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.