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.