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.
Sunday, March 18, 2012
Friday, March 16, 2012
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.
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.
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.
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.
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.
Wednesday, March 14, 2012
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 !
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 !
Tuesday, March 13, 2012
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.
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.
Monday, March 12, 2012
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.
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.
Sunday, March 11, 2012
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.
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.
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.
Friday, March 9, 2012
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
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
Thursday, March 8, 2012
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.
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.
Wednesday, March 7, 2012
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
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
Tuesday, March 6, 2012
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 .
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 .
Monday, March 5, 2012
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.
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.
Saturday, March 3, 2012
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
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
Thursday, March 1, 2012
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 !
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 !
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