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.