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.