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.