Friday September 14/Saturday September 15

 The final day of this trip started with us seeing the thyroidectomy patient from yesterday who had the post-op bleed and re-exploration following cardiac arrest and resuscitation. She spent the night in the “ICU”; she remains intubated but breathing on her own. Her pupils are reactive, and she showed occasional glimmers of waking up, but I think she may have suffered permanent damage. Time will tell. Then we saw Francis and changed his dressing. We encouraged him to get up and move around; he will need further encouragement to exercise the arm and regain full function. He will see Dr. Gbozee for immediate follow-up, and I asked him to come see me when I return in March. We said our goodbyes to the surgical faculty at morning report, and then went upstairs to the OT. Jonathan did 2 upper endoscopies with dilation on children with esophageal strictures from lye ingestion. This is a continuing public health problem which really needs to be addressed.

      We said our goodbyes to the Operating Theater staff, and bought them pizza for lunch. Led by Ama, they worked incredibly hard and well during this visit, When we come, they are always asked to perform at a more intense level than they are used to in their day-to-day routine, but this volume of surgery on this trip was way beyond any previous time. I think all of us felt that we were doing something especially good for the people of Liberia but providing surgery that was free for almost all of the patients. It was my sense that a substantial percentage of the patients we operated on this time would not have been able to have their surgery if they had to pay for it. We then went to the Administration Building to say our goodbyes; Dr Brown was away, but we saw Dama Yekeson-Koffa, the Deputy Administrator, and expressed our sincere thanks for their part in making this a very successful trip.

       Back to the hotel around 12:30; I decided to take a nap while the others went mask and cloth shopping with Teresa Cummings. After a shower and packing up, I went down to the lobby and checked out. Fortunately this time there was no issue about the bill going to HEARTT as Masmina had arranged !! I then made a significant error by have 2 deliciously cold Club beers before the driver came to pick us up to go to the airport: big mistake to drink beer before the 75 minute ride to the airport! I made it, but it wasn’t pleasant ! 

       We had an uneventful flight from Monrovia to Brussels, and now we are in flight to NY(JFK). I was surprised at the gate to be upgraded to Business Class, since I had the same pleasure back in March…but I’m not complaining !! 

        As I have written in many posts about this trip, it was very productive, and not just because the five of us worked hard putting in long hours. I felt strongly that there were so many people at JFK who were behind this effort, in large part because they liked the fact that they were part of a team providing free care for a lot of people who needed it. In the past we have had many productive visits, but we have never before come close to 107 cases. We leave with a good feeling about what we (meaning us and HEARTT and JFK and everyone involved) accomplished, but some trepidation that we have raised the bar quite high for our visit next March and beyond. 

Wednesday September 12

    Another big day for the HEARTT Surgery team ! We (Jonathan and I) started with Francis, the young man with schwannomas involving his left axilla and arm. The plan was attempt to remove as much as we could without doing damage, and I think we were successful. We had consulted with the Nigerian orthopedic surgeon who is part of the surgery faculty, and he stayed thru the case. We had told Francis that we might find it necessary to amputate his arm, and he was willing to accept that if it would provide him with some pain relief; fortunately we didn't feel that was necessary. I think they will turn out to be benign schwannomas, but its weird that they grew all along the axillary and brachial nerve from axilla to elbow. We took out 13 of them, ranging in size from 8 cm to 1 cm; some will be examined back home by the pathologists. At the end of the operation he was able to grasp with his hand; further evaluation will have to wait till his operative pain subsides.
       After than we did thyroids and hernias and a variety of lumps and bumps; we did a total of 12 cases, which is particularly impressive when we take into account that Professor Golakai had a room for much of the day, and the Nigerian orthopedic surgeon took a room to do an emergent amputation. We finally finished around 8 pm.
       With the 12 cases done today, by Ama's count we are at 97, and we will almost certainly break the century mark tomorrow when we have 8 cases scheduled including 2 thyroids we weren't able to do today and 3 mastectomies. It will be another busy day, but satisfying knowing that we are helping a lot of people. One of the downsides to being so busy on this trip is that I'm too tired to write a lot a night on this blog, though I suppose for some people that might be a blessing in disguise! It's amazing how quickly the time has passed !

Tuesday September 11

       Today we have a guest blogger because I was too tired to write last night. So here is Dr. Laryeas synopsis of the day, as written on Facebook:
       Today turned out to be a busy day. We got to the hospital around 8:30 am and we tried to go to morning report but we were immediately whisked away to go start our cases. By the time we arrived, the electrical problem from yesterday had been fixed. As I reported yesterday, we had 18 cases scheduled for today. We actually ended up doing 16 cases. Two patients did not show up. I felt a little wiped out at the end of the day. So our running total is now 86. We finished around 7:30 pm. We did not see tomorrow’s list before we left and so we don’t know how many cases are scheduled. There is one case though that is going to be challenging and requires both Dr. Knight and I to be scrubbed together. It could take a while and so it will influence the number of cases we can do. We are hoping and praying that it would be easier than anticipated.

Sunday September 9 and Monday September 10

        Sunday was a day of rest. I got up around 9, had breakfast, and then went back for a nap! Dan and Michael wanted to go to Kendeja, the RLJ beach resort, but there was a football match (Liberia vs. DRC) yesterday afternoon, and that precluded driving past the stadium. It's difficult to explain driving here: traffic rules and stoplights appear to be thought of as advisory rather than mandatory, and when there is a big event like the football match, the traffic is real bad. So instead they walked around locally, and I understand Mike went swimming. Anyway, around 2 we went to a birthday party at Mrs. Cooper's house. She runs the Admitting Office, and it was her husband's 78th birthday! t was great fun to be there as guests at a family celebration and to see some Liberian friends once again. Then we came back and I conked out early.

      Monday was a very busy day in which it felt like we struggled to get 7 cases done. The struggles were not personnel, but the system. The power went out a number of times today; that is tolerable when operating on an adult, but it makes for scary moments when operating on a child, as we  were at the end of the day. The last 3 cases were all 5 years old, and two of them were twins. The twins (Peter and Paul) each had a large right inguinal hernia; I didn't think a child could have a huge inguino-scrotal hernia like the adults, but I was proved wrong. They both did well, but it was scary when the power went out and the anesthesia machine was therefore out also.

      In the afternoon our patient Francis came to dee us. He is the 21 year old with a schwannoma involving his left axilla and left arm. Schwannomas arise from the Schwann cells which create the myelin sheath around nerves; 98% of schwannomas are benign. One of my main concerns is that Francis is in the 2% with a malignant schwannoma causing the pain and other nerve symptoms. So I thought it would be prudent to get a chest x-ray to look for evidence of metastatic disease. unfortunately, he told us later in the afternoon that JFK Radiology had not film to print the image. He went to anther healthcare facility and was told that the only technician who could do a chest X-ray was out sick. We were planning to operate on Francis tomorrow, but due to the delay caused by no X-ray, we plan to attempt his surgery on Wednesday instead.                                                                                                         

     When he came back, he said he wanted to ask us a question. He told us that his mother had died when he was young, and she never had anything like his tumor. And that he knew he wasn't born with it. So, he asked, had he done something wrong in his life to get it? We tried to reassure him that he hadn't, but the whole situation is clearly a difficult process for him to grasp. His situation is one of the most challenging and difficult clinical problems I have seen in Liberia. We don't actually know if this is malignant or not, and we won't know till after we get back to the USA and the pathologists have looked at his tissue specimens. Despite not knowing if it is cancer or not, we may have to amputate his arm in an attempt to palliate his pain. We have talked to a number of people here and elsewhere about him, and no one has a good answer as to how we decide whether to cut off his arm. He is willing to go thru anything to get rid of the pain; I hope we can do that for him.

       Another big day in the OR tomorrow, even with putting Francis off till Wednesday. We have 17 cases scheduled; completing all of them seems like an impossible task at this point, but we will try.

                

Saturday September 8

     We did another 10 cases today including a colonoscopy, a thyroid, a couple of breast lumps, and several hernias. The OT staff was amazing; we were running 3 rooms, and it was a Saturday ! At one point, Dan Slack and Albertha Clark were in one room repairing a hernia, Jonathan was in another room doing a hernia assisted by a medical student, and I was in the third room doing a hernia alone. With yesterday, Ama tells us that we have performed 63 cases since starting on Tuesday; that is a huge volume, far surpassing any previous trip. With 4.5 days of operating left, we could approach 100 cases! There are many reasons for our increased productivity on this trip including Ama organizing and inspiring the OT staff, having 2 anesthesiologists with us, and a great team of surgeons supplemented by Drs. Gbozee and Cassell as well as Liberian postgraduate trainees. I think another big factor is that One Day Surgery has finally arrived at JFK. We have talked about it for years, but there was always resistance. This time it is being encouraged, and the result is that we can do a lot more since many patients don't need to be admitted the day before. We aren't as dependent on the availability of inpatient beds, and the cost to the hospital is less.
       Last night we went to the home of former President Sirleaf for dinner and a wonderful evening of conversation. It was quite an honor for us to sit in the palava hut enjoying Fufu and other dishes while we chatted about a variety of topics. Listening to Madame talk about the Ebola epidemic still fills with me admiration for her decisiveness in dealing with this unseen enemy.

Friday September 7

      Another wild day at JFK ! Today we did 13 cases, bringing us to 51 cases in 4 days which is amazing and gratifying. I cannot praise the OT team enough for their willingness and desire to work hard all day to get all of these cases done. This morning Dan and I did a thyroid which was a surprise: the pre-op ultrasound reading was the she had an enlarged homogeneous left lobe of the thyroid, but on exploration we found a number of enlarged lymph nodes making cancer a likely diagnosis unfortunately.

     In Tuesday's blog I described a 14 year old male with a mass in his axilla; it turns out that he is 21 years old. I told him that I needed to do some research and that he should come back on Friday, so today he appeared at the OT. To refresh you, he has a huge mass in his axilla, and then several more masses going down his arm to the elbow. We biopsied one of the arm masses in March, and pathologically it appeared to be a schwannoma, which is a  benign peripheral nerve sheath tumor. When I saw him on Tuesday, the axillary mass was significantly bigger than it was in March, raising in my mind the possibility that we are dealing with a malignant rather than benign condition. The major problem is that he is in a lot of pain; today he was in tears. I had several people look at him, and we aren't sure what we can or should do for him. The fact that he has multiple areas of swelling running from his armpit to his elbow makes the situation even more complicated, because any one of the swelling could be causing his pain.  Today I told him that he might require amputation of his arm, and he readily agreed to that course if that is what is necessary to give him relief from the pain. From what I have read, that shouldn't be necessary, but I don't know what else to do.
       Tomorrow 9Saturday) we have 10 cases scheduled, so we will again be busy. Time to get some sleep.                                                                                                                  

Thursday September 6

       This was quite an amazing and busy day! There have been times in the past when doing 5 OR cases in a day seemed like a big accomplishment; today the general surgery team did 18 operations ! Some were big, and some were small, but nonetheless it was quite an accomplishment by the OT staff in particular. The cases included 2 mastectomies, several hernias, several colonoscopies, an endoscopic esophageal dilation for a child who swallowed lye, and the final case was a large lipoma on the shoulder which Dan Slack and I attempted under local anesthesia, but it was too big and too painful so he was given some sedation.
       One of the cases we had scheduled to do today was on a patient who sadly passed away yesterday. His name was Anthony Hne, and he was a nurse anesthetist at JFK for several of the first years I came here. He was excellent, knowledgeable, and caring, and I know we all miss him. He was admitted to the hospital last week, and asked his son to get in contact with me, which he did. I saw Mr. Hne downstairs on the ward the other day, and I knew his time was quite limited. We were going to attempt a small operation to make him more comfortable, but he took a turn for the worse yesterday morning.
       The two mastectomies are representative of the frustrations that are part of surgical and healthcare decision making here. One patient, whom Dr. Cassell and I operated on, is 40 years old and had a large breast cancer which had spread to her lymph nodes. We don't know if it had spread yet to other areas such as liver and lungs because at this time sophisticated x-ray imaging is not available here. Though they are saying that a CT scan will be running at JFK early in the new year. In any case, chemotherapy is for the most part available only to Liberians who have enough money to travel to Ghana or elsewhere for treatment. Hopefully as healthcare delivery in Liberia improves, that will change, and more cancer treatment will be available here in Liberia. The second patient, operated on by Dr. Gbozee and Dr. Slack, is a 50 year old with a relatively small cancer (2.5 cm) in a large breast. She would have been a good candidate for tumor excision followed by radiation therapy to the remaining breast to significantly reduce the risk of recurrence, but radiation is not available in Liberia. She does not have adequate resources to go to Ghana for radiation, so she chose mastectomy; I have every reason to believe she will do well.
       We got back to our hotel around 7:30pm. After a quick shower and dinner, I ready for sleep so we can do it all again tomorrow !

Wednesday September 5

    This was another excellent and satisfying day at JFK ! Special credit goes to Ama, the nurse manager who really keeps things moving. We had 12 cases booked for the day, which is a lot by our standards. At 9AM she came down to the area where we meet for morning Surgical Rounds and hauled Jonathan and I out, telling us it was time to get started! So we went up and got started doing a variety of cases including a burn contracture, a thyroid, some hernias, and some other cases which I can't remember right now. My particular enjoyment came form doing a pediatric hernia with Dan Slack, then an adult hernia with Albertha Clark, and finally having Albertha and Dan do an adult hernia together with minimal supervision. For me it was the ideal teaching set-up, and I think they both really enjoyed it also.
    It turned out that a couple of patients didn't show, including a prisoner with a large lipoma on his shoulder. We think he decided not to have the surgery when he learned it would be day surgery and he wouldn't be admitted to the hospital !! So we had 8 of the 12 scheduled show up, and then in the afternoon a guy who works at the hospital came with a lipoma on his back, so Dan and I did him under local to make 9 cases. During the day I had a conversation with Prof. Ikpi, who thinks we should really go for it...so tomorrow we have 19 cases scheduled lol. If we do them all, or even 15 of them, that will be a milestone for us as well as JFK. I think the fact that we are able to even consider scheduling that many cases is a testament to the dedication and professionalism of the OT staff, the Liberian residents, the anesthesia personnel both Liberian and American, and Professor Ikpi who has made it clear that these trips are a significant initiative.
      Speaking of which, today I learned that JFK Hospital announced that the surgery done by us during these 2 weeks would essentially be free to patients. In the past there was no surgeon's fee, but the patients were charged a bed fee as well as being charged for drugs used. This trip it appears that the hospital is taking on all comers regardless of their ability to pay.  This is a good move by the hospital!!
      After we finished today, we were waiting on the steps of the Administration Building for our ride. A young woman came out, and said hi. We started talking about the new CT scan coming by the end of the year, and then I realized that I was talking to Marie, the woman standing in front of me in line to board the flight from Brussels to Monrovia.                                                            
       This evening we went to a bar/restaurant for dinner; the establishment is owned by Charles Sirleaf, another son of Madame Sirleaf. The former President joined us, and we had a very interesting time. Then back to sleep for a big day tomorrow .                                                                                                                      
                                                                                                                                                                                                      

Monday September 3/ Tuesday September 4

      Monday was yesterday;  I wrote half the post yesterday before collapsing in sweet sleep last night. I then wrote the other half this evening, but for some reason it has all been lost. I'm tempted to blame a temperamental Internet connection between Liberia and the rest of the world, and I actually do think that might be at the root of it. There is a fiberoptic sea cable which comes from France down the west coast of Africa, and countries join to that cable. My understanding is that Liberia has just the one connection, so it can be a problem. Right now it is rainy season in this part of Africa, and today there were frequent deluges, so roofs were leaking, roads were bad, and it was generally not pleasant to be outside.  Maybe water got into the cable? who knows...
      So yesterday we started with Grand Rounds, which was a celebration of the tenure of Dr. Billy Johnson as Chief Medical Officer at JFK from 2010 till now. It was also a gathering of lots of people across the hospital, and thus a great way to greet friends once again.The rest of the day was spent in the clinic seeing patients who thought they might need surgery; apparently there was an announcement on the radio that we are here, and as a result fees for surgery are reduced or waived. From what we saw yesterday, these two weeks will involve a lot of thyroid surgery. We also saw Dr. Brown and had the chance to talk to him about his vision for the future of JFK. There are many challenges ahead, but he seems to be moving ahead with determination and clear ideas on how to accomplish the possible. I think this is going to be another very good trip.
      Today was a great first day of surgery for this trip. We started around 9:30, and did 9 cases including a mastectomy, 2 thyroids, some hernias, and a couple of other things. Throughout the day, Dr. Albertha Clark was in a room next to the OR screening patients for surgery. I would stop in to see her and patients from time to time, and I really enjoyed most of it.
         We saw several women with operable breast cancer whom we will schedule for surgery while we are here. By "operable" I mean that there is a reasonable chance that surgery will prolong their lives significantly. In general, breast cancer treatment involves removing the cancer itself and then reducing the risk of the patient developing another cancer in the same breast by either radiating the remaining breast tissue or removing it by means of a mastectomy. Unfortunately, for women in Liberia, radiation is not an option because there are no radiation therapy facilities here; the nearest is in Ghana. So we offer the women a mastectomy because that is really all we have to offer.
         I saw a 14 year old boy with a large mass in his left axilla, and then lumps several cm in diameter going down his arm. We biopsied one of the lumps when we saw him in March, the path showed it was a schwannoma. Now it seems to be growing and causing his left hand to be numb and unable to grasp. Schwannomas are generally benign tumors of the nerve sheath, but this is acting much more like a malignancy. I have no idea what if anything can be offered to this boy; I told him I would do some research, and he will come back to see us on Friday.
        I also saw a 5 year old boy on Pediatrics with some sort of orbital tumor which appears small on the surface but must be large inside. They asked us to do a biopsy, and we likely will, but first we are going to collect further information from skull X-rays, and an opinion from a pediatric oncologist who apparently is here. I don't have high hopes for this boy.
      After we finished operating, Adamah and Masmina took up on a tour of the city, including a stop at the Snapper Clinic (started by his uncle and Masmina's father). We stopped at the Capitol Bar for a drink, and then back here for sleep. The power has been going on and off all evening; hopefully I can publish this before it gets lost !