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.