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.
Wednesday, March 16, 2016
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.
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, 2016
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.
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.
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.
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.
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.
Thursday, March 10, 2016
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.
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.
Wednesday, March 9, 2016
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 !
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.
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, 2016
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 !
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