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.