Sunday March 16

Sunday March 16

         We packed up our things, and then went to the dorm for breakfast and to say goodbye to Sotu who did such a wonderful job cooking for us during this trip. Then we went to the hospital to collect our empty duffles from the conference room, and to say our goodbyes.
          In the OR, Dr Mcdonald came up to see the work John Wasik had done. He cleaned up and transformed the old fistula room back into a working OR. The anesthesia machine in their now works, there are 2 Bovies that work, and the overhead surgical light works. Two of the JFK biomedical engineers were there who have been working with John, and I think they have a new sense of the importance of their work. Dr. Mcdonald tested Leon to see that he knew how to work the anesthesia machine, which he did, and she then told him it was his responsibility to use it, to teach others on it, and to make sure that he used the biomedical engineers to keep it in working order. In other words, as I said to him, that machine is his baby and he needs to take care of it. I think that maybe I haven't talked about Leon before: he is a young Liberian who trained as a nurse anesthetist in Morocco, and just started at JFK a few months ago. He is clearly smart, and organized, and I think he will be a good leader despite his young age.
         While we were up in the OR with Dr. McDonald, Dr Joseph Kerkula stopped in to say hello and goodbye. He is an ophthalmologist and county medical officer in Buchanan, whom I met in CT when he was staying with my friend Karen King earlier this year. We were unable to organize a trip to Buchanan on this visit because of time constraints and our schedule, but we will try again for September. Joseph suggested it could be a more official visit where we might do cases at the hospital there; Dr. McDonald was quite enthusiastic about that possibility as a means of strengthening the reputation of JFK as a referral center. We shall see how that works out.
           After another stop in the surgical unit on the 2nd floor, where we met Francis and his mother on his way out. He is the young boy with the possible Burkitt's, and whose pathology we will all be anxiously awaiting to see. We gave the nurses more ostomy supplies, for which they were profusely grateful.
          I met with Dr. McDonald to talk about this trip and future plans. She expressed her tremendous gratitude for all that we bring to JFK on these trips: supplies as well as talent, inspiration and teaching. I told her that I see significant progress at JFK in many areas. There are a number of bright lights among the physicians and other staff such as Dr. Borbor, Dr. Phil Ireland in the ED, Dr. Gbozee who is a smart and eager surgical intern, and Leon among others. I am heartened that they are developing the nucleus of a group who can lead JFK to the next level of re-development as a referral hospital. We discussed some other matters such as future directions for JFK as well as us,  and then we all piled into the van to go to Mamba Point. We stopped at the shops and bought a few things, and then had a delightful final lunch at Lila Brown's, across the street from the Mamba Point Hotel.
           As usual, I am sad to leave, but pleased that we had such a successful trip. We leave feeling good about what we have accomplished, and full of hope for future visits.
         

Saturday March 15

 Saturday March 15

      We started the day with a mastectomy on a patient referred by Dr. . We saw her in the OPD Clinic earlier in the week, and then had the usual bureaucratic nightmare of trying to get her admitted. Fortunately all it took yesterday was a word to Mary, and she was admitted for surgery today. Unfortunately the lab was unable to measure hemoglobin this week, so we didn't know if she was anemic. The nurse anesthetist  complained a little, but she didn't resist when I told her that the surgery had to be done. Period. The patient unfortunately has an at least locally advanced breast cancer with a fungating external lesion and palpable axillary adenopathy; having pathology could be important in determining further therapy.
      Then Santiago and Rakesh did a skin graft on the scalp of a young man who has been waiting for surgery for a long time. He kept asking when we would do it, so this was the last opportunity.
       We then said our goodbyes to the OR Staff, and went down town to the new Chevron Park to watch an exhibition of dance and acrobatics put on especially for us and the group from Indiana University working on developing the nursing program. It was quite entertaining and fun to watch ! After a short tour around Mamba Point we went back to the apartments to rest before the party.
       For the evening, all of us plus the Indiana University group were invited to Adelaide's house for a party. Adelaide is a longtime friend of the President, and she is also the host of the radio show that Santiago appeared on. We arrived early, and were sitting in her backyard patio when another guest arrived; she introduced herself, but I didn't catch her name. She was quite interested in the work we have been doing on this trip, and we had an especially interesting discussion about John's experience as a biomedical engineer. I told her that we all thought we had done good medical work on this trip, but John was clearly the MVP for what he had been able to fix as well as what he was able to teach the local biomedical engineering staff. We talked about how the tendency here is to push broken things to the side and ignore them rather than try to fix them. It seems easier to ignore the problem and hope that someone else will fix it rather than putting ones self out to find a solution. It was quite a fascinating discussion as she applied what we have learned into the broader context of Liberian society and culture in general. Then Adelaide came out, and we learned that this erudite woman was Olubanke King-Akerele, former Minister of Foreign Affairs and former Minister of Commerce and Industry for President Sirleaf ! She just completed a stint as the UN Representative in Zambia. One of the joys of making these trips is the not infrequent unexpected encounter with an inspiring figure such as her.
      I had several interesting discussions with the Indiana people as well as others during the course of the evening. It was a great time, and a wonderful last night before we leave tomorrow.
       

Friday March 14

Friday March 14

         We began our day with breakfast at the President's house. There was a large group of people at the breakfast which was held in the palava hut and around the pool. Besides us, there was a large group of church people from Anchorage Alaska including Aunt Jenny's son Dr. Estrada Bernard. He is a neurosurgeon in Anchorage, but on this trip they were all working at Todee Mission School doing building projects. There were also a number of other friends joining the group. As usual, the President was extremely gracious, referring to me as "family"; at the end she asked when I would be back, and I told her that I would "see you in September". She laughed and said " I like the sound of that !"
         We left there and went to the hospital to work, except for Santiago. He went with Muna to get a passport photo so he can have a JFK ID like I have, and then he went downtown to be interviewed on the radio by Adelaide, an old friend of the President who was at the breakfast and who has a regular radio show. Unfortunately we didn't get to hear it, but when he came back he said it was a blast ! In the meantime we did a baby hernia, which went well with no problems, and in the other room Rakesh did an adult hernia with Moses.
          The next patient was a 16 year old boy with a month history of fever, weight loss, and loss of appetite, and a tender mass in his left abdomen. He had an ultrasound, and then went to Tepita for a CT scan which showed massive splenomegaly with a large area of possible necrosis in his spleen, and questionable "nodules" in his abdomen. He was seen by Dr. Venee Tubman, a native Liberian who is a hematologist/oncologist at Children's Hospital in Boston who was here until last week; she is a friend of the family as is Dr. Yvonne Butler, an OB-Gyn from Baylor who has been here for 2 years on a grant from Chevron. The diagnosis was uncertain, and I eventually decided that open surgery with splenectomy and biopsy of the nodules would be the quickest way to find out what was going on. When we opened his abdomen, what we found was shocking and frightening. His massive spleen was covered with omentum contained large nodules of tumor deposits; then spleen was also adherent to his stomach, making removal impossible. I asked Santiago to scrub in to feel it and confirm my feeling that this was unresectable, and he agreed. So we biopsied the nodes and called it a day. For me, like for many surgeons, unresectability is akin to being defeated; we don't take it easily. But in this case I was worried that if we even started dissecting, we would get into bleeding that would force us into a very bad situation, and the very real chance that he would not survive. Venee thinks this might well be Burkitt's lymphoma, which is treatable with chemotherapy, so I think we made the right decision. We will get the results of the biopsies next week when we are back in Waterbury.
       Before we started the surgery on that boy, I was asked to see the son of one of the employees here. This 27 year old male had 3 days of left testicle pain, and on examination is was very hard and tender. I was pretty certain he had a torsion, but after 3 days it was most likely infarcted and would need to be removed. Mary was able to expedite his admission and paperwork, so that we brought him to the OR next where my suspicions were confirmed. We removed his left testicle, repaired his hernia on the right, and fixed his right testicle to avoid to possibility of him developing a torsion on that side.
      The last case was a 7 year old boy with constipation and "anal stenosis" whom Santiago had seen. They did a barium enema and he has a huge rectum, so he thinks he has Hirshsprung's disease. He did a rectal biopsy, and we shall see what that shows.
      In the evening we went to a ceremony celebrating the first 6 months of school for nurses and physician assistants. It was a long ceremony with many, many speakers; we had been recognized as special guests, and at one point they asked if I would like to say a few words. Unfortunately, or perhaps fortunately, I developed a coughing fit, so I pointed to Santiago sitting next to me to make the comments which he did very well. Once he was finished speaking, my coughing miraculously ceased... He let me know that I will pay for that !
       As usual, it is a sprint to the finish as we end our 2 weeks here. We weren't able to get to Buchanan to see Dr. Kerkula, which was unfortunate, but I told him we would try again in September. We have a couple of cases to do tomorrow morning, and that should be it.

Thursday March 13

Thursday March 13

         My cold seems to be better ( perhaps because of the Indian food last night), and so I slept well. We had a lot of cases on our schedule today; as usual we didn't do all of them for a variety of reasons, but we still had a good day. We started out with a 1 year old boy who had a moderately large hernia. All seemed to be going well until midway through the operation when he coughed and bucked a little, and his airway was lost. There was a scramble at the head of the table as Philomina, Mr.Hne, and others tried to get it back; in the meantime the tone of the pulse oximeter was low and worrisome. To explain: the pulse oximeter measures the oxygen saturation in the blood using a fingertip probe with a light. Normal oxygen saturation is in the 95-98% range and with such a reading the oximeter we have emits a high pitched beep; when the saturation starts to fall, the tone becomes lower pitched. One of the things about working on small children is that their saturation can fall much more quickly than an adult's would. Fortunately, we have some excellent pulse oximeters obtained from Lifebox (www.lifebox.org) which are produced at a low cost to make them available in minimal/low resource settings. I had heard about Lifebox in a talk by Dr, Atul Gawande at the American College of Surgeons meeting, and with help ( thank you Darryle and Jon) I was able to obtain several for use at JFK.          
        Returning to today, they were able to mask and then eventually intubate the baby, and we finished the operation as quickly as we could. It then took several hours for the baby to wake up, and for us to feel that he could safely breathe on his own. Throughout those several hours, we sat and watched him in the OR, and listened to the tone of the pulse oximeter as it went up and down. Eventually he did wake up, and he is fine, but it was a difficult experience for all of us particularly at the beginning when they were struggling to oxygenate him. Philomina did a fantastic job staying cool and figuring out solutions, and we were all very grateful she was there.
      While we were in one room dealing with that, Santiago and Rakesh did a couple of hernias, and a breast mass excision. Santiago was momentarily indisposed during the breast mass excision, so Yuk went in to help. By that time we were ready to start the next case in the other room, so Santiago came in to help me with a splenectomy. The patient is in her mid 40s, and had a huge, uncomfortable spleen which was probably enlarged by repeated bouts of malaria. Sometimes when a spleen gets big, it starts eating up platelets, and that is a reason for removal; her platelet count was 40 thousand, with normal being 150-300 thousand. When the platelet count goes under 50 thousand, there is an increased risk of bleeding; ideally we would have liked to give her platelets during surgery, but that capacity does no exist here. I reassured Philomina that we could do it with minimal blood loss, and we did. As always, it's fun and good to operate with Santiago.
       The last case of the day was a young girl with Crohn's disease whom Jonathan Laryea met at Phebe Hospital on a previous visit to Liberia, and then he and Santiago have been seeing her each trip and bringing her medicine. Her Crohn's has progressed, and so she was admitted yesterday so that Santiago could examine her under anesthesia today. based on the exam, they will play around with some different medicines and hope for the best.
        We have only 2 days left for operations on this trip, and as usual it is very hectic coming to the end. Time to go to sleep and rest for another busy day tomorrow.

Wednesday March 12

Tuesday March 11

1 year old LIH
Femoral hernia
RTA head and neck lacerations
R lobe thyroid
Parotid
Ex lap and washout

       We had another relatively busy day today, but thought we would finish early until the last case came along. We started with a 1 year old boy with a hernia while Santiago was doing a femoral hernia repair. Then they brought up a man who came into the ED comatose a few days ago; the story was that he was a pedestrian struck by a motorbike, but the ED physician thought that story was bogus. In any case, the said his GCS was 3 when he arrived ; he had an open skull fracture, a neck laceration, and a fractured humerus. Over the course of 2 days, he wakened from his coma, so I guess they thought is would be reasonable to repair the lacerations, and thus we became involved. Due to lack of beds, he came from the Trauma ED to the OR for the repair, and then was returned to the Trauma ED. Weird system, but it sort of works !  Next on the docket was a parotid mass for me and Yuk and a thyroid mass, probably cancer, for Santiago, Rakesh, and Konneh.
       The final case was a 40 year old man who had presented 2 weeks ago with an acute abdomen and was operated on by Dr. Konneh, who said he found a perforation of his cecum, and another in his sigmoid colon, presumably due to typhoid. But he also said there were patchy areas of necrosis on the anti-mesenteric border of the colon, and he didn't know what the significance of that finding was. We had seen him in his bed on a regular basis since we have been here; he wasn't going downhill, but he also wasn't progressing the way we thought he should be. Intuition remains a critical element in medical and surgical decision-making here, in large part because there is often no way to confirm a hunch. Santiago and I had talked almost daily about whether this man needed another look inside his belly, so yesterday afternoon I went down to see him. The nurses said he was eating and getting out of bed, and I was thinking maybe we could continue to hold off on further surgery. I asked Diana, the head nurse on the surgical ward and very clinically astute, what she thought, and she said we should take him to the OR. So we did.
       Santiago and Yuk found an ungodly mess with abscesses, another perforation, and necrotic omentum. He ended up doing a total abdominal colectomy. Philomina was superb with his anesthesia, giving him blood and fluids over the 3 hours of operating. He was intermittently hypotensive during the case, and then he just didn't want to wake up and breathe on his own. This year, in contrast to last year, they have a ventilator at JFK so he was transferred there for overnight observation.
        We went to have our dinner at the dorm around 10 pm, and then stopped at the ICU to see the last patient. He was very cold, and obviously in critical condition; we left around midnight with our fingers crossed.

Tuesday March 11

Tuesday March 11

1 year old LIH
Femoral hernia
RTA head and neck lacerations
R lobe thyroid
Parotid
Ex lap and washout

       We had another relatively busy day today, but thought we would finish early until the last case came along. We started with a 1 year old boy with a hernia while Santiago was doing a femoral hernia repair. Then they brought up a man who came into the ED comatose a few days ago; the story was that he was a pedestrian struck by a motorbike, but the ED physician thought that story was bogus. In any case, the said his GCS was 3 when he arrived ; he had an open skull fracture, a neck laceration, and a fractured humerus. Over the course of 2 days, he wakened from his coma, so I guess they thought is would be reasonable to repair the lacerations, and thus we became involved. Due to lack of beds, he came from the Trauma ED to the OR for the repair, and then was returned to the Trauma ED. Weird system, but it sort of works !  Next on the docket was a parotid mass for me and Yuk and a thyroid mass, probably cancer, for Santiago, Rakesh, and Konneh.
       The final case was a 40 year old man who had presented 2 weeks ago with an acute abdomen and was operated on by Dr. Konneh, who said he found a perforation of his cecum, and another in his sigmoid colon, presumably due to typhoid. But he also said there were patchy areas of necrosis on the anti-mesenteric border of the colon, and he didn't know what the significance of that finding was. We had seen him in his bed on a regular basis since we have been here; he wasn't going downhill, but he also wasn't progressing the way we thought he should be. Intuition remains a critical element in medical and surgical decision-making here, in large part because there is often no way to confirm a hunch. Santiago and I had talked almost daily about whether this man needed another look inside his belly, so yesterday afternoon I went down to see him. The nurses said he was eating and getting out of bed, and I was thinking maybe we could continue to hold off on further surgery. I asked Diana, the head nurse on the surgical ward and very clinically astute, what she thought, and she said we should take him to the OR. So we did.
       Santiago and Yuk found an ungodly mess with abscesses, another perforation, and necrotic omentum. He ended up doing a total abdominal colectomy. Philomina was superb with his anesthesia, giving him blood and fluids over the 3 hours of operating. He was intermittently hypotensive during the case, and then he just didn't want to wake up and breathe on his own. This year, in contrast to last year, they have a ventilator at JFK so he was transferred there for overnight observation.
        We went to have our dinner at the dorm around 10 pm, and then stopped at the ICU to see the last patient. He was very cold, and obviously in critical condition; we left around midnight with our fingers crossed.

Monday March 10

Monday March 10

        I have a miserable cold with a stuffy runny nose and a cough; this isn't a whole lot of fun when operating with a mask on etc., but our work goes on. Yuk and Rakesh reported at breakfast that our patients were doing well with no particular post-op problems. We then all went to Grand Rounds, but it was cancelled so we went to the OR for another productive day. First Yuk and I repaired a ventral hernia on Barbu's wife, and then we did a 10 month old with a hernia. In the meantime, Santiago and Rakesh did an adult hernia in the other room. After that we switched rooms so that they could do a splenectomy followed by surgery on Thomas, an 8 year old boy.
        Putting a story together based on information in the chart is an interesting and quite inexact science here. It would seem that Thomas came to the hospital last August with 3 days of abdominal pain, and a history of constipation. It is unclear to me how, but they made a diagnosis of Hirshsprung's disease, and did a colostomy. Subsequently, in November, he underwent recto-sigmoid resection and reanastomosis, but he developed an anastomotic leak and underwent another surgery to create a colostomy again. He is well now, so Santiago wanted to try to restore his intestinal continuity. We think the diagnosis of Hirshsprung's is most likely incorrect. So in the OR after a rigid sigmoidoscopy they took down the colostomy, found the rectal stump, and did an EEA anastomosis. Flying on a wing and a prayer, and hoping for the best, he decided not to do a diverting ileostomy in hopes of sparing Thomas yet another operation.
         We thought we were done for the day, but then we received word of a patient with appendicitis in the ED. This 57 year old man had a 3 day history of RLQ pain, and an exam consistent with appendicitis. The problem was that we had apparently run out of anesthetic gas. Philomina asked if we could do it under spinal, and I said I would try. We made a small RLQ incision, and immediately a lot of pus and stool came out, causing me to abandon that approach. So we made a lower midline incision, but with the patient breathing and pushing, it was impossible to do what we needed to do because he was pushing his intestines out through the incision. I looked at Philomina, and she said ok, so then she gave him a muscle relaxant and I don't know what else but we were able to complete the surgery. It turned out that he had a large cecal perforation rather than appendicitis, and I ended up doing a right hemicolectomy. I imagine the perforation was due to typhoid; I will bring a specimen home for the pathologists to tell us what they see.
      After finishing that, we went to the dorm for dinner, and then back to the apartments. I'm miserable with this cold, and would give my eye teeth for a bottle of Afrin right now !!

Sunday March 9

Sunday March 9

After breakfast, all of the others went to the beach at the RLJ Resort; I stayed home trying to feel better from a head and chest cold. I re-read President Sirleaf's autobiography, and gleaned some new details which I found interesting after spending a lot of time here. She, and her family, made a lot of sacrifices along the way for her career; the choices must have been very difficult, but clearly she possesses an indomitable spirit with which she overcame all sorts of roadblocks.

I have a head and chest cold unfortunately. I am going with the "air conditioning" theory of disease, whether or not Louis Pasteur would agree ! I think the cold air blowing on me at night brought it on, and in the future I will be more cautious about it. The first couple of nights I was awoken because my feet were cold, and I then turned off the A/C; after a while I would get hot and turn it back on again. We live and learn.

We have completed our first week, and I think we have been quite successful so far. Our surgery volume is at a record-setting pace, and the team is functioning very well. Once again, having an anesthesiologist with us has been critical to our success, and having Philomina in particular has been great! She is adaptable, conscientious, smart, and always thinking of how we can do things better or faster. Kenna is a wonderful scrub tech who is organized, bright, and funny as well; I like to think that the Liberian scrubs are learning a lot from the way she does things. Yuk and Rakesh are doing an excellent job of keeping us organized and on target, and they are also obviously enjoying the experience. John Wasik is the gem of the trip: I knew he would be useful, but I had no idea that he would be able to do as much as he has done to repair and organize equipment. Finally, as always, Santiago is an awesome co-leader of this venture as well as a friend and compatriot. He brings wit, wisdom, and joy to the team which makes the experience better for all of us.

On to Week 2 !!

Saturday March 8

Saturday March 9

     After breakfast at the dorm we went to JFK to do some surgery. We had 2 cases planned, but Sano( one of the scrub techs) brought his brother in who has a recurrent hernia. We discussed doing it as a One Day Surgery, and Sano said that would be fine and he would take care of him. Then Percillar came in, and thought that was crazy because it was too big of a case to do as a one day; she and Sano had a discussion, and then she relented. So while Santiago and Rakesh decommissioned an ileostomy in a 12 year old boy who had had a typhoid perforation, Yuk and I repaired the recurrent hernia. It was a big mess, and difficult to sort out what was what, but eventually I was happy with our repair. We used a piece of Ultrapro mesh, and that made the job of the repair much easier I think. As always sterility was a concern : we soaked the mesh in Betadine until just prior to implantation, but we has the windows open in the OR because there was no air conditioning. I think it will all work out.
      The other case we did was rather interesting. He is a 55 year old man with an abdominal mass for a year which was getting bigger, though it doesn't seem like it was particularly painful. He had an ultrasound which showed a cystic mass extending from his liver to his bladder, and the diagnosis given was a mesenteric cyst. Santiago and I like to do a case together on each of these trips, to remind us of the old days when he was a resident, so we did this operation together.  After the patient was asleep I felt this large, volleyball sized mass in his abdomen; after a Foley catheter was placed with ease into his bladder, the urine started coming out and the mass shrunk considerably ! Eventually, after draining about 6000ml, the mass was gone! We decided we would take a look to see what was going on, and we found just a huge bladder with no obvious obstruction. We decided to reduce his bladder volume with a partial cystectomy, which went smoothly.
       Later in the afternoon we went for an excursion around Monrovia, taking Dewalt with us,  to the carving shop as well as Mamba Point and the Hotel Ducor. Then back to the apartment for a short nap prior to going to The Great Wall for Chinese food. Wilfred joined us, and then he took some of the younger ones out for drinks. Santiago, Kenna, and I decided to call it an evening and went back to the apartments.

Friday March 7

Friday March 7

I like the way we are adapting and organizing. We try to leave from the apartments at 7:45, and Albert has been very good about being here waiting for us to go in the van. We have breakfast in the dorm; Yuk and Rakesh have already rounded, so they are able to give us updates on all the patients. The sad news this morning was that the young girl with the burns died overnight; it is not clear what the cause was, but I have to say that I was not surprised given her overall condition. All of our other patients are doing well. Then we walked over to the hospital to start our work day, announcing with some fanfare to the OR staff that we have arrived and are ready to begin working. The initiation of activity sometimes requires more prodding than should be necessary, but I have to remember that this is Liberia!! Philomina Thuruthumaly, our anesthesiologist, has been fantastic about getting things going, and also figuring out ways to maximize our ability to use the resources we have available. We currently have only one anesthesia machine available; John Wasik is working on getting a second one up and running but it hasn't happened yet. So we are limited to one room for general anesthesia, but we can use spinal and/ or local with sedation on other patients in the other room; Philomina has been fantastic about suggesting ways to do that.
      Our first case today was a one year old boy with a large right inguinal hernia; his father works at JFK. Yuk and I took care of it; as usual there were moments of intense anxiety with going into and coming out of anesthesia, but it went well. It was kind of weird having the father in the room while we operated; I will talk to Percillar about whether that is a custom here. While we did that case, Santiago and Rakesh did an adult hernia in the other room
      Next was a 19 year old male with an abdominal mass. Apparently he had appendicitis, and was operated on at another hospital where the surgeon found an unidentifiable mass and closed him up after doing the appendectomy. He then referred him to JFK for further evaluation. He turned out to have a large retro peritoneal mass involving the base of the small bowel mesentery. There was no adenopathy and no evidence of spread. It was clearly not resectable, so we took a biopsy of it and closed. With luck it might be a desmoid tumor.        
       Our 4th case was an adult hydrocele which Yuk and I took care of.
       Later in the afternoon we went to their first "Mortality" conference, which is different from what I had expected. It seems like this is an attempt to introduce more accountability in the departments at JFK; I'm not sure the system they have developed is optimal, but it is a start.
        After changing we went for dinner at Sajj at the invitation of Tony, the owner, whom I had met at Aunt Jenny's the other night. In fact, I had met him several years ago when I and others were invited to lunch at his house next to Sajj after we had repaired his brother's hernia. Anyway, he came and joined us with a hookah as we ate, and then assured us that our meals were on the house. It was very kind of him, and we had a delightful meal.
     

Thursday March 6

Thursday March 6

Everyone is doing well after yesterday's marathon, so that was welcome news this morning. One of my constant worries is that we will arrive at the hospital in the morning to learn of some disaster overnight with one of our patients. But today the disaster happened during the day: I mentioned previously a 4 year old girl with a recurrent chest wall tumor that I thought might be a sarcoma. We talked with Venee Tubman, a hematologist-oncologist at Children's Hospital in Boston, whom we have met here previously several times; she thought it might be some sort of lymphangiomatous process, and I thought she might be right. Venee is going back to Boston on Saturday, and we decided to get a biopsy of the mass, so that we might know what it is before we leave, and perhaps we could do something like debulk it. So we brought her to the OR, and Philomina gave her some Ketamine so we could examine her. The mass was huge covering her entire left chest and extending over her shoulder to her back. It was predominantly jelly-like, and I was able to remove a large piece for biopsy just using my fingers to squeeze it off. It was one of the most bizarre things I have ever seen.
      Unfortunately a hour or two later, Yuk was called to the Pedi floor because the girl was unresponsive. She didn't bleed, she tolerated the Ketamine with apparent ease, and everything seemed to go smoothly as far as we were concerned. But she faded away, and died soon after Yuk got there. I have no explanation for it, but I can't help thinking it was probably a blessing for her.
       After that Santiago spent several hours doing an abdomino-perineal resection on a patient with rectal cancer whom we have seen here several times in the past. In fact, we saw her at the end of our trip in September, and she decided she wanted to wait till Santiago came back in March for the surgery she knew she needed to have. She is a Jehovah's Witness, and thus refused to allow any blood transfusions; the operation can be bloody under the best of circumstances, so doing an APR on a Jehovah's Witness in Liberia is a huge challenge. Those of you who know Santiago know he was up to the challenge, and it seemed to all work out very well.
      While he was doing that, Yuk and I excised a breast mass from the mother of one of the nursing supervisors. I think it is benign, but we won't know until the pathologists at Waterbury Hospital check it when we get back. A couple of interesting points: the daughter was in the OR taking photos with her cell phone ( I was too astonished to comment on the appropriateness of it), and after a short stay in recovery, the patient went home! I believe that is the first surgery at JFK where a patient received more than local anesthesia and then did not stay overnight. Yes, One Day Surgery is coming to JFK!
       We then did a couple of minor cases, and finished up with a mastectomy on a 37 year old woman. She first noticed changes in her nipple more than a year ago, but delayed seeking treatment. She had obviously involved lymph nodes which we removed with the breast, so I think the long term prognosis for her is not good unless she can get access to chemotherapy. Unfortunately it is not readily available, and what is available is costly, so not many people receive it.
        We are so lucky to have John Wasik with us on this trip. He is a biomedical engineer who is able to figure out al sorts of problems and fix them. He has been fixing all sorts of machines at JFK, and it is great to be able to call on him when we have a problem, just as we do in the OR at Waterbury !! He has also been finding all kinds of equipment stored away; today he found a suction machine and got it working ! Many others in the hospital want him to come work on their problems, but for the time being we are keeping him in the OR. Today I was asked if John was teaching the Liberians how to fix things like he does; my answer was that what he possesses cannot be taught. He has the knack, the smarts, the skills to see solutions that others can't see.
        After making some rounds we went to the dorm for dinner, and then back to the apartments for an early night.

Wednesday March 5

Wednesday March 5

      We had quite a day today ! We did 9 cases, which might be a record for us! Yuk and I started with a large pediatric hernia and hydrocele, and then did Emil who had an incisional hernia.
      One of the pediatricians, Dr. Shankar, had messaged me on Facebook that he had a friend who had a large incisional hernia which needed repair, probably with mesh. I was reluctant to put in synthetic mesh because of the risk of infection, so I told him I would try to get a piece of biological mesh, which is less likely to get infected. I spoke to the rep from Cook Medical, Alyssa, who then gave me the email address for their mission donation program. I filled out the application, and shortly before we left they emailed me to say it had been approved; soon thereafter I received 4 large pieces of mesh! This was an incredibly generous donation as the product is very expensive; I am extremely grateful to Cook Medical. We used one of the pieces for the repair of Emil's hernia today, and the operation went very well.  
      The next case was an acute abdomen from the ED which Santiago and Rakesh did, and which proved to be an ideal perforation from typhoid. Then we removed a large round keloid from the neck of a young man who had been referred to us by Aunt Jenny while the other tools care of another melanoma of the heel with palpable groin nodes.
      Next we all worked on an unfortunate 6 year old girl who received bad body burns from boiling water spilled on her. She has no IV access, and so they asked us to help. I tried a saphenous vein cutdown, but she is so dehydrated that proved impossible; we tried a cephalic vein cutdown which was also unsuccessful; finally Santiago put in an IJ line. We changed her dressings under anesthesia; her burns look and smell infected, and I suspect she will not survive, but we shall see.
        Then we did a couple of hernias: Rakesh and I did the biggest inguinal- scrotal hernia I have ever seen. It was truly an African hernia, which the scrotum filled with bowel and extending more than halfway to his knee. It was a difficult but interesting experience fixing it, as the anatomy was totally distorted by the size of the hernia, and the fact that this was a recurrence from a repair previously made in the late 1990s. We finally finished it, and in the meantime Santiago had been called about another acute abdomen in the ER; that one turned out to be a perforated gastric ulcer which he repaired. We finally finished around 10:30, went to the dorm for a quick bite to eat, and then to the apartments for bed. It was a long, but productive and rewarding day !

Tuesday March 4

     We had quite a good and productive day today, despite starting later then usual. Percillar and others were delayed because they had to get their cars registered as a new law is taking effect requiring that; until now, registration has not been required apparently ! We started with a young man we were asked to see in the ED yesterday who presented with a history of a month of vomiting. It was described as projectile, but bilious, and that didn't make much sense since typically projectile vomiting is not bilious. They had done a barium swallow and follow-through which showed barium in his colon while some was still in his stomach, indicating that there was no obstruction. But the doctors were convinced he had something serious going on that required surgical correction, so I agreed to operate on him to find out what was going on. It came as no great surprise to me that today we found nothing wrong. Perhaps he has gastritis or perhaps it is psychological; in any case I wish I had listened more to that little voice inside telling me that the story didn't add up. The problem is that I have been fooled a few times in Liberia by that little voice, so sometimes I don't listen to it. In this case the patient had an "unnecessary" operation, but it did prove to everyone that there was no serious internal pathology so I guess maybe it was worth it.
     Rakesh and I then did a little girl with a large umbilical hernia. Apparently her mother had tried to make it go away by tying it off with a string around the base; all that did was to cause an ulcer on the overlying skin. The was bowel in the hernia, so I guess the little girl was lucky that the damage from home treatment wasn't worse.
      We then went over to the Maternity Hospital to operate on 2 women at the request of Dr Butler; both of them had burst incisions following C-sections. One of then had burst about a week ago and had small bowel exposed; we were able to close the fascia and hopefully they will do well, though I think they are both at high risk for developing a hernia.
      While we were doing that, Santiago and Yuk were doing a 60 year old man who had presented with an acute bowel obstruction. He turned out to have a sigmoid volvulus which they resected and did a primary anastomosis.
     The final case of the day with one of the men with a malignant melanoma on his heel and big nodes in his groin. We doubled teamed him, with Santiago and Rakesh doing his foot which Yuk and I did his groin. Since the only OR light was a single portable one, I was glad to have a headlamp ! I how we have provided some palliation for the man so that he can walk around without the mass on his heal, but unfortunately his prognosis is rather grim.
     Right now we are limited to one OR because there is only one working anesthesia machine, so while we were operating, John Wasik was trying to fix one of the anesthesia machines that isn't working. He thinks he is making good progress, and hopes to have it up and running in the next day or two; having a second machine, and thus a second room available will allow us to be much more productive, and given the amount of work ahead, that will be a very good thing!
     

Monday March 3

Monday March 3
      After an uneventful but long trip here through Brussels on Brussels Airllnes, we and our 21 bags arrived in Monrovia last night. We have brought an extraordinary amount of supplies, thanks to the generosity of many people, especially including Alyssa at Cook Medical, Jenn and Rose at Ethicon, Mary and Tanya and Donna at Waterbury Hospital, and Brussels Airlines for allowing us to bring an extra bag each at no charge. A further huge thank you to our Waterbury Hospital family who have pitched in so remarkably to help us do this work.
      We drove to JFK Hospital where we were met by Dr Mcdonald; she had arranged to have a meal waiting for us at the Maternity Hospital. We learned that the bungalow is once again out of order, so the 4 of us will be staying at the TGH Apartments, where Jonathan Laryea and I had stayed a couple of years ago. They are very nice, and have hot water and a/c; the only problem is that they are a drive from the hospital, and that can be a long drive in morning traffic. In addition to the issues at the bungalow, apparently there was a transformer fire, and the dormitory is without power, though it is expected to be fixed in a day or two.So in the meantime, the other 3 members of our team had rooms at Bella Casa,a hotel nearby.
      Oh, I forgot to tell you about the team. Besides me, the team includes Dr. Santiago Arruffat, a former resident now colo-rectal surgeon in Indiana making his 4th trip to Liberia; Dr. Philomina Thruthumaly, and anesthesiologist from Indiana; Kenna Besing, an OR Tech from Indiana who came last year; Dr. Yuk Ming Liu, one of the current Chief Residents at Waterbury Hospital who came here with us 3 years ago; Dr. Rakesh Hegde, a junior resident in our program; and John Wasik, a biomedical engineer at Waterbury Hospital.
      After a good night's sleep we all met fro breakfast in the dorm,and the went to Grand Rounds. The presentation was on trauma, and road traffic accidents in particular, presented by 2 doctors from the ED. It was a very well-presented talk, and there was lively discussion afterwards about how to go about involving all interested parties, from medical to law enforcement to government, in the process of forming regulations to decrease preventable deaths from accidents. Not much different than the discussion we have in the US on a regular basis.
       We then went to the OR to greet our friends, and then went on the wards with Dr. Konneh. By early afternoon, we had a list of 14 people who need surgery, and they are just the ones already in the hospital. Several interesting problems: 2 men with malignant melanoma on their heel and palpable inguinal adenopathy; a 4 year old with a recurrent huge mass on her left chest which must be a liposarcoma; an young man with an enterocutaneous fistula after laparotomy last week; a child with a huge umbilical hernia; and a young man with several months of projectile vomiting of bilious material. And at the Maternity Hospital there are two women with wound dehiscence and evisceration which was treated conservatively. There is no doubt that we will be quite busy over the next 2 weeks !!
       Santiago and Yuk operated with Dr. Moses on the young man with the enterocutaneous fistula. He was operated on by Dr. Moses a week ago, and has had a rocky post-op course with renal insufficiency which resolved...but yesterday he started leaking enteric contents through his wound. So they took him back to the OR and found several holes in his small bowel which they repaired; hopefully he will improve now.
       At dinner tonight, we were discussing the electrical problem at the dorm with the burnt out transformer which apparently could not be fixed today. So Dr Mcdonald bought a generator which is in the process of being installed. I asked John Wasik how complicated a procedure the connection might be, and he responded : "After what I have seen today, I couldn't even imagine !" I thought that was a pretty good summation. The Liberian people are able to do a lot with very little, and often what they do defies imagination.
          I was invited to Aunt Jenny's tonight for a small party. I went with Dr. McDonald; I knew more of the  guests than I would have expected, and all in all it was a very good time. Tomorrow we have a busy day, so it's time for bed.

Preparations

As we prepare for another trip to Liberia, I want say a special thanks to the following:

* Brussels Airlines : they have provided us with discounted tickets, and have allowed each of us an extra bag of checked luggage! There are 7 of us on this trip, so we can check 21 bags without an extra fee!! That will allow us to bring a lot more supplies, and that's a wonderful thing !
* Clarine Vaughn : Clarine is the Executive Director of HEARTT, and she was able to get us the excellent deal with the airline. Big thank you for that, Clarine !
* Alyssa Redmon and Cook Medical: Without going into great detail now, since I will be telling the story in the blog later, we have a patient waiting in Liberia who needs a special item that is quite expensive. Alyssa listened to my stories of Liberia, and then put me in touch with the right people at Cook Medical, who have donated this item for us to use.
*Jenn Imerini and Rose Esposito and Ethicon: Through their efforts and generosity, we will be bringing a large duffel bag weighing 45 pounds which contains just sutures!
*Ann Sawyer and Americares : Americares does wonderful relief work delivering medical supplies and people to disaster areas. The have set up a program, directed by Ann Sawyer, to provide supply assistance to medical missions such as ours. The have an on-line inventory, and they make it simple to browse the inventory and ask for needed supplies. It's very organized, very easy, and very generous.
*The OR Staff at Waterbury Hospital: About a month ago I asked if they could start saving supplies that would otherwise be discarded for us to take to Liberia. I put a large container in the OR for this purpose; within days it was filled, and I have emptied it several times since. It feels good to be able to make use of supplies which would otherwise be thrown away.
*Mary and Tanya are in charge of maintaining the OR Supply system at WH. They are always thinking of our work in Liberia, and what they can do to help. Their aid is invaluable, and their encouragement is priceless. And the cookies they baked for us were awesome!!
*Donna is the OR Supply buyer in the Purchasing Department at WH. Like Mary and Tanya, she is constantly looking for ways to help our work and the people of Liberia.
*The staff of the Department of Surgery at Waterbury Hospital, the staff at Alliance Medical Group, Dr. Scott Kurtzman and my surgical colleagues : all of them contribute in so many ways to our success in Liberia. My gratitude for your support is immense.

There are many others who have helped in innumerable ways; some of them know the material and financial support they have provided, and others only know that they have offered encouragement, but they don't realize how much that encouragement has meant to all of us who have the honor and pleasure of doing this work in Liberia.