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.