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.