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.