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.