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.