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.