bucking and moving a lot; it is not something I tolerate well at home, but there isn't much I can say here. I really do think it is their way of minimizing the expense of anesthesia !
Now we are waiting on a 16 year old girl in the ED with an acute abdomen. Moses thinks it is a typhoid perforation. We are waiting for her relatives to collect the money required for her to have surgery. Konneh was saying that he thinks there has been a decrease in the number of typhoid perforations they see because of better sanitation and earlier treatment of typhoid.
Moses, Konneh and I had an interesting discussion about different aspects of surgery. They feel sort of left out because they have no access to laparoscopic surgery, nor do they expect it will happen any time soon. Even if visitors came and brought equipment, they wouldn't get enough experience to feel comfortable doing it. Moses has only done 2 cholecystectomies in his 15-20 year career !! They also understand the the expense of laparoscopic surgery is a major problem in terms of bringing it here.
We just finished surgery on the 16 year old girl who had a belly full of pus but no perforation that we could identify. We looked at everything, then washed her out and put in drains. I'm not sure what will happen with her, but I worry that she will not survive. Apparently she has been ill for a month at home; the failure of so many to seek medical attention early is a huge problem here.
We then attended Grand Rounds on glaucoma presented by the ophthalmologist. It was quite interesting, and reminded me that I need an eye appointment when I get home !
Our cases today included 3 hernias, and an appendectomy. It is difficult to criticize surgical technique given the equipment they and, the conditions under which they work ( dim lighting), and without knowing their results over time. I think that follow-up is an issue, as the system works against it. Moses says that when he tells patients to come to the outpatient clinic following discharge after surgery, he tells them not to register, as it is tedious, time-consuming, and costly. They just come to his clinic office directly to have their sutures removed etc. Of course that means there is no documentation in the chart, but so it goes.
They have had us bouncing between 2 rooms today, which has clearly made everything go faster. They also use MAD ( Minimal Anesthesia Dosing) as a standard technique. I don't think it has been written up, but clearly having the patient awake halfway through the operation allows them to get the patient off the table faster at the end of the case ! It is pretty much routine to have patients bucking and moving a lot; it is not something I tolerate well at home, but there isn't much I can say here. I really do think it is their way of minimizing the expense of anesthesia !
Now we are waiting on a 16 year old girl in the ED with an acute abdomen. Moses thinks it is a typhoid perforation. We are waiting for her relatives to collect the money required for her to have surgery. Konneh was saying that he thinks there has been a decrease in the number of typhoid perforations they see because of better sanitation and earlier treatment of typhoid.
Moses, Konneh and I had an interesting discussion about different aspects of surgery. They feel sort of left out because they have no access to laparoscopic surgery, nor do they expect it will happen any time soon. Even if visitors came and brought equipment, they wouldn't get enough experience to feel comfortable doing it. Moses has only done 2 cholecystectomies in his 15-20 year career !! They also understand the the expense of laparoscopic surgery is a major problem in terms of bringing it here.
We just finished surgery on the 16 year old girl who had a belly full of pus but no perforation that we could identify. We looked at everything, then washed her out and put in drains. I'm not sure what will happen with her, but I worry that she will not survive. Apparently she has been ill for a month at home; the failure of so many to seek medical attention early is a huge problem here.
Sunday, September 12, 2010
Saturday September 11
I slept quite late for me, thanks to Ambien and a late night !! Sometime after noon we all drove out to the house of Edwin, who is a representative in the Liberian House from Nimba county. Nimba is where Adamah grew up, and is the site of a new Chinese-built hospital complete with CT scanner. They haven't staffed it yet, but they are intreated in getting HEARTT to go out there. Apparently it is about 8 hours drive, and Adamah wants to see the place, so he is negotiating a UN helicopter ride out three this week. I would love to go if it works out, but we shall see. The current law is that no one in Liberia can have a helicopter except the UN.
After lunch, which was really mid-afternoon snack of fufu and rice ( I did have some fufu and it wasn't as disgusting as I had thought it would be !) we came back to the house, and then Simon and I went to the Royal Hotel to use the free WIFi. We had intreating conversation about global health, and the likelihood of Liberia sinking down into the chaos of civil war again. He is worried, as am I, that if President Sirleaf is not re-elected next year, the country is at great risk for deterioration and bloodshed. Hopefully that won't happen.
Tonight we have been invited to dinner at Adamah's brothers house. This is his oldest brother, Jess, who lives at the family compound in Congo Town, a suburb of Monrovia. One of the houses is where his mother was when she was arrested by the government of Samuel Doe ( I think) and put in prison. Adamah and his brothers were in the US at the time, and were told that she had been killed; they didn't learn that she was still alive until many months later. In any case, we went to Jess's house for dinner and drinks, and were joined by Ben and a female cousin and her daughter. lots of laughs, and we got to see the animals that Jess has: a crocodile maybe 8 inches long, a sea turtle, and a monkey. Next he wants to have a leopard ! Yes, a bit of a strange dude.
After dinner we went to the casino where Erin ( and others) played blackjack and she won $250 ! home at some early hour of the morning...
After lunch, which was really mid-afternoon snack of fufu and rice ( I did have some fufu and it wasn't as disgusting as I had thought it would be !) we came back to the house, and then Simon and I went to the Royal Hotel to use the free WIFi. We had intreating conversation about global health, and the likelihood of Liberia sinking down into the chaos of civil war again. He is worried, as am I, that if President Sirleaf is not re-elected next year, the country is at great risk for deterioration and bloodshed. Hopefully that won't happen.
Tonight we have been invited to dinner at Adamah's brothers house. This is his oldest brother, Jess, who lives at the family compound in Congo Town, a suburb of Monrovia. One of the houses is where his mother was when she was arrested by the government of Samuel Doe ( I think) and put in prison. Adamah and his brothers were in the US at the time, and were told that she had been killed; they didn't learn that she was still alive until many months later. In any case, we went to Jess's house for dinner and drinks, and were joined by Ben and a female cousin and her daughter. lots of laughs, and we got to see the animals that Jess has: a crocodile maybe 8 inches long, a sea turtle, and a monkey. Next he wants to have a leopard ! Yes, a bit of a strange dude.
After dinner we went to the casino where Erin ( and others) played blackjack and she won $250 ! home at some early hour of the morning...
Saturday, September 11, 2010
Friday September 10
It rained incredibly hard last night around 3 AM; I thought the roof would fall in ! Fortunately I was able to get back to sleep.
Discussing operative findings with patients is an interesting aspect of care here. In the absence of pathology, it 'hard to be definitive, and in the absence of treatment it is hard to be hopeful. Moses told me that he spoke with the man who had cancer involving his transverse colon as well as liver mets; he told him that the mass was very close to important structures and so we decided not to remove it. In a way, sort of partially the truth. I'm not at all sure what we tell the guy with lymphadenopathy which could be lymphoma, or it could be a localized typhoid perforation possibly. But since there is no effective treatment here for his lymphoma, I suppose some of the pressure is off.
We had 5 cases scheduled for today, but one was cancelled because she got her period last night, and anesthesia was concerned about heavy blood loss. Seems like a bogus reason to me, but you can't argue with them. If we argued that we should do the case, and they relented, and then something bad happened, we would never hear the end of it. The four cases we did were a pediatric hernia, an adult hernia, a breast mass, and a skin graft to a "tropical ulcer". The breast mass was in a 44 year old woman who had a mass excised from the same area in 2005. During the past 2 or 3 years she had noticed it growing again, and it was painful. I couldn't feel any axillary nodes. We took it out with wide margins. When I cut into it later, it felt gritty like a cancer, so I am bringing some tissue home for pathology. Tamoxifen is available in Liberia if this cancer is receptor positive; Moses says they would also prescribe cytoxan, since it is also available.
It doesn't look like we are going to do any surgery over the weekend. Moses is going to conference tomorrow and Konneh is on call. Today was the last day of Ramadan, so Konneh wasn't here for me to ask if he had anything brewing, but it sounds unlikely. Liberia is predominantly Christian, but there is a significant (10%) Muslim community.
I think this was a good idea for me to come alone this time, but I'm not sure I would do it again. It is certainly more fun to be part of a surgical team, and we could stay busy on weekends, as we did in March. Being here alone has allowed me to do some interesting cases with Moses and Konneh, and to get a better idea of their thought processes and skills, but I'm not sure how useful it would be for me to make such solo visits on an ongoing basis. Bringing residents has the advantage of providing a team to cover all aspects of surgical care, rather than the focus on the OR as it is with me here alone. I miss team rounds and discussions of pre- and post-operative care.
After dinner here with the usual suspects, we all went out to a bar called the Tides which had a nice balcony overlooking the water. And then around 1AM we moved Deja Vu with is a loud dance club. Stayed there for a while, was propositioned twice by the ever-present hookers, and then Eric took Nathan, Dave, Erin, and me home.
Discussing operative findings with patients is an interesting aspect of care here. In the absence of pathology, it 'hard to be definitive, and in the absence of treatment it is hard to be hopeful. Moses told me that he spoke with the man who had cancer involving his transverse colon as well as liver mets; he told him that the mass was very close to important structures and so we decided not to remove it. In a way, sort of partially the truth. I'm not at all sure what we tell the guy with lymphadenopathy which could be lymphoma, or it could be a localized typhoid perforation possibly. But since there is no effective treatment here for his lymphoma, I suppose some of the pressure is off.
We had 5 cases scheduled for today, but one was cancelled because she got her period last night, and anesthesia was concerned about heavy blood loss. Seems like a bogus reason to me, but you can't argue with them. If we argued that we should do the case, and they relented, and then something bad happened, we would never hear the end of it. The four cases we did were a pediatric hernia, an adult hernia, a breast mass, and a skin graft to a "tropical ulcer". The breast mass was in a 44 year old woman who had a mass excised from the same area in 2005. During the past 2 or 3 years she had noticed it growing again, and it was painful. I couldn't feel any axillary nodes. We took it out with wide margins. When I cut into it later, it felt gritty like a cancer, so I am bringing some tissue home for pathology. Tamoxifen is available in Liberia if this cancer is receptor positive; Moses says they would also prescribe cytoxan, since it is also available.
It doesn't look like we are going to do any surgery over the weekend. Moses is going to conference tomorrow and Konneh is on call. Today was the last day of Ramadan, so Konneh wasn't here for me to ask if he had anything brewing, but it sounds unlikely. Liberia is predominantly Christian, but there is a significant (10%) Muslim community.
I think this was a good idea for me to come alone this time, but I'm not sure I would do it again. It is certainly more fun to be part of a surgical team, and we could stay busy on weekends, as we did in March. Being here alone has allowed me to do some interesting cases with Moses and Konneh, and to get a better idea of their thought processes and skills, but I'm not sure how useful it would be for me to make such solo visits on an ongoing basis. Bringing residents has the advantage of providing a team to cover all aspects of surgical care, rather than the focus on the OR as it is with me here alone. I miss team rounds and discussions of pre- and post-operative care.
After dinner here with the usual suspects, we all went out to a bar called the Tides which had a nice balcony overlooking the water. And then around 1AM we moved Deja Vu with is a loud dance club. Stayed there for a while, was propositioned twice by the ever-present hookers, and then Eric took Nathan, Dave, Erin, and me home.
Friday, September 10, 2010
Thursday sept 9
My cold is better, so that is a good thing; it is no fun having a head cold in this heat and humidity.
I asked Moses and Konneh about some of our patients from last March. Mr. Too was seen a couple of times in clinic and was healing well before stopping his visits. The sweet large lady with advanced breast cancer developed a fairly rapid chest wall recurrence, and went home to die with her children around her. Everyone else did well, according to them.
The issue of finances continues to be frustrating. We have a young man in the ER with a palpable RLQ mass which is probably an appendiceal phlegmon. He was treated elsewhere with antibiotics, but his symptoms didn't resolve so he came to the clinic on Tuesday. Apparently he doesn't have the funds yet to be admitted, so he stays in the ER until he can find enough to cover the cost of admission and probable cost of his surgery. This is pretty much a constant problem with no solution in sight.
I gave Priscilla the dermatome blades yesterday to keep in secure storage, and they were all most appreciative ! They use each blade until it is dull, but they were completely out of them so this supply will allow them to do skin grafts again. They also very much appreciated the surgical scrub brushes, as they had none left. They had bought several of the little brushes with a glass container on top used for doing dishes, and suggested that these were okay for hand scrubbing. But the bristles are too hard and no one wanted to use them.
So far today Moses and I have done 3 children with hernias (well, 2 hernias and one hydrocele of the cord). His approach to pediatric hernias is somewhat different from mine, but it works so I don't suggest that he do it differently. We talked about pediatric surgery, and the fact that he has never seen pyloric stenosis. I described the operation to him in case he ever does see it. But i wonder if it really is that rare in Liberia, or if the babies who have it die of malnutrition and it is thought to be due to some other cause. If I remember, I will ask Dr. Emmanuel, the pediatrician. Now we are waiting to do the man with the appendiceal phlegmon, who apparently has been able to come up with the necessary funds to be admitted for surgery.
Surprise, surprise !! This appendiceal phlegmon was not that ! Zellah Mulbah is a 25 year old man who presented with the chief complaint of "a knot". He had pain in his right abdomen for a month, and had not responded to a course of antibiotics. He was seen at JFK by persons unknown who ordered an ultrasound. The Chinese radiologist reported that his liver, spleen, gallbladder, pancreas, and kidneys were normal and that there was a 6.8. X 7.5 X 6 cm mass in the right lower quadrant. His diagnosis as "?RLQ mass". His hb is 13. At surgery we found a long appendix with some evidence of serosal inflammation . There was a huge mass of adenopathy in the retroperitoneum extending from the root of the mesentery up over the pancreas and laterally into the area of the hepatic flexure and duodenum. The liver felt clean. The spleen felt normal with no adjacent adenopathy. For biopsies I took a full node next to the cecum, an incisional biopsy of one of the retroperitoneal nodes, and the tip of the appendix. My working diagnosis is lymphoma, but I suppose it could be something infectious. Moses says cyclophosphamide is the only chemotherapy available in Liberia.
I did some cleaning up and sorting of our supplies in the OR closet and then went to the dorm where i found slow but mostly present WiFi access, so i sent out some episodes of this. Then I walked home thru the hood...I couldn't remember the shortcut, so I took the main path, getting some stares from people who apparently could figure out that I wasn't a native of the area !
Tonight at dinner we talked about the mindset needed in coming to a place like this. The temptation for many is to think that we come here to teach, but really we should be coming here to learn. In doing so, we actually do teach, and provide an example for those who learn from us. It is mutually beneficial for both parties. As Simon pointed out, in Liberia we have the advantage that they have no colonialist past. He said it is much different in East Africa where paternalistic attitudes are poorly received, and individuals or organizations going there with the idea that they are going to show the Africans how things should be done don't get very far.
I asked Moses and Konneh about some of our patients from last March. Mr. Too was seen a couple of times in clinic and was healing well before stopping his visits. The sweet large lady with advanced breast cancer developed a fairly rapid chest wall recurrence, and went home to die with her children around her. Everyone else did well, according to them.
The issue of finances continues to be frustrating. We have a young man in the ER with a palpable RLQ mass which is probably an appendiceal phlegmon. He was treated elsewhere with antibiotics, but his symptoms didn't resolve so he came to the clinic on Tuesday. Apparently he doesn't have the funds yet to be admitted, so he stays in the ER until he can find enough to cover the cost of admission and probable cost of his surgery. This is pretty much a constant problem with no solution in sight.
I gave Priscilla the dermatome blades yesterday to keep in secure storage, and they were all most appreciative ! They use each blade until it is dull, but they were completely out of them so this supply will allow them to do skin grafts again. They also very much appreciated the surgical scrub brushes, as they had none left. They had bought several of the little brushes with a glass container on top used for doing dishes, and suggested that these were okay for hand scrubbing. But the bristles are too hard and no one wanted to use them.
So far today Moses and I have done 3 children with hernias (well, 2 hernias and one hydrocele of the cord). His approach to pediatric hernias is somewhat different from mine, but it works so I don't suggest that he do it differently. We talked about pediatric surgery, and the fact that he has never seen pyloric stenosis. I described the operation to him in case he ever does see it. But i wonder if it really is that rare in Liberia, or if the babies who have it die of malnutrition and it is thought to be due to some other cause. If I remember, I will ask Dr. Emmanuel, the pediatrician. Now we are waiting to do the man with the appendiceal phlegmon, who apparently has been able to come up with the necessary funds to be admitted for surgery.
Surprise, surprise !! This appendiceal phlegmon was not that ! Zellah Mulbah is a 25 year old man who presented with the chief complaint of "a knot". He had pain in his right abdomen for a month, and had not responded to a course of antibiotics. He was seen at JFK by persons unknown who ordered an ultrasound. The Chinese radiologist reported that his liver, spleen, gallbladder, pancreas, and kidneys were normal and that there was a 6.8. X 7.5 X 6 cm mass in the right lower quadrant. His diagnosis as "?RLQ mass". His hb is 13. At surgery we found a long appendix with some evidence of serosal inflammation . There was a huge mass of adenopathy in the retroperitoneum extending from the root of the mesentery up over the pancreas and laterally into the area of the hepatic flexure and duodenum. The liver felt clean. The spleen felt normal with no adjacent adenopathy. For biopsies I took a full node next to the cecum, an incisional biopsy of one of the retroperitoneal nodes, and the tip of the appendix. My working diagnosis is lymphoma, but I suppose it could be something infectious. Moses says cyclophosphamide is the only chemotherapy available in Liberia.
I did some cleaning up and sorting of our supplies in the OR closet and then went to the dorm where i found slow but mostly present WiFi access, so i sent out some episodes of this. Then I walked home thru the hood...I couldn't remember the shortcut, so I took the main path, getting some stares from people who apparently could figure out that I wasn't a native of the area !
Tonight at dinner we talked about the mindset needed in coming to a place like this. The temptation for many is to think that we come here to teach, but really we should be coming here to learn. In doing so, we actually do teach, and provide an example for those who learn from us. It is mutually beneficial for both parties. As Simon pointed out, in Liberia we have the advantage that they have no colonialist past. He said it is much different in East Africa where paternalistic attitudes are poorly received, and individuals or organizations going there with the idea that they are going to show the Africans how things should be done don't get very far.
Thursday, September 9, 2010
Wednesday September 8
I have developed a head cold, but I am thankful that I packed some Sudafed. Today we did 3 cases: a urethral stricture, bilateral hernias, and at last the young man with the periumbilical mass. The urethral stricture was a youngish man who had a laparotomy a few months ago. According the Moses and Konneh, pre-operatively the nurse put in a
Foley but not all the way,and then blew up the balloon disrupting his urethra and causing a subsequent stricture. We attempted to dilate the stricture, but couldn't pass any of the rather large sounds thru it. Eventually we opened his bladder, and then his membranous urethra, and finally we managed to get both a retrograde Foley through his urethra, or neo-urethra, and then also a supra pubic tube. Honestly I'm not sure we left him any better off, but we shall hope. The second case was bilateral minimal hernias which Moses and I did fairly quickly . The final case was the mass,which turned out to be an enormous cancer involving his transverse colon and stomach, and he had liver mets. It was clearly unresectable, so we just closed him up .
Tonight Simon arrived, and after dinner here with Erin, Nathan, and James, we all wen with Ben to Golden Beach to have a few drinks while sitting at the shore and listening to then surf. it was quite a pleasant evening.
The place where I am staying is not far from the hospital, and is a house with 3 bedrooms. Apparently the hospital rents it for use by visiting doctors. This section of Monrovia has no electricity supply ( 80% of the homes in Monrovia are not connected to the national grid) so we have a generator stalled in the carport. It's hard to know which is more annoying: the sound of the generator running or the smell of diesel exhaust. I think I have gotten used to the sound, so I would go for the smell as being the most annoying ! Anyway, 2 boys Frederick and another are paid to watch and care for the place. It is in the middle of some pretty poor housing, so I imagine that having guards is rather important. Adamah explained to them early on what he expected from them, and they seem to understand; they are friendly and helpful and I believe trustworthy.
Foley but not all the way,and then blew up the balloon disrupting his urethra and causing a subsequent stricture. We attempted to dilate the stricture, but couldn't pass any of the rather large sounds thru it. Eventually we opened his bladder, and then his membranous urethra, and finally we managed to get both a retrograde Foley through his urethra, or neo-urethra, and then also a supra pubic tube. Honestly I'm not sure we left him any better off, but we shall hope. The second case was bilateral minimal hernias which Moses and I did fairly quickly . The final case was the mass,which turned out to be an enormous cancer involving his transverse colon and stomach, and he had liver mets. It was clearly unresectable, so we just closed him up .
Tonight Simon arrived, and after dinner here with Erin, Nathan, and James, we all wen with Ben to Golden Beach to have a few drinks while sitting at the shore and listening to then surf. it was quite a pleasant evening.
The place where I am staying is not far from the hospital, and is a house with 3 bedrooms. Apparently the hospital rents it for use by visiting doctors. This section of Monrovia has no electricity supply ( 80% of the homes in Monrovia are not connected to the national grid) so we have a generator stalled in the carport. It's hard to know which is more annoying: the sound of the generator running or the smell of diesel exhaust. I think I have gotten used to the sound, so I would go for the smell as being the most annoying ! Anyway, 2 boys Frederick and another are paid to watch and care for the place. It is in the middle of some pretty poor housing, so I imagine that having guards is rather important. Adamah explained to them early on what he expected from them, and they seem to understand; they are friendly and helpful and I believe trustworthy.
Tuesday September 7
I came to the hospital today at 7:30 AM with Adamah to make rounds with him in the ER. For a variety of reasons having to do with the intern covering both the medicine floor and the medical ER, there was no one around who knew the patients well, and that got Adamah quite irritated. Later Nathan and I talked about it as a bigger question of how do you get people to accept the ethical and moral responsibility of professionalism. For many of the Liberian doctors (and I fear some younger physicians in the US) medicine is a job which they do to survive, but they don't have the sense of commitment and responsibility that is necessary for professionalism. But here, unless there is a sense that the future for them will be better, and that there will be rewards for hard work, then it will be hard to instill that in them.
Communication is a big issue. Sign-out in the ER was an issue, and anesthesia was complaining that they don't know enough about patients pre-op. It is a difficult problem to solve, like so many problems here or anywhere. Again, I think that developing a sense of professionalism along with a sense of responsibility to patients will go a long way toward solving these problems.
In the OR we started with a Lebanese gentleman who has a hernia. Unfortunately just before getting his spinal, he developed severe acid reflux and hiccoughs, and so anesthesia has postponed or cancelled his surgery. We are waiting to hear which. Konneh and I then did a hernia on a prisoner which went well. So then we did another man with an inguinal hernia and bilateral hydroceles, and then a perirectal abscess, and finally we did the hernia on the Lebanese man under MAC. The anesthesiologist was nervous about using much, so she asked me if I could do a regional nerve block and local. So that is what we did, using some Versed and some Ketamine, and local. I did it with Moses, fairly quickly and easily, and that kept everyone happy.
Now it is not yet 2 PM and we have finished our 4 cases much to everyone's surprise and delight. Tomorrow we might schedule more than 4 ! I went to clinic with Moses and saw an amazing variety of pathology. A 19 year old woman with a weird eruption on her nose and nasolabial folds which has been present for 15 years. I took pictures and hope that someone will help me figure out what it is. A young man who had a large portion of his lower lip bit off several weeks ago. An old man with a hard mass in the flexor compartment of his right forearm. A baby with torticollis. And a middle-aged woman with a huge abdominal mass which is probably ovarian in origin. We will try to get her in to operate on her. Then Konneh and I went to see a woman who is a friend of Aunt Jennie's who has a weird story including severe diarrhea, profound weight loss, atrial fibrillation, and an enlarged thyroid. Apparently her thyroid has shrunk considerably on medication, so I am inclined to keep that going.
Ben came over to the house, and then we went to the RLJ resort to drop off a package and have a drink. After that Dewalt picked us up and we went to PJ's Steakhouse where we met the other HEARTT people as well as some other ex-pats working for The World Bank, The Carter Center, WHO, and others. An interesting group and good conversation.
Communication is a big issue. Sign-out in the ER was an issue, and anesthesia was complaining that they don't know enough about patients pre-op. It is a difficult problem to solve, like so many problems here or anywhere. Again, I think that developing a sense of professionalism along with a sense of responsibility to patients will go a long way toward solving these problems.
In the OR we started with a Lebanese gentleman who has a hernia. Unfortunately just before getting his spinal, he developed severe acid reflux and hiccoughs, and so anesthesia has postponed or cancelled his surgery. We are waiting to hear which. Konneh and I then did a hernia on a prisoner which went well. So then we did another man with an inguinal hernia and bilateral hydroceles, and then a perirectal abscess, and finally we did the hernia on the Lebanese man under MAC. The anesthesiologist was nervous about using much, so she asked me if I could do a regional nerve block and local. So that is what we did, using some Versed and some Ketamine, and local. I did it with Moses, fairly quickly and easily, and that kept everyone happy.
Now it is not yet 2 PM and we have finished our 4 cases much to everyone's surprise and delight. Tomorrow we might schedule more than 4 ! I went to clinic with Moses and saw an amazing variety of pathology. A 19 year old woman with a weird eruption on her nose and nasolabial folds which has been present for 15 years. I took pictures and hope that someone will help me figure out what it is. A young man who had a large portion of his lower lip bit off several weeks ago. An old man with a hard mass in the flexor compartment of his right forearm. A baby with torticollis. And a middle-aged woman with a huge abdominal mass which is probably ovarian in origin. We will try to get her in to operate on her. Then Konneh and I went to see a woman who is a friend of Aunt Jennie's who has a weird story including severe diarrhea, profound weight loss, atrial fibrillation, and an enlarged thyroid. Apparently her thyroid has shrunk considerably on medication, so I am inclined to keep that going.
Ben came over to the house, and then we went to the RLJ resort to drop off a package and have a drink. After that Dewalt picked us up and we went to PJ's Steakhouse where we met the other HEARTT people as well as some other ex-pats working for The World Bank, The Carter Center, WHO, and others. An interesting group and good conversation.
Monday September 6
A decent sleep last night after I got used to the hum of the generator outside. I'm not sure if we have a generator at this house to ensure an uninterrupted supply of electricity for the air conditioning, etc., or because the is no electricity supply here. No matter...it did keep the a/c going all night, and that made sleeping much easier.
Mirrors: as I sit here in the living room, I see 2 large mirrors on the walls, and there is one over the dresser in my bedroom. But no mirror in the bathroom! I recall someone mentioning the same thing about the dorm last year...I wonder if the Liberians just don't like to look at themselves undressed!?
Adamah and I went to the hospital this morning, starting with the Chiefs of Service meeting. I was greeted very warmly by many who welcomed me and thanked me for coming back. Dr Moses was at the meeting and it was great to see him again; he said that they have a lot of cases lined up me. The meeting was interesting in that many problems and complaints are universal no matter what system is in place: bed control, or the problem of getting a patient discharged so that a new patient can be admitted, is an issue everywhere.
I left that meeting with Dr Konneh so that we could go to the ED to see some patients needing surgery. One was a man apparently trampled at the Liberia-Zimbabwe soccer game yesterday; he is hypotensive but stable and has blood in his abdomen by ultrasound. Another is a young man with a huge incarcerated inguinal hernia. We also saw a man who had been stabbed in the posterior chest, but he was getting a chest tube and probably will not require surgery.
We then went to the OR to start the day. The man who had been trampled didn't have blood ready yet, so Dr Moses and I did a man with a recurrent inguinal hernia putting in a piece of mesh. Then we did the trampled man, who turned out to have a lacerated right lobe of his liver. He had about 2 liters of blood in his abdomen; this liver laceration was oozing, so we put gel foam on it. We made a drain out of a Foley and left that in. Then we did the man with the incarcerated hernia, which turned out to be a strangulation of perhaps half of his small bowel. We resected that, but I am nervous about him.
It turns out that Moses and Konneh have really p,annex for these two weeks, and have developed a significant list of patients to be brought in for surgery. Many hernias, but also other interesting cases. We are hoping to do 4 cases a day, not including emergencies.
Tonight we had several HEARTT people for dinner: Erin, Nathan, and James are residents, and Daniel is an ER attending from Stanford. Also Ben from Cellcom was here, and another old friend of Adamah's whose name I didn't catch.
I learned in the course of the evening that the Internet service at the Administration Building is out, and that someone stole the modem and the printer from the dorm. So I will not be able to put this up on my blog for a while.
Mirrors: as I sit here in the living room, I see 2 large mirrors on the walls, and there is one over the dresser in my bedroom. But no mirror in the bathroom! I recall someone mentioning the same thing about the dorm last year...I wonder if the Liberians just don't like to look at themselves undressed!?
Adamah and I went to the hospital this morning, starting with the Chiefs of Service meeting. I was greeted very warmly by many who welcomed me and thanked me for coming back. Dr Moses was at the meeting and it was great to see him again; he said that they have a lot of cases lined up me. The meeting was interesting in that many problems and complaints are universal no matter what system is in place: bed control, or the problem of getting a patient discharged so that a new patient can be admitted, is an issue everywhere.
I left that meeting with Dr Konneh so that we could go to the ED to see some patients needing surgery. One was a man apparently trampled at the Liberia-Zimbabwe soccer game yesterday; he is hypotensive but stable and has blood in his abdomen by ultrasound. Another is a young man with a huge incarcerated inguinal hernia. We also saw a man who had been stabbed in the posterior chest, but he was getting a chest tube and probably will not require surgery.
We then went to the OR to start the day. The man who had been trampled didn't have blood ready yet, so Dr Moses and I did a man with a recurrent inguinal hernia putting in a piece of mesh. Then we did the trampled man, who turned out to have a lacerated right lobe of his liver. He had about 2 liters of blood in his abdomen; this liver laceration was oozing, so we put gel foam on it. We made a drain out of a Foley and left that in. Then we did the man with the incarcerated hernia, which turned out to be a strangulation of perhaps half of his small bowel. We resected that, but I am nervous about him.
It turns out that Moses and Konneh have really p,annex for these two weeks, and have developed a significant list of patients to be brought in for surgery. Many hernias, but also other interesting cases. We are hoping to do 4 cases a day, not including emergencies.
Tonight we had several HEARTT people for dinner: Erin, Nathan, and James are residents, and Daniel is an ER attending from Stanford. Also Ben from Cellcom was here, and another old friend of Adamah's whose name I didn't catch.
I learned in the course of the evening that the Internet service at the Administration Building is out, and that someone stole the modem and the printer from the dorm. So I will not be able to put this up on my blog for a while.
On the flight from Atlanta to Accra, and then on to Monrovia...11 hours to Accra, 2 more to Monrovia makes it a long flight, but once again I have been quite lucky. Adamah had been upgraded to Business Class, but it was not possible to do that for both of us, so I was in coach. Adamah was quite insistent that I take the upgraded seat, and I was equally insistent that he was an important person and he should keep it. Anyway, in Atlanta there was a ceremony marking the occasion of Delta flying to Monrovia, and among the dignitaries was Perry Cantarutti, Senior Vice President at Delta for Europe and Africa. He is on the flight with is, and after we were all seated, several people were invited up to Business Class, including yours truly; I'm pretty sure it was Mr Cantarutti's idea, and one that I had no trouble accepting ! So it has been quite a pleasant flight despite the length !!
This flight by Delta is really quite a big deal to Liberians. In addition to providing a shorter means of getting to and from the USA, it is symbolic of the growth if the country and it's return to the ranks of civilized nations following the destruction wrought by the civil war. Thus there was a big ceremony upon our arrival at Roberts International Airport, complete with a ribbon cutting ceremony by Madame President with all sorts of dignitaries in attendance. Adamah was able to speak with his mother briefly before she flew off to Rwanda and then
we came to the house where we will be staying. It is a short distance from the hospital, and seems like it will do quite nicely. There are 4 bedrooms, several with their own bath, and a big living room/dining room.
There was another party being held tonight in honor of the Delta flight at the Robert Johnson resort just outside Monrovia. I decided to give it a pass since I was dead tired.
This flight by Delta is really quite a big deal to Liberians. In addition to providing a shorter means of getting to and from the USA, it is symbolic of the growth if the country and it's return to the ranks of civilized nations following the destruction wrought by the civil war. Thus there was a big ceremony upon our arrival at Roberts International Airport, complete with a ribbon cutting ceremony by Madame President with all sorts of dignitaries in attendance. Adamah was able to speak with his mother briefly before she flew off to Rwanda and then
we came to the house where we will be staying. It is a short distance from the hospital, and seems like it will do quite nicely. There are 4 bedrooms, several with their own bath, and a big living room/dining room.
There was another party being held tonight in honor of the Delta flight at the Robert Johnson resort just outside Monrovia. I decided to give it a pass since I was dead tired.
Friday, September 3, 2010
Tomorrow
I am almost completely packed !! It isn't my personal stuff but the supplies which require a lot of sorting and packing, trying to prioritize given that I have a limited amount of room. Though I am happy to say that Adamah (Dr. James Sirleaf) told me that Delta has agreed to allow us 3 bags each at no extra expense, so that's good. I have 3 rolling duffel bags nearly filled; less than a half of one is my personal belongings, and the remainder are supplies.
Adamah spoke to the Chief Medical Officer at JFK the other day, and he asked that we bring gauze and surgical scrub brushes. As it turns out, Waterbury Hospital is in the process of phasing out certain lines of scrub brushes, so they have donated more than I can bring. I put about 100 of them in a Space Bag, and the sucked all the air out with a vaccuum, and it is absolutely astonishing how much it shrinks allowing me to pack a lot more ! Yay Space Bags !
Speaking of Waterbury Hospital, I would like to thank everyone in and around the OR who have been so generous in helping me get supplies to take to Liberia. For example, a particular request from the Liberian surgeons was that I bring some blades for a dermatome ( a dermatome is used to harvest skin for skin grafts, like for a burned patient). Through Ro Murphy in the OR, the hospital kindly ordered, obtained. and donated a set of 10 replacement blades for me to bring over. Mary, Tanya, and Evelyn, who run the OR Supply system and who make sure we always have everything we want and need, have been so wonderful about collecting sutures, the aforementioned scrub brushes, and an incredibly useful collection of other supplies for me to bring. And a number of suppliers including Ethicon and Atrium have been extraordinarily generous in providing sutures, instruments, and other supplies! I never cease to be amazed by the goodwill of so many people who are eager to help make life a little better for a hospital and patients in a far-off land; I feel honored to work with them on a daily basis.
Now I still have to figure out how to get the proverbial 20 pounds into the 5 pound bag, so I better finish packing! Next time I think we should rent a shipping container !!
10:42 PM : I have everything packed. With the 3 duffel system, all 3 of them were over 50 pounds. So I have elected to bring a 4th duffel, and now all 4 are under the weight limit of 50 pounds with everything that I wanted to bring included!! They are each around 45 pounds, in large part because stell surgical instruments are heavy ! We will see if Delta charges for another bag; in any case it is cheaper to have one more rather than have 3 overweight.
Adamah spoke to the Chief Medical Officer at JFK the other day, and he asked that we bring gauze and surgical scrub brushes. As it turns out, Waterbury Hospital is in the process of phasing out certain lines of scrub brushes, so they have donated more than I can bring. I put about 100 of them in a Space Bag, and the sucked all the air out with a vaccuum, and it is absolutely astonishing how much it shrinks allowing me to pack a lot more ! Yay Space Bags !
Speaking of Waterbury Hospital, I would like to thank everyone in and around the OR who have been so generous in helping me get supplies to take to Liberia. For example, a particular request from the Liberian surgeons was that I bring some blades for a dermatome ( a dermatome is used to harvest skin for skin grafts, like for a burned patient). Through Ro Murphy in the OR, the hospital kindly ordered, obtained. and donated a set of 10 replacement blades for me to bring over. Mary, Tanya, and Evelyn, who run the OR Supply system and who make sure we always have everything we want and need, have been so wonderful about collecting sutures, the aforementioned scrub brushes, and an incredibly useful collection of other supplies for me to bring. And a number of suppliers including Ethicon and Atrium have been extraordinarily generous in providing sutures, instruments, and other supplies! I never cease to be amazed by the goodwill of so many people who are eager to help make life a little better for a hospital and patients in a far-off land; I feel honored to work with them on a daily basis.
Now I still have to figure out how to get the proverbial 20 pounds into the 5 pound bag, so I better finish packing! Next time I think we should rent a shipping container !!
10:42 PM : I have everything packed. With the 3 duffel system, all 3 of them were over 50 pounds. So I have elected to bring a 4th duffel, and now all 4 are under the weight limit of 50 pounds with everything that I wanted to bring included!! They are each around 45 pounds, in large part because stell surgical instruments are heavy ! We will see if Delta charges for another bag; in any case it is cheaper to have one more rather than have 3 overweight.
Wednesday, September 1, 2010
Preparations for departure 9/1/10
Earlier this week I asked one of the nurse managers in the Waterbury Hospital OR if perhaps there were some old, ready to be retired surgical instruments in Central Supply which I might bring to Liberia. She said that she would ask, and then came back to say that Charles Walker, Manager of Central Supply and his assistant Jeff would be coming up to talk with me. Charles has been at Waterbury Hospital for just a few months, and I had never met him. So they came up to the OR, and I started to explain that I was going to Liberia and wondered if there were any old instruments I could take. Charles cracked this funny smile...when I stopped speaking and looked at him, he said :" You know that I am from Liberia, don't you?" Of course I had no idea, so we had a great conversation about JFK Hospital, and I told him about our experience last March. He said that he was last there a year and a half ago when he visited his family. He and Jeff said that they could find plenty of instruments for me, so yesterday I went down and picked up a heavy box filled with all sorts of good tools which will be so appreciated in Monrovia! And today they gave me more ! Charles said that I should make a list of what they need when I am there, and when I return they will set to work finding those instruments so we can bring them back next March. Once again, I am surprised and pleased by how small the world really is !
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