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 !