Our final day on this trip. We did several biopsies on patients who had an unknown diagnosis, or at least needed pathological examination of their problem. One was a guy with multiple lumps of varying sizes all over his body; another was a man complaining that his left wrist was painful, He had incurred some minor trauma to the wrist a few years ago, but said no bones were broken. It started getting painful in the past year. On examining him, he has a huge node in his left axilla which is not painful.He kept saying that his wrist was the problem while I kept telling him that the enlarged node was a bigger problem. They could be related, or it could be two different things going on. In any case, after consulting with my colleagues, we all agreed that the node biopsy was important to do first since we are leaving. He needs an X-ray of his wrist, but he doesn't have money to pay for it right now. So we did the biopsy.
We finished around 1 pm, and then ordered pizza from Sajj for the OT staff to thank them for their hard work. We ended up with a total of 78 or 79 procedures done(the final total is still being worked on). On past trips we have done 55-60 most of the time, so this was a substantial increase in volume. This is particularly notable in view of the fact that 1 of the 2 ORs we were using had limited use because there was no surgical lighting other than our headlights, and the ventilator on the anesthesia machine wasn't working. Joshi was reluctant to use that room for anything other than spinals or short cases, so we had to do a lot of juggling with the schedule. I think we had an excellent team pitching in and getting things done and that includes our HEARTT people as well as the Liberian staff. Without question we could not have been that productive without the encouragement and help from Mary, Munah, and Dr. Macdonald as well as Selina in the Admitting Office and many others.
After lunch we went back to the hotel to change and get ready to depart. Moses was going to take Sandeep, Greg, and Murphy to the mask shops at Mamba Point, but one of the political parties was launching their campaign downtown, and traffic was a total mess, so that didn't happen. Masmina came to the hotel and we had a good debriefing/chat with some ideas for our next trip. Then Murphy, Sandeep, Greg and I went to leave with Morris; Jonathan and Chandra have a later flight going to Amsterdam, so Moses will bring them to the airport in a few hours. Before we left the hotel, Morris couldn't get one of his back doors to latch, so we had a delay while that got fixed. In my usual pre-flight anxiety, I let out some of my frustration...but then the latch got fixed and we left for the airport.
Robertsfield Airport is about an hour drive from Monrovia under good conditions; Friday afternoon at 5 pm is never a good time to go anywhere ! Getting out of Monrovia was a struggle with traffic, but Morris found some interesting, rutted dirt road shortcuts, and then we seemed to be cruising until about 5 miles from the airport. We found that there was a traffic jam because there was about 18 inches of water on the road due to flooding from recent rains. I had never seen this on any previous trip. Many cars were having trouble getting thru it because they were slung low enough that water got in the exhaust or engine or whatever so people were getting out to push them thru. Fortunately we didn't get stuck, though I certainly had some anxious moments. we arrived at the airport and left on time flying to Brussels and then on to JFK(NY). Aside from having to wait 2 hours while Sandeep went thru the line for non-US passport holders, it was okay. As we walked down the hallway from the plane to Immigration, we separated into 2 lines based on signs saying "US" and "Non-US"; I wondered if they will be changing the signs soon to "US" and "THEM".
Sunday, September 17, 2017
Thursday, September 14, 2017
Thursday September 14
Today was our last full day of surgery before we leave tomorrow night. We had another 11 case day including pediatric hernias, male and female, an adult hernia, a breast mass(fibroadenoma), an incisional biopsy of advanced breast cancer, a colostomy closure, and a wound closure among the cases. We also saw a young(21 year old) woman with what I think is thyroid cancer: she had huge masses on both sides of her neck which have been growing for a couple of years. Dr.Cassell came up with Dr.Sally to ultrasound her, and we could see that the masses are surrounding her carotid artery and jugular vein among other things. I spoke to her father and recommended that he take her to Ghana for further evaluation such as a CT scan and then surgery, possibly after a course of medical treatment to see if the masses can be shrunk.
She brings up the point that while we like to push the surgical envelope to some extent, and move little outside of our comfort zone, it remains important to recognize our limitations.Traveling to Ghana for medical treatment is an expensive proposition for most Liberians, and many just can't afford to do it. Sometimes when we are told that someone can't afford to go to Ghana it becomes tempting to push the envelope too far and want to try to do the surgery ourselves; I think in most cases this urge must be resisted.
We also had several occasions on this trip when we were forced to think about the concept of palliative care in Liberia. A cases in point is the incisional breast biopsy we did today: the patient is 32 years old, and has a very advanced breast cancer. We did the biopsy to prove to ourselves that the cancer is aggressive histologically, though it is pretty obvious clinically that is the case. We also did the biopsy to see if it is hormone sensitive, which is unlikely but probably worth finding out. While we want to offer hope to all patients, the fact is that even in the best medical system with optimum care, this woman is not likely to survive her very aggressive disease. It wouldn't be unreasonable to think that for her, a trip to Ghana would likely be a waste of money as whatever treatment she could receive is unlikely to change the course of her disease. Having a conversation about such matters is difficult under the best of circumstances; here it is often impossible because of societal, cultural, and educational differences.
This has been quite an amazing trip: if we do the 6 cases we have planned for tomorrow, our total will be 78 cases in 11 days of operating, which is a significant increase over our previous trips. More important than the actual number of cases, however, is the fact that we were able to be so productive, and that is a reflection of many factors including organization and teamwork. The JFK Administration, from Dr.Macdonald, Munah, and Mary on down worked very hard through long hours to give us what we needed to be successful. While the OT staff seemed slow to get started on some days, they soon got into the swing of things and kept the patients flowing. Dr. Gbozee and Cassell and other residents helped keep us organized and informed about patient admissions and discharges as well as frequently coming to the OT to assist. Sandeep and Greg quickly adapted their thinking to the Liberian system, and became efficient navigators and communicators. Murphy was amazing in the OT not only doing a lot of work herself, but also helping the other staff to efficiently prepare for cases. Having Joshi with us turned out to be critically important in some individual cases as well as overall; through each day he kept his eye on our schedule, working to make sure we were as efficient as possible in getting cases done. And, once again, it was a joy and an honor to work with my friend Jonathan Laryea whose skills as a surgeon and endoscopist combine with his knowledge and extraordinary humanism to make these trips so successful.
She brings up the point that while we like to push the surgical envelope to some extent, and move little outside of our comfort zone, it remains important to recognize our limitations.Traveling to Ghana for medical treatment is an expensive proposition for most Liberians, and many just can't afford to do it. Sometimes when we are told that someone can't afford to go to Ghana it becomes tempting to push the envelope too far and want to try to do the surgery ourselves; I think in most cases this urge must be resisted.
We also had several occasions on this trip when we were forced to think about the concept of palliative care in Liberia. A cases in point is the incisional breast biopsy we did today: the patient is 32 years old, and has a very advanced breast cancer. We did the biopsy to prove to ourselves that the cancer is aggressive histologically, though it is pretty obvious clinically that is the case. We also did the biopsy to see if it is hormone sensitive, which is unlikely but probably worth finding out. While we want to offer hope to all patients, the fact is that even in the best medical system with optimum care, this woman is not likely to survive her very aggressive disease. It wouldn't be unreasonable to think that for her, a trip to Ghana would likely be a waste of money as whatever treatment she could receive is unlikely to change the course of her disease. Having a conversation about such matters is difficult under the best of circumstances; here it is often impossible because of societal, cultural, and educational differences.
This has been quite an amazing trip: if we do the 6 cases we have planned for tomorrow, our total will be 78 cases in 11 days of operating, which is a significant increase over our previous trips. More important than the actual number of cases, however, is the fact that we were able to be so productive, and that is a reflection of many factors including organization and teamwork. The JFK Administration, from Dr.Macdonald, Munah, and Mary on down worked very hard through long hours to give us what we needed to be successful. While the OT staff seemed slow to get started on some days, they soon got into the swing of things and kept the patients flowing. Dr. Gbozee and Cassell and other residents helped keep us organized and informed about patient admissions and discharges as well as frequently coming to the OT to assist. Sandeep and Greg quickly adapted their thinking to the Liberian system, and became efficient navigators and communicators. Murphy was amazing in the OT not only doing a lot of work herself, but also helping the other staff to efficiently prepare for cases. Having Joshi with us turned out to be critically important in some individual cases as well as overall; through each day he kept his eye on our schedule, working to make sure we were as efficient as possible in getting cases done. And, once again, it was a joy and an honor to work with my friend Jonathan Laryea whose skills as a surgeon and endoscopist combine with his knowledge and extraordinary humanism to make these trips so successful.
Wednesday, September 13, 2017
Wednesday September 13
Another superbly crazy busy day in which did 11 cases including 3 endoscopies, 4 inguinal hernias, an incisional hernia, a thyroidectomy, removal of an oral cyst in a 5 month old, and something else which I can't remember right now. Tomorrow looks equally busy as we try to fit in surgery for as many people as possible, but particularly those needing pathological examination of tissue.
When I asked Dr.Konneh why so many people were coming to JFK wanting us to fix their hernias, he explained that many people want the American doctors to do their surgery. One of our goals is to help in the effort to improve Liberian surgery so that won't be an issue anymore; on this trip we have seen further evidence of progress in that direction, but we were still inundated with requests.In the past couple of days, I have had to tell people that we will have to schedule their surgery for when we return in March, as there is just not enough time to do it on this trip. Since many of these people have had their hernia, or goiter, or whatever, for many years, waiting 6 months for surgery may be inconvenient and disappointing, but it's not bad medicine.
I wrote in an earlier blog about Varney, a 4 year old boy who swallowed lye and developed an esophageal stricture. Today Jonathan scoped him again, and dilated the stricture again, and was able to pass the endoscope thru the stricture into the stomach. Jonathan told us that this afternoon he went to see Varney who was happily drinking fruit juice thru a straw; this is a boy who prior to being dilated, had not been able to swallow food or drink for many months. Being able to do this for Varney has far reaching effects not just for his life, but for others in his situation, for the Liberian doctors who are being taught endoscopy, and for JFK Hospital as an institution. I hope and think it will turn out to be an important step for Liberia on the road to recovery. Having the ability to do endoscopy will pay huge dividends in patient care, and we have it at JFK because of the work of my colleagues Dr.Santiago Arruffat and Dr.Jonathan Laryea; I am very proud to be associated with both of them !
When I asked Dr.Konneh why so many people were coming to JFK wanting us to fix their hernias, he explained that many people want the American doctors to do their surgery. One of our goals is to help in the effort to improve Liberian surgery so that won't be an issue anymore; on this trip we have seen further evidence of progress in that direction, but we were still inundated with requests.In the past couple of days, I have had to tell people that we will have to schedule their surgery for when we return in March, as there is just not enough time to do it on this trip. Since many of these people have had their hernia, or goiter, or whatever, for many years, waiting 6 months for surgery may be inconvenient and disappointing, but it's not bad medicine.
I wrote in an earlier blog about Varney, a 4 year old boy who swallowed lye and developed an esophageal stricture. Today Jonathan scoped him again, and dilated the stricture again, and was able to pass the endoscope thru the stricture into the stomach. Jonathan told us that this afternoon he went to see Varney who was happily drinking fruit juice thru a straw; this is a boy who prior to being dilated, had not been able to swallow food or drink for many months. Being able to do this for Varney has far reaching effects not just for his life, but for others in his situation, for the Liberian doctors who are being taught endoscopy, and for JFK Hospital as an institution. I hope and think it will turn out to be an important step for Liberia on the road to recovery. Having the ability to do endoscopy will pay huge dividends in patient care, and we have it at JFK because of the work of my colleagues Dr.Santiago Arruffat and Dr.Jonathan Laryea; I am very proud to be associated with both of them !
Tuesday, September 12, 2017
Tuesday September 12
Another very busy day. We arrived at the hospital around 8:25am, and left at 11pm.We did 9 cases today, which is a lot for us at JFK. There are a number of factors which cause delays, many of which are just inherent in the system and the constraints under which we labor. So I try to remain calm, and not let my impatience overrule my understanding; it is what it is, and its getting better with each visit. The cases we did included a hernia, a hydrocele, a colostomy on a 3 day old baby with an imperforate anus, a partial mastectomy for a large breast mass, and biopsy of a large pelvic tumor in a 19 year old man. In between cases we saw more people wanting surgery, but our time is running short. We have mapped out a schedule thru Friday when we leave, and our days will be filled. But its all good. I'm going to cut this short because its midnight and I need to sleep !
Monday, September 11, 2017
Monday September 11
Yesterday we had the day off, and I took a day off from blogging. We had a leisurely morning and then went to the beach at RLJ Kendeja for the afternoon.
Today we started our second week, and I expect it will be just as good and as busy as our first week. The morning started off with Grand Rounds presented by Dr.Gbozee and Dr. Philip Ireland reporting on their experience in the US. They were both financed by HEARTT for a month of observing in the US; Philip spent a month at Yale, and Lawuobah spent the month traveling between Waterbury,CT, Little Rock,AR, and Evansville,IN.The presentations were awesome, and marvelous, and fascinating !! Clearly they took advantage of the opportunity to see a different healthcare system and to start considering the sort of systematic improvements which could be transferred to Liberia.
After rounds I had a good talk with Dr. Marshall about the state of the postgraduate surgical training program, and especially it relates to surgery at JFK.
For surgery today we did a ventral hernia, a colonoscopy, a boy with probably a dermoid cyst of his neck which I had thought pre-op to be a thyroglossal duct cyst, a young man who was stabbed in the abdomen the previous night, and a 3day old with an imperforate anus. We also saw a number of consultations, some of which were surgical problems which we could help, and others which we referred to medicine. A 34 year old man came to see us this afternoon with significant ascites(fluid in the abdominal cavity); this is usually the result of severe liver disease, but he didn't appear to have that. Fortunately I was able to find Dr. Ireland downstairs and arrange for the patient to be seen by the medical team to get worked up.
In the evening we went to the apartment of Teresa and Alex Cummings for a delightful dinner. Teresa is Chair of the Board of HEARTT, and is a wonderfully kind and generous woman. Alex is fascinating: he was born and educated in Liberia, and then pursued a career in business, ending up as Chief Administrative Officer and Executive VP of Coca-Cola. A year or two ago he retired from Coke and they moved back to Liberia where he is running for President currently ( President Sirleaf is not eligible to run again as she has served 2 terms). There are about 20 candidates for the office; if none get over 50%of the vote in October, there will be a run-off between to top two. The polls put him in the top 3 or 4, and he was widely considered to have won the first debate between the candidates. He is definitely not in the usual mold of a politician, but thankfully neither is he like the current US businessman President!! The Cummings live in the penthouse of an apartment building which they started building in 2011; they were able to move in just recently. It is spectacularly beautiful inside and out! There is a rooftop terrace with amazing views of the city. Their interior designer was also at the dinner along with several other guests, and it was a most enjoyable evening.
Today we started our second week, and I expect it will be just as good and as busy as our first week. The morning started off with Grand Rounds presented by Dr.Gbozee and Dr. Philip Ireland reporting on their experience in the US. They were both financed by HEARTT for a month of observing in the US; Philip spent a month at Yale, and Lawuobah spent the month traveling between Waterbury,CT, Little Rock,AR, and Evansville,IN.The presentations were awesome, and marvelous, and fascinating !! Clearly they took advantage of the opportunity to see a different healthcare system and to start considering the sort of systematic improvements which could be transferred to Liberia.
After rounds I had a good talk with Dr. Marshall about the state of the postgraduate surgical training program, and especially it relates to surgery at JFK.
For surgery today we did a ventral hernia, a colonoscopy, a boy with probably a dermoid cyst of his neck which I had thought pre-op to be a thyroglossal duct cyst, a young man who was stabbed in the abdomen the previous night, and a 3day old with an imperforate anus. We also saw a number of consultations, some of which were surgical problems which we could help, and others which we referred to medicine. A 34 year old man came to see us this afternoon with significant ascites(fluid in the abdominal cavity); this is usually the result of severe liver disease, but he didn't appear to have that. Fortunately I was able to find Dr. Ireland downstairs and arrange for the patient to be seen by the medical team to get worked up.
In the evening we went to the apartment of Teresa and Alex Cummings for a delightful dinner. Teresa is Chair of the Board of HEARTT, and is a wonderfully kind and generous woman. Alex is fascinating: he was born and educated in Liberia, and then pursued a career in business, ending up as Chief Administrative Officer and Executive VP of Coca-Cola. A year or two ago he retired from Coke and they moved back to Liberia where he is running for President currently ( President Sirleaf is not eligible to run again as she has served 2 terms). There are about 20 candidates for the office; if none get over 50%of the vote in October, there will be a run-off between to top two. The polls put him in the top 3 or 4, and he was widely considered to have won the first debate between the candidates. He is definitely not in the usual mold of a politician, but thankfully neither is he like the current US businessman President!! The Cummings live in the penthouse of an apartment building which they started building in 2011; they were able to move in just recently. It is spectacularly beautiful inside and out! There is a rooftop terrace with amazing views of the city. Their interior designer was also at the dinner along with several other guests, and it was a most enjoyable evening.
Saturday, September 9, 2017
Saturday September 9
I'm not sure if it's my age starting to show, but this has been a pretty tiring trip so far. I might be just that we get up at 7 to leave for the hospital at 8:15, and then most days we have returned to the hotel around 8 PM to have dinner, then go to bed and start again the next morning. I'm looking forward to a longer sleep tomorrow !
Today we were up at the usual time to start our Saturday, though the thunder woke me around 6am. It is rainy season, and most days this past week it has rained pretty hard in the early morning, but then cleared up around noon. They put on extra people today, so we were able to use two rooms for our cases. Some days the impediments to a smoothly functioning surgical schedule are astonishing; today the problem was that there was only one stretcher available to transport patients, so they couldn't get the next patient until the last patient was brought to his or her room.one might think there would be an easy solution to this problem ( like having more stretchers) but maybe I'm optimistic.
Our cases today included a cholecystectomy, an adult hernia, a large neck lipoma,a scope, and some minor surgery. Everything went reasonable smoothly; it was pretty fun to take out an easy gallbladder the old fashioned way, and it brought back lots of memories for me. These days the only gallbladders we remove through an incision rather than laparoscopically are the really difficult ones.
Friday, September 8, 2017
Friday September 8
Friday September 8
Another very busy but productive day at JFK: we did a total of 9 cases- 7 elective and 2 emergencies. The elective cases included the usual couple of large African hernias as well as a pediatric hernia, a screening colonoscopy, a cholecystectomy, and the excision of a plunging ranula. You might be asking yourself “What in the heck is a plunging ranula?” And you would be in good company because we had no idea either. A 15 year old boy came to see us complaining of a bulging mass inside his mouth, and a mass in his neck. On examination, they seemed to be connected. An ultrasound showed that it was a cystic structure filled with clear fluid, so I aspirated it partially with a needle, and indeed it looked like saliva. With help from Google, Sandeep was able to identify is as a plunging ranula, and we were all able to read articles on how to best remove it. It is a salivary gland cyst, and the best treatment involves removing the cyst along with the sublingual salivary gland, taking care not to injure the lingual nerve. The approach is thru the floor of the mouth. So this morning Sandeep and Jonathan excised it! We are general surgeons, and so we do what general surgeons do: find surgical solutions to problems when possible ! Sometimes the problem is outside of our normal range of practice, like with this boy, but there is no oral or maxillofacial or ENT surgeon here, and it is unlikely that there will be one in the foreseeable future. Under such circumstances, how can we refuse?
I saw a very sad case this afternoon: a woman I had operated on in March came to see me. She is 35 years old, and was diagnosed with locally advanced breast cancer a little over a year ago. She was advised to go to Ghana for neoadjuvant chemo-radiation, since neither chemotherapy nor radiotherapy is available in Liberia. She went to Ghana and received 2 rounds of chemo, but it was very expensive and she could feel the cancer growing despite the chemo. So she came back to Liberia and begged me to operate to try to decrease the pain she was feeling from the weight of the increasing breast mass. I did a palliative mastectomy, explaining to her that I was not able to remove all of the cancer. Pathology showed it was a very aggressive cancer that was not hormone-responsive. Today, less than 6 months later, the cancer has grown back significantly, and we have nothing to offer her. Her parents have died and she has no siblings; she is alone in the world. It was an exceptionally difficult conversation to have with her as I tried to find something to hold out to her as hope, but I came up empty.
I felt better after going to visit Varney and his mother. He is the boy who has an esophageal stricture who had his stricture dilated the other day in retrograde fashion thru a gastrostomy. He was able to eat yesterday, albeit small amounts, but its the first food he has kept down in a long time. He hasn't smiled for me yet, but I'm determined to get a photo of him smiing before we leave.
Thursday, September 7, 2017
Thursday September 7
Two more children with esophageal strictures from drinking lye solution underwent endoscopy today: one had no identifiable passage thru the stricture, and therefore it was not possible to pass the wire with balloon attached. The other one was successfully dilated, so hopefully he will be able to swallow better now. Our 4 year old patient from yesterday vomited after he was allowed to drink milk this morning, but that was not entirely unexpected after his surgery. I think he will get better over the next few days.
We have had another busy day operating and seeing patients to schedule them for the 10 days we have left on this trip. Other cases included a colostomy takedown, a partial thyroidectomy, and a couple of hernias, including one man with most of his small bowel and his right colon in a left inguinal hernia. He also turned out to have Fournier’s gangrene involving his huge pendulous scrotum so he also had to have that debrided. There was also a woman who m we saw early in the week with a thyroid mass which we anticipated removing, but she turned out to have other more pressing issues including significant anemia and widespread adenopathy. She also complained of not being able to eat much, so today she had an upper endoscopy and a lymph node biopsy. I think her thyroid mass is the least of her worries at this point.
We had good involvement by the Liberian residents with our work today. Gbozee and Konneh were eager to participate as usual; we also had Dr. Que in the big hernia case and other residents were in and out.
Wednesday, September 6, 2017
Wednesday September 6
This was a very good day ! Our first case was the 4 year old boy with an esophageal stricture from caustic ingestion 2 years ago. He has been unable treat, and looks obviously malnourished with stunted growth. We planned to place a gastrostomy tube to allow direct placement of food into his stomach; since we now have to ability to look at his esophagus with a scope, we decided to do that also. Jonathan looked with the scope and we could see the stricture at mid-esophagus, but there was no clear lumen. So we opened his abdomen and made a hole in his stomach wall for the gastrostomy, and then Jonathan used the scope to look from the stomach back up the distal esophagus in retrograde fashion. He was then able to pass a balloon through the stricture, and blow that up to dilate it. After doing that twice, he looked again with the scope from the mouth down, and then dilate the stricture with another balloon catheter. When he passed that catheter further in(with the balloon deflated, I was able to feel it with my finger in the stomach, so we knew we had an open passage. We then placed the gastrostomy tube button and closed him up.We will get a barium swallow X-ray in a couple of days to see what his esophagus looks like now, and then probably scope him again before we leave. If this works, we have made his future much brighter!
We then did a variety of cases throughout the day including a couple of hernias, a partial thyroidectomy, biopsy of a neck mass (adenopathy), a colonoscopy, and an upper endoscopy on a man who has an air-filled mass in his neck which is probably a laryngocele. We also saw a large number of consultations during the day including 2 kids with esophageal strictures, more thyroids, hernias, and a neck mass extending into the floor of the mouth (which Sandeep diagnosed as a plunging ranula!)(more on that later). Apparently there was an announcement on the radio that we were in town, so a fair number of people came to the hospital to see us as a result. They are brought to a room near the Operating Rooms, and we go out between cases to see what they have and if there is anything we can offer. There is a ER doc (Dr.Sally) from Mass General here teaching the residents how to do ultrasound, and she has a radiologist/ultrasonographer (Dr. Rao) with her for 2 weeks; they spent time this afternoon doing ultrasounds on several of these patients which is very helpful in guiding our surgery.
Throughout the day we had Liberian residents with us in the OR and evaluating the many patients; Dr.Gbozee, Dr. Cassell, and Dr. Konneh were particularly involved in the operations. During the morning Dr.Gbozee's mother came to the hospital to say hello to us, and it was a great honor for me to meet her.
We had some mechanical/electrical issues with the newest endoscopy equipment, but through a concerted effort by the biomedical engineers as well as Mary, Munah, and Dr. Macdonald, the issues were resolved and by afternoon everything was working. There are still significant hurdles to overcome in returning JFK to its place as a referral hospital, but there is definitely progress. Today we saw a glimpse of that progress, and it felt good.
We then did a variety of cases throughout the day including a couple of hernias, a partial thyroidectomy, biopsy of a neck mass (adenopathy), a colonoscopy, and an upper endoscopy on a man who has an air-filled mass in his neck which is probably a laryngocele. We also saw a large number of consultations during the day including 2 kids with esophageal strictures, more thyroids, hernias, and a neck mass extending into the floor of the mouth (which Sandeep diagnosed as a plunging ranula!)(more on that later). Apparently there was an announcement on the radio that we were in town, so a fair number of people came to the hospital to see us as a result. They are brought to a room near the Operating Rooms, and we go out between cases to see what they have and if there is anything we can offer. There is a ER doc (Dr.Sally) from Mass General here teaching the residents how to do ultrasound, and she has a radiologist/ultrasonographer (Dr. Rao) with her for 2 weeks; they spent time this afternoon doing ultrasounds on several of these patients which is very helpful in guiding our surgery.
Throughout the day we had Liberian residents with us in the OR and evaluating the many patients; Dr.Gbozee, Dr. Cassell, and Dr. Konneh were particularly involved in the operations. During the morning Dr.Gbozee's mother came to the hospital to say hello to us, and it was a great honor for me to meet her.
We had some mechanical/electrical issues with the newest endoscopy equipment, but through a concerted effort by the biomedical engineers as well as Mary, Munah, and Dr. Macdonald, the issues were resolved and by afternoon everything was working. There are still significant hurdles to overcome in returning JFK to its place as a referral hospital, but there is definitely progress. Today we saw a glimpse of that progress, and it felt good.
Tuesday, September 5, 2017
Tuesday September 5
We had 3 cases planned for today, but Gbozee informed us this morning that a woman scheduled for thyroid surgery was anemic and had other problems, so that her surgery is postponed while we work up her anemia etc. That left us with a neck mass which Sandeep and I did, and a huge knee mass which Greg and Cassell did with Jonathan supervising.
Equipment issues continue to pose a major stumbling block. Video endoscopes used for looking top down into the stomach or bottom up as in colonoscopy require a process to convert the video signal coming from the scope into something intelligible on a TV screen. We had 2 Fuji processors for our scopes which died a while ago; part of the container shipment from Santiago and myself last February was new scopes and a new processor donated by Fuji. The container didn't arrive in time for our March visit because of a dock strike in Spain, but it did arrive eventually. So we unpacked it yesterday, and found that we need the cables from the older processors to make it functional. Unfortunately the older processors and their cables have disappeared. We have multiple people looking for them, but so far no luck. It will be quite disappointing for our patients as well if we can't perform an colonoscopies on this trip.
Throughout the day today potential patients were being brought to the 4th floor for me so decide if their particular condition could be appropriately treated through surgery. it was a crazy experience, but we saw a lot of people whose lives can be improved by a surgical procedure, I think we pretty much filled out our dance card for the next several days of week. Fortunately we had Gbozee and Cassell to help us; I found Gbozee was particularly helpful in translating my English into Liberian English which the patient could understand !! Similarly he was very useful in translating the patient's stories for me !!
Another nice and fun dinner tonight, and now Im off to sleep.
Equipment issues continue to pose a major stumbling block. Video endoscopes used for looking top down into the stomach or bottom up as in colonoscopy require a process to convert the video signal coming from the scope into something intelligible on a TV screen. We had 2 Fuji processors for our scopes which died a while ago; part of the container shipment from Santiago and myself last February was new scopes and a new processor donated by Fuji. The container didn't arrive in time for our March visit because of a dock strike in Spain, but it did arrive eventually. So we unpacked it yesterday, and found that we need the cables from the older processors to make it functional. Unfortunately the older processors and their cables have disappeared. We have multiple people looking for them, but so far no luck. It will be quite disappointing for our patients as well if we can't perform an colonoscopies on this trip.
Throughout the day today potential patients were being brought to the 4th floor for me so decide if their particular condition could be appropriately treated through surgery. it was a crazy experience, but we saw a lot of people whose lives can be improved by a surgical procedure, I think we pretty much filled out our dance card for the next several days of week. Fortunately we had Gbozee and Cassell to help us; I found Gbozee was particularly helpful in translating my English into Liberian English which the patient could understand !! Similarly he was very useful in translating the patient's stories for me !!
Another nice and fun dinner tonight, and now Im off to sleep.
Monday September 4,2017
We arrived last night after a long but uneventful flight. Perhaps the best thing about the trip was that I could use my Priority Pass for all of us to enjoy the departure lounges at JFK and again in Brussels. But its still a long flight and just not that enjoyable. We came from the airport into Monrovia to stay at the Murex Plaza Hotel, which is where we stayed last March and enjoyed it a lot. Before coming to the hotel we stopped at the JFK Administration Building to drop off the 9 duffel bags of supplies we brought with us. While we were there, Munah I'm very pleased that we are staying here again ! After a late dinner we retired, and then Jonathan and Chandra arrived so I got up to greet them briefly.
The team this time includes Dr. Jonathan Laryea and myself; Jonathan is a former resident of ours at Waterbury Hospital who is now a colo-rectal surgeon at the University of Arkansas for Medical Sciences. I think this is his 7th trip to Liberia. Also on the team is Dr.Chandra Joshi, an anesthesiologist at Mass who was here once before; Dr. Sandeep Sachidananda, one of our Chief Residents at Waterbury Hospital; Dr. Greg Ricketts, a PGY-3 in our program; and Ms. Murphy Pena, a scrub tech at Waterbury Hospital.
After breakfast we went to the hospital to see our friends.We stopped in at surgical chart rounds where we were greeted happily by all present including Dr. Gbozee; this was his return to work day after his month in the USA. We went on a quick tour of the hospital, and learned that we will be able to use the Ors on the 4th floor starting today !! We will use the old general surgery room looking out on the shantytown and ocean, and also the Ortho room next door. Prior to our arrival there was some question about what we would use for ORs; this is the best possible result !!
Grand Rounds was a visiting radiologist from the USA who talked about using the ultrasound to get necessary clinical information. It was quite a good presentation, and I learned from it. I told Murphy yesterday that today would likely be a slow day as we got organized; obviously I had forgotten where we were ! We ended up doing 3 operations (2 ruptured appendix, one baby with an imperforate anus who needed a colostomy) and saw a multitude of consults some of which we will be able to help through surgery, but others for which we have neither the resources or talent. We saw a 17 year old boy with a huge tumor on the left side of his jaw; this is most likely an ameloblastoma, which is an unusual tumor dental enamel. It is benign, but locally aggressive; the only treatment is surgery which typically involved removing some of the mandible and then reconstructing it with a rib.These surgeries usually involve a team of specialists including maxillo-facial surgery, dental surgery, and plastic surgery; Liberia has none of those specialists, so we will try to find an alternative solution for this unfortunate young man.
After we finished surgery around 8:30,we went to see a 4 year old with an esophageal stricture due to lye ingestion.I have written before about these cases; we see them frequently here, and it is a serious public health problem.the victims are mostly kids who have no idea that the clear water their Mom put in the Coke bottle is not water, but rather a highly concentrated alkali solution. This effectively burns the layers of the esophagus, and then it forms a hard scar, effectively closing off the esophagus. For the boy we saw, it has been over a year since he drank the lye, and he is now unable to swallow food or liquid. The only possible solution for him is a major surgical procedure for which there is neither the talent nor the resources to perform in Liberia. We will be reaching out for advice and help.
After dinner at 9:30PM, the end to a long day. Despite everything, Liberia is a happy place for me.With each visit, I see progress, and I love my friends here.
The team this time includes Dr. Jonathan Laryea and myself; Jonathan is a former resident of ours at Waterbury Hospital who is now a colo-rectal surgeon at the University of Arkansas for Medical Sciences. I think this is his 7th trip to Liberia. Also on the team is Dr.Chandra Joshi, an anesthesiologist at Mass who was here once before; Dr. Sandeep Sachidananda, one of our Chief Residents at Waterbury Hospital; Dr. Greg Ricketts, a PGY-3 in our program; and Ms. Murphy Pena, a scrub tech at Waterbury Hospital.
After breakfast we went to the hospital to see our friends.We stopped in at surgical chart rounds where we were greeted happily by all present including Dr. Gbozee; this was his return to work day after his month in the USA. We went on a quick tour of the hospital, and learned that we will be able to use the Ors on the 4th floor starting today !! We will use the old general surgery room looking out on the shantytown and ocean, and also the Ortho room next door. Prior to our arrival there was some question about what we would use for ORs; this is the best possible result !!
Grand Rounds was a visiting radiologist from the USA who talked about using the ultrasound to get necessary clinical information. It was quite a good presentation, and I learned from it. I told Murphy yesterday that today would likely be a slow day as we got organized; obviously I had forgotten where we were ! We ended up doing 3 operations (2 ruptured appendix, one baby with an imperforate anus who needed a colostomy) and saw a multitude of consults some of which we will be able to help through surgery, but others for which we have neither the resources or talent. We saw a 17 year old boy with a huge tumor on the left side of his jaw; this is most likely an ameloblastoma, which is an unusual tumor dental enamel. It is benign, but locally aggressive; the only treatment is surgery which typically involved removing some of the mandible and then reconstructing it with a rib.These surgeries usually involve a team of specialists including maxillo-facial surgery, dental surgery, and plastic surgery; Liberia has none of those specialists, so we will try to find an alternative solution for this unfortunate young man.
After we finished surgery around 8:30,we went to see a 4 year old with an esophageal stricture due to lye ingestion.I have written before about these cases; we see them frequently here, and it is a serious public health problem.the victims are mostly kids who have no idea that the clear water their Mom put in the Coke bottle is not water, but rather a highly concentrated alkali solution. This effectively burns the layers of the esophagus, and then it forms a hard scar, effectively closing off the esophagus. For the boy we saw, it has been over a year since he drank the lye, and he is now unable to swallow food or liquid. The only possible solution for him is a major surgical procedure for which there is neither the talent nor the resources to perform in Liberia. We will be reaching out for advice and help.
After dinner at 9:30PM, the end to a long day. Despite everything, Liberia is a happy place for me.With each visit, I see progress, and I love my friends here.
Sunday, April 9, 2017
Wednesday March 29
In the morning we went to the hospital to say our goodbyes, and to take care of a couple of minor medical problems for a couple of friends. From there we went to the mask shops in Mamba Point and made a few purchases before going back to the hotel to relax before heading to the airport. Aaron and Philomina will be heading back to the US directly from Brussels, while Sam, Santiago and I will take a few days to see some of the sights of Paris before going home.
This was another very successful trip by whatever measure of success is used. We did a large volume of surgery, and I think the level of complexity was higher overall. Resident involvement in our cases was at a high level, and I believe our active involvement in the teaching program was appreciated. With the upcoming Presidential election and the certainty of a change in management at JFK, we have been concerned about what our role will be at JFK in the future; while there is still uncertainty, I’m fairly certain that whoever is in charge will recognize the value of our work and want us to continue. And on a personal note, while I have celebrated some wonderful birthdays in the past, this one clearly topped them all !!
Tuesday, March 28, 2017
Tuesday March 28
This was quite a day !! At the end of chart rounds with the surgical residents and faculty, Santiago told them all it was my birthday so they serenaded me with the Liberian version of "Happy Birthday". We went off to the OT and did a few cases before lunchtime when the OT staff surprised me with a cake and pizza for lunch; they also sang to me !! Then Aaron and I did a skin graft on the leg a 15 year old boy who had survived necrotizing fasciitis, and that was our last case of this trip. The final tally isn't in yet, but we believe we did 50 cases in 9 days of operating; that's pretty good production.
We went back to the hotel to shower, and then at 8 pm we went to the roof of our hotel for a party. There were about 20 people there from JFK as well as Masmina and Clara, and it was a wonderful time. Certainly the highlight was the arrival of Madame President who stopped in to extend her greetings; to say I was taken aback would be a huge understatement ! It was really very cool: she asked me to introduce the members of our team which I did, and then I had the opportunity to introduce her to Dr. Gbozee, Casell, and Clark who as surgical residents are the future of Liberian medicine. They all said later that it was incredible honor for them to meet her; I'm glad that my birthday provided the occasion. We then had a delicious dinner with cake and champagne for dessert, followed by brief remarks by a number of guests including myself several times lol. It was really quite a fantastic evening, and a most memorable birthday indeed !
I was deeply honored by the very kind words spoken about the work we have done at JFK, but that work would mean little without the strong efforts by the friends who gathered to celebrate with me. They talked about the mentoring, and the experience that Santiago, Jonathan Laryea, and I have brought to the surgical residents, but it would mean little without the sustained education provided by Dr. Atem and the other members of the faculty. It was an honor to introduce the tall man from Sudan to Madame President, and to acknowledge his very important role in the development and education of the residents. Similarly, the work of so many people in helping to organize and facilitate our trips cannot be ignored. Everyone at JFK, from Dr.Macdonald and Dr. Johnson on down the ladder, has played a key role in making our visits as productive as possible. People praised my commitment to HEARTT and Liberia, but it never would have happened without the strong support of the people who surrounded me on the roof of the Murex Hotel.
We went back to the hotel to shower, and then at 8 pm we went to the roof of our hotel for a party. There were about 20 people there from JFK as well as Masmina and Clara, and it was a wonderful time. Certainly the highlight was the arrival of Madame President who stopped in to extend her greetings; to say I was taken aback would be a huge understatement ! It was really very cool: she asked me to introduce the members of our team which I did, and then I had the opportunity to introduce her to Dr. Gbozee, Casell, and Clark who as surgical residents are the future of Liberian medicine. They all said later that it was incredible honor for them to meet her; I'm glad that my birthday provided the occasion. We then had a delicious dinner with cake and champagne for dessert, followed by brief remarks by a number of guests including myself several times lol. It was really quite a fantastic evening, and a most memorable birthday indeed !
I was deeply honored by the very kind words spoken about the work we have done at JFK, but that work would mean little without the strong efforts by the friends who gathered to celebrate with me. They talked about the mentoring, and the experience that Santiago, Jonathan Laryea, and I have brought to the surgical residents, but it would mean little without the sustained education provided by Dr. Atem and the other members of the faculty. It was an honor to introduce the tall man from Sudan to Madame President, and to acknowledge his very important role in the development and education of the residents. Similarly, the work of so many people in helping to organize and facilitate our trips cannot be ignored. Everyone at JFK, from Dr.Macdonald and Dr. Johnson on down the ladder, has played a key role in making our visits as productive as possible. People praised my commitment to HEARTT and Liberia, but it never would have happened without the strong support of the people who surrounded me on the roof of the Murex Hotel.
Monday March 27
For a day that we didn't think would be busy...we were wrong !! We went to Grand Rounds to hear a talk on Graves' disease, which was presented very well and directed by a new endocrinologist at JFK. After the talk Santiago and I spoke with him about a protocol for the work-up of patients with multinodular goiter, an entity which we have seen with frequency on this trip.
We then went to the OT where Santiago and Konneh operated on a young man who came in last night with a perforation, probably gastric. Apparently they felt he was too ill from sepsis to be operated on last night, so they kept him for this morning. He was clearly on death's door the he was brought to the OT, and then we went thru the door early in the operation dying on the table. My view of this is that it was good for them to realize that he needed resuscitation before surgery last night, but they didn't realize that the window of opportunity in these patients is quite narrow. After rapid vigorous fluid resuscitation, he needed to come to the OR right away not several hours later; then he might have had a chance. But the way it was handled doomed his surgery and outcome for the start.
Aaron and I did a 1 year old boy wth a large hernia, and we did a couple of local anesthesia cases.Between cases Mrs Cooper had me come down to the Admitting Office to see some patients. On was a girl in her 30s who has a huge ulcerating breast cancer. If she has a mastectomy, she will need a skin graft to cover the wound on her chest. I had already seen a man who says he has been waiting for 2 years to have a skin graft placed on his ankle; I admitted him so the girl with the breast cancer will have to wait as we can only do one skin graft a day. She is scheduled to see Prof. Golokai in clinic tomorrow, so he can deal with it.
We finished around 5:30, then went back to the hotel to change for dinner. Theresa and Alex Cummings met us and Masmina and her brother at the Mamba Point Hotel for a delicious sushi dinner. I still can't get over the fact that there are 2 really good sushi restaurants in Monrovia!! We had a wonderful time with them talking about all sorts of things including the upcoming race for President. Alex is one of the 20+ declared candidates !!
Santiago and I talked earlier in the day about feeling the way we always feel at the end of these visits: anxious to get home to see friends and family, but always leaving with a sense that there is so much left undone. We work hard, and do a lot, but there is always the wish that we could have done more.
We then went to the OT where Santiago and Konneh operated on a young man who came in last night with a perforation, probably gastric. Apparently they felt he was too ill from sepsis to be operated on last night, so they kept him for this morning. He was clearly on death's door the he was brought to the OT, and then we went thru the door early in the operation dying on the table. My view of this is that it was good for them to realize that he needed resuscitation before surgery last night, but they didn't realize that the window of opportunity in these patients is quite narrow. After rapid vigorous fluid resuscitation, he needed to come to the OR right away not several hours later; then he might have had a chance. But the way it was handled doomed his surgery and outcome for the start.
Aaron and I did a 1 year old boy wth a large hernia, and we did a couple of local anesthesia cases.Between cases Mrs Cooper had me come down to the Admitting Office to see some patients. On was a girl in her 30s who has a huge ulcerating breast cancer. If she has a mastectomy, she will need a skin graft to cover the wound on her chest. I had already seen a man who says he has been waiting for 2 years to have a skin graft placed on his ankle; I admitted him so the girl with the breast cancer will have to wait as we can only do one skin graft a day. She is scheduled to see Prof. Golokai in clinic tomorrow, so he can deal with it.
We finished around 5:30, then went back to the hotel to change for dinner. Theresa and Alex Cummings met us and Masmina and her brother at the Mamba Point Hotel for a delicious sushi dinner. I still can't get over the fact that there are 2 really good sushi restaurants in Monrovia!! We had a wonderful time with them talking about all sorts of things including the upcoming race for President. Alex is one of the 20+ declared candidates !!
Santiago and I talked earlier in the day about feeling the way we always feel at the end of these visits: anxious to get home to see friends and family, but always leaving with a sense that there is so much left undone. We work hard, and do a lot, but there is always the wish that we could have done more.
Sunday, March 26, 2017
Sunday March 26
Today was another one of those amazing days...we thought we were going to do 2 cases today, but it turned out to be 4, and they were big ones.
The first one was a 45 year old woman with a painful upper abdominal mass. For those of you reading who don't know, in the US or other developed country, the woman would have had a CT scan and perhaps a needle biopsy so that if she did have surgery, the surgeon would know before starting what he/she was dealing with. Here we don't have those sophisticated diagnostic entities; the patient had an ultrasound which said this was "liver cancer". We were confused by this diagnosis because the mass was quite mobile, and that is not typical with cancer. SO we decided to operate and see if there was something we could do. What we found after some dissection was a melon-sized mass coming off the left lobe of her liver, and at that point we needed to decide what we were going to do and how we were going to do it.
Santiago and I were doing this operation. Most of the time we work with a resident, but there are occasions (like this) when we know ahead of time that it will be better for the patient to have 2 attendings doing the surgery. So we arrived at this decision point, and in less than a minute, we both came to the same conclusion about what we should do. In thinking about this afterwards, what amazes me is that we never spoke a word to each other about the decision; it was like we were communicating telepathically on the same wavelength, and coming up with the same answer. That is a beautiful thing when it happens.
So we resected the mass, and then I went to the other OR to do a mastectomy. The patient is a 38 year old female who noticed a lump in her right breast a year ago. She eventually sought medical attention late in 2016, when the breast cancer was quite advanced. She was referred to Ghana for pre-operative chemotherapy(it is not available in Liberia); she had a few cycles but then stopped because it was too expensive and didn't seem to be doing any good. She came back to Liberia, and I saw her a couple of days ago; she wanted to have the surgery because the breast was quite painful, and 3-4 times the size of her left breast. I believe she understands that the surgery is palliative, and it will not prolong her life. So Aaron and I did her mastectomy, and it was quite bloody as expected; she had a lot of nodal disease which we could not safely remove. It wasn't a very satisfying operation, but I think she will have a better life for whatever time she has left than if we didn't do the surgery.
Santiago did a hernia on the wife of one of the pharmacists while Aaron and I did that, and then our final case was another abdominal mass in a 65 year old female which Santiago, Konneh, and I tackled. This was a football sized mass protruding from the abdominal wall, which we thought pre-operatively was most likely a hernia; one confusing element was that it was very hard. What we found was a hernia with a lot of bowel stuck in it, and it seemed like it was involved with probable cancer. There was also evidence of peritoneal seeding, though we wondered if that could be miliary tuberculosis. It was really a big mess of bowel stuck together in the hernia sac, and it was every hard to tell what was what. Eventually we removed the whole thing, and joyfully discovered that our assumptions were correct ! She received an ileostomy, and I will bring tissue home for our pathologists to analyze; that will provide us with the final piece of the puzzle.
Unfortunately all of this work today meant that we were unable to join Masmina and others at the beach for a relaxing afternoon. We felt badly that Masmina had gone to a lot of trouble and expense to arrange things, but thankfully she was very understanding. Our patients today had all been told that they would have their surgery today, and I couldn't bear the thought of telling them it would be postponed, particularly if our reason was to go have fun at the beach. We come here to operate and teach, and we do that work intensely for the relatively short time of our visit. At the end of this day, we had a great sense of accomplishment; I believe we certainly reached our overall goal on these trips, which is to make life better for at least one person each day.
The first one was a 45 year old woman with a painful upper abdominal mass. For those of you reading who don't know, in the US or other developed country, the woman would have had a CT scan and perhaps a needle biopsy so that if she did have surgery, the surgeon would know before starting what he/she was dealing with. Here we don't have those sophisticated diagnostic entities; the patient had an ultrasound which said this was "liver cancer". We were confused by this diagnosis because the mass was quite mobile, and that is not typical with cancer. SO we decided to operate and see if there was something we could do. What we found after some dissection was a melon-sized mass coming off the left lobe of her liver, and at that point we needed to decide what we were going to do and how we were going to do it.
Santiago and I were doing this operation. Most of the time we work with a resident, but there are occasions (like this) when we know ahead of time that it will be better for the patient to have 2 attendings doing the surgery. So we arrived at this decision point, and in less than a minute, we both came to the same conclusion about what we should do. In thinking about this afterwards, what amazes me is that we never spoke a word to each other about the decision; it was like we were communicating telepathically on the same wavelength, and coming up with the same answer. That is a beautiful thing when it happens.
So we resected the mass, and then I went to the other OR to do a mastectomy. The patient is a 38 year old female who noticed a lump in her right breast a year ago. She eventually sought medical attention late in 2016, when the breast cancer was quite advanced. She was referred to Ghana for pre-operative chemotherapy(it is not available in Liberia); she had a few cycles but then stopped because it was too expensive and didn't seem to be doing any good. She came back to Liberia, and I saw her a couple of days ago; she wanted to have the surgery because the breast was quite painful, and 3-4 times the size of her left breast. I believe she understands that the surgery is palliative, and it will not prolong her life. So Aaron and I did her mastectomy, and it was quite bloody as expected; she had a lot of nodal disease which we could not safely remove. It wasn't a very satisfying operation, but I think she will have a better life for whatever time she has left than if we didn't do the surgery.
Santiago did a hernia on the wife of one of the pharmacists while Aaron and I did that, and then our final case was another abdominal mass in a 65 year old female which Santiago, Konneh, and I tackled. This was a football sized mass protruding from the abdominal wall, which we thought pre-operatively was most likely a hernia; one confusing element was that it was very hard. What we found was a hernia with a lot of bowel stuck in it, and it seemed like it was involved with probable cancer. There was also evidence of peritoneal seeding, though we wondered if that could be miliary tuberculosis. It was really a big mess of bowel stuck together in the hernia sac, and it was every hard to tell what was what. Eventually we removed the whole thing, and joyfully discovered that our assumptions were correct ! She received an ileostomy, and I will bring tissue home for our pathologists to analyze; that will provide us with the final piece of the puzzle.
Unfortunately all of this work today meant that we were unable to join Masmina and others at the beach for a relaxing afternoon. We felt badly that Masmina had gone to a lot of trouble and expense to arrange things, but thankfully she was very understanding. Our patients today had all been told that they would have their surgery today, and I couldn't bear the thought of telling them it would be postponed, particularly if our reason was to go have fun at the beach. We come here to operate and teach, and we do that work intensely for the relatively short time of our visit. At the end of this day, we had a great sense of accomplishment; I believe we certainly reached our overall goal on these trips, which is to make life better for at least one person each day.
Saturday, March 25, 2017
Saturday March 25
This morning we went with Masmina and her brother to Benson Hospital in Paynesville, where we were shown around by Dr. and Dr. Benson who own and run the facility. I believe he is an internist and she is a pediatrician. They are clearly doing the best they can under difficult circumstances, the main problem being that not many of their clientele can afford to pay for the services they receive.
After that we went back to JFK to do a couple of cases: a hemorrhoidectomy and another thyroid. We also lined up more cases for the remaining days of our visit here; as usual, we will be pressed to do all of the cases that people are hoping we will do, and on top of that, the endoscopy equipment has failed once again. We spent part of today trying to jury rig some arrangement that would allow us to do some of the cases, but nothing has worked out so far. We have equipment donated by the World Bank which is what we were using, but it died yesterday; we have the Fujinon processors and scopes which we used last March and September, but we can't get the light to come on; and we have some quite old Olympus equipment on which the bulbs seem to have blown. We will try again tomorrow to find a solution.
This evening we were invited for dinner to Adelaide Gardner's house; she has entertained us before, and its always good fun. She is a lively women who once had a talk show on local radio, and a couple of years ago she had Santiago on as a guest. One of the other guests tonight was a Mrs. Cooper, and hearing her name reminded me of a situation. In 2011 I think, while we were here there was a HEARTT fundraiser dinner at City Hall which we attended, and at some point I spoke for a few minutes telling the guests how a surgeon from Connecticut came to be in Liberia on that occasion. After the dinner, a young woman approached me and said that she had gone to school in CT; when I asked where, she said it was a boarding school in Wallingford called Choate Rosemary Hall. We were both amazed when I told her that I was also a graduate of Choate! The young woman was Idela Cooper, so when I met Mrs Cooper tonight I asked her if she knew of anyone fitting that description. Almost immediately, our host Adelaide said that she knew her, and would call her right away. Not too much later, Idela Cooper came by to say hello to me !! We had a wonderful conversation, and a delightful reminder of how small the world really is.
After that we went back to JFK to do a couple of cases: a hemorrhoidectomy and another thyroid. We also lined up more cases for the remaining days of our visit here; as usual, we will be pressed to do all of the cases that people are hoping we will do, and on top of that, the endoscopy equipment has failed once again. We spent part of today trying to jury rig some arrangement that would allow us to do some of the cases, but nothing has worked out so far. We have equipment donated by the World Bank which is what we were using, but it died yesterday; we have the Fujinon processors and scopes which we used last March and September, but we can't get the light to come on; and we have some quite old Olympus equipment on which the bulbs seem to have blown. We will try again tomorrow to find a solution.
This evening we were invited for dinner to Adelaide Gardner's house; she has entertained us before, and its always good fun. She is a lively women who once had a talk show on local radio, and a couple of years ago she had Santiago on as a guest. One of the other guests tonight was a Mrs. Cooper, and hearing her name reminded me of a situation. In 2011 I think, while we were here there was a HEARTT fundraiser dinner at City Hall which we attended, and at some point I spoke for a few minutes telling the guests how a surgeon from Connecticut came to be in Liberia on that occasion. After the dinner, a young woman approached me and said that she had gone to school in CT; when I asked where, she said it was a boarding school in Wallingford called Choate Rosemary Hall. We were both amazed when I told her that I was also a graduate of Choate! The young woman was Idela Cooper, so when I met Mrs Cooper tonight I asked her if she knew of anyone fitting that description. Almost immediately, our host Adelaide said that she knew her, and would call her right away. Not too much later, Idela Cooper came by to say hello to me !! We had a wonderful conversation, and a delightful reminder of how small the world really is.
Friday March 24
This was an interesting and amazing day in many ways. We did 10 operations, including 5 thyroidectomies, and I believe that sets a new single day volume record for the HEARTT surgical team. To be honest, while we are proud to have done 10 cases, what is more significant is that the Liberian OT team was willing to put themselves out so that we could accomplish this. And our team worked extremely well together to make it all happen.
Goiter is quite common here. Lack of iodine in the diet causes the thyroid gland to enlarge into what is called a goiter, which is typically a mass in the neck. As usual in Liberia, by the time these patients seek medical attention, the goiter is often huge; this was the case with several of our patients today. From a surgical perspective, removing an enlarged thyroid is a challenge because the gland has a big blood supply, and there are several important structures in the neighborhood which you have to take care not to injure. Another aspect of the surgery is that in Liberia we don't take out the entire gland; we want to leave some behind which will produce enough thyroid hormone for the bodies needs since oral thyroid hormone replacement (like Synthroid) is generally not available.
In addition to the thyroidectomies, we excised a thyroglossal duct cyst in a 4 year old boy, did a hemorrhoidectomy, and a couple of other small cases. We also saw several patients to add to our list of surgeries that need to be done before we leave on Wednesday evening. The woman I mentioned in yesterday's posting with the huge breast tumor came back to the hospital today apparently ready to have surgery, but then she left again before we could get her done. It's sad that she is so overwhelmed by fear; I wish I knew how to help her conquer it.
As I said at the beginning, doing as much as we did today was the result of a team effort by a lot of people. Yassah, who runs the OR, encouraged her people to keep going and provided the example by staying till we finished at 8:30pm. Our team meshed with our hosts to keep things moving; in particular our anesthesiologist Philomina made sure there were no unnecessary delays. Aaron Gilson also ran all over getting patients ready and upstairs, as well as operating with us.
Goiter is quite common here. Lack of iodine in the diet causes the thyroid gland to enlarge into what is called a goiter, which is typically a mass in the neck. As usual in Liberia, by the time these patients seek medical attention, the goiter is often huge; this was the case with several of our patients today. From a surgical perspective, removing an enlarged thyroid is a challenge because the gland has a big blood supply, and there are several important structures in the neighborhood which you have to take care not to injure. Another aspect of the surgery is that in Liberia we don't take out the entire gland; we want to leave some behind which will produce enough thyroid hormone for the bodies needs since oral thyroid hormone replacement (like Synthroid) is generally not available.
In addition to the thyroidectomies, we excised a thyroglossal duct cyst in a 4 year old boy, did a hemorrhoidectomy, and a couple of other small cases. We also saw several patients to add to our list of surgeries that need to be done before we leave on Wednesday evening. The woman I mentioned in yesterday's posting with the huge breast tumor came back to the hospital today apparently ready to have surgery, but then she left again before we could get her done. It's sad that she is so overwhelmed by fear; I wish I knew how to help her conquer it.
As I said at the beginning, doing as much as we did today was the result of a team effort by a lot of people. Yassah, who runs the OR, encouraged her people to keep going and provided the example by staying till we finished at 8:30pm. Our team meshed with our hosts to keep things moving; in particular our anesthesiologist Philomina made sure there were no unnecessary delays. Aaron Gilson also ran all over getting patients ready and upstairs, as well as operating with us.
Thursday, March 23, 2017
Thursday March 23
Today was a great day ! I felt like we accomplished a lot today in terms of the number of surgeries but equally importantly the amount of teaching. We had medical students as well as residents around us all day, and it was a lot of fun. We started out as always in morning report where the residents tell the faculty about admissions and events overnight. A major event was the death of a young man who had presented to the hospital about 2 weeks ago with a small bowel perforation from trauma. He was operated on, and seemed to be getting better, but then took a turn for the worse earlier this week. Santiago took him back to the OR and re-explored his abdomen; he found some leakage from the repaired perforation and reclosed it. He had a rocky postoperative course and then developed kidney failure followed by death last night. We will be discussing the case at length tomorrow in Morbidity and Mortality Conference, but we started the discussion today trying to understand what we could learn from the case so that the result might be different for the next case that presents in the same way. Some of the discussion today revolved around the difficulty of making a complex diagnosis in this resource-poor environment where lab tests and sophisticated X-rays are not available. Under such circumstances, close attention to detail and using ones brain are really the only things we can do to sort out the complexities. I'm sure the discussion tomorrow will be very interesting.
We had several surgery cancellations and no-shows today, but we managed to keep a fairly full schedule in the OT with a bunch of small cases, some scopes, and a thyroid goiter. Tomorrow we will have a full day with more cases scheduled than we can possibly do including 4 thyroids, but we will do the best we can. We have less than a week left on this trip, and as usual, there will be several patients we planned to operate on but won't have time to do them. I think we have done pretty well in prioritizing cases, and doing the ones that were most important because of the need for a tissue diagnosis or the value of doing the surgery as a teaching exercise. As I said at the beginning of this entry, I really enjoyed today because I was able to teach medical students some basics, and then see some consults with the residents and share my thought processes. They seemed to think it was valuable !
We had several surgery cancellations and no-shows today, but we managed to keep a fairly full schedule in the OT with a bunch of small cases, some scopes, and a thyroid goiter. Tomorrow we will have a full day with more cases scheduled than we can possibly do including 4 thyroids, but we will do the best we can. We have less than a week left on this trip, and as usual, there will be several patients we planned to operate on but won't have time to do them. I think we have done pretty well in prioritizing cases, and doing the ones that were most important because of the need for a tissue diagnosis or the value of doing the surgery as a teaching exercise. As I said at the beginning of this entry, I really enjoyed today because I was able to teach medical students some basics, and then see some consults with the residents and share my thought processes. They seemed to think it was valuable !
Wednesday March 22
We started the day with an emergency: a 40-something year old man with a perforated gastric ulcer. We had seen him briefly in the ED as we were leaving last night, but at that point he still needed X-rays and fluid resuscitation. By the morning he was ready for surgery, and we took care of him. He had a perforated pre-pyloric ulcer which we closed with a Graham patch.
I realiz that I have forgotten to tell you about a very sad case. We knew about Rosetta before we arrived, and then met her on Monday. She is a young woman in her 20s who has a massive tumor extending from her right breast around the side to her back she says it has been growing for about a year. The skin over it is intact, and it is seriously the size of a basketball. We admitted her on Monday with plans for surgery on Tuesday, but Tuesday morning she told the nurses she was refusing surgery because she had a bad dream about African spirits on Monday night. I spoke with her, and I had Gbozee speak with her, but she said she wouldn't do anything until her mother arrived. I let her use my phone to call her mother. Eventually her mother arrived with a sister and an aunt, and after talking her mother said yes of course she would have the surgery. I went back to the OR to do a short case, and then received word that she had signed herself out of the hospital AMA ( against medical advice). Late in the afternoon her mother called to say she had reconsidered, and wanted to come back and have the surgery; I told them that would be alright, but she hasn't shown up yet. I'm pretty sure this is a phyllo idea tumor, which is a sarcoma-like lesion. They can be benign or malignant; I'm guessing this one is malignant based on the rapid growth. They don't generally metastasize, so they is a reasonable possibility that surgical removal could result in a long term cure. But I and Gbozee told her that doing nothing would be fatal. Sadly I think her fear overwhelmed her despite the work of many people to reassure her.
We did several other cases on Wednesday, and had a visit at the hospital from Masmina Sirleaf, the Executive Director of HEARTT. When we arrived back at our hotel around 7:30 pm, Masmina called to say she was in the hotel restaurant and would like us to join her. So after cleaning up we went down to see Masmina, Clara ( her cousin) and Delarue ( a friend), and we had a wonderful evening of conversation talking about Liberia, and Ebola, and the future, etc. it was a great evening !
I realiz that I have forgotten to tell you about a very sad case. We knew about Rosetta before we arrived, and then met her on Monday. She is a young woman in her 20s who has a massive tumor extending from her right breast around the side to her back she says it has been growing for about a year. The skin over it is intact, and it is seriously the size of a basketball. We admitted her on Monday with plans for surgery on Tuesday, but Tuesday morning she told the nurses she was refusing surgery because she had a bad dream about African spirits on Monday night. I spoke with her, and I had Gbozee speak with her, but she said she wouldn't do anything until her mother arrived. I let her use my phone to call her mother. Eventually her mother arrived with a sister and an aunt, and after talking her mother said yes of course she would have the surgery. I went back to the OR to do a short case, and then received word that she had signed herself out of the hospital AMA ( against medical advice). Late in the afternoon her mother called to say she had reconsidered, and wanted to come back and have the surgery; I told them that would be alright, but she hasn't shown up yet. I'm pretty sure this is a phyllo idea tumor, which is a sarcoma-like lesion. They can be benign or malignant; I'm guessing this one is malignant based on the rapid growth. They don't generally metastasize, so they is a reasonable possibility that surgical removal could result in a long term cure. But I and Gbozee told her that doing nothing would be fatal. Sadly I think her fear overwhelmed her despite the work of many people to reassure her.
We did several other cases on Wednesday, and had a visit at the hospital from Masmina Sirleaf, the Executive Director of HEARTT. When we arrived back at our hotel around 7:30 pm, Masmina called to say she was in the hotel restaurant and would like us to join her. So after cleaning up we went down to see Masmina, Clara ( her cousin) and Delarue ( a friend), and we had a wonderful evening of conversation talking about Liberia, and Ebola, and the future, etc. it was a great evening !
Wednesday, March 22, 2017
Tuesday March 21
There was an interesting discussion at rounds on resident desire for more educational aids, followed by opinion from the faculty about the need for more self-study iniative. This seemed very similar to the discussions we have in Waterbury. Then Aaron and I went to the OPD Clinic to screen some patients for admission while Santiago and Sam were in the OT doing a screening colonoscopy with biopsy of a sigmoid polyp. They then did a laparotomy on a 49 year old woman with advanced rectal cancer. She had ascites and omental/peritoneal mets, and she is yet another sad example of how delay in diagnosis is both common and fatal around here.
In the afternoon I drained a large liver abscess in a young man who was referred by Dr. Carol Humphrey; she is a family medicine doctor who is here with the Peace Corps working a Redemption Hospital. It was very satisfying!
Dr. Gbozee and Aaron and Jake did a skin graft. Gbozee is currently assigned to ELWA Hospital, but he came to see us and work with us. Between cases, we were able to do some useful teaching I think, and Gbozee continues to impress us with his knowledge. At one point I asked him why we wait 5 days before changing the dressing on a skin graft; he answered by talking about the phases of wound healing and the need for stable neovascularization. He also has good hands and is a facile surgeon.
As we were leaving we stopped in the medical unit on the ground floor to see an unfortunate man having difficulty breathing. We have no reliable history, but his neck is diffusely hard and woody and he has bilateral axillary adenopathy. It appears that he is developing change in mental status due to venous obstruction as in an SVC syndrome. The only time I have ever felt a neck like this was when I was a resident and there was a woman with a anaplastic thyroid cancer. The medical people were concerned about his airway, and wanted initially to have him intubated. Anesthesia suggested a tracheostomy. My question to the medicine people was to what end? Whatever he has is almost certainly a malignancy which we cannot treat here, so I wasn't sure what the point would be in doing anything other than provide him with a morphine drip. They said they would consider it overnight.
We went back for another nice dinner at our hotel, and then we all crashed early.
In the afternoon I drained a large liver abscess in a young man who was referred by Dr. Carol Humphrey; she is a family medicine doctor who is here with the Peace Corps working a Redemption Hospital. It was very satisfying!
Dr. Gbozee and Aaron and Jake did a skin graft. Gbozee is currently assigned to ELWA Hospital, but he came to see us and work with us. Between cases, we were able to do some useful teaching I think, and Gbozee continues to impress us with his knowledge. At one point I asked him why we wait 5 days before changing the dressing on a skin graft; he answered by talking about the phases of wound healing and the need for stable neovascularization. He also has good hands and is a facile surgeon.
As we were leaving we stopped in the medical unit on the ground floor to see an unfortunate man having difficulty breathing. We have no reliable history, but his neck is diffusely hard and woody and he has bilateral axillary adenopathy. It appears that he is developing change in mental status due to venous obstruction as in an SVC syndrome. The only time I have ever felt a neck like this was when I was a resident and there was a woman with a anaplastic thyroid cancer. The medical people were concerned about his airway, and wanted initially to have him intubated. Anesthesia suggested a tracheostomy. My question to the medicine people was to what end? Whatever he has is almost certainly a malignancy which we cannot treat here, so I wasn't sure what the point would be in doing anything other than provide him with a morphine drip. They said they would consider it overnight.
We went back for another nice dinner at our hotel, and then we all crashed early.
Tuesday, March 21, 2017
Monday March 20
Our first day at JFK on this trip, and it was as expected: planned as a light, getting acquainted again day, but then it became busy. We started by going to surgical rounds and seeing a lot of friends among the residents and faculty, and then more of the same at the hospital-wide Grand Rounds. After that we went to the OR today hello and see the state of affairs. The exterior of the hospital is scaffolded and renovation is underway; inside there isn't much evidence of active renovations, although there are fewer buckets in the hallways catching water coming thru the roof.
In the course of our travels thru the hospital, we encountered Dr. Philip Ireland, who looks great ! He is an Ebola survivor who came to Waterbury Hospital to speak about his experience surviving the disease last year while he was in New Haven for a month observing. He told us about a 39 year old woman in the ED who had a large mass in her rectum and a swollen abdomen; when we saw her it was obvious that she needed surgery so relieve her bowel obstruction soon. She was placed on the schedule for later in the day. We also consulted on a young man who was operated on a week ago for a bowel perforation, and hasn't done well post finally got back to our hotel around 730, and then had a late dinner before heading to bed as we were all very tired from traveling.
The hotel we are staying in is quite lovely and new. It is called the Murex Plaza and is on Tubman Boulevard. It is a boutique-ish hotel with large, well-appointed rooms and bathrooms; I particularly enjoyed the shower which features a large high shower head and great water pressure as well as lots of hot water. The restaurant is quite excellent also.
In the course of our travels thru the hospital, we encountered Dr. Philip Ireland, who looks great ! He is an Ebola survivor who came to Waterbury Hospital to speak about his experience surviving the disease last year while he was in New Haven for a month observing. He told us about a 39 year old woman in the ED who had a large mass in her rectum and a swollen abdomen; when we saw her it was obvious that she needed surgery so relieve her bowel obstruction soon. She was placed on the schedule for later in the day. We also consulted on a young man who was operated on a week ago for a bowel perforation, and hasn't done well post finally got back to our hotel around 730, and then had a late dinner before heading to bed as we were all very tired from traveling.
The hotel we are staying in is quite lovely and new. It is called the Murex Plaza and is on Tubman Boulevard. It is a boutique-ish hotel with large, well-appointed rooms and bathrooms; I particularly enjoyed the shower which features a large high shower head and great water pressure as well as lots of hot water. The restaurant is quite excellent also.
Sunday, March 19, 2017
Sunday March 19
We have arrived in Liberia after long journey. This will be short as we will be getting up early tomorrow and I need some sleep. Nothing special about the7 hour flight from NY to Brussels, and then the 7 hour flight to Monrovia with a stop in Freetown,Sierra Leone. There was an interesting contretemps at the airport between our drivers and the guys who collect parking fees. I'm not sure if the collectors have an official job,or just do it as a freelance operation; in any case they were upset that Alvin, Dr.McDonalds driver who came to pick us up, seemingly disrespected the collector or something.
We were brought to the Murex Hotel which is a new hotel close to JFK and quite nice. We had dinner, and its now after midnight so I need to go to bed.
We were brought to the Murex Hotel which is a new hotel close to JFK and quite nice. We had dinner, and its now after midnight so I need to go to bed.
Friday, March 17, 2017
Preparation
In preparation for this (March2017) trip, we have sent a huge amount of supplies ahead. Thru Masmina Sirleaf, the wonderful Executive Director of HEARTT who lives in Monrovia, we were notified that a container would be filled in Philadelphia for shipment to Liberia and JFK. Seizing this as an opportunity to clear out a lot of the donated material I had stored in my basement, I went to UHaul to buy 18" X18" X 24" boxes and filled 23 of them for a total of 900lbs of various medical supplies. Similarly, Santiago emptied a room of supplies at his office in Indiana into 24 boxes; also included in his boxes are 3 colonoscopes and a processor kindly donated by Fuji. His boxes and my boxes were trucked to Philadelphia where they were loaded into the container.
The good news is that the 47 boxes made it to Philadelphia and the ship sailed. The bad news heard yesterday from Masmina is that our container is currently in Spain being held up by a dock strike or something. We were hoping that the shipment would arrive in Liberia before or during our visit, but that is starting to look unlikely. Fortunately we planned to bring many other supplies with us on the plane, so our work won't suffer too much if the container doesn't arrive in time.
Our surgical team for this trip includes Dr. Aaron Gilson, a senior surgical resident at Waterbury Hospital; Dr. Philomina Thuruthumaly, an anesthesiologist from Indiana who returns after coming on our March 2014 trip; Samantha Shoultz, a surgical (Scrub) tech from Indiana; and my friend, colleague, and every March trip companion Dr. Santiago Arruffat.
The wonderful people at JFK Hospital get better organized each time for our visit. Mrs. Cooper, who runs the Admitting Office, sent me a list of possible surgery candidates last week; I was able to review them and prioritize them so that we can make the most effective use of our time. From the list I can see that we will have a number of very interesting surgical cases, and that doesn't include the large number of patients who will show up during the course of our visit.
Several years ago Dr. Arruffat, Dr.Jonathan Laryea, and I set up a charitable foundation called Support JFK Inc to provide funding support for this work. We would not be able to do what we do without the contributions to Support JFK by our generous donors including Mr. and Mrs. Peter Knight, Mr. Samuel Francis thru Dr. Arruffat, and the Barbara and Marty Zweig Foundation. Thank you !!
The good news is that the 47 boxes made it to Philadelphia and the ship sailed. The bad news heard yesterday from Masmina is that our container is currently in Spain being held up by a dock strike or something. We were hoping that the shipment would arrive in Liberia before or during our visit, but that is starting to look unlikely. Fortunately we planned to bring many other supplies with us on the plane, so our work won't suffer too much if the container doesn't arrive in time.
Our surgical team for this trip includes Dr. Aaron Gilson, a senior surgical resident at Waterbury Hospital; Dr. Philomina Thuruthumaly, an anesthesiologist from Indiana who returns after coming on our March 2014 trip; Samantha Shoultz, a surgical (Scrub) tech from Indiana; and my friend, colleague, and every March trip companion Dr. Santiago Arruffat.
The wonderful people at JFK Hospital get better organized each time for our visit. Mrs. Cooper, who runs the Admitting Office, sent me a list of possible surgery candidates last week; I was able to review them and prioritize them so that we can make the most effective use of our time. From the list I can see that we will have a number of very interesting surgical cases, and that doesn't include the large number of patients who will show up during the course of our visit.
Several years ago Dr. Arruffat, Dr.Jonathan Laryea, and I set up a charitable foundation called Support JFK Inc to provide funding support for this work. We would not be able to do what we do without the contributions to Support JFK by our generous donors including Mr. and Mrs. Peter Knight, Mr. Samuel Francis thru Dr. Arruffat, and the Barbara and Marty Zweig Foundation. Thank you !!
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