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.