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.