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.

Sunday March 10

We all slept late this morning... Well, to 8:30 or so ! We had another nice breakfast, but then learned that the water pump which gets water from the well across the street to the cistern on the roof is broken, so there is no water for bathing or flushing toilets or doing dishes. They have put a big tub if water near our bedrooms, and from that we transfer water into smaller tubs to bring into the shower. It's not great, but it works, and hopefully tomorrow the pump will be fixed. John and Nathan joined us around 11, and reported that everyone was doing well including the nightmare sigmoid volvulus from yesterday. Dimple was very pleased to hear that ! Readers with a weak stomach may want to skip to the next paragraph! I forgot to mention that in our late night dinner conversation last evening, we had come up with a new descriptive, based on our experience with abscesses here, and particularly the one Santiago operated on who is known to us as the Fountain of Youth. The term we coined is a "Vesuvial abscess"; in order to be called that, it has to meet the Knight criteria of spurting at least 6 cm in the air for at least 6 seconds and it must contain not less than 600 cc. Around 1pm Moses picked us up to take us to Kendeja, the RLJ resort on the beach. We had a lovely, relaxed afternoon which was well-deserved if I do say so myself. Tomorrow begins another week, which will be shortened by the fact that there are 2 holidays: Wednesday is Decoration Day, where families go out to decorate the graves of family members who have passed, and Friday celebrates the birthday of the first President of Liberia. We will work on Wednesday, but not on Friday as the President has invited us for brunch at 11am.

Saturday March 9

It's hard to believe that we are halfway through this trip. I think we have done well so far, and that we are making progress in terms of organization and planning. It isn't perfect by any means, but each time it seems better than the last, and I think that is the definition of progress. Santiago, John, and I are particularly excited today because we are planning to see Harriett, the 4 year old whom we operated on last March and removed the 9 lb. duplication cyst. As it turns out, one of the HEARTT pediatricians, Camille, has been in contact with Harriet's father (who wanted photos of what we removed) so we had a phone number. Wilfred called them the other day to say that we would like to see her perhaps on Saturday, and apparently they didn't understand because they showed up here at JFK the next day. The address we had for her was about 30 min away, but it turns out she has moved with her mother much further away, like a days drive. But they said they would stay in Monrovia until Saturday night or Sunday morning so they could see us, and hopefully that will be what happens. Santiago and John did an advancement flap on a lady with anal stenosis this morning. She had presented last year with rectal cancer, and Santiago did a local excision. Apparently she received some form of chemotherapy in the past year, and he was very excited to see her in the clinic last week since none of us expected she would still be alive. The stenosis appeared to be benign scarring rather than recurrent cancer, and here's hoping she will see us next year , After a quick lunch we got in the van with Wilfred and Camille, and went to see Harriet ! She is living with her grandmother quite close to the Executive Mansion, and we had no trouble finding the house. It was quite a celebration when we got out of the van, and Harriet looks beautiful ! I admit that I needed to pull up her shirt and look at the scar to be sure it was the same child, and it was! We attracted a gaggle of kids and others, and it really was fun and satisfying. As we headed back to the hospital, Santiago and discussed how we want to make a point of seeing patients from previous trips, because it is really a wonderful feeling to see that we have made a difference. We then came back to the hospital to operate on a 50 year old man with an acute abdomen who came to the hospital this morning. John and Nathan and I opened him to find the biggest sigmoid volvulus I have ever seen; I'm pleased to note that a sigmoid volvulus was out pre-op diagnosis also ! We resected his sigmoid, and tried to do a primary anastomosis, but it became clear that wasn't going to work so we did a Hartmann's. He is very slow waking up...we think in large part because of hypothermia...so I was able to get the Gaymar warming blanket working and we are warming him up. Because there is no ventilator available at JFK, we are staying him with him until he is awake enough to go back to the floor. Unfortunately it is Saturday night and we had plans for dinner at the Mamba Point Hotel followed by an expedition to Groovie's and possibly Deja Vu, but as I write it is 8:30pm and we are still here. We will do something tonight, but I'm not sure what ! As it turned out, our patient finally woke up enough to be transferred downstairs, and we went back to the bungalow around 11. In the meantime, John and Nathan went to Sajj with Moses the hospital driver to pick up some pizzas and other food; they arrived back shortly after we arrived, and we all had an excellent meal. After that no one was interested in going out, so we all went to bed.

Friday March 8

Today was another busy day. John and I did a 2 year old with a right inguinal hernia, followed by a friend of Barbu's with an umbilical hernia which we are hoping will be a One Day Surgery. Then we did almost bizarre case of a 40 year old man with a mass in his thigh for a year. He denied any pain, antecedent trauma, or systemic symptoms. An ultrasound showed a 20 cm mass which was mixed cystic and solid, and the radiologist suggested that it might be an abscess. That seemed unlikely to me since it wasn't particularly painful, it had been present for a year, and he had no fever or systemic symptoms. So we explored to find out what it was, and indeed it was an abscess...extending from halfway down his thigh to way up in his retroperitoneum. There were chunks of debris, leading. Us to think we were doing a pancreatic necrosectomy. We ended up putting 2 chest tubes in as drains. It was so much fun to see John so excited by the weirdness of the case !! We met up with Robert from the Eye Clinic and gave him the glasses and glucose test strips from Karen. It was very good to see him again, and we will try to have dinner next week. While we were doing all that, Santiago and Nathan did skin grafts on a little boy with thigh burns, and then a thyroidectomy. When they finished that, we went downstairs to check on our patients and then came home to change. We went back to the hospital to attend a long service and retirement ceremony for employees of JFK. Mr. Hne, the anesthetist, was being honored for 31 years of service, and sadly he will be retiring soon. It's amazing to think that he and many of the other honorees stayed around throughout the civil war years; it's hard to imagine what life was like in those times. He invited us to attend a couple of days ago, and it was easy to see that he was thrilled we were there. After that we came back here for dinner. We were thinking about going out with Wilfred to Sajj for karaoke or something, but I am dead tired. This morning I was a bit under the weather with a GI disturbance as well as aches and maybe a fever; I feel much better tonight, but I think I won't push things too far. We have one case scheduled for tomorrow morning, and then in the afternoon we are going to see Harriett !!

Thursday

It rained incredibly hard last night; the sound of it on the metal roof woke me, and confused me initially, but then I remembered the cause of the sound. John and Nathan came over to join us for breakfast; as usual they had already been to the hospital and reported that our patients were doing well. They also said that we would have 5 cases today as planned, because the parents of the 2 children on our schedule had come in last night and signed the consents. It is an interesting aspect of life here that nurses always get the consent rather than the surgeon; I will take a look tomorrow, but my guess is that the "consent" they sign is for an operation without particular consideration of the risks, benefits, or alternatives. Our first case was a 5 year old boy burned by hot water a few months ago, primarily on his left side. He developed severe scar contractures of his left shoulder, left elbow, left hip, and left knee. The hip had been released previously; today we released his shoulder and elbow, both of which had major webs. It took quite a while with Santiago, Nathan, and I trying to figure out how to use Z-pasties and the like to release the scars and allow return of normal movement. We were quite happy with the result when we were done; we plan to bring him back next week to do some skin grafting on his hip and thigh, and to release a contracture of his lower leg. While we were doing that, John assisted Dr Muvu with an above-knee amputation. Then John and I excised a breast mass and repaired an inguinal hernia while Santiago and Nathan took down and closed a colostomy. Just before we did the hernia Dr McDonald called to ask us to see a young man in the ED, and to talk about Rita. We went to the ED and saw the patient; he needed emergency surgery for strangulating bowel, so we got that process started through Mary. I went to see Dr McDonald in her office, and told her that I didn't think we could offer Rita anything; Rita is a young woman in her 20s who had a criminal abortion, and then seems to have developed a septic arthritis of her left hip complicated by a pathological fracture of the femoral neck. She was operated on twice by Dr Muvu, but now she needs more expert help than we can offer. While disappointed that we could not help, especially since Rita's father is a politician, I think Dr McDonald understood the rationale for us declining to operate. We then talked a little about the planned development of JFK, and that the re-establishment of JFK as a medical resource and academic center for Liberia was one of the lasting legacies that President Sirleaf would like to leave. Finally she expressed her sincere gratitude to us and all of our donors for the amazing amount of supplies we brought. Our last case was the hernia from the ED which John and I did; he had a loop of ileum stuck in the hernia which remained purple and flaccid after release, so we elected to resect it. It went well, and we finally finished around 7. After a stop at the dorm for our Internet fix, we came back o the bungalow for a great dinner of barracuda, couscous, and fresh salad. We had a wonderful discussion covering everything from JFK to pitstaches ( you really don't want to know about this concept dreamed up by Kenna!), and then off to an early bed after a long day.

Wednesday March 6

Today we had a big breakfast brought by Mrs Peabody, the head of dietary at JFK; I guess she is arranging for our meals, and she is doing a wonderful job ! After breakfast we went to the second floor ward to find our patients doing well, and then headed up to the OR. John and I did the first case which was an African hernia in Mr.Hne's uncle. It was huge, but reducible and we did a standard Bassini repair. He did well post-op, due I think in large part to the Marcaine which Dimple brought and which I injected. The next case was a 21 year old woman who had a huge cauliflower like mass on her left thigh. It was large enough that she was wrapping a kerchief around it ! None of us have any idea what it is, so a sample will go back for pathology. Santiago and Nathan and the intern whose name I cannot remember did that one. The last case was a skin graft on a 44 year old man man with a melanoma on his mid foot which had been excised a month ago. It was granulating well, but Dr. Kiiza was convinced that a skin graft was needed, so we did it. As we were leaving, we stopped by the 2nd floor to check on patients for the OR tomorrow. We found a couple and talked about them, and then out of the blue one of the nurses asked John about a young lady with a breast mass. It turned out that I saw her yesterday in clinic, but there is no way for me to know that she had been admitted other than to wander the floors and hope someone say something . That's part of the system problem here. For dinner we went to the Royal, which is all renovated. Very nice ! We are very busy on this trip, which is one reason that my postings are short. Perhaps things will settle down and I will write more later.

Tuesday March 5

There was some confusion this morning about what cases we were going to do, but it settled out when we learned that the woman with the cauliflower growth on her leg didn't get a bed apparently, so she won't be done today. Nathan and I did an orchidopexy on Jonathan which went well, and then we went down to the outpatient clinic. The. clinic is an amazing experience, in large part because it is ever clear why many of the patients have been referred to Surgery, if in fact they have. Many of them appear because they have aches and pains which they relate to a trauma; our standard for them is an X-ray and pain relief. This year Santiago brought a plastic bag filled with samples of Tylenol which he was giving out by the fistful ! He went up to do an EUA on a 10 year old boy with rectal trauma who had a diverting colostomy and now has a fistula. He might be ready for a decommissioning next week. When Santiago left, I took his place in the clinic and saw all sorts of interesting pathology including a woman with a spleen down to her pelvis; hopefully we will get her in soon for surgery. I also saw an older woman with chronic cholecystitis, which was interesting because I have never seen gallbladder disease here before, and today there were 2 in clinic. And I saw a 32 year old woman with several liver masses by ultrasound; I talked to Konneh and we sent her to the Chinese hospital for a CT scan. The problem is the the new Chinese hospital is about an 8 hour drive from here; they have spanking new facilities, including a CT scanner, but they have no specialist medical staff as of yet. After clinic and lunch, we came back to the OR for an emergency laparotomy on a 20 year old man. It seems he had been sick at home for 2 or 3 weeks; he saw an herbalist,to no avail. Apparently some of his friends told him he was being poisoned; they had no idea how right they were ! Santiago, John, and Nathan o Erased on him, and found a HUGE abscess, the contents of which virtually shot in the air when they got into it. They spent several hours peeling bowel apart, and eventually found the perforation, which they brought out as an ostomy. We have our fingers crossed. It really is astonishing that he could stay home for 2 weeks, unable to eat, virtually unable to move because of pain, before finally deciding to seek medical help. Raising awareness and expectations for the public is yet another hurdle in rebuilding the Liberian healthcare system. We came bak to the bungalow, showered, and then went to Sajj for a pleasant dinner. I never was able to connect to the Internet, so I will post this and yesterday tomorrow.

Monday march 4

Our first day of work on this trip, and it was a good one !! We went to the 2nd floor surgical ward at 8:30, and were introduced to a man with an acute abdomen who was looking very poor; my initial thought was that he had acutely ischemic or dead bowel. Dr Kiiza and Dr Konneh arrived soon after, and we all soon agreed that he needed an urgent laparotomy. We got that in the works, and then saw a few more patients before heading off to Grand Rounds....only to discover they were not on for today. But when we were there we met Dr. Bobo, one of the senior internists, who told me that he had heard from Adamah last week about the possible endoscopy unit, and he was extremely excited !! So Santiago and I went to the 3rd floor to meet with Dr. Bobo and Dr. Brisbane to discuss this possibility. Dr Brisbane is probably the most senior internist at JFK, and he is a remarkable man; he stayed at JFK during the civil war to keep it running as best he could, and he is a hero in the eyes of many. Interestingly, and perhaps not surprisingly, he is quite reluctant to talk about the war years, and takes little credit for the amazing work he did. In any case, the endoscopy deal is that a GI group in Evansville decided to upgrade their scopes, and so they have about 9 colonoscopes and 4 upper scopes which they would like to donate to JFK. In addition, one of the manufacturers has offered to donate a tower, which contains the video screen, the light source, and all of the electronics for endoscopy. Santiago and I had discussed earlier how we would need a physician champion to get this up and running, and we were extremely excited to have identified them this early in our visit. We will have more meetings about this project during this visit, and hopefully we can get it up and running in 6-9 months. Having it would definitely enhance the desired role of JFK as a referral center. After that we reclaimed Dimple's 3 bags of anesthesia supplies and went off to the OR. To say the reception that we received was joyous would be an understatement !! It was a wonderful,exciting moment that I will never forget ! Santiago and Nathan did a Hartmann's decommissioning as the first case. John and I were going to do the acute abdomen as the second case, but he coded and could not be resuscitated in the preop area; In a way I was glad we didn't subject him to an operation he was unlikely to survive. Then I went to the Admin building to get more of our supplies and met Dr McDonald just outside the ED; she asked me to come with her to see a VIP who had just arrived. He had been to JFK twice in the past week with the same complaint. It sounded to me and others that a leaking cerebral aneurysm was a definite possibility, so they got a UN helicopter to fly him to Ghana. Dewalt went to the airport and was able to get the bag we forgot, and that was another good addition to the day. Dimple went right to work with the anesthetists, and I could see that they were thrilled to have an anesthesiologist with them. She was impressed with what they could do with limited resources, and they were pleased with all the supplies she brought. Mr. Hne was also very happy to receive the pulse Oximeters, which will help make surgery safer at JFK; I also gave one to Mr Moore to use when he accompanied the VIP on the flight to Ghana. Kenna also fit in well, and I could see that she will have no problems working with the scrub techs and nurses. It was a great day in the OR, and that sets a wonderful tone for our visit .

Sunday March 3 2013

We have arrived at JFK after a relatively easy journey. The flight To Accra seemed like a short 9 hours, and then the continuation to Monrovia was easy. I was quite surprised by the speed with which we were able to claim our 21 pieces of luggage; unfortunately in counting to make sure we had all 21, we counted a carry on bag, and thus discovered that we had left one bag of medical supplies at the airport. It is well marked with multiple tags and decals identifying it as a JFK Surgery bag; Wilfred said we would pick it up in the morning. I had asked for a van and a truck to meet us, but only the van was sent; somehow we managed to get all of the bags ....oh except one...and ourselves into the van for the ride to JFK. A couple of notable things : there are 2 traffic lights on Tubman Boulevard now that weren't there in September ! And here are electric poles up n the neighborhood of the bungalow ! No wires yet, but I imagine that will be happening soon...and then the generator would no longer be needed here which would be wonderful ! In the meantime, the generator is running, and it's noisy, but I think i'm getting used to it already. We all went to the hospital tonight for a quick walk around and to scope things out. It appears that there are several cases waiting for us to operate on, so hopefully we can get off to a good start tomorrow. Then we cam back to the bungalow for dinner and an early night....we are all pretty exhausted from traveling.

Saturday March 2

The team has assembled and we are at JFK Airport awaiting our flight. Everything has gone very well so far, which I hope is a harbinger of things to come. We ended up checking 18 bags, 12 of which are filled with medical supplies, and because we had been granted an excess baggage waiver by Delta, there was no charge for the extra bags. We are tremendously grateful to Delta for their support of our humanitarian mission. In those 12 bags we have a variety of supplies, some of which we will use during the 2 weeks we are at JFK Medical Center, but mostly they will be used after we leave. The supplies include everything from surgical gowns and scrub brushes to baby blankets. We are very grateful to everyone at Waterbury Hospital who saved supplies for us, as well as suppliers who provided material for us to bring. The team members are : Dr Santiago Arruffat, a former resident at Waterbury Hospital and currently a colorectal surgeon on Evansville, Indiana. This is his third trip to Liberia with us; in addition to being a superb surgeon and friend, he is an accomplished runner of the bulls in Pamplona, Spain; Dr Dimple Amin, an anesthesiologist who did med school and residency in Miami and is now in practice in Evansville; Ms Kenna Besing, a CST (Certified Surgical Technologist) from Evansville who went to Haiti with Santiago after the earthquake; Dr John Dussel, a surgical resident at Waterbury Hospital who came with us to Liberia last year; Dr Nathan Lafayette, who is also a surgical resident at Waterbury Hospital; and myself. I want to thank all of the people who have been so supportive in so many different ways as we embark on this mission. While it will be my 7th visit to JFK and Liberia, there is still a certain amount of anxious excitement about what I will be writing and feeling in 2 weeks at the end of this trip.