Tuesday October 4
Our last full day at JFK for this trip. We checked on Keita, who is doing great and will start on oral liquids today; I still feel really good about her ! Then we went to the OR for some cases: the recurrent hernia that Paell had seen in Robertsport, another hernia in one of the security guards for the President, and an older man with presumed prostate cancer who had a bilateral orchiectomy. Interspersed with my cases, Ly did a keloid/ tattoo excision in a young woman, and a urethra repair in an infant. Apparently he had a circumcision in which his urethra was torn, and the it got infected, and it was a mess.Ly tells me that in Cambodia it is not unusual for plastic/reconstructive surgeons to do urological repairs like hypospadius, but it isn't something he commonly does. Nonetheless the initial result was excellent !
After we finished in the OR we did some patient rounds (Keita tolerated her oral feedings fine) and then went to the dorm for Internet before going back to the bungalow. Tonight most of us went for dinner at Sajj; Ly and Jim went to The Great Wall for Chinese food. We had a wonderful time at Sajj, and gave everyone one of the T shirts Ly had made in Cambodia before coming here. They have the HEARTT logo on the front, and a picture of one of the sacred Buddhist temples of Cambodia on the back. They were very well received !
I am very happy that this trip has been quite successful in terms of my goals and hopes. I had some trepidation about bringing Ly, just because I wasn't sure how it would work out. But I would have to say that it has exceeded even my most optimistic hopes, in that he has contributed greatly to all that we have done. His expertise and his knowledge of tricks to solve problems have been tremendous assets, but the other factor which has contributed greatly to our success has been his engaging personality. He is very outgoing, having no hesitation about greeting patients and other doctors, and he has been very willing to provide "curbside" advice whenever asked.
An example of one of his "tricks": orthopedic drills. They like drills for putting in screws to fix bones etc. So you go to Home Depot and buy a Makita or Dewalt or whatever. How do you sterilize it? Place a gauze soaked in formalin in the case and close it. In 12 hours, it will be sterilized.
Tomorrow Ly is going to to a musculocutaneous flap on the guy with the dislocated ankle from last week with Dr. Muvu. I will be free in the morning to take care of the supplies we have brought, as well as any other last minute details. Our plane leaves at 6 PM; we plan to be at the airport in plenty of time to avoid another race to the airport like we had in March !
Wednesday, October 5, 2011
Tuesday, October 4, 2011
Monday October 3
Monday October 3
After breakfast we went to JFK to check on Keita, who is doing very well fortunately. Then we went to the OR and did several cases : a 7 yr old with an undescended testis, a couple of hernias, and a chest wall mass in a 65 year old woman. The mass looked and felt like a lipoma, except that it was clearly deeper than usual. In the operation, I split the muscle and immediately encountered the mass, which showed itself to be highly vascular. I ended up scooping out the insides, which seemed necrotic to me, and then trying to figure out how to stop the profuse bleeding. I sutured a lot, and eventually it seemed safe to close. I took the inside material for pathological review back home; I'm guessing metastatic renal cell might be a possibility.
While I was doing those cases, Ly helped Dr. Muvu with a complicated femur fracture, and then did some plastic surgery. One of the JFK doctors brought his son who was about 10 years old and had a large keloid on his cheek which Ly removed. Then he did a guy with a severe wrist contracture from burns.
Emilie asked me to check out a woman in the Trauma ED: she had had a criminal abortion, and then got beat up by someone, incurring a blowout fracture of her left orbit. The reason for calling me was that she has a large abrasion on her right buttock, and a swollen right thigh with crepitus proximally.we spent a while talking about what the right thing to do was; I don't think there is any way to survive necrotizing fasciitis in Monrovia! LiberIa in 2011. Everyone agreed that aggressive debridement was unlikely to change the course of events and the likely outcome for her, so we elected to be conservative and just keep her on broad spectrum antibiotics.
Tonight we went to the Mamba Point Hotel for dinner, and it was very good. I wouldn't have guessed that I would be eating good sushi in Monrovia, but I did ! There were about 14 of us, including Dr Andy Pollock, Chief of Orthopedic Surgery at Maryland Shock Trauma,who is visiting or a few days. After we had eaten Tobias, the Administrator of Redemption, stopped by and we had a good conversation. A new 200 bed Redemption should be finished in a year or less; he pointed out that they are the biggest pediatric inpatient facility in the country , and thus they have a good reason to want to provide some basic pediatric surgery.
P
After breakfast we went to JFK to check on Keita, who is doing very well fortunately. Then we went to the OR and did several cases : a 7 yr old with an undescended testis, a couple of hernias, and a chest wall mass in a 65 year old woman. The mass looked and felt like a lipoma, except that it was clearly deeper than usual. In the operation, I split the muscle and immediately encountered the mass, which showed itself to be highly vascular. I ended up scooping out the insides, which seemed necrotic to me, and then trying to figure out how to stop the profuse bleeding. I sutured a lot, and eventually it seemed safe to close. I took the inside material for pathological review back home; I'm guessing metastatic renal cell might be a possibility.
While I was doing those cases, Ly helped Dr. Muvu with a complicated femur fracture, and then did some plastic surgery. One of the JFK doctors brought his son who was about 10 years old and had a large keloid on his cheek which Ly removed. Then he did a guy with a severe wrist contracture from burns.
Emilie asked me to check out a woman in the Trauma ED: she had had a criminal abortion, and then got beat up by someone, incurring a blowout fracture of her left orbit. The reason for calling me was that she has a large abrasion on her right buttock, and a swollen right thigh with crepitus proximally.we spent a while talking about what the right thing to do was; I don't think there is any way to survive necrotizing fasciitis in Monrovia! LiberIa in 2011. Everyone agreed that aggressive debridement was unlikely to change the course of events and the likely outcome for her, so we elected to be conservative and just keep her on broad spectrum antibiotics.
Tonight we went to the Mamba Point Hotel for dinner, and it was very good. I wouldn't have guessed that I would be eating good sushi in Monrovia, but I did ! There were about 14 of us, including Dr Andy Pollock, Chief of Orthopedic Surgery at Maryland Shock Trauma,who is visiting or a few days. After we had eaten Tobias, the Administrator of Redemption, stopped by and we had a good conversation. A new 200 bed Redemption should be finished in a year or less; he pointed out that they are the biggest pediatric inpatient facility in the country , and thus they have a good reason to want to provide some basic pediatric surgery.
P
Monday, October 3, 2011
Sunday October 2
Sunday October 2
I slept till 9, and then Ly and I went to the dorm to make plans for a relaxing Sunday. We were going to go to the RLJ resort around noon...but then Michelle called and said the baby Ketia was worse. So I went back to the house and changed into scrubs, and then went to JFK , where I found that she was indeed correct. She was somnolent, and her abdomen was tender, and her repeat abdominal film was much worse. So we decided that she needed to go to the OR today.
We started the planning, trying to make sure we had all bases covered. I went to the OR and turned in the written Anesthesia consult, only to discover that there was a case going on. Michelle kindly offered to stay in the OR during the case to help the anesthetists, which I thought was a brilliant idea. I took her to the OR Pharmacy so she could see which drugs were available. She and I talked to the parents, explaining as best we could what was wrong and how we might fix it, and the substantial risks involved in operating. My feeling was that if we operated today, e baby had a 50-50 chance; if we waited till tomorrow,ere was probably only a 10% chance of survival.
Finally the other patient was moved out of the OR ( there is no Recovery Room nurse on e weekend, so patients recover in the OR), and the anesthetist went to see our patient. He said that we could not proceed because there was no bed for the baby; I knew I forgot something in all of our preparations ! Michelle called Adamah and Dr. Macdonald, and soon a bed was available in the Pediatric Surgery ward on the second floor.
The operation went very well. The Liberian anesthetists and Michelle worked well together, with Michelle managing the intubation and care. From my side of things, their care was a model of cooperation and teaching each other some tricks. We could find no evidence to support any abuse allegation. In the abdomen we found an intussusception which extended to her left colon. When I attempted to gently reduce it manually, the bowel wall split, indicating just how close she was to perforation. We ended up resecting a significant amount of her colon, and did a primary anastomosis. She was awake and extubated about 20 minutes after we finished closing; she was kept in the OR recovering for an hour and a half, and then we brought her down to the ward. I was thrilled to see that Gwendolyn was working overnight; she is an excellent, caring, smart nurse so I think Ketia is in good hands.
After a quick shower and change of clothes, Dewalt came and got us to go to the house of Adamah's brother Jess. Many people were there, and it was fun chatting with them. We came home around 10 PM to get ready for a busy day tomorrow.
Obviously there are many things that could go wrong with Ketia, but I am optimistic. The experience we had today is why I am here, because I think we really made a difference. It speaks to the importance of a team; having Michelle willing and able to assume responsibility for the anesthesia care, while at the same time working comfortably with the Liberian anesthetists, was a major factor in having it all work out as well as it did. Having Ly to assist me was a godsend also. We are all keeping our fingers crossed !
I also think this is a good example of why pediatric surgery should be done in a hospital where the appropriate personnel and equipment are available. Adamah has asked me to write something up about this which he will present to the Ministry of Health, and I am happy to do that.
I slept till 9, and then Ly and I went to the dorm to make plans for a relaxing Sunday. We were going to go to the RLJ resort around noon...but then Michelle called and said the baby Ketia was worse. So I went back to the house and changed into scrubs, and then went to JFK , where I found that she was indeed correct. She was somnolent, and her abdomen was tender, and her repeat abdominal film was much worse. So we decided that she needed to go to the OR today.
We started the planning, trying to make sure we had all bases covered. I went to the OR and turned in the written Anesthesia consult, only to discover that there was a case going on. Michelle kindly offered to stay in the OR during the case to help the anesthetists, which I thought was a brilliant idea. I took her to the OR Pharmacy so she could see which drugs were available. She and I talked to the parents, explaining as best we could what was wrong and how we might fix it, and the substantial risks involved in operating. My feeling was that if we operated today, e baby had a 50-50 chance; if we waited till tomorrow,ere was probably only a 10% chance of survival.
Finally the other patient was moved out of the OR ( there is no Recovery Room nurse on e weekend, so patients recover in the OR), and the anesthetist went to see our patient. He said that we could not proceed because there was no bed for the baby; I knew I forgot something in all of our preparations ! Michelle called Adamah and Dr. Macdonald, and soon a bed was available in the Pediatric Surgery ward on the second floor.
The operation went very well. The Liberian anesthetists and Michelle worked well together, with Michelle managing the intubation and care. From my side of things, their care was a model of cooperation and teaching each other some tricks. We could find no evidence to support any abuse allegation. In the abdomen we found an intussusception which extended to her left colon. When I attempted to gently reduce it manually, the bowel wall split, indicating just how close she was to perforation. We ended up resecting a significant amount of her colon, and did a primary anastomosis. She was awake and extubated about 20 minutes after we finished closing; she was kept in the OR recovering for an hour and a half, and then we brought her down to the ward. I was thrilled to see that Gwendolyn was working overnight; she is an excellent, caring, smart nurse so I think Ketia is in good hands.
After a quick shower and change of clothes, Dewalt came and got us to go to the house of Adamah's brother Jess. Many people were there, and it was fun chatting with them. We came home around 10 PM to get ready for a busy day tomorrow.
Obviously there are many things that could go wrong with Ketia, but I am optimistic. The experience we had today is why I am here, because I think we really made a difference. It speaks to the importance of a team; having Michelle willing and able to assume responsibility for the anesthesia care, while at the same time working comfortably with the Liberian anesthetists, was a major factor in having it all work out as well as it did. Having Ly to assist me was a godsend also. We are all keeping our fingers crossed !
I also think this is a good example of why pediatric surgery should be done in a hospital where the appropriate personnel and equipment are available. Adamah has asked me to write something up about this which he will present to the Ministry of Health, and I am happy to do that.
Saturday October 1
Saturday October 1
Today was one of those days which epitomizes the frustration and pleasure of being here doing what we do. Today was the day Ly and I were scheduled to go to Redemption Hospital where they had 6 cases on the list for us. My first frustration relates to time, and punctuality; I know I need to adapt to the African way of doing things, but when I am assured someone will be here at 8:30, I expect them here closer to 8:30 than to 9:30 ! In any case, we arrived at Redemption to find that they were doing an emergency C-section, so we had some time to wait anyway and our being late wasn't a problem. So we went around to see the 6 patients on the list for us: an incarcerated hernia in an 11 year old boy, a hernia in a 4 year old and one in a 2 year old, a 4 month old with a bowel obstruction, a 7 year old boy with a fractured humerus just above his elbow, and a 2 year old with a myelomeningocoele. I immediately ruled out the last one, telling them that I don't do that type of surgery. The 7 year old had an xray which Ly looked at, and said that it needed operative fixation at JFK; subsequently we were informed that the mother refused to take him to JFK, and had decided to take him to a traditional healer. There is no point is arguing the futility of such beliefs. After seeing the baby girl with the bowel obstruction, I decided that she could easily have an intussusception, and recommended that she be transferred to JFK for monitoring and possible surgery. So of the 6 on our list, we eliminated 3 off the bat. They then told us about an addition, which was a 50 year old man with bilateral hernias.
The OR at Redemption could be charitably described as sparse. They have no cautery, no much for lights, and minimal instruments. Ly and I both felt lucky that we didn't encounter a serious problem, given the available resources. I suggested to the anesthetist that we do the pediatric cases first, and they agreed. The first case we did was the 11 year old with an apparently incarcerated hernia; I was struck by how tender he was in the area. Interestingly, and definitely different from our usual procedure, the groin area was prepped and draped before the anesthetist would put him to sleep. Anyway, his hernia proved to be an infarcted testicle, and so we did an orchiectomy. I assume he had a torsion which was undiagnosed, but who knows for sure.
After that case, the anesthetist told me that the anesthesia mating was not
working properly, and so we would not be able to do the other children; instead we would do that add-on bilateral hernia case under spinal. They did the spinal, but it didn't work, and so we did the case mostly with ketamine. We found that he had a huge left inguinal hernia with a large amount of bloody ascites in the sac and in his abdominal cavity. I couldn't find any dead bowel, but I remained concerned about possible compromise of his bowel. I thought about what I would do at home in the same situation: probably just close observation, but maybe a post-op CT to know that everything was or was not alright.
After we finished him, I called our driver to come pick us up. After making that call, the anesthetist said that the anesthesia machine was now working. I told him that it was too late as we had already called for our ride, and that other arrangements would have to be made for the hernia repairs. They weren't happy, but I wasn't very happy with their games; I also felt uncomfortable doing more pediatric surgery there.
On the way back to JFK Michelle called to say that the 4 month old baby girl names Ketia Kumar had arrived at JFK, and that she also thought intussusception was a likely diagnosis, but there was more to the story. Subsequently, I learned that there were suspicious activities just before the child got sick, which was 8 days earlier. She had been at a neighbors house, and shortly thereafter the mother noticed blood in her diaper, raising the specter of sexual abuse.
Ly and I had a meal at the Royal, and then we went to the dorm. I met up with Michelle, and we went over to see the baby. She seemed alert; her abdomen was distended but she was not tender. We decided we would watch her overnight, and repeat her abdominal x-ray in the morning.
I was back at the dorm when someone heard from Adamah that the Superintendent was not doing well. Each county in Liberia has a Superintendent who seems to basically be the Manager of the county. This particular superintendent came to e hospital 2 days after falling asleep at the wheel and crashing his car. He was seen in a district hospital, and then transferred to JFK. His injuries seemed to be mostly contusions of the chest and back, but there was also concern about a intra-abdominal injury. Emilie had done a FAST ultrasound exam when he came in, and now Adamah was calling to ask where the ultrasound machine was kept so he could repast the exam as the Superintendent was more distended. So Emilie and I went over to see him, and she repeated the FAST, and we thought the distension was mostly gas. We were leaving when a bunch of guys and UN troops came running up the stairs. It turned out the the Vice President had come to visit the Superintendent, so we all went back to his room so Adamah could say hello and introduce Emilie and me.
I was tired after a long day, so I went back to the bungalow. Ly went out to a Chinese restaurant with some Cambodian friends, and I went to bed early.
I spoke to Adamah about our experience at Redemption. My strong feeling is that JFK should improve it's pediatric surgery services so that most pediatric surgery is done ere rather than in a district hospital like Redemption. It is just too dangerous to do pediatric surgery where there is no support or equipment for it.
Today was one of those days which epitomizes the frustration and pleasure of being here doing what we do. Today was the day Ly and I were scheduled to go to Redemption Hospital where they had 6 cases on the list for us. My first frustration relates to time, and punctuality; I know I need to adapt to the African way of doing things, but when I am assured someone will be here at 8:30, I expect them here closer to 8:30 than to 9:30 ! In any case, we arrived at Redemption to find that they were doing an emergency C-section, so we had some time to wait anyway and our being late wasn't a problem. So we went around to see the 6 patients on the list for us: an incarcerated hernia in an 11 year old boy, a hernia in a 4 year old and one in a 2 year old, a 4 month old with a bowel obstruction, a 7 year old boy with a fractured humerus just above his elbow, and a 2 year old with a myelomeningocoele. I immediately ruled out the last one, telling them that I don't do that type of surgery. The 7 year old had an xray which Ly looked at, and said that it needed operative fixation at JFK; subsequently we were informed that the mother refused to take him to JFK, and had decided to take him to a traditional healer. There is no point is arguing the futility of such beliefs. After seeing the baby girl with the bowel obstruction, I decided that she could easily have an intussusception, and recommended that she be transferred to JFK for monitoring and possible surgery. So of the 6 on our list, we eliminated 3 off the bat. They then told us about an addition, which was a 50 year old man with bilateral hernias.
The OR at Redemption could be charitably described as sparse. They have no cautery, no much for lights, and minimal instruments. Ly and I both felt lucky that we didn't encounter a serious problem, given the available resources. I suggested to the anesthetist that we do the pediatric cases first, and they agreed. The first case we did was the 11 year old with an apparently incarcerated hernia; I was struck by how tender he was in the area. Interestingly, and definitely different from our usual procedure, the groin area was prepped and draped before the anesthetist would put him to sleep. Anyway, his hernia proved to be an infarcted testicle, and so we did an orchiectomy. I assume he had a torsion which was undiagnosed, but who knows for sure.
After that case, the anesthetist told me that the anesthesia mating was not
working properly, and so we would not be able to do the other children; instead we would do that add-on bilateral hernia case under spinal. They did the spinal, but it didn't work, and so we did the case mostly with ketamine. We found that he had a huge left inguinal hernia with a large amount of bloody ascites in the sac and in his abdominal cavity. I couldn't find any dead bowel, but I remained concerned about possible compromise of his bowel. I thought about what I would do at home in the same situation: probably just close observation, but maybe a post-op CT to know that everything was or was not alright.
After we finished him, I called our driver to come pick us up. After making that call, the anesthetist said that the anesthesia machine was now working. I told him that it was too late as we had already called for our ride, and that other arrangements would have to be made for the hernia repairs. They weren't happy, but I wasn't very happy with their games; I also felt uncomfortable doing more pediatric surgery there.
On the way back to JFK Michelle called to say that the 4 month old baby girl names Ketia Kumar had arrived at JFK, and that she also thought intussusception was a likely diagnosis, but there was more to the story. Subsequently, I learned that there were suspicious activities just before the child got sick, which was 8 days earlier. She had been at a neighbors house, and shortly thereafter the mother noticed blood in her diaper, raising the specter of sexual abuse.
Ly and I had a meal at the Royal, and then we went to the dorm. I met up with Michelle, and we went over to see the baby. She seemed alert; her abdomen was distended but she was not tender. We decided we would watch her overnight, and repeat her abdominal x-ray in the morning.
I was back at the dorm when someone heard from Adamah that the Superintendent was not doing well. Each county in Liberia has a Superintendent who seems to basically be the Manager of the county. This particular superintendent came to e hospital 2 days after falling asleep at the wheel and crashing his car. He was seen in a district hospital, and then transferred to JFK. His injuries seemed to be mostly contusions of the chest and back, but there was also concern about a intra-abdominal injury. Emilie had done a FAST ultrasound exam when he came in, and now Adamah was calling to ask where the ultrasound machine was kept so he could repast the exam as the Superintendent was more distended. So Emilie and I went over to see him, and she repeated the FAST, and we thought the distension was mostly gas. We were leaving when a bunch of guys and UN troops came running up the stairs. It turned out the the Vice President had come to visit the Superintendent, so we all went back to his room so Adamah could say hello and introduce Emilie and me.
I was tired after a long day, so I went back to the bungalow. Ly went out to a Chinese restaurant with some Cambodian friends, and I went to bed early.
I spoke to Adamah about our experience at Redemption. My strong feeling is that JFK should improve it's pediatric surgery services so that most pediatric surgery is done ere rather than in a district hospital like Redemption. It is just too dangerous to do pediatric surgery where there is no support or equipment for it.
Saturday, October 1, 2011
Friday September 30
Friday September 30
We had a full morning in the OR with several hernias and a burn debridement. Ly also worked with Dr. Muvu on the open dislocated ankle. We finished in the OR around 3 and then went to have lunch, but got stopped at the Administration Building by Dr. Macdonald and Mary ( I referred to Mary in an earlier post as our angel social worker, but she is in fact the acting assistant administrator. No mater what, she is still an angel !) to see several patients. One was a young woman with caustic burns on her back and neck whom we saw in the clinic twice. She can't seem to accept the fact that her keloids can't all simply be removed so she will look perfect again. She has a contracture of her left neck which can be released, but that is really all that can be done for her. Another consultation was a young girl with a burn from last February of the left side of her face and shoulder which has a big keloid scar. Ly felt it is too early to do anything surgically with the keloid, and recommended massage with Vitamin E to soften it up; the mother was clearly disappointed, having expected a miracle fix. The final patient there was a young man with a small but symptomatic inguinal hernia who is a member of the Presidential security detail. Mary will arrange for him to be admitted Monday for surgery on Tuesday.
Oh, one other consult: an American ex-pat named Nate who had a hernia that he was concerned about since he is heading off not the bush for a few months. I reassured him that he has a small ventral hernia which can be repaired at a later date. It turns out that he is from Beverly, Ma and has lived in West Africa for the past 10 years. I'm not sure what he does for a living, but clearly he enjoys living in West Africa.
For dinner a group of us went to Tajj and had a good time. then many of us went to Groovie's where we met up with Adamah and Chris. Ly and I came home around 12:30 as it appears we will have a busy day at Redemption tomorrow. Apparently they have 6 cases on the list for us to do; I'm not sure if we will get through that many, but we can try.
We had a full morning in the OR with several hernias and a burn debridement. Ly also worked with Dr. Muvu on the open dislocated ankle. We finished in the OR around 3 and then went to have lunch, but got stopped at the Administration Building by Dr. Macdonald and Mary ( I referred to Mary in an earlier post as our angel social worker, but she is in fact the acting assistant administrator. No mater what, she is still an angel !) to see several patients. One was a young woman with caustic burns on her back and neck whom we saw in the clinic twice. She can't seem to accept the fact that her keloids can't all simply be removed so she will look perfect again. She has a contracture of her left neck which can be released, but that is really all that can be done for her. Another consultation was a young girl with a burn from last February of the left side of her face and shoulder which has a big keloid scar. Ly felt it is too early to do anything surgically with the keloid, and recommended massage with Vitamin E to soften it up; the mother was clearly disappointed, having expected a miracle fix. The final patient there was a young man with a small but symptomatic inguinal hernia who is a member of the Presidential security detail. Mary will arrange for him to be admitted Monday for surgery on Tuesday.
Oh, one other consult: an American ex-pat named Nate who had a hernia that he was concerned about since he is heading off not the bush for a few months. I reassured him that he has a small ventral hernia which can be repaired at a later date. It turns out that he is from Beverly, Ma and has lived in West Africa for the past 10 years. I'm not sure what he does for a living, but clearly he enjoys living in West Africa.
For dinner a group of us went to Tajj and had a good time. then many of us went to Groovie's where we met up with Adamah and Chris. Ly and I came home around 12:30 as it appears we will have a busy day at Redemption tomorrow. Apparently they have 6 cases on the list for us to do; I'm not sure if we will get through that many, but we can try.
Friday, September 30, 2011
Thursday September 29
Thursday September 29
After breakfast at the dorm, we went to the OR. I did a 3 year old with a hydrocele with Moses, and then he went to the outpatient clinic . Ly and I then did the woman with the traumatic injury to her left foot that he had hoped to do last night. She had a chunk of her 4th and 5th metatarsals hanging by a short tissue pedicle, but Ly thought it was possible to reconstruct, so he put two pins in and we will hope for the best. Finding a pin cutter was something of an effort; they suggested a bone cutter, but it wasn't up to the task, and after opening several kits a pin cutter was found. After that, Ly and I did bilateral inguinal hernias in a 60 year old man.
Then we went to the clinic and saw a lot of pathology. Among the standouts: a 20 year old with a large umbilical hernia, a spleen extending to below his umbilicus, and diffuse adenopathy, seen by Moses last week; various tests were ordered and he came back this week for a reevaluation. Abdominal ultrasound showed a huge spleen, and a liven with multiple lesions. His WBC is 60K ! I didn't think a splenectomy would do much good, so we referred him to e medical clinic for further evaluation of his lymphoma or leukemia. Another patient was a 25 year old man with bad burns of his arms and hands; the burns occurred a year ago, and he now has a bad flexion contracture at his wrist which makes his left hand virtually useless. Ly wants to release the contracture and probably do a pedicle graft from his flank; this is the sort of surgery that no one currently practicing in Liberia would do, so I think it's important for him to do it. Fortunately everyone cooperated, and our angel social worker Mary made it all happen, I think. We will know for sure tomorrow, but I believe he was admitted to the hospital today.
After finishing clinic we went to Redemption Hospital with Adamah to see the OR and meet the staff. On the way there, we crossed paths with the President out campaigning; we stopped, and got out of the car to go over and say hello. As usual, she was very gracious in welcoming me back and in greeting Ly, and then she said she had to get back to campaigning ! The bridge was blocked off for her motorcade, but we snuck into it and then when they turned off we went straight ahead across the bridge with no traffic ! The people at Redemption were very excited about having us come to do surgery, so I think we will go there on Saturday to do some hernia repairs. We shall see how it all works out. The major downside to Redemption is that it is across town and over the bridge, so it will probably take an hour to get there most days. Coming home, the bridge was still backed up because of the President, so we had to go the long way around and it took us about 90 min to get back to JFK.
Tonight we went for dinner at The Boulevard, near the Royal. There were 9 of us celebrating Paell's birthday. We had a good time with interesting conversation. Paell was working up at a clinic in Robertsport where she came across an 18 year old with a recurrent hernia. We are trying to get him down here, perhaps to operate on him on Saturday at Redemption, since it would be totally free. At JFK he would most likely have to pay the admission fee of 2500LD (about $35) plus a drugs charge of 2000LD, for a total charge of about $65. If he couldn't pay that money, and we really want to operate on him, then HEARTT will pay the fees.
I am thrilled that everything is working out so well with Ly. I had some concerns before we came about how well it would work for him, but those concerns were obviously groundless. He is a star, and has been providing all sorts of advice to physicians, staff, and families as well as patients. They love the idea of having a plastic surgeon, and an orthopedic surgeon, here to help; he has responded wonderfully and generously, and I would have to say he is a home run ! Speaking of which, I wonder what has happened to my Red Sox? Unfortunately we don't get NESN on Liberian TV !
Oh, I have just received an email from my son indicating that the Red Sox will have to wait till next year...again. Oh well
After breakfast at the dorm, we went to the OR. I did a 3 year old with a hydrocele with Moses, and then he went to the outpatient clinic . Ly and I then did the woman with the traumatic injury to her left foot that he had hoped to do last night. She had a chunk of her 4th and 5th metatarsals hanging by a short tissue pedicle, but Ly thought it was possible to reconstruct, so he put two pins in and we will hope for the best. Finding a pin cutter was something of an effort; they suggested a bone cutter, but it wasn't up to the task, and after opening several kits a pin cutter was found. After that, Ly and I did bilateral inguinal hernias in a 60 year old man.
Then we went to the clinic and saw a lot of pathology. Among the standouts: a 20 year old with a large umbilical hernia, a spleen extending to below his umbilicus, and diffuse adenopathy, seen by Moses last week; various tests were ordered and he came back this week for a reevaluation. Abdominal ultrasound showed a huge spleen, and a liven with multiple lesions. His WBC is 60K ! I didn't think a splenectomy would do much good, so we referred him to e medical clinic for further evaluation of his lymphoma or leukemia. Another patient was a 25 year old man with bad burns of his arms and hands; the burns occurred a year ago, and he now has a bad flexion contracture at his wrist which makes his left hand virtually useless. Ly wants to release the contracture and probably do a pedicle graft from his flank; this is the sort of surgery that no one currently practicing in Liberia would do, so I think it's important for him to do it. Fortunately everyone cooperated, and our angel social worker Mary made it all happen, I think. We will know for sure tomorrow, but I believe he was admitted to the hospital today.
After finishing clinic we went to Redemption Hospital with Adamah to see the OR and meet the staff. On the way there, we crossed paths with the President out campaigning; we stopped, and got out of the car to go over and say hello. As usual, she was very gracious in welcoming me back and in greeting Ly, and then she said she had to get back to campaigning ! The bridge was blocked off for her motorcade, but we snuck into it and then when they turned off we went straight ahead across the bridge with no traffic ! The people at Redemption were very excited about having us come to do surgery, so I think we will go there on Saturday to do some hernia repairs. We shall see how it all works out. The major downside to Redemption is that it is across town and over the bridge, so it will probably take an hour to get there most days. Coming home, the bridge was still backed up because of the President, so we had to go the long way around and it took us about 90 min to get back to JFK.
Tonight we went for dinner at The Boulevard, near the Royal. There were 9 of us celebrating Paell's birthday. We had a good time with interesting conversation. Paell was working up at a clinic in Robertsport where she came across an 18 year old with a recurrent hernia. We are trying to get him down here, perhaps to operate on him on Saturday at Redemption, since it would be totally free. At JFK he would most likely have to pay the admission fee of 2500LD (about $35) plus a drugs charge of 2000LD, for a total charge of about $65. If he couldn't pay that money, and we really want to operate on him, then HEARTT will pay the fees.
I am thrilled that everything is working out so well with Ly. I had some concerns before we came about how well it would work for him, but those concerns were obviously groundless. He is a star, and has been providing all sorts of advice to physicians, staff, and families as well as patients. They love the idea of having a plastic surgeon, and an orthopedic surgeon, here to help; he has responded wonderfully and generously, and I would have to say he is a home run ! Speaking of which, I wonder what has happened to my Red Sox? Unfortunately we don't get NESN on Liberian TV !
Oh, I have just received an email from my son indicating that the Red Sox will have to wait till next year...again. Oh well
Thursday, September 29, 2011
Wednesday
Wednesday September 28
Even at my age, I am astonished that days which start out dull and boring can change very quickly. We started out by discovering this morning that we had little to do: the General Surgery room was being used by Dr. Golikae, Chief of Surgery and Dean of the Medical School. He had 5 cases scheduled, including a rectal prolapse, a thyroid, a urethral stricture, release of a burn contracture, and a skin graft to a burn. Apparently, he doesn't operate too many days, and it was important that he get his schedule taken care of. He came back to Liberia last year to become Dean; I remember meeting him in March. In any case, his style in the OR reminds me very much of Sid Luria, including the aversion to light handles and his general demeanor; many of you will know exactly what I mean ! Having said that, I was impressed with the speed of his partial thyroidectomy for a massive goiter in the left lobe. There was significant blood loss as one would expect from an unsuppressed thyroid, but he got the job done.
Ly assisted Dr. Muvu in removing a forearm plate, and then we seemed to be done, which was a rather unfulfilling day. Soon, however, we were busy seeing some interesting cases in the ED. One was a woman with an open fracture of her foot whom Ly wanted to take to the OR right away. We successfully negotiated to complexities of an anesthetist consult, getting a bed, getting her hemoglobin checked, etc, only to learn that after hours there is only one team of nurses on duty for the main hospital and the Maternity hospital. They had just gone to !Maternity for an ectopic pregnancy, and no one knew when they would be back, so we decided to defer her surgery till tomorrow. We also found a large hernia to do tomorrow, and an open ankle dislocation for Ly, so I think we will have a busy day tomorrow.
The availability of surgical beds is a limiting factor for admissions and surgery. Moses has been saying all week that there are no surgical beds, but miraculously yesterday I spoke to Dr Macdonald and Mary, and we have 8 beds empty and ready for us. They have also put up signs around the hospital advertising our presence, so I think the rest of this trip we will be quite busy.
Last night we had dinner at the Royal again.
Even at my age, I am astonished that days which start out dull and boring can change very quickly. We started out by discovering this morning that we had little to do: the General Surgery room was being used by Dr. Golikae, Chief of Surgery and Dean of the Medical School. He had 5 cases scheduled, including a rectal prolapse, a thyroid, a urethral stricture, release of a burn contracture, and a skin graft to a burn. Apparently, he doesn't operate too many days, and it was important that he get his schedule taken care of. He came back to Liberia last year to become Dean; I remember meeting him in March. In any case, his style in the OR reminds me very much of Sid Luria, including the aversion to light handles and his general demeanor; many of you will know exactly what I mean ! Having said that, I was impressed with the speed of his partial thyroidectomy for a massive goiter in the left lobe. There was significant blood loss as one would expect from an unsuppressed thyroid, but he got the job done.
Ly assisted Dr. Muvu in removing a forearm plate, and then we seemed to be done, which was a rather unfulfilling day. Soon, however, we were busy seeing some interesting cases in the ED. One was a woman with an open fracture of her foot whom Ly wanted to take to the OR right away. We successfully negotiated to complexities of an anesthetist consult, getting a bed, getting her hemoglobin checked, etc, only to learn that after hours there is only one team of nurses on duty for the main hospital and the Maternity hospital. They had just gone to !Maternity for an ectopic pregnancy, and no one knew when they would be back, so we decided to defer her surgery till tomorrow. We also found a large hernia to do tomorrow, and an open ankle dislocation for Ly, so I think we will have a busy day tomorrow.
The availability of surgical beds is a limiting factor for admissions and surgery. Moses has been saying all week that there are no surgical beds, but miraculously yesterday I spoke to Dr Macdonald and Mary, and we have 8 beds empty and ready for us. They have also put up signs around the hospital advertising our presence, so I think the rest of this trip we will be quite busy.
Last night we had dinner at the Royal again.
Wednesday, September 28, 2011
Apologies
It has been brought to my attention that there are more than the usual number of spelling and grammar mistakes in my blog writings this time, and for that I apologize. I can provide any number of excuses, like the fact that I am usually in a hurry to get it posted online while the Internet is working, or my iPad loves to finish words for me, but I suspect the real problem is that I haven't been proofreading carefully.ni will do my best to do better editing in the future !!
Tuesday
Tuesday September 27
We met Moses in the OR at 8:30, and did 2 cases: he did a skin graft with Ly, and then a colostomy closure with me. I think everyone is very pleased to have Ly here, and to learn from him. I forgot to mention that last night before and during dinner at the Royal, he was mentioning some techniques that he uses, such as wound packing soaked with Flagyl and the use of honey to encourage wound granulation. He had a very interested and attentive audience ! The colostomy closure was a pretty miserable slog through a lot of adhesions, and since her previous chart could not be located, we had no idea either why the colostomy was done or how it was performed. It was located in the left lateral abdomen, and I would have thought it was a sigmoid colostomy...but it turned out to be a transverse loop. Eventually we figured it out, took it down, and did a resection and reanastomosis; there was moderate blood loss, but hopefully she will be fine.
After the OR we went to the Outpatient Clinic, where patients had been waiting since 8 AM or so. We saw an interesting collection of maladies, some surgical and others not, ranging from keloids to BPH, with a thigh abscess, an undescended testicle, and a mass of the left lobe of the thyroid mixed in. Hopefully we will operate on some, but it all depends on bed availability, and that is hard to work around. We are told that there are patients in the hospital for a long time awaiting surgery, and that they are kept "on bed" awaiting the surgeon's availability. It doesn't seem fair to either the patients waiting, or to the other surgeons, but I'm not sure how to fight it. It may turn out that there is more availability at Redemption.
An interesting anomaly in Liberian health care has come to our attention: Redemption Hospital, which is in Monrovia, is classified as a district hospital, and as such comes under the authority of the Ministry of Health. As a district hospital, patients are not charged any fees for services rendered there. On the other hand, JFK is a tertiary teaching hospital, and it's budget is part of the Executive Mansion; for some reason unclear to most of us, JFK is expected to pay it's own way for the most part, and thus it is forced to charge fees. The fee for evaluation in the ED was recently raised from 100 LD (about $1.50) to 600 LD ($9.00); this represents a large hurdle for most people in a society where 80% live on less than a dollar a day, and the unemployment rate approaches 75% . According to Adamah, Liberia is the second poorest nation in the world, ranking only above The Congo .
We then met up with Adamah and others in the dining room of the Maternity Hospital chatting about the possibility of HEARTT extending out to other hospitals in the Monrovia area including Redemption and ELWA. The medical director at ELWA is going to bring a patient to clinic on Thursday for me to evaluate; it sounds like she has a far advanced breast cancer and I doubt there is anything we can do about it.
Tonight I went out for dinner to a Chinese restaurant with Ly and 2 of his friends from Cambodia, both of whom are here with the UN. One works for UNICEF in Cambodia, and was sent here on an emergency 3 month mission to work in the refugee camps in spinach Liberia, populated by people escaping the recent violence in Cote d'Ivoire. His term is almost up, and they want him to stay for another 3 months, but understandably he says he can only handle another month. Liberia is a difficult place under the best of circumstances; I can't imagine what it would be like to reside in a refugee camp for 3 months. The other Cambodian works as a budget analyst for the UN peacekeeping force; he has been here for 2 years, and seems to have settled in. He drove us in a UN Land Cruiser, and seems quite at home dealing with Monrovia traffic. We had a nice mean and an interesting conversation before going to the grocery store and then home.
We met Moses in the OR at 8:30, and did 2 cases: he did a skin graft with Ly, and then a colostomy closure with me. I think everyone is very pleased to have Ly here, and to learn from him. I forgot to mention that last night before and during dinner at the Royal, he was mentioning some techniques that he uses, such as wound packing soaked with Flagyl and the use of honey to encourage wound granulation. He had a very interested and attentive audience ! The colostomy closure was a pretty miserable slog through a lot of adhesions, and since her previous chart could not be located, we had no idea either why the colostomy was done or how it was performed. It was located in the left lateral abdomen, and I would have thought it was a sigmoid colostomy...but it turned out to be a transverse loop. Eventually we figured it out, took it down, and did a resection and reanastomosis; there was moderate blood loss, but hopefully she will be fine.
After the OR we went to the Outpatient Clinic, where patients had been waiting since 8 AM or so. We saw an interesting collection of maladies, some surgical and others not, ranging from keloids to BPH, with a thigh abscess, an undescended testicle, and a mass of the left lobe of the thyroid mixed in. Hopefully we will operate on some, but it all depends on bed availability, and that is hard to work around. We are told that there are patients in the hospital for a long time awaiting surgery, and that they are kept "on bed" awaiting the surgeon's availability. It doesn't seem fair to either the patients waiting, or to the other surgeons, but I'm not sure how to fight it. It may turn out that there is more availability at Redemption.
An interesting anomaly in Liberian health care has come to our attention: Redemption Hospital, which is in Monrovia, is classified as a district hospital, and as such comes under the authority of the Ministry of Health. As a district hospital, patients are not charged any fees for services rendered there. On the other hand, JFK is a tertiary teaching hospital, and it's budget is part of the Executive Mansion; for some reason unclear to most of us, JFK is expected to pay it's own way for the most part, and thus it is forced to charge fees. The fee for evaluation in the ED was recently raised from 100 LD (about $1.50) to 600 LD ($9.00); this represents a large hurdle for most people in a society where 80% live on less than a dollar a day, and the unemployment rate approaches 75% . According to Adamah, Liberia is the second poorest nation in the world, ranking only above The Congo .
We then met up with Adamah and others in the dining room of the Maternity Hospital chatting about the possibility of HEARTT extending out to other hospitals in the Monrovia area including Redemption and ELWA. The medical director at ELWA is going to bring a patient to clinic on Thursday for me to evaluate; it sounds like she has a far advanced breast cancer and I doubt there is anything we can do about it.
Tonight I went out for dinner to a Chinese restaurant with Ly and 2 of his friends from Cambodia, both of whom are here with the UN. One works for UNICEF in Cambodia, and was sent here on an emergency 3 month mission to work in the refugee camps in spinach Liberia, populated by people escaping the recent violence in Cote d'Ivoire. His term is almost up, and they want him to stay for another 3 months, but understandably he says he can only handle another month. Liberia is a difficult place under the best of circumstances; I can't imagine what it would be like to reside in a refugee camp for 3 months. The other Cambodian works as a budget analyst for the UN peacekeeping force; he has been here for 2 years, and seems to have settled in. He drove us in a UN Land Cruiser, and seems quite at home dealing with Monrovia traffic. We had a nice mean and an interesting conversation before going to the grocery store and then home.
Tuesday, September 27, 2011
Monday September 26
Monday September 26
I slept surprisingly well despite the noise of the generator ! The noise canceling headphones proved difficult to sleep with, but the noise of e generator is a steady one, and I think I just tuned it out after a while.
After breakfast at the dorm, we went to JFK to attend morning report, then walk through the ED to see what was there before going to Grand Rounds. The trauma ED had a large population with several one stretchers on the floor; it was really nothing unexpected, but I think each time I come back I hope for some dramatic improvement. My mind tells me that improvements don't happen overnight, but my heart wishes that they would.
At morning report, and again at Grand Rounds, I was warmly greeted by many friends who welcomed me back; that felt very good. Ly was introduced at Grand Rounds, and afterwards several doctors approached him regarding particular patient problems. We then went with Moses to the Radiology Department, where they now have digital stays rather than film ! It is really quite amazing to see this technology in use at JFK ! We looked at fills of a man with 30 or pieces of buckshot in his abdominal wall who didn't
Want to go ho,e until they were all removed, a d a man who had been shot by someone with an AK-47. In both cases I recommended leaving well enough alone, and we then went to the floors to tell the patients so. Then we went to the OR to greet many old friends including, Priscilla, Barboo, The General, and many others.
Moses and I did a baby hernia, and then we were going to do an ex-lap on a young man with peritonitis....but his family said they wanted to "carry him". This was a new expression to me, and it means that his family decided to carry him to church for prayers to make him well rather than to undergo surgery. So we didn't operate on him, and the likelihood is that he will not survive.
We both saw several consults today: Dr.McDonald brought us to Radiology to see a 10 year old boy who reportedly had fallen off his bicycle last week, hurting his left elbow. We saw the boy, and his xrays, and the amount of callus formation made it pretty clear that the injury was at least several weeks old. The bones were well aligned, and Ly felt that nothing should be done now except to help him get some movement back in the joint through PT. Dr. McDonald then wanted me to see a woman with abnormal vaginal bleeding for a second opinion, but I told her "that's not my area" ! This produced howls of laughter from her and her aides, as one of President Sirleaf's popular phrases during this election is "That's my area!" when talking about economics or finance or women's development or whatever. I then saw a man in the ED with cirrhosis and a liver mass on ultrasound whose family wanted everything possible done for him; unfortunately there really wasn't much to do given his state, probable diagnosis of liver cancer, and no pathologist here to prove it by biopsy. Cathy Nelson, an ER resident from Wisconsin, thought the family would be ok that at least a surgeon had layer hands on him and said no. Then I helped Cathy put a chest tube back into a 10 year old with a recurrent pneumothorax following an empyema.
We went out to the Royal for dinner, then back to the bungalow around 10 PM. Tomorrow Moses has some cases for us, and we will try to plan when we will go to Redemption this week.
I slept surprisingly well despite the noise of the generator ! The noise canceling headphones proved difficult to sleep with, but the noise of e generator is a steady one, and I think I just tuned it out after a while.
After breakfast at the dorm, we went to JFK to attend morning report, then walk through the ED to see what was there before going to Grand Rounds. The trauma ED had a large population with several one stretchers on the floor; it was really nothing unexpected, but I think each time I come back I hope for some dramatic improvement. My mind tells me that improvements don't happen overnight, but my heart wishes that they would.
At morning report, and again at Grand Rounds, I was warmly greeted by many friends who welcomed me back; that felt very good. Ly was introduced at Grand Rounds, and afterwards several doctors approached him regarding particular patient problems. We then went with Moses to the Radiology Department, where they now have digital stays rather than film ! It is really quite amazing to see this technology in use at JFK ! We looked at fills of a man with 30 or pieces of buckshot in his abdominal wall who didn't
Want to go ho,e until they were all removed, a d a man who had been shot by someone with an AK-47. In both cases I recommended leaving well enough alone, and we then went to the floors to tell the patients so. Then we went to the OR to greet many old friends including, Priscilla, Barboo, The General, and many others.
Moses and I did a baby hernia, and then we were going to do an ex-lap on a young man with peritonitis....but his family said they wanted to "carry him". This was a new expression to me, and it means that his family decided to carry him to church for prayers to make him well rather than to undergo surgery. So we didn't operate on him, and the likelihood is that he will not survive.
We both saw several consults today: Dr.McDonald brought us to Radiology to see a 10 year old boy who reportedly had fallen off his bicycle last week, hurting his left elbow. We saw the boy, and his xrays, and the amount of callus formation made it pretty clear that the injury was at least several weeks old. The bones were well aligned, and Ly felt that nothing should be done now except to help him get some movement back in the joint through PT. Dr. McDonald then wanted me to see a woman with abnormal vaginal bleeding for a second opinion, but I told her "that's not my area" ! This produced howls of laughter from her and her aides, as one of President Sirleaf's popular phrases during this election is "That's my area!" when talking about economics or finance or women's development or whatever. I then saw a man in the ED with cirrhosis and a liver mass on ultrasound whose family wanted everything possible done for him; unfortunately there really wasn't much to do given his state, probable diagnosis of liver cancer, and no pathologist here to prove it by biopsy. Cathy Nelson, an ER resident from Wisconsin, thought the family would be ok that at least a surgeon had layer hands on him and said no. Then I helped Cathy put a chest tube back into a 10 year old with a recurrent pneumothorax following an empyema.
We went out to the Royal for dinner, then back to the bungalow around 10 PM. Tomorrow Moses has some cases for us, and we will try to plan when we will go to Redemption this week.
Monday, September 26, 2011
Sunday September 25
We arrived in Monrovia around 3 this afternoon after an uneventful flight. The US Ambassador to Liberia was on the plane, as was the. Minister for Agriculture who was quite a charming and funny woman. When we arrived we were taken in a van to the VIP lounge/ waiting area where I was able to have my first Club beer of this visit while waiting for our luggage to be delivered. I must say there is something very nice about special treatment that occurs when traveling here with Adamah ! Among the people meeting us was Dewalt ! Yes, he returned from his trip to the USA, and seems no worse for wear lol
We then drove to the bungalow, which is where Ly, Emily ( an ER doc from Maryland) and I will be staying. The young men who guard and take care of the house seemed happy to see me again; not much has changed, and the diesel generator is still loud... I am in the room closest to the generator, so I am going to try wearing my noise cancelling headphones to bed !
It sounds like there is a lot planned for us. Some interesting cases at JFK, and apparently Redemptionist Hospital also would like us to operate there. I have heard of Redemptionist, but I have no idea what the facility is like, so I guess we will go on a scouting expedition soon.
Tonight we had dinner at Saj; there were 14 of us who had the chance to renew old friendships and make some new ones. Janis Tupelsis is here with his wife Nicky till Weds; he and I had a great conversation at dinner. Mrs Howard and Will were there as well as several HEARTT volunteers, many of whom I had met at the HEARTT meeting in Worcester last summer. And of course Ben was there !
I'm tired, so I'm off to an early sleep.
We then drove to the bungalow, which is where Ly, Emily ( an ER doc from Maryland) and I will be staying. The young men who guard and take care of the house seemed happy to see me again; not much has changed, and the diesel generator is still loud... I am in the room closest to the generator, so I am going to try wearing my noise cancelling headphones to bed !
It sounds like there is a lot planned for us. Some interesting cases at JFK, and apparently Redemptionist Hospital also would like us to operate there. I have heard of Redemptionist, but I have no idea what the facility is like, so I guess we will go on a scouting expedition soon.
Tonight we had dinner at Saj; there were 14 of us who had the chance to renew old friendships and make some new ones. Janis Tupelsis is here with his wife Nicky till Weds; he and I had a great conversation at dinner. Mrs Howard and Will were there as well as several HEARTT volunteers, many of whom I had met at the HEARTT meeting in Worcester last summer. And of course Ben was there !
I'm tired, so I'm off to an early sleep.
Saturday, September 24, 2011
Going back...Saturday, Spetember 24
I am getting ready to leave for another trip to JFK Hospital in Monrovia. This time I am accompanied by Dr. Ly Heng, a plastic/reconstructive surgeon as well as orthopedic surgeon from Phnom Penh, Cambodia. I met Ly 5 years ago when I visited one of the hospitals where he works. In the course of our conversation about some of the trauma patients he was caring for, I learned that he did not have a pair of surgical loupes because they were too expensive. The result was the formation of Loupes Around The World, our charitable foundation which has now provided over 180 pair of loupes to surgeons in 42 different countries !
This morning we will drive to White Plains (NY) airport where we will meet up with Adamah (Dr. James Sirleaf). We will fly to Atlanta, and this evening we catch the Delta flight to Accra (Ghana) and then on to Monrovia. We should arrive in Monrovia mid-afternoon on Sunday.
This morning we will drive to White Plains (NY) airport where we will meet up with Adamah (Dr. James Sirleaf). We will fly to Atlanta, and this evening we catch the Delta flight to Accra (Ghana) and then on to Monrovia. We should arrive in Monrovia mid-afternoon on Sunday.
Thursday, March 17, 2011
Wednesday March 16
Wednesday March 16
We all packed last night in anticipation of a busy day. We had breakfast at the Guest House, and then were invited to have breakfast with Madame President. So we went next door to her house, and after taking pictures with her, we sat down for another breakfast, She thanked me for my note sent the previous day, in which I thanked her for her hospitality and congratulated her on being named the Commencement speaker at the Harvard graduation this year.
Adamah told her about the young mother whose 3 year old son's hernia we fixed on Monday. I can't remember if I wrote his, but the woman has been disowned by her family because she is Muslim and she married a Christian; she is totally illiterate, and has no understanding of time or money. Anyway, the President's reaction immediately was that we will do something to help her. She said she would try to get her a job or something. By the time we got to the hospital about 20 minutes later, the President had already spoken to Dr. McDonald about her and a process had started. I guess it is one of the things about a small country that people in positions of power can more easily do things to help, perhaps; I think it is also a testament to President Sirleaf that she naturally and quickly responds to problems in this way. At the end of breakfast, she announced " it's time to do the people's business" and set off to work.
We went to hospital to say goodbye to patents and staff. As before, the next thing after "goodbye" was "when are you coming back?" there really was a sense of warmth and affection on both sides with our goodbyes, which was quite gratifying. While I was at the hospital Sondra Tyler caller. she had just received the note I left at RLJ on Sunday, and the guy from the Philanthropy Secretariat had forgotten to tell her that I was there looking for her. In any case, they were having a busy time, and they are scheduled to visit JFK on Thursday. I asked her to speak with Dr. McDonald personally, andnshe said she would. We agreed that we would have a nice long conversation when we bother were home.
Adamah was in meetings so we went to Front St. with Dewalt and Albert driving to go shopping at the mask store; additionally drums were purchased across the street. Then we went back to the Guest House to have lunch, say our goodbyes to the staff, and wait for Adamah to come so we could leave for the airport. He was rather late, so we didn't leave the Guest House till 3:35, and we drove like a bat out of hell to the airport. I was sitting in the back so I could see the speedometer well, and Albert hit 140 km/hr, or 87 mph on the two lane road to the airport, dodging taxis and trucks, and intermittently giving me cause to wonder if we would make it alive to the airport. Fortunately we did make it, arriving around 4:15 for our 5:30 flight; initially they said they wouldn't check us in because it was too late, but some phone calls were made and eventually we did get checked in and through security to board the plane. I told Adamah that next time maybe I would make my own arrangements to travel to the airport !!
We are now in Atlanta on the way home.
We all packed last night in anticipation of a busy day. We had breakfast at the Guest House, and then were invited to have breakfast with Madame President. So we went next door to her house, and after taking pictures with her, we sat down for another breakfast, She thanked me for my note sent the previous day, in which I thanked her for her hospitality and congratulated her on being named the Commencement speaker at the Harvard graduation this year.
Adamah told her about the young mother whose 3 year old son's hernia we fixed on Monday. I can't remember if I wrote his, but the woman has been disowned by her family because she is Muslim and she married a Christian; she is totally illiterate, and has no understanding of time or money. Anyway, the President's reaction immediately was that we will do something to help her. She said she would try to get her a job or something. By the time we got to the hospital about 20 minutes later, the President had already spoken to Dr. McDonald about her and a process had started. I guess it is one of the things about a small country that people in positions of power can more easily do things to help, perhaps; I think it is also a testament to President Sirleaf that she naturally and quickly responds to problems in this way. At the end of breakfast, she announced " it's time to do the people's business" and set off to work.
We went to hospital to say goodbye to patents and staff. As before, the next thing after "goodbye" was "when are you coming back?" there really was a sense of warmth and affection on both sides with our goodbyes, which was quite gratifying. While I was at the hospital Sondra Tyler caller. she had just received the note I left at RLJ on Sunday, and the guy from the Philanthropy Secretariat had forgotten to tell her that I was there looking for her. In any case, they were having a busy time, and they are scheduled to visit JFK on Thursday. I asked her to speak with Dr. McDonald personally, andnshe said she would. We agreed that we would have a nice long conversation when we bother were home.
Adamah was in meetings so we went to Front St. with Dewalt and Albert driving to go shopping at the mask store; additionally drums were purchased across the street. Then we went back to the Guest House to have lunch, say our goodbyes to the staff, and wait for Adamah to come so we could leave for the airport. He was rather late, so we didn't leave the Guest House till 3:35, and we drove like a bat out of hell to the airport. I was sitting in the back so I could see the speedometer well, and Albert hit 140 km/hr, or 87 mph on the two lane road to the airport, dodging taxis and trucks, and intermittently giving me cause to wonder if we would make it alive to the airport. Fortunately we did make it, arriving around 4:15 for our 5:30 flight; initially they said they wouldn't check us in because it was too late, but some phone calls were made and eventually we did get checked in and through security to board the plane. I told Adamah that next time maybe I would make my own arrangements to travel to the airport !!
We are now in Atlanta on the way home.
Wednesday, March 16, 2011
Tuesday March 15
Tuesday March 15
Today is a national holiday celebrating the birth of the first President of Liberia, Mr Roberts, so we did a short schedule. We biopsied a groin node on Joseph N, a 20 year old who looks like he has a Burkitt's lymphoma despite being so,what older than usual for it. I will bring the nodal tissue back to Waterbury, where our pathologists have become quite interested in looking at Liberian tissue samples for us. As fate would have it, just the other day I was talking with some of the pediatric residents and attendings at dinner, and they told me about a protocol they have been using with success for Burkitts using methotrexate, cyclophosphamide, and prednisone. I asked them today if they would be willing to try it on Mr Nah if his pathology shows Burkitts, and they said absolutely, so we shall see what happens.
After Mr Nah we did Hans B, a 30s aged economist with the Ministry of Finance, who has a located pleural effusion from TB. He has one chest tube in place, but apparently still has an effusion, so Dr Mike asked if we would do a typewriting and decortication. Santiago and I discussed it several times, and in e end we decided that it just wouldnt be the right thing for us to do for all sorts of reasons, including anesthesia, post-op pain control and breathing, the fact that we are leaving tomorrow, and the fact that neither of us are boracic surgeons. So we put another chest tube in, and didn't get much drainage despite significant manipulation, but we decided to leave well enough alone.
This afternoon we had a fascinating trip to Toode Mission School, about an hour away, and we were accompanied by Adamah's Aunt Ophelia ( she is married to Varney, the Presidents brother). Ophelia is a fascinating woman who has her Masters in geology or something, and has taken on this school as her project. In fact, the school was started by the President's mother, and was pretty much destroyed during the war. Ophelia now has it up and running with 106 students, about 30 being day students and the rest boarders. Boarding costs about $550 a year, but no one is turned away for lack of ability to pay, and in fact none of the students are paying full fees. The age/grades go from kindergarten to 10th grade. The students we met were great: healthy, happy, friendly, and outgoing ! A group of the girls sang for us, and everyone smiled for the many cameras. The current principal is a retired school administrator from Bridgeport, CT who volunteered in the ED at Bridgeport Hospital where he met Adamah and became interested in Liberia. He was looking for an opportuntity to use his skills where they were really needed, and this came along, so he is spending 4 months helping in Liberia. It was quite an inspiring visit, and I particularly enjoyed the opportunity to chat with Ophelia about how this project came to happen for her.
On the way back we stopped at the graves of Adamah's father, and of his uncle Dr. Varsay Sirleaf, which are quite close to the school. Then we drove back to Monrovia and stopped the family compound where two of his brothers live, and we discovered that there was a big celebration going on, perhaps because of the holiday, and President Sirleaf was there. There were a lot of people sitting at tables outside, and she came out to say hello. Then we had dinner, and after dinner when she was leaving she came to where we were to take pictures. Protocol does not allow her to have photos taken with people in shorts, so Santiago and I were out. But she told Adamah that she would meet us in the morning for pictures, so that works out better as Jenn and Eric did not make the trip; her Tubman's revenge continues to be a problem.
Today is a national holiday celebrating the birth of the first President of Liberia, Mr Roberts, so we did a short schedule. We biopsied a groin node on Joseph N, a 20 year old who looks like he has a Burkitt's lymphoma despite being so,what older than usual for it. I will bring the nodal tissue back to Waterbury, where our pathologists have become quite interested in looking at Liberian tissue samples for us. As fate would have it, just the other day I was talking with some of the pediatric residents and attendings at dinner, and they told me about a protocol they have been using with success for Burkitts using methotrexate, cyclophosphamide, and prednisone. I asked them today if they would be willing to try it on Mr Nah if his pathology shows Burkitts, and they said absolutely, so we shall see what happens.
After Mr Nah we did Hans B, a 30s aged economist with the Ministry of Finance, who has a located pleural effusion from TB. He has one chest tube in place, but apparently still has an effusion, so Dr Mike asked if we would do a typewriting and decortication. Santiago and I discussed it several times, and in e end we decided that it just wouldnt be the right thing for us to do for all sorts of reasons, including anesthesia, post-op pain control and breathing, the fact that we are leaving tomorrow, and the fact that neither of us are boracic surgeons. So we put another chest tube in, and didn't get much drainage despite significant manipulation, but we decided to leave well enough alone.
This afternoon we had a fascinating trip to Toode Mission School, about an hour away, and we were accompanied by Adamah's Aunt Ophelia ( she is married to Varney, the Presidents brother). Ophelia is a fascinating woman who has her Masters in geology or something, and has taken on this school as her project. In fact, the school was started by the President's mother, and was pretty much destroyed during the war. Ophelia now has it up and running with 106 students, about 30 being day students and the rest boarders. Boarding costs about $550 a year, but no one is turned away for lack of ability to pay, and in fact none of the students are paying full fees. The age/grades go from kindergarten to 10th grade. The students we met were great: healthy, happy, friendly, and outgoing ! A group of the girls sang for us, and everyone smiled for the many cameras. The current principal is a retired school administrator from Bridgeport, CT who volunteered in the ED at Bridgeport Hospital where he met Adamah and became interested in Liberia. He was looking for an opportuntity to use his skills where they were really needed, and this came along, so he is spending 4 months helping in Liberia. It was quite an inspiring visit, and I particularly enjoyed the opportunity to chat with Ophelia about how this project came to happen for her.
On the way back we stopped at the graves of Adamah's father, and of his uncle Dr. Varsay Sirleaf, which are quite close to the school. Then we drove back to Monrovia and stopped the family compound where two of his brothers live, and we discovered that there was a big celebration going on, perhaps because of the holiday, and President Sirleaf was there. There were a lot of people sitting at tables outside, and she came out to say hello. Then we had dinner, and after dinner when she was leaving she came to where we were to take pictures. Protocol does not allow her to have photos taken with people in shorts, so Santiago and I were out. But she told Adamah that she would meet us in the morning for pictures, so that works out better as Jenn and Eric did not make the trip; her Tubman's revenge continues to be a problem.
Tuesday, March 15, 2011
Monday March 14
Monday March 14
Jenn had to take the day off today as she has developed rather severe Tubman's revenge. We went in thinking that we would have a couple of small cases to do, but as often happens that was not the case. We found several emergencies to keep ourselves busy for most of the day.
First Yuk did a hypospadius repair with Konneh, and while she was doing that, Santiago, Eric, and I went to the ER to see a couple of patients. One was a man with a large scrotal mass, and the other was a man with peritonitis who was guarding and tympanitic, and looked like he was either obstructed or perforated or both. Then we had a call from Jenn saying that she had received a call from the mother who had shown up at the Guest House yesterday with her 3 year old son Santa saying that now they were at the ED. So we went in search of them, and found her and the 2 kids, one strapped to her back, and all of her worldly possessions in a blue plastic bag she was carrying on her head.
I should back up a day. When Santiago, Adamah, and I came back from our visit to JFK with the President, we found a woman with 2 young children sitting in the carport with a policeman standing next to her and the two psychiatrists also staying in the Guest House sitting nearby talking to her. The story was that she was from Nimba County; she is Muslim and had married a Christian who died in a car accident 7 months ago; as a result of the marriage she was ostracized from her family, and had no means of support; and her 3 year old son had a large communicating hydrocele. The policeman had taken pity on her, and had brought her to the Guest House because he knew that Adamah was in town and that HEARTT could possibly take care of her. So anyway, after much discussion, we said that we would take care of her, and that she should come to the hospital in the morning. In fact, Jenn asked her to come at 9:30 AM, but Adamah pointed out that she is illiterate, and actually had no concept of what 9:30 meant.
Anyway, she showed up, and had actually remembered to keep Santa NPO, so there was a good chance we could do his surgery today, if we could get through the necessary hoops. Fortunately we ran into Mary, the Clinical Coordinator, who took charge and made sure that it was all done expeditiously.
We went back up to the OR to learn that the next case was another emergency, but this one had been admitted yesterday with a strangulated right inguinal hernia. Why his surgery wasn't done yesterday by Dr. Muvu remains a mystery. Anyway, he is 33 years old and had a huge recurrent hernia. Yuk and I started the case under spinal, but found on opening the sac that his right colon was in it and dead. We converted to a laparotomy, and after some urging by me, anesthesia converted him to general anesthesia. On opening his abdomen, we found more dead bowel, but some still alive, so I asked Santiago to scrub in. We ended up resecting about half of his small bowel, and his right colon up to mid-transverse colon. At one point I saw his blood pressure was 50, and I was pretty convinced he was not going to survive. We removed his dead bowel quite expeditiously, and also his dead right testicle, and gave him an ileostomy.
After that we learned that the man with the acute abdomen in the ED had expired; I thought he was sick, but I was surprised at the speed of his demise. Moses went to see the man with the scrotal mass, and said that it was filariasis (elephantiasis) and did not require surgery. So Yuk and I did the 3 year old next, and that was uneventful, while Moses and Santiago did an incarcerated umbilical hernia next door.
On post-op rounds, we saw the man with the strangulated hernia and now with an ileostomy. He looked remarkably good for what he had been through. I explained that we had to remove half of his intestines, and that he had a temporary ileostomy which could be reversed in a couple of months. He held out his hand to shake mine, and said "thank you" in a very heartfelt way. As Santiago said, he knew he had been close to death, and he appreciated that his life had been saved; it was quite a memorable moment.
We came back to the Guest House to find Jenn in about the same condition; she said that the staff, especially Catherine and Welke, had been checking on her during the day. Having collected the necessary supplies from the hospital, we then did a little home surgery in the kitchen to remove a 3 cm lipoma from Catherine's upper arm; while conditions were somewhat primitive, the surgery was successful !
Santiago, Catherine the psychiatry resident, and I then went for dinner at Cafe Jamal with Yuk, Melissa, Robyn, and Guy, a visiting medical student from Oxford. We had an interesting conversation on a number of topics, and then back here for bed.
Jenn had to take the day off today as she has developed rather severe Tubman's revenge. We went in thinking that we would have a couple of small cases to do, but as often happens that was not the case. We found several emergencies to keep ourselves busy for most of the day.
First Yuk did a hypospadius repair with Konneh, and while she was doing that, Santiago, Eric, and I went to the ER to see a couple of patients. One was a man with a large scrotal mass, and the other was a man with peritonitis who was guarding and tympanitic, and looked like he was either obstructed or perforated or both. Then we had a call from Jenn saying that she had received a call from the mother who had shown up at the Guest House yesterday with her 3 year old son Santa saying that now they were at the ED. So we went in search of them, and found her and the 2 kids, one strapped to her back, and all of her worldly possessions in a blue plastic bag she was carrying on her head.
I should back up a day. When Santiago, Adamah, and I came back from our visit to JFK with the President, we found a woman with 2 young children sitting in the carport with a policeman standing next to her and the two psychiatrists also staying in the Guest House sitting nearby talking to her. The story was that she was from Nimba County; she is Muslim and had married a Christian who died in a car accident 7 months ago; as a result of the marriage she was ostracized from her family, and had no means of support; and her 3 year old son had a large communicating hydrocele. The policeman had taken pity on her, and had brought her to the Guest House because he knew that Adamah was in town and that HEARTT could possibly take care of her. So anyway, after much discussion, we said that we would take care of her, and that she should come to the hospital in the morning. In fact, Jenn asked her to come at 9:30 AM, but Adamah pointed out that she is illiterate, and actually had no concept of what 9:30 meant.
Anyway, she showed up, and had actually remembered to keep Santa NPO, so there was a good chance we could do his surgery today, if we could get through the necessary hoops. Fortunately we ran into Mary, the Clinical Coordinator, who took charge and made sure that it was all done expeditiously.
We went back up to the OR to learn that the next case was another emergency, but this one had been admitted yesterday with a strangulated right inguinal hernia. Why his surgery wasn't done yesterday by Dr. Muvu remains a mystery. Anyway, he is 33 years old and had a huge recurrent hernia. Yuk and I started the case under spinal, but found on opening the sac that his right colon was in it and dead. We converted to a laparotomy, and after some urging by me, anesthesia converted him to general anesthesia. On opening his abdomen, we found more dead bowel, but some still alive, so I asked Santiago to scrub in. We ended up resecting about half of his small bowel, and his right colon up to mid-transverse colon. At one point I saw his blood pressure was 50, and I was pretty convinced he was not going to survive. We removed his dead bowel quite expeditiously, and also his dead right testicle, and gave him an ileostomy.
After that we learned that the man with the acute abdomen in the ED had expired; I thought he was sick, but I was surprised at the speed of his demise. Moses went to see the man with the scrotal mass, and said that it was filariasis (elephantiasis) and did not require surgery. So Yuk and I did the 3 year old next, and that was uneventful, while Moses and Santiago did an incarcerated umbilical hernia next door.
On post-op rounds, we saw the man with the strangulated hernia and now with an ileostomy. He looked remarkably good for what he had been through. I explained that we had to remove half of his intestines, and that he had a temporary ileostomy which could be reversed in a couple of months. He held out his hand to shake mine, and said "thank you" in a very heartfelt way. As Santiago said, he knew he had been close to death, and he appreciated that his life had been saved; it was quite a memorable moment.
We came back to the Guest House to find Jenn in about the same condition; she said that the staff, especially Catherine and Welke, had been checking on her during the day. Having collected the necessary supplies from the hospital, we then did a little home surgery in the kitchen to remove a 3 cm lipoma from Catherine's upper arm; while conditions were somewhat primitive, the surgery was successful !
Santiago, Catherine the psychiatry resident, and I then went for dinner at Cafe Jamal with Yuk, Melissa, Robyn, and Guy, a visiting medical student from Oxford. We had an interesting conversation on a number of topics, and then back here for bed.
Monday, March 14, 2011
Sunday March 13
Sunday March 13
I was resting comfortably in that netherworld between sleep and awake when my phone rang around 9 AM. It was Adamah who said that Auntie Jennie wanted to speak to me; she then got on the phone to ask if I was up and about. I said of course, and she asked if I would come next door to the President's house as she wanted to speak to me. I got up, put in my contacts, and quickly dressed. I was ushered into the President's house, and upstairs when I met Madame and Auntie Jenny in the hallway so we all went into the dining room together where Adamah and Rob were waiting. Apparently the President was out with people yesterday, and one of the young men she spoke with was later assaulted and stabbed; he was brought to JFK and observed overnight. His hemoglobin was 8.6 and apparently there was some concern that he had lost enough blood to need a transfusion. Dr. Moses had seen him and said that he could be discharged, but apparently someone was worried about that, and by means unknown, had contacted Auntie Jennie, and now the President was concerned. So she wanted to know if I would be willing to go to JFK to provide another surgical opinion, and of course I said yes. Adamah asked if I wanted to bring anyone with me, and I thought that in case it was serious, it would be good to have Santiago along. So he was roused from bed by Dewalt since he wouldn't answer his phone, and soon he was at the table eating breakfast with us.
The President decided she wanted to go to JFK to see this man and his family also on her way to church. So before long, we went downstairs and I was told to ride in the Presidential limousine with herself; Santiago rode in the Secret Service vehicle ahead, with 3 M-16s on the seat next to him. We proceeded the short distance to JFK, and were met by the CMO Dr. Johnson, and then went through the hospital to the Trauma ER where we found the patient. He had a small laceration on his right shoulder, and a superficial laceration of his left upper abdominal wall; he was stable, talking, and in no distress. I assured the President that he was fine. The patient's mother was then brought in, and she talked for several minutes about what had happened to her son, and the fact that she couldn't donate blood last night when he came in because she had been drinking beer, and a whole lot more which I couldn't understand. I was quite astonished that this woman was yammering on so much to the President, but Madame took it all in stride and only commented at the end on how important it was to reduce violence among young people. We all then went outside, where the President said that we should not go back to JFK today, but rather we should take the day off and go to the beach ! She then left for church and we came back here.
In the afternoon we went to RLJ as instructed by the President ! My sister-in-law's friend Sondra Tyler was arriving with her group to stay at RLJ for a few days, so I left a note for her at the desk and also spoke to one of the people from the host organization, but I haven't heard back yet.
We left the beach around 6:30 to go back to the Guest House. Later we went for dinner at Sajj, and then home to get to bed early, at least compared to our last couple of nights.
I was resting comfortably in that netherworld between sleep and awake when my phone rang around 9 AM. It was Adamah who said that Auntie Jennie wanted to speak to me; she then got on the phone to ask if I was up and about. I said of course, and she asked if I would come next door to the President's house as she wanted to speak to me. I got up, put in my contacts, and quickly dressed. I was ushered into the President's house, and upstairs when I met Madame and Auntie Jenny in the hallway so we all went into the dining room together where Adamah and Rob were waiting. Apparently the President was out with people yesterday, and one of the young men she spoke with was later assaulted and stabbed; he was brought to JFK and observed overnight. His hemoglobin was 8.6 and apparently there was some concern that he had lost enough blood to need a transfusion. Dr. Moses had seen him and said that he could be discharged, but apparently someone was worried about that, and by means unknown, had contacted Auntie Jennie, and now the President was concerned. So she wanted to know if I would be willing to go to JFK to provide another surgical opinion, and of course I said yes. Adamah asked if I wanted to bring anyone with me, and I thought that in case it was serious, it would be good to have Santiago along. So he was roused from bed by Dewalt since he wouldn't answer his phone, and soon he was at the table eating breakfast with us.
The President decided she wanted to go to JFK to see this man and his family also on her way to church. So before long, we went downstairs and I was told to ride in the Presidential limousine with herself; Santiago rode in the Secret Service vehicle ahead, with 3 M-16s on the seat next to him. We proceeded the short distance to JFK, and were met by the CMO Dr. Johnson, and then went through the hospital to the Trauma ER where we found the patient. He had a small laceration on his right shoulder, and a superficial laceration of his left upper abdominal wall; he was stable, talking, and in no distress. I assured the President that he was fine. The patient's mother was then brought in, and she talked for several minutes about what had happened to her son, and the fact that she couldn't donate blood last night when he came in because she had been drinking beer, and a whole lot more which I couldn't understand. I was quite astonished that this woman was yammering on so much to the President, but Madame took it all in stride and only commented at the end on how important it was to reduce violence among young people. We all then went outside, where the President said that we should not go back to JFK today, but rather we should take the day off and go to the beach ! She then left for church and we came back here.
In the afternoon we went to RLJ as instructed by the President ! My sister-in-law's friend Sondra Tyler was arriving with her group to stay at RLJ for a few days, so I left a note for her at the desk and also spoke to one of the people from the host organization, but I haven't heard back yet.
We left the beach around 6:30 to go back to the Guest House. Later we went for dinner at Sajj, and then home to get to bed early, at least compared to our last couple of nights.
Sunday, March 13, 2011
Saturday March 12
Saturday March 12
No one really wanted to get up this morning, but we did anyway. I did a hernia repair with Chris Hughes, which was a fun experience for both of us. After the surgery and rounds, we came back to the guest house for a nap.
Late in the afternoon Dr. McDonald came over with Althea and 2 of the Rhode Island Liberian nurses to have lunch. I sat with them, and Dr. McDonald told of the conditions at JFK right after the war. There was no food for patients, or water, or electricity; it is hard to imagine coming back to such circumstances and seeing a way out, but they did.
In the evening we attended the HEARTT Gala fundraiser at City Hall. This was the first time they have tried to raise money in Liberia to support HEARTT, and it was an unqualified success ! The President attended as the Guest of Honor, and I'm sure that was the big draw. They sold all 250 available tickets, and had another 100 people on a waiting list. Several people gave testimonials about their experience; I spoke briefly about the honor and privilege of being part of HEARTT.
After the dinner and speeches, Madame President made the rounds of the room greeting guests while Eric did an amazing and wonderful rendition of Amazing Grace on his trumpet, accompanied by the keyboard player from the band. He started out with the standard tune, and then morphed into a jazz rendition that was awesome. The President then came over and asked Eric to play it again when she was back in her seat so that she could really listen and enjoy it. So he played it again and she clearly loved it, tapping along to the jazzy beat.
As the evening was breaking up and we were all milling about, a young woman came up to me to say that she heard me say I was from Connecticut, and that she had gone to school in Connecticut. I asked her where, and she said "Choate Rosemary Hall" ! Her name is Idella Cooper, CRH '94 , and she is the Deputy Minister for Justice for Economic Affairs . Her fiancé took our picture together, which I will be submitting to the CRH Alumni magazine...who would have guessed that 2 CRH alumni would meet up in Monrovia, Liberia ?!
From the gala at City Hall we all went to Groovie's for more dancing. Eric sat in with the band for several tunes and was awesome; having him with us on this trip has definitely added an unexpected dimension of enjoyment for all of us. The band and the singer were fantastic, and we all had a great time dancing. After Groovie's we went to the Palm Springs Casino; I had a very pleasant chat with the President's social secretary, who invited me to come back next January for the President's inauguration !! Assuming she is re-elected of course, but of that there can be little doubt at this point. One should never overestimate the intelligence of a voting population, but it would seem particularly foolish not to reelect her to keep the very powerful sense of forward momentum going. After a good discussion with Wilfred and Michelle at the bar, we all piled into vehicles and headed home to bed.
Oh I forgot to mention one detail. Santiago dared me to get the phrase "Easy Peasy Lemon Squeezy" into my remarks...and I did so seamlessly ! It was a big hit for those in the know lol
No one really wanted to get up this morning, but we did anyway. I did a hernia repair with Chris Hughes, which was a fun experience for both of us. After the surgery and rounds, we came back to the guest house for a nap.
Late in the afternoon Dr. McDonald came over with Althea and 2 of the Rhode Island Liberian nurses to have lunch. I sat with them, and Dr. McDonald told of the conditions at JFK right after the war. There was no food for patients, or water, or electricity; it is hard to imagine coming back to such circumstances and seeing a way out, but they did.
In the evening we attended the HEARTT Gala fundraiser at City Hall. This was the first time they have tried to raise money in Liberia to support HEARTT, and it was an unqualified success ! The President attended as the Guest of Honor, and I'm sure that was the big draw. They sold all 250 available tickets, and had another 100 people on a waiting list. Several people gave testimonials about their experience; I spoke briefly about the honor and privilege of being part of HEARTT.
After the dinner and speeches, Madame President made the rounds of the room greeting guests while Eric did an amazing and wonderful rendition of Amazing Grace on his trumpet, accompanied by the keyboard player from the band. He started out with the standard tune, and then morphed into a jazz rendition that was awesome. The President then came over and asked Eric to play it again when she was back in her seat so that she could really listen and enjoy it. So he played it again and she clearly loved it, tapping along to the jazzy beat.
As the evening was breaking up and we were all milling about, a young woman came up to me to say that she heard me say I was from Connecticut, and that she had gone to school in Connecticut. I asked her where, and she said "Choate Rosemary Hall" ! Her name is Idella Cooper, CRH '94 , and she is the Deputy Minister for Justice for Economic Affairs . Her fiancé took our picture together, which I will be submitting to the CRH Alumni magazine...who would have guessed that 2 CRH alumni would meet up in Monrovia, Liberia ?!
From the gala at City Hall we all went to Groovie's for more dancing. Eric sat in with the band for several tunes and was awesome; having him with us on this trip has definitely added an unexpected dimension of enjoyment for all of us. The band and the singer were fantastic, and we all had a great time dancing. After Groovie's we went to the Palm Springs Casino; I had a very pleasant chat with the President's social secretary, who invited me to come back next January for the President's inauguration !! Assuming she is re-elected of course, but of that there can be little doubt at this point. One should never overestimate the intelligence of a voting population, but it would seem particularly foolish not to reelect her to keep the very powerful sense of forward momentum going. After a good discussion with Wilfred and Michelle at the bar, we all piled into vehicles and headed home to bed.
Oh I forgot to mention one detail. Santiago dared me to get the phrase "Easy Peasy Lemon Squeezy" into my remarks...and I did so seamlessly ! It was a big hit for those in the know lol
Saturday, March 12, 2011
Friday March 11
Friday, March 11
The first news this morning was that the elevator was broken and therefore surgery was delayed; later in the day they got it working again. Then we learned that the woman with the breast cancer upon whom we operated yesterday did not survive the night. I can't say that it was a huge surprise, given her overall condition, but still it came as something of a shock. And I forgot to mention in yesterday's posting that one of the esophageal dilations from Tuesday had died. Little Marie was terribly malnourished; the feeling is that perhaps there was a perforation with the dilation, but who knows.
When we finally got to the OR, we started the day with me and Yuk doing a 12 year old boy with an inguinal hernia, and found that his appendix was stuck in the hernia sac. This has a name which escapes me at present, but I will look it up when I can. The next case was a boy with a 3 cm mass on his heel, which was advertised as a lipoma, but it wasn't; rather, I think it was some sort of hemangioma which one of us had ever seen before. I took some pieces of it for pathology, and perhaps that will help us figure out what it was and whether further surgery will be needed. Next I did an adult hernia with Dr. Cocola, and that went well; I think he is trainable, but he will need a good teacher.
Between cases I went to the Administration building to meet Mr. Ofora, whose wife has been organizing our meals here at the guest house. He had a neck operation locally many years ago, then more, the last being at Howard University several years ago. He has what appears to me to be a hemangioma in his lower right neck, but it also involves the right half of his tongue. He says his tongue is enlarging and it is starting to make it difficult to eat and talk. He said that with his last surgery he had a trach rather than endo tracheal or nasotracheal intubation. I'm not sure what ICANN do, but I told him that I would research it and see if something can be done with laser or other modern means. How it would get paid for if he had to go to the USA is another problem.
After that Santiago and I did the most massive hernia I have ever done ! We both thought it would be fun to operate together again like we did when he was a resident, and indeed it was a most enjoyable experience. It was a huge inguino-scrotal hernia containing small bowel and cecum, but it all appeared viable,so we reduced it and then repaired the hernia. We both remarked afterwards on how enjoyable it was and that such experiences are an added attraction for former residents who want to come to Liberia.
Tonight we had dinner at the Guest House, and since it is Eric's birthday, they put on a great dinner. There were 25 or 30 people here,and they served wine in addition to the usual beer along was a lovely dinner, and a birthday cake for Eric ! After dinner we went to Tides for a few drinks, and then to Deja Vu for some dancing. We came home around 2:30 AM as we have a hernia to do in the morning, and then the Gala tomorrow night.
The Gala is the first fundraiser for HEARTT held in Monrovia, and it will be a formal affair at City Hall tomorrow night. According to Wilfred, ticket sales were slow until this week when they went through the roof, and currently it is filled to the capacity of 250 with 100 people on a waiting list ! Adamah asked me a few weeks ago if I would say a few words, and I said that I would; now it seems somewhat more daunting a task, especially since it seems like others are interested in hearing what I will say. I'm pretty sure I can pull it off, but it is still a little nerve-wracking to know that I will ve speaking to l the President.
The first news this morning was that the elevator was broken and therefore surgery was delayed; later in the day they got it working again. Then we learned that the woman with the breast cancer upon whom we operated yesterday did not survive the night. I can't say that it was a huge surprise, given her overall condition, but still it came as something of a shock. And I forgot to mention in yesterday's posting that one of the esophageal dilations from Tuesday had died. Little Marie was terribly malnourished; the feeling is that perhaps there was a perforation with the dilation, but who knows.
When we finally got to the OR, we started the day with me and Yuk doing a 12 year old boy with an inguinal hernia, and found that his appendix was stuck in the hernia sac. This has a name which escapes me at present, but I will look it up when I can. The next case was a boy with a 3 cm mass on his heel, which was advertised as a lipoma, but it wasn't; rather, I think it was some sort of hemangioma which one of us had ever seen before. I took some pieces of it for pathology, and perhaps that will help us figure out what it was and whether further surgery will be needed. Next I did an adult hernia with Dr. Cocola, and that went well; I think he is trainable, but he will need a good teacher.
Between cases I went to the Administration building to meet Mr. Ofora, whose wife has been organizing our meals here at the guest house. He had a neck operation locally many years ago, then more, the last being at Howard University several years ago. He has what appears to me to be a hemangioma in his lower right neck, but it also involves the right half of his tongue. He says his tongue is enlarging and it is starting to make it difficult to eat and talk. He said that with his last surgery he had a trach rather than endo tracheal or nasotracheal intubation. I'm not sure what ICANN do, but I told him that I would research it and see if something can be done with laser or other modern means. How it would get paid for if he had to go to the USA is another problem.
After that Santiago and I did the most massive hernia I have ever done ! We both thought it would be fun to operate together again like we did when he was a resident, and indeed it was a most enjoyable experience. It was a huge inguino-scrotal hernia containing small bowel and cecum, but it all appeared viable,so we reduced it and then repaired the hernia. We both remarked afterwards on how enjoyable it was and that such experiences are an added attraction for former residents who want to come to Liberia.
Tonight we had dinner at the Guest House, and since it is Eric's birthday, they put on a great dinner. There were 25 or 30 people here,and they served wine in addition to the usual beer along was a lovely dinner, and a birthday cake for Eric ! After dinner we went to Tides for a few drinks, and then to Deja Vu for some dancing. We came home around 2:30 AM as we have a hernia to do in the morning, and then the Gala tomorrow night.
The Gala is the first fundraiser for HEARTT held in Monrovia, and it will be a formal affair at City Hall tomorrow night. According to Wilfred, ticket sales were slow until this week when they went through the roof, and currently it is filled to the capacity of 250 with 100 people on a waiting list ! Adamah asked me a few weeks ago if I would say a few words, and I said that I would; now it seems somewhat more daunting a task, especially since it seems like others are interested in hearing what I will say. I'm pretty sure I can pull it off, but it is still a little nerve-wracking to know that I will ve speaking to l the President.
Friday, March 11, 2011
Thursday March 10
Thursday March 10
My day in the OR today doing a ventral/umbilical hernia, a breast cancer, and an adult inguinal hernia. I'm not sure why it was so hot in the OR, and maybe it was the new Goretex sterile gowns we were wearing, but especially in the first case I was sweating like it was a steam room.
The 56 year old woman with breast cancer was interesting from several points of view. When I met her in the pre-op area, Moses and Santiago were with me, and without actually looking at her breast, Moses said that this type of patient is the kind that he would delay surgery for a long time, hoping that death would come before he was forced to operate, because the outcome is so dismal. I think there is wisdom in his comments; on the other hand her chest X-ray was normal, and so who knows how long it would take for her to die. The second interesting feature was that her breast cancer was unlike anything I have ever seen. It looked like a small tree trunk growing up from her chest, and it was hollowed out in the middle. She had an axillary ode the size of a lemon. In any case we took her to surgery, and managed to close the would after doing a mastectomy. I don't know how long she will survive, but I hope that what we did for her improves her remaining time.
While Jenn and I were doing the mastectomy, Dr. Jallah was operating on a girl with a recto-vaginal fistula. She sent out a request for help, and Santiago went in to work his magic. He did some kind of fancy advancement flap to close the defect; hopefully it will work ! I am very pleased that he is here with us, providing expertise to us and the other doctors !
This team is working out well, and everyone seems quite happy with their experience to date. It is also interesting and fun to be here with so many other HEARTT people; I think the cross-cultural exchange ( between medicine,pediatrics, and surgery) benefits all of us more than we realize.
Tonight we all went to Taaj, an Indian restaurant on Tubbman Boulevard near Golden Beach. We had an excellent meal, and great conversation. One of the pediatrics residents was telling me that they do have some IV chemotherapy for kids with retinoblastoma and for Burkitt's lymphoma. She showed me before and after pictures of one boy with a Burkitt's, and his response to chemotherapy in 5 weeks was astonishing ! This type of story is that kind of information that will hopefully get people to realize that there is always hope, and that things are looking up for Liberia.
My day in the OR today doing a ventral/umbilical hernia, a breast cancer, and an adult inguinal hernia. I'm not sure why it was so hot in the OR, and maybe it was the new Goretex sterile gowns we were wearing, but especially in the first case I was sweating like it was a steam room.
The 56 year old woman with breast cancer was interesting from several points of view. When I met her in the pre-op area, Moses and Santiago were with me, and without actually looking at her breast, Moses said that this type of patient is the kind that he would delay surgery for a long time, hoping that death would come before he was forced to operate, because the outcome is so dismal. I think there is wisdom in his comments; on the other hand her chest X-ray was normal, and so who knows how long it would take for her to die. The second interesting feature was that her breast cancer was unlike anything I have ever seen. It looked like a small tree trunk growing up from her chest, and it was hollowed out in the middle. She had an axillary ode the size of a lemon. In any case we took her to surgery, and managed to close the would after doing a mastectomy. I don't know how long she will survive, but I hope that what we did for her improves her remaining time.
While Jenn and I were doing the mastectomy, Dr. Jallah was operating on a girl with a recto-vaginal fistula. She sent out a request for help, and Santiago went in to work his magic. He did some kind of fancy advancement flap to close the defect; hopefully it will work ! I am very pleased that he is here with us, providing expertise to us and the other doctors !
This team is working out well, and everyone seems quite happy with their experience to date. It is also interesting and fun to be here with so many other HEARTT people; I think the cross-cultural exchange ( between medicine,pediatrics, and surgery) benefits all of us more than we realize.
Tonight we all went to Taaj, an Indian restaurant on Tubbman Boulevard near Golden Beach. We had an excellent meal, and great conversation. One of the pediatrics residents was telling me that they do have some IV chemotherapy for kids with retinoblastoma and for Burkitt's lymphoma. She showed me before and after pictures of one boy with a Burkitt's, and his response to chemotherapy in 5 weeks was astonishing ! This type of story is that kind of information that will hopefully get people to realize that there is always hope, and that things are looking up for Liberia.
Thursday, March 10, 2011
Wednesday
Wednesday March 9
Today is Decoration Day, sort of like our Memorial Day, and the day on which families go to the graves of loved ones the clean them up and redecorate them. It is a national holiday, so there isn't much going on, except that we are operating. Moses is back from Lofa County, an 11 hour drive, where he went for the funeral of his mother-in-law or sister-in-law or something. He and Yuk did a hernia on a 3 year old, then Cocola and I did a Halstead repair of a recurrent hernia in a 60 year old, and now Santiago and Jenn are doing Trifecta. It appears to me that she had a strangulated Spigelian hernia, which has to be pretty rare. In any case the surgery went well and was not as difficult as expected, so that was all good.
After the usual HEARTT lunch in the cafeteria at the Maternity Hospital, we were walking back when we met a group including Cynthia Nash, the Liberian Consul in Atlanta; I had met her before on the trip in September. She was leading a group of interested church people and others from Atlanta. A group of us then went sightseeing to Mamba Point and the Hotel Ducor, and then to the Capitol grounds. Following that we came back to the Guest House to wait for everyone else coming for dinner.
Around 7:30 Catherine came into the living room to say that we (Santiago, Jenn, Eric, and me) were wanted next door at the President's house. We went over there to find that all of the other HEARTT people were there, and had just said hello to Madame President, who had just arrived home from the office. Adamah sent the others to the Guest House, while we were escorted to the gazebo to meet the President. She was very gracious and warm, greeting us each individually; we also met the Minister of Labor and the Minister of Health. Santiago noted afterwards that he couldn't remember the last time he was nervous meeting someone, but he was this time.
We then went back to the Guest House for a wonderful dinner and excellent company including the Dean of the UMass Medical school and a group with him including a librarian. We talked about books and Internet and knowledge etc.
At the end of the evening I spent some time chatting with Chris Hughes, who has finished his PGY-2 at Hartford, and is now a Global Surgery fellow at Childrens Hospital in Boston. He is also engaged to Amy, a daughter of Jock Lawrason who is my friend and boss as he is Chief Medical Officer of Alliance. Yes, indeed it is a small world !! they are interested in seeing what sort of program they could set up to help in Liberia, and he is here on a scouting mission.
Today is Decoration Day, sort of like our Memorial Day, and the day on which families go to the graves of loved ones the clean them up and redecorate them. It is a national holiday, so there isn't much going on, except that we are operating. Moses is back from Lofa County, an 11 hour drive, where he went for the funeral of his mother-in-law or sister-in-law or something. He and Yuk did a hernia on a 3 year old, then Cocola and I did a Halstead repair of a recurrent hernia in a 60 year old, and now Santiago and Jenn are doing Trifecta. It appears to me that she had a strangulated Spigelian hernia, which has to be pretty rare. In any case the surgery went well and was not as difficult as expected, so that was all good.
After the usual HEARTT lunch in the cafeteria at the Maternity Hospital, we were walking back when we met a group including Cynthia Nash, the Liberian Consul in Atlanta; I had met her before on the trip in September. She was leading a group of interested church people and others from Atlanta. A group of us then went sightseeing to Mamba Point and the Hotel Ducor, and then to the Capitol grounds. Following that we came back to the Guest House to wait for everyone else coming for dinner.
Around 7:30 Catherine came into the living room to say that we (Santiago, Jenn, Eric, and me) were wanted next door at the President's house. We went over there to find that all of the other HEARTT people were there, and had just said hello to Madame President, who had just arrived home from the office. Adamah sent the others to the Guest House, while we were escorted to the gazebo to meet the President. She was very gracious and warm, greeting us each individually; we also met the Minister of Labor and the Minister of Health. Santiago noted afterwards that he couldn't remember the last time he was nervous meeting someone, but he was this time.
We then went back to the Guest House for a wonderful dinner and excellent company including the Dean of the UMass Medical school and a group with him including a librarian. We talked about books and Internet and knowledge etc.
At the end of the evening I spent some time chatting with Chris Hughes, who has finished his PGY-2 at Hartford, and is now a Global Surgery fellow at Childrens Hospital in Boston. He is also engaged to Amy, a daughter of Jock Lawrason who is my friend and boss as he is Chief Medical Officer of Alliance. Yes, indeed it is a small world !! they are interested in seeing what sort of program they could set up to help in Liberia, and he is here on a scouting mission.
Wednesday, March 9, 2011
Tuesday March 8
Tuesday March 8
Yuk messaged us while we were waiting for our ride to the hospital that the man with the enterocutaneous fistula was a go, but the woman with the 3 enterocutaneous fistulae( we have given her the nickname of "Trifecta") was refusing to have surgery till she saw her family. On the good side, however, 3 children who had swallowed caustic chemicals and had esophageal strictures were given the go-ahead for today. So Santiago and Jenn started on the man, and Yuk and Konneh started on the kids, as we had been allowed to have 2 rooms. Soon after that Yuk and went down to start clinic...oh, before we started Dr. McDonald came up to the OR to ask us to come down to evaluate a man with a bad leg who was outside the ED. In fact he was sitting in the bed of a police pickup truck,mandate had what has to be oneof the grossest things I have ever seen. He has filariasis (elephantiasis) with secondary ulceration and infection. And it really was enough to make one gag! I told her that I couldnt think of any surgical procedure that would be likely to improve things.
In clinic we saw a number of interesting cases including a recurrent large goiter which Santiago and I decided would be more of a surgical challenge than we wanted to accept on this visit; a man with advanced anal cancer; a possible Kaposi's sarcoma of the leg; and the usual variety of hernias.
Konneh has malaria, and son he will be taking tomorrow's holiday (Decoration Day) off to rest. Most people living in malaria-endemic areas develop malaria occasionally during their adult life, but it is generally mild and short lived.
After clinic we chatted with Señora for a while about patient financial issues, and then went back to make afternoon rounds. Everyone is looking good, and we took a number of photos.
After going back to the Guest House we went out to Sajj again for dinner, mostly because they have a big screen TV so that Santiago could watch Arsenal playing Barcelona. The place was packed with similar fans, and a good time was had by all, especially since Barcelona won !
Yuk messaged us while we were waiting for our ride to the hospital that the man with the enterocutaneous fistula was a go, but the woman with the 3 enterocutaneous fistulae( we have given her the nickname of "Trifecta") was refusing to have surgery till she saw her family. On the good side, however, 3 children who had swallowed caustic chemicals and had esophageal strictures were given the go-ahead for today. So Santiago and Jenn started on the man, and Yuk and Konneh started on the kids, as we had been allowed to have 2 rooms. Soon after that Yuk and went down to start clinic...oh, before we started Dr. McDonald came up to the OR to ask us to come down to evaluate a man with a bad leg who was outside the ED. In fact he was sitting in the bed of a police pickup truck,mandate had what has to be oneof the grossest things I have ever seen. He has filariasis (elephantiasis) with secondary ulceration and infection. And it really was enough to make one gag! I told her that I couldnt think of any surgical procedure that would be likely to improve things.
In clinic we saw a number of interesting cases including a recurrent large goiter which Santiago and I decided would be more of a surgical challenge than we wanted to accept on this visit; a man with advanced anal cancer; a possible Kaposi's sarcoma of the leg; and the usual variety of hernias.
Konneh has malaria, and son he will be taking tomorrow's holiday (Decoration Day) off to rest. Most people living in malaria-endemic areas develop malaria occasionally during their adult life, but it is generally mild and short lived.
After clinic we chatted with Señora for a while about patient financial issues, and then went back to make afternoon rounds. Everyone is looking good, and we took a number of photos.
After going back to the Guest House we went out to Sajj again for dinner, mostly because they have a big screen TV so that Santiago could watch Arsenal playing Barcelona. The place was packed with similar fans, and a good time was had by all, especially since Barcelona won !
Tuesday, March 8, 2011
Monday March 7
Monday March 7
After breakfast we went to the hospital with the expectation of doing 3 cases, but to no ones surprise there were complications : the older man with the left groin enterocutaneous fistula said he didn't want surgery until he saw his son, and his son hadn't visited in 5 days; the parents of the 14 year old boy scheduled for colostomy decommissioning hadn't shown up to sign the consent; and the 16 year old girl scheduled for an ileostomy decommissioning had not yet put money down for the second surgery. So it was looking rather bleak, but then the parents came so Santiago, Konneh, and Yuk were able to go ahead with the boy. They took down his colostomy, resected his sigmoid, and did an EEA anastomosis. I took a pice of his colon for pathology to see if indeed he does have a lack of ganglion cells. I then spoke to Señora, who spoke to Lisa, the social worker, and we were allowed to proceed with the ileostomy decommissioning because the fees were waved for our patient. That is a very nice thing that happens for us here : if there are patients we feel we should operate upon because we have a particular skill set, then Dr McDonald is very generous in making it happen through waving the usual fees, or getting extra OR staff, or whatever.
After finishing we saw some consults in the ED; one in particular was heartbreaking. A 9 year old girl who had surgery at another hospital in November for what was suspected to be an intussusception now comes in with a severely distended abdomen, serious malnutrition, fevers, and weight loss. She has several masses in her abdomen, and looks like she has some malignant process going on, most likely lymphoma. But I'm not sure if we will ever know the exact diagnosis.
Later we went back to the guest house and I took a short nap, and then we joined the dorm people at Cafe Jamal for pizza and beer. After returning to the guest house, Santiago, Eric, and I stayed up talking to Emmanuel and Catherine about Liberia, and the war mostly. It seems like the wounds of the war may have healed on e surface, but there are scars which run deep.
After breakfast we went to the hospital with the expectation of doing 3 cases, but to no ones surprise there were complications : the older man with the left groin enterocutaneous fistula said he didn't want surgery until he saw his son, and his son hadn't visited in 5 days; the parents of the 14 year old boy scheduled for colostomy decommissioning hadn't shown up to sign the consent; and the 16 year old girl scheduled for an ileostomy decommissioning had not yet put money down for the second surgery. So it was looking rather bleak, but then the parents came so Santiago, Konneh, and Yuk were able to go ahead with the boy. They took down his colostomy, resected his sigmoid, and did an EEA anastomosis. I took a pice of his colon for pathology to see if indeed he does have a lack of ganglion cells. I then spoke to Señora, who spoke to Lisa, the social worker, and we were allowed to proceed with the ileostomy decommissioning because the fees were waved for our patient. That is a very nice thing that happens for us here : if there are patients we feel we should operate upon because we have a particular skill set, then Dr McDonald is very generous in making it happen through waving the usual fees, or getting extra OR staff, or whatever.
After finishing we saw some consults in the ED; one in particular was heartbreaking. A 9 year old girl who had surgery at another hospital in November for what was suspected to be an intussusception now comes in with a severely distended abdomen, serious malnutrition, fevers, and weight loss. She has several masses in her abdomen, and looks like she has some malignant process going on, most likely lymphoma. But I'm not sure if we will ever know the exact diagnosis.
Later we went back to the guest house and I took a short nap, and then we joined the dorm people at Cafe Jamal for pizza and beer. After returning to the guest house, Santiago, Eric, and I stayed up talking to Emmanuel and Catherine about Liberia, and the war mostly. It seems like the wounds of the war may have healed on e surface, but there are scars which run deep.
Monday, March 7, 2011
Sunday
Sunday March 6
We all slept late this morning...I needed it after a night of Tubman's Revenge !! I haven't been hit by traveler's trots on previous trips here, but during the night it seemed like my intestines had decided the third time was the charm, or not so charming. Anyway, I started Cipro just in case, but it got better by this evening, so I doubt that it was anything needing Cipro.
This afternoon we went to the RLJ Kendeja Resort for some R & R, and it was very pleasant. Sat on the beach, walked on the beach, had some drinks and some food...we left around 7 to come back to meet Señora and 3 psychiatrists from Mt Sinai in NYC who are here to investigate the possibility of setting up a program in child psychiatry for the country. They will be here for a week, and at this point anyway they are staying in the guesthouse with us. We went to The Royal with them for dinner, and then back here for an early evening.
We all slept late this morning...I needed it after a night of Tubman's Revenge !! I haven't been hit by traveler's trots on previous trips here, but during the night it seemed like my intestines had decided the third time was the charm, or not so charming. Anyway, I started Cipro just in case, but it got better by this evening, so I doubt that it was anything needing Cipro.
This afternoon we went to the RLJ Kendeja Resort for some R & R, and it was very pleasant. Sat on the beach, walked on the beach, had some drinks and some food...we left around 7 to come back to meet Señora and 3 psychiatrists from Mt Sinai in NYC who are here to investigate the possibility of setting up a program in child psychiatry for the country. They will be here for a week, and at this point anyway they are staying in the guesthouse with us. We went to The Royal with them for dinner, and then back here for an early evening.
Sunday, March 6, 2011
Saturday
Saturday March 5
The administration at JFK wants us to be as busy as possible, so they arranged with the OR to have staff available for us to work today. Originally we were goingto do just one case, but we were convinced to do three. So we started this morning with a hypospadius repair on a 4 year old boy; it was likely a traumatic hypospadius from his circumcision. Konneh did it with Yuk and I was quite impressed with his technique; afterwards I asked him if he would like a pair of loupes, and he was really quite excited about that !, so I will arrange for a HEARTT volunteer to bring them over to him when we get back. The next case was an unfortunate 37 year old woman who was thought to have a recto vaginal fistula from childbirth 2 years ago, but she turns out to have a huge cancer which has destroyed her recto vaginal septum. Dr Jallah asked us to see her, and we recommended a palliative colostomy just to make hygiene a bit easier. We also biopsies to mass to see if it is rectal, cervical, or cloacogenic. The final case was an inguinal hernia which we finished around 3.
We then went to the dorm for lunch, which was brought over by the staff from the Guest House. We had a nice lunch, and I had the opportunity to chat for a long time with Dr. McDonald about a variety of subjects. One of the ladies on staff at the Guest House asked Dr McDonald if she could arrange for her husband to see me about a growth on his face/neck; I will see him on Monday. She also said that JFK could advertise our presence on the radio, but I think we have plenty to do as it is, so I don't think we need an advertising campaign !
After that we came back to the Guest House and had a nap. Later on we decided that we would meet some of the other HEARTT people for dinner at Sajj, a Lebanese restaurant near the hospital. Since Dewalt is driving Adamah to Freetown, we needed to find a way to get to Sajj. I called Señora, who said that Adamah had told her that a guy named Alfred would be our driver while Dewalt was away. She tried to contact Alfred, but was not able to get a response; she thought his phone was turned off. So, at her suggestion, we decided to walk up to the end of the lane and ask the security guards to get us a taxi. Outside the President's house, we told one of the Special Security Service agents of this plan, which she nixed immediately. She explained that we were guests of the President, and as such they would take care of us. So within a few minutes we had a vehicle, a driver, and another agent who sat in the restaurant (at a discrete distance) while we ate. It seemed like they made a much bigger deal out of it than was really necessary, but then again it is not unreasonable that they don't want to take chances. It was a good meal and good company, so it all worked out in the end.
The administration at JFK wants us to be as busy as possible, so they arranged with the OR to have staff available for us to work today. Originally we were goingto do just one case, but we were convinced to do three. So we started this morning with a hypospadius repair on a 4 year old boy; it was likely a traumatic hypospadius from his circumcision. Konneh did it with Yuk and I was quite impressed with his technique; afterwards I asked him if he would like a pair of loupes, and he was really quite excited about that !, so I will arrange for a HEARTT volunteer to bring them over to him when we get back. The next case was an unfortunate 37 year old woman who was thought to have a recto vaginal fistula from childbirth 2 years ago, but she turns out to have a huge cancer which has destroyed her recto vaginal septum. Dr Jallah asked us to see her, and we recommended a palliative colostomy just to make hygiene a bit easier. We also biopsies to mass to see if it is rectal, cervical, or cloacogenic. The final case was an inguinal hernia which we finished around 3.
We then went to the dorm for lunch, which was brought over by the staff from the Guest House. We had a nice lunch, and I had the opportunity to chat for a long time with Dr. McDonald about a variety of subjects. One of the ladies on staff at the Guest House asked Dr McDonald if she could arrange for her husband to see me about a growth on his face/neck; I will see him on Monday. She also said that JFK could advertise our presence on the radio, but I think we have plenty to do as it is, so I don't think we need an advertising campaign !
After that we came back to the Guest House and had a nap. Later on we decided that we would meet some of the other HEARTT people for dinner at Sajj, a Lebanese restaurant near the hospital. Since Dewalt is driving Adamah to Freetown, we needed to find a way to get to Sajj. I called Señora, who said that Adamah had told her that a guy named Alfred would be our driver while Dewalt was away. She tried to contact Alfred, but was not able to get a response; she thought his phone was turned off. So, at her suggestion, we decided to walk up to the end of the lane and ask the security guards to get us a taxi. Outside the President's house, we told one of the Special Security Service agents of this plan, which she nixed immediately. She explained that we were guests of the President, and as such they would take care of us. So within a few minutes we had a vehicle, a driver, and another agent who sat in the restaurant (at a discrete distance) while we ate. It seemed like they made a much bigger deal out of it than was really necessary, but then again it is not unreasonable that they don't want to take chances. It was a good meal and good company, so it all worked out in the end.
Saturday, March 5, 2011
March 4
Friday March 4
After a restful sleep, we had a busy day in the OR. The first case was a 4 year old boy with a hernia/hydrocele. Jenn and I did the operation in about 25 minutes, but then it took about 90 minutes for him to wake up. Jenn stayed with him as they bagged him in the PACU, feeling not unreasonably that if she left they would stop, and the outcome would be a disaster. Eventually he did wake up, but the experience brought up some of the issues and problems with anesthesia in this setting. There is no anesthesiologist since Dr. Gouma went back to Nigeria, and the nurse anesthetists are of varying quality. Some are quite good, but others are less competent, and they seem to be the ones who don't provide much supervision or feedback to the nurse anesthetist students. Jenn wondered about bringing our own anesthesia team over when we come but there are major issues with that approach. It will be worth some discussion.
After that case we did some more hernias, and Konneh and Jenn did a gastrostomy on a 14 year old boy who swallowed lye. Konneh was unable to dilate his esophagus either antegrade or retrograde. When I asked him what the future held for the boy, Konneh said "hopefully he will be lucky and be able to go to another country where he could be cared for."
We finished our last case around 5 PM, and then made rounds on our post-op patients. All of them, including the 4 year old boy, were doing very well. One of the hernia patients, who had a huge African incarcerated hernia, smiled when I said "How are you doing?" and then replied "I'm doing fine...how are you doing?" it was really quite gratifying to see all of then doing well after so many worries in the morning. We went back to the Guest House to shower and change, and the we all went out to Senator Edmonde Snow's house for drinks and dinner. He has a lovely and rather palatial house on the ocean, and he was a wonderful host with his girlfriend Peggy. We were joined there by Lydia, and a group of Liberian nurses from Rhode Island who have come over to help in whatever way they can. There were some toasts and thanks from a variety of people for the work we are doing through HEARTT. After that, we went to Lydia's house for some wine and chat; The Honorable (aka Senator Snow) personally drove some of us over in his Nissan SUV. At Lydia's, we were also entertained by a trumpet recital by Eric...it was awesome !
After Lydia's, we went to Groovie's for some dancing till 1:30 AM.
After a restful sleep, we had a busy day in the OR. The first case was a 4 year old boy with a hernia/hydrocele. Jenn and I did the operation in about 25 minutes, but then it took about 90 minutes for him to wake up. Jenn stayed with him as they bagged him in the PACU, feeling not unreasonably that if she left they would stop, and the outcome would be a disaster. Eventually he did wake up, but the experience brought up some of the issues and problems with anesthesia in this setting. There is no anesthesiologist since Dr. Gouma went back to Nigeria, and the nurse anesthetists are of varying quality. Some are quite good, but others are less competent, and they seem to be the ones who don't provide much supervision or feedback to the nurse anesthetist students. Jenn wondered about bringing our own anesthesia team over when we come but there are major issues with that approach. It will be worth some discussion.
After that case we did some more hernias, and Konneh and Jenn did a gastrostomy on a 14 year old boy who swallowed lye. Konneh was unable to dilate his esophagus either antegrade or retrograde. When I asked him what the future held for the boy, Konneh said "hopefully he will be lucky and be able to go to another country where he could be cared for."
We finished our last case around 5 PM, and then made rounds on our post-op patients. All of them, including the 4 year old boy, were doing very well. One of the hernia patients, who had a huge African incarcerated hernia, smiled when I said "How are you doing?" and then replied "I'm doing fine...how are you doing?" it was really quite gratifying to see all of then doing well after so many worries in the morning. We went back to the Guest House to shower and change, and the we all went out to Senator Edmonde Snow's house for drinks and dinner. He has a lovely and rather palatial house on the ocean, and he was a wonderful host with his girlfriend Peggy. We were joined there by Lydia, and a group of Liberian nurses from Rhode Island who have come over to help in whatever way they can. There were some toasts and thanks from a variety of people for the work we are doing through HEARTT. After that, we went to Lydia's house for some wine and chat; The Honorable (aka Senator Snow) personally drove some of us over in his Nissan SUV. At Lydia's, we were also entertained by a trumpet recital by Eric...it was awesome !
After Lydia's, we went to Groovie's for some dancing till 1:30 AM.
Thursday, March 3, 2011
March 3
Back to Liberia....March 1/2/3
Yesterday we ( Jenn Malsbury, Eric Lucero, Yuk Ming Liu, Adamah Sirleaf, and I ) flew from Westchester Airport to Atlanta, where we met up with Santiago Arruffat, We then left Atlanta at 7:30PM for for 10 1/2 hour flight to Accra, Ghana. After a couple of hour stopover where we had to stay on the plane, we left for Monrovia, and arrived mid-afternoon.
Our first stop coming in from the airport was JFK, where I saw a lot of familiar faces. One of the things which is most gratifying for me is the joyful reception by people who appear to be genuinely pleased that I have returned. After that we went to he bungalow to drop off our luggage, and then to the Presidential Guest House for dinner. We had about 15 people at the house, and it was good fun. I then retired early as I was pooped!
Today was our first clinical day, and it was very busy. We met up with Konneh and went onto the wards to see some patients, several of whom have been waiting for us to arrive. There is a man with an enterocutaneous fistula probably due to a strangulated left inguinal hernia; a woman with at least 3 enterocutaneous fistulae and an open abdominal wall; and a 14 year old boy with a colostomy because he was thought or maybe have Hirshsprung's, but maybe just has chronic constipation. We will be operating on al of them as well as others next week. We also saw a 30 year old albino man who had a typhoid bowel perforation and resection 2 days ago. When we saw him he looked very ill, and was having trouble breathing; a half hour later we came back to see him and the nurse told us he had expired. We also saw a woman in the Trauma ED who apparently was beaten up by her boyfriend last night, and then came to the ED complaining of abdominal pain. Complicating matters is the fact that she is HIV+. While being observed in the ED she was getting worse clinically, so she went to the OR is afternoon, Santiago and Dr. Cocola, a family practitioner/surgeon from the Congo, explored her and found some blood and contusions but no source. She had a cardiac arrest on e table, but they resuscitated her and got her closed and off the table. Unfortunately she was never able to breathe on her own, and passed away. I have no idea what caused her demise, but i think anesthetic hypoxia is the leading candidate.
We saw about 40 people in the clinic, with an amazing variety of pathology; actually I should point out that Jenn and Yuk saw virtually all of them, and Santiago, Konneh, and I were consultants. We will operate on many of them in the coming days.
Late this afternoon we met up with Dr. Jallah who took us to the new maternity unit to see a baby born today with an amputated foot; it looks to me like maybe he had a hair or congenital band around it. Then we saw a 37 year old woman with a probable rectal cancer and a recto-vaginal fistula. She will need a colostomy for palliation, as there is no treatment available to her. Very sad.
Yesterday we ( Jenn Malsbury, Eric Lucero, Yuk Ming Liu, Adamah Sirleaf, and I ) flew from Westchester Airport to Atlanta, where we met up with Santiago Arruffat, We then left Atlanta at 7:30PM for for 10 1/2 hour flight to Accra, Ghana. After a couple of hour stopover where we had to stay on the plane, we left for Monrovia, and arrived mid-afternoon.
Our first stop coming in from the airport was JFK, where I saw a lot of familiar faces. One of the things which is most gratifying for me is the joyful reception by people who appear to be genuinely pleased that I have returned. After that we went to he bungalow to drop off our luggage, and then to the Presidential Guest House for dinner. We had about 15 people at the house, and it was good fun. I then retired early as I was pooped!
Today was our first clinical day, and it was very busy. We met up with Konneh and went onto the wards to see some patients, several of whom have been waiting for us to arrive. There is a man with an enterocutaneous fistula probably due to a strangulated left inguinal hernia; a woman with at least 3 enterocutaneous fistulae and an open abdominal wall; and a 14 year old boy with a colostomy because he was thought or maybe have Hirshsprung's, but maybe just has chronic constipation. We will be operating on al of them as well as others next week. We also saw a 30 year old albino man who had a typhoid bowel perforation and resection 2 days ago. When we saw him he looked very ill, and was having trouble breathing; a half hour later we came back to see him and the nurse told us he had expired. We also saw a woman in the Trauma ED who apparently was beaten up by her boyfriend last night, and then came to the ED complaining of abdominal pain. Complicating matters is the fact that she is HIV+. While being observed in the ED she was getting worse clinically, so she went to the OR is afternoon, Santiago and Dr. Cocola, a family practitioner/surgeon from the Congo, explored her and found some blood and contusions but no source. She had a cardiac arrest on e table, but they resuscitated her and got her closed and off the table. Unfortunately she was never able to breathe on her own, and passed away. I have no idea what caused her demise, but i think anesthetic hypoxia is the leading candidate.
We saw about 40 people in the clinic, with an amazing variety of pathology; actually I should point out that Jenn and Yuk saw virtually all of them, and Santiago, Konneh, and I were consultants. We will operate on many of them in the coming days.
Late this afternoon we met up with Dr. Jallah who took us to the new maternity unit to see a baby born today with an amputated foot; it looks to me like maybe he had a hair or congenital band around it. Then we saw a 37 year old woman with a probable rectal cancer and a recto-vaginal fistula. She will need a colostomy for palliation, as there is no treatment available to her. Very sad.
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