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.