Weds, Thurs, Fri

Wednesday, Thursday, Friday

     Wednesday was a busy day day with more thyroids, more hernias, and an assortment of other operations the details of which I cannot recall. What I do remember is that nurses walked out that evening. The basis for the strike was failure to pay their earned wages, but it turned out that there were other grievances such as lack of basic medicines in many public hospitals, and lack of electricity in many rural hospitals. During the day Alex and I focused on hernias while Jonathan did a couple of thyroids and other operations. Alex and i did some of the hernia repairs together, and she did a couple with Arthur, one of the Liberian surgical residents. Alex functioned as scrub nurse and surgeon, and learned that she could do the operation with minimal instruments. For one of them, she had no scissors and no needle driver; she used the scalpel to cut sutures and used a clamp for a needle driver. Not elegant or what we are used to, but she got the job done!

      Thursday was a full-blown strike day with nurses chanting at the entrances to JFK. We were still able to get cases done including a thyroid, decommissioning of a colostomy, several hernias, a breast lumpectomy(benign), and removal of a large lipoma from the back of one of the Liberian surgical residents ! I enjoy the opportunity to teach surgical technique and strategy during those cases...experience has value still!

       Jonathan had kidded the hotel management that the September trip members were being discriminated against because only in March did the owner (Shinny) put on a farewell dinner for us on the rooftop terrace. So he gave us a dinner last night and it was great fun! Masmina was there as well as her co-worker/friend, and Dr Sherif, a radiologist and ambassador whom i have met previously. The food was great, and the conversation spirited !

       Today(Friday) Jonathan is leaving at noon for Accra (Ghana), and we will go to the airport this afternoon for our flight to Brussels this evening. We did a final couple of hernia repairs this morning, and then said our goodbyes. We stopped in to have a nice chat with Dr. Camanor, the CMO at JFK, talking about our experience this trip and ideas for the future. Then we went back to the hotel for lunch, showers, and packing up.

Sunday-Tuesday Sept 22-24

Sunday September 22,Monday September 23,Tuesday September 24

     Sunday was our day of rest. I slept and napped in the morning, and then we went to The Capital Room for brunch with Masmina and friends. I have been there before; it’s a beautiful setting overlooking the ocean. We had a nice meal and great conversation. When we left there, we went to shopping for souvenirs; several members of the team found items to bring home. We returned to the hotel and had a final beer at the bar to say goodbye to Thu Ha Nguyen who leaves for Little Rock via Chicago tonight. It has been a great pleasure having her on this trip: she is bright, energetic, a great team player, and full of smiles and laughter! We were sorry she had to leave, and look forward to welcoming her back to JFK again soon!

     Monday we were back to work doing the usual variety of cases including endoscopy, colostomy closure, excision of a massive dermatofibrosarcoma protuberans of the back, and a variety of hernias. We learned that there was going to be a nurses strike because the government hasn’t paid them for July and August yet, and they, like all public sector employees except for members of the House and Senate, are part of the “harmonization” scheme in which all public salaries are being cut. The Liberian economy is suffering from significant inflation: for most of the years i have been coming here the conversion rate has been about 70 Liberian dollars to 1 US Dollar, but it is now 208 Liberian dollars to 1 USD. Since most of the goods sold here are imported, this has a big impact on cost of living. US dollars are readily accepted in commerce, so we don’t change money while here.

     Tuesday there was less staff than usual because of the strike, but we were able to work. We had a few patients who didn’t show up for surgery; whether it was because of the strike, or forgetting, or other obligations i don’t know. We did 9 cases including a thyroid, takedown of a colostomy, a bunch of hernias, and endoscopies. We were done by 5pm, and were able to go back to the hotel and shower before dinner; it was nice to relax and not be in a hurry to eat and get to bed !

Friday September 20 and Saturday September 21

Friday September 20 and Saturday September 21

Friday was another long day: we arrived at JFK at 8:15am, and left at 9:30pm having done 14 cases. That was quite an achievement in itself, but considering we only had one room to operate in for the morning, then 2 rooms in the afternoon, and finally 3 rooms after 5pm it was quite an accomplishment ! Major kudos to Ama, Adeola. and the entire OR and PACU staff for working with us to get all of our scheduled cases done as well as some add-ons. The reason our rooms were limited was because local surgeons needed to some urgent cases, and there was no staff to open up others rooms. I’m pleased that there is increasing surgical activity by Liberian surgeons; i think that is an indication of progress. At the same time it was frustrating to have our scheduled cases delayed, but I was able to get over my frustration fairly quickly. Late in the afternoon we still had 6 cases to do; the option of cancelling those patients for today was offered, but we decided to push ahead and get them done rather than disappoint the patients by rescheduling for another day.

     One concern/time limitation/concern was that the hotel restaurant typically closes around 9:30pm. While i was doing our last case of the day, Jonathan spoke to Adil at the hotel, who told him we didn’t need to worry, and they would feed us whenever we got back to the hotel. That turned out to be 9:45pm, and then we had a lovely dinner ! 

      After our long day yesterday, we slept in an extra 30 min and came to the hospital at 8:30 today ! We had 12 cases scheduled, but had to do some switching around because of emergencies and ended up doing 10 cases in total. The scheduled cases included thyroids, hernia as, endoscopy, and a variety of lumps and bumps. The emergencies included a 22 year old man who had an intestinal perforation repaired a week ago, but postoperatively he was going downhill. On exploration we found he had a hole in his repaired colon; working with one of the Liberian residents, I  removed the damaged part of his colon and gave him a temporary ostomy. He is likely to have a stormy course after this operation.

       The other emergency was a young boy with abdominal pain. We were asked to see him this morning, and his examination was quite concerning for appendicitis or some other infection. Ideally he would get a CT scan to help nail down the diagnosis, but they cost money, and his mother said she couldn’t afford it. On clinical grounds we thought appendicitis was likely enough to recommend surgery, and his mother consented. At operation we found that he had mesenteric adenitis which is swelling of the lymph nodes near the appendix; this was the most common cause for a “negative appendix” early in my surgical career before CT scans were common. I don’t feel badly about putting him thru an operation to obtain this diagnosis; it was the right thing to do under the circumstances, and he will do well.

        Jonathan and Thu Ha are doing an endoscopy and putting in a gastrostomy( feeding tube directly into the stomach) for a 2 year old who drank lye and has an esophageal stricture. I have written about this as a public health problem here and in other countries in sub-Saharan Africa. It is a terrible and deathly childhood problem in search of a solution; in the meantime we do what we can to try to keep them nourished and alive.

         It’s just 9pm now. As soon as they are done we will call our van driver to take us back to our hotel so we can have dinner and go to bed. Tomorrow we have the day off !

Wednesday September 18

       Feeling quite energetic, we had 9 cases booked for today; we had 2 rooms available rather than the the 3 rooms we had yesterday, but we figured we could do it. We did 2 thyroids, and then 2 hernias; after that someone noticed a strange smell suggestive of burning plastic emanating from the far end of the corridor. The electricians came, and determined that there was overheating wire in the newly renovated ceiling; that pretty much shut us down for the day. Everyone's sensibilities were heightened by the tragic fire in Paynesville, a suburb of Monrovia, last night: 27 children perished in a fire in the dormitory of a boarding school. Sadly, the building had no fire exits, and all the windows had security bars on them. 2 children survived, and they have been hospitalized with burns but are expected to survive.
     We were told it would be 3 or 4 hours before the electricity was repaired, so we sent almost all of the scheduled patients home. The fix happened sooner than expected, so Jonathan was able to do an endoscopy and dilation on a 3 year old with an esophageal stricture following lye ingestion. While the dilation was successful, it is likely to recur and we are planning to place a gastrostomy tube in the child next week.
      We had a fun dinner at the hotel, and now I'm ready to sleep.
   
   

Monday and Tuesday September 16 and 17

      We arrived Sunday night, ready to start another interesting and educational 2 weeks in Liberia. Six of us came on the flight from Brussels; Jonathan Laryea arrived earlier after flying to Acra and then on to here.
    The "dramatis personae" for this trip includes:
            Dr. Jonathan Laryea, a native of Ghana, a graduate of the Waterbury Hospital Surgical residency. Professor of Surgery at the University of Arkansas for Medical Sciences, and annual September visitor to JFK with our team, co-founder of Support JFK Inc, and friend;
            Dr. Chandra Joshi, anesthesiologist at UMass, and humanitarian who has come to Liberia with us several times;
           Dr. Hilary Hutt, PGY-4 Anesthesia resident at UMass;
           Dr. Thu Ha Nguyen, PGY-4 Surgery resident at the University of Arkansas;
           Dr. Alex Sanowski-Bell, PGY-3 Surgery resident at Waterbury Hospital
           Dr. Georgios Mihalopulos, PGY-2 Surgery resident at Waterbury Hospital
   and of course me lol.
      Monday we started out by bringing our 9 or 10 bags of supplies to the Operating Suite on the 4th floor. The entire suite has been renovated, and looks very good ! We then went to greet the Surgical faculty and residents, and see dear friends like Dr. Jerry Brown, Dr. Lawuobah Gbozee, Dr. Albertha Clark, and many others, as well as a surprise: Dr. Edet Ikpi has returned to JFK from Nigeria to continue the great work he did a couple of years ago as Chairman of Surgery!
      After Grand Rounds Marie Knuckles took us on a tour of the new Radiology Suite complete with CT scanner. Having this technology at JFK is a major accomplishment many years in planning, and the new facility is beautiful. The best news was that they have a 5 year service contract on the scanner with Siemens.
     Around noon we located our endoscopy equipment which had been shipped over in a container along with a whole lot of supplies collected by Santiago, Jonathan, and me. It was easily accessible in the hospital warehouse, and they delivered it to the Operating Suite very promptly. Much to my surprise and pleasure, we put the system together and it worked right away !! no damage in shipping, no problem with the electrics!
      Later in the afternoon, Albertha Clark let us know that there are 150 patients on our list for surgery on this visit. It's highly unlikely that we would be able to do that many, so our goal now is to prioritize patients in terms of who really needs to have their surgery while we are here, and who could wait. Also, it is very likely that during our time here there will be a number of patients whose condition is such that they need urgent surgery, and they will obviously become a priority. We will do as much as we can for as many people as we can.
      Last night Teresa and Alex Cummings invited us to their apartment for dinner. It was a lovely dinner in a lovely place, and the occasion was enjoyed by all!
      Today (Tuesday) we had a good day doing 9 cases including  thyroids, hernia and scopes. We were able to mix things around so that Jonathan did one thyroid with Thu Ha and one with Alex. I did several hernias with Georgios; Gbozee did a an umbilical hernia with Thu Na, and I did a hernia with Arthur, one of the Liberian residents. There was nothing spectacular about the day; it was s fairly typical day, and it was a good introduction to Liberian healthcare for the new kids.



       

Thursday March 21

    Today was our last full day of operating at JFK for this trip, and what a day it was ! We had 3 thyroid operations scheduled for today: the first one was a 26 year old female who had a very hard and nodular gland which to my mind increased the possibility of cancer. My sense was that successful treatment might require a total thyroidectomy, but that would require thyroid hormone replacement for life after surgery, and that medication is not readily available here. I decided that we shouldn't do her surgery without at least more information such as an ultrasound. The cancellation put her into tears, and made me feel bad for having done it, but I think I was right in terms of her safety and the best treatment.
     Shortly after that, Santiago told me that there was a patient with Ludwig's angina downstairs.  This is a condition in which swelling in the submental space(under the chin) compresses the trachea and causes difficulty with breathing; it creates an emergent need for a tracheostomy. So everyone went into action, and quite rapidly the critically ill patient was in the OT. Santiago and I successfully did her trach under local anesthesia, and felt good about that. Unfortunately I heard tonight that she passed away this afternoon.
      We then spent the day doing a variety of cases, trying to get as much as possible done as soon as possible so that we could come back to the hotel and get ready for a celebratory dinner. Of course that was dangerous thinking, because when you do that something always happens. In our case today, around 5 pm a young woman was brought to the ED after her husband bit off about 1/3 of her lower lip. I would have no idea how to repair that, but fortunately we had Rob Kimmel Sr available and ready. I thought it would take a long time, but the Kimmel duo did it in short time and produced an amazing result.
     We got back to the hotel, showered, and bot ready for our annual dinner on the rooftop of our Hotel hosted by Shinny, the owner. It was a lovely gathering of about 20 people, and the Minister of Health Dr. Wilhemina Jallah even stopped by to offer her thanks. It was a lot of fun, and a fitting celebratory end to this trip

Tuesday March 19/Wednesday March 20

    I have not been as faithful as I wanted to be about writing my blog on this trip, and for that I apologize. I'm going to blame the effects of aging and being very busy; I get to my room at night after dinner and I just want to sleep. The work in invigorating, and I enjoy it while I am doing it, but at the end of the day I am beat.
    Our days have been quite busy with surgery. We have been doing 8-13 cases every day, depending on the mix. That's not bad considering that we have 2 rooms available to work in, plus a third for endoscopy and patients who can have procedures done under local anesthesia or local with sedation. We also have to share the rooms with other services who have emergencies: Orthopedics has needed to use on of the general anesthesia rooms on occasion, and Urology needed it yesterday. The OT staff, led by Ama, has once again been outstanding in their willingness to work and ability to juggles cases.
     Wednesday we did 13 cases in a typical day which included a thyroid, 3 colostomy closures, a couple of breast masses, several hernias, an endoscopy, removal of a couple of large lipomas (back, axilla, head) and removal of a small nodule from the neck of a medical student. I'm fairly certain that the nodule is benign, but it looks odd and will be examined by a pathologist. We started at 9 AM and finished our day at 7pm. While we were working in the main OT, Dr. Cindy Basinski was working in the Maternity Hospital with the Ob/Gyn residents. In her short time here she has taught them how to perform hysteroscopy, among other things. She leaves tonight after a successful first trip, having made new friends and being bitten by the bug to return again.                                                                                                                                                                                                      
   

Monday March 18

  It’s hard to believe that we are halfway thru this trip already. As usual, I feel the press of time entering this second week, where it seems like we have more to do than we have time for. We will have a very busy week.

       This morning was typical for a Monday in our second week. When I woke up this morning, I started wondering how Larry had fared over the weekend. There was no reason to think he wouldn’t do well, and yet we know that the unexpected can occur, so I wasn’t at peace this morning until I saw him. Rob Kimmel and I made the Pediatric Ward our first stop; as we were walking down the hall, he was standing in the doorway of his 6 bed room and he started smiling brightly when he saw us coming. He is fine, and he will be discharged today. ‘m so happy that we were able to do the surgery that has changed his life for the better.

      Santiago and the others joined us, and we went to the second floor to see the woman he had operated upon on Friday night. He had the same anxiety, only worse probably because there was a strong chance that she had succumbed. Fortunately she was alive, and feeling better; she was dehydrated because no one could get an IV in her. Drs. Nowicki, Kimmel, and Clark put in a central line, and we are hopeful.

      Between the Liberian residents and our team, we have more surgeons than rooms available to work in, so while Santiago was extracting a thyroid, and Dr. Kimmel Sr. was removing a large ear keloid, and others were doing hernias, I spent much of the morning in the Outpatient Clinic with Dr. Albertha Clark. She is one of the stellar residents coming up, and it was a real pleasure to work with her in the clinic, seeing all sorts of interesting problems, many of which we will try to get on our surgery schedule for this week.

       As I was leaving the clinic, I saw the uncle of Francis, a patient from last year; the uncle works in the JFK Dental Clinic. Francis was the young man who had multiple Schwannomas in his left axilla and extending down his left arm. We took out 13 of these tumors in September, relieving the pain and burning symptoms he was having. The pathology was benign, and we hoped for a longer term relief, though we knew they were likely to recur. A few weeks ago I received a photo of him, and it seemed likely that the tumor had transformed into malignancy. The mass was huge, and was ulcerating thru the skin. Dr. Gbozee saw him and said the tumor was fixed; I hoped to be able to see him, although there was little we could offer in the way of palliation. I never did get to see him on this trip; his uncle informed me this morning that Francis passed away on March 5. He will live in my memory forever.

    We did more surgery in the afternoon, and finally finished around 6:30. then as usual back to the hotel for showers and dinner.

Saturday March 16

     Today we took the day off from surgery to travel to Tubmanburg, which is about a 2 hour drive from Monrovia. We were invited to "The Farm", which is former President Sirleaf's country "home". We met at her Monrovia house, and then proceeded in a convoy with a police escort, which was a great help in dealing with the traffic in Monrovia. The trip is about 1.5 hours on paved roads, and then 30 minutes on a dirt road. At points along the dirt road, there would be groups of children waving and shouting, and singing. The convoy included a busload of college students who were in Liberia for 10 days to do service work of various types as well as relatives of Madam President and others. We arrived at her house, and we were immediately offered a coconut with the top cut off and a small hole with a straw to enjoy the coconut milk.
     Santiago and I had been to the Farm once before: it was at the declared end of the Ebola epidemic when we sitting on her veranda sipping coconut juice when she received a congratulatory phone call from Secretary of State Hillary Clinton! Since then she has closed in the veranda and put in a beautiful swimming pool right next to the house.
     It was really quite a remarkable afternoon. The students were fascinating and refreshing, and wonderfully easy to talk to. I was impressed that so many of them came up to me and introduced themselves. We had lots of excellent conversations with many of them including the two young guys who started the program. They have a 501(c)3 which is funded by the universities that they work with.  Then Santiago, Rob Kimmel Sr, and I had an awesome chat with Madame over lunch in which she talked about personalities and issues on the world stage.At one point in the afternoon I was interviewed by 3 young reporters. One of their questions was: "Why is it taking so long to see improvement in health care in Liberia?" I tried to explain that it is a process, and patience is required
     We left around 4 pm in a convoy; this time with the President in the lead car (She was already at the Farm when we traveled there this morning). e arrived back at out hotel and had some dinner, then decided to go to the rooftop bar at the Royal Hotel just down the street. It was a fun evening to conclude a rather amazing day !

Friday March 15

   This day is another national holiday, honoring the birthday of J J Roberts, first President of the Republic of Liberia. Nonetheless, with the critical and uncomplaining assistance of the staff at JFK, we worked. We did 9 cases spanning the variety of surgery that we are called on to do on theses trips. A couple of hernias, two thyroids, endoscopies, closure of a colostomy in a baby who was born with imperforate anus. removal of a large benign salivary gland tumor in a 10 year old boy, and a bowel resection for cancer.
      The 19 year old boy has had this mass growing just under his jaw for several years. He lives in the southern part of the country, and had been to several hospitals, but apparently no surgeon felt comfortable removing it. He was then admitted to Pediatrics here at JFK, I believe the plan was to wait for our arrival. The tumor extended from the angle of the mandible near the ear to his chin; it was mobile and nodular, and had the physical characteristics of a pleomorphic adenoma arising from the submandibular gland. I think is is quite unusual to see such things in a 10 year old, but this is Liberia and we have become used to seeing unusual things! Rob Kimmel Jr, Arthur Wouh ( a PGY-1 Liberian surgery resident), and I did the surgery; I think it went very well. One of the joys of removing benign tumors is that there is little attachment to the surrounding tissue so it can be peeled off.At the end of the operation I felt that we had changed the course of this boy's life, and that is pretty cool; at the same time, there was a lot of teaching and learning for Arthur and Rob, and that was great.
      We heard in the morning that a woman had been admitted with a bowel obstruction, and she might need surgery later in the day. By late afternoon it was clear that she was getting worse, and that surgical relief of her obstruction was needed. The only problem was that there had been problems with the elevators and the electricity supply all day, and now the elevators weren't working. The HEARTT Surgery team along with several OT staff members then went down to the second floor, strapped  this significantly sized, very ill, 250 pound woman to a backboard, and carried her upstairs to the 4th floor Operating Theater! Santiago and Albertha Clark, and Samantha, then proceed to explore this woman and find an obstructing transverse colon cancer. They removed it and did a primary anastomosis. It was an interesting scene in the OT with them doing surgery with no light other than their headlights and the glow of the anesthesia machine monitors powered by reserve battery, and with Santiago's techno beat music playing in the background! We had sent the other members of our team back to the hotel, and we joined them in the restaurant around 10 pm.
      I write this a 7:30am on Saturday. Usually we would work on Saturday, but we have received a special invitation to go to Tubmanburg to visit former President Sirleaf at "The Farm". I had some reservations about skipping one of our normal working days, but in the end I decided it was an opportunity for the members of this team that was too good to pass up. We have worked hard this week, and have done 32 cases in 4 days under difficult conditions, and next week we will do a lot more. Time to take a little time to enjoy Liberia !

Tuesday March 12/ Wednesday March 13/Thursday March 14

Tuesday March 12/ Wednesday March 13/Thursday March 14

    I apologize to anyone who has been disappointed that I haven’t written my blog; I can only say that between being busy and power outages, it has just not been possible. We are having a wonderful trip for many reasons: we are seeing and operating on many interesting patients, and we have a great team. We have done 23 cases in 3 days, which is really quite remarkable since we are in temporary ORs (the main OR suite is being renovate, and will hopefully be ready by the time our September trip comes along) . We have had daily power outages and current fluctuations, such that  being told a case is delayed because the elevator isn’t working to bring patients up to the 4th floor. There are the usual shortages of supplies and drugs, but nonetheless the entire OT staff works together with our team to take care of our patients. Its a beautiful thing to see.                                                                                                                                                                                                                    

     

March 10/11, 2019

     We left NY(JFK) on Saturday night, arriving in Brussels on Sunday morning. When I say "we", I mean Dr. Rob Kimmel Sr, a plastic surgeon in PA, Dr. Michael Nowicki, one of our Chief residents at Waterbury Hospital, Dr. Dr. Rob Kimmel Jr, a PGY-3 surgery resident at Waterbury Hospital. I think it is very cool having a father-son combination as part of our team!! The other members have been delayed by bad weather in the Midwest, which cancelled the flight to Brussels for Dr. Santiago Arruffat, Samantha Shoultz, and Dr. Cindy Basinski, Santiago and Samantha will come a day later; Cindy is working on her arrangements.
     In one of the coincidences in life that adds unexpected joy, or perhaps it is just the joy of the unexpected, we discovered that Dr. Aaron Gilson and his girlfriend Mia would be in the airport in Brussels at the some time we were there. Aaron graduated from the Waterbury Hospital Surgical Residency last year, and is now in Chattanooga doing a plastic surgery fellowship; he came to Liberia with us in 2017. He and Mia were on their way to visit friends in Rotterdam; it was fun to spend an hour or two with them.
     We finally arrived at our hotel in Monrovia at 10pm; after some food, and Club beers, we all went to bed. Mike Nowicki was the only one who got up on time this morning; I was in a deep sleep when he knocked on my door at 8:15 !
      We went to JFK Hospital, and had a wonderful morning seeing old friends and meeting some new ones. We brought 6 duffel bags of supplies to the Operating Theater (OT) at 9am; when we went back there at 2 pm, Ama had all the bags unpacked with the supplies organized and on shelves in cabinets. She is is nurse manager of the OT, and she is awesome, and fantastic, and organized, and wonderful !
      We met up with the surgical staff and trainees, including Dr. Gbozee. After Grand Rounds, we went to the Out-Patient Clinic (OPD) with Dr. Gbozee and Dr. Clark where we saw a number of patients with an astonishing variety of problems. By the time we were done in OPD we had pretty much filled up our operating schedule for the rest of this week with a variety of interesting clinical problems. Having Dr. Kimmel Sr here is definitely a wonderful thing, and I know he will be busy.
      Adamah arrived in the middle of the night, and came to the hospital to be with us for much of the day. We came back to the hotel around 4 pm; we had decided yesterday that today would be a day to scope things out, and organize, but not operate. After a nap we had dinner, and then Santiago and Sam arrived for a glorious reunion. Tomorrow we will start operating. I love being here.