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 !