Thursday and Friday May 15

Thursday May 14 and Friday May 15 I failed to write yesterday, so this one will be a double. Yesterday was a national holiday, Unity Day, though unfortunately I have no idea what Unity refers to since the holiday goes way way back in history. In any case, we went to the hospital where Santiago spent most of the day teaching Precillar and other personnel about the endoscopy equipment. By the end of the day he was feeling pretty confident that they understood how to take care of it. We discovered that the system needs a power conditioner, which prevents spikes in voltage; the spikes do a job on delicate instruments and blow out expensive light bulbs quite readily. Fortunately they had a large power conditioner in the room used for endoscopic ventriculostomies, so Santiago moved the scope tower etc into that room. The training seemed to go very well, and at the end he was confident that the endoscopy equipment is in good hands. When we were done there, we went for lunch at Sajj, and then back to the apartment for a nap. Last night we had dinner at Taj, and then packed up to leave in the am. Today we were up early to get to JFK and say our goodbyes to the Operating Theater staff, the surgical faculty, Dr. Johnson, etc. Robert Dolo picked us up at 9:30, and we went to see the new Eye clinic he is building, the current clinic he is using, and a school which my friend Karen raised money to build. Robert is a Liberian who trained as an ophthalmic technician, and then went to Ghana for a year to learn cataract surgery. Karen met him there, and he told her of his dream to build an eye clinic in Liberia; she helped make his dream come true by speaking to nearly every Rotary Club in CT in addition to many other people. He has built up his clinic so that he offers exams, same day cataract surgery, and an optical shop to make glasses. There aren't many other places in Liberia where people can get glasses made, so this is a very important service. In his new clinic being built, he will offer all of the above, plus he will have a dental clinic there: teeth and eyes in one shop ! In addition to all of the above, he and his staff go out into the country to do outreach programs, and operate on cataracts. It may seem odd that a non-MD is doing cataract surgery, but he is appropriately selective about the patients he operates on, and an ophthalmologist from the U.S. has vetted his work and found it quite good. The school we visited was the New Life Christian Academy, and it was very sweet. At each classroom we visited, the students stood up and said in unison:" Welcome visitors. Thank you for coming to our school"! One couldn't help but smile, and recall that these students missed most of the year since all schools were closed due to Ebola from September till early April. Upon our return to JFK, we met with Munah to discuss our trip, and some of the things that need to be done to keep the endoscopy unit functional. She called Dr. McDonald in Indiana so that we could say goodbye, and discuss our visit. Then Masmina came and we had a good discussion about HEARTT etc. Now we are at the airport waiting for our plane, which we have just learned is at least 3 hours late, so we are in the airport bar with Michelle having a free beer courtesy of Brussels Airlines !!

Wednesday May 13

Wednesday May 13 We arrived at the hospital in time to catch the tail end of the surgical conference being held in a library room near the dental clinic. Moses was fortuitously discussing upper gastrointestinal bleeding; he was asked a number of questions by the faculty, and then we were asked if we had any questions for him. It seemed like the right moment to tell them that through Santiago, JFK was the recipient of a full endoscopy set-up including 2 upper scopes, 3 colonoscopies, 3 flexible sigmoidoscopes, and a tower with 2 Fuji processors. He had sent all of the 15 boxes of equipment from Evansville to a shipper in Maryland who then freighted them to Liberia last fall. The faculty, especially Dr. Sherman, was beside himself with excitement, so we immediately went to the old fistula room in the OT where the equipment had been set up. You might have thought it was Christmas with the number of smiles in the room ! The endoscopy unit is a big deal for a lot of reasons: it is an important resource as JFK rebuilds itself as a major referral center; it provides the surgeons, and surgical trainees, the chance to use current technology; and it will help build pride in the services provided by JFK. We left there to make rounds as a group. There was a pediatric burn patient, and the trainees were grilled in detail on burn care. Santiago and I agreed that it was a wonderful thing to see because through such grilling they will learn and not forget. As we left the Pedi unit, Santiago and I were discussing the need for a pathologist with Dr. Freeman. A ways into the conversation, he began telling us about when the Japanese government donated 2 microtomes (machines used to cut extremely thin slices of tissue for viewing under a microscope) in the late 1990s in the midst of the Civil War here. He then proceeded to tell the riveting story of his life in Liberia during that time, with war going on all around. He eventually walked with others from Monrovia to Robertsfield, the site of the airport; it takes an hour to drive that distance today. It took them a day in which they had to hide from combatants, stop to sleep in an abandoned house, and basically feared for their lives. It was yet another Liberian story that should be recorded for posterity. After lunch we were asked to stop in to the ED CCU to see a hospital employee who was quite ill. She had started feeling sick a month ago, and soon went to Ghana where she was diagnosed with acute myeloid leukemia. Her daughter told us that in Ghana they recommended that she go to India for treatment, but it would cost $20,000. They didn't have that kind of money so they brought her back to Liberia. In the past day she was have increasing difficulty breathing, and her eyes were bloody and swollen, so they brought her to JFK. I told the daughter that unfortunately there was nothing to be done, and that she was in no condition to fly to India at this point even if they had the money. It was a sad, but not atypical situation. For the rest of the afternoon, Santiago continued to fix up the endoscopy suite and teach Precillar some of the tricks involved in the care and feeding of scopes. I went to the Admin building to meet Robert Dolu, and to give him some funds from Karen. We had an excellent conversation about Ebola etc; we will spend some time with him on Friday morning visiting the Eye Clinic and the school that Karen worked on funding. For dinner we met Michelle and Payla at Fuzion(used to be Jamal's on the Boulevard). They are working to build community awareness of infection control at government hospitals through a grant from the Paul Allen Foundation. Michelle has been in Liberia for 6 months, got malaria despite taking malarone, and got amebiasis; other than that she is doing well and seems to be enjoying herself.

Tuesday May 12

Tuesday May 12 Tubman's revenge struck me last night unfortunately so I was up and down a lot, and felt quite tired this morning as a result. We made rounds with the surgical team this morning, and had some interesting discussions about chest trauma and caustic ingestion in a child. We also went to the Maternity Hospital to see a baby with a myelomeningocele. From there we went to the OPD where Santiago saw Ophelia Jallah: he did a transanal resection of a cancer several years ago, and then did her APR a year ago March. She seems to be doing very well with no evidence of recurrence at this point. We then saw a 25 yr old female patient of Konneh who presented with abdominal pain in March, and was found to have a mucin out adenocarcinoma involving both the ovary and her recto sigmoid. It isn't clear whether this is ovarian cancer invading the colon or colon cancer invading her ovary; in any case, this is not good for her. She has a colostomy and wants to be put back together; this is understandable, but I think it is too early and I suggested we wait till September. I think she should have a CT scan at Tapitta, and perhaps a colonoscopy prior to putting her back together. After the OPD, Masmina, Adamah, Dr. Johnson, Munah,Santiago and myself met to discuss the plans for JFK and HEARTT and the postgraduate program among other things. Dr Johnson suggested that they need $50-$60 million to restore JFK to where it needs to be; finding that kind of money seems like an impossible task to me. We also discussed the working of the postgraduate program, and how HEARTT will fit into that. From that meeting Dr Johnson, Munah, Santiago and myself moved to a meeting with Dr Freeman, the Chairman of the postgraduate Surgery program; Dr. Kiiza; Dr. Atem from Sudan who trained in Liberia and Ghana; Dr. Patrick from Uganda; and Konneh. We asked for the meeting to clarify the relationship of HEARTT to the Postgraduate program, in this case specifically surgery. I think it was a productive meeting in which cards were laid on the table. Dr Johnson and Dr Freeman will bring it up at a meeting of the Postgraduate program leadership council. There is clearly a lot of politics involved in all this, which I don't want to get involved in. After the meeting we went up to the 4th floor where Santiago found all of the endoscopy equipment he had sent over last fall. It was being stored behind locked doors at the other end of the building from the Operating Theatres; yet again there is a huge stockpile of supplies in that area which I suspect no one knows it there. There was one room filled with cartons of gloves, for instance; I hope no one asks us to bring gloves on our next trip. In any case Santiago found his equipment, and spent the rest of the afternoon bringing/ having it brought to the old fistula room where he set it al up. There were problems with the endoscopic light so they called the biomed engineers to come up; they were all asking about John Wasik and hoping he will be back soon ! During most of the time they were doing that, I was napping in the lounge, trying to recover from my GI disturbance. I'm better now !

Monday May 11

Apparently the very spicy shrimp at Charles's house last night didn't sit well with Santiago, and he was up much of the night as it ran through him. I took his temp this morning with my infrared thermometer brought along for just this eventuality, and he didn't have a fever. His stomach improved during the day, but it served as a reminder that while Liberia has been declared Ebola-free, it isn't far from everyone's mind. We arrived at JFK for Grand Rounds and were warmly greeted by many friends. The talk was given by Eric from the lab on the immunological diagnosis of hepatitis B, and he did a superb job. The audience was sparse with no medical students, and in fact mostly surgical personnel. Dr. Freeman was there; he is the new chair of the postgraduate surgical program. Dr Sherman was also present, as were Konneh and Moses and 4 surgical trainees as well as Dr. Gbozee, who was hired as a house officer at JFK, in part due to my recommendation I believe.he is eager to pursue surgical training, and I think he will be very successful. After rounds, Santiago and I chatted with him for a while before we went to the Administration Building to fetch the surgical textbook which I had brought for him. He was excited and happy! We then went up to the Operting Theatre where we were warmly greeted by Percillar, Viola, and Barbu! We learned a lot about the current operating conditions: they are doing only emergencies ( no elective surgery); they have one OR available to be shared by general surgery and ortho; they have minimal supplies available, and frequently surgery is cancelled or delayed because they lack essential anesthetics or other supplies ( a case was cancelled recently because they had no gauze); and all surgery is performed wearing full PPE ( personal protective equipment including waterproof Hazmat suit, boots, gloves, and face shield...before putting on a sterile gown and gloves.) The full PPE is terribly hot, even for Liberians; one of the reasons that the general surgery room was not being used was that the A/C was broken. The A/C unit was replaced last week so now if they can get the anesthesia machine working they will be back to 2 rooms. We then went down to the surgical floor and met Moses, who told us about a young patient who had been found to he as mall bowel obstruction with strangulation; she underwent resection and primary anastomosis, but that fell apart so she now has both ends brought out as ostomies. They aren't getting a good deal on her appliance,Mao she is leaking enteric contents onto her abdominal wall skin, crating a painful mess. He wondered about putting her bowel back together, but I think she really needs a better fit of her appliance. We ran into Munah and Adamah taking a tour of the hospital and we joined them. The first floor is being renovated quite nicely for a library and outpatient clinics, as well as a NIH- funded Ebola Survivors Research Unit. The second and third floors are sparsely populated with patients, but that will change in time I'm sure. Currently the triage system is that everyone is held in the ED for 48 hours prior to being admitted to the floor, so that any potential Ebola patients can be identified prior to being admitted to a hospital floor. Each floor now has a "fever" room which allows them to isolate any patient on the floor who develops a fever while they await results of an Ebola blood test. There is a rapid Ebola test available, but apparently it is only about 75% accurate at this point. On the third floor(medical) I ran into one of the nurses who used to work on the surgical floor, and who took care of a 4 year old girl with an intusseption whom I operated on several years ago. Knowing that she was caring for the child the first postoperative night was very reassuring for me; today when I asked her if she remembered, she gave a wonderful smile and said yes. We talked with Munah for a while about the timeline for winding down the intense Ebola precautions now in place; it is really unknown territory for which there are no good recommendations, and I think time will tell. That was particularly brought home later in the afternoon when we went with Adamah to Redemption Hospital. Redemption is on the other side on Monrovia in New Kru Town, and was an epicenter for much of the Ebola epidemic. The first patient with Ebola in Monrovia died there, and the last patient was triaged through there. We met with the Acting Administrator, and walked through the hospital. I had been there before, and in fact Ly Heng and I operated there several years ago. We found the young girl with the intususception mentioned previously at Redemption, and had her transferred to JFK. We visited the OR there, and some of the staff remembered me from that visit; prior to The Ebola epidemic they had renovated the main OR and added lights, so it looks much less like a dungeon now. Unfortunately they lost several physicians to Ebola as well as a number of nurses; they are currently doing no general surgery because the general surgeon there was one of the Ebola casualties. It was fascinating, depressing, and amazing to listen to the Administrator talk about what they went through during the months of severe crisis: he talked about going home at night and forcing his children to stay away from him until he had taken off all his clothes to soak in bleach solution, and taken a bath to minimize the chances of passing the virus to his children. One of the recurring themes of this visit is the number of people we are meeting who should write a book, or be filmed for a documentary, so that their stories of surviving Ebola are preserved. Another theme is how the Liberian people have come to accept Ebola rules like hand washing and not touching. They are generally adverse to following rules: they create their own rules of the road, they don't wait in line well, and they avoid paying taxes among other things, but when it comes to Ebola they have learned to follow the rules. And healthcare workers do not hesitate to call others out to insist that they follow the rules, as they should ! At some point today we saw a young lady with a mass on her neck; I followed my natural instinct to reach out and feel it, and was chastised for doing so without gloves on. I them washed my hands with bleach solution, put gloves on, and continued my exam more aware than before that I need to restrain my natural instincts under the current circumstances. Santiago and I went to Sajj for dinner and then back to the apartment where his Tubmann's Revenge continues to take its toll. Hopefully he will feel better in the morning.

Sunday May 10

     After breakfast, Dewalt picked us up and brought us to the President's house; she had driven to the Farm yesterday, and we were invited to come there for lunch today. Joining us was Adamah's relative from Zambia, Caroline, who works for the World Bank. The skies were overcast, but it didn't rain on the 1 1/2 hour drive up there, and in fact the sun came out and stayed out. The Farm is land that was owned by her parents; she has built a nice home there, and is an active farmer. In addition to growing small quantities of vegetables, she has planted palm trees for palm oil as well as other crops. It is a lovely, quiet rural setting and it was immediately clear why she likes to go there to get some peace and quiet when she can. We sat on the veranda and chatted some more about the Ebola experience while enjoying fresh coconuts, some fresh corn delivered by a neighbor, and relaxing. After a while, we had a bountiful lunch indoors.
     After lunch we walked down and sat by the river which flows through the property. I think we were supposed to have her "Happy Mothers Day" cake down there, but everyone was full from lunch. Around 4 pm we left to drive back to Monrovia where we stopped in to see Adamah's brother Charles at his usual Sunday afternoon get-together. After a while Santiago and I pleaded exhaustion so Dewalt brought us back to the apartment; we will have an early night in preparation for a big day at JFK tomorrow.
      It was quite fun, and indeed a privilege to visit The Farm today. As Santiago pointed out, it is the Liberian equivalent of Camp David. Madame President is on the job 24/7; while it is obviously relaxing and restoring for her to be able to get away to The Farm, she is never off the job. While we were relaxing on the veranda before lunch, she took several phone calls, and while we were sitting by the river one of her Cabinet Ministers came by to report on a conference she had just attended.

Saturday May 9, 2015

      Liberia is Ebola-free!! Having gone 42 days since the last case, today WHO declared the country Ebola-free, and this is worth celebrating, which is what we have done. But let me back up...
      We left NY on Thursday night for the 7 hour flight to Brussels; Brussels Airlines was kind enough to not only give us an excess baggage waiver so that we could each bring several duffel bags of supplies, but they also offered us an upgrade to Business Class for a reasonable price. Santiago and I hesitated briefly in considering the offer, and then decided we should take it ! Being able to lie flat for the overnight flight was quite pleasant; although I didn't sleep as well as I might have liked, it was definitely more relaxing than sitting upright.
      We had a 5 hour layover in Brussels, and while waiting we met up with Masmina Sirleaf and Adamah; until I actually put eyes on him, I wasn't sure if he was coming to Liberia at this time or not ! Anyway, we had the 7 hr flight to Monrovia where we were picked up and brought to the apartment. We are staying in the same apartments in Congo Town that we have occasionally stayed in before; they are nicely furnished and comfortable. Soon after we arrived Munah Tarpeh, the assistant Administrator at JFK, brought us dinner and we had a good conversation about what they have been through in the past year, the current situation, and what they anticipate for the future. Ebola has affected life here in many different ways, and I think probably in some ways that have yet to be seen. One interesting example: the emphasis on hand washing to prevent the spread of Ebola had the beneficial effect of significantly decreasing the infection rate from all causes in the Neonatal ICU. Hand washing is important, and now it has become a normal habit here where it wasn't pre-Ebola.
     After a good nights sleep, we had breakfast and then were told that Adamah was sending someone to bring us to the President's house. En route there, it was decided that we would change plans and go to ELWA Hospital where we would meet up with the Presidential bus taking a celebration tour ! ELWA Hospital is a missionary hospital which has been in Liberia for many years; it was also the site of several Ebola Treatment Units(ETU), and was the place where Dr. Kent Brantley worked prior to his infection with Ebola and subsequent airlift to Atlanta for successful treatment. Madame President had decided to celebrate this day by visiting a number of facilities to thank the workers for their help in making this day possible; she took a bus to be able to include the many people in her government who had waged the battle against Ebola as well as other important supporters such as the American Ambassador, people from USAID, WHO, and also stragglers such as myself and Santiago !  In addition to ELWA, we went to Catholic Hospital, Redemption Hospital, the Ministry of Health ETU, a couple of clinics, a small settlement called Banjour that was devastated by Ebola, and of course we also stopped at JFK. It was such a thrill to get off the bus and see many of my friends at JFK, and to be able to celebrate this wonderful day with them. I look forward to going there on Monday to spend more time with them !
      Banjour was a very interesting and sad place to visit. It is a primarily Muslim community, and as I said it was particularly hard hit by the virus. As we drove down the dirt road into the community, I noticed that each house had various letters and codes spray painted on the front. Similar to the houses I saw in New Orleans after Katrina, these were codes to indicate whether searchers had found corpses within, or infectious persons needing quarantine, or whatever.
      After returning from the bus trip, Santiago, Adamah, and I had lunch with The President and one of her staff. We listened to them tell of their experience during the past year: the pain of hearing each evening the count of bodies found that day; the sense of isolation when it seemed like no airline was going to continue to fly into Monrovia because of fear ( Brussels Airlines kept flying, in part because Madame President called the President of Senegal to beg him to allow continued refueling stops in Dakar for planes going in or out of Liberia); the horror of seeing the people of Liberia being decimated by this unknown enemy, and feeling like the virus was unstoppable. There must have been times when she felt totally defeated, and yet she pressed on, because that is the kind of woman she is. Her strength, tenacity, and leadership were crucial elements in getting Liberia to this goal. Having the opportunity to have a conversation with her about the battle against Ebola during the past year was inspiring and unforgettable.
       Tonight we went for dinner at the Mamba Point Hotel with Lydia, and 2 young Americans Jessie and Janessa who work with Lydia at one of the orphanages we visited today. We were joined by Ben, who is now doing consulting work in Lisbon, and Eric, who is Jessie's boyfriend as well as commandant of the Marine squad at the U.S. Embassy. After a delicious dinner we want across the street to Lila Brown's for a nightcap, and then headed home.
       Talking to Lydia about Banjour, I learned some facts about the tight-Muslim community there: pre-Ebola, there were 5 husbands ( 3 died of Ebola ); 13 wives between the 5 husbands, of whom 10 died of Ebola; and 56 children ! So when we went there today, and there were many rows of children, I assumed we were dealing with a school...but in fact it was one "family" quite
-amazingly one family.

Wednesday May 6, 2015

    Tomorrow Dr. Santiago Arruffat and I will leave for another trip to JFK Hospital in Liberia. It has been just over a year since we were last there; our planned trips in September and March were cancelled because of the scourge of Ebola. The threat from that virus has diminished significantly, and with luck, on Saturday May 9, Liberia will celebrate 42 days with no new cases of Ebola; that length of time is the WHO standard for declaring the epidemic over. We all recognize that while there may be no clinical cases of Ebola virus disease, the virus itself has not been eradicated, and the threat of another epidemic will always be present. The people of Liberia must be vigilant, and careful, and prepared to swing into action against the virus if necessary; this is the new reality.
    Tomorrow also marks one year since I discovered an enlarged lymph node under my arm, and soon thereafter began chemotherapy for lymphoma. There were many times during that process when I doubted that I would ever be able to return to Liberia. Fortunately, due to the great care I received, the support and love shown to me by family and friends, the luck of the Irish, and a whole variety of imponderables relating to everything from tumor behavior to Divine Providence, I am now well. All signs point to a complete knockout of the lymphoma and excellent odds that it will not come back. After that interruption, I feel good; I am excited to return to my "home" in Liberia and to see my friends once again. Sadly, I know that some of those friends succumbed to Ebola : I will miss greeting Dr. Brisbane and Dr. Borbor, and learning from them about the progress being made in rebuilding JFK. I fear learning about others who succumbed during the epidemic, and I know there were many; on the other hand, I look forward to celebrating with those who survived.
     This promises to be a memorable trip !