Wednesday September 21 and Thursday September 22

 The time on this trip is flying by ! We had a busy day on Wednesday doing cases, and then Wednesday night we went to the Mamba Point Hotel to meet Masmina and the Cummings for a dinner of sushi. It was was great as usual !! Alex and Teresa Cummings  were so gracious as usual. It's hard to imagine sometimes that Alex, having had a successful career in business, was willing to come back to his native Liberia to enter politics and run for President. I know that all over the world politics is a blood sport, not for the weak or just partially interested. Politics in Liberia seems to be especially bloodthirsty with parties willing to do whatever they can to destroy their opponents. It seems especially unfair for opponents to accuse Alex of having ulterior motives when it is so clear that he is running for President because he has the knowledge and skill to raise the country up, We shall see what happens in October 2023,

Today was out last day of operating on this trip. Tomorrow we fly out at 8:30pm, but Masmina has advised us that we need to leave for the airport early because the only road to the airport is under reconstruction, and there will be a lot of traffic on Friday afternoon. So to avoid problems we will not operate tomorrow, and leave for the airport early. Today we had another active day doing 13 operations, leading to a total of 103 surgeries on this trip. We averaged 10 operations a day, and that is a great accomplishment due to the work of our team as well as the incredible work of the OR staff. It still amazes me the way the OR staff steps up during our visits to get things done. They love the fact that they are pitching in to help their fellow Liberians receive the care they need. 

Tonight we had our usual farewell dinner on the rooftop terrace at the Murex, and as usual it as an amazing feast. Many wonderful Lebanese foods as well as freshly caught marlin sushi and an incredible cooked barracuda.

As we end this trip,  I am especially proud that with each trip we have introduced young surgical residents to a world and a practice of surgery that is different from anything they have ever experienced before. I'm honored to have been able to play a part in introducing them to an experience that is new for most of them, and which they will remember forever. Needless to say, none of this could have been accomplished with the support and assistance of a great number of people. Some have been previously mentioned in this blog, and many others have helped behind the scenes. To all of you, my sincere thanks for helping this dream become reality.

Tuesday September 20

 Another busy day for us at JFK today with a few interesting sidelights. We had a bunch of hernias, an abdominal exploration and repositioning of a stoma, and a ruptured retro-cecal appendicitis. The appendicitis case is a friend of Masmina who had a couple of days of pain and then went to a clinic where he had an ultrasound which showed a probable ruptured appendix with a complex abscess. Apparently his initial thought was that he would fly to Ghana for laparoscopic surgery, but he soon realized that was not feasible, We arranged for him to be admitted to JFK last night and started on IV antibiotics with plans for surgery today.  We did his surgery in the afternoon, and it was certainly a challenge but the goal was accomplished. He is recovering now.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           n

Monday September 19

Today was an excellent day ! I think we have probably eradicated hernia as a problem in Liberia ! No, I'm just kidding, but there are a lot of people with hernias who are clamoring to get them fixed for free while we are here, so we did about 8 more today. At the end of the day we were told that there was a young man in the ED who had been stabbed in the abdomen. Fortunately for him, while the knife penetrated his abdominal wall and punctured his stomach, it was not a particularly serious injury and he should do well. The man who had surgery on Saturday evening and is in the ICU remains stable and has improving chances of survival.

When we were here in April, near the end of our visit, I was asked to see a 69 year old woman with locally advanced and metastatic breast cancer. A mastectomy was recommended, but my opinion was that she needed chemo rather than surgery. Her breast was filled with cancer, her axilla (armpit) was filled with malignant nodes, and her arm was swollen by the nodes which severely restricted her arm movement. She started chemo under the direction of Dr. Dehdeh Supuwood; the patient and I have frequently chatted on Facebook since I met her in April,  At the end of last week she asked if she could come see me today, I was excited waiting to see her, not knowing what I would find. Today she came up to the Surgical Suite at JFK, and she looks fantastic! I was astounded to find that she has had a complete clinical response: her breast feels normal, there are no palpable axillary lymph nodes, her arm is no longer swollen, and she has full range of motion in the arm, She is very pleased, as am I, for a result that seemed like an impossible dream in a place like Liberia. She isn't out of the woods, and will require more treatment, but clearly the signs are good.

Friday September 16 and Saturday September 17 and Sunday September 18

      We are challenged here by knowing the best way to treat a certain condition and then trying to figure out how to provide the best treatment we can with limited resources. Sometimes its just simple things: in the case of each of the 2 young women with large breast masses, I spent time thinking about where I would place the incision to be least obvious cosmetically while providing adequate access to remove the tumor. In the end, my decision was largely based on the fact that there was one minimally mobile OR light, and that would have made it difficult to work deeply under a skin flap for instance. Lights and available tools are just 2 of the practical considerations that go into decision making in this setting. I think that these challenges are one of the main reasons I enjoy coming to Liberia.

This trip has been a whirlwind and quite busy; the result for me is that the days and the cases blur together. I have been writing this blog every 2 days because I am tired at the end of each day, but I think for the next week I will go back to blogging every day if I can. Friday was another busy day of a variety of hernias (umbilical, inguinal, and femoral) as well as some other miscellaneous cases. Nothing too exciting, and yet each case brought its own set of challenges which had to be overcome. 

We had expected to work a half day yesterday, but it didn't work out that way as we did 13 cases ending around 8pm. Some were scheduled, and several were emergencies that had to be done. The JFK Administration announced on Monday that the only charge for surgery by the HEARTT team (us) would be any JFK drugs or supplies used; there would be no charge for registration, surgery, or hospital stay less than a week. I think this has stimulated many patients to finally get their hernia repaired etc. So with 15 patients on the schedule, we felt obligated to push on to get as many of them done as possible. One patient had been in the hospital since Wednesday awaiting her surgery, but was put off to the next day twice. Yesterday she came up to the Surgical Suite and announced that she wasn't going to leave until her surgery was done. After examining her, I told her that her problem would be best taken care of by a plastic surgeon, and I might have one coming on our March trip if she wanted to wait; she said that she wanted me to do it, and so I did !

The final case of the day yesterday was a patient who came to the ED yesterday seriously ill with an acute abdomen. Jonathan brought him to surgery and found his abdomen was full of pus, but no visceral perforation could be identified. He went into the OR in critical condition, and came out still critical and requiring medication to maintain his blood pressure. He was brought to the new JFK ICU to recover. I was pessimistic about his chances of survival, but the word this morning was that he had survived the night and was off the ventilator. Here's hoping he continues to do well.

As we were leaving, I stopped in on the 3rd floor medical ward to see a Facebook friend. Gwendolyn Remmie, a longtime JFK nurse. 11 years ago she took care of a 5 year old girl I had operated on, and did a wonderful job; we have been friends ever since.  We greeted each other with big hugs, and had a wonderful short reunion.

Today we had the day off, and enjoyed doing nothing but resting and having a team lunch on the rooftop terrace of this hotel. We had hoped to go to Libassa, the eco-resort we enjoyed in April, but there were difficulties with transportation. Just like the challenges in surgery, there are challenges in most things here. from the main paved road, to get to Libassa you need to travel a couple of miles on a dirt road. During rainy season, the dirt road is impassible without 4 wheel drive, so we were out of luck. Having a rest day was very nice though !

Wednesday September 14 and Thursday September 15

 Overnight I thought a lot about how I should do the surgery on the 17 year old girl with the phylloides tumor. The suggestions I received from my US colleagues were excellent, but none of them have ever experienced doing surgery in Liberia. By morning I had figured out the approach I would take if she still refused a mastectomy; when we arrived in the surgical suite and I spoke with her, she remained adamant that she did not want a mastectomy. So we did the operation as I had planned it out overnight, and it worked out well, and I think she was happy with the result. Truth be told, she didn't need a mastectomy and I'm glad she pushed me to figure out an alternative!

We had quite a busy day doing hernias and other surgeries. I spent much of the day thinking that I'm too old to work this hard, but I enjoy it so much. Its personally rewarding to cure people's problems with an operation, but it is equally satisfying to provide surgical residents with this opportunity to work and learn in a very different setting from what they are used to working in. There is also great satisfaction and joy in working with my Liberian colleagues, trading "war" stories, and learning from each other. I have no desire to stop, and will continue doing this as long as I am able.

Today was another busy day for us. The first case that Mickey and I did this morning was a 16 year old girl with a giant juvenile fibroadenoma. These benign tumors grow rapidly, and are always a source of concern for the young patients who have them. Using the same thought processes we used yesterday, I decided on an incision and strategy which again worked out well.

So far in 4 days on this trip we have done 41 cases, which is considerably more that I expected we would do. Ama Taplah, the nurse manager in the OR, has been a big part of making this possible because she is a hands-on hard worker who keep things moving. Dr. Mabenza and Dr. Kukolo have been superb in organizing our work, and in coordinating the whole process.

Monday and Tuesday, September 12 and 13

     We arrived in Monrovia at Sunday night around 7:30pm, after the usual long journey from the US. Tired after 20 hours of travel, it was an incredible joy to be greeted so warmly at the Murex Hotel! It's the little touches like smiles and hugs, and being handed the key to room 203 with the words:"Your usual room, Doctor"! We had a lovely dinner; it will come as no surprise to those who have been on these trips that I had the spaghetti bolognese, and it was great!

     Monday morning we arrived at JFK to more warm greetings as we brought our 9 supply bags to the surgical Suite. Leaving the bags there we went to Surgical Morning Report to greet friends and then to the Hospital Grand Rounds. The speaker was a urologist from the Royal College of Surgeons in Edinburgh who was discussing the collaboration between them and the Liberian College of Physicians and Surgeons to bring laparoscopy to Liberia. It was a very interesting talk, and brought up a number of issues about introducing technology into less resourced countries.

     We went back to the Surgical Suite to see what was the plan for the day. For a variety of reasons, we expected that this trip would have a slow start, but we were very wrong! Dr. Mabenza and Dr. Kukulol had planned to get us operating right away and so we started with hernias, several endoscopies, and a lot more to come. We were also pleasantly surprised to find that several of the OR staff had unpacked all of our supplies, sorted them, and shelved them for easy availability. We ended up having a busy half day of surgery, and then arrived back at the Murex around 8pm for dinner and early bed. Mickey and Sean, the 2 surgical residents from Waterbury Hospital on the trip, were both very pleased with the day !

     Today we had another busy day with several more complex cases. After doing a routine hernia this morning, Mickey and I had a patient with a huge incarcerated/strangulated recurrent inguinal hernia who was brought up from the Emergency Department. At surgery he was found to have about 5 feet of dead small bowel in the hernia sac. We were able to resect the dead bowel and perform a handsewn anastomosis thru the incision we had made, and then we found a creative way to repair the hernia defect. I'm expecting him to recover well; time will tell. 

   Then Dr. Mabenza and Sean and I went to see a 17 year old female with a large breast mass who was waiting in the pre-op area for her anticipated surgery. A previous biopsy of the mass indicated that it is a benign phylloides tumor; it's not cancer, but it has a propensity to recur. I had been told that the tumor was not large and could be easily removed, but it was immediately apparent to me that this would not be a simple surgery. The tumor is huge, and there is very little normal breast tissue. Additionally she told Dr. Mabenza that she does not want a mastectomy, and she wants her nipple preserved. At that point I told Dr. Mabenza that I was not comfortable operating on her today, and we should put her on the schedule for tomorrow so I have some time to consider and plan an approach which would accomplish the goal of removing the tumor while offering her the best chance of an acceptable cosmetic outcome. Fortunately with modern communication being what it is, I was able to send her clinical information and pictures to my colleagues in CT, and they had some good ideas for consideration. Before we left the hospital I asked Dr. Mabenza to speak with her again and see if she would agree to a mastectomy; if not, tomorrow I will do my best to give her a good operation that will get rid of the tumor and have a decent cosmetic outcome.

    

April18

 

Masmina Sirleaf is the Executive Director of HEARTT and a miracle worker! We had to have a COVID test to be allowed to enter the airport as well as to travel back to the US. The system requires filling out a form online and then going to a single place in Monrovia where the test is done. Thru her connections, she was able to arrange for an official tester to come to our hotel to swab us this morning, and we had the results before we left this afternoon. After the trouble they had getting to the airport on Friday, we decided to play it safe and leave around 3pm. Of course, the ride was long and there was lots of traffic in the market areas, but it took under 2 hours for us. We skated thru the formalities, and have been now waiting for our plane for 2 hours with scheduled departure in another hour. I’ve always preferred to wait at the airport rather than rushing at the last minute, but maybe this was excessive!

April 17

 We had a final day of leisure do we went to Libassa again to enjoy tha ambience and the water. It’s really a lovely spot which everyone enjoyed fully. 

April15

 This is our last day of operating on this trip, and we did more than expected. I saw a 68 yr old woman yesterday who had been told that she has breast cancer and needed a mastectomy. Thru acquaintances Mrs Cooper, retired from the JFK Admitting Offuce and living in Maryland, asked if I would see her to render an opinion. So she came to the hospital yesterday and I found that she had at least a locally advanced breast cancer and probably metastatic. She is not a candidate for surgery, but she is willing to take palliative chemotherapy. She and had a good discussion, and I told her I would contact Dr. Dehdeh Supuwood, a young Liberian physician who has done medical oncology training in Cairo. She and I talked about this woman in particular, and the challenges of being a medical oncologist in Liberia currently. At the end, I agreed to bring the patient back today so I could do a biopsy and bring it to Waterbury Hospital for faster evaluation so today she came, and we did the biopsy, and later as she was leaving she gave me a big hug of thanks. Other cases today included several hernias, and Becca assisted Dr. Mabenza on a thyroid. It was a good ending day on a successful trip. Santiago and Sam and Chandra Joshi left in the afternoon for the airport. The drive took over 3 hours because of a football match and it being Good Friday and who knows what else. They were concerned about missing their plane, but the made it in time.

April 14

 Today was another slow day for us, tho there was plenty of activity in the OR by other specialties. Until recently we have often been fixated on the number of cases done as a marker for success; with the development and evolution of general surgery at JFK, we are no longer the only ones working during these 2 week visits. We now measure success by the level of collaboration with Liberian attending staff and residents; in that respect I think this trip has been more successful than I anticipated. Our cases today involved some large hernias, and an interesting lipoma on the side of a foot extending in dumbbell fashion halfway across the sole. Santiago and I wrestled it out with encouragement from Sam; it was quite the struggle! We came back to the hotel in the afternoon, and in the evening we had a delicious dinner on the rooftop terrace courtesy of the owners of the Murex Plaza in thanks for our work in Liberia. There was an amazing amount of food and drink consumed, and we brought leftover food to JFK the next day for us and the staff.

Wednesday April 13

 This was a long and busy day for us. I worked with Becca on a man with a recurrent inguinal hernia which had been repaired twice previously. Reoperative surgery is always a challenge because the anatomy has been distorted by the previous interventions, and because normal tissue plans have been obliterated. In this setting a further challenge is the good chance that a previous repair was unconventional and wasn’t a standard textbook repair. All of that was true for this man, but with time and patience we were able to give him a good mesh repair. We then operated on a 3 year old boy with a large protruding umbilical hernia we thought. The overlying skin changes made us think he had been born with an incompletely formed abdominal wall, and appears to have had surgery to close it. His mother was unable to give us the details. Going into the surgery I was concerned that it would be quite complicated, and as surgeons do in those circumstances, I had thought thru a number of scenarios trying to figure out what I would do in each. Fortunately it turned out to be not as complex as I had expected, and the repair was relatively straight forward. Other cases included drainage of a tuberculous abscess associated with Pott’s disease , endoscopies, and Yuk did dressing changes on 3 kids with burns. One of them is an 11 year old boy who was caught in a house fire and has greater than 50% of his body burned. It breaks my heart to see him.

Tuesday April 12

 Internet communications have been more difficult than usual this trip it seems to me. Sometimes they have been quick and problem free, but other times it’s very slow. This was a slow day. 

Monday April 11

 A full day to start our second and final week of this trip. We started with breakfast at Madam President’s house and fascinating conversation as usual. Santiago asked her if she missed being President; she responded that while overall she was happy doing what she wanted without harping from adversaries, she missed having the power to fix things immediately. After that we went to JFK and did a variety of operations. The last case was a 38 year old man with a large right inguinal hernia which had been present for years. In the past week it was causing him worsening pain, but he didn’t want to come to the hospital, maybe because of fear of hospitals or fear of the cost. In any case, he finally came in early yesterday morning. He was in the ED most of the day getting IV fluids and making arrangements for his hospital bill. He was carried up the 4 flights to the Operating Suite because none of the elevators are working yet. At surgery he was found to have a perforated colon with extensive fecal contamination; during the operation he had a cardiac arrest and could not be resuscitated. It was a very sad ending to the day,  and a reminder that health issues are often complicated by social and economic factors that are out of our control.

April 9 and 10

 Saturday was a lazy day. We went to JFK and did one case, and then we were back at the Murex by noon. We all napped and relaxed got the afternoon before going to dinner at the Mamba Point Hotel. Our team of eight was joined (and hosted) by Masmina, Adamah, and Theresa Cummings, the Chair of the Board of HEARTT. We had a delicious sushi dinner mixed with lively and fun conversation.

Sunday we went to Libassa, an ecolodge in Marshall out near the airport. There are swimming pools and beaches and huts to stay overnight. It was a great afternoon, and we might go back there before we leave. On the way back to the hotel we stopped at Adamah’s brother Charles house for beer and food. A number of other people were there, many of whom I have met before, and it was great to see them all again.

April 8

 Today is National Fasting and Prayer Day in Liberia, a national holiday, so we were expecting a limited schedule today. When we arrived at 9AM, it seemed like we had 2 cases and would be finished quickly. To no one’s great surprise, we ended up doing 7 cases and finishing at the hospital around 4:30pm. The final case was complicated: a 22 year old female with abdominal pain and distension for several days, but her abdomen was soft. The major logistical issue was getting her from the Trauma ED on the ground floor to the Operating Theater on the 4th floor. Because it was a holiday, it wasn’t easy to find strong men to carry her up; eventually it happened thanks to intervention by Dr Mbasa. On exploration by Santiago, Sepehr, and Becca, she was found to have 900cc of bilious ascites, cirrhosis, and a probable retroperitoneal duodenal perforation. Based on the tissue reaction, it looked like the perforation occurred days ago; it seemed like the best course of action was to wash out her abdominal cavity, place drains, and hope for the best. It’s not clear why she has cirrhosis, but a reference in her chart to asthma made us wonder if she has alpha-1 antitrypsin deficiency. After dinner we went to the rooftop terrace and had a nice time chatting with Joe Morris, Clarence, and Adamah.

April 7

 Another good day of variety and interesting cases to learn and teach from. We did a variety of hernias, some adult and a couple of pediatric; the latter included a 10 month old baby who had had a colostomy for imperforate anus which was decommissioned later. She developed an incisional hernia at the colostomy site which was symptomatic, and thus the reason for repair now. She did fine! We also had a breast mass excision(benign), and some endoscopies. At the same time, Dr Ayun Cassell was performing urological procedures including a TURP. He was an excellent general surgery resident who worked with us in that capacity for several years before going to Dakar, Senegal to train in urology. He is now back in Liberia, and I believe he is the only trained urologist in the country. And Dr. Doe was in another room revising the cranial end of a VP shunt in a 2 yr old with hydrocephalus. 

April 6

 This morning JFK has a real crazy busy schedule going in the Operating Suite! As I write this, at the far end of the hall Santiago is working with Liberians doing endoscopy; in another room Sepehr is repairing an incarcerated hernia with Yuk; in another room Becca worked with Dr. Kokulo to repair an incarcerated hernia in an 11 yr old boy; and in another room Dr. Doe is evacuating an epidural hematoma. Dr. Gbozee had some orthopedic cases to do today, but with the crowded situation up here, he decided to do them in the new mini-OR built downstairs next to the newly renovated trauma ward and ICU. The multitude of surgeries and surgeons reflects the progress that has been made at JFK over the past decade, and I feel privileged to have been here to see it. There are still many problems to overcome, but there is movement forward. An aspect that occurred to me is that with the increased number of trained surgeons, there is a pressing need to increase the capacity of the Operating Suite. There are several operating rooms being used for storage now; they will need to be outfitted and converted to active rooms, more staff will need to be trained, etc. Meanwhile, other cases today included removal of a large polyploid growth from the lower back of an older woman by Dr. Kokulo and Becca, and a laparotomy by Sepehr and Yuk and  2 of the Liberian residents on a young man who was shot the previous night. He was stable and it appeared his injuries wouldn’t be too bad, but they found he had a hole in his small bowel and one in his transverse colon. Possession of firearms by private citizens is supposed to be illegal in Liberia, but there appears to be increasing availability of weapons. That seems like a dangerous trend in this country still recovering from the violence of a long civil war. We went back to the hotel and were joined for dinner by Adamah and Masmina. It was a good time!

April 5

 We arrived at JFK to find a number of cases scheduled for us, and that was a surprise. Sepehr and I operated on a man with large bilateral African hernias, and used mesh for the floor repair. Becca and Yuk did a couple of less than African hernias. I removed a fibroadenoma from Precillar’s sister. We ended up doing 7 cases, which was pretty good considering that we weren’t sure we would do any before we arrived at the hospital. Last night Santiago and Samantha arrived to complete the team.

April 4, 2022

 Went to JFK at 8:30 am with our 13 bags of supplies, and found that the elevator was not working. Without too much trouble a group of men was recruited to bring them all up to the Operating Suite on the 4th floor. We then went to Grand Rounds and were warmly greeted by a number of old friends. After the meeting, Dr Gbozee showed us the new ICU as well as the new trauma ward, and the we went back upstairs to unpack our supplies. I think we did well in matching their needs with what we brought! Mary, our Administrator Angel, came up and we reviewed some patient charts for possible surgery: most were routine, and some might be interesting. One is a right colon “mass” for which there is no documented proof, and the other is a “sarcoma of the sacral region”; I asked that both patients be asked to come in so we can see them before committing to surgery. Earlier in the hallway downstairs I saw Miatta; she is a young woman with inflammatory bowel disease who may need yet another operation. I asked her to come back on Wednesday morning when Santiago is here. Masmina came to the hospital to check on us; we decided there wasn’t much more for us to do at JFK today, so we went back to the hotel for lunch. In the afternoon we went out to the 14th Military Hospital which is on the road to the airport. It is quite new and sparkling! There we met Kevin and Nuta Strachy, who I have heard about but never met. She is Liberian and a nurse; he is a retired plastic surgeon. He closed his practice in Florida, and they moved to Liberia where he is essentially CMO of the 14th. We had a wonderful tour and discussion, and I think we will find a way to work together a few times on this trip. After a lovely dinner, we all went to bed early to get ready for the beginning of serious work tomorrow.

April 3, 2023

 We are back in Liberia!! Yesterday afternoon Sepehr, Becca, and I met Yuk at JFK Airport for our departure. The mandatory Covid document checking had been painful, but we all passed. I had packed up 11 duffel bags of supplies and equipment which we brought with us; all totaled it was about 400 lbs of goods. We flew overnight to Brussels where we met up with Chandra Joshi (anesthesiologist) and Kevin Leadholm, one his senior residents at the Lacey Clinic/Hospital. After a 4 hour layover we flew to Abidjan (Ivory Coast) before arriving in Liberia around 8pm. Fortunately for us, Masmina Sirleaf, Executive Director of HEARTT had everything very well organized, so our arrival in Liberia was the least difficult part of the trip. We are now at the Murex And I’m falling asleep after a lovely shower.