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.