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.