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.