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!