Our last day at JFK on this trip, and it was filled with the joys of doing the work we do, and the occasional frustration of trying to get things done. We planned to have a short operating day so we could go to the souvenir shop to get carved masks etc., but it didn't work out that way. When we arrived at JFK we learned that they had forgotten we were leaving, and thought we would be available to staff more cases. After resolving that issue, and emphasizing to the OT staff that we needed to be out by 12 or 1pm, we discovered that the Pharmacy tech for the OT had not arrived yet; he has the key to the drug room, and he keeps track of which patient is charged for what drugs. After multiple phone calls from me and others, he strolled in at 10 am to some icy stares. We then did our 2 cases, the second one being a 6 yr old girl with an inguinal hernia. I had Dr. Quaye with me, and we did what needed to be done in about 30 min; it then took at least an hour and a rocky emergence from anesthesia before she could be taken to the Recovery Room. The final case I was involved in was a 4 year old girl with what was thought to be vaginal mass with bleeding, and Dr. Konneh wanted to get it done in case there was tissue to be sent for pathology. Upon examination under anesthesia, we were not able to see any mass; it turned out later that the real story was quite different from what I was told, and that I had been subjected to some false advertising.
After saying our goodbyes to everyone, we were driven back to the hotel around 1pm by the JFK driver, and I confirmed with him that he would be back at 4 pm to take us to the airport. We showered and packed, and around 2:30 I went to leave my luggage in the lobby and check out. Upon speaking to the receptionist, I learned that she knew of no arrangement with Masmina to pay the bill, and therefore they were expecting me to pay the charges for the three of us. I then had a half hour of panic as we tried my American Express as well as other cards, and all of them were denied. I knew they would be: the credit card processors are naturally suspect of any charges emanating from West Africa, which is why I have never used a credit card to pay for anything in Liberia. The receptionist suggested I could go to an ATM; I told her that no ATM would allow me to withdraw that much money. She then suggested that I could go to several ATMs; it seemed pointless to explain how that would look to the computers at the Bank of America !! I asked the receptionist to contact the owner of the hotel, who had hosted our rooftop dinner the other night, but she couldn't reach him. I was in something of a panic over this, and I knew that at that moment Masmina was over the Atlantic flying to the US, so I called Adamah to ask for help. He said he would call me back; just then the manager returned from outside business, and took care of everything once I explained. She knows Masmina well, and knows that the bill will be settled up when Masmina returns from her short trip to the US.
After a couple of Club beers in the hotel restaurant we went to the lobby at 4pm to await the hospital driver. By 4:10 he hadn't arrived so I called him; he said he was on his way. By 4:40pm he still wasn't there, so I called him again and he said traffic was heavy. At 4:45 Mrs. Cooper called to say goodbye, and said that she assumed we were in the car on the way to the airport. When I told her that we were still waiting, she said that she would take care of it and call me back. She did, and shortly before 5pm Mrs. Koffa, the new Acting Deputy Administrator, came in her car to personally drive us to the airport. My mother always used to say that every cloud has a silver lining, and it was certainly true in this case as we had an hour drive to talk about her impressions of JFK and her plans and hopes for the future. We arrived at the airport in plenty of time for our flight home!
This was a great trip with many accomplishments that everyone involved can be proud of. As a HEARTT Surgery team, I believe we have at last made the transition into a true collaboration with the JFK Surgery Department including consultants as well as the postgraduate trainees. This has always been the the goal of these visits, but in the past it was difficult to accomplish for a multitude of reasons. This time we were able to do it because of strong leadership from Professor Ikpi as well as strong support from the new JFK Administration, and a group of postgraduate trainees who are eager to develop and refine their clinical surgical skills. I think that we have moved to a new level with this program, and this collaboration can help JFK accomplish a lot for Liberia over the next several years. On top of all that, we once again had many memorable clinical experiences which will be remembered and cherished for years to come.
Sunday, March 25, 2018
Saturday, March 24, 2018
Thursday March 22
As Mark Schiffmiller, one of the anesthesiologists at Waterbury Hospital likes to :" You can't make this shit up!" That applies to this day especially!
We started out with the 5 day old baby put off from yesterday who has a multitude of problems. Professor Ikpi put a suprapubic tube in her bladder and a percutaneous nephrostomy in he massively dilated hydrfonephrotic right kidney working with Cassell and Sandeep, and then they (C&S) did a transverse loop colostomy. The surgery took 2 hours, and then we had to wait another 2 hours for the baby to be awake enough to go back to the neonatal ICU next door at the maternity hospital. The lack of an intensive recovery area can really slow down the day as the patients recover in the OT.
We were about to move on to the next case when Cassell said there was a major trauma who was bleeding from his arm and needed to come us emergently. The patient appeared to be in his 30s; the story we heard was that he was standing in the back of a lorry (truck) doing something when he was electrocuted, and fell on a sharp object lacerating his right arm just above the elbow. Cassel had applied a tourniquet (using a Foley catheter) and brought him right up to the OT. Quickly he was put to sleep, a Foley catheter inserted, David put in a femoral venous line, Cassel and Sandeep prepped his arm, and when they were ready I cut off his bloody bandages and the tourniquet. The vascular injury was mainly venous, and quickly taken care of. The skin around the laceration was burned full-thickness, and on later reflection we though that might be a main point of electrical contact. The burn eschar was almost circumferential, so an escharotomy was made to avoid compartment syndrome.
As they were wrapping him up came word of a disaster in the ED. A busload of teenage school kids were on an outing when the bus crashed, and 37 of them were brought to JFK! We went down to the ED to see what we could do to help, and as you can expect it was a madhouse! Fortunately most of the injuries were pretty minor; no one needed operative intervention. I think there may have been a fractured femur, and that was probably the most severe injury. I was impressed that the JFK team mobilized a lot of resources quickly: doctors and nurses, scribes to take down information to notify parents, etc. After a while it became clear that no one would require immediate surgery, so we went back upstairs to finish our planned surgery schedule. I placed a gastrostomy on a 3 year old with an esophageal stricture from caustic ingestion while Sandeep and David repaired an inguinal hernia and an umbilical hernia in a 14 year old girl.
The last case was Varney. Sandeep was able to identify the esophageal lumen and pass a dilating balloon thru it, allowing the stricture at 20 cm to be dilated. Hopefully he will be able to eat, at least for a while until it strictures down again. We tried to emphasize to his mother the importance of serial dilations; I'm not sure she understood.
We got back to the hotel around 8:15, and then had dinner at which I talked too much, not being aware of the time! This has been a very good trip as we have transitioned to a new way of doing things, primarily because many of the Liberian residents are now capable of shouldering more responsibility. I'm looking forward to our trip in September !
We started out with the 5 day old baby put off from yesterday who has a multitude of problems. Professor Ikpi put a suprapubic tube in her bladder and a percutaneous nephrostomy in he massively dilated hydrfonephrotic right kidney working with Cassell and Sandeep, and then they (C&S) did a transverse loop colostomy. The surgery took 2 hours, and then we had to wait another 2 hours for the baby to be awake enough to go back to the neonatal ICU next door at the maternity hospital. The lack of an intensive recovery area can really slow down the day as the patients recover in the OT.
We were about to move on to the next case when Cassell said there was a major trauma who was bleeding from his arm and needed to come us emergently. The patient appeared to be in his 30s; the story we heard was that he was standing in the back of a lorry (truck) doing something when he was electrocuted, and fell on a sharp object lacerating his right arm just above the elbow. Cassel had applied a tourniquet (using a Foley catheter) and brought him right up to the OT. Quickly he was put to sleep, a Foley catheter inserted, David put in a femoral venous line, Cassel and Sandeep prepped his arm, and when they were ready I cut off his bloody bandages and the tourniquet. The vascular injury was mainly venous, and quickly taken care of. The skin around the laceration was burned full-thickness, and on later reflection we though that might be a main point of electrical contact. The burn eschar was almost circumferential, so an escharotomy was made to avoid compartment syndrome.
As they were wrapping him up came word of a disaster in the ED. A busload of teenage school kids were on an outing when the bus crashed, and 37 of them were brought to JFK! We went down to the ED to see what we could do to help, and as you can expect it was a madhouse! Fortunately most of the injuries were pretty minor; no one needed operative intervention. I think there may have been a fractured femur, and that was probably the most severe injury. I was impressed that the JFK team mobilized a lot of resources quickly: doctors and nurses, scribes to take down information to notify parents, etc. After a while it became clear that no one would require immediate surgery, so we went back upstairs to finish our planned surgery schedule. I placed a gastrostomy on a 3 year old with an esophageal stricture from caustic ingestion while Sandeep and David repaired an inguinal hernia and an umbilical hernia in a 14 year old girl.
The last case was Varney. Sandeep was able to identify the esophageal lumen and pass a dilating balloon thru it, allowing the stricture at 20 cm to be dilated. Hopefully he will be able to eat, at least for a while until it strictures down again. We tried to emphasize to his mother the importance of serial dilations; I'm not sure she understood.
We got back to the hotel around 8:15, and then had dinner at which I talked too much, not being aware of the time! This has been a very good trip as we have transitioned to a new way of doing things, primarily because many of the Liberian residents are now capable of shouldering more responsibility. I'm looking forward to our trip in September !
Thursday, March 22, 2018
Wednesday March 21
We are approaching the end of this visit, and as usual things get hectic. We had several patients brought up to our " consulting room" outside the OR who were disappointed to learn that we couldn't do their surgery tomorrow. Most of them were invited to return in September when we will be back, and I hope they show up.
The first disruption to our day's schedule was the addition of an emergency who came in to the ED yesterday afternoon. We saw him around 5 pm, and I felt he needed more hydration with IV fluids before any surgery, expecting that he would be operated on by the on-call team later in the evening. For whatever reason, he wasn't, so we did his surgery as the first case of the day. He turned out to have a perforated gastric ulcer, with spillage of over a liter of bile into his abdominal cavity. In keeping with our new role, I decided to let Gbozee lead the team with Albertha Clark and Mike Quaye assisting him. I was in and out of the room, kibitzing, pimping, and really enjoying my role as teacher. I particularly wanted Gbozee to make decisions about operative strategy, and he did; I think as a team they worked well, and for me it was another milestone in this Liberian experience.
At some point in the morning I was told that Varney was here, and I couldn't believe it ! Varney is the 4 year old boy with an esophageal stricture from lye ingestion whom we saw in September; through an interesting combination of skills, Jonathan Laryea was able to dilate his esophagus so that he was eating Cream of Wheat before we left. We told his mother that he would need serial dilations, but she didn't bring him back to JFK till today. He is not able to eat much, but apparently gets something down because he looks reasonably nourished. He isn't swallowing well, so we admitted him for endoscopy and possible dilation tomorrow.
The big item on the schedule was a 5 year old girl with multiple anomalies including urinary and intestinal; she seems to have no outlet to her bladder, and her rectum ends blindly, and she has a mass on her low spinal cord. She also probably has other abnormalities including heart. But her abdomen is distended with no way for poop and pee to get out, so that was what we were planning to take care of. Unfortunately it got late n the day, and we decided eventually that it would be better to wait till tomorrow.
The final two cases were hernias, so we have Sandeep and Seville doing the repair in one room, and Cassel and David in the other, and I was going back and forth offering advice. I like this change in our way of doing things, and so does everyone else I think.
We were done around 7 and called the car service. This was a new driver (for us), and as we were traveling the short distance to the hotel, he was telling me that he has a hydrocele that he wants to get removed. (A hydrocele is fluid around the testicle in the scrotum, and they can get quite big). He has had it for 20 years, but heard we were in town so he wondered if we could do it tomorrow. I explained that we had a full day already, and it was our last day of operating, so it would have to wait till September. He was unhappy, and tried one more attempt at convincing me when we pulled up to the hotel by pulling down his ants to show me !! We all thought it was pretty funny and amazing, but it didn't change my plan to make him wait till September.
The first disruption to our day's schedule was the addition of an emergency who came in to the ED yesterday afternoon. We saw him around 5 pm, and I felt he needed more hydration with IV fluids before any surgery, expecting that he would be operated on by the on-call team later in the evening. For whatever reason, he wasn't, so we did his surgery as the first case of the day. He turned out to have a perforated gastric ulcer, with spillage of over a liter of bile into his abdominal cavity. In keeping with our new role, I decided to let Gbozee lead the team with Albertha Clark and Mike Quaye assisting him. I was in and out of the room, kibitzing, pimping, and really enjoying my role as teacher. I particularly wanted Gbozee to make decisions about operative strategy, and he did; I think as a team they worked well, and for me it was another milestone in this Liberian experience.
At some point in the morning I was told that Varney was here, and I couldn't believe it ! Varney is the 4 year old boy with an esophageal stricture from lye ingestion whom we saw in September; through an interesting combination of skills, Jonathan Laryea was able to dilate his esophagus so that he was eating Cream of Wheat before we left. We told his mother that he would need serial dilations, but she didn't bring him back to JFK till today. He is not able to eat much, but apparently gets something down because he looks reasonably nourished. He isn't swallowing well, so we admitted him for endoscopy and possible dilation tomorrow.
The big item on the schedule was a 5 year old girl with multiple anomalies including urinary and intestinal; she seems to have no outlet to her bladder, and her rectum ends blindly, and she has a mass on her low spinal cord. She also probably has other abnormalities including heart. But her abdomen is distended with no way for poop and pee to get out, so that was what we were planning to take care of. Unfortunately it got late n the day, and we decided eventually that it would be better to wait till tomorrow.
The final two cases were hernias, so we have Sandeep and Seville doing the repair in one room, and Cassel and David in the other, and I was going back and forth offering advice. I like this change in our way of doing things, and so does everyone else I think.
We were done around 7 and called the car service. This was a new driver (for us), and as we were traveling the short distance to the hotel, he was telling me that he has a hydrocele that he wants to get removed. (A hydrocele is fluid around the testicle in the scrotum, and they can get quite big). He has had it for 20 years, but heard we were in town so he wondered if we could do it tomorrow. I explained that we had a full day already, and it was our last day of operating, so it would have to wait till September. He was unhappy, and tried one more attempt at convincing me when we pulled up to the hotel by pulling down his ants to show me !! We all thought it was pretty funny and amazing, but it didn't change my plan to make him wait till September.
Wednesday, March 21, 2018
Tuesday March 20
Today we thought we would be busier than we were, but a couple of cases were cancelled. One was a planned thyroidectomy for goiter. She has a large goiter, but she is mildly hypothyroid, so we decided that taking out a large part of her poorly functioning thyroid would not be beneficial for her except from a cosmetic standpoint. We had a bit of discussion with the anesthesiologist who was concerned that she was hyperthyroid and might have post-operative problems as a result; after a time he agreed with us that hyperthyroidism was not the issue. Sandeep then had a text discussion with one of our ENT surgeons in CT, and we decided to encourage her to increase her iodine intake and come back in September. If her thyroid function is better, surgery might be considered then.
Two of the other cancellations were planned biopsies: one was a man who had some sort of tumor excised from his left shoulder 10-15 years ago, and it has now grown back as quite a large protuberant mass. Additionally, he appears to have another similar growth starting on the right side. Reportedly he declined biopsy because he thought it would cause it to grow faster. We have seen these worries before, and there really isn't much to do; they generally don't respond to reason.The other was a woman with a strange nodular eruption on her left lower leg which I have never seen before. We planned to biopsy one of the nodules to make a diagnosis, but apparently Prof Golokai thinks this is elephantiasis, and she should be treated with anti-worm medication; he won the day lol!
My 10 year old patient J went home today feeling good after removal of that 10 pound cyst. Hopefully her aunt will bring her to see us in September.
We did finally get around to some surgery today: I did a couple of cases each with a Liberian resident. Nothing big, but it was fun to impart some teaching. Gbozee. and Sandeep and Albertha Clark did a thyroid for goiter, and they did a good job. I was in and out supervising, but trying to let them get the feel of independent operating. Sandeep said he was nervous to start, but then got into it and felt quite comfortable by the end.
Two of the other cancellations were planned biopsies: one was a man who had some sort of tumor excised from his left shoulder 10-15 years ago, and it has now grown back as quite a large protuberant mass. Additionally, he appears to have another similar growth starting on the right side. Reportedly he declined biopsy because he thought it would cause it to grow faster. We have seen these worries before, and there really isn't much to do; they generally don't respond to reason.The other was a woman with a strange nodular eruption on her left lower leg which I have never seen before. We planned to biopsy one of the nodules to make a diagnosis, but apparently Prof Golokai thinks this is elephantiasis, and she should be treated with anti-worm medication; he won the day lol!
My 10 year old patient J went home today feeling good after removal of that 10 pound cyst. Hopefully her aunt will bring her to see us in September.
We did finally get around to some surgery today: I did a couple of cases each with a Liberian resident. Nothing big, but it was fun to impart some teaching. Gbozee. and Sandeep and Albertha Clark did a thyroid for goiter, and they did a good job. I was in and out supervising, but trying to let them get the feel of independent operating. Sandeep said he was nervous to start, but then got into it and felt quite comfortable by the end.
Monday, March 19, 2018
Monday March 19
Another interesting day in Liberia :-) Surgical rounds followed by hospital Grand Rounds which finished at 10am. We didn't have a busy operating day planned, and that was probably a good thing. Sandeep and Gbozee did a parotid tumor, and I was going to do a skin graft with David but the patient decided he had other issues after getting on the operating table, so we cancelled that case. Thought the morning we were screening patients for potential surgery, and we seem to have filled up the schedule for the next couple of days.
I was feeling frustrated with the slow pace of the day, so I sought some relief...which I found by visiting J, the 10 year old with the kidney cyst which we removed last Friday. She is doing very well, and will probably go home tomorrow. I will miss her smile, which certainly lifted my spirits today.
We left JFK around 4:30pm and came to the hotel for a rest before dinner. Tonight we had a party on the rooftop terrace with about 20 of our friends form JFK, organized by Masmina and Abdullah Shehny, the owner of the hotel. It was a wonderful occasion with great food including an amazing whole fish, and great conversation. It was quite an honor to have Dr. Jerry Brown, the Administrator of JFK as well as Mrs. Koffa, Deputy Administrator, present as well as Dr.Johnson, Chief Medical Officer at JFK and Prof. Ikpi, Chief of Surgery, and my operating buddy ! No one will replace Santiago, but the experience operating with Prof Ikpi was very cool !
As we plunge into our second week, it is pretty clear that this HEARTT surgery program will continue for the foreseeable future. It was made very clear to me tonight by several people that we are a valued addition to the Department of Surgery, and to the postgraduate teaching program. Not that I doubted it, but it was still nice to have that affirmation.
Tomorrow looks to be a busy day, so I'm going to end this and go to sleep.
I was feeling frustrated with the slow pace of the day, so I sought some relief...which I found by visiting J, the 10 year old with the kidney cyst which we removed last Friday. She is doing very well, and will probably go home tomorrow. I will miss her smile, which certainly lifted my spirits today.
We left JFK around 4:30pm and came to the hotel for a rest before dinner. Tonight we had a party on the rooftop terrace with about 20 of our friends form JFK, organized by Masmina and Abdullah Shehny, the owner of the hotel. It was a wonderful occasion with great food including an amazing whole fish, and great conversation. It was quite an honor to have Dr. Jerry Brown, the Administrator of JFK as well as Mrs. Koffa, Deputy Administrator, present as well as Dr.Johnson, Chief Medical Officer at JFK and Prof. Ikpi, Chief of Surgery, and my operating buddy ! No one will replace Santiago, but the experience operating with Prof Ikpi was very cool !
As we plunge into our second week, it is pretty clear that this HEARTT surgery program will continue for the foreseeable future. It was made very clear to me tonight by several people that we are a valued addition to the Department of Surgery, and to the postgraduate teaching program. Not that I doubted it, but it was still nice to have that affirmation.
Tomorrow looks to be a busy day, so I'm going to end this and go to sleep.
Sunday, March 18, 2018
Sunday March 18
We decided to take the day off to relax, and as we have done before we went to the RLJ Kendeja Resort just outside Monrovia for the afternoon. We enjoyed food, drink, and the ocean breeze while sitting in the shade and looking out at the beautiful sand and surf. We saw a few brave surfers; apparently several areas of the west coast of Africa have a sudden and significant drop off as you go out from shore. This creates some excellent surf, and also some serious undertows, so generally swimming is not advised in these areas unless you are a strong swimmer. Naturally this does not stop people for going in, and we have seen a couple of near-drownings over the years.
Toward the end of the afternoon several of our doctor friends from JFK came for a meeting at RLJ; they indicated they were waiting for Dr. Jerry Brown , the newly appointed Acting General Administrator, to join their meeting. As we were walking away from the beach, he came walking the other way, and we had a chat. He informed us that the autoclave (sterilizer) at JFK "blew up" this afternoon, and there were people there trying to fix it. We shall see tomorrow morning how our surgery schedule will be affected; it will be a big problem if it can't be fixed quickly.
We are halfway thru this trip, and I would say that it is going better than I had expected. I knew it would be different, but I wasn't sure in what ways. I think the main aspect that is better is that we are integrated into the postgraduate training program; patients are not separated into "our" patients and "their" patients, but rather they are all together, being cared for by all of us. Its a good feeling, and I believe it is a good model for the future.
Toward the end of the afternoon several of our doctor friends from JFK came for a meeting at RLJ; they indicated they were waiting for Dr. Jerry Brown , the newly appointed Acting General Administrator, to join their meeting. As we were walking away from the beach, he came walking the other way, and we had a chat. He informed us that the autoclave (sterilizer) at JFK "blew up" this afternoon, and there were people there trying to fix it. We shall see tomorrow morning how our surgery schedule will be affected; it will be a big problem if it can't be fixed quickly.
We are halfway thru this trip, and I would say that it is going better than I had expected. I knew it would be different, but I wasn't sure in what ways. I think the main aspect that is better is that we are integrated into the postgraduate training program; patients are not separated into "our" patients and "their" patients, but rather they are all together, being cared for by all of us. Its a good feeling, and I believe it is a good model for the future.
Saturday May 17
Our major case for today was a mastectomy on a 41 year old female who is related to one of the nurse anesthetists. The patient's 40 year old sister is currently in Ghana receiving chemotherapy for breast cancer, and according to the family it isn't working. The main reason my patient wants surgery is to get rid of the smell from the large ulcerated.fungating lesion on the upper part of her left breast. Gbozee and I did her surgery, and maybe we will be surprised that she will do well if she goes to Ghana for chemo treatment. But I'm not optimistic. Unfortunately, in my experience breast cancer in a 41 year old is rarely curable, even with the best chemo and radiation available. But there is certainly a much better chance of longer term survival if it is diagnosed early. One of the great public health tasks for Liberia over the next several years will be public education about the importance of early diagnosis and treatment for all sorts of diseases. People here tend to stay away from hospitals and medical for all sorts of reasons including cost, fear of disease, and fear of hospitals; it will take a concerted effort to change that.
The rest of the day involved a smattering of cases including a ruptured appendix done by Sandeep and Mike Quaye, biopsy of a strange looking leg mass, and a hernia among others. We kept the OT staff busy from 9 am to 5 pm, and they made no complaints. In fact, the only yelling and complaining was that the pharmacist was not there at 9am, delaying our start.
The other patients are doing well; in particular the 10 year old girl with the huge renal cyst is recovering nicely. As you can tell, I'm pretty happy about that one !
The rest of the day involved a smattering of cases including a ruptured appendix done by Sandeep and Mike Quaye, biopsy of a strange looking leg mass, and a hernia among others. We kept the OT staff busy from 9 am to 5 pm, and they made no complaints. In fact, the only yelling and complaining was that the pharmacist was not there at 9am, delaying our start.
The other patients are doing well; in particular the 10 year old girl with the huge renal cyst is recovering nicely. As you can tell, I'm pretty happy about that one !
Saturday, March 17, 2018
Friday March 16
Today was a great day ! I suspect it might be difficult for non-medical and non-surgical readers to understand what follows, but give it a try. To me this represents the ultimate experience of our profession. J. is 10 years old, and had a large abdominal mass filling her abdominal cavity; she looked like she was full-term pregnant. It seems to have happened slowly over the past several years, according to her aunt who is her caretaker. She stopped going to school because she was so embarrassed by her protruding belly. It was not causing her pain, and she was able to eat and run around like a normal 10 year old. She was seen at Redemption Hospital, and then referred to us by Dr. Carol Humphrey, and American Peace Corps physician who is working there. They did an ultrasound at Redemption which showed the mass was cystic, and extended from her pelvis to her liver. After she was admitted here, one of the superb surgical residents, Dr. Ayon Cassell, repeated the ultrasound; he thought the cyst was arising from the right kidney, so I asked Professor Edet Ikpi if he would join us for the surgery. Professor Ikpi is a Nigerian urologist who is here on sabbatical to run the Postgraduate Surgical Training program and be Head of Surgery at JFK Hospital; he is a wonderful, enthusiastic, smart guy who has made this particular trip quite wonderfully memorable.
We scheduled J. for Friday morning. Like Harriet several years ago, I approached this surgery with some trepidation, because she is a child, and we really didn't know what we were going to encounter. One of my favorite themes with the US residents who come with us to Liberia is that we have to learn to deal with diagnostic uncertainty here. In the US, it is very rare that a surgeon carries out an abdominal operation and doesn't know what he is going to find because all of the patients get CT scans and MRIs pre-op; obviously here it is different, and challenging, and fun when it works out.
Professor Ikpi, Dr. Konneh, Sandeep, and I explored her abdomen, and discovered fairly early that Cassell was right, and this huge cyst was arising fro her right kidney. In fact, it had pretty much destroyed her kidney so that there was just a nubbin of what looked like kidney left. Sometimes operations move along like a beautiful symphony or a well- choreographed and danced ballet; this was one of those occasions. I intended to step aside and let Dr. Konneh work with Prof. Ikpi, but I was having so much fun I just couldn't until Prof and I had the mass removed intact. It weighed 10 pounds !
Later on I went to see J in the Recovery Room. She had mucus and said the it hurt to cough, so I pressed on her abdomen while encouraging her to cough the junk up, and she did. Then she took my hand and held it, and smiled at me. I melted 😊
As we finished the operation, Professor Ikpi said:" This is what JFK is for !" and he is right on target. JFK needs to develop itself as a referral center known for tackling tough problems with excellent clinical surgery and medicine. I see the beginnings of that on this trip, and I have a good feeling about the future here.
After that Gbozee and Sandeep and David did a fellow with a complex enter-cutaneous fistula following a typhoid perforation. I would go in occasionally to see how they were doing, and they called me in once or twice to see something, but I did my best to let them make the clinical/surgical decisions. I think it worked out well.
I didn't write this last night because I was feeling superstitious that talking about J would jinx usvlol. I'm happy to say that she is looking good today, and smiled when she held my hand, again.
We scheduled J. for Friday morning. Like Harriet several years ago, I approached this surgery with some trepidation, because she is a child, and we really didn't know what we were going to encounter. One of my favorite themes with the US residents who come with us to Liberia is that we have to learn to deal with diagnostic uncertainty here. In the US, it is very rare that a surgeon carries out an abdominal operation and doesn't know what he is going to find because all of the patients get CT scans and MRIs pre-op; obviously here it is different, and challenging, and fun when it works out.
Professor Ikpi, Dr. Konneh, Sandeep, and I explored her abdomen, and discovered fairly early that Cassell was right, and this huge cyst was arising fro her right kidney. In fact, it had pretty much destroyed her kidney so that there was just a nubbin of what looked like kidney left. Sometimes operations move along like a beautiful symphony or a well- choreographed and danced ballet; this was one of those occasions. I intended to step aside and let Dr. Konneh work with Prof. Ikpi, but I was having so much fun I just couldn't until Prof and I had the mass removed intact. It weighed 10 pounds !
Later on I went to see J in the Recovery Room. She had mucus and said the it hurt to cough, so I pressed on her abdomen while encouraging her to cough the junk up, and she did. Then she took my hand and held it, and smiled at me. I melted 😊
As we finished the operation, Professor Ikpi said:" This is what JFK is for !" and he is right on target. JFK needs to develop itself as a referral center known for tackling tough problems with excellent clinical surgery and medicine. I see the beginnings of that on this trip, and I have a good feeling about the future here.
After that Gbozee and Sandeep and David did a fellow with a complex enter-cutaneous fistula following a typhoid perforation. I would go in occasionally to see how they were doing, and they called me in once or twice to see something, but I did my best to let them make the clinical/surgical decisions. I think it worked out well.
I didn't write this last night because I was feeling superstitious that talking about J would jinx usvlol. I'm happy to say that she is looking good today, and smiled when she held my hand, again.
Friday, March 16, 2018
Thursday March15
Sad news this morning when we arrived at JFK: the man we operated on yesterday for a perforated ulcer did not survive the night. He had trouble regaining his respiratory drive, and was kept in the OR on the anesthesia machine ventilator for several hours because of his weak breathing. Unfortunately there are no ventilators at JFK other than the anesthesia machines in the OR; the option of leaving him on a ventilator overnight just doesn't exist.
David and Sandeep did a man with a large hydrocele, and then 2 of the Liberian residents repaired and epigastric hernia primarily. While they were doing that, the biomedical engineer came up and put a newer, larger monitor on the stand we brought for the endoscopy cart. We had some difficulty finding the endoscopes that Santiago had sent over, and which we had used last September. Eventually we found them, and were pleased to see that the equipment is all in working order and we will do some endoscopy in the coming days.
After a brief rest we went to the Royal for dinner with Lisa Travis and her friends Christine and Lawrence, a Liberian couple. Lisa is from North Carolina, and has extensive business and philanthropic interests in Africa. She recently met Jonathan Laryea in Kinshasa, and was interested in learning more about our work in Liberia which she was here visiting. Her business involves analysis of drugs to see if they are really what they are being sold as; apparently there is a large problem with fake drugs in Africa. Additionally she has ideas about setting up a cancer center at JFK, and we talked some about that. Christine and Lawrence have a fascinating background, having lived through the war years here and abroad. We had a lively conversation, and a great time !
David and Sandeep did a man with a large hydrocele, and then 2 of the Liberian residents repaired and epigastric hernia primarily. While they were doing that, the biomedical engineer came up and put a newer, larger monitor on the stand we brought for the endoscopy cart. We had some difficulty finding the endoscopes that Santiago had sent over, and which we had used last September. Eventually we found them, and were pleased to see that the equipment is all in working order and we will do some endoscopy in the coming days.
After a brief rest we went to the Royal for dinner with Lisa Travis and her friends Christine and Lawrence, a Liberian couple. Lisa is from North Carolina, and has extensive business and philanthropic interests in Africa. She recently met Jonathan Laryea in Kinshasa, and was interested in learning more about our work in Liberia which she was here visiting. Her business involves analysis of drugs to see if they are really what they are being sold as; apparently there is a large problem with fake drugs in Africa. Additionally she has ideas about setting up a cancer center at JFK, and we talked some about that. Christine and Lawrence have a fascinating background, having lived through the war years here and abroad. We had a lively conversation, and a great time !
Thursday, March 15, 2018
Wednesday March 14
It seems that the daily report I wrote last night didn't post until just now. These things happen.
Today was a National holiday in Liberia: Decoration Day, upon which occasion families decorate the graves of their ancestors. As it turns out, tomorrow is another National holiday celebrating the birth of Liberia's first President, J.J. Roberts. Decoration Day is the second Wednesday in March, and J.J. Roberts Birthday is March 15; it just happens that this year it means there are 2 holidays on successive days in the middle of the week. Kind of unusual, but this is Liberia :-)
In any case, we worked despite the holiday and had another good day of interesting cases including an emergency laparotomy for a perforated gastric ulcer as well as some scheduled cases. Among the cases today, Professor Ikpi did an inguinal hernia with Sandeep, David Aughton did an epigastric hernia with one of the Liberian interns, Dr. Weh, and I did the perforated ulcer with Dr. Cassel, one of the Liberian Chief residents. It was a really good day of teaching !
In addition to the surgery, we saw several new patients who have conditions requiring surgery, and hopefully we can get them done while we are here. Already I can see the logjam approaching, in that we won't have enough time to take care of all of the patients hoping for our services. Two weeks turns out to be not very much time.
The patient who took so long to wake up last night apparently was finally transferred to the ward at 2 am, and was doing well when we saw her this morning. She has a very devoted family who hovered last night during her surgery and afterwards, worrying about the surgery and the aftermath, hanging on every word of hope. They asked to meet me prior to her surgery, and invoked my name and my hands in praying that God would guide us to a good outcome. It was definitely an interestingly experience to be the subject of prayers for a successful outcome when I had serious doubts myself. So far so good anyway.
After dinner, we have come o bed. To sleep and then see what tomorrow brings.
Today was a National holiday in Liberia: Decoration Day, upon which occasion families decorate the graves of their ancestors. As it turns out, tomorrow is another National holiday celebrating the birth of Liberia's first President, J.J. Roberts. Decoration Day is the second Wednesday in March, and J.J. Roberts Birthday is March 15; it just happens that this year it means there are 2 holidays on successive days in the middle of the week. Kind of unusual, but this is Liberia :-)
In any case, we worked despite the holiday and had another good day of interesting cases including an emergency laparotomy for a perforated gastric ulcer as well as some scheduled cases. Among the cases today, Professor Ikpi did an inguinal hernia with Sandeep, David Aughton did an epigastric hernia with one of the Liberian interns, Dr. Weh, and I did the perforated ulcer with Dr. Cassel, one of the Liberian Chief residents. It was a really good day of teaching !
In addition to the surgery, we saw several new patients who have conditions requiring surgery, and hopefully we can get them done while we are here. Already I can see the logjam approaching, in that we won't have enough time to take care of all of the patients hoping for our services. Two weeks turns out to be not very much time.
The patient who took so long to wake up last night apparently was finally transferred to the ward at 2 am, and was doing well when we saw her this morning. She has a very devoted family who hovered last night during her surgery and afterwards, worrying about the surgery and the aftermath, hanging on every word of hope. They asked to meet me prior to her surgery, and invoked my name and my hands in praying that God would guide us to a good outcome. It was definitely an interestingly experience to be the subject of prayers for a successful outcome when I had serious doubts myself. So far so good anyway.
After dinner, we have come o bed. To sleep and then see what tomorrow brings.
Wednesday, March 14, 2018
Tuesday March 13
This is probably going to be short because the day was very long! I think we did 10 cases today; that wasn't our intent starting out, but between elective cases and emergencies it turned out that way. And in between cases we were screening potential patients, since the word went out yesterday that we were here and we would screening patients for surgery at no charge. For those patients who do have surgery, obviously there is no charge for our services, but they are generally required to pay a hospital fee and a fee for drugs used. In circumstances where a patient really needs the surgery done urgently but they don't have the ability to pay for it, we are usually able to work something out. I suspect that we could nearly fill our OR schedule for the two weeks with the patients we saw yesterday and today, but we won't; instead we will be somewhat selective.
Several aspects of today stand out: first, in each case a Liberian resident was part of the surgical team either as surgeon or first assistant, emphasizing the importance of teaching in what we are doing. Second, Professor Ikpi is an amazing and wonderful addition to the postgraduate program. He is engaged and enthusiastic, and even said to a group of us toward the end of a long day "This is so much fun!"
The last case we did today demonstrated some of the difficulties of doing surgery here. The patient is a mid-70s years old woman who came to the Emergency Room complaining of 3 days of abdominal pain. She has diabetes, hypertension, and congestive heart failure, for which she is on multiple medications. She had a tender abdomen, and was groaning in pain more than one might expect from the exam of her abdomen. The point of telling my non-medical readers about this background is that this is high stakes: there are some pretty disastrous potential causes for her pain where waiting would probably be fatal, but on the other hand she has co-morbid conditions (diabetes, hypertension, and congestive heart failure) which make her a high risk for surgery. Under the circumstances, one would like to be more sure what was going on in her abdomen, in the hopes that surgery could be avoided because she would get better without it. But we don't have a CT scan or other means to develop that certainty; the only way to know what was going on was to operate and take a look. So we did, and discovered that she probably would have gotten better without an operation, but I still think we made the right decision to operate. Her breathing was labored as she woke up from anesthesia, and the anesthesiologist wanted to keep monitoring her in the OR room till she was breathing better. Dr Gbozee and I and Sandeep did the surgery; after 2 hours in the OR waiting for her the breathe better, we Sandeep, David, and I) decided that we needed to get some sleep so we left her in the capable hands of Dr. Gbozee and the anesthesiologist, who felt it would be another couple of hours before he would want her to go back to the ward. I felt guilty leaving her, but we have another bust day planned for tomorrow, and I need some sleep. We had some pizza and beer back at the hotel, and then off to bed.
Several aspects of today stand out: first, in each case a Liberian resident was part of the surgical team either as surgeon or first assistant, emphasizing the importance of teaching in what we are doing. Second, Professor Ikpi is an amazing and wonderful addition to the postgraduate program. He is engaged and enthusiastic, and even said to a group of us toward the end of a long day "This is so much fun!"
The last case we did today demonstrated some of the difficulties of doing surgery here. The patient is a mid-70s years old woman who came to the Emergency Room complaining of 3 days of abdominal pain. She has diabetes, hypertension, and congestive heart failure, for which she is on multiple medications. She had a tender abdomen, and was groaning in pain more than one might expect from the exam of her abdomen. The point of telling my non-medical readers about this background is that this is high stakes: there are some pretty disastrous potential causes for her pain where waiting would probably be fatal, but on the other hand she has co-morbid conditions (diabetes, hypertension, and congestive heart failure) which make her a high risk for surgery. Under the circumstances, one would like to be more sure what was going on in her abdomen, in the hopes that surgery could be avoided because she would get better without it. But we don't have a CT scan or other means to develop that certainty; the only way to know what was going on was to operate and take a look. So we did, and discovered that she probably would have gotten better without an operation, but I still think we made the right decision to operate. Her breathing was labored as she woke up from anesthesia, and the anesthesiologist wanted to keep monitoring her in the OR room till she was breathing better. Dr Gbozee and I and Sandeep did the surgery; after 2 hours in the OR waiting for her the breathe better, we Sandeep, David, and I) decided that we needed to get some sleep so we left her in the capable hands of Dr. Gbozee and the anesthesiologist, who felt it would be another couple of hours before he would want her to go back to the ward. I felt guilty leaving her, but we have another bust day planned for tomorrow, and I need some sleep. We had some pizza and beer back at the hotel, and then off to bed.
Monday, March 12, 2018
Monday March 12, 2018
After a long but uneventful two flights from JFK(NY) to Brussels and then Brussels to Liberia, we arrived at Robertsfield Airport last night around 8:30 pm. As I came through Immigration into the baggage area, there was a Liberian man waiting for me with a paper sign saying "Dr. Knight and team HEARTT." After we collected our 12 bags ( 9 of them duffel bags filled with medical supplies), we made our way outside to the 2 vehicles waiting for us. We loaded the supplies into one car, which headed to JFK Hospital, and we went in the other car with our personal bags headed to our hotel. The airport is about an hour drive from Monrovia; as we drove in, I realized that the man who had greeted me, and who was driving the car loaded with our medical supplies, was Dr. Jerry Brown, the newly appointed Acting General Administrator of JFK. He was a surgeon at ELWA Hospital prior to assuming the position at JFK, and I had met him once or twice at past surgical rounds at JFK; I felt totally embarrassed that I didn't recognize him at the airport. So I asked our driver to stop at JFK on the way to our hotel, where we helped them unload the medical supplies and I was able to apologize to Dr. Brown for being an idiot and not recognizing him at the airport. He was very gracious, and we had a good chat before heading to our hotel. We are staying at the Murex Plaza Hotel where we have stayed on our previous 2 trips, and as usual they took good care of us last night.
Today we went to JFK around 8:30am, and joined surgical rounds in progress, followed by attending the hospital-wide Grand Rounds. At each occasion we were warmly welcomed, and the good vibes helped me know this is going to be a productive trip. I had several conversations during the day with Professor Ikpi, the new Head of Surgery for the Postgraduate Training Program and Chief of Surgery at JFK; it became very clear to me this afternoon that he and I are on the same page about the goals of this visit. When we started coming to Liberia in 2010, the main goal was to perform high volumes of surgery because it was unlikely to get done if we didn't do it; now, with a core group of strong residents and faculty, our mission has changed to a collaborative teaching role. I want this to be a mutually beneficial educational experience for everyone involved: faculty as well as both the Liberian and the US residents. Today we made a good start !
For several hours from morning into the early afternoon, we were in the Out-Patient Clinic with Dr. Gbozee seeing patients and scheduling many of them for surgery. And as usual, we saw some very large hernias, some small little problems, and some conditions that left me speechless. In general, the conditions we see that boggle my mind are not tropical or exclusive to Liberia; rather, they are often conditions which could be seen anywhere in the world, but here they have progressed much further because of lack of access to healthcare. For several patients that we saw today, I think their disease has progressed well past our ability to do any good for them surgically.
We spent some time at the Liberia Medical and Dental Board office this afternoon taking care of licensing business. While Sandeep and David had a short interview with the physician Head of the Board, I had a nice chat with Masmina and Mary. Then we went back to JFK and joined the last part of the Surgery Morbidity and Mortality Conference. Most Surgical Departments do a weekly or biweekly "M&M" Conference in which complications and deaths are discussed candidly in an attempt to educate all participants so that we are less likely to make the same mistakes again. I think M&M conference is a critically important piece in surgical education, and it was a pleasure to see that Professor Ikpi has added this to the schedule at JFK.
After going through our supplies, we made a quick trip to the Operating Theater to see our friends, deliver some supplies including the dermatome that Support JFK bought for them, and to plan out the operating schedule for tomorrow and the rest of the week. We have made ambitious plans, but I think we will accomplish most of our goals because we are all going to work together to make it happen.
Today we went to JFK around 8:30am, and joined surgical rounds in progress, followed by attending the hospital-wide Grand Rounds. At each occasion we were warmly welcomed, and the good vibes helped me know this is going to be a productive trip. I had several conversations during the day with Professor Ikpi, the new Head of Surgery for the Postgraduate Training Program and Chief of Surgery at JFK; it became very clear to me this afternoon that he and I are on the same page about the goals of this visit. When we started coming to Liberia in 2010, the main goal was to perform high volumes of surgery because it was unlikely to get done if we didn't do it; now, with a core group of strong residents and faculty, our mission has changed to a collaborative teaching role. I want this to be a mutually beneficial educational experience for everyone involved: faculty as well as both the Liberian and the US residents. Today we made a good start !
For several hours from morning into the early afternoon, we were in the Out-Patient Clinic with Dr. Gbozee seeing patients and scheduling many of them for surgery. And as usual, we saw some very large hernias, some small little problems, and some conditions that left me speechless. In general, the conditions we see that boggle my mind are not tropical or exclusive to Liberia; rather, they are often conditions which could be seen anywhere in the world, but here they have progressed much further because of lack of access to healthcare. For several patients that we saw today, I think their disease has progressed well past our ability to do any good for them surgically.
We spent some time at the Liberia Medical and Dental Board office this afternoon taking care of licensing business. While Sandeep and David had a short interview with the physician Head of the Board, I had a nice chat with Masmina and Mary. Then we went back to JFK and joined the last part of the Surgery Morbidity and Mortality Conference. Most Surgical Departments do a weekly or biweekly "M&M" Conference in which complications and deaths are discussed candidly in an attempt to educate all participants so that we are less likely to make the same mistakes again. I think M&M conference is a critically important piece in surgical education, and it was a pleasure to see that Professor Ikpi has added this to the schedule at JFK.
After going through our supplies, we made a quick trip to the Operating Theater to see our friends, deliver some supplies including the dermatome that Support JFK bought for them, and to plan out the operating schedule for tomorrow and the rest of the week. We have made ambitious plans, but I think we will accomplish most of our goals because we are all going to work together to make it happen.
Sunday, March 4, 2018
6 days to go before departure, March 2018
We will leave next Saturday, March 10, for another 2 week visit to JFK Hospital. I have almost completed packing supplies; I'm waiting for a few things to arrive this week such as a Padgett dermatome. For those who don't know, a Padgett dermatome is a powered device with a blade which is used to take very thin pieces of normal skin to be grafted onto another area of the patient's body where there is a burn, or an ulcer, or the like. I was informed recently that the dermatome at JFK isn't working properly, and they have a number of patients in need of skin grafting, so the only choice was to get another Padgett dermatome. Fortunately I was able to find one on eBay, and it is expected to arrive at my house this week.
We will have a small team for this trip. I will be accompanied by Dr. Sandeep Sachidananda, a Chief Resident at Waterbury Hospital who came with us last September, and Dr. David Aughton, a PGY-3 surgical resident at Waterbury Hospital. Dr. Santiago Arruffat, my faithful colleague, friend, and usual team member on the March trips, is unable to come this time as he is about to have surgery for a complete rotator cuff tear. His presence will be greatly missed, but I know he will soon be back in the groove.
Liberia has a new President since our last visit, and JFK Hospital has a new General Administrator and Deputy Administrator. I am excited to meet with them and talk about what we can do to help JFK advance into the future. And of course I am excited about seeing my Liberian friends again !
We will have a small team for this trip. I will be accompanied by Dr. Sandeep Sachidananda, a Chief Resident at Waterbury Hospital who came with us last September, and Dr. David Aughton, a PGY-3 surgical resident at Waterbury Hospital. Dr. Santiago Arruffat, my faithful colleague, friend, and usual team member on the March trips, is unable to come this time as he is about to have surgery for a complete rotator cuff tear. His presence will be greatly missed, but I know he will soon be back in the groove.
Liberia has a new President since our last visit, and JFK Hospital has a new General Administrator and Deputy Administrator. I am excited to meet with them and talk about what we can do to help JFK advance into the future. And of course I am excited about seeing my Liberian friends again !
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