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.