Monday March 9

   Monday morning begins our second and last week of this trip. We arrived in the Operating Suite at JFK at 8:30 to learn disappointing news: one of our incisional hernia patients who seemed to be doing well on Saturday and almost ready to go home passed away on Sunday. It's not clear what happened, except her eyes looked pale and her blood count was low, and then there was difficulty getting her a blood transfusion and getting an IV restarted. The  other piece of bad news was Ama telling us that there was no gauze available, and therefore there would be no surgery. Santiago and I each gave Adiola $20 to go buy some rolls of gauze from the pharmacy, and then Adamah went and bought more, so we were able to carry out our expected schedule of 8 cases.
     Prior to our surgical day, we attended Grand Rounds where the presentation was by the Department of Internal Medicine on Chronic Kidney Disease. They  presented some of their data, including the fact that there is a 98% mortality in patients admitted with renal failure because there is no hemodialysis or peritoneal dialysis currently available in Liberia. Most of the patients had loosely-defined "glomerulonephritis", but a significant percentage also had diabetes and/or hypertension. There was much talk about the need for a dialysis facility in Liberia, and the difficulties they will have maintaining a supply chain. Prof. Ikpi and others made the strong point that it will be much more cost-effective to focus on prevention of kidney failure thru treatment of diabetes and hypertension, and education of the public of the need for BP checks etc. This is a public health issue, and that should be a prime focus.
      Then we went to operate. Sepehr and I operated on a 46 year woman with an abdominal wall mass which had been growing for several years. It was now the size of my hand, and I guess she decided something should be done about it.We thought it was going to be an unusual tumor called a dermatofibrosarcoma protuberans, but were surprised to find that intra-abdominal structures were involved; we had to resect a piece of small bowel which was caught up in the mass as well as part of the wall of her uterus. We were able to take out what needed to be removed, and close her abdomen with some difficulty. One aspect of surgery here that is makes it most interesting is the possibility of surprise findings: in the US, this patient would have had a CT and other imaging studies which would have made operative surprise much less likely.
     Mo and I did a 71 year old man with a large mass on his back which surgeons elsewhere had tried to remove it 4 times previously. He presented to us with a large 20cm mass which was ulcerated and odiferous. My initial impression was that this was an elastofibroma based on its characteristic location at the lower end of the scapula. There was no way that we would be able to remove it and close the skin, so our goal was to remove it and later he can have it closed with skin grafts. The surgery went pretty much as expected, but then there was much activity from the head of the table; on questioning, the anesthetists indicated they were having trouble hearing a heart beat. With alacrity, we removed the mass so that we could move him from his side onto his back, and felt a weak femoral pulse. After making sure he was okay, we bandaged his wound and he is okay. Close call.
     We had dinner on the rooftop of the Murex Hotel last night, and it was delightful as usual. Adamah and Mary and Sam came over, and then Joe and Abraham joined us, so it was a lot of fun.