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.
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