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
Friday, September 30, 2011
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.
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