Saturday September 14

      With Jonathan and Tom gone, I took the liberty of sleeping in the back bedroom last night where the noise of the generator was less intrusive; yes, it was definitely a better sleep. Dr Mcdonald did assure us the other night that when we come back in March, there will be a much quieter generator in place, and we all look forward to that ! This morning we plan to go to JFK to say our final final goodbyes to patients and staff, and then we will find something to do while waiting to go to the airport this afternoon. We might go to the Post Office and try to buy and mail some postcards; rumor has it that there is a postal service in Liberia, so it might be fun to test it. In fact, now that I think about it, the President once suggested that I should test it at some point !
      With the cases and procedures we did yesterday, we hit a total of 51 which makes us all feel quite proud. It isn't just a matter of doing a lot of operating; to do that number of cases says a lot about better organization by the local staff as well as ourselves. JFK was prepared for us; patients had been screened, and we had a list of them with diagnosis, etc. so we had some choice in who was called. The way the system works is that patients are called and asked if they have the funds available to be admitted; if they do, they pay and get admitted. Our surgical services are free, but the patients are required to pay an admission fee as well as a drug deposit.
      The OR was better organized, so that virtually every day there was enough staff for us to run 2 rooms, and that helped a lot. They were also more malleable than some times in the past about accommodating additions to the OR list as needed.
      We were quite impressed on this visit by the better organization and professionalism shown by the nurses on the surgical ward. One of them always was with us on rounds, and they showed us that they knew their patients better than they have sometimes in the past.
       There is no question in my mind that much of this improvement is due to familiarity: they know us, and they know what we are capable of doing if given the opportunity, while equally we know and respect the excellent care that the JFK staff is able to provide under less than optimal conditions. They are asked to do a lot with minimal support in the way of supplies and support; they are able to improvise very well.
       There are major hurdles to overcome in the rebuilding process for JFK as well as for Liberia as a country. It continues to be exciting for us to be a part of the JFK rebuild; it is definitely frustrating at times, and it will take a lot longer than any of us would like, but there is progress being made. Each time I come here, I leave with more ideas on what we can do to help advance the process, and what members we should include in the next visit. There is general agreement that we should try to bring a biomedical engineer with us next March to help fix what can be fixed, and scavenge parts off those machines which cannot be fixed totally. The engineer might also help make some sense out of the power situation in the OR, where lights, cautery machines, suction, and anesthesia machines are all competing for power strips and transformers in a tangled mass of cords. Some require 220V supply, while others are 110V; there have been times when it seemed that we could have suction or cautery, but not both, and that needs to be fixed. Fortunately, I have someone in mind...he has asked if he could come to help, and I hope now we can make it happen.
      I think that's it for this visit. As Kenna says, Lord willin and if the creek don't rise, we will be back in the USA tomorrow.

Friday September 13

     I guess there is a reason to check email at 6:30 in the morning; in my case today, in it was an email from Delta saying that our flight tonight has been cancelled. Unfortunately, this seems to happen quite frequently with Delta in Monrovia, leading a number of people to tell me I should fly some other airline. So I called Delta, and we are rebooked on the Air France flight tomorrow night, going through Paris and arriving at 10:30am on Sunday in New York. Spending an extra day here is not terrible, though I was anxious to get home; being able to fly on a better plane with better service than Delta provides might get me to switch for the next trip and thereafter.
     In the OR this morning John and I did a boy with a hernia, and then Diego and Jonathan did a young man with an incarcerated hernia. Following our surgery, John and I went around to see some patients, and then went to XRay to try to understand what has been happening with the batteries. We learned that the equipment requires 30 batteries, and they now have enough and that part of the machine is working; when we were there the computer seemed to have a software glitch, but hopefully that will be corrected shortly.
       While we were in XRay waiting for the engineer who would explain it all to us, a man who was there to get an Xray looked at me and said: " Hey ! I saw you on TV last night !" and then looking at John he said:"And you're the one with the hat !" Apparently they showed 45 minutes of interviews and actual surgery on the show, which was a first for Liberia. And thus we are celebrities in addition to anything else !
       We said goodbye to a few more patients and staff, and then went for lunch at the Maternity Hospital. Jonathan and Tom left after lunch, since they had rescheduled onto Brussels Airlines leaving tonight because it will fly them from Brussels directly to Atlanta tomorrow, making it easier for them to get home to Little Rock. after they left we had a nice long chat with Dr. Marshall, the head of Pediatrics, about pediatric surgery and some of the issues and needs that will be increasingly necessary if more complex surgery is going to be done here. We also talked about the postgraduate training program starting at the end of the month, and John also talked to her about research possibilities in terms of information and privacy protection, since Dr.Marshall is also head of the Institutional Review Board at JFK.
       Tonight we will go to Sajj for a final meal on this trip, and then wait through the day tomorrow to get on our flight.
     
     
     

Thursday September 12

    No bad news this morning when we arrived at the hospital, so that was good. We spoke at length with the woman who appears to have recurrent rectal cancer; after thinking about it, she doesn't like the idea of us operating on her and then leaving. Not surprisingly, she is concerned about who will care for her after we leave tomorrow, and as a result she has decided to take her chances and wait till we come back in March. She understands the risks involved, like the cancer spreading. She has agreed to come to the clinic in February to see Dr Moses, who will order a CT scan for her at Tapita, so we will have the results when we arrive on March 3.
     In the OR, our first case was an 11 month old baby with bilateral hernias, who is somehow related to one of the OR nurses, so that added a little more pressure !  John and I repaired the hernias after I experienced the usual coronary spasm inducing process of intubation and anesthetic stabilization. Anesthesia for these babies can be difficult under the best of circumstances; in Liberia it can be frightening. In any case, it went fine.
     Coming out of that case I found Jonathan and Diego in the lounge talking to a crew from Power TV who were there to interview us and film our work. I imagine that after the film appears on Liberian TV it will be picked up by 60 Minutes lol ! Anyway, our next case was Ahmad, a 10 or 13 year old boy with a painful growth on his left knee. He is an orphan living in an orphanage supported by an American charity called Orphan Relief and Rescue; the President of that group had contacted Wilfred, the HEARTT coordinator at JFK, to ask for help, and Wilfred asked me if I would see him. Obviously I don't do orthopedics, and an x-ray of his knee showed that this mass was calcified like bone, but we saw him and thought it could be removed. With the availability of modern communications, I was able to send the X-ray to my friend Dr Michael Kaplan, an orthopedic surgeon at Waterbury Hospital; he thought it looked benign and should be removed. So today we removed it, even more easily than I had expected; I suspect it was ectopic bone growing in an area of trauma, and it is unlikely to recur. I like the idea that so many different people worked together to improve life for this orphan.
     We then did a couple more hernias: Diego and I did an easy one, while John and Jonathan did a hernia in which the appendix was part of the sac, so they did an appendectomy as part of the repair. Following those we did a couple of minor surgeries under just local anesthesia.
      All total, we did 48 cases during this trip, which is more than we have done on any trip in the past. And we have a couple of cases we might do tomorrow morning to hit 50.
      We went to the Administration Building to get our empty supply duffles, and I had the chance to speak with Dr Mcdonald about a few matters. She is going to come to the bungalow tonight to talk to all of us and get suggestions about the impending postgraduate training program.

Wednesday September 11

    We received more sad news this morning: the 8 yr old obese girl with a ruptured appendix who had her surgery on Monday died last night. By report from Dr. Shankar, an excellent pediatric resident, she was fine and talking to her father at 6:30 pm. In the early morning hours Dr Shankar was called because her breathing was rapid and labored; he felt she needed fluids and he gave her a bolus, but about 10 minutes later she stopped breathing and could not be resuscitated. I think that she had some adrenal insufficiency, or other hormonal problem, that somehow contributed to her unexpected and sudden demise, but we will never know for sure.
   Another busy day for us in the OR, but we were limited to one room because Professor Golokai was operating today. Jonathan and John first did an adult hernia, and then Diego and I re-explored a 14 year old boy who was operated on for perforated appendicitis 10 days ago, just before we came. Apparently he did will initially, but lately has been going down hill. He has developed bilateral pedal edema, and blood work showed he has an acute kidney injury. He also has elevated liver enzymes, but that may be long-standing as he is known to have hepatitis B. This morning when I saw him he looked toxic, and clearly had a tender abdomen that needed to be opened. Upon doing so, we found an abscess near his cecum as well as another at the root of the mesentery. Perhaps the infection is the cause of his kidney problems, but I fear it is due to some other unknown cause; time will tell.
    During the course of the day we had several consults: one was a 6 year old boy whom Diego and I saw in the Pedi ED in the morning. He had been off food for a couple of days, and his abdomen was distended but not tender. We recommended IV hydration and observation, but when I saw him again in the afternoon he was significantly tender, so we decided to explore him for possible appendicitis. After Jonathan and Diego finished a thyroid, we brought him to the OR; on opening his abdomen we found a large volume of serous ascites, and evidence of mesenteric adenitis. Despite the negative surgical findings, I think operating was the right thing to do. We did take out his appendix anyway.
    Another consult during the day was a 17 year old female in the Maternity Hospital whom Johanna asked us to see. She had suffered a fetal demise at 7 months 2 weeks ago, and delivered the stillborn at home. She presented to the Maternity hospital with weakness, a distended abdomen, and a drop in her hemoglobin. An ultrasound showed a lot of abdominal fluid and a normal looking uterus. One of the maternity docs had aspirated some of the abdominal fluid and it looked cloudy yellow. John had the briliant idea of putting some of the fluid on his glove and smelling it; the odor was feculent. When we saw her, her abdomen was distended and firm, but it did not appear tender. It was a confusing picture, but We felt she clearly needed exploration. So she was transferred over, and Jonathan and Diego did her surgery. It was another Vesuvial abscess, this time recorded on film ! It turned out to be perforated appendicitis, and it could have been the cause of her fetal demise. How she managed to live with what was going in his her abdomen remains a mystery to me; she is another one for whom I have my fingers crossed.
     Another consult during the day was an old patient of Dr. Arruffat who had a low rectal cancer 2 years ago, and then further surgery for a stricture last March. She now appears to have a recurrence of her rectal cancer as well as a mass in her ascending colon seen on a CT done in Tapita. If this is true clinically, she probably needs to have her whole colon removed and a permanent ileostomy created. We gave her the option of having it done tomorrow before we leave, or waiting till March when we are back with Santiago. She wants it done now, so that is what we will try to do. Complicating the surgery is the fact that she is a Jehovah's Witness, and absolutely refuses any blood transfusions. This will be a huge challenge. Jonathan and I talked to Santiago in Indiana, and he is in agreement with our plan; I know he also wishes he was here.
    We finally finished around 10pm. We came home to have dinner and get to bed, knowing that our last day on this trip tomorrow will be a big one.

Tuesday September 10

We had another productive day, even if it wasn't filled with exciting cases. Diego and I started with a 4 year old who had the biggest inguinal hernia I have ever seen in someone that age! It was indeed an African hernia, filling his scrotum so that it extended halfway down to his knee ! We also explored the other side, and fixed his large umbilical hernia. While we were doing that, John and Jonathan removed a large lipoma from the shoulder of a relative of Barbu. Then we had two more inguinal hernias in adults; the man that Diego and I repaired is an Assistant Minister in one of the government departments who had his hernia repaired originally in a clinic about 10 years ago, but it recurred. With some difficulty we were able to identify some decent tissue to use in the repair. At home most everyone would use mesh for such repairs, but I remain nervous about implanting mesh under aseptic, but not necessarily sterile, conditions. Finally John and Jonathan drained a subphrenic abscess.
      After lunch, I met Robert Dulo from the New Sight Eye Clinic to give him an item from Karen King. Robert is an ophthalmic nurse who went to The Gambia ( I think) to learn how to do cataract surgery. His dream was to come back to Liberia and set up a clinic; he met Karen when she was in Africa, and she decided to help make it happen. Karen is an elementary school teacher in Newtown, CT whom I met through Adamah Sirleaf, and who has now become a good friend. To raise money for the clinic, I think Karen spoke to every Rotary Club in CT, and lots of other groups as well, and managed to raise the money Robert needed for his clinic. It is been in operation for about 2 years, and he is already looking to move to larger premises to accommodate all of his patients. It's really a fascinating story of dreams, kindness, motivation, and vision in every sense of the word. We will try to have dinner later this week before we leave.
      We then went to the Conference Room in the Administration Building to empty our duffels, and to look through all of the supplies which I had sent via cargo container through Mr. Garbla. We have about 9000 pair of gloves as well as sterile disposable gowns and drapes, and many other supplies donated by my friends at Waterbury Hospital and its suppliers. Once again my special thanks to Donna, Mary, and Tanya for their kindness and diligence in finding supplies to donate to JFK. In this vein, I should also note that the charitable organization Americares now has a program to provide medical supplies to mission trios such as ours, and we were able to obtain a number of useful items which we have used on is trip.
   

Monday September 9

    We are excited entering into our second week: excited to see what cases we will have this week, excited that we already feel a sense of accomplishment, and naturally excited to return home at the end of the week. The first thing we learned this morning is that all of our patients are doing well. I was particularly pleased that Rashid looks good, as does the lady who had the choledochoduodenostomy. She will get to eat real food today !  We then went to the OR to find 5 cases planned for us today. Jonathan started out with a man with hemorrhoids, then I had a woman with lymphadenopathy in her left neck and left axils which was thought to be suspicious for lymphoma. Fortunately for her I think our pathologists will say it is TB and she can start treatment. Then Jonathan had another baby with imperforate anus and also some genitourinary abnormalities; he and Diego put in a supra public bladder catheter and did a colostomy. John and I ended the day with an interesting case, sort of: she is 8 years old, and appears to have precocious puberty with breast development, but also significant obesity. We were asked to see her because of an umbilical hernia, but she was found to have a rather tender abdomen. When we explored her, we found that she had a ruptured appendix as we had suspected. We carefully looked at her ovaries for any abnormality that might play a role in her precocious puberty, but they appeared normal.
     As virtually always happens on these trips, throughout the day we were approached by people who work at the hospital asking if we would see a friend, or a relative, about some medical issue. As we get closer to our departure, it gets harder and harder to fit them in for surgery if they need it. But we try to see everyone, and do what we can now. For this trip, I had some business cards printed up with "HEARTT SURGERY TEAM.  JFK HOSPITAL" and a big heart with a bandaid on it; we can give them to some patients to remind them to follow up with us on our next trip in 6 months. I'm hopeful they will work !
      We got back to the bungalow around 7:30, had dinner, and everyone retired early after a long day. I expect we will have a similar day tomorrow.

Sunday September 8

A slow and quiet day of rest, which seemed appropriate since it rained most of the day. Jonathan and Larry Kim came back from Phebe this morning, so after sitting around watching football(soccer) on the TV for a while, in the afternoon we went to have lunch at the Royal. After that we visited the Hotel Ducor so they could see the view of the city from there. For those who don't remember it from previous writing, it is up on a hill overlooking the sea and the northwest part of Monrovia. It was a luxury hotel, and must have been beautiful in its day, but it suffered badly in the fighting of the Civil War. Eventually it was abandoned, and then taken over by squatters. The hope is that it will be renovated soon, but there is apparently a dispute over ownership between Libya and Liberia, so for the time it remains abandoned. Today, while walking on cement near the swimming pool, I slipped in a slimy puddle, falling on my back, and lightly hitting my head ! It was really quite gross, and I couldn't wait to take a shower when we got back to the bungalow !
    Diego made rounds this morning, and tells me that everyone is doing well, including Rashid. After talking to Jonathan, and doing a google search, I have learned that Rashid's condition is a rare event called ileo-sigmoid knotting; from what I can tell, it has been reported more commonly in Africa, but I will need to look into it further when we are back home. It is described as a sigmoid volvulus in which the small bowel wraps around the base of the volvulized sigmoid, leading potentially to infarction of both segments, as it did in our case.
     Dr. McDonald called me this morning to check on us, and to say that the President sent her thanks to the team. She is leaving for India today, and won't be back till after we leave on Friday, so she won't have the chance to thank the others in person. I thought that was pretty nice that she took the time to think about us and send that message, but then again, it isn't surprising. She pays remarkable attention to details.
     We will have an early night tonight in preparation for the second half or our work ahead this week. If things proceed as they have on previous trips, by Friday we will find that we have run out of time with patients still needing surgery. There really isn't much we can do about that except try to prioritize those who need us the most.

Saturday September 7

    There are always surprises on these trips, and today had its share. The plan was that we would work in the morning, and then go touring around Monrovia in the afternoon. Jonathan went to Phebe Hospital this morning, and we expect him to come back tomorrow night. They have some difficult colo-rectal cases for him to do, apparently. We started in the OR with a man from Mr.Hne's village who had a recurrent inguinal hernia. I guess he had approached Mr Hne, who recommended that he come to JFK during one of our visits, and so he did. Apparently he had bilateral inguinal hernias repaired in 2010 in his home of Maryland County; Mr.Hne says that in fact a physician's assistant did the surgery. He had a huge recurrence on the left, and was extruding sutures from his incision on the right. We ended up doing a somewhat unconventional repair on the left, and just excising the skin and sutures on the right, with plans for him to come back when that is healed and we will fix the recurrence on the right.
     We then went to the Pedi ED to see Rashid, a 15 y.o. male with abdominal pain and what was advertised as appendicitis. He was quite tender, and we agreed that he needed an operation soon. While that was being organized, we made rounds and saw that everyone was doing well, including the woman with the choledochoduodenostomy. When we went back upstairs to the OR, we learned that initially the father of Rashid had refused to sign the consent for surgery, apparently thinking that he didn't need an operation. Fortunately Mary, the clinical administrator and go-to woman when we need anything, talked to the father and convinced him that surgery was necessary. When Rashid arrived in the OR there were several signs that something else was going on: he wanted to lay on his left side, he was breathing fast, and his abdomen was much more distended than it had been in the ED. When we opened his abdomen, we encountered bloody fluid, a sign that appendicitis was the wrong diagnosis. I thought initially he had a malrotation with a small bowel volvulus, but i couldn't figure out how to untwist it, and then we discovered his right colon was correctly positioned; thus he did not have a malrotation. He turned out to have a sigmoid volvulus, into which was twisted about a third of his small bowel, which was necrotic as was the sigmoid colon. For those readers who are not medical, a volvulus means a twist on its base (the mesentery) where the blood supply comes in; the twist cause occlusion of the blood vessels and then gangrene of the affected part. So in essence he had 2 twists together, causing gangrene of both his sigmoid colon and about 1/3 of his small intestine. I have never seen anything like it, nor have I heard of it happening. Anyway, we resected the bad parts and put him back together; when we left the hospital this evening he was awake, making urine, and seemed to be doing well. Here's hoping he continues to improve ! After we finished the operation, Rashid's father and mother were waiting; I told them that if they had waited another day, he would not have survived. His father asked to see the specimen of dead bowel we removed, and then took a picture of it with his cellphone !
     We finished our OR day by doing a skin graft on the leg of a man who had burned it some time ago. He has been on the OR list to do for the past 3 days, but kept getting pushed out because we had other, more critical surgery to do. So we were determined to do it today, and we did, thanks to amazing help from the OR staff who didn't utter any complaint about working well past time. Although the plan was for us to be done operating today by noon, we didn't end till 5:30; it was a good day made better by teamwork and a sense of purpose.
      In the evening we went to the Mamba Point Hotel for dinner with Johanna, Jessica ( an internal medicine resident from Boston Medical Center), and Yvonne Butler. Yvonne  has appeared in this blog before: she is an OB-Gyn from Baylor who has been here for a year and will be here for another year, supported by Chevron. She was born in Liberia, and left as a young child during the Civil War. Today she is leaving to go back to the US for 6 weeks and get married ! She is a wonderful addition to JFK, and I look forward to seeing her on future trips in the next year. We had a wonderful sushi dinner over several hours with great conversation and stories.

Friday September 6

    After our experience with Jacob, I was anxious walking into the hospital this morning as I wondered what happened overnight with our choledochoduodenostomy, and I was thrilled to see that she is doing well. She complained of the expected amount of pain, but overall I am pleased.
     In the OR, it was a somewhat disorganized day but we were able to get a number of cases done. Jonathan and John decommissioned another ostomy while Diego and I repaired an incisional hernia on a woman who works in the Presidents house. I had seen her in July, and through some miracle we actually got her a bed in the hospital and got her hernia fixed when we said we would ! Yes, today I reached that final stage in the process i go through on each visit: that of resignation.  We are here, prepared to do whatever work needs to be done; if the system with its many inefficiencies cannot make full use of what we bring, so it goes. I'm not going to get angry or frustrated about it; I have passed beyond that stage for this trip.
      Another patient had a large keloid on his scalp from a traumatic injury; J and J excised that and then created some flaps to close the defect. Then Diego operated on an unfortunate man with a very bad infection in his private parts. I won't go into detail, but it was not pleasant at all. Finally we cleaned up the leg of a young man who had some sort of infection in his posterior calf. He was first treated by a local healer with burning herbs and the like, and then came to JFK for antibiotics. There was a skin wound, but each time they cleaned it, it would bleed significantly. So they wanted us to clean it in the OR. We found a lot of clot, but could not identify a bleeding source. We cleaned it and packed it, and hopefully he will start healing.
      John is doing an excellent job of keeping our records on his iPhone: We did 23 cases this week, which is right on target for our expected 40-45 overall. We will do a couple of cases tomorrow ( Saturday) morning, and then have a 1 1/2 day rest.
      Tonight we went to dinner at the apartment of Jonathan's aunt Augustina;  she is here working for the UN Peacekeeping Force. She cooked a delicious meal which we all enjoyed before coming back to the bungalow.

Thursday September 5

      I had a restless night listening to the generator and the rain, and thinking about Jacob. Perhaps there was a reason for all that, because when we went to Pediatrics as our first stop this morning, we saw that his bed was empty. The nurse told us that he passed away around 2 am. According to the nurses notes, he was doing well at 11:30 pm; sometime later his mother told us that he asked for some water to drink (she told him he couldn't have any), then he asked for his father. Soon after that his breathing became rapid, and soon after that he expired. His mother and father, and other family members were there when we arrived; his mother asked to see a picture of the tumor, and she took a picture of the picture with her cellphone.
        My guess is that he died of hypovolemic shock because his fluid requirement was larger than the pediatric nurses realized, but who knows for sure. Part of me feels totally defeated by such cases; on the other hand, we gave him the only chance he had for a better life at least shortterm, but it wasn't to be.
      To start this day Diego and I operated on a 38 year old woman with obstructive jaundice. She was here on the Medicine service, and then was sent to Tappeta for a CT scan; that show a stone impacted in his distal common duct. We planned to do a cholecystectomy and common duct exploration, and we had scavenged around yesterday looking for the appropriate tools. After much effort, we found that we could not pass anything through her distal common duct, and so we ended up doing a choledochoduodenostomy. I am  hopeful that she will do well, and I see no reason why she shouldn't, but an experience like Jacob can make you a bit gun shy, It was another 4 hour operation, and required quite a lot of creative thinking since we didn't have the usual armamentarium of tools and assists we have back home. I enjoy that challenge over here, and at the end of the operation I felt pleased that we had met the challenge and done well.
     While we were doing that, Jonathan and John were busy with an emergency incarcerated umbilical hernia in a 2 year old, and then a colostomy decommissioning in a 29 year old. At the end of the day, on our way out, we stopped in the Pedi ER to see a 2 month old boy with abdominal distension. He was born at 28 weeks and has a twin sibling, so effectively he is just at term now. He stopped eating on Monday, and now he little abdomen looks like he swallowed a balloon, and yet he didn't seem to be that tender. We examined him, and ultrasounded him, and eventually decided that we should watch him overnight. I'm not sure what going on in his belly, and so I'm not sure it's a problem that needs surgery to fix; I am sure that an operation would be hazardous for him if he doesn't need it.
     After dinner at the house, I went with Dr. McDonald to see my private patient who is doing well. Then back here to bed.

Wednesday, September 4

    Today was quite a remarkable day. We started surgery this morning with one of the patients I had been told about before we arrived: Jacob, a 6 year old boy with a huge abdominal tumor, which was thought to be a Wilm's tumor or nephroblastoma. It is a pediatric cancer which arises  from the kidney, and can involve both kidneys. In this case, ultrasound examination had shown that only the right kidney was involved.
     We thought it was large when we examined him, and it seemed even larger once he was asleep under anesthesia. When we opened his abdomen, we realized that it was massive, extending from his diaphragm down to his pelvis, pushing his liver over to the left. These tumors are typically very vascular, and Jacob was typical in that respect. We lost a lot of blood, which was replaced, but his blood pressure dropped perilously low on several occasions; at those times, I could feel the faint pulse of blood in his aorta, worrying that it would stop at any moment. Fortunately for us, we have an anesthesiologist with us--Dr. Tom Feinberg from the University of Arkansas--and he did an incredible job keeping Jacob going. The Liberian nurse anesthetists, and particularly Mr. Anthony Hne, are wonderful but I doubt Jacob would have survived if Tom wasn't there. After we removed the tumor, there was persistent oozing from the right lobe of the liver where it had been attached; eventually we decided to pack the liver with a sterile towel, and we plan to return to the OR with him in 1-2 days to remove it and make sure all is ok. He was under anesthesia for about 4 hours, and probably had his blood volume completely replaced, but he woke up and was quickly able to be extubated. I don't have illusions about his long term outlook: the tumor is likely to recur, unfortunately. But perhaps we have given him some time in which he can feel better than he has for the past year.
     There were many times during the operation, particularly at those times when I thought we were going to lose Jacob on the OR table, when I wondered why I had ever agreed to operate on him. But the sad fact of life is that he had no other options, and therefore, in my mind, there wasn't a choice. If we didn't operate on him, he would have died fairly soon from this huge expanding mass in his abdomen, which had already caused him to lose weight and become listless. With surgery, and good luck, and prayers, and whatever else, he at least has a chance to enjoy life for whatever time he has left.
     We did more cases after Jacob: Jonathan and John did an acute abdomen which was thought to be appendicitis but which turned out to be a perforated ulcer; we had a 15 year old with a retained Foley catheter in which the balloon wouldn't deflate, so we used ultrasound to see the balloon and a spinal needle to pop it; and then Johanna, the PGY-3 from MGH, and I did a biopsy on a weird clavicular mass in a 17 year old girl.
    After finishing, we went to see Jacob, and he looked amazingly good: awake, responding to me, and stable. His father was there, and asked if he could see the tumor we removed; he was happy settling for seeing pictures of it. I am worried about Jacob overnight, and a part of me wanted to park myself at his bedside for the night, but I think he will be okay.
     For dinner we went to Sajj where we had a delicious Lebanese meal, and enjoyed listening to some live jazz. As Diego noted, what an amazing day it was spanning between Jacob and the jazz. I feel exceedingly fortunate to be able to have these experiences.

Tuesday September 3

      I admit that I like my creature comforts, so last night was not the best for me. I slept in the bedroom next to the diesel generator, but as long as my earplugs stayed in it was tolerable. Unfortunately keeping them in was something of a chore which was repeated several times during the night. The other item was my air conditioner, which was fixed during the day so I shouldn't complain...but the remote has been lost so my two choices are to either leave it off or have an arctic wind blowing across me. So I got up several time to turn it off or on, and those times pretty much coincided with when my earplugs fell out !
      On arriving at the OR we expected to have 2 cases to do today, but discovered that 5 were booked for us. The first was the 2 week old baby with an imperforate anus and CDH that we examined yesterday; Jonathan and Diego did a colostomy on him, so sow hopefully he can eat and gain some weight prior to having his CDH repaired. He will also likely need a pull through for his imperforate anus, and then sometimes after that he would have his colostomy taken down and normal bowel function restored. It's hard to imagine how all of that is going to happen here, but we remain hopeful. It took forever to get that case started because of problems with machinery, problems with his IV, and just problems in general. I went to the Outpatient Clinic for a while and we admitted 2 young men for ostomy decommissioning.
     One of the unanticipated cases for us was a 30 year old woman with a bad gallbladder which has been in the hospital for over a week awaiting surgery. Dr. Moses made the interesting comment that cholelithiasis is a surgical disease, but cholecystitis is a medical problem. I explained that we don't think about it that way, and that the quickest way to cure cholecystitis is to remove the gallbladder. So that is what John and I did, after waiting an hour for electricity to be restored to the outlets in the room, and thus the anesthesia machine regained power as did the Bovie and the portable surgical lights ( the overhead lights are dead). Once we got started it went relatively smoothly.
     Diego and Jonathan did an appendectomy, and then John and I finished our day with a hernia repair. We left the hospital to go to the dorm to use the Internet, which was interminably slow, and then we came home for dinner. After dinner Dr McDonald picked me up for a return visit to my house call of last night. I did a small procedure and then came home.Larry Kim had arrived after a long journey through Paris; he will be going out to Phebe tomorrow.
   
     

Monday September 2

     After a restful night disturbed only by torrential rains at 3 am, we came to the hospital at 8:30 am to see what was in store for the day. We were greeted very joyfully in the OR, and it was wonderful to see so many familiar faces. The first case scheduled was a 48 year old man with obvious abdominal carcinomatosis who has been losing weight and having difficulty eating. I couldn't understand why anyone would expect us to operate on him since he was obviously inoperable. He did have a Virchow's node, so after consulting with Dr Moses and Dr. Konneh, we decided we would biopsy the node on the unlikely chance that the process going on was lymphoma rather than gastric cancer. If its lymphoma, it is at least potentially treatable. When we went down to the surgical ward to talk to those doctors before we did the case, we were again greeted with outstretched arms and lots of smiles by the doctors and nurses. I am astonished by the warmth of feeling and outright joy expressed by everyone from the Administrator to the elevator operator when I come back here; it is rather intoxicating, and very gratifying.
     The second case was a neonate 2 weeks old with an imperforate anus scheduled for examination and dilation if there was an opening to dilate. We spoke with the pediatric resident Dr Shankar, who noted that the baby had a congenital diaphragmatic hernia(CDH) also; it is quite common for babies with one anomaly to have others. He had a blind end sinus about 1.5 cm in length. As he is he is unable to eat, so after some discussion we decided that we will do a colostomy on him tomorrow. Then he can eat, and gain weight, and be nutritionally prepared to have the CDH repaired. Because of the CDH, and hypoplasia of his left lung as a result, he is at significantly higher risk for anesthesia, but it appears that we have no choice. That is a common dilemma we find ourselves in over here: choosing between two suboptimal alternatives .
      The third case was an inguinal hernia done by John and Diego. The fourth was an ileostomy decommissioning by Jonathan and Diego, and at the same time John and I did an emergency laparotomy on a 40 year old man. He had presented with a typhoid perforation 10 days ago, and had a small bowel resection and primary anastomosis. A couple of days ago he started leaking intestinal content from one of his drain sites, and today he was looking toxic, so John and I operated on him this afternoon. He had several more perforations, so we did another resection and brought out ostomies. The fifth case was a 15 year old with perforated appendicitis who came into the ED this morning after 2 days of abdominal pain. It seems like most patients with abdominal pain like to stay home for a least a week or two, so it was good that he came early. Jonathan and Diego did his surgery with Joanna, a 3rd year surgical resident at MGH who spending a month at JFK as part of her Paul Farmer Global Surgery research fellowship.
    As we were walking out of the hospital to come back to the bungalow for dinner, we saw Dr. McDonald and had a pleasant chat. Apparently I would be making a house call after dinner to look at a painful swelling on the hand of a VIP. Definitely not my field of expertise, but when asked for an opinion, it would be rude to refuse. It turned out to be a ganglion cyst, and I will aspirate it tomorrow evening after work.
     When we returned to the bungalow this evening, not only was the a/c repaired and working in my room, but we have running water also. On top of that, for the first time, we have hot water at he house ! Yes, I know, it isn't that bad taking a shower with ambient temperature water, but its nice to have it hot.

Sunday September 1

      We are en route to Liberia for another 2 weeks of working at JFK. The team for this trip includes Dr. Diego Holguin and Dr. John Dussel, both residents at Waterbury Hospital who have been on previous trips; Dr. Jonathan Laryea, a former Waterbury Hospital resident who is now a colorectal surgeon at the University of Arkansas; Dr. Larry Kim, a surgical endocrinologist at the University of Arkansas; and Dr. Tom Fineberg, an anesthesiologist at the University of Arkansas. We are all on the plane together except for Dr Kim, who will hopefully arrive on Tuesday. He plans to go to Nigeria after being in Liberia; apparently there was some hang-up with his Nigerian visa, so he had to go to Dallas yesterday to get it released, and as a result couldn't get to NYC to make our flight.
     I had an interesting experience with the TSA yesterday at JFK airport. JFK Hospital has a digital X-ray system donated by the Government of India a couple of years ago. In order to minimize electrical current fluctuations ( I think) the power is run through a bank of rechargeable batteries. These batteries are similar to those used for scooters; they are 4" X 6" X 6" rectangular shaped items that weigh 5 pounds each. Apparently the hospital has been unable to get replacement batteries in Liberia or in Ghana, and so last March they asked us to bring 14 with us, which we did. Then they said they needed more, so I brought another 12 on my July trip. They still needed more, so I obtained another 10 to bring this time. The problem is that at 5 pounds each these are heavy, and they quickly cause an excess baggage weight problem. In July, I decided that I would bring a couple as carry-on baggage, but I wasn't sure if they would be allowed. These batteries are sealed, leakproof, lead-acid type; I looked very carefully at the manufacturers website as well as the TSA website to see if there would be a problem, and I couldn't find anything saying it wouldn't be allowed. When I went through security with them in July, that bag was hand-searched; the TSA official asked me what they were for, and then let me bring them on board. Yesterday I increased the load by having 6 of them in my carry-on, each one individually wrapped in plastic. The TSA inspector said I would have to go back and check them as they were not allowed; when I objected they brought over a supervisor who agreed that they were not allowed as cabin baggage. I explained to him that I thought he was wrong, and that I had combed the TSA website looking for a prohibition, but there was none. I explained that these are lead-acid rather than lithium ion, which is a big difference. After a conclave of a couple of inspectors and the supervisor, they then called a super supervisor, who apparently informed them that I was right ! So they are in the overhead bin above my seat as I write, and I am feeling pretty happy that I fought the TSA and won ! One of our projects on this trip will be to help the hospital people figure out what the problem is with the X-ray system, since this seems to be an inordinate number of batteries required. In the meantime, they haven't had a working digital X-ray system since February.
    Albert and Moses picked us up at the airport, and brought us to the bungalow which Cedric and Brian greeted us. John and Diego will be staying in the dorm; they came over for dinner, and then we all went to bed fairly early. Unfortunately there is no running water for bathing and flushing at the bungalow; they hope to remedy that tomorrow. And the air conditioner in the generator bedroom isn't working, so I slept in the big double room with Jonathan. They expect the a/c to be fixed tomorrow also.

Saturday July 27

We aren't quite done with the celebrations ! This morning we left around 9am to drive the former Nigerian President Obasanjo's chicken farm for a dedication. Fortunately, it was a lot closer than expected, so it was only a 45 minute drive, and all on paved roads ! The value of fresh eggs as a protein source for the Liberian people is huge; this farm is expected to produce 75,000 eggs a day when operating at capacity. After the dedication we had a tour of the farm; it is on 155 acres where they grow crops for feeding the chickens as well. They don't waste anything; the chicken ummm excrement is composted to use as fertilizer for the crops. The farm is expected to produce significant employment opportunities also.

One of the topics that I haven't talked about much here is the work by the government on decentralizing government functions outside of Monrovia. This effort has several goals: one is to bring the government closer to the people in outlying areas, and another is to provide jobs and a better life outside of Monrovia which might help induce some out-migration. Nearly a million people live in Monrovia, and it is terribly overcrowded; the government cannot provide needed services to everyone in this crowded city. A lot of people moved from the country into Monrovia in the immediate post-war period because it was safer and there were more opportunities to scratch out an existence. Now it is time to reverse that trend; many of the buildings dedicated this week are part of that process.

After the chicken farm, we were on our way to a children's party celebrating the 26th when the President decided to make an unscheduled stop at Redemption Hospital, mostly to talk to the nurses. During this week, around the country, nurses have been taking part in a job action; some have refused to show up for work, and others have just been in a go-slow, no overtime mode. I think the main complaint is wages, but there are some complaints about working conditions also. In any case, at Redemption she talked briefly with some of the nurses present, and then Aunt Jenny ( a retired nurse) privately gave them what appeared to be a strong tongue-lashing ! And of course afterwards the purser came along and dispensed some cash. I had the chance to chat with Tobias, the Administrator at Redemption whom I have met before; Ly Heng and I did some operating at Redemption, but I don't expect to do that again. Hopefully when I am back here in a month to work we can collaborate with Redemption to get surgical patients transferred to JFK for surgery. That process has been tangled in politics and economics in the past, but we will keep trying.

Then we went on to the children's party at the football stadium downtown. It was quite a joyous occasion with music and dancing, and clearly the kids were very excited that the President was paying them a visit. It was a wonderful way to end the public celebration of 26 !

Last night I first went to Aunt Jenny's for dinner with the President, the American Ambassador, and Steve Cashin. It was an interesting and fun conversation around the dinner table ! I had some fufu once again, and it was delicious ! After dinner we went to Antoinette's for a party with Ambassador Straz and many others; he had brought strip steaks and lamb chops with him on his plane. I had a good chat with him and his pilots; they fly a Global Express, but I have no idea what that means lol. Aunt Jenny and Uncle Jeff and the President also came to the party, and it was good to see her in a nice relaxed setting.

Friday July 26

Today is July 26, 2013: this is the 166th anniversary of the founding of the Republic of Liberia. Of equal importance, we are celebrating 10 years of peace in Liberia since the signing of the accord ending the Civil War on August 3, 2003. It is a day of celebration for the accomplishments already achieved, and a day of contemplation about the serious work ahead.

  Up at 7 this morning to have coffee, and then drive to the parade grounds so the the Commander-In-Chief could review the troops. That was fun to watch, and who doesn't like a military parade with the troops passing by in salute ! Mr. Straz was at the house, and was very welcoming, so I guess my earlier faux pas wasn't that bad. Then back to the "Palace" for breakfast before heading down the hill to the ceremony at Tubmanburg Town Hall.

The hall was packed when we arrived; my guess it that it held 300 people or so. Debbie and I were seated in the front row of the stage to the right of the podium along with Father Gary, another honoree, who was also celebrating his birthday on July 26. He had come to Liberia in 1973, and had stayed throughout the war. He said that at one point he was taken by the LURD rebels into the jungle; they said they were protecting him from harm, but who knows.

The ceremony itself was over 2 hours long; it included an very lengthy introduction of the National Orator by what appeared to be a high school aged girl; perhaps in thenfuture the protocol officer might consider vetting such speeches ! Then the Orator, who is an older politician and head of the Unity party (the same party as the President) spoke at length about her accomplishments and also the areas that he thought needed improvement. My sense in listening to him that he is looking to run for the Presidency. After his speech came the honors, being Debbie, me and Gary. I have to say that it was a momentous and amazing feeling to be standing in front of a crowd of people who, for the most part, had no idea who I am or why I was standing up there, but afterwards they were very gracious in their thanks.  After the honorings, there was more talk, including the former President of Nigeria ( more about him later), who promised he would be short in his speech, but wasn't . One of the things I have learned on this road trip with the President is that asking a politician to be brief will rarely have the desired results. They say they will make their remarks brief, but once they start talking, they don't seem to know how to stop!

After that ceremony, we returned to the Guest House to get our bags, and then we went to lunch at the WEAC building for a luncheon. While there I met the Ambassador from South Africa and his wife; he taught in the Government department at Harvard until the ANC was no longer prohibited, and Nelson Mandela was released from prison. She grew up in Hebron CT, and met him in Boston I think. In any case, they are quite an interesting couple and I enjoyed our conversation.

Everything was running late (not surprising), so we finished there around 4pm and then left to come back to Monrovia for a formal dinner benefitting Messongee, a foundation started by the President to provide funds for rural education and development. The honoree was the former President of Nigeria, affectionately known as Baba to his friends. As I understand it, he was an Army General who took over after his predecessor died under mysterious circumstances, and then won an election. After his term was over, there were some who thought he should retain office, but he decided to follow the rule of law and retired. Since retiring, he has developed a modern chicken farming business in Nigeria, and has just recently started a branch of the operation in Liberia. Anyway, the dinner was actually quite fun, and the evening ended with Madam President and the ex-President of Nigeria leading a conga line dancing through the hall, and the American Ambassador and I joined in.

Throughout the evening a number of people, some of whom I have met before, but many whom I have not, congratulated me for my honor, and thanked me for coming to Liberia as a surgeon. I feel blessed and privileged to have the opportunity to do this work; compared to the work that others are doing, I'm not sure I deserve these accolades, but it sure has been a fun week !

Thursday July 25

It was a cloudy morning, but the beach at Robertsport was still beautiful. I could see the fishermen going out in their skiffs from the beach which reminded me of Duxbury Beach. Apparently the surfing here is spectacular, though Aunt Jenny says it is best during dry season for some unexplainable reason. Anyway we piled into the cars, and drove back to the Lake Pizo guesthouse for breakfast. The President has oatmeal each morning, and so this morning I tried it and discovered one of the secrets: nutmeg !! Something else is added to sweeten it, but the nutmeg gives it a great flavor!

We left at 9 am to start a long day dedicating bridges, markets, clinics, and a Baptist mission school ! President Sirleaf has inspired the Sirleaf Women's Market Fund, and she dedicated one of them in Gbah today. The idea is to get women to sell their produce and wares in a fixed building, rather than alone or in 2 or 3 along the side of the road. Incorporated into the concept is that by having many women together, other services can be provided such as literacy training, business training and basic economics. Additionally, her idea is to have a school as part of it, so the women can bring their kids to the school, knowing it is safe, and then start to build around the market such things as stores for goods, a clean water supply, and maybe even a health clinic. The market then serves as a nidus for growth in the community, making it even more desirable for the women to be a part of.

The clinic she opened is a new maternity unit in an existing clinic. One of the health care delivery issues, and a part of the reason for the high maternal mortality rate, is that women stay at home or in their villages for far too long. The concept of this maternity clinic with about 15 beds is to get women to come in to stay there sooner, so that when they deliver, it can be under more controlled circumstances. This would help decrease infant mortality as well as maternal.

An interesting aspect of these visits is  that she rewards the workers with cash, rice, or both. One of her staff is the "purser" (well, that's what I call him), and he has a backpack with bundles of cash. Remember that 72 Liberian dollars equals 1 US Dollar, so bundles of Liberian dollars are not necessarily a lot of money to us, but it is to them. Anyway, he hands out cash...usually a wad of it to one person in a crowd, and I guess that person is responsible for dividing it up. I asked my driver, Macintosh, today why the person who gets the wad wouldn't just take it for himself; he said the crowd makes sure that doesn't happen.

Anyway, after a long day of driving around, and a stop outside of her farm near Tubmanburg, we went to the hotel we had christened the day before to stay for the night. After getting a room, and getting unpacked, we were informed that in fact we would be staying in what they referred to as the "Presidential Palace", which is another guest house for the President. So we packed up and went there, and it certainly was quite nice. She invited a number of officials, including the guy who is in charge of urban water and sewer; he was very interesting, in part because he was formerly a banker, and he decided he wanted to do something different. He felt that the department needed management more than a professional engineer, and so far he feels like he was right. After a lovely dinner, I went to bed in preparation for the big day tomorrow.

Wednesday July 24

Not much going on this morning. Had a leisurely time, and got several days of blogs posted. Next on the agenda was packing as we will be out for two nights leading up to Friday. Then in the afternoon we left for where we celebrated the opening of a hotel in Tubmanburg, which is owned by a Senator. Apparently he and the President worked together to get the financing and arrangements made; he got what he wanted (a hotel) and she got what she wanted (people investing in properties and the like outside of Monrovia).

From there we went back to the Guest House on Lake Pizo near Robertsport, where we had dinner. We sat with the President and Jenny at a table in the house, then the rest of the staff sat inside and outside as they ate. After dinner we went with several of her staff to Robertsport, where we stayed in the new house belonging to the Minister of Agriculture. It is brand new by all appearances, and is located up on a bluff overlooking the beach; what a gorgeous view from the deck in the morning. Since it is brand new, some of the basics aren't there yet...like running water, so there were no showers to be had, but worse things can happen. I had a reasonably restful sleep, other the drivers outside talking lol

Tuesday July 23

We drove in convoy to the Presidential Guest House in Grand Cape Mount county, and after refreshing and relieving, we went from there to Robertsport to attend a Muslim service of Thanksgiving. It was held in the Town Hall, and wasn't overly religious. I think the President saw it as an opportunity to reach out to the Muslim community, which comprises about 30% of the population by some estimates. There have been politicians suggesting that Liberia should declare itself a Christian nation, which naturally has made the Muslim community worried. The President gave a wonderful extemporaneous response to their remarks reaffirming the unity of the nation, and that was quite well received.

We then went back to the Guest House for lunch; I sat at the table with Debbie Harding, Dr. Emmet Dennis, President of the University of Liberia, Mr. David Straz, and the President. Mr Straz is a retired banker who is now a philanthropist; in Tampa there is the David Straz Center for the Performing Arts. He is also quite involved in Liberia, and donated $1.2 million to build a campus for the University of Liberia in Sinje, which we went to visit later in the day. He is also Chairman of the Board of Trustees of Tampa General Hospital, and I had a conversation with him about that. He is supporting a team from there who is working with Adamah to arrange a visit later this year; he talked about something in the range of 15-20 people on the team, and they will bring their supplies. He mentioned that "I will fly them here in my plane, naturally !" I actually first met Mr. Straz yesterday at the Muslim service when Debbie introduced us; I was clueless, so I asked him what he does. He told me that he was retired and now a philanthropist. I had the feeling that it was expected that I should have known that before engaging in conversation with him. Oh well.

We had a table conversation with Dr. Dennis about higher education in Liberia, and the difficulties therein because of lack of educational structure and teachers in the earlier years. There is also the issue of poverty and affordability; tuition at the University of Liberia rose from $2.50 to $3.00 per credit and that caused a storm of protest. Unfortunately, a large percentage of those applying for graduate school after college fail the GRE equivalent, primarily he thinks because of a lack of basic preparation in math and english before college.

After lunch we waited for the Vice President to arrive, and then we left with him to go to the campus at Sinje; the President was planning to return to Monrovia so she could go to her office and do some work. The school at Sinje looked great; one of the big programs is in agriculture, and they took us to see some of the planting fields, etc. After that we came back to Monrovia to have dinner with Steve Cashen at Mamba Point. He is from Washington, but has spent a lot of time in Africa; he runs an investment bank here as well as being quite involved in Liberian redevelopment. We enjoyed an excellent conversation about kids, colleges, and other things over a great Indian dinner.

Monday July 22

Sleeping on the couch was alright, but this morning there was still no sign of Melvin or Comfort. So Security from the Presidents house came with a locksmith who pried open the bedroom doors; he came back later and replaced the locks, so now each of us has a key. Mr Bernard, Aunt Jenny's husband, aka Uncle Jeff, came to check on us and was as happy as we are that all is well. Comfort also showed up and told us that she had gone home yesterday to cook some food for her son, but was robbed of the food and her phone.

Mr Bernard has an interesting story told to me by Debbie. Under President Tolbert in the late 1970s, he was in the government as Minister of Youth and Sport. When Samuel Doe staged his coup in 1980, his troops took the President and 12 cabinet Ministers down to the beach where they were executed by firing squad. It happened that Mr Bernard was in Ghana at a sports function, and that is why he is still alive today. Aunt Jenny and their sons were able to escape the country, and I believe they all ended up in the US for many years afterwards.

Macintosh and I left just after noon to deliver some instruments to Robert at his New Eye Clinic. I was able to see him briefly as he had just finished operating for the morning, and we made plans to have dinner in September. We then went to Harbel to the Firestone Hospital for me to meet Dr. Lawrence Sherman who is a surgeon and Chief of the Medical Staff there. I have heard a lot about him over the course of my visits, and he had heard about me, so we were both happy to finally meet. We had a wonderful conversation, and then he toured me around the hospital, and then we had more conversation. Firestone Hospital is quite clean, and certainly appears to be well run. They have significant amounts of fairly up-to-date equipment: a laparoscopy unit, but they are unable to obtain CO2. The only places that have bottled CO2 are the Coca-Cola factory and another industrial place, but neither of them will sell CO2 to the hospital. So they are looking for another source. They have a med tech guy who fixes everything for them, and they have a supply area with at least 2 inventory clerks who label and track all supplies, donated and bought, and they make sure that the supplies closest to expiration get used first. Basic inventory control, but it requires organization and thought, and I think JFK needs more of that.

Debby was off meeting people about education issues today. Tonight we are going to the Mamba Point Hotel for dinner and then probably an early bed. Tomorrow we go back up country, and we have been told to pack for a few days traveling.

Sunday July 21

Today we had a major expedition! We left in a 30 car convoy to drive to Bopulo City for a church service. I don't know if I mentioned it earlier but we have a fairly new Black Range Rover at our disposal for the week, with Dewalt and Macintosh sharing driving and security duties. Anyway, the road to Bopulo was paved for about an hour north from Monrovia, and then dirt road for another 2 hours. As we passed through small villages on the first road, groups of children and adults would be standing beside the road cheering and dancing. Every once in a while, we would stop so that the President could get out and greet the people, offering soccer balls to the kids and dispensing cash to the chiefs of the village. Security was always tight, as it is around her; fortunately I appear to stick out so they know who I am and would typically encourage me to get closer to her ! We arrived in Bopulo City and went into the service; it was attended by many of the cabinet as well as some Ambassadors. Fortunately the service was not too long, except for the minister introducing the guest speaker; the introduction went on for so long that eventually he had to be told to stop ! They then served a lunch, which we were told to eat quickly because we were behind schedule and the President wanted to get going. The next stop was Bella Yaleh.

Bella Yaleh is a town best known for having a prison that people went to and rarely came home from. There was no road to the town; apparently during the time of Charles Taylor, prisoners were brought there by helicopter. Soon after President Sirleaf took office, she promised the town that a road would be built to Bella Yaleh, and that she would visit them at Christmas. That was a couple of years ago, and she took a group to Bella Yaleh; unfortunately the road was not quite finished, and she famously led the group on foot through the jungle over the last couple of miles. With our visit, the road was finished, and so we drove into the village to the cheers of the hundreds of inhabitants. During the dedication ceremony in the village, the tribal chief gave her the traditional welcoming gifts of a plate of fruit and vegetables, a hammock, a chicken, and a sheep! The District superintendent announced during his remarks that they were going to petition the government to name the road the "President Ellen Johnson Sirleaf Highway". He also announced that the local government was giving her 10 acres of land so she could build a house and always have a home in Bella Yaleh.

The road to Bella Yaleh is a dirt road, and during rainy season like now it is a mud road. There were several times when we nearly got stuck in the deep mud, in part because the Range Rover has relatively low clearance. Having arrived in Bella Yaleh at about 5:30pm, we could see that most of us would have to sleep in the cars if we stayed there.  The President was staying in a small 2 room house, and she said we could all bunk in there, but that seemed impossible. So a convoy of about 15 cars was put together to drive back to Monrovia, which is what we did. Fortunately we had security and 2-way radios to communicate and stay together; as with the trip out, there were a couple of times when i thought we would be stuck in the clay-like mud, but we got through. The convoy was led by Representative Edwin Snow, who took us via Tubmanburg where he has a farm; we stopped there to use the facilities and have something to eat. We ended up arriving back at the guest house around 1 am, and found that not only was the front door locked, but our bedrooms were locked also and no one knew how to find Comfort, the housekeeper, or the keys to our rooms. So Debbie and I slept on couches, but at least we got to sleep.

Saturday July 20

I slept a little later this morning, and then around 11 we went to the President's office. We saw her briefly before she went in to do a radio interview, and then we waited till she was done. From there we spent the afternoon going to the dedication of a new science building at Brownley Mission School. This is a school for girls, and because of the President's strong push  to educate young women, they were ecstatic to have her there. There was a formal dedication with ribbon cutting, the speeches, and then a walk through the new facility.I had the opportunity to meet the US Ambassador, Deborah Malik, who told me that her husband grew up in Southington, CT which is not far from Waterbury. The school appeared quite nice, a bit surprising for being out in the middle of nowhere. After leaving the school, on the dirt road, there would be collections of people, and frequently the President would stop to listen to them singing or whatever. One place we stopped was an open air market where there were lots of people making joyful noise. She got out, bought some of the fruits and what looked like biscuits, and then gave it all to the kids. She really is a remarkable woman.

Tonight we went to the Golden Image Awards dinner, for which the President is the inspiration and original award winner. They give out awards to people who foster cooperation and peace. The ceremony was pleasant enough, but it dragged on for 2 hours, and they weren't serving dinner till the awarding was over. The President decided it was time to go after the speeches, so off we went back home. Dinners like that are one reason I wouldn't want to be a politician, but I guess if you can leave when u want the being President would be ok !

Friday July 19

This is rainy season, but I continue to be surprised by the torrential nature of the rain. It is intermittent, night and day; last night I was awoken several times by the loud pounding of rain on the metal roof.

Today I got up around 8, showered, and came downstairs to see that they bought me Raisin Bran for my breakfast !! Yay !! This morning I finished a wonderful book called "God's House" by Victoria Sweet, a physician who worked in Laguna Honda, a public hospital for the chronically ill in San Francisco. She interweaves the story of that hospital with details of her exploration of medieval medicine, and especially the work of Hildegard of Bingen; the result is a fascinating story of old medicine, new medicine, and the surprising connections between them. It also has some remarkable insights into the changes in medical practice which have occurred in the past several decades, leading to the demise of places like Laguna Honda, killed off by perhaps well-intentioned bureaucrats who decided a new model of care was needed.

At 4 pm Dewalt and Macintosh drove me to the Ministry of Foreign Affairs for the honoring ceremony. The auditorium was packed when I walked in with Macintosh; the usher asked if I was a diplomat, and Macintosh replied that I was a guest of the President, so I was escorted to a seat in the second row. It was quite an interesting process: there were 12 honorees who were called up individually, and then their citation was read, followed by the President affixing their medal and posing for a photograph with them. There was then a toast to the honorees, and a toast back to the President. The military band played selections such as "Que sera, sera" and the Mexican Hat Dance, and then we adjourned to a reception in the foyer. There was a receiving line of sorts with the President and Vice President, drinks, and canapés; I met a psychiatrist from Meharry Medical School who spent time at Yale. I didn't go through the receiving line, so when the President was leaving, she stopped when she saw me to ask if everything was okay with my schedule. I told her that Aunt Jenny was taking care of it and she laughed, saying that she uses her sister Jenny for the same purpose !

Soon after I returned to the guesthouse, Dr. Debby Harding arrived and we got acquainted. She is the other honoree besides me and the orator who will be invested next Friday in Tubmanburg. We learned later that normally only the Orator is invested on Independence Day itself, but there was a miscommunication in the protocol office, and since Debby wasn't arriving till after the ceremony today, they decided to invest her and me in Tubmanburg next Friday. Shortly after Debby arrived, Aunt Jenny came with copies of the schedule for the next several days to review with us and see what we want to do. It's going to be a busy week ! During the week the President will be dedicating a variety of roads, buildings, and programs, and we are invited to accompany her to all of them. It remains unclear what nights we will stay outside of Monrovia, but definitely at least one or two. Aunt Jenny suggested that we come back here some of the nights, although the President will be staying out there, because the accommodations are sparse. But she said we should talk to the President tomorrow to find out what she wants us to do.

After Aunt Jenny left, Debby and I had dinner and got acquainted more. She lives in Washington,DC and has known the President since 1985. She has worked in philanthropy for much of her professional life, and after the 2005 election in Liberia she was asked by President Sirleaf to harness the good will and money being offered by Americans to use for education. Initially it was planned that she would run the Liberian Education Trust for 3 years and then turn it over to Liberians to run it; it has been 8 years of program development, and it is getting close to ready to be turned over. We had a wonderful conversation, and I'm sure we will have many more as we travel during this week.

Shortly after heading up to bed I was summoned next door to the President's house for a potential medical emergency; happily it resolved with no intervention necessary on my part. Now I can go to sleep and be ready for a long day tomorrow. Wait...not quite yet. Persistent discomfort led to a trip to JFK and some tests, and all of them were negative, so I think I can go to bed now.

Thursday July 18

When I walked into the terminal from the plane yesterday, a man came up to me and said "Dr. Knight ?" He then escorted me through immigration, handing my passport to someone with instructions to take care of it, and we picked up my luggage. Outside I was met by Dewalt and Macintosh; I have subsequently learned that Macintosh is from the President's security detail and is assigned to me for the duration of my stay! We drove in pouring rain (yes, it is rainy season) to the President's house where I met Aunt Jenny. She explained that the President had gone to Nigeria for an ECOWAS meeting, and would be back tomorrow, at which time my schedule would be discussed. We then drove next door to the Presidential Guest House where I will be staying. After a meal and 2 Club beers, I took a shower and fell nicely asleep. Aunt Jenny came over after my breakfast this morning to discuss my schedule a bit more. This morning I will go to JFK around 10, and then I will go to her house for lunch at 1. Not surprisingly, there has been a change in the Honoring schedule: the original plan was for me to be part of a group of 35 honorees on Friday, but now my honoring has been moved to the actual Independence Day ceremony itself on Friday the 26th. One of the facts of life in Liberia is that plans change frequently based on unanticipated circumstances, and one has to learn to go with the flow. I think that one of the personal benefits to me of spending time in Liberia has been just that: I have to put aside my compulsion for timeliness and planning, and recognize that I don't have control so I might as well just enjoy it. They take good care of me and everything works out. I went to JFK and met Dr. McDonald outside the Administration Building as she was on her way to a ceremony thanking Chevron for some donations. I went with her, and saw several old friends as well as meeting some new ones. Afterwards Dr. McDonald and I talked briefly about the needs of the surgery department, especially as it relates to the soon-to-start postgraduate education program. After that I went up to the OR to say hello to Percillar, Anthony Hne, and the others; it feels weird being here and not working, but I assured them that I would be back in September to work. I then went to Aunt Jennie's for lunch, and had a very nice time as expected. Her husband was there as was one of her sons, Carney, who I think is an accountant. We had a very interesting discussion about the current state of politics in Liberia, and concerns about the possibility of unrest which is just under the surface. There is no doubt that some people are discontent; I think that is only natural when things are getting better, but some people are impatient and think that change can happen overnight. The planning for all of the Independence Day celebrations seems like it continues to be a work in progress. The big ceremony on July 26 will be in Tubmanburg, but it remains unclear whether we will go there the night before or the morning of; I think it is about 2 hours drive. From what I am told, the uncertainty mostly relates to the availability of accommodations. Aunt Jennie told me that three of us will be honored on that occasion: Debby Harding, a US woman who has done a lot to support education in Liberia, myself, and "The Orator", whose name and accomplishments remain a mystery so far, but he is the one who will speak for the honorees as I understand it. Aunt Jenny said she would get more information soon, and would let me know in the next day or two what I will be doing. After another visit to JFK and a meeting with Dr. McDonald and Dr. Johnson at 4 pm, Dewalt and I went across the street to get some passport type photos so I can get a JFK ID ! I told Dr. McDonald that I thought I should have one, and she readily agreed, so that is now in the works. Then back to the house for a quiet dinner and evening. Tomorrow the celebrations begin !

Wednesday July 17

This is a special edition of my blog because of it being a different kind of trip to Liberia. I'm not here to do the usual surgical work at JFK, but rather I am here to join the celebrations of Liberian Independence Day on July 26. As part of those celebrations, each year The President chooses to honor certain individuals, and this year I am one of them. On Friday, in a ceremony at the Ministry of Foreign Affairs, she will confer on me the distinction of Knight Grand Commander, Humane Order of African Redemption; I really have no idea what it means, other than that it is a great honor and I am proud to be so recognized. It goes without saying that the honor is shared by all of my fellow travelers over the past 4 years (Robert Numoo, Colleen Pietras, Santiago Arruffat, Jenn Malsbury, Eric Lucero, Yuk Ming Liu, Ly Heng, Diego Holguin, John Dussel, Jonathan Laryea, and Nathan Lafayette) as well as all of the people who have helped our work with donations and encouragement. A particularly loud shout out in that regard to Mary, Tanya, and Donna at Waterbury Hospital who have been amazing in finding opportunities to help our work ! As part of the Independence Day celebrations, The President will be bringing the festivities to 3 northern counties in Liberia next week, and I have been invited to join her entourage. I particularly excited about this, since I have been outside if Monrovia for one afternoon only in the 7 trips I have made here. For the most part we come, we work at JFK Hospital, and we go home; I am looking forward to this opportunity to see some of the rest of the country.

Sunday March 17

As planned, we were at the hospital a bit earlier than usual, and we were able to use both OR rooms to do our cases. John and I did the mastectomy so that we can bring tissue back for pathology, and Santiago and Nathan did the 2 year old with a hernia. The OR staff was very kind and accommodating in not only making it easy for us to do these last cases on a Sunday morning, but even having people come in so that we could use both rooms and be done sooner. After the cases, we went downstairs to say goodbye to patients and staff, and as always that wasn't easy. We hope that our patients continue to make progress; I know that we will see some of them again, but hopefully not as patients at JFK. We went back to the bungalow to shower and change for our flight. Moses came early, so we decided to go to Sajj one more time for chicken bread and pizza (I think that was Nathan's idea !) Then we went off to the airport for our flight to Accra and then JFK in NYC. I think this was perhaps our most successful trip for a number of reasons. There is no doubt that our familiarity with the people at JFK, and their familiarity with us after many trips makes the relationship easier for everyone. We all have a reasonable idea about what to expect from the others; even though I do let my frustrations reach a boiling point, I do know in my heart that they are trying, and that they are improving each time. Another key reason for our success was having Dimple with us. Her presence is what allowed us to do more complex, riskier surgery, mainly because the anesthetists knew they had back-up. The other day I was talking with Mr. Hne about the splenectomy we brought back for bleeding. He told me that when the patients of Liberian surgeons have problems, the surgeons tend to stand there and not do much; he was impressed that with the splenectomy all of the members of our team pitched in to try to find equipment and solutions to the critical problems we were facing. I think that part of what we do is to display that sort of teamwork, and perhaps others see how effective it can be. Finally, without doubt, much of our success on this trip reflects the fact that we all got along very well, and there were absolutely no personality issues at all between us. Everyone contributed to the success of the trip by not only doing their job well, but by helping others do the same. Kenna is a spark of joy and laughter, whether entertaining us at the table or in the OR, or getting into a soccer game with the neighborhood kids as we walked home; in addition, she is an incredibly good Surgical Tech! Dimple was a rock: steady, determined, flexible when she needed to be, but she would not accept "we can't do that" for an answer to anesthesia issues. She is also witty, and fun, and a great team player. John and Nathan were wonderful about keeping us organized. I told them at the beginning that I wanted to stress organization and information on this trip, and they did a good job at it, given the limitations of the system. John's full-blooded enthusiasm for everything he does, and his desire to learn everything he can from each case, was an inspiration; Nathan settled right in to this new experience, and seemed right at home within a few days doing complicated cases and learning how to care for patients without any of our usual tools such as labs, xrays, etc. And he loved that chicken bread at Sajj ! Finally, Santiago is an exceptional surgeon, a superb physician, a warm and engaging personality, and a great friend; he is an amazing resource for this work, and I am honored that we can work as partners in Liberia. I will return in September with a different team, and then many of this team will be back next March.

Saturday March 16

This morning we did our last 2 cases for this trip: Nathan and I excised a rather large ulcerated lesion on a woman's flank, and John and Santiago fixed a hernia to removed lipomas on the same guy. Then we collected our duffel bags, and brought more supplies over here to the OR. After helping to organize them, John and Nathan went to Sajj to pick up pizzas to bring back for everyone. As we were having our pizza party, Keffla, the surgical intern, came up to tell us that the woman I had seen with a large but operable breast cancer had been admitted on Friday night. Somehow that bit of information didn't get passed on, despite our asking the nurses multiple times if she was " on bed". Anyway, she had eaten yesterday, so we opulent do her surgery then....but the OR staff graciously agreed to let us operate tomorrow morning (Sunday) before we leave in the afternoon. We will also do a hernia on the 2 year old son of one of the OR staff; he didn't tell us until late in the trip that it needed to be done, and it looked like it would need to wait till September, but he pushed us and that's fine. We came back to the bungalow to find it being set up for a party, and at 7 many of the OR staff, Dr McDonald, Dr Marshall, Mary, and all of the HEARTT people came over or food, drinks, and dancing with a DJ set up in the living room. Mrs Peabody and her staff did all the arranging, and it was a wonderful evening. Dr McDonald was very kind in her remarks thanking us for our contributions to JFK, and I responded with our thanks for being allowed to be part of the team. John tells me that after our 2 cases in the morning, we will have done a total of 42 operations on this trip. We have definitely had a more complex case mix, and we all feel very good about what we have accomplished.

Friday March 15

This morning we were invited to have breakfast with the President, and it was a special occasion as always. John and Nathan came here to the bungalow before we left for breakfast,mand reported that Abdul was alive and well ! Then we went to the President's house; besides the 6 of us, the other invitees were Camille Henry, a pediatrician, and Mike Scott and Joe Tunno, both ED residents as well as Dr. McDonald. I had the honor of sitting on the President's right; she asked about our surgical cases, and the state of JFK, and we had a good discussion around the table. Partway through Auntie Jenny came in, exclaiming " And how is our favorite surgeon?" , and came over to give me a big hug and a kiss ! Around 10am the President excused herself to go to work; today is a national holiday, but of course she works anyway. At some point in the discussion I mentioned that I would be back in September, and Aunt Jenny said " But you know you have to come in July ! Or did I let the cat out of the bag?" Dr. McDonald had said something at the retirement function we attended about the President wanting me to be here for Independence Day celebrations at the end of July. I pressed Aunt Jenny gently to explain, but she wouldn't say anything more than I should plan to be here for the July 22-28 week; I'm hoping that more details will follow. But I guess if the President asks you to attend, then the apprppriate thing to do is to attend ! After breakfast we came back here to change, and then went to the hospital. Obviously Abdul was my main interest, and happily he was looking pretty good. He had been transferred downstairs to the ward around 12:30, and said he was feeling better today. His breathing was better, and I am optimistic that he will make it now. Our other patients were all looking good, including the mastectomy from yesterday, and Victor was looking better. At noon we met with Dr. McDonald and Dr. Bobo to talk about the development of postgraduate education at JFK, and the development of surgery in particular. We had in interesting and wide-ranging discussion of needs and resources; for me, the top priorities would be getting a pathologist, and an anesthesiologist, and surgical staff, and developing critical care services such as ventilators, etc. we also had a good discussion about the proposed endoscopy unit, including the equipment needs, staffing and resources, etc. They are extremely enthusiastic about this possibility, and Santiago and I have committed to doing what we can to get the process moving. We then went to look at the proposed site on the first floor, across from where pediatrics used to be. In the afternoon we went down to Front St to the carving shops; I bought an ebony mask and a few other things. It was good having Dewalt with us to do some hard bargaining ! Then after dinner at Sajj we went out to the 704 club in Painesville to meet up with Persillar and many other OR staff or a night of dancing. Dewalt was also there, being very protective of us. At one point I went into the bar with Barbu, and one of the bartenders said "Hi Dr Knight !" He is a friend of Persillar's, and last September she brought him to see me with enlarged cervical nodes. I biopsied one, and it showed granulomas consistent with TB. He told me he is on TB medication and is doing well ! We came home around 11:30, tired and ready to sleep before our last day of surgery tomorrow.

Thursday March 14

Thursday March 14 For the first time on this trip, it was raining when we left the house after breakfast. Not a hard rain like during rainy season, but more than a mist. On this trip, our meals have been taken care of by Mrs. Peabody, Head of Dietary Services at JFK, and her staff, and they have done an excellent job. Mrs Peabody left Liberia during the Civil War, and lived in Michigan until 3 years ago when she decided to come back because "her country needed her". She still has children in the US whom she visits regularly, but she seems genuinely happy to have come back to make a contribution to post-war Liberia. We knew today was going to be a big day for cases, and indeed it has been. John and I did bilateral inguinal hernias in an 8 month old boy, and then did a radical mastectomy on a 60 yr old woman. We learned of her because her daughter approached us on Monday as we were leaving the hospital. Her mother had been seen in the Surgical Clinic last October, and had paid her fees for surgery, butt she could never get a bed. We told her to bring her mother to clinic on Tuesday, which she did, and we were able to get her a bed through Mary. It's a sad story, because her breast cancer was ulcerated and advanced; I have no idea what it looked like in October, but today it was a salvage mastectomy. Finally we did a man with a nodular mass above and in his umbilicus. Pre-op we suspected carcinomatosis, and I am quite certain we were right. We biopsied some tissue to take back for pathology. In the other room Santiago and Nathan brought back the boy with burn contractures of his left arm, which we had operated on last week, and his left leg.. The arm looked pretty good, and the Dimple graft looked like a complete take. He has significantly improved range of motion in both his arm and his leg, but now he will need regular PT to stretch the tendons and get to full range of motion. We hope he will get that here in Liberia, but like so many things, there are many hurdles to overcome. Then they did a 14 year old boy admitted yesterday with a tender mass on his right lower ribs, and post- prawn dial abdominal pain. He had an ultrasound showing a probable abscess on his ribs and stones in his gallbladder. They did a cholecystectomy, and then drained the abscess which appeared to be going up to his chest, suggesting an empyema. Between cases I saw several patients sent up from the clic for me to see. One was a 9 year old girl who was shot 3 years ago, and lately she has been having intermittent abdominal pain. Santiago sent her for a CT, which showed the bullet had gone through her lung and diaphragm, and was lodged in her liver. I explained to her grandmother, and then to her American sponsor by phone, that her pain was not likely related to the bullet, and there was no need to take it out. Furthermore taking it out would involve a big and dangerous operation, and that was not advisable. Everyone was ok with that. Then I saw a 32 year old woman whom I had seen in the clinic. She is jaundiced, and had a suspicious ultrasound; I sent her for a CT which shows many heterogenous masses throughout the liver, probably a multifilament hepatocellular carcinoma unfortunately there is nothing to be done for her; that was a difficult conversation to have in a room full of people when the patient and I hardly appeared to speak the same language. Persillar was kind enough to stay and translate, but I don't think the patient really understands her dire prognosis. Finally I saw a 12 year old boy who started having pain in his right hip last September. No trauma or obvious inciting event. He had an X-ray which appeared to show a cyst on his femoral head; subsequent X-rays including one today have shown destruction of the femoral head,Mao now there is none. Dr Muvu has declined to biopsy it, not knowing what he would get into; I felt the same. It is clearly not something which can be handled in Liberia. At his mothers urging I spoke to his aunt in Minneapolis, and suggested that perhaps she could find a pediatric orthopedic surgeon at the University of Minnesota who would take an interest in helping out. It's frustrating an disappointing to see some of these complex problems in young people, which would be a challenge at the best medical centers, going unsolved because of lack of access to care. I know it is just the way the world works, but that doesn't mean I accept it. I thought we were headed home for a quiet evening, but when we stopped by the 2nd floor we found Abdul, the splenectomy we did 2 days ago, looking rather bad. He was tachycardic and tachypneic, and we decided to take him back to the OR for suspected bleeding. He had a lot of old blood in his abdomen, but no active bleeding that we could find. Post-op we have been waiting for him to wake up enough to be extubated, but it has been a slow process. The major problem is that there are no ventilators, so someone having difficulty breathing post-op or any other time is in big trouble; all they can be given is oxygen by nasal cannula. Mr. Hne pointed out that there is an anesthesia machine with ventilator which is brand new, but it is reserved for the shunt room, where it has been used maybe 15 times in 2 years. We were ready to seize it by eminent domain, but now Abdul has been extubated and seems to be able to breathe on his own. It is 11:30 pm, and we are going to go home. Joseph (anesthetist) and Sara (O2 therapy) have agreed to stay with Abdul in the OR because he needs the oxygen concentration available here rather than what is available through the concentrator machine. We are hoping Abdul will be better in the morning.

Wednesday March 11

Wednesday March 13 Today was Decoration Day in Liberia, so we operated on a holiday schedule in the OR. The first case was Santiago and John resection a transverse colon cancer; Santiago had seen him in the clinic along with his barium enema, which showed a classic apple core. That went smoothly, but with it being a holiday, nothing moved fast today. I did announce to everyone that I was over my frustration from yesterday; I have now entered the final phase, which is acceptance, or perhaps resignation. The next patient was a woman I saw in the clinic with a huge spleen; since I did a huge spleen yesterday, it seemed only fair to let Santiago and Nathan do it. It wasn't as big as the one John and I did yesterday, but it was still a challenge ! The final case was supposed to be a liver abscess next to a sick gallbladder, but when we looked we found a pretty normal looking GB and no evidence externally of anything in his liver. He did have some momentum stuck down to the pre-pyloric region of his stomach suggesting a possible recent perforated ulcer, and I think that might be the reason for his pain. We will treat him for that and hope or the best. We made afternoon rounds, and we were particularly happy to see Victor smiling again now that his Foley and NG tube came out. He showed us some of his drawings, and he is quite an artist. We went to Taaj for dinner with 3 of the HEARTT people. One of the things that Santiago and I talked about was the joy of developing a patient base here. In thinking about the advantages of returning to the same place each time, I had never thought about that aspect, but it really is quite an experience to have patients know that we will be back in 6 months, and they seek us out. We has also decided that seeing former patients, like Harriet and Victor, is important and gratifying and fun, and we will definitely being making a point of doing it on future visits. One of the other wonderful pieces of news today was that Mr Hne, the chief anesthetist who is retiring, told me that he would be happy to come back to work when we visit ! That would be wonderful !

Tuesday March 12

An interesting day today, from many perspectives. On each trip I seem to have a day when my frustrations reach their peak; today was it for this trip. We made our usual rounds, and found that all of our patients were doing well, but the rounds were somewhat hectic and disorganized. We then went to the OR to discover that Presillar didn't know we had planned to do any cases today, because neither she nor Anthony had received a list. We gave them the list, and then it turned out that the Chinese ophthalmologist needed to use our room for general anesthesia for a child. We convinced them to let us start in the Ortho room, so Nathan and I did a cholecystectomy in there. Of interest, that was the first cholecystectomy I have done in Liberia. It was frustrating was that we didnt start till 10:30 or 11:00, and nothing moved easily throughout the day. Next case was a splenectomy for me and John, and a colostomy decommissioning for Santiago and Nathan. The spleen was HUGE, weighing 4.2 kg, ans extending from LUQ to pelvis and across the midline. It was really quite fun to do, mixed with the normal level of anxiety about bleeding, and boosted by John's quite understandable enthusiasm ! The frustration was that circulating nurse was out of the room more than in it, and that created numerous delays. For reasons that were unclear, we then had to wait about 2 hours to do the final case, which was another colostomy decommissioning in a young boy. Santiago and John did that fairly quickly, and then we all went to Sajj for dinner and to watch a football match on the TV there. Interspersed with cases during the day were several patients brought to the OR area from the OPD Clinic by the intern for me to evaluate, such as a woman with a large fungating skin cancer on her left flank, and another woman with a large breast cancer which is potentially treatable. They clearly both need surgery, but I have no idea how we will fit them in as we move into our final days. I spoke to Mary, our angel who somehow manages to solve all of our problems, and I know she will take care of things. I find it frustrating that there are so many in need of services, and yet sometimes it is so difficult to arrange to provide those services. That frustrates me, and then the delays in the OR, the lack of efficiency, and a host of other factors push me above my tolerance. As I mentioned, this happens just about every trip, and by tomorrow I will have settled into the final stage of the process, which is accepting that we can't change everything, and we can only do what we can do.

Monday March 11

The beginning of our second and last week on this trip. On rounds it was nice to see that the man who wouldn't wake up on Saturday night Is doing well.we sent several patients home, and then went to Grand Rounds where the Internal Medicine team presented statistics for the past year. One of the interesting ones was that sepsis has the highest case fatality rate of all; not surprising in view of the late stage at which many patients come to the hospital, and the rather modest resources available to treat them. Then to the OR where Santiago and I did surgery on Victor, a 12 year old boy who presented in early January with an acute abdomen. At surgery he was found to have perforations of his ileum and descending colon; the colon was repaired and the ileum brought out as a loop ileostomy. He got better, and in February had his ileostomy decommissioned by a visiting American surgeon. He went home, and came back a few days later with peritonitis. On March 1 Moses did another laparotomy, washed him out, found the ideal anastomosis had broken down, and gave him another ileostomy. We saw him first a few days ago when the intern showed us his wound was breaking down, and stool was coming out a small hole near the ostomy. We really didn't want to reoperate on him, but felt we had no choice. Today we found an abscess, with obstruction, and a fistula. We took it all apart, and resected the distal several feet of ileum and cecum. Knock on wood it went well ! Santiago and I like to do one case together each trip, because it reminds us of the old days when he was a resident, and it also reminds us of why we enjoy doing this work together. The next case was a thyroidectomy for goiter with John. I thought maybe we could get away with just taking out the huge left lobe and isthmus, but the right lobe was nodule and I knew the right thing to do was to take it as a subtotal. Then we were going to do a cholecystectomy, but we were told about a 9 year old boy named Alvin admitted today with abdominal pain and dissension, and positive for typhoid. He was looking quite sick, so Santiago and Nathan brought him to the OR for a laparotomy; they found a lot of fluid in his abdomen, and 2 distinct perforations. They were working away when he became unstable, and eventually coded. We tried to resuscitate him for about 45 minutes to no avail. It seems like we experience the death of a child on every trip, but it doesn't get any easier. I know it is part and parcel of the work we do, and that we have a lot more successes than failures, but it still hurts.