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 !!