Friday Sept 16

Friday September 16

       The last day of this trip...Deidre and I did a 5 year old boy with undescended testes, and then Deidre and Daniel fittingly ended by taking care of 5 year old Princess with her ruptured appendix. We said our goodbyes to the OR staff and the residents, and Professor Freeman, and  Mary. We collected and packed up the 2 broken colonoscopes and the 2 broken dermatomes to bring home and try to get repaired. We ended up running late, so we didn't have time to go souvenir shopping and I felt bad about that for Deidre and Daniel, but since they are both saying that they really want to come back, I guess they will have another chance !
      I think the final total is 51 cases on this trip; I think that is quite remarkable, and a testament to the OR staff for truly stepping up and working hard to get things done. I believe that we added a dimension to the education of the Liberian residents that they would not have otherwise received, and that is our main purpose. Without doubt it was an eye-opening and surgically enriching experience for Deidre and Daniel; having residents from different programs had unexpected benefits also.
      Hard to believe that in just 6 months we will be back again !

Thursday September 15

.  This was our final full day of operating, and as usual, several interesting surprises. First we brought back the 12 year old boy we had circumcised earlier. He needed to be cleaned up, but that could best be done under sedation. Then we went over to the Maternity Hospital to operate on a woman we saw yesterday who had a vaginal delivery about 2 weeks ago but was not recovering as expected, and she had in fact necrosed the skin of her belly button. I have never seen that before. We thought this might be a small operation to fix an umbilical hernia, but it turned into a full laparotomy and washout. As often happens here, decisions must be made on less than complete information.she had a lot of necrotic debris in her abdominal cavity, but no frank purulence. Her small bowel was matted under a thin  omentum, and there was a dense adhesion of something to the dome of her uterus. I was concerned that if we tried to free everything up, we would likely cause damage. So after discussing it with Dr. Louise Kpoto, a senior Ob-Gyn resident, we decided that since we saw nothing green or brown which might be indicative of a bowel perforation, we should leave well enough alone. Our hypothesis is that she ruptured her uterus during labor ( she had had a previous C-section), and it was now sealed off, but that would account for all of the debris and inflammation. After finishing there, we stopped by to see Leela, the now 11 day old with jejunal atresia that Deidre and Jonathan operated on; she is doing well and will start feeds today.
      We went back to JFK Hospital and did a debridement, a hernia, and an arm mass/tumor, and we saw some potential operative candidates. One was a woman with a locally advanced breast cancer who would benefit from a toilet mastectomy. We made arrangements to admit her today for surgery tomorrow, but later on in the day she back out because she was scared. That is a major problem here, and I wish I knew how to solve it. I also saw a lady with a goiter who will come back in March, and a 5 day old infant with what is reported as a congenital rectovesical fistula. I told the mother that it was too soon to operate, and she should bring the child back in March also.
      Then Dr Utam brought up a mother with her 2 week old baby who has a large cyst below his right eye which is forcing the eye closed and pushing his nose to the left. It is soft and non- tender, and it transilluminates, but I have no idea what it is. We sent text messages containing pictures of it to
Connecticut, Arkansas, Liberia, and Ghana asking if anyone could help us figure out what it is. Several voiced the desire for advanced imaging studies( x-rays) but this is Liberia. Eventually we decided that we could aspirate it to see the quality of the fluid; we emptied it of 15cc of clean fluid. We will bring the fluid back for examination, and then we will see how fast it reaccumulates.
        After changing we went to the Mamba Point Hotel for a delightful and delicious dinner with Masmina Sirleaf, her brother, and a business associate. They are currently renovating the Sirleaf Clinic in downtown Monrovia, planning to turn it into an outpatient center. I think they have the vision to make it happen. After dinner we went to Angler's, a new nightclub Karaoke bar in the Capitol Hill neighborhood where we met Precillar and some of the OR staff. It was good fun, and a great way to celebrate the last night of this trip.

Wednesday September 14

      The first item on the docket today was to see if the equipment was working which would allow the 3 GI bleed patients to have endoscopy this morning. It seemed to be working, but during the first case, the video monitor froze which brought everything to a halt. Various attempts by Jonathan and others to switch things around didn't get it working....and then I remembered something similar had happened last March with Santiago. Thank heavens for modern communication ! I texted him in Indiana, and after some thinking he remembered that we had a problem when the endoscopy equipment was plugged into a transformer plugged into a 220volt socket, but it worked when we switched it to plug it into a 110volt socket directly. It is one of the peculiar aspects of JFK that it is wired with both 220V and 110V sockets; this, as you might imagine, causes confusion and the occasional mishap when something is plugged into the wrong voltage. In any case, we switched things around and the equipment was working, and the scopes got done.

      The most interesting was the 16 or 19 year old female. The 2 middle-aged men could easily have had peptic ulcers to account for their bleeding, but it's hard to come up with a reason for repeated GI bleeding at her age. It turned out on endoscopy that she has large esophageal varices ( veins) just under the lining of the esophagus. They can bleed easily, and the bleeding can be torrential. Most of the time esophageal varices are related to cirrhosis of the liver, but this patient had no other evidence of liver disease. In looking on the Internet, it turns out that this could be caused by schistosomiasis ( infestation by an amoeba), in which case it is treatable and reversible. We spoke to the medicine people who will investigate further. Schistosomiasis is not common in Liberia, so maybe they will identify some other cause; in any case, hopefully it was be a treatable entity, in which case the  availability of endoscopy will have saved her life.

      Jonathan had to leave at 12:30 to catch a plane to Accra,Ghana where he has some meetings at the medical school on Thursday and Friday before heading back to Little Rock on Saturday. Once again it was a great pleasure for us to work together on this trip; he is smart, and skilled, and has a wonderful dry sense of humor. He has also taken a real interest in educating the Liberian residents, and I know this means a lot to them. Additionally, for this trip, it was a stroke of genius for him to bring Deidre Wyrick along on the team: she is smart and funny, and an excellent team player. On top of that, her interest and expertise in pediatric surgery paid huge dividends for our young patient yesterday in particular as well as many others. I have really enjoyed working with her, and I intend to remind her frequently about her stated desire to return to Liberia in the future ! Another very pleasant aspect of this trip has been the interaction between Deidre and Daniel, and knowing how much they have enjoyed working with each other, exchanging stories about residency, and helping each other get things done. Daniel has set up an Excel spreadsheet for all of our patient data, which will allow us to follow up patients a lot more efficiently than we have been able to do in the past. both of them have taken a strong interest in working with the Liberian residents, and that will have lasting positive effects I know.

      After we repaired a hernia in a 12 year old boy under spinal anesthesia, we walked around to check on out post-op patients, all of whom are doing well. We met up with Bola, the daughter of our patient Ophelia; Bola runs a clothing business, and she very kindly made beautiful African shirts for all of us. We also saw Robert Dolo, who runs the New Sight Eye Center; I had hoped to get out to visit his newly built clinic, but I don't think we will have time on this trip. 

       I think tomorrow will be busy, and then we plan to operate on Friday morning, leaving the afternoon to go souvenir shopping before we get on the plane on Friday night.

Tuesday September 13

     I am annoyed to see that my postings for yesterday and today have disappeared into the vapors, for reasons that are beyond my level of understanding. This is particularly unfortunate because I thought yesterday's blog was quite good ! Oh well, so it goes....
     The major case yesterday was the 9 day old girl from the Neonatal ICU who had an intestinal obstruction.  For surgeons, the most worrisome part of an operation on a small child is the anesthetic management, mostly because there is not a lot of leeway. Kids can crash quickly, and babies even quicker. This child weighed 2.1 kg (4.8 lbs), which is quite small  for an operation under the best of conditions. The problem was that if we did not try, she would not have survived. The anesthetists were unable to intubate her despite repeated attempts, so eventually they decided the surgery would be done under Ketamine sedation. Deirdre and Jonathan did the surgery, and a wonderful job they did ! It turned out that the baby had a jejunal atresia, in which a segment of the bowel is block due to some maloccurence during development. In her case they found a large dilated proximal small bowel, and then a transition, and then collapsed distal small bowel. They worked their magic by taking out the blockage in the transition zone, and then sewing her intestine back together. It was really quite an impressive piece of work, and I was very proud of them !
      While they finished that, I did a minor surgery and then we did a few smaller operations like hernias. When we thought we were done and heading out, Dr Macdonald asked us to stop in the Medical ICU to see 3 people with GI bleeds. Two were middle-aged men with a reason to have a bleeding ulcer; the third was a young woman ( variously reported as 16 or 19) who had had several episodes of significant bleeding in the past few years. All of the patients were stable, and did not require urgent intervention.  They will undergo endoscopy in the morning if the equipment is working.
      During the day we received word that Madame President had invited us for dinner that night, so we went back to the apartment to get ready for that. At her house we joined the other guests including 3 members of the Peace Corps who are in Monrovia for the year: Gary, an ED doctor, Kevin, a family practice doctor from the University of Vermont who is working at the medical school, and Nicole, a nurse midwife from NYC. Also attending were Dr. McDonald, Prof. Njoh the head of internal medicine at JFK, Masmina, Adelaide Gardner, and Ophelia and Carney Johnson. After drinks around the pool, the 4 of us, the 3 Peace Corps volunteers, Dr. McDonald, and Prof. Njoh had dinner with the President in the palava hut. As usual, it was fascinating to hear her talking about her work, would she still want to take on the job knowing what she knows now after 11 years (yes !), and a variety of other insights. I think it is particularly wonderful to have young residents like Deirdre and Daniel sit, listen, and converse with a Head of State. It's one more thing that will make this trip a memory they will savor forever.

Monday September 12

     After morning report with the residents, we all went to Grand Rounds presented by the Ob-Gyn residents. They presented a well-done survey regarding the incidence and complications associated with illegal abortions in Liberia; they found that there was significant morbidity and mortality associated with it. Following their presentation there was a spirited discussion, especially since one of the surgeons present was Dr. Peter Coleman who is also a Senator in the Liberian legislature. For me, the presentation was another example of the strides being made in the postgraduate program with residents being held to a higher standard of scholarship and intellectual thinking.
     Our OR day was shorter than usual because of the late start due to Grand Rounds, and also due to equipment issues. There were a couple of people scheduled for endoscopy today, but because of the breakdown of equipment, some cases could not be done. Jonathan and Deirdre and Moses first did an emergent washout and repair of an abdominal dehiscence who had been operated on by others a week ago following a perforation of her uterus and small bowel. After that they did a second look debridement of the man with a bad infection of his privates; apparently he is looking better. While they were doing that Daniel and I and Dr. Clark removed another large parotid tumor, which again appeared to be a benign pleomorphic adenopathy confined to the superficial lobe. It was quite bloody, but it went well and I believe her facial nerve remained intact; the proof will be when we see her tomorrow !
      Between cases we made rounds on the wards. We saw one unfortunate woman who was in tears because she has been waiting for an operation on her breast. I'm not sure who admitted her, but it was a mistake because there really is nothing that we can do surgically. She has a large, fun gating, ulcerated breast cancer with ulceration of the skin of her axilla as well. It is too extensive for any hope of surgical excision, and particularly since we don't have a dermatome to do skin grafts, I'm afraid it is pretty hopeless. I guess the one thing we could do would be to biopsy it to see if it is hormone receptor positive, in which case Tamoxifen, which is available here, might be of some palliative use.
       We went over to the Neonatal ICU at the Maternity Hospital to see a 9 day old baby with some form of intestinal atresia; she has not passed any stool or meconium yet. Deidre will graduate from the general surgery program at the University of Arkansas next June, and then she will do a fellowship in pediatric surgery there. So she is naturally filled with excitement and trepidation over the thought of operating on this baby with Jonathan tomorrow ! The baby weighs 2.3 kg, so she is just a peanut; the big concern with surgery in small babies is always the anesthesia. We were happy to learn that Leon will be working tomorrow, as we think he is one of the best of the anesthetists here. In an ideal world the baby would be transferred to a specialized pediatric surgery center, but that isn't the reality here. If we don't try, the baby will not get an operation and she will die.
      We also saw a 5 year old boy who drank lye about 2 months ago. He has developed an esophageal stricture as expected, and is now not able to eat, so we will put in a gastrostomy tube tomorrow so he can be fed directly into his stomach. He is skin and bones unfortunately; Daniel offered him a Tootsie Roll pop to suck on, but he turned it down because what he really wants is a drink of milk. I have written before on this blog about the public health problem of lye ingestion here: women buy crystalline lye to mix with water, and then use is to saponification fat and make soap. When they mix the lye with water, they typically put it in any available container, be it a Coke bottle or whatever. Then children pick it up thinking it's just water, and when they drink it they get a burn of the esophageal lining which most often progresses to scarring and narrowing. Once they drink it, there is really not much anyone can do to halt or reverse the process. The only surgical solution is replacing the esophagus by interposing a length of colon, but this is a major operation requiring more intra-operative and post-operative resources than this country has to offer currently. I believe it is a relatively common problem in developing countries, and it is crying out for a way to prevent it from happening.

Sunday September 11

     We took the day off today to relax, and we were very successful in doing that ! It rained all day, hard at times, so a trip to the beach really wasn't in the cards. In the morning we watched some of the September 11 commemoration on CNN; I am still amazed by the bravery of the firefighters and other first responders who were involved in that.
       Around noon Moses came to pick us up, and we drove out to the other side of Monrovia past Redemption Hospital and the street market to visit Jonathan's aunt who is here working for the UN. She is living in a lovely new apartment in a very nice complex, apparently built by a Nigerian fellow who also runs the Monrovia Brewing Company !
       After leaving there we took a short tour of Monrovia to show Deirdre and Daniel some of the sights including Mamba Point and Capitol Hill. Since it was raining, it was a short tour...We then went to Sajj for a lunch of pita and hummus followed by chicken bread for all of us. I think Deirdre and Daniel understood why I raved about the food !
       After lunch we came back for a nap, and then watched a variety of sports on TV prior to retiring for the night. If past experience is any guide, we will have another busy week coming up !

Saturday September 10

     Another night of rain, which I guess is to be expected during rainy season here, but the rain has been heavier than I remember in any previous September. We made rounds and found our patients in good condition, and then went to the OR for another busy day. Despite it being a Saturday with a diminished work staff, the OR came thru for us and we did 6 cases today. Jonathan did a colon resection with Daniel and Moses while Deirdre and I did 2 hernias using mosquito net mesh for the repair.
     It is generally accepted in the developed world that synthetic mesh implantation provides a superior hernia repair compared to the standard tissue repair, in terms of rate of recurrence as well as postoperative pain and disability. The problem is that the mesh we use in the US, for instance, costs about $200 per patient, and that makes commercially available mesh much too expensive for Liberia. The idea of using sterilized mosquito netting has been around for several years, and then an excellent trial comparing mosquito netting with commercial mesh was published in the New England Journal of  Medicine last January. The trial showed that the two were equivalent in all important measures, and the piece of mosquito netting cost about 25 cents compared to the $200 cost per patient of commercial mesh. In that paper, they gave the specifics of the mosquito netting and how it was prepared. I prepared pieces of mosquito netting exactly as described, packed them in sterilization envelopes, and brought them here where they underwent sterilization in the OR.
      I received a call this morning from a Liberian surgeon who expressed concern that in using mosquito netting for hernia repair, we are experimenting on patients and that has ethical as well as legal implications. I feel comfortable that while it is a new technique, the trial published in NEJM moves it from experimental to scientifically established, and therefore I didn't think it was a problem, but I would stop if he thought I should. After some discussion, he agreed that wasn't necessary.
      We had another parotid tumor on the schedule for today, but her blood pressure was elevated and anesthesia did not feel it was safe for us to operate on her today. Hopefully her pressure will come down over the weekend, and we will do her on Monday.
      The downer for today was that the last available colonoscope has developed a malfunction making it unusable. This is a most unfortunate development, as the colonoscopy program was really starting to develop. I'm not sure if we will try to get the scopes fixed or replaced; in any case I'm sure we will have the necessary equipment available next March. Similarly we have no dermatome,  which is a machine we use to take skin grafts; their old one broke last spring and we were able to replace it with a refurbished model, but now that one isn't working. I will bring them both home with me to send them to a repair shop in Florida; if they can be repaired, I will find someone to bring them back to JFK ASAP. There are patients who have been in the hospital for weeks ( and over a month in one case) awaiting skin grafts, so not having a dermatome available is a real problem.
      Dr. Gbozee came from Tappita to see us yesterday, and he dropped by again today. He is in the second year of his postgraduate surgical training, and is currently working at the hospital in Tappita; the postgraduate surgical trainees rotate between Tappita and JFK for their 5 years of training. In case anyone thinks they have a tough commute, when I asked him how long it takes to travel from JFK to Tappita, he said it was variable. The Monrovia to Ganta road is now paved, and is about a 4 hour drive; the road from Ganta to Tappita is unpaved, and can take anywhere from 4 hours to 2 days !! As an unpaved road, it is particularly difficult traveling during rainy season ( like now) when the potholes, mud, and trucks getting stuck can make it quite a nightmare!

Friday September 9

  Another busy day at JFK ! Today's cases included 2 colonoscopies, closure of a gastrostomy site, a circumcision, 2 hernias, a debridement, and a planned ostomy decommissioning. The unfortunate woman who was to have her ostomy taken down had had several operations in the past, and was known to be a difficult intubation because of an apparent mass in her hypopharynx. It was never clear what that mass was. In any case, after intubation today she started bleeding heavily from her endotracheal tube, and eventually had a cardiac arrest. Despite our best efforts for over an hour, we were unable to bring her back. It was a sad and sobering event; while we recognize that there is a risk of such things occurring during anesthesia and surgery whether in the US or in Liberia, it is always a shock when it does occur. Our natural reaction is to wonder if there was something we could have or should have done differently to avoid such an outcome; in this case we have been unable to think of anything.
     Fortunately we had done most of the cases before they started her surgery, and the cases my had all gone well. Jonathan found a mass in the colon of one of the patients he scoped, so that man remained in the hospital for surgery to remove part of his colon tomorrow. The boy who needed his gastrostomy site closed and the boy for the circumcision were about the same age. We were under the impression that we were doing the circumcision first, so I was somewhat surprised when I went into the OR and saw a boy who had already been circumcised. This brought out the point for all of us that you have to check the patients very carefully before proceeding! There is no wristband identification system at JFK, and so sometimes it can be difficult to know who you are operating on for what !  At home in Waterbury Hospital, for instance, it is required that I see the patient in the pre-op area and mark the site of surgery with my initials so there can be no mistake. Perhaps in the future this system will be adopted at JFK, but I think a wristband showing the patient's name should come first.
     After the death we still had more work to do. Deirdre and I repaired a large inguinal-scrotal hernia and Daniel filmed parts of it for me; if it works out, I will use some of that for a presentation later this fall. Then Daniel and Jonathan finished up by debriding a gentleman who we were initially told had Fournier's gangrene, but I think it was just a bad  soft tissue infection involving his private parts. You don't want me to go into any more detail than that !
       It poured rain virtually all last night and all day today, and you could tell by the amount of water in the hospital corridors etc. Before you can repair the inside, you need to repair the roof, and that is pretty impossible when it is raining as hard as it was today. I don't remember this heavy a rain on previous September trips, but I'm told it isn't that unusual. In any case, it's just one more burden for a country and a people struggling to survive day to day.

Thursday September 8

     Another very good day in Liberia !  We did 7 cases in the OR, which was quite a feat under the circumstances; it happened because of the concerted efforts by a lot of people to make it happen. The cases included a ventral hernia, 3 ostomy decommissionings, 2 inguinal hernias, and a submandibular gland excision. On one of the hernias, a recurrent right inguinal hernia, we used sterilized mosquito netting as a mesh; we believe this is a first in Liberia. The use of mosquito netting for mesh has been described in a trial in Uganda reported in the New England Journal of Medicine last January ; we were excited to bring the practice to Liberia.I had a large mosquito net which I bought for Liberia but never needed to use; at home I cut out some pieces of it, washed and dried them, and put them in sterilizer bags. I brought them here, and Precillar sterilized them for us. I didn't think they would be ready, but just as we were wishing we had a mesh to implant, Precillar walked into our OR and said they were sterilized and ready for use !! Amazingly coincidentally perfect timing !!
       We kept people working till 6 pm, and there was never a complaint, a whine, or any suggestion that anyone was unhappy doing all this work. The residents stayed with us all day also. Deirdre and I work together with Dr. Teseer Utam all day; he is a PGY-3 and has great potential.  It was an excellent teaching day, and I think we were all quite happy at the end of it.
      After refreshing ourselves at the apartments, we went out for dinner at the Royal Hotel with Masmina, Teresa and Alex Cummings, and some friends of theirs. The sushi was outstanding, and the company was excellent. Teresa is Chair of the Board of HEARTT; Alex is Liberian and recently retired as Chief Administrative Officer of Coca-Cola in Atlanta, and he is now running for President of Liberia. It was a wonderful evening, and most appreciated by all of us. Who would have ever thought you could get good sushi in Monrovia, Liberia ? Lol
       There are so many aspects of this work that I love: teaching the Liberian residents, helping the Liberian people, learning about life in Liberia, and tonight I was focused on the amazing experience this offers to the residents we bring along. It's hard to explain it, but they are often wide- eyed with wonder at the pathology they see, and the solutions to problems that they are able to come up with. And on top of all that, they be to do operations which they rarely ever see or do in the USA. I am truly grateful for the opportunity to help them experience all of this.

Wednesday September 7

       Today was an excellent day for a lot of reasons. We accomplished a lot, mostly because so many people helped out in the effort. When you consider that for the past several months, the OR team has only been doing occasional emergency cases in the Maternity Hospital, doing 6 cases with us today on Day 2 of our visit was really quite remarkable and commendable!
        The cases were a 5 cm lipoma over the clavicle under local anesthesia, excision of a recurrent cyst of the thyroid isthmus, a large inguinal hernia in a 3 yr old, decommissioning of a loop ileostomy, excision of a huge parotid tumor, a colonoscopy, and decommissioning of an end sigmoid colostomy. The huge parotid tumor was done by me and Daniel. The 40 year old patient first noticed it several years ago, and I guess finally it became big enough and was leaking so he decided to seek medical attention. I have certainly never seen anything quite like it ! I wasn't at all sure we would be able to remove it, but it was somewhat mobile and that gave us hope. For those who don't know, the important thing about surgery on the parotid gland is that the facial nerve goes through it, dividing it into a superficial and a deep lobe. The facial nerve inner ages the muscles of the face, so damage to the nerve during parotid surgery can cause quite noticeable effects like drooping of one side of the mouth, especially obvious when smiling, or inability to close the eye. In the case,d the tumor was in the superficial lobe ( as it usually is), and postoperative lay the patient had near normal muscular activity in his face. I suspect when we see him tomorrow, and he has had a chance to look in a mirror and see that the alien living on his left cheek is gone, he will be smiling broadly !
         Another gratifying aspect today was the presence of postgraduate trainees in the OR with us all day. It turns out that they have made a written schedule for the 2 weeks we are here assigning PGY-1 and PGY-3 residents to our cases. This is a big change, and a wonderful one, and I'm pleased that it is happening. Sometimes it's easy to forget that our main purpose here is to teach Liberian surgeons how to do the surgery. In the heat of battle against a parotid tumor, the level of concentration is intense and it's easy to tune out everyone around you; I tried to stop every once in a while to explain my thought process, or my strategy, or point out anatomy. Tomorrow we will have some hernias to do, and I look forward to working one-on-one with the Liberian residents to teach them my approach to hernia repairs in Liberia.
        As you can imagine, surgery is a team sport requiring efforts from anesthesia, nurses, techs, and cleaners as well as surgeons. I can't say enough good things about the way everyone at JFK has stepped up to help us. They have stepped up in the past, but I think this is different in view of the major problems existing in the hospital over the past several months from the leaky roof. I'm truly grateful  for their work on our behalf.
        Back to the apartment for dinner and conversation, and then to bed.
        An interesting note on global trade : the bottled water we have here in the apartment, bought in a local grocery store, is Poland Spring, the taste of Maine !!

Tuesday September 6.

     We did 4 cases today, which is quite an accomplishment considering everything that has happened. Back in June, they were forced to evacuate several of the Operating Rooms because of a leaky roof; in fact, for several months they have only done emergency operations at the Maternity Hospital next door. This meant that they had to transport equipment and patients over there to do the surgery, and then bring everything back to the main hospital in the rain. Repairing the roof during an unusually heavy rainy season presents its own set of difficulties, and work is ongoing. In the meantime, to accommodate us, we are using the Eye surgery room and the half of the Recovery Room has been turned into a temporary OR.
     The first case was a 10 month old child with an unusual growth on her left shoulder. It might be just a pyogenic granuloma ( benign) but it could also be a sarcoma. Deirdre and I did a wide excision, and we will check the pathology when we get home. Jonathan and Deirdre then closed a loop ileostomy in a young woman who have a perforated appendix with damage to her cecum last May. Her cecum was repaired, and appropriately to protect the repair the ileostomy was performed. Next Daniel and I debrided a burn on a 4 year old. The clinical story was peculiar, as was the burn which extends over most of his left buttock up onto his back. It is quite deep with gluteus muscle exposed. The story was that his mother brought him to her sister in Sierra Leone, and then went to get him a month later at which time she discovered he was sick and had this burn.There are some pieces missing to this puzzle. The final case was another loop ileostomy decommissioning by Daniel and Jonathan which went well.
       In between these cases, Konneh brought up several patients from the Outpatient Clinic for me to see and consider for admission and surgery. As usual, the pathology here is quite amazing: a huge parotid tumor, massive neck adenopathy which almost certainly is lymphoma in a 30 year old, several hernias of various shapes, sizes, and locations, and some friends from years past. Ophelia came to see us: she had an abdominoperineal resection for recurrent rectal cancer a couple of years ago. She is feeling well, and has no evidence of recurrence, but she is worried and thinks that she " needs a little cancer medicine". I tried to reassure her that she didn't need it, and she said okay. For those of you who have seen the photo of me wearing my Liberian garb at the Resident Graduation Party in June, that outfit was made by Ophelia !
     Miata also came to see us: she is a 17 year old female who met Jonathan at Phoebe Hospital several years ago. She has Crohn's disease, and has suffered mightily as a result. Last March Saniago repaired her rectovaginal fistula, and created a diverting loop ileostomy to protect the repair. She has done very well and is feeling great; she also looks fantastic. She is not having an perineal problems, and Jonathan thinks it will be reasonable to decommission her ileostomy during this trip.
      It took a long time to get started this morning, and I felt my frustration building, but it all turned out pretty well, thanks to cooperation from everyone involved. Hopefully after this start we will pick up steam over the next several days !

Monday September 5

      We went to Grand Rounds this morning, held in the cafeteria rather than in the amphitheater because of some leakage problems, I believe. It rained all day today, and was torrential at times; even for a country with a rainy season, I think this year they have had more than usual. We spent the day getting organized, and I think it went quite well. Mrs. Cooper, from Admitting, found us early on so she could show us the list of potential patients and we could start thinking about what surgeries we want to do. There are a number on the list who will clearly benefit from pathological examination of tissue, so they move to the top of the list. Others are interesting operations to do from a surgical perspective, so we will likely do them also. There is a large list of hernia patients, both pediatric and adult, which we will fill in the schedule with. When I suggested that we didn't need to do a lot of adult hernias, Dr. Konneh pointed out that there are 1st and 2nd year residents who would benefit from operating with us, and I think his point is valid. We are here to teach, and that is what we will do !
     We sat in for their chart rounds, and then made walk rounds through Pediatrics with Dr. Konneh and others. The level of knowledge and discourse is clearly improving among the postgraduate trainees, and that is a wonderful thing to see. The patient stories remain heartbreaking; today we saw a 2 year old who drank caustic material a couple of days ago. It's the same story we have heard before: mother is making soap, so she takes the crystalline caustic(like Drano), mixes it with water in any available container, and then sets it aside. Young patient comes along, and thinks the liquid is in a cup ( or a Coke bottle or whatever) so it's ok to drink. Unfortunately it causes a deep alkali burn to the esophagus, which most of the time leads to a stricture, and that prevents the child from eating or drinking. There is no medical solution to this problem. The surgical solution is far too complex to be carried out in these surroundings. It is really a public health issue, and the solution will come from prevention.
       Dr. Jonathan Laryea arrived from Little Rock, AK vis Accra, Ghana this afternoon so out team is complete. We came back to our apartment where we had dinner and then we are all retiring early, partially in response to jet lag but also in anticipation of a busy day in surgery tomorrow.

Sunday September 4

     Another trip to Liberia begins !! Dr. Daniel Ricaurte and I left from JFK(NY) last evening, and arrived in Monrovia that s evening after passing through Brussels. The team for this adventure includes Daniel, a PGY-2 in our program, Dr. Deirdre Wyrack, a Chief Resident at the University of Arkansas, and Dr Jonathan Laryea. Deirdre met up with Daniel and myself in Brussels, and Jonathan will join us tomorrow when he arrives after a brief visit to Accra, Ghana.
      There were no issues on our trip here, other than a momentary hesitation when we checked in at JFK(NY) and the desk people at Brussels Airlines found it difficult to believe that we had been allotted 2 extra bags each, giving us a total of 8 bags, 7 of which were stuffed with medical supplies weighing just under  50 pounds each.
      We were brought to the apartments they have rented for us which a spacious and quite pleasant. I'll need to get my bearings in daylight to figure out exactly where we are, but it is relatively close to the hospital and behind the Royal Hotel on the other side of Tubman Boulevard.
      Dr. McDonald and Munah were waiting for us at the apartment, and had dinner for us also. We had a pleasant conversation, and then to bed early for our first day tomorrow.

Tuesday March 15

       Today is a holiday in Liberia celebrating the birthday of the first President. We had hoped to do some skin grafts, but the lack of a dermatome precludes that. Santiago saw a woman yesterday that Jonathan Laryea had operated on last September. She had several operations in the past including a colostomy for unclear reasons, mostly at Phoebe Hospital, and then was referred to Jonathan for further work. After studying her situation, he thought it was safe to put her colon back together and decommission her ostomy. Apparently she had some problems immediately post-op, but was discharged home after a short stay. Out of respect for my readers, I will avoid a gross discussion of what was going on; suffice it to say it wasn't pretty. So we brought her to the OT to explore her abdomen, and give her another colostomy. It will take a brave soul to want to put her back together again.
        During the course of the morning, Ophelia came by to wish us goodbye. Santiago has done several operations on her, most recently in 2014 she had an abdominoperineal resection for recurrent rectal cancer. She is feeling great now, and there is no gross evidence of the cancer coming back. She gave us each a suit of African garb which is quite handsome, and she got the sizes right just by guessing ! Well, almost right...my cap is too small because I seem to have a large head, but I think the hat can be retailored to fit me.
        A woman was brought to me yesterday for evaluation of her breast. She is 50 years old, and has an obvious locally advanced breast cancer with a very deep ulcer above the breast. There is nothing to do for her surgically, but I offered to biopsy the tumor to see if it is receptor positive; if it is, then it might be reasonable for her to buy Tamoxifen to retard the growth rate of the tumor. More to the point, if it not receptor positive, there is no point in her wasting her money on a medication that will do her no good.
      After finishing the cases we went back to the hotel to shower and check out. We then went to a lunch on our honor put on by one of Santiago's colonoscopy patients. She is a nurse, a lawyer, and a judge, and she invited a number of guests several of whom had also had cololonoscopies on this trip. It was a fun occasion with real Liberian food including Fufu !
       We returned to JFK to say our goodbyes, and then off to the airport.
       We did a total of 42 cases during our 8 days of operating, which is quite an accomplishment. More than the number, I am particularly pleased that 32 of the cases were done with a resident, and that is a fantastic change from previous experience. Another positive note on this trip was that while Ebola has caused changes in practice, and clearly had a major effect on the delivery of healthcare while the epidemic raged, they have recovered from it better than I had anticipated. I think we will be able to resume bringing residents and others when we come again in September.
 

Monday March 14

Our last full day of operating on this trip. After chart rounds, we skipped Grand Rounds to go to the OT as we knew it would be a busy day. And as expected, we had a slow start to the day. Santiago had 3 patients scheduled for colonoscopy, and they all showed up to be admitted to the VIP section at 8 am, but the first didn't arrive upstairs in the OT till about 9:30, and he wasn't able to get started till 10. While he was doing scopes, I looked again at the little boy with the partially amputated penis. In the end, I couldn't be certain what was going on, so we put a suprapubic tube into his bladder to drain it; that will also allow a contrast x-ray study to define his urethra. Unfortunately they have no contrast material at present, so he is out of luck till they do. The rally difficult part of the story, according to Precillar, is that they live in a village several hours away, which would make it difficult for them to schedule return visits, and in the end he would probably fall out of the system. it might be wiser to keep him in the hospital and at least assure that he gets the care he needs that way.
     After that, while Gbozee and Cassel did a hernia, Santiago and I were joined by Konneh in doing a superficial parotidectomy. For those who don't know, the parotid gland is a major salivary gland located in the cheek just in front of the ear. We divide it into superficial and deep lobes; the importance of this is that the lobes are divided by the facial nerve which controls the muscles around the mouth and eye among other functions. One of the great fears in parotid surgery is damage to a branch or branches of the facial nerve, and resultant paralysis of those muscles, which is a devastating and very recognizable surgical event. Santiago and I debated whether we wanted to do this operation, since neither of us had done one since residency days; after much cajoling and begging by the powers that be, who were naturally concerned about this woman having to spend more days in the hospital waiting for someone to operate on her, we agreed that we would take it on. I think we both suspected that this would be a benign tumor, and we might be lucky enough to have it come out rather easily; in fact we were right, and the operation went very well and relatively easily with no damage to the facial nerve. While we were doing the surgery, a news team came in to film and interview Santiago and myself, so it was nice that the operation went well !
       We then did a partial hysterectomy for a woman with a large, grapefruit-sized fibroid. We told her that we would try to do a myomectomy ( just removing the fibroid) but it was possible that a hysterectomy would be required. She is 34 years old, and has children, so she had no problem with us doing a hysterectomy if needed. Dr. Billy Johnson, an Ob-Gyn and CMO of JFK, came up to check on the news crew, and so I mentioned that we were doing some gyn work but we really weren't trying to poach on his turf. He was fine with it.
       Finally we did the woman whose recurrent breast cancer we had respected the other day, but the dermatologist didn't work so we didn't cover the defect with skin grafts as planned. I decided we needed to find a way to cover the large wound, and then Sano said he had fixed the dermatome...but it again failed us. So we took full thickness skin grafts from her abdomen, but they were too thick to mesh in the meshed, and Sano sliced openings in them. Anyway, we were able to get coverage of the wound, albeit not the best or most desirable way, but this is Liberia ! Clearly they need a new dermatologist, and so getting one is my next project. Then we have to figure out how to get it there, but that shouldn't be too difficult.
        We finished operating at 9pm. We had planned to go to Fuxion for a final meal, but it was too late. Janty had made food for us so we ate at the hospital and then went back to the hotel to pack up.
       The e pertinence with the parotid and the uterine fibroid brings up an interesting and frequent ethical concern for us.  While maintaining a level of comfort would have us only doing the operations that we normally do in the USA, we know that for many of these patients, an attempt by by us is the only option. So we push our level of comfort, but try to stay with the bounds of reasonable care and avoid being reckless. Our desire to help is also tempered by the knowledge of what care the patient will require after surgery, and the realization that there isn't a whole lot of that available.

Sunday March 13

        Another interesting day in Monrovia. Santiago had 2 colonoscopies lined up for today, but one of them decided she was hungry this morning and had breakfast, so she was cancelled. Then we had scheduled the little girl with the umbilical hernia which I wrote about yesterday; for reasons that remain a mystery, her mother decided she needed food this morning also. So initially she was cancelled, but then anesthesia agreed we could do her later in the day so we did. Mary, the hospital administrator and solver of all problems, had a meltdown over that one because she was understandably frustrated by the failure of the system when everyone had gone out of their way to make this happen. Fortunately she recovered quickly, and was fine later in the day when we saw her again. Then they brought up a woman who had a huge lipoma on her hip that was to be excised...except they brought up the wrong patient ! They brought a woman with a large parotid tumor whom we had seen and were trying to decide whether to operate on her; despite my saying that it was the wrong patient, they brought her into the room and started getting her ready for anesthesia. i pointed out again that it was the wrong patient, and she was brought back downstairs to be traded for the lipoma lady. It's worth noting once again that the patients have no name bands or other form of attached identification; I think this needs to be remedied soon.
       Then we had a 60ish year old woman who was operated on at ELWA Hospital in January for presumed gallbladder disease, but at surgery was found to have a liver nodule. A biopsy was taken and sent to the US where a diagnosis of metastatic adenocarcinoma was made; special stains suggested breast, lung, or gyn origin. She came to see us because she had developed an incisional hernia, and was in pain. We got a chest X-ray yesterday which looked fine, and she had no breast masses, so we thought we would repair her hernia today and explore her abdomen at the same time. Unfortunately we discovered that she had a large pancreatic mass with many liver metastases, so there wasn't much we could do other than to repair the hernia. I realized during the case that what she was calling hernia pain was most likely pain for her pancreatic cancer; regrettably I don't think there is much that anyone can do for her. Sadly there is no facility here for palliative hospice care.
         The best part of the day was having Dr Gbozee on call and with us most of the day. While I had hoped the other residents would show as much interest in actual surgery as he does, I'm happy that we have at least one motivated, intelligent, eager surgical resident. After we finished our cases today we went to the ward with him and reviewed all of the patients. He knew them all without having to ask the nurses, and we were both impressed.
         Tonight we went back to Fuxion for dinner, and I cured myself of a pizza craving. As we walked back to the hotel, members of the Liberian National Police Emergency Reaponse Unit (ERU) pulled up, and two heavily armed members parked themselves inside the gate of the hotel driveway. We think this is a response to the attack in Côte d'Ivoire today by Muslim militants. Liberia has a significant Muslim population, in the range of 30%, and lately they aren't real happy: there is a move afoot in the Legislature to amend the Liberian Constitution to declare that Liberia is a Christian nation. To an outsider (me), it seems that such a move is designed to piss off the Muslim community, and serves no real purpose. Hopefully nothing will come of that, and there will be no further attacks in Côte d'Ivoire or next door in Liberia. Time will tell.

Saturday March 12

      Telecommunications is a bigger problem this visit than it has been in the past. For reasons that remain unclear to me, I am not able to access the Internet except through Wifi. In the past, we have been able to use Wifi, and when that wasn't available, we could use cellular data access. Anyway, the only Wifi access we have is at the JFK Administration building or at our hotel; the result is that while I have been good about writing my blog, i haven't always remembered to post it when I could. My apologies.
       We did a lot of surgery today, mostly hernias large and small. Having advertised that our services were available, and then admitted many patients who wished to take advantage of them, we were under a certain amount of pressure to clear out the patients who are waiting for surgery. We ended up doing 6 cases, all hernias large and small...Oh one was a hydrocele.
       Between cases we saw some other patients that we had heard about. One is a 3 year old girl with a large umbilical hernia that will obviously not close on its own. She was in the hospital recently to have it repaired, but her mother grew frustrated and scared and took her home. Somehow Aunt Jenny knew about her, and asked if I would fix it if she could get the girl and her mother back; of course I agreed. It turns out that during the war, the mother was separated from her 2 children, and they were thought to be orphans; they ended up being adopted to the US and she has never heard from them again. She is desperately afraid of losing this little girl. Auntie Jenny brought her to the hospital today, and with encouragement and the promise that I would do her surgery tomorrow, she was admitted.
       We also saw a little boy with what looks to me like a retinoblastoma ( malignant tumor of the eye). I was shown a picture of him the other night at Aunt Jennie's when the eye was all swollen and inflamed after his mother took him to a native healer who blew some magic powder into the eye. Now that the inflammation has settled down, the tumor is obvious, but there is no one in Liberia who can take care of this problem. They need to take him to Ghana, but that is expensive; I'm not sure what will happen.
      After we finished surgery, Moses took us to the mask shops at Mamba Point where we looked around and bought a few things. Santiago bought a couple of gorgeous, but huge, masks; getting them back to the US is going to be something of a trick I think. I bought some smaller items, including another Command Stick; I'm not sure why I need such a thing, but it's good to have !
      After dinner at FuzionAfrica, we came back to the hotel and I crashed.

Friday March 11

      Morning rounds again starting at 8:30. Dr Atem runs a tight ship, and doesn't let the reporting residents get away with unnecessary ambiguity or obfuscation. Compared to years past, the degree of organization is quite impressive, and bodes well for the future, I think. The improvement is partly the increased level of organization, but also clearly the personnel are critically important, both in terms of faculty and in terms of the residents. Santiago and I both are impressed with the different attitude and approach on this trip.
      We did 7 cases today, which is a fairly impressive production. Some small, like aspiration of a thyroid cyst, several hernias, and some interesting challenges. One of the latter was a young boy who underwent circumcision by someone with limited skills, and who managed to amputate the glans along with the foreskin. The boy presented here with a large collection of urine around the shaft of his hemi-penis. I found a way to drain the urinoma, and we thought we identified the urethra, but I'm not really sure. Hopefully we can do some radiological exams to better define what is going on.
     Santiago brought Miatta to the OT today. She is about 17 or 19; Jonathan Laryea first met her when he went to Phoebe Hospital a few months before he came to JFK with us. He diagnosed her as having Crohn's disease, which is uncommon in Liberia. Over the subsequent several years, he and Santiago have been checking on her each visit, and bringing her medication. Her Crohn's has progressed, and she now had a recto-vaginal fistula as a result of it. One of the nice things about working here is that we we ask for special consideration for a patient, it is granted without question. When we are here, there is no surgeon's charge to the patient, but they are expected to pay for hospitalization and drugs, and the estimated payment is required to be paid in advance. For Miatta, these fees are waived so that Santiago could proceed with taking care of her. He did a repair of the fistula and a diverting ileostomy, and everything went well. The last case of the day was a woman whom I operated on 2 years ago for locally advanced breast cancer; she presented to the clinic with a chest wall recurrence and Santiago admitted her the other day. My plan was to excise the large recurrence and then cover the defect with a skin graft; I brought fresh new blades for the dermatome  and was assured by Sano that while the machine had been not working he had fixed it. You can perhaps guess where this story is going: we excised the recurrence, and then went to take the skin graft, only to discover that the dermatome was in fact not functional. I was already feeling totally frustrated by the delays encountered during the day so this was just the icing on the cake, We bandaged the wound and finished the operation around 7pm; perhaps Monday we will bring her back to take freehand skin grafts for her.
       After finishing, we rushed back to the hotel to shower and change, and then went to Aunt Jenny's for, food, drink, and conversation with her and a number of family, many of whom we already knew. It was a nice relaxing evening, and a couple of glasses of champagne washed away my sense of frustration.
     

Thursday March 10

     We again joined the residents and faculty for "chart rounds" at 8:30am, where they review admissions, consultations, deaths, and overnight operations. Each case is presented by one of the residents who was on call, and they are subject to questioning by the faculty. Being embarrassed in front of your colleagues because you don't know the answer to a question, or didn't elect an important fact from the patient, is a well established technique in surgery ( and medicine generally) which decreases the chances that it will ever happen again. While humiliation is uncomfortable, and needs to be tempered by a degree of understanding, it is a powerful educational weapon.
      After 30 minutes of this, Santiago and I went off to the OT to start the day's work while the faculty had a curriculum meeting. We ended up doing 6 of the 9 cases we had scheduled, which was a pretty good days work. Santiago and Dr. Cassel started with a woman who had a small bowel obstruction in an incisional hernia who had come in last night; she turned out to have a perforation,miso Dr. Gbozee was smart in scheduling her for the OT. While they were doing that, I was in the Orthopedic room doing recurrent bilateral inguinal hernias and then a new unilateral inguinal hernia. For reasons that are unclear, there was no resident to help me; I thought that was unfortunate since I am here to teach, and I really don't need more experience doing hernia repairs ! On the other hand, doing a hernia repair with inadequate lighting, instruments consisting of a meat cleaver and a samurai sword ( okay a bit of an exaggeration, but not nearly as much as you might think!), and a scrub nurse to assist who isn't sure why he signed up for this gig in the first place...now that makes it an interesting challenge.
        One of the cancelled cases is a women whom I operated on 2 years ago for advanced breast cancer. She now has an exophytic raw mass over her right chest wall which smells and she wants to be rid of. She likely doesn't have long to live; I hope we can make whatever time she has left the best possible. But she had no blood available for the operation, and the anesthetists quite reasonably felt it was unsafe to proceed without blood. So after some time my patient finally got her son to agree to come in tomorrow morning with money so she can pay for 2 units of blood.

Wednesday March 9

     Sleep was better last night, though still far from perfect; sadly that is no different than at home !
     Today is a national holiday: Decoration Day, when the tradition is to decorate the graves of your ancestors. Without a word of complaint or otherwise, the OT staff was quite willing to work today so we did 4 cases with Dr. Gbozee. Santiago and I each did an inguinal hernia with him, and then he and I did a large recurrent incisional hernia on a large woman. I also took a strange cyst off a man's arm; it may be just a sebaceous cyst, but it seemed odd, and knowing the large number of odd things we have seen here, I will bring it home for pathology.
     Dr. Gbozee is the embodiment of future surgery in Liberia. We first met him 2 years ago when he was an intern at JFK; apparently I made an impression on him, and he decided that he wanted to be a surgeon. I wrote him a letter of recommendation based on his clinical skill,  his intelligence, and his hugely apparent desire to learn. He was accepted into the postgraduate surgical training program and has obviously flourished. when we came last May, he asked me to bring textbooks for himself and his fellow residents which I did. This time he asked me to get him 2 white coats with " Lawuobah Gbozee, M.D.  Department of Surgery" on them, and I was happy to do so. He is wearing them with obvious, and deserved, pride ! He is well-organized ( not necessarily a trait that comes easily to the Liberian people), exceptionally motivated, and really a joy to work with and teach. Today was exactly what I had been hoping for in this Liberian experience: the opportunity to work with a resident/student who has a mind like a sponge, soaking up every bit of teaching I could offer. I loved it.
     Robert Dolo came by to pick up the things I brought for him from Karen. He has moved into his new building which we saw under construction last May ! It was great to see him again.
     Adamah asked us to go to a meeting organized by the country director of the Peace Corps to informally bring together some groups working in healthcare in Liberia. The Peace Corps has a subset now called the Global Health Service Partnership which places doctors and nurses in countries to help educate in medical schools, hospitals, and the like.The group has an interesting, if esoteric in some places, discussion of the desire to have all of the NGOs and others work together without conflict, following the agenda set forth by the Ministry of Health rather each organization's own agenda. Hopeful thinking for sure!! One of the people there was Sister Barbara, whom I immediately recognized from the documentary " Liberia: An Uncivil War" as being the kick-ass nun who was working to save children in a war zone. Lest night she demonstrated that she still has the kick-ass spirit, and it was enjoyable and enlightening to hear her speak.
      After the meeting we went to what was formerly Taj for dinner with Adamah and his 2 traveling companions, and then Lydia joined us. After dinner we went back to the Royal and crashed.

Tuesday March 8s

After a more fitful nights sleep than I prefer, we had our breakfast downstairs and then Moses(our assigned driver) picked us up and took us to the hospital. We participated in morning rounds with the residents and faculty, enjoying the lively and pointed questions particularly by Dr. Ate and Senator Dr. Coleman. Following chart rounds on new patients and the ward rounds, we went to the OT to begin our day. I should note that the practice here is to refer to it as the Operating Theater or OT rather the the Operating Room or OR, so when in Rome we do like the Romans ! The first case was the guy with a bad perineal injury following a motorbike accident. They had done a colostomy and placed a supra pubic tube immediately after the accident several months ago, but they weren't sure how to proceed further. Santiago discovered that his anode fm had been denuded and then everything fused together in healing, leaving him with something like an imperforate anus. He broke thru the fusion, and then did a flexible sigmoidoscopy; the question remains as to how to proceed from here. An assessment of his sphincter function is vital before making any decisions.
     The next case was a youngish woman  who had been sodomized by her husband several times, and subsequently developed a painful anal mass. On examination under anesthesia, it appears that she has a hard mass extending from the anus several centimeters into her rectum; Santiago is suspicious of malignancy.mhe took a biopsy which we will bring back to the US for analysis, and he did a diverting colostomy.
     For much of the morning I was in the OPD Surgical clinic seeing a variety of patients, many of whom had no surgical issues so I'm not sur why they were there. There were also several referrals to me of one sort and another: a benign breast mass in a young woman, several patients with keloids, a couple of hernias, etc. Already it is unclear to me how we will have time to do all the work being offered, but better too much than too little I suppose.
       Dr. Gbozee and Dr. Moses did a recurrent hernia while I was in the OPD, and then I cam up and did another recurrent hernia wth Dr. Gbozee. While we were doing those in the Orthopedic room, Santiago and Dr. Cassell did an ileostomy dcommisioning. So we did 6 cases that day, finishing at 6 pm, and that was a good days work !

Monday March 7

We arrived at 9 AM for Grand Rounds, and it was quite the joyful scene greeting our many friends. Adamah came in at the end with an ER doc and an ER nurse from his place in Georgia; it was great seeing him again. After that we went upstairs to see Precillar and everyone else in the OT, and that was another joyous reception. We then went down to the surgical ward to make rounds; many.
similar stories to what we have heard in the past of accidents and misadventures and neglect of the condition until it is really too late. We saw a number of adults, one of whom had a tree fall on him fracturing his pelvis; Another unfortunate man was riding a motorbike in a collision and he suffered severe perineal trauma. Both of them need to go to the OT for examination under anesthesia and possible surgery.
    The surgical faculty is strong and demanding, as they should be. There are now 2 years of residents with 5 surgical residents in school year; this is the beginning of Liberia being able to "grow their own" in terms of producing qualified physicians.Postgraduate training following medical school stopped around 2000 because of the civil war; it restarted in 2014 just before Ebola.
     In the afternoon we saw Adamah with an ER colleague from Georgia and a nurse from Georgia also. They will be here for the week.
     Santiago and I are staying at the Royal, and it is very pleasant having all of the modern comforts such as A/C, hot water, and wifi !! I'm puzzled that I can't connect to the Internet except by wifi; in years past we could always connect directly thru one of the carriers. It was expensive, but at least it orovided an alternative when wifi was not available. Anyway, we came back to the Royal and then went for dinner at Sajj followed by an early night as we were both travel-tired.

Sunday, March 6

We have arrived after a long journey !! We left JFK (NY) yesterday evening. Brussels Airlines was very kind and allowed us each 2 extra bags at no charge, so we were able to bring a lot of supplies. We arrived in Brussels at 7 am, and then caught the flight to Monrovia at 12:30; the flight included a stop in Freetown, Sierra Leone. Interestingly, this flight was full to capacity, and one of the noticeable things was that there were a lot more Caucasians than we typically have seen on these flights. And a lot of Chinese as well, but that isn't a surprise as China has worked to become a dominant force in Africa, and they have been successful. At Robertsfield, the international airport in Liberia, you deplane onto the Tarmac and then a large bus takes you to the Arrivals building. Tonight we were met at Arrivals by Louise, who seems to run the VIP facility at the terminal. She was holding a piece of paper with my name on it, and I remembered her from previous encounters. She took our passport documents and baggage slips, and someone took care of the formalities as well as picking up our 8 duffel bags while we enjoyed a refreshment in the VIP lounge. We then drove to JFK Hospital; Dr McDonald called Alvin while we were driving in to welcome me home ! Munah was at the hospital ready with a meal for us, and then Moses brought us to the Royal Hotel where we will be staying on this trip. It is very comfortable, and after a nice hot shower I'm ready for bed. Rumor has it that we will have plenty to do on this trip !

Upcoming trip March 2016

We are preparing for our trip in March: getting supplies, and thinking about what we need to bring that we didn't have on the last trip. It has been almost a year since I have been in Monrovia, and I am looking forward to this return trip. I had planned to go with Dr. Jonathan Laryea in September, but I developed some personal health issues which precluded me from making the trip. Jonathan went by himself, and by all reports had an excellent and productive time. This trip will be Santiago Arruffat and myself for the surgical team; also traveling to Monrovia at this time will be Dr. Sirleaf and one or two other medical doctors. Our goal on this trip is to do some operating and teaching, but also to assess the situation to determine whether it will be safe and appropriate to resume bringing residents and others in the fall. Liberia, Sierra Leone, and Guinea have all been declared Ebola-free by WHO, but everyone recognizes that the disease has not been eradicated, and it is likely that there will be sporadic cases popping up from time to time. My understanding is that all patients being admitted to JFK Hospital are triaged for Ebola symptoms, and that all surgery is being done with full Ebola precautions. It is unclear if this is the new reality which will stay in place forever, or if at some point they will be able to return to a more normal OR atmosphere. Obviously we and everyone else needs to take whatever precautions are necessary to insure the safety of everyone involved to the extent that is possible. On a related note, we recently had Dr. Philip Ireland speaking at Waterbury Hospital. He is an ER physician at JFK Hospital, and an Ebola survivor; through a program we have started at HEARTT, he is at Yale in New Haven for a month observing in the Emergency Room. I met him a few years ago in Monrovia, so he didn't hesitate when I invited him to Waterbury to speak; the title of his talk was "To Hell and Back in 21 days", and it was very well received by a large audience. When he came down with Ebola, there was no room in any of the Ebola Treatment Units (ETUs) so he stayed at home. He had his wife and 4 children move elsewhere so they wouldn't be at risk, but his mother refused to leave, electing instead to stay to nurse him. She did not have access to Personal Protective Equipment (the Hazmat suits) so she wore her raincoat, her boots, and wrapped her hands with plastic shopping bags as protection. She did not catch Ebola! I have told him that I would like to meet her when we are there in March ! Finally, I would like to give a shout out to Mr. Joey Glass, a service representative at Summit Medical Specialties in Jacksonville FL. In Liberia, there are many patients who need skin grafts because of burns and tropical ulcers. We use a dermatome, which is essentially a powered skin shaver, to take very thin pieces of skin from one part of the body and place it on the affected area. Before each trip I am asked to bring dermatome blades, which I have often been able to buy on eBay. About a month ago, Dr. Gbozee, a surgical resident at JFK who is destined for greatness, informed me that they had lost one of the screws on the dermatome which holds the blade in place, and they wondered if I could bring a new one. I spoke to Italo in our Central Supply department; he looked all over including going to Home Depot and Lowe's looking for a replacement screw but couldn't find one. I looked online, and emailed one place asking but I never received a reply. Last week I decided to try one more time, and I found Summit Medical Specialties on a Google search for dermatome repair outfits. I wrote them explaining what I needed to buy, and why it was important to have a working dermatome at JFK; that afternoon I reviewed an email back from Mr. Glass telling me that he wanted to donate 4 screws, and he would put them in the mail immediately. His heartfelt gesture of generosity made my day; in my note thanking him, I pointed out that having the opportunity to come into contact with people like him is one of the greatest joys of doing this work. We leave on March 5. As usual, I will be posting a daily blog whenever possible.