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.