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.
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