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.