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.