March 29

     Busy days on the 26th and 27th, ending with the biggest inguino-scrotal hernia I have ever seen. It extended to below his knee when standing.Emery, Dr. Mabanza, and one of the Liberian surgeons found a way to return all of the bowels to his abdomen, and then create a repair combined with a scrotoplasty. It was quite a surgical tour de force!

     Thursday night there was a birthday celebration for me as well as a recognition of my last trip. Masmina organized everything, and it was quite a special event for me. Many people spoke of the contributions we have made of the past 15 years, and several who couldn't be present provided comments that were read by Masmina. The guest of honor was former President Sirleaf who was very generous in her praise. She surprised me by saying that while it was nice to have this celebration by our medical colleagues, she thinks that a lot of people in Liberia would like a proper celebration of my contributions, and she proposed that there should be a planned public occasion in September celebrating our work which I would obviously be expected to attend! Someone asked me afterwards if I would come back for such an event; my response was that when Madam commands, I do what I'm told!

Professor Coleman, Chairman of Surgery, then said that there are plans to make me an Honorary Fellow of the Liberian College of Physicians and Surgeons at their annual meeting in September. HEARTT gave me a quilt with the names of all the residents who have come to Liberia with us since we started coming in 2010 which is beautiful and a moving memento; JFK presented me with a plaque and a stunning ceremonial robe; and Dr. Gbozee told me that I now have a new name added to mine recognizing me as a warrior of Lofa County or something !

On Friday we went to JFK to say goodbye, and then went to Madam Sirleaf's house to say goodbye and to each receive an inscribed copy of her autobiography. We then had one of those amazing drives to the airport by Richard, a driver for Madam and a tiger on the road. Equipped with a full set of sirens and horns, and the ability to aggressively navigate narrow corridors between lines of cars and trucks, he went thru traffic like a knife thru butter ! And now we are in Brussels awaiting our flight to the US.

As a final working trip, it could not have been better for me. It's gratifying to see the progress that has been made in Liberia in general and in surgical services at JFK in particular in the past 15 years. I know that we have helped with our provision of supplies and our teaching, but I think perhaps our biggest contribution has been our reliability and consistency. We made a commitment and we kept it over 15 years and 26 trips, and we have created new leadership to insure it will continue as long as they want us to come. 

March 25

 I have no good excuse for not writing every day, except that we have been very busy working and I have been very tired at night. We have had some interesting cases, and some real challenges which have made the trip interesting and fun. We have been challenged by a number of abdominal cases in particular: one last week was a 19 year old with abdominal pain which progressed to an acute abdomen. His abdomen with distended and very tender; Emery and I had no clue what to expect, other than he needed surgery sooner rather than later.On opening his abdomen he had bowel twisted around itself; this is called a volvulus. What made him unusual was the part of his colon (sigmoid) was twisted, and we think that process brought in small intesting which also twisted. Twisting cuts off the blood supply to the affected bowel and it dies; we ended up removing about half of his small bowel and 1/3 of his colon. He is doing well at this point, so I continue to be optimistic.

Saturday night Masmina took us to the Mamba Point Hotel for sushi. We had a great time! Then Sunday we went to Libassa, the eco-resort about an hour drive from Monrovia that we have visited on previous trips. It is situated in jungle next to the ocean, has a lazy river as well as several pools, and  it provided a most pleasant day off.

This week we have been busy, and we are running up against the usual difficulty of have more to do than we can do in the tome available.

March17-18-19 2025

    We arrived in Liberia on Sunday night March 15 after a long pair of flights from NYC. We were greeted by thunderstorms and torrential rains on the drive from the airport to the Murex hotel. After s short but solid sleep we brought our 12 bags of supplies to the JFK Operating Suite and greeted many old friends. We then went to Grand Rounds and listened to a talk on HIV Care in Liberia presented by the Infectious Disease physicians. They noted that the HIV medications which they receive for patients comes from WHO so they still have access to them, but a USAID  grant provided the funding for computers and staff tor their surveillance and contact tracing. Without that USAID funding, they are not able to continue that work. After that talk, Dr. Tamba, the CMO, invited me to introduce the team which I did, and then I informed them that this would be my last trip. I was moved by their expressions of sadness and thanks.

     On Monday and Tuesday we did about 15 cases, and almost every one involved a member of our team and a Liberian resident. Our previous experience has been that the Liberian residents were reluctant to operate with us, perhaps somewhat out of fear but  the Liberian surgeons told me often that their residents seemed to think they could learn all that the needed to know from  books rather than operative experience. I think finally the message has gotten thru that there is no substitute for operating  if you want to learn surgery!

    Yesterday the best news was speaking to Dr. Williefrank Benson, a Liberian surgeon who trained here and then went to Nairobi to learn pediatric surgery. I have talked in previous blogs about the problem of caustic ingestion in children. Women buy crystalline sodium hydroxide and mix it with water to make lye which they use for making soap. They store the lye in any convenient container, such as a coke bottle; the children see a bottle of clear tasteless liquid and think it’s water. The lye can cause serious injury to the esophagus leading to stricture and inability to swallow food. Sometimes we have been able to dilate the stricture, but they often recur.the only longterm solution is to replace the esophagus but moving a length of colon into the chest to bypass the strictured esophagus. This is a big operation on a child requiring combined abdominal and chest surgery;  it’s not something a general surgeon would want to do, and until Dr. Benson came back from his fellowship, there was no pediatric surgeon in Liberia. But now he is here and he has done several successfully! This is yet another milestone for Liberian surgery!

     Looking back over 15 years I am impressed by the progress Liberia has made in healthcare. The are still a lot of problems, but overall I’m thrilled to have been here to witness the improvements.

    I’m going to stop now. I wrote the above during the day today, but there was bad internet. Now its 10pm and we have just finished dinner. And we have a long day ahead tomorrow.

Wednesday March 15 and Thursday March 14

 This has been an interesting trip for me in a number of ways. Because Santiago couldn’t make it this time,  there are just the 2 residents and myself; as a result, they have done many cases as a pair, and many with Dr Mabanza. In turn, I have done several solo, snd I have had the opportunity to work with Liberian residents. I’m searching for the next Dr. Gbozee with a mind like a sponge, technically adept, and eager to learn. I’m not naming any names at this point, but I think have identified someone who has that potential.

On Wednesday Adamah arrived with his friend Dr. John McGill who is a urologist in Georgia at the same hospital as Adamah. He came with Adamah for a week to check it out; he was astonished by the urology equipment being used (old) and was pleasantly surprised when he met Dr. Ayun Cassell, the main urologist at JFK. I have known Ayun for several years as he went thru the general surgery training program at JFK and then after he came back from urology fellowship training in Senegal. Not too many years ago, it was difficult if not impossible for graduates of the University of Liberia medical school to obtain specialty surgical training outside of Liberia. A few years ago, while still a surgical resident, Ayun decided to go to the West African College of Surgeons meeting where he presented 3 papers on original research he had done at JFK. The incoming President of the College, a urologist in Dakar Senegal, was so impressed that he offered him a training position in Dakar on the spot!

Thursday was our final day of operating on this trip. We did more hernias of various types, a mastectomy, an an incisional biopsy of a neck mass among others. They all did well.

Last night we had our farewell dinner on the rooftop terrace of the Murex. It was great fun, tho a bit embarrassing for me when Masmina asked each person at the table(there were 15) to say something nice about me. You might have thought it was my wake ! In any case the coomentsxwere kind and most appreciated.

Monday and Tuesday

Yes, My apologies to readers: we are having internet problems and as a result my Monday-Tuesday post has been lost into space or someplace. I will try to recreate it.

Monday was a busy day: we arrived at the hospital at 8:45sm and returned to the hotel at 9pm. We did a variety of cases including hernias and thyroids and lumps of various types, but I want to tell you about one patient in particular. She is a 39 yo woman with a large but operable breast cancer. Ominously she had several large palpable axillary lymph nodes. Several aspects of her treatment were and will be dictated by what is available here. There is no radiation facility in Liberia; patients who need it must go to Ghana or India, and that obviously involves significant expense. Because of her circumstances she chose to have a mastectomy instead, and perhaps avoid the need for radiation. She would have probably benefited from a course of neo-adjuvant chemotherapy given before surgery, but without the ability to assess her for metastatic disease, it would be hard to advocate for that. Furthermore, an essential element in decisions about breast cancer treatment is the presence or absence of tumor hormone receptors; the pathology department here often lacks the solutions necessary to do those tests. So she was scheduled for a modified radical mastectomy(removal and f the breast and the axillary contents), and Dr. Mabanza asked me to take Dr. Kempe,one of the senior registrars, thru the procedure. Gaspar and Dr. Kempe did the first part of the procedure by removing the breast, and then I helped show them how to do an axillary dissection. As a side note, axillary dissection is disappearing from the common surgical procedure list due to improvements in technology, understanding of cancer behavior, and improved chemotherapy. I expect that in the next decade any surgery for breast cancer will become rare in well-resourced countries 

Tuesday we did more hernias: Gaspar and Paul did several inguinal hernias, and I did a large incisional hernia with Gaspar and Kempe. There are an increasing number of Liberian residents who are eager to scrub with us, and that is very gratifying. I’m 

Sunday March 12

 Waking up to go down and sit on the dock drinking coffee and looking out at serene Lake Piso was idyllic! It is a most beautiful setting, and helped recharge the batteries for Week 2. Breakfast included the usual yellow pineapple as well as white pineapple. The white variety has a different taste: more subtle, and with a hint of mango in it I think. Habib says it grows as an oblong fruit without the spines of yellow pineapple. Seeing one before it is cut is now my quest ! After breakfast we went for a boat ride out to the entrance to Lake Piso at the ocean. As I mentioned before, Lake Piso is a tidal lagoon with open access to the ocean at Robertsport. We passed the fishing fleet docked in Lake Piso; from there they go out into the ocean to cast their nets. Robertsport has nice beaches, and surf; it is the surfing hotspot for West Africa, and attracts an international crowd who come to ride the waves. Around noon Gaspar, Paul, and Mark went to the beach at Robertsport to swim and enjoy the sun. Dr Joshi and I chose to remain well shaded at the lake. Gaspar, who was born in Cubs and thought he was resistant to the burning effects of the sun, got significantly burned after maybe 2 hours. I was glad that I stayed in the shade!

For the drive back, I rode shotgun in the lead car, and I think that qualified as an adventure sport experience ! No harm occurred to person or vehicle, but there were several close calls! We arrived back at the hotel around 5pm. It was a great weekend, and we are very grateful to our friends at the Murex Hotel for making it happen. 

Saturday March 11

Today we planned to do 3 cases in the morning, and finish by noon so we could drive to a lake house near Robertsport which is owned by the family who owns the Murex Hotel, our home in Monrovia. The 3 cases were an anal fistulotomy, and abdominal wall mass, and a huge lipoma of the upper arm. We arrived at JFK at 9am, and by 11:30 we had done only the 15 minute fistulotomy. Yes i was quite frustrated, but there are some things that we just have to accept. The abdominal wall lipoma was quick; the arm lipoma was intramuscular, but came out more easily than I expected. We then went back to the hotel and we’re ready to leave by 3:30. We had the same EPS drivers who brought us from the airport, and was again a high speed siren enhanced jaw clenching 50 mile drive with about a third on dirt road, and the paved portion is rutted and potholed. I was riding shotgun in the 2nd car (of 2) when we passed thru some small community at high speed. A motorcyclist pulled over when he heard the siren of the first car, but apparently didn’t know we were coming as he turned into the middle of the road striking our front tire on my side. He wasn’t hurt and got right up, but he destroyed the tire. We had to stop to chsnge the tire, and soon a crowd gathered with a lot of yelling going on. They called the police; one came and after some time an agreement was reached in which we paid $40 to the motorcyclist for damage incurred, and $10 to the cop for his service. While the negotiations were going on, we were chatting pleasantly with a number of the young men who had gathered. There was never any threat of violence; it was just a lot of yelling, and another interesting experience in Liberia!