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
Thursday, March 21, 2019
Wednesday, March 20, 2019
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.
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, 2019
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.
Sunday, March 17, 2019
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 !
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 !
Saturday, March 16, 2019
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 !
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 !
Thursday, March 14, 2019
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.
Monday, March 11, 2019
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.
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.
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