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 !