Pathology

The pathology results on the specimens we brought back contained no big surprises, which was I suppose good and bad. The mass on Joshua's back was an aggressive myxoid liposarcoma; his prognosis would not have been good. Adam's neck mass is a large cell lymphoma; I had been hoping it would be a Burkitt's lymphoma, which could be treated. I am trying to find out if he could be treated. The breast cancers were all pretty much as expected, though none of the three were hormone receptor positive, and that is a poor prognostic factor. Dr. Johnson's patient with the probably uterine sarcoma turns out to have a carcinosarcoma, or malignant mixed Mullerian tumor, which apparently is difficult to treat even in a resource-intense setting. So nothing too surprising, but no particularly good news either. Oh, except for Precillar's friend with the enlarged cervical lymph nodes: that appears to be infectious or inflammatory in nature rather than neoplastic, so that is good for him.

Friday September 14, 2012

Our last day on this trip, and it was a sad one. We agreed with the OR staff and with anesthesia that we would start at 8am, to insure that there was no sense of hurry to get things done before we left for the airport. The cases we planned were Joshua, the 3 year old with the huge back mass, and a guy with thrombosed hemorrhoids. When we arrived at 8 am, Precillar informed me that there was a problem with Joshua. We had gotten him a bed in the pedi ER, but the nurses would not allow him to return there after surgery so he needed a floor bed, and there were none free. Konneh went to check on the second floor, and I went to see Mary, who is the Clinical Administrator, and an angel and blessing for our work. She soon said that we should go ahead with the surgery, and by the time we were done, she would have made him a bed. Dr. Kiiza and I did the surgery. The mass appeared to be some sort of lipoma or liposarcoma perhaps. It was not very vascular except for the distended veins overlying it. We had Joshua on his stomach and worked fairly quickly, but when we were about 3/4 of the way of getting it out, we noticed that his blood was dark. Jonathan was right there, and was concerned about his O2 sat dropping, but Anthony assured us he heard breath sounds and a heart beat. We got the mass out, and then Anthony couldn't hear heart sounds, so we stopped and flipped him onto his back and started CPR. We then worked on him for about 1 1/2 hours utilizing everything we had including blood, intracardiac epinephrine, the defibrillator, and continuous CPR but we were not able to bring him back. It was a fairly shattering experience for all of us. I know that the anesthetists did the best they could, but I believe it was a preventable death. The anesthetic combination they used included ketamine, pentazocine, and succinylcholine. Anthony was convinced that the ET tube didn't kink, but I'm pretty sure something happened to it that resulted in hypoxia. It put a large dark cloud over our departure; though unexpected deaths have happened before, Joshua's affected us more than the Liberians, I think largely because they live with limitations and untimely death every day. The anesthetists have inadequate support, a minimal drug supply, and poor monitoring instruments; they do the best they can under the circumstances, and sometimes things like this are going to happen, I guess. After that we went around and said our goodbyes, and then left for the airport around 2:15. Aunt Jenny is on the plane, and Jonathan and I went to chat with her during the stopover in Accra. She is on her way to her house on Long Island, and will then go to Alaska for a few days to see her son who is a neurosurgeon in Anchorage. She will then come back to New York to meet up with her sister (Madam President) who will be coming for meetings and the opening of the UN General Assembly. Because Aunt Jenny is involved with the affairs of JFK and interested in things medical, I told her abut Joshua and made a pitch for more support of anesthesia. She was supportive; she reassured me that we did the best we could and ultimately it was God's decision to take Joshua. While comforting, that doesn't resolve questions in my mind about whether there was something else we could have done to avoid his death.

Thursday September 13, 2012

Today my frustration is at an all time high. It is our last full day of operating, and once again patients who have not been mentioned to us have been placed on the OR schedule, as well as an older man with a hernia. We specifically agreed that we would not do hernias today, as we had too much else to do. We arrived in the OR to find we have 6 cases scheduled, including the acute abdomen, a boy for an ileostomy decommissioning, a mastectomy, an axillary dissection, and a hernia ! Our first case was the acute abdomen admitted yesterday. Anesthesia finally put him to sleep around 9:30; the length of time from patient in the room to induction of anesthesia seems to have lengthened exponentially on this trip, for reasons that are unclear. Anyway, he turned out to have an unresectable gastric cancer with carcinomatosis, so Jonathan and Moses just closed him up. I went to the Out-patient Clinic and saw patients of what seemed to me to be at least an hour and a half. When I came back up to the OR, they were just starting the second case, which was the ileostomy decommissioning. Of course nothing is simple today, and that is taking a long time. Meanwhile, the lady for the axillary dissection is getting antsy, and the man with the hernia is up here wondering when he will get done. I asked about opening a second room, but there aren't monitors for that room or there isn't staff or there is some reason they can't. It's now almost 1 PM, and we still have a lot of work to do. I'm irritated to say the least. On the good news side, young Joshua with the huge mass on his back returned to the clinic today. His chest xray looks fine, as do his labs, so Konneh is arranging for him to be admitted and have blood for surgery tomorrow. Josephine Reece, the Chevron/Baylor pediatrician, was kind enough to allow us to take a Pedi ER bed for him as there are no pedi surgical beds available to us currently. I'm hopeful that we can excise it rather than just biopsy it. I forgot to mention that Tubman's revenge ( Tubman being the West African cousin of Montezuma) struck me last night with full force. I was a bit shaken, but seemed okay this morning. While we were doing the mastectomy this afternoon, I started sweating and got dizzy and nauseous, I think due to dehydration. I thought I was going to faint, so I asked Moses to scrub in with Jonathan and finish the case. I went to the lounge, and Percillar was kind enough to get me a couple of bottles of water. I felt well enough to do the axillary dissection on Ms. Johnson, but I am sitting out the last case of an acute abdomen. My GI tract feels fine, but I'm feeling achy and feverish, and I'm looking forward to going home to rest. We were supposed to go to Jonathan's aunt place again, but I think I will give that a pass. He might too depending on how late it is when they finish. There was a significant delay in starting the last case because they needed someone from Pharmacy to come up and man the OR Pharmacy room; that room not only dispenses drugs, but also sutures, gloves, and IV fluids among other things. I am reminded that after our first visit, Colleen compiled a list of the Top 10 hurdles to getting an operation done at JFK; over the intervening 3 years, I think some of the hurdles might have changed, but not too many. After we left the hospital Jonathan went to see his relative; I chose to come back to the apartment as I have no desire for food or anything other than my bed and some water. I'm hoping this is gone tomorrow !

Wednesday September 12, 2012

The day started with breakfast at Fishmarket, the President's house. The 2 other heart volunteers, Michael Politka, the 2 Chevron doctors, Dr. McDonald, Dr. Johnson, Jonathan, and myself all gathered in the palava hut and then we were joined by Madame President and later by Aunt Jennie. She was as usual very warm and kind and friendly. At one point there was silence, so I said " So how is the governing thing going for you?" She laughed, and talked a little about the difficulties, like trying to build roads in a country where in rainy season amazing amounts of rain fall on the country, washing away even the best built roads. ( as I write this on Wednesday evening, the skies have opened up once again. The noise of the rain on the roof is deafening!) Anyway, our discussion with the President moved to health care, and we continued to discuss that after she excused herself to go to work. After that we went to the hospital. Dr. Golikai was doing a hernia, so we went to the ward and made rounds with Dr. Kiiza and one of the interns. Happily, all patients are doing well, though ileostomy man from a few days ago remains weak and uninterested in getting out of bed. Eventually they were ready upstairs, so we went up and first did a cervical node biopsy in a friend of Percillar. Then we took a look at Victoria, but found that her low rectal anastomosis was strictured severely and could not be dilated, and we think she still has a defect in her posterior vaginal wall. I called Santiago in Indiana to tell him; because she was having a lot of trouble with her ileostomy, which had retracted to below skin level, Jonathan felt the wise thing to do would be to close the ileostomy and give her a colostomy. It was disappointing that we couldn't put her back together, but the stricture was not an unexpected finding and she understood that. So we opened her up and found a huge left ovarian cyst, which we removed, and then we closed her ileostomy and did her colostomy. The next patient was a woman that Jonathan had seen at Phebe last February who had developed a rectovaginal fistula as a result of a complicated delivery, and had a Hartmann's procedure done. They had tried to hook her back up at Phebe after the fistula healed, but they backed out feeling it was too complicated. This patient also had a big ovarian cyst inn the way, but we were able to identify her rectal stump, and after taking down her colostomy, we put her back together using an EEA stapler. Assuming she does well, I think we can feel very good about that one ! The last case was a fistula-in-ano which was pretty simple and superficial. Tomorrow is our last full day of operating, but I think it is entirely possible that we will do a case or two on Friday morning. As has often been the case, we are leaving some patients undone, but I imagine that would probably happen if we were here for 2 months rather than just 2 weeks. There are so many hurdles to get over in planning, scheduling, admitting, and doing surgery; sometimes I think it is a wonder we can as much done as we do ! I have finished today's blog, and it is still pouring rain. The electricity went out for a while but now it is back; however the Internet went out and has not returned. Speaking of electricity, I learned from Weltee that this compound has its own generator to provide a reliable sourcenofnpower to the occupants of the apartments, most of whom are ex-pats. But they turn off the generator between 9am and 5pm, so I guess if you live here you better have a day job

Tuesday, September 11, 2012

A painful date to write, filled with memories of a horrifying event that continues to affect the world, in good and bad ways. The memory of those who perished reminds us of the fleeting nature of our existence, and the need to make every day count. The traffic was really bad again this morning, and Jonathan figured out that it was because the children started back to school this week. Jonathan did a baby hernia with Moses this morning, and en I did the biopsy of the neck mass on Adam. If he is lucky it will be a Burkitts lymphoma, but I fear something worse. Then while Jonathan did another hernia, I went to see a woman with an acute abdomen admitted yesterday. Dr. Kiiza was with the medical students nearby, so we had a teaching session which I enjoyed. I think he is a great benefit to JFK, and I love seeing the interest of the medical students; their presence makes the work here more interesting and worthwhile for me. We scheduled the woman for surgery. I then went to the outpatient clinic to see a patient whom Diego and I had done a lumpectomy in March for presumed cancer. She had never come for follow-up until today, when she came because she had noticed a lump in her axilla; otherwise she feels well. Her breast feels normal, i.e. no recurrence at the surgical site. I couldn't remember the details of her pathology, so I called Jeff Pinco in Waterbury and he was able to refresh my memory. He couldn't find her ER/PR result, so he is going to run it again as he still has the tissue block. Back in the OR, a woman came up and introduced herself to me as Sandra Roberts; it took me a little while before I realized that she is the nurse with whom I have been exchanging emails for several months about her mother, who had a mastectomy by Dr. Golokai in the spring. Percillar sent me the tissue, and Dr.Pinco determined that it was indeed invasive breast cancer which is ER/PR positive. Dr. Golokai has been giving her chemotherapy consisting for Cyclophosphamide, Cisplatinum, and Tamoxifen. She was there with her daughter, and she looks very well; in Liberian fashion, displaying little modesty, she took off her top in the recovery room so that I could see there is no evidence of local or regional recurrence at this point ! I thought it was sweet of Sandra to seek me out and introduce me to her mother; I have no doubt that our correspondence will continue. Later I went back to the clinic to ask Konneh about someone, and he showed me a 3 year old boy named Joshua who has a huge ulcerated mass on his back. He has been operated on twice at outside hospitals, but it keeps recurring. His mother says it started as a little lump when he was a few months old. It extends nearly the full length of his back, and is almost as wide. It is ulcerated at the top. It doesn't seem to be causing him any pain; in fact, I had him laughing out loud when I was playing peek-a-boo with him. Unfortunately for us, he had already seen Dr.Golokai just before I got there, and plans were underway for him to do surgery next week. Very diplomatically Konneh suggested that if we could do the surgery before we leave, then we could take tissue back and find out what this is. However, Dr. Golokai was not the least bit receptive to that notion, and Konneh quite appropriately didn't want to press the point. I'm still hoping, but it seems unlikely. Jonathan and then did the woman with the acute abdomen, who turned out to have a perforated gastric ulcer. Happily for us, that was our working hypothesis, and we made an upper midline incision; afterwards Moses expressed his surprise that we felt confident enough abut the diagnosis to make a smallish incision in the right place ! After that We went over to the Maternity Hospital to see a patient whom we will do tomorrow. Jonathan saw her at Phebe Hospital last February; she has had a couple of surgeries for a colovaginal or rectovaginal fistula, and we are told that she is now ready to get rid of her colostomy and have GI continuity reestabliahed. So she and Victoria are on the schedule for tomorrow to have ostomies decommissioned; we will do them after we have breakfast with Madam President at her house. For our trip in March, I am going to do my best to keep us away from routine hernias because they really seem to clog the schedule, and they can be done easily when we aren't here. We will do pediatric hernias, and huge African hernias, but I think we need to maximize our benefit by taking on challenging and teaching point cases rather than too many routine ones. I'm not complaining about the case load this time, because it has been varied and good, but it could be better.

Monday, September 10, 2012

I'm still trying to figure out who was playing music and singing all night near the apartments; sometimes it sounded like a choir, and other times more like a dance club ! I won't say they woke me up, but when I did wake up during the night, I was quite aware of the noise. Weltee was late getting here with breakfast, and Albert was late to pick us up, and the traffic going in on Tubmann Blvd was horrendous. So instead of arriving at 8:30 to make rounds with the surgical team, we arrived at 9, just in time to go to Grand Rounds. Jonathan gave a talk on Colon cancer which was quite well received and sparked an interesting discussion afterwards regarding the changes in disease patterns as a country like Liberia develops. With progress in fighting infectious diseases of childhood, it is expected that lifespan will increase, and with it with come more diabetes, hypertension, and cancer, among others. It remains an open question as to whether this pattern, repeated throughout the world, can be altered by proactive measures to improve diet, avoid obesity, and generally have the population be more health conscious. Liberia has the opportunity to be proactive, but it's not clear if the opportunity will be seized. After rounds we went to the OR to discover that the 4 cases we had on the schedule for today were going to be cancelled. Victoria, one of our cases from last March who was scheduled to have her ileostomy decommissioned, had developed a cold and cough, so she will be delayed till Wednesday. Adam, a 13 yr old boy with a huge neck mass had no blood available because his family hadn't either paid or donated; another ostomy decommissioning also had no blood; and the 4 th case was a debridement of leg ulcers that Konneh was going to do. We negotiated with Anthony, the head anesthetist, and after Konneh signed for blood, we did the young man with the ostomy. He has been in JFK since July when he was first operated on. He was initially found to have a single perforation of his sigmoid colon. The was repaired primarily, but when he deteriorated clinically 3 days later, he was re-explored and found to have multiple perforations of his terminal ileum, consistent with typhoid. He underwent resection of the affected segment, and an ileostomy; he had a third surgery soon after that one to irrigate his abdomen. So we had him for the fourth operation, with plans to close his ileostomy, in large part because it was leaking and difficult to manage. We found his abdomen to be a concrete mess, and it was quite difficult to find anything that looked normal. We took down his ileostomy, and decided that the best thing to do would be to simply close it and restore intestinal continuity without trying to free up everything else. It took us a while, but we did it! Of interest is the fact that we still do not have any inhalational anesthetic agents such as fluothane, so this young man received pentazocine and a muscle relaxant, and only oxygen via his endotracheal tube. They are working on getting some gaseous agents, but so far no luck. We didn't get started till about 11:30 on him, so by the time we were done and ready to do Adam, Anthony from Anesthesia said it was too late so we will do him first thing tomorrow. We took the opportunity of the delay to get Mike to come with his handheld ultrasound machine to take a look at the neck mass; it doesn't look cystic, and adenopahy sounds most likely. We went to the Pedi OPD to talk to Courtney and Dr. Reece abut him; they agreed that a biopsy for definitive pathological diagnosis would be a good idea. Tonight we went back to the Royal to have dinner with Robert, the guy who set up the Eye Clinic with Karen. We had a wonderful dinner, and as Karen rightly said, Robert is a very good guy. He grew up in Liberia, and then went to Ghana to train as an opthalmology technician. While there he had the idea for the clinic; after a while, he went to The Gambia to learn cataract surgery, and then he came back to Liberia. He has started a clinic in Monrovia, and is doing about 40 cataract surgeries a month. He does only the straightforward ones, and is providing a much needed service to the country. There are just 3 working ophthalmologists in Liberia at present.

Sunday September 9, 2012

A leisurely rainy day in Monrovia. I slept in a little, then read for the morning. It rained off and on all day. Mid-afternoon Dewalt came with his 2 year old daughter Leemu, who is very cute. We then went with Alfred , Dewalt, and Leemu to the carving shops where we bought a few things. Then we came back here for a little while before going to the apartment of the aunt of Jonathan' wife who works for the UN. She again made us a lovely dinner, following which we came back here to go to bed early. Tomorrow starts our second and final week for this trip. Oh, we learned that the baby whom Dr. McDonald referred to was a 3 day old with an imperforate anus. We would have done a colostomy tomorrow, but apparently the mother took her out of the hospital against medical advice.

Saturday September 8, 2012

At the hospital this morning our first stop was the ward, where we found good news and bad news. Most of our patients were doing well, including ileostomy man who looked better than expected, but the woman with the small bowel perforation looked worse. She was tachypneic (breathing rapidly) and diaphoretic, and didn't look like she would last too long. One of the difficult aspects of medicine for us here is the sense of helplessness in the face of serious illness. We couldn't put her on a ventilator, or move her to a real ICU, or put her on pressors, or anything else. We were doing all we could by supplying IV hydration and oxygen by mask. We then went to the OR to do an African hernia ( huge, sliding type) in an older man, and then bilateral scapular masses in an older woman. I think these will prove to be fibroelastomas, but they were worrisomely hard, and removal required a lot of work. Oh, yes, we seemed to be waiting a long time between cases. We soon learned that the pharmacist,stationed in the OR to control the flow of drugs and supplies, had to go downstairs to do something, and there was no one in the OR pharmacy for about an hour, so we waited, and I did a little fuming before resigning myself to the situation. Yesterday we had the idea of going to the Liberia-Nigeria football match being held today, so I called Dewalt to see if he could get us tickets. He said he would look into it this morning, and when we were done in the OR he was at JFK with our tickets. We were standing outside the Administration Building when Dr. McDonald came by; we told her about our plans, and she suggested we could go one better by sitting in the VIP section with the President. It turns out that the President is a big football fan; she was out of the country today, but planned to return in time to come to the stadium at halftime. So around 4 pm, with Albert driving and Dewalt, me, Jonathan, and Weltee in the car we left for the game. The traffic was horrendous, and the Liberians have an interesting way of dealing with it: create more lanes going in the direction you want by taking lanes from the opposite direction. We were stuck in a logjam until an official Presidential convoy came by. We joined them (Dewalt arranged it) and that got us to the Samuel K. Doe stadium a whole lot faster. Getting through the crowds into the stadium was interesting,and required a modest amount of pushing and jamming, but again Dewalt made it happen. We ended up sitting in the middle of the second row of the VIP section, right behind the seats for Madame President and the Vice President.The game was a good match, ending in a 2-2 tie, and the President arrived just after halftime as expected. I was surprised at the hooliganism-- throwing water bottles from the stands onto the field, etc --but i guess that is a part of soccer most everywhere these days. Leaving the stadium with the other 35,000 fans was even more interesting than arriving: we got outside to head for the car, but Dewalt and Jonathan got ahead of me, and I eventually lost them in the crowd although Jonathan kept holding his hand up to try to signal me. We were going against the crowd flow, and I admit that I was more concerned for my safety than I ever have been before in Liberia. When I couldn't see them anymore, I was next to a UN ambulance, and there was a UN soldier standing there, so I just stood next to him and started to call Dewalt on my cell phone. But before I could complete it, Dewalt was back to pick me up and take me the short remaining distance to our vehicle. It then took us about an hour and a half to get home with all the departing crowd traffic etc. For me,it was an experience not unlike skydiving: I'm glad I did it, it was interesting and fun and a bit frightening, and I have no desire to do it again. After we were back here at the apartments, Dr.Mcdonald called to make sure we got home safely. She said that she thought a baby had been admitted who might need surgery, but she thinks it can wait till Monday. We aren't planning to go in to JFK tomorrow, but this is one of the problems of being a distance from the hospital and having to depend on others for transportation. I guess it will all work out somehow.

Friday September 7, 2012

It rained all night, and sometimes very hard; I was surprised that we weren't swept away in a deluge ! Alfred picked us up around 8:15 and we went to the hospital, where we met with Dr. Kiiza, Moses, and Konneh to discuss the pans for the day. The woman with bilateral infra scapular masses, who I saw in the clinic on Tuesday, and who was admitted on Wednesday, was still not on the OR schedule for today because no one seemed to remember she was here. I made a it of a stink over it because she is taking up a bed that could be occupied by someone in greater need, and because it is just stupid that the people in charge don't have any idea who is occupying their beds. The second reason for frustration this morning was that we had suggested yesterday that the man with the ileostomy who looks cadaveric should have his electrolytes checked before surgery. Those tests were ordered yesterday; today we learned that they weren't done because the laboratory does not have the necessary reagents to perform the tests. Jonathan and I spent some time discussing the situation; i guess we could insist that we won't do the surgery till we see the results of the tests, but i think there is a good chance that he will die before the tests get done. So in the end we decided to proceed. First we did a 5 year old with a hernia; the OR booking said right, but his chart said left and my exam said left, so we did the left side ( which turned out to be the correct side)! Then we did ileostomy man: it wasn't easy,but it wasn't as difficult as it could have been. We resected a few feet of small bowel and did an ileocolic anastomosis using the EEA, he remained stable throughout the case. We are keeping our fingers crossed that he will recover. Next we did a 12 year old boy with appendicitis. He had been in the ED on antibiotics since Wednesday; fortunately he had not perforated, and it was relatively straight forward. I think we did him through the smallest McBurney incision ever seen at JFK ! We ended the day with surgery on a 32 year old woman who had also been in the ED for a couple of days awaiting a bed. She had developed abdominal pain and vomiting a couple of days earlier, and was thought to have an obstruction due to adhesions from a previous C section. When I saw her just before we brought her into the room she looked very toxic; I don't know how long she had looked that way. When we opened her up, we found gross foul smelling contamination with a greenish grey fluid containing vegetable matter and seeds. There was a huge collection inferior to the transverse mesocolon, and eventually we were able to identify a complete transaction/perforation of her ileum. The etiology remains unclea, but based on the appearance, I would guess that e perforation occurred several days ago. In any case we cleaned her out, resected that segment, and restored GI continuity with an EEA stapled end to side anastomosis. Another case where our fingers are crossed that she will be lucky, but as Konneh pointed out during the surgery, this scenario is generally not survivable at JFK. We then came back to the apartments for dinner and an early bed. We were both exhausted after a long day. We plan to do 2 cases tomorrow morning, and then hopefully Dewalt, Jonathan, and I will go to the Nigeria-Liberia football match tomorrow afternoon ! That should be interesting !

Thursday, September 6, 2012

I guess the rain precluded delivery of breakfast this morning, but we aren't starving and I'm sure we will survive! We went to the 2nd floor to make rounds, and met Moses and Dr. Kiiza there along with a gaggle of medical students. Our patients are well, and it seems my fears about the splenorrhaphy patient were groundless, thank goodness. The word was that there was one case, a hernia, to do today. We went up to the Operating Theater to discover the Konneh had booked 2 cases: the man with an ileostomy for decommissioning, and a mastectomy. The man is the guy we saw the first day who looks like death warmed over; he is horribly malnourished, and just flesh and bones. The likelihood of him surviving surgery is small, but I can't see any alternative; if we don't do surgery, the likelihood of him surviving is nil. Nonetheless, he was ill-prepared for surgery today, and needs more work like checking his electrolytes and Hb so maybe we will do him tomorrow or Monday. The woman booked for a mastectomy had 2 fibroadenomas which I removed and closed her incisions with subcuticular stitches and Dermabond. I think that was a crowd pleaser ! The failure of communication regarding which cases we were doing and why is a persisting problem that cries out for a solution, but it's more difficult than you can imagine. After finishing there I went to hear the end of Jonathan's talk to the medical students about gallbladder disease, and then we went downstairs. In the hallway I met Victoria Konu, the young woman with a rectal stricture and fistula following a lye enema that Santiago had operated on in March. She is looking great, and came because she knew I would be back in September, and she wants her ostomy taken down. I spoke to Mary and we will get her admitted soon for surgery. We then went to the maternity hospital where Dr. Johnson wanted our input on a woman with a huge pelvic/abdominal mass that he was operating on. It looks like it is some form of uterine sarcoma, and I think her prognosis is grim. I met Dr. Yvonne Butler, an Ob-Gyn who is part of the Baylor / Chevron program and who will be spending a year in Monrovia primarily at JFK. She was born in Liberia, and moved to the US as a child. I think she will be a wonderful addition to JFK ! We the stayed to be available as she and the Liberian Ob-Gyn did the two women we saw the other day at the request of Aunt Jenny. The first is 24 years old and was advertised as a myoma and ovarian cyst; she turned out to have what we think is miliary TB with studding of her bowel surfaces. Her abdomen was pretty well socked in with adhesions; we suggested that they avoid trouble and close, which they did. The second case was also supposedmto be a myoma and ovarian cyst, and it was exactly as advertised, so we left them to do it. This afternoon we saw one of the HEARTT ER residents, who had seen a young boy the other day and asked us to look at him and his abdominal mass. He was on the pediatric floor with his father at his bedside. Julius is 5 years old, and was in his normal state of health until about a year ago when he started having a swollen abdomen. This has progressed, and now he apparently is having trouble eating as well as just being weak. He has a huge abdominal mass extending from his pelvis up to his epigastrium which felt pretty solid on exam. Dr. Mike Piotrowski has a handheld ultrasound, and used it on him yesterday; he came down and showed us the images, and it looks quite malignant , being mostly solid with irregular cystic spaces. The liver appears to be normal. The most likely diagnosis is a Wilm's tumor, perhaps bilateral. The question was whether we should biopsy it or not. Intellectually it would be satisfying to have a pathological diagnosis, but having that is very unlikely to change his poor prognosis given the lack of treatment options here. Furthermore, there are significant risks associated with doing a biopsy, risks that I felt were not worth taking. So I declined to do a biopsy, at least for now. It is possible that his father will push to have something done, even if only a biopsy, and we will check with him tomorrow about that. Tonight Dr McDonald was going to join us for dinner at the apartments, but something came up so she didn't. Perhaps it was the torrential downpours ... I don't believe I have ever seen rain come down in such volumes so quickly! It is rainy season here, so it isn't unusual. As I write, we just had another downpour and the electricity went off; I don't know if the two are related, and now the power is back on.

Wednesday September 5, 2012

Another interesting day at JFK ! No rain overnight, so I had a good sleep and felt refreshed when we arrived at the hospital this morning. We soon ran into Konneh, who told us that there was a young boy in the Trauma ED who had been kicked in the stomach while playing football (soccer for you Americans!) we went there to find an 11 year old with a very tender abdomen, so we decided to do him first on the schedule. While waiting for him to clear the various admission hurdles, we went up and made rounds. The boy with the bowel resection and incisional hernia repair was doing well,mcplaining of thirst. We talked for a little with Dr. Kiiza who would like us to give se lectures to the medical students, so Jonathan and I will confer on that. We went to the OR where Konneh and I did Andrew, the trauma boy, while Jonathan and e intern did a hernia repair. As we expected, Andrew had a splenic tear and about 500 cc of blood in his abdominal cavity.the splenic tear was at the lower pole, and perhaps some at the hilum where there was adherent clot. We were faced with a decision about preserving his spleen: at home there is no doubt that we would have preserved it, but there we have the benefit of close monitoring, and a CT scan if there is any question about rebleeding. We watched Andrew for a while, and fully checked the remainder of his abdominal cavity to be sure there were no other injuries. Then I scrubbed out and went to The Administration building to get the SurgiCel I had brought with me, which we then tucked around the spleen for some extra security. Konneh tells me that he has preserved an injured spleen before, so I can't claim it was a first at JFK, but it was a first for me at JFK, and I hope it was the right decision. Then Jonathan and I did a mastectomy on a 52 year old woman. She had a breast mass removed at Redemption in January which was said to be a fibroadenoma. It recurred in the spring and she had another lumpectomy. Then it recurred again, and this time she had palpable axillary nodes, so I guess the diagnosis of fibroadenoma was in doubt, and she was referred to JFK. Moses recommended chemotherapy for her obviously advanced great cancer, but Konneh admitted her, and so we operated on her. She is a small woman, and the cancer was pretty big; it was also invading the pectoralis muscle. We were able to get it out and debulk her axillary of all palpable disease. It was pretty bloody, and the closure was tight, and i think Moses might be right in his nihilistic approach to advanced breast cancer in Liberia...but I still feel like we did the right thing, and she at least has the possibility of a few months of good life before it recurs. After doing another hernia, we came home for a short rest and a shower, and then went to the Royal to have dinner with Tom Graham, the head of Veterinarians Without Borders whom I met on the plane, and Dave, a British fellow working for USAID to help the Liberians develop their agriculture and engineering schools. We had a wide ranging discussion where we learned of some mutual interests and goals, and all in all it was quite worthwhile. Several incidents today demonstrated just how challenging it can be here. With Andrew, induction of anesthesia was a heart-stopping, gut-wrenching process during which his O2 sat dropped to 23 percent. At some point later Anthony told me that they had no inhalational anesthetics, so they were using IV sedation and muscle relaxants. He said the pharmacist was working on getting some, and we might have them tomorrow. Both the splenorrhaphy and the mastectomy brought up interesting and difficult clinical questions regarding the transferability of standards of care from the USA to Liberia, particularly as their health care capabilities improve. It's not that there is a right answer, but I found myself truly befuddled as I tried to decide whether to try to save Andrew's spleen. It could be argued either way, and that is just what went on in my head! In retrospect, I think I enjoyed trying to decide what was the right thing to do. Time will tell if I made the right decision.

Tuesday September 4

This is rainy season, and it sure rained last night. I was awoken several times by the pounding of rain on the metal roof. It would pour for a few minutes, and then stop for a while...but by 7 am it had settled into a fairly steady downpour. Heavy rain here is kind of like snow at home; it delayed everything. Anyway, after we arrivid in the OR we did a child hernia, then excised seething that looked like a wart off a child's head, and then Jonathan and I did the 12 year old boy we saw yesterday. He had been operated on twice at Redemption for typhoid perforations over the summer, and then came to JFK with a bowel obstruction. That had resolved, and we thought we were just going to fix his incisional hernia today. However when we explored his abdomen we found that they had done a right colectomy with a sewn end-to-end anastomosis, and it appeared to be twisted. So we decided it needed to be redone, and we did that before fixing the incisional hernia primarily. After that we expected to do a mastectomy on a lady with breast cancer, but she got cold feet and said she didn't want it. A little while later she. Hanged her mind and said yes, but by en anesthesia had decidedmshenwould have to wait till tomorrow. We went to the maternity hospital with Mary to see 2 patients for whom my services had been specifically requested. They both have large uterine fibroids and ovarian cysts, but it was unclear to me why I was needed. It seems that Dr. Jallah, an excellent Ob-Gyn who had trained at Jefferson in Philadelphia, and who was one of our stalwart friends here, decided she had had enough and retired! Then it also seems that these two women were brought to JFK at the urging of Auntie Jenny, and she was the one who requested that I be involved in their surgery. So I spoke with the Liberian Ob-Gyn who is there, and I think we agreed that I would assist him on Thursday. Should be interesting! We then went to clinic and saw the usual diverse array of patients including a 4 year old with a large abdominal cyst which appears to be coming from her pelvis (shades of Harriett)(we will operate on her soon); a 60 year old woman with advanced breast cancer; a 62 year old man with a melanoma on his heel and large inguinal nodes; and then a bunch of strange complaints that we hope will respond to ibuprofen! We went to check on the 12 year old boy after his laparotomy, and found him in pain. The nurses said that they hadn't given him anything because I had not written post-op orders; I showed them where I had indeed written orders, but they explained that I should not write them on the "Physician Order" sheet, but rather post-op orders are supposed to be written on the back of the written op note sheet. While it defies any logic to me, I have learned my lesson and will write them where directed in the future! After coming home for a shower, we went to the house of an aunt of Jonathan's wife. She is stationed here while working for the UN. She prepared us a lovely dinner which was most enjoyable. She lives in an apartment complex off Tubman Boulevard; the complex has a generator to provide power, and the noise brought back memories of the Bungalow! I have to say that the current accommodations are quite nice, and I don't miss the noise of the generator; I do however miss the proximity to the hospital. Being able to walk to and from the hospital when we wanted to was a big advantage to the Bungalow; here we need a driver to take us to and fro, and while they are very gracious and willing, it is still less convenient.

Monday September 3

We arrived at JFK around 8:30 this morning, and soon ran into Dr. Moses who greeted us very warmly. We went up to the surgical floor with him, and found Konneh with a large group of medical students. This is a wonderful development; I think we can offer a lot to medical students, so I am very pleased to see that they are at JFK doing surgical rotations. We also met Dr. Michael Kiiza, a surgeon from Uganda who is a fellow of the West African College of Surgeons, and a delightful man with a great smile and a very friendly demeanor. He was hired by JFK in May, and appears to be settling in well. The first patient we saw is a 50 something year old man who came in with a strangulated right inguinal hernia, and strangulation of his tests also. They resected the strangulated parts, and gave him an ileostomy. The surgery was 3 weeks ago. Unfortunately he looks badly nourished and is losing weight despite eating; his right groin wound is open and clean, but his ileostomy is pouring out. The skin around the ileostomy is excoriated due to ill-fitting stoma appliances, and apparently he is now developing decubitus ulcers. The question is when should we operate to restore his intestinal continuity; my feeling is that he will not get better till we do, so we may operate on him later this week. The second patient, in the bed next to him, is a z12 year old yo admitted with a bowel obstruction. He apparently was operated on at Redemption for typhoid perforation several months ago. His bowel obstruction was ought to be due to adhesions, and has resolved, but he has a large incisional hernia. I think we will probably fix that soon. We then went to Grand Rounds, and greeted a number of friends. The discussion was about postgraduate education; apparently the President has declared it to be an important step to take in restoring the health care system, so there is a lot of a tivity currently trying to figure out what is needed etc. there was a group from Baylor Resnt; they at placing a pediatrician and an Ob-Gyn here for at least a year. After Grand Rounds we went to the OR, and it was like a school reunion with lots of joy and hugs ! Then Jonathan and I did a man with bilateral inguinal hernias, another man with a right inguinal hernia, and a young woman with keloids on her earlobes. One of the process improvements is the development of a computer printed list of surgical patients for us, divided into 3 categories: patients already "on bed"( admitted to the hospital), patients who are Category 1 for admission, and patients who are Category 2 for admission. We still have the issue that they need to pay to get admitted, so the priority for admission is not just their medical condition, but also their financial circumstances; at least it is a bit more organized. I learned that the bungalow has a leaky roof and other repairs are needed,Mao ats why we aren't staying there. Apparently there are other occupying the Presidential Guest House, and that is why we are being housed in these apartments. I feel bad that they are costing JFK some serious money to rent for us, but I'm not sure there was much other choice. After a short nap we went to Jamal's for dinner to meet Jonathan Ryan. I was put in touch with him by a patient of mine in Waterbury, Dr. Peggy Sheehan, who taught him English when he attended Post University in Waterbury. He grew up on Willow St in Waterbury before the family moved to North St. In Watertown; he graduated in 1994 from Watertown High School. he is a lieutenant in the US Navy, currently on assignment as the Information Officer in a UN Peacekeeping Force unit in Ginta,about 6 hours from Monrovia. We had an interesting evening learning his take on Liberia and sharing experiences.

We were 2 hours late leaving JFK because someone checked a bag and then didn't get on the flight,so they called us back from the takeoff runway. The baggage handlers then had to go through the checked baggage to find the one they were looking for...not an enviable task for sure. The flight was long but uneventful. I met a man on the plane who is the head of Veterinarians Without Borders. We had an interesting discussion, and I may see him at JFK Hospital later this week; he wants to see the lab facilities. We arrived at Roberts Field around 4 PM, sailed through immigration easily, and we were met at the baggage claim by a woman from the hospital. We loaded all of our bags into a pick-up and a Prado, and heeded into Monrovia. The driver then took an unexpected turn, and I learned that we are staying in an apartment building in CongoTown ! Jonathan and I have apartments next to each other, and they are spacious, air-conditioned, and they have Wifi ! When we arrived, I found Weltee here to greet us; he has taken care of us before by preparing meals etc at the Presidential Guest House as well as the Bungalow, and he will be taking care of us here also. After we settled in, we had dinner, and then Dr. McDonald came by to say hello. I guess she decided that we deserved better accommodations than what the Bungalow offers. Wile I will miss the pounding sound of the generator, having hot water and Wifi is hard to pass up !! The downside to being here is that we will be dependent on a driver to get to and from anywhere, but I think it will all work out. From what Dr. McDonald said, we will likely have a busy and productive trip as they already have a number of cases lined up for us to consider. So I'm going to bed early.

Saturday, September 1, 2012 I am at JFK Airport waiting for Jonathan Laryea to arrive, and then we will leave on our flight to Monrovia via Accra. I'm happy to report that there were no issues with my Liberian visa this time ! Check-in was relatively smooth, though I did have to pay to check an extra bag; I was turned down when I asked for a waiver on humanitarian grounds. Oh well. Accompanying me on this trip will be Dr. Jonathan Laryea. Jonathan went through our general surgery residency program, finishing about 6 years ago. His co-Chief Resident was Dr. Amy Rezak, whose wedding I will be attending at the end of the month after I get back. Jonathan did a colorectal fellowship in Atlanta, and is now a colorectal surgeon at the University of Arkansas, which he is also Associate Director of their Surgical Resicdency Program. Jonathan is a native of Ghana, and has been involved with the West African College of Surgeons; he was in Monrovia for their meeting last February. As usual, I am looking forward to this trip for all sorts of reasons. I want to see what progress has been made at JFK in e past 6 months; I'm wondering which of our former patients I will see again; and of course I wonder what surgical challenges we will face. For the first time, I am going without my colleague, friend, and protector Adamah so it will be interesting to see how it all works out. I'll be letting you readers know !!

Saturday March 18

Saturday March 18

     All of our patients are looking well this morning, especially Peter, Cynthia, and Harriet. One of the peditricians told me yesterday that Harriet was not allowed to register for nursery school because her belly was so big, and they thought she was possessed by the devil. I'm very glad that we were able to help her.
     For surgery today, we had 5 cases scheduled. One of them is a 48 year old man with a goiter, but his thyroid is particularly hard and irregular, and he has a lot of adenopathy in his posterior neck.nafter thinking about it last night and this morning, I have decided not to operate on him. I am quite certain that he has thyroid cancer, and he really needs a total thyroidectomy sand functional right neck dissection; I don't think that is an appropriate operation for me to do here, and so I have suggested that perhaps he should go to Ghana. They do not have thyroid replacement (thyroxine) in Liberia, so no one gets a total thyroidectomy, but in his case I think it would be inappropriate.
       So the cases we did do today included a 2 year old with a hydrocele, and a 47 year old woman who had a mastectomy by Dr. Golekae; during that surgery they found that the tumor extended into her abdominal wall. Having no pathologist here, they had no idea what it was. But she was left with a 5-7 cm mass in her right lower abdomen which she wanted it gone before she would go home. We agreed to remove it, and thus get tissue for biopsy. Moses and I did the debunking surgery, and it is a strange looking tumor; I'm wondering if it perhaps is fibromatosis, which I have never seen before. I have specimens of it for our pathologists. 
     Santiago and John removed an enlarged submandibular gland from Percillas mother, and as I write he is removing a simple goiter from an obese woman with Diego and John. They have been at it for about 3 hours, and are close to finishing; I'm suspecting Santiago wishes he had never told me that he wanted to do the case !
      I saw Dr. Johnson, the Chief Medical Officer, on the ward this morning. He once again expressed his gratitude for our coming to JFK, and his hopes that these visits will continue. I have no doubt that they will, and in fact I have already lined up several cases to do when I return in September. 
      I think our total number of cases during this visit will be about 45, and that represents a significant amount of work. Looking at the OR log book, they usually do about 30-35 general surgery cases a month; to do 45 cases in 2 weeks required a lot of extra effort by the OR staff, anesthesia, and others, and we are very thankful that they were willing to do so. It made a huge difference for us, and for our patients.
       They finished the thyroid around 4 pm, and then we came back to the Bungalow. We had an Italian dinner with pasta and meatballs, and then went out for a few drinks at a new nightspot which was quite pleasant. Home for bed around 1 am.
        

Friday March 16

Friday March 16

Today is our last full day of operating on this tripa,nthough we will do some more cases tomorrow to finish up.
We started with Harriet, the 3 year old ( previously I said 4, but apparently she is 3) with the swollen abdomen that made her look like she has ascites. We were supposed to do her surgery earlier in the week, but she developed acute malaria last weekend,nso we had to postpone while she was treated for that. Today we did her surgery....and it turned out to be a huge cyst attached to the greater curve of her stomach, and which occupied her entire abdomen. We made a relatively small incision, and delivered it out of the abdominal cavity pretty easily. We then detached it from her stomach; there was no connection to the gastric lumen,nso I don't think it was a duplication cyst. It weighed nearly 9 pounds !! We closed her now shrunken abdomen with a subcuticular stitch and Dermabond.bwhen we fished, Santiago and I went downstairs to the Pedi ward to see her mother. She was in the waiting area and looked at me anxiously; I raised my thumbs, and she fell to the floor, crawling on her hands and knees to embrace my legs.mi don't believe I have ever had such a response to good news from a patients family before ! Later in the day we stopped by to check on her, and the grandmother was there, praising God, praising us, and just totally relieved by the outcome. She even had me talk to her husband on her cellphone so he could thank all of us. It turns out that they are from far away, and had been to 2 other district hospitals and a witch doctor trying to find a solution to Harriet's swollen belly; for them, coming to Monrovia was a last gasp. Harriet made the day for all of us !
John did a hernia with Konneh, and he was so excited at the end, because he actually did it ! His excitement is infectious, and that has been a wonderful addition to this trip. Then Santiago and Diego operated on Ophelia, a 48 year old woman with rectal cancer, very close to the anal verge. He was able to excise it, but with no adjuvant radiation or chemotherapy available, her prognosis is not very good. While he was finishing that case, they decided to start one of the two thyroids on the schedule. Santiago was planning to help, but since he was busy, I did it with John. The patient had had a previous left thyroidectomy for goiter, so that made the re-do somewhat more of a challenge. In addition, her right lobe was significantly substernal. Fortunately we were able to do what needed to be done, and hopefully we left enough thyroid behind to take care of her needs.
We decided it was too late to start the second thyroid, so we will do her tomorrow. We went to the Maternity Hospital to see Victoria, whom Santiago had operated on earlier in the week for her rectal stricture and rectovaginal fistula. She looks great and is ready to be discharged. He told her to contact me when I am back in September and hopefully we can decommission her ileostomy.
        After showering, Dewalt picked us up and took us to The Lagoon to meet up with Percilla and some others from the OR. Aftervdinnervand a couple if beers,new went in search of dancing. After a few false starts we ended at Sajj, and stayed till 1 am or so before coming home to bed.

Thursday March 15

Thursday March 15

      Today is another national holiday celebrating the birth of the first President of Liberia, but it isnt as important a holiday as yesterday, so we have more cases scheduled today than we did yesterday. After making rounds, and finding that our patients are all doing well, we went to the OR to find that they were down to one tank of oxygen and had no muscle relaxants. So the anesthetist Mr Hne wanted to do the kids on the schedule, and hopefully we would have gotten the oxygen and muscle relaxants by the time we were ready to do Santiago's case. So we did pediatric hernias under ketamine and spinal, and all 3 of them went well. Then Santiago and Diego did an adult hernia. When they were doing that, Noah called me about a patient in e ER with Ludwigs angina, which is an abscess in the neck which causes upper airway obstruction. The treatment for it is antibiotics, and a tracheostomy. So I went to the ER to see the patient,Benjamin Morris, who was in obvious distress, but I wasn't certain what to do. I have read about Ludwigs, but I had never seen a case until today. Anyway, Rachel Fowler, one of the ER attendings from Brown, was there; we discussed the dangers of waiting for the antibiotics to kick in, and I decided we should just do it. I went back to the OR, told them we needed to do an emergency trach, and within maybe 10 minutes we had the patient upstairs and ready to go. Diego and I did his trach under local with some Versed; it went very well, and within a half hour he was a changed man. As he was wheeled out of the OR, he smiled and shook my hand. I am pretty sure he had looked death in the face, and felt relieved to have survived!
     Then Santiago did the young woman referred from Redemption. He and Diego and John worked on her for about 5 hours; they found several holes in her small bowel, presumably the work of her abortionist. They ended up resecting a couple of feet of small bowel, and then creating a double barrel enterostomy. It was interesting, and noted, that Mr. Hne stayed till the end, which was about 9!pm, though I believe he was off as of 4 pm. Anthony is a caring soul, and quite a good anesthetist, and I'm happy when he is around.
      We were supposed to go out with the OR staff tonight, but because we were working till 9 pm we decided to try for tomorrow night. Dewalt called a couple of times to tell us about the Mayors function that night; she had invited all of us when she saw us at the Presidents house the other night. But we were all pretty well beat last night, so we had Dewalt take us to Sajj for dinner and then home.

We'dnesdsy March 14

Wednesday March 14

      Today was Decoration Day, a national holiday on which the Liberian people go to cemeteries to decorate the graves of their deceased family members. As such, we only did one case in the OR: Ainhoa and Diego released a burn contracture on the finger of a little girl. We saw Adamah and wished him goodbye; he is going back tonight as is Ainhoa. In the afternoon we walked to the Royal Hotel for nice lunch; we had a good conversation about Liberia and the people and the pace of change which is  impossibly slow sometimes. But when you think about what they have been through it all becomes more understandable. During lunch, in part because it is Decoration Day, John suggested that we stop and remember those who have passed on during our time at JFK, which we did. 
     As we were walking back through the grounds of JFK the ER residents asked us to help put a suprapubic tube, which was quickly assented to. We decided to show them how easy it was to in the ED...it took 4 of us to hold him down, plus Noah delivering Valium, pentazocin, and ketamine, and eventually we were successful. I personally sweated off several pounds holding his legs down !
      Last night we went to Tajj for dinner with the dorm group; it turns out that one of the new pedi residents is from Duxbury ! We had a good dinner, and then back to the dorm. I think Welky was disappointed that we didn't eat the food which had been prepared for our dinner, but so it goes.
      In the course of the afternoon Anne-Marie called from Redemption to say that she had a 23 year old patient there who needed our help. The woman apparently had a backstreet abortion about 2 weeks ago during which they perforated her uterus and colon. She was admitted to Redemption and placed on antibiotics, but was getting worse. So last week she was taken to the OR for an exploratory laparotomy; apparently the surgeon found pus and stool, but not the perforation, and felt he couldn't do anything more so he closed her up. Anne-Marie saw her yesterday, and noted stool leaking from her midline incision, and hence the call for help. Somehow we will fit her into the schedule to do tomorrow, though it will likely mean we have to cancel some cases.

We'dnesdsy March 14

Wednesday March 14

      Today was Decoration Day, a national holiday on which the Liberian people go to cemeteries to decorate the graves of their deceased family members. As such, we only did one case in the OR: Ainhoa and Diego released a burn contracture on the finger of a little girl. We saw Adamah and wished him goodbye; he is going back tonight as is Ainhoa. In the afternoon we walked to the Royal Hotel for nice lunch; we had a good conversation about Liberia and the people and the pace of change which is  impossibly slow sometimes. But when you think about what they have been through it all becomes more understandable. During lunch, in part because it is Decoration Day, John suggested that we stop and remember those who have passed on during our time at JFK, which we did. 
     As we were walking back through the grounds of JFK the ER residents asked us to help put a suprapubic tube, which was quickly assented to. We decided to show them how easy it was to in the ED...it took 4 of us to hold him down, plus Noah delivering Valium, pentazocin, and ketamine, and eventually we were successful. I personally sweated off several pounds holding his legs down !
      Last night we went to Tajj for dinner with the dorm group; it turns out that one of the new pedi residents is from Duxbury ! We had a good dinner, and then back to the dorm. I think Welky was disappointed that we didn't eat the food which had been prepared for our dinner, but so it goes.
      In the course of the afternoon Anne-Marie called from Redemption to say that she had a 23 year old patient there who needed our help. The woman apparently had a backstreet abortion about 2 weeks ago during which they perforated her uterus and colon. She was admitted to Redemption and placed on antibiotics, but was getting worse. So last week she was taken to the OR for an exploratory laparotomy; apparently the surgeon found pus and stool, but not the perforation, and felt he couldn't do anything more so he closed her up. Anne-Marie saw her yesterday, and noted stool leaking from her midline incision, and hence the call for help. Somehow we will fit her into the schedule to do tomorrow, though it will likely mean we have to cancel some cases.

Tuesday March 13

Tuesday March 13

  We had 6 cases scheduled for today, and cancelled 3 before we got started. One was a child with a hernia who had a cold; the second was a woman admitted with an epigastric hernia which we couldn't find and her pain had disappeared; and the third was an older man scheduled for a bilateral orchiectomy but Dr. Golikae had written in the chart that he was suitable for a prostatectomy. So we were able to add on a 5 year old with a right flank mass. John and I did Mohammed Sanho, younger brother of Sanho the scrub tech; he had a quite large nearly African hernia which we successfully reduced and repaired. Then we did the 5 year old girl with. the right flank mass, which actually extended retroperitoneally across the abdomen into the left lower quadrant. It was intensely vascular; we biopsied the wall, and found that the mass was a largely mucinous. I elected not to do a bigger biopsy because of the significant bleeding, and the risk that by being curious we would get into significant trouble. I am quite certain that this is malignant, and most likely untreatable.
  In the other room Ainhoa and Diego did some Z-plastics on the man with the burn contracture of his leg, hopefully starting the process of him being able to straighten his knee.
  I went to the clinic, and Santiago and Diego did a woman with an umbilical and inguinal hernia. Then Santiago called me up to the OR to see a man who had just been brought in after falling off the back of a moving pickup truck. He has massive facial degloving involving his nose hand upper lip, and was actively bleeding so the the ER doctor got him out of the pickup truck that brought him to JFK and brought him directly to the OR bypassing the ED. Santiago told me that he had done a case similar to this as a resident at Waterbury Hospital, and would love to do one again, so who was I to refuse!! We left them in the OR as we went home to shower and get dressed for an evening at the President's house.
   We arrived at her house and were directed to the gazebo and pool area where there was a bar set up as well as a buffet of finger foods. In addition to the HEARTT people, Dr. Macdonald was there as well as Lydia, Ben, and the usual cast . We all had drink and food, and then the President arrived home from her office. After a brief stop upstairs, she came out and joined us where she greeted us and then we each sat next other for a photo op. My conversation with her  was heartfelt and wonderful, and she was very kind in her comments. I told her how exciting it was for me to be present at the rebirth of Liberia, and how I see progress with each visit; she told me that she considers my contribution to that progress and rebirth to be very significant. While I am quite certain that she overstated the effect of my visits, it was a very kind and complimentary thing for her to say.
     After photos John was saying that he would love to talk to her one-on-one, and I encouraged him to do so. He sat down next to her and had a 10-15 min conversation, and came away from it in awe. I loved the look on his face as he described the feeling of just having had a conversation with a President.
     Santiago phoned me to say that they had finished operating and would be on their way over after a quick shower. I guess I was pacing a bit, worried that Madame President would leave before they arrived. Adamah was speaking with his mother, and called me over because she wondered why I was looking so concerned; I explained why, and she said :" don't worry, I won't leave "! About 15 minutes later they arrived and were greeted warmly by her.  Santiago told her about the case they had been doing; he mentioned that he had before and after photos, which she said she would like to see, so there he was showing her the rather graphic photos. Then she had photos taken and conversation with Diego and Santiago before she retired inside. We all stayed a little longer, chatting with Mayor Broh, and enjoying ourselves before piling into the van and heading home. It was definitely quite a night !

Monday march 12

Monday March 12

     I guess the meeting last Friday did have some impact, as the OR had our first patient on the table and close to being put to sleep at 8:35 AM. Unfortunately, being Monday,we had Grand Rounds so we couldn't start till 10:30...but it was good to see that they were primed and ready to go. Our patients were all doing well, with 2 exceptions: the woman who had the amputation on Friday passed away last night, and the 4 yo girl with the large abdominal cyst developed malaria over the weekend. She is getting appropriate treatment, and hopefully we can do her surgery on Friday.
     Grand Rounds was a presentation on sepsis by 3 of the HEARTT ER residents: Noah from Brown, and Sewena and Jenny from Yale. They gave a very good presentation, and there was lively discussion afterwards about the role of steroids and of lasix.
      With our first case cancelled, we moved to the thyroid: a multinodular goiter that Konneh had been asking me to do with him since we arrived. We did a subtotal thyroidectomy, and to my surprise it wasn't bad at all. In fact, afterwards I told Konneh that I would do more thyroids on my next visit. After that Diego and I did a guy with a hepatic abscess. We did ultrasound pre-op and could see that is was superficial; our plans to do intra-operative ultrasound were thwarted by battery failure in the litlle handheld ultrasound. As it turned out, when we got inside his abdomen, we found his liver was stuck to the chest wall medially, and in bluntly taking down that adhesion, we found the abscess and drained it, leaving a foley in it. While we were doing thyroid, Santiago and John did a bilateral orchiectomy for prostate cancer, and then Santiago, Ainhoa, and John started on Victoria. She is the young woman about 30 who was given a lye enema for reasons unclear, and who developed serious complications as a result. She had previous surgery which included a colostomy, but the full extent was unknowable. Santiago examined her under anesthesia last week, and thought he could offer her a way out of her ostomy. The good news is that after about five hours of surgery, she is back together with a diverting ileostomy, and there is the hope that the ostomy will be decommissioned in 4-6 months.
     After they finished we went to the dorm for our daily Internet fix, and then home. The four of us had dinner, and then sat around talking about surgery, and our education, and life history. It was a chance to get to ow one another better, and was very enjoyable.

Sunday March 11

We slept a little later, and then went to the RLJ Kenjabe resort to spend the day eating, drinking, laying in the sun, reading, and relaxing. It was quite pleasant as always. Then in the evening we went to Adamah's brother Charles's house for some spicy food. He lives in the family compound in CongoTown. We didn't stay too long, and then came home and went to bed fairly early.
Halfway through this trip, I am very pleased with what we have accomplished so far, and I expect that the next week will also be busy. lots of routine, but some interesting cases also I'm sure. And of course who knows what surprises are in store for us. I'm happy to say that Diego, John, and Santiago are also having a great time learning, teaching, and living in Liberia.

Saturday march 10

aturday March 10

A bit painful to wake up at 7:30 this morning, but so it goes. We went to the hospital and made rounds; to my surprise our amputation patient from yesterday is mentally brighter and seems to be improving.  Then to the OR where we found Moses and Konneh dressed in scrubs and ready to work. Percilla was there with a full staff, contrary to some expectations, so that we actually ran 2 rooms at the same time. John and I did a combination inguinal and ventral hernia in one room, and Moses and Diego did an inguinal hernia in the other room.
I think the meeting yesterday evening must have had some effect. As we were leaving, I thanked Percilla and asked her to extend our thanks to the whole staff, and she said that she was  pleased that things will be different next week. By that I think she was referring to starting on time and not wasting time; we shall see.
After a short nap in the afternoon, we went to the home of Lydia's boyfriend for a party. He lives in a spacious new apartment off Tubbman Boulevard; the complex is still under construction. It is a good example of the rebirth and rebuilding going on here. After a few drinks there, we went to another party at the home of Gino, who I think is the Deputy Chief of Mission at the US Embassy here. He told me that Linda Greenhouse (?) had just left here as US Ambassador to return to Washington and become Chief of the Foreign Service. Other people at the party included Adamah's brother Kumba, who is head of National Security in Liberia, and several people from the embassy including the defense attaché and a CiA rep. All in all, a very interesting group of people ! We enjoyed plenty of food, drink, and laughter before coming home. Happily when we got here we found the generator fixed, so we have air conditioning once again !
I have had some excellent conversations with Diego and John about this experience, which they are both enjoying totally. It has clearly surpassed their expectations, not only in terms of the surgery, but also because of the other aspects, such as the people we met this evening. They have both told me that this is a life-changing experience for them; I am proud to have played a part in the process.

Friday March

We amputated the leg of a woman with a severe diabetic foot infection today. We had hoped to do it yesterday, but it got late and she was getting blood, so we decided to delay it till this morning. John reported that she had developed crepitus up her leg,  signifying the development of necrotizing fasciitis, and diminished mental status indicating the infection was overtaking her ability to resist. So we brought her up to the OR and did a guillotine BK amputation ; we shall see if that solves her immediate problem.
The big case for the day was Cynthia, the 9 yr old transferred from Redemption. She was admitted there with typhoid perforation, and had several operations including an ileostomy, but she developed septic complications. She came to us looking emaciated, with an open abdominal wound and an a couple of wounds in her right lower quadrant and groin leaking stool; I think at least one of the leaking areas was the planned ileostomy, but it was hard to know for sure. Santiago and Diego sorted things out, finding 3 ends of small bowel, and the other end open and deep in her left lower quadrant. They resected some of her bowel and brought out the ends as an ileostomy. Post operatively she had respiratory issues, and was brought back from the recovery room to the OR to be reintubated. By the time they were ready to do the last case, it was 4:30 and too late to start a thyroidectomy for goiter. So she was postponed till Monday.
Ainoha, Santiago, and I then went to a meeting in the Administration Building with Dr. Macdonald and Dr. Johnson regarding surgical services. We had a wide ranging discussion about admitting procedures as well as the functioning of the OR, and we will have another meeting next week with Anesthesia and Percilla ( the OR Manager) involved. One of the things we want to do is to get started on time : "KOS at 8:30" ( knife on skin). I think it was a good discussion, and perhaps it will lead to a better organized and more productive Surgical department.
After the meeting we went to the dorm, where we learned that the generator for the Bungalow had broken. Dr. Macdonald went to the house to check on it, and then brought food from the house to the dorm for us. Eventually Santiago and I headed back to the Bungalow to take cold showers in the dark, but as we were leaving the dorm he received a phone call from Ainhoa saying that Cynthia had sto:pped breathing, had coded, and could not be resuscitated. We went to the hospital, and expressed our sorrow to her grandmother who was distraught and wailing with grief. Looking at this emaciated, very ill little girl before the operation, it was clear to all of us that she was unlikely to survive, but it is still hurts to see her die so soon. In many ways, she exemplifies the Liberian experience for us: we do our best, but so many of our patients have such advanced disease on presentation that the cards are stacked against us from the outset. As we were walking back from the hospital, Santiago asked me what was the highlight of my day; I told him that it was seeing her abdomen closed and cleaned up after he fished her surgery. It was truly a remarkable transformation from pre-op to post-op. Obviously the low point was her death. But as I told him, if we didn't try she was certain to have died; surgery offered her the only possible chance, long shot as it was.
We went back to the Bungalow and showered. Eventually they brought in a small generator that allowed use of lights, but no air conditioning. Then we all went out, first to the Casino for we very loud music and a few drinks, and then to Groovies for beer and dancing. We had a fun time, and came home around 2 , knowing that we have to get up in the morning for surgery. The decision to go out after Cynthia's death was a conscious one; as sad as it was, the death of children is a fact of life in Liberia. Hopefully in time that will change; that's why we are here.

Thursday March 8

The post that I wrote yesterday for this day was lost into my iPad somehow, so I am rewriting it tonight, with the help of my colleagues who are sitting with me in the dorm. Our surgery included Theo,the boy we cancelled on Tuesday; a 3 year old girl with bilateral inguinal hernias; and an adult hernia. The 3 year old is the daughter of a medical student, and the niece of Mary,the Clinical Director so it was a special request. Mary was in the OR room the whole time, as was a male medical student who might be the father ( my assumption, not that of the mother). It was weird having family watching and taking photos, but I didn't feel comfortable asking them to leave. Fortunately the surgery went beautifully, and we wowed them by doing a subcuticular closure and then Dermabond . Unfortunately she developed bronchospasm and had to be reintubated, and that was fairly nerve wracking for the family, but it all turned out well. Diego did the adult hernia with Moses, and it was a valuable learning experience for him in many ways. The last case was a woman with metastatic thyroid cancer to her posterior cervical nodes. Ainoha and I did it, and it was a beautiful surgery,mifindonsay so myself. She has excellent hands, and moved right along, and we both enjoyed doing it. I know that she has more dusease, but hopefully by debunking her neck we will give the patient a little more time.
Diego and John had their meeting with the Medical Board, and I guess it all went well. Last night we had all of the HEARTT people over to the Bungalow again, and then to bed

Wednesday March 7

March 7

   They are really going all out for us in the bungalow this trip. Welke, whom we knew from the Presidential Guest House last year, has been at the Bungalow to take care of us for breakfast and dinner. I think the meals are prepared at the Guest House and then brought to us. It really is very nice!
   After breakfast we went to the hospital to make rounds. To my surprise and distress, the older man with the possible bowel obstruction whom we decided to observe overnight had expired. I'm not sure what happened, and there is no way to find out, but it's disconcerting to say the least. On the brighter side, the man with the liver abscess that we drained yesterday looked fantastic and was obviously very pleased with his surgery !
    Then we went to the OR to start our day. A child with a recurrent hernia, a woman with a breast lump which is probably cancer ( I'm bringing a piece of it home for our pathologists to look at), Santiago did an EUA on a complicated colo-rectal patient, the trauma patient from Redemption who probably had an extraperitoneal bladder rupture, and then a liver abscess which turned out to be a right renal cyst. We had more cases scheduled, but time ran out; in fact, we were only able to do the liver abscess with a lot of begging and pleading the anesthetists. One of the big problems is that there is no nurse staffing the PACU/ Recovery Room, so the patients are all recovered in the OR. Thus it was an hour between finishing the boys hernia and doing the breast lump as we waited for the boy to recover so he could go back downstairs to the ward.
    This morning Welke told us that we would be having dinner at the Presidential Guest House, but I asked Adamah about it a couple of times and he wasnt able to confirm it. Apparently former British Prime Minister Tony Blair dropped into town for a visit, and was meeting with
Madame President, so there was some thought that plans had changed. So we got Dewalt to  drive us to Sajj...but then right after we ordered Adamah called to invite us to the Guest Houe to meet his cousin Elias and his wife Cora and the group with them who are going out to the Toade Mission School which we visited last year. It was a pleasant evening, and then Dewalt drove us back to the bungalow where some of the unbeaten food from Sajj was eaten. Then to bed.

March 6

March 6
    As usual, another interesting day at JFK, filled with frustration as well as satisfaction. We had planned a busy day with 8 cases to be done in 2 separate OR rooms. After rounds we went to the OR to discover that there was only one anesthetist available, since Anthony's son was sick. Anthony is the excellent anesthetist who helped us take care of Keita last September. So we were down to one room, and then we learned that Moses and Konneh were going somewhere to a lecture at noon, and Ainhoa was going to Redemption, so there would be no one to staff the clinic in the afternoon. So it was important for us to get through as many cases as possible in the morning...but the reality was that such an idea was pure fantasy.
   The first case was an 11 month old with hernias. They had a hard time with the intubation, and eventually decided that the child needed to be cancelled and rescheduled for Thursday. The next patient was a 4 year old girl with an inguinal hernia, and they had trouble intubating her also. Eventually they did, and we did her surgery fairly quickly, so that at 11:15 am we could say that we had finished one case finished. John and I were in the OR while Santiago and Diego were in the clinic with Moses and Konneh first, and then with Dr. Golokae. We had a 10 year old with a hernia to do, but anesthesia refused because there had not been a formal anesthesia consult requested the day before. Very frustrating for the patients mother as well as us. the next case was interesting: a 40 year old man with a hepatic abscess. He had been in the hospital on antibiotics for a month, but the abscess had not gone away. We explored him through a subcostal incision, and found that his liver felt fairly normal. So I had no idea where the abscess was, but I did know that by ultrasound it was 20 cm in diameter, so I ought to be able to find it. I stuck a needle in lateral to the gallbladder, and with penetration was able to aspirated pus, but it took nearly the full length of the needle. I then used the Bovie make a hole on the surface, followed by a long Kelly clamp into the substance of the liver...with great trepidation. But we hit the abscess, and drained probably a liter of pus out. ( My apologies to the non-medical readers, but the details are important !) I was quite pleased that we found the abscess, and drained it without causing major injury or bleeding; I think he will get better faster.
   On morning rounds we saw the man mentioned yesterday who had a bowel obstruction. His abdomen seemed worse, so we put him on the OR schedule for an emergency laparotomy, hoping that we would fit him into the schedule in the morning. Around noon the anesthetist told us that she wouldn't do him unless she had 3 units of blood for him; he only had 2 ordered, so the case was delayed while attempts were made to reach his family and get them to donate or pay for another unit. Later in the afternoon another anesthetist saw him who said he didn't care about another unit of blood, but we couldn't take him to the OR until his family made a downpayment on hospital expenses, especially drugs. We examined him again at that point, and his abdomen was less tender, so we decided we could observe him overnight.
    We went back to the Bungalow to eat, and soon after our meal Adamah called to say that they came back from Redemption with the accident victim as well as a young man with an incarcerated hernia who was getting worse. So we all came over to see him; Santiago and Diego ended up operating on him to do a small bowel resection and hernia repair. We got back home around 11. I had a good conversation with Santiago about being here, and then off to bed.
O

Monday March 5

March 5

    After a good nights sleep, we went to JFK around 8 am. We learned that Ainhoa, the Global Surgery follow from Children's Hospital (Boston) had organized a full day of surgery for us. We saw Dr. Johnson and Dr. Moses outside, and they greeted us warmly. As we walked in the ED entrance, Santiago called me to stop and say hello to Joseph Nah: he is the 20 year old in whom we diagnosed Burkitts lymphoma last March and who underwent successful chemotherapy ! What a way to start the day! He looks great, and was very pleased and excited to see us! We also saw Emilie, who will be here for a few more days, and then we met up with Ainhoa. We rounded with her, and saw that there are a lot of patients awaiting surgery, so we will be busy!
   Then we went to the OR, and we were greeted warmly by lots of old friends. Diego and I did a baby with an inguinal and umbilical hernia, and then John and I did the same in a toddler. Then Santiago and Diego did a 9 year old with a solitary typhoid perforation of his mid small bowel while John and I did a 60 yr old female with an inguinal hernia. We had more cases scheduled, but it was 4 pm so those cases were put off till tomorrow. Delays are a part of life here, due to many reasons; lack of anesthetists was a big one today. And there was no one to staff the PACU, so the patients were all recovered in the OR and that delayed things significantly.
    After we finished in the OR we went to see a few more patients, including a young girl ( 4 yrs old I think) with a massively distended abdomen. She looks healthy otherwise; she is not malnourished, and has no other health issues. Her abdomen looks like she has ascites, but it is quite soft and compressible. My gut tells me that this isn't ascites, but rather some sort of cystic structure, perhaps mutinous, perhaps a duplication. She will have an ultrasound, and I think we will end up exploring her. Stay tuned !
     At one point in the morning Dr Jallah came to find Santiago because she has a challenging case for him: a young woman who was given a lye enema, and developed a recto-vaginal fistula. She had a low anterior resection and diverting colostomy elsewhere, but now has a low rectal stricture. Santiago wants to try to fix her with a redo low anterior, so I guess we will try on Wednesday.
      Tonight we had all of the HEARTT people over here at the Bungalow for dinner. As usual, we discovered all sorts of connections. Ann Marie is a 4th year Ob-Gyn resident at NYU who is at Redemption Hospital; it turns out that she was a year ahead of Diego in med school at UConn, and they knew each other. 
      It was most heartening and gratifying today for me to be greeted so warmly by so many here, some of whom I remembered, others I didn't. Clearly we are having a positive impact on the people at JFK; not only the patients that we care for, but also the staff. They sincerely appreciate us making repeat visits, and it feels good to be part of the JFK family .

March

Travel Day

I guess we had good tail winds, so the flight to Accra was only ten or eleven hours instead of 15 ! It is still a fairly uncomfortable overnight trip. Anyway we collected our checked baggage : 11bags plus the cooler containing the ultrasound machine. It appears to have arrived intact, but we will see for sure when we unpack it tomorrow. Dewalt and Wilfred were there to meet us. As we were driving in from the airport, Madame President called to say hello to Adamah, and  she invited us to come directly to her house for dinner. After enjoying that, and telling her the story of my experience at the airport with my visa, we all came back to the Bungalow where we will be staying. Santiago has ear plugs so he offered to take the bedroom next to the generator; I wasn't going to fight him on that ! Dr Macdonald came over to say hello and make sure we were all settled. After a glass of wine and a pleasant conversation, it was time for bed.

March 3 : ilana

      We are on the plane to Atlanta, but it definitely wasn't a sure bet that we would make it. We left Waterbury, and then picked up Adamah before proceeding to the White Plains Airport. We were being checked in by a very pleasant attendant when her supervisor, Ilana, came over and started looking at my passport. She decided that the expiration date on my Liberian visa had been altered by persons unknown, and cast an accusing stare at me, before going into the back room for probably 20 minutes. She then came out and announced that I would not be allowed to fly because she suspected a forgery. Adamah was standing next to me as we tried to argue for some common sense, but she was having none of it. I pointed out the nature of our trip, and the fact that we are given the visas for free; there would really be no reason or point in me forging the expiration date. We then brought out the big guns, like Adamah's mother being President etc. but she wouldn't budge. Her concern was that if the Liberian authorities refused me entry, then Delta would have to pay for my flight back to the USA. Adamah pointed out the sheer absurdity of that, but she still wouldn't relent. I asked to talk to her supervisor, but she said that she was the supervisor. Adamah asked for her fax number there so that he could have the Liberian Ambassador to the USA send a letter testifying to my bona fides; she refused. We pointed out that on the computer, in the comment section of the tickets, they would find a note from high up in the corporate chain giving us free baggage transport, so someone up ere had a personal interest in our work. Finally she brought someone else over who suggested that we go to another building on the other side of the airport and talk to US Customs and Immigration. We left Diego and John with the bags, and went to the other side of the airport in a taxi.
   Once there, we explained the situation to a group of the agents. They pointed out the they have nothing to do with the issuance of Liberian visas, and therefore couldn't really get involved. But the guy in charge did look up my travel record, and noted that there was nothing suspicious going on there. In the meantime, Adamah got the Ambassador on the phone, and he agreed to fax to a letter on Embassy stationery indicating that I did indeed have a valid visa, etc. Also, I called Shawn, e assistant to the senior VP t Delta who had arranged our free baggage...and who had been kind enough to give me her cell phone number in case there were any problems. Eventually Ilana talked to the Immigration guys, who told her that I seemed like a reasonable character and it would probably be okay to let me get on the plane. She wanted to see the letter from the Ambassador first. She also noted that it was 3:40, and if we weren't ticketed by 4:15 we would not be allowed on the flight. We waited for what seemed like an eternity, and finally at 3:55 the fax from the Ambassador came through, and we rushed back in time to get our tickets.
    Several aspects of this: I'm sure glad we were traveling with Adamah; I doubt that the Ambassador would have done what he did on a Saturday afternoon for too many other people ! I'm glad I had connected with the senior VP at Delta and his assistant; the phone call from her to the supervisor must have helped ratchet up the pressure. And the Immigration agents went out of their way to be helpful, where they could have easily said " it's not my job" and left us hanging. Finally, I know Ilana was just doing her job as she sees it, but she was so rigid and devoid of common sense, in the beginning anyway; I'm glad that she finally saw  the light !
    Hopefully that will be the end of problems for this trip rather than a portent of things to come!


Sent from my iPad

Preparations: March 1, 2012

We will leave in 2 days for another visit to JFK Hospital. The team this time includes 2 Waterbury Hospital residents ( Dr. Diego Holguin and Dr. John Dussel ), and Dr. Santiago Arruffat. Readers will remember that Santiago is a former resident at Waterbury Hospital who is now a colo-rectal surgeon in Evansville, IN; he came with us to JFK last March, and then decided that he wanted to come again. I am thrilled to have him with us because he an a superior surgeon as well as a great friend. And I am pleased that Adamah (Dr. James Sirleaf) is traveling with us, and will be in Monrovia for most of the time that we are there.
One of the wonderful aspects of this work is the number of people who go out of their way to help us find and collect supplies to bring. At Waterbury Hospital, we are fortunate in having people like Mary and Tanya, who organize supplies for the OR, helping us by saving material that might have otherwise been discarded; Peter in the OR; Giovanni and Jeff in Central Sterile Supply; and a host of others. Dr. Chris Michos, Chair of the Emergency Department, offered us an older ultrasound machine that they no longer needed. I think the people at JFK will love having another ultrasound machine, so I immediately accepted his offer.
We bring all of these supplies with us, mostly because it is unlikely that they would get to JFK if we shipped them separately. On a previous trip, I was fortunate to meet a senior executive of Delta; I found his business card last week, and emailed him asking if it would be possible for Delta to waive charges for excess baggage for us since we were bringing donated medical supplies. Yesterday I received an e-mail indicating that they would, so here's a big shout out to Delta for making a huge contribution to our efforts ! Thank you Delta!
So now the question is: how would you bring an ultrasound machine with you on the plane to Monrovia? The dimensions of the machine are 13"wide X 14" tall X 17" deep; it weighs maybe 30 pounds. My initial thought was to bring it on board as cabin baggage, but I'm not sure the TSA would like that. So then the question was how to bring it as baggage, and protect it from damage as it is a fairly sensitive piece of electronic equipment. My solution was to go to Sports Authority with my tape measure, and to find a wheeled cooler into which the ultrasound machine would fit ! I found it, and I have packed it up, and now I sure hope it all works out ! I will post a picture of it later.
Final preparations tomorrow, and then we leave at noon on Saturday. We will fly to Atlanta to meet Santiago, and then on to Accra and Monrovia !