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.
Tuesday, March 28, 2017
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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