day 2

We met Adaman pretty close to 9 AM, and he took us on a tour of the hospital. Oh my. Some areas of the hospital are quite new, and look very nice; other areas such as the ER and the Outpatient Clinics are witness to a teeming mass of humanity under the most difficult conditions imaginable.

Here is a common scenario: the patient is seen and needs surgery, but it doesn’t need to be done emergently. He or she is told to go home, and come back when they have enough money to pay up front for the operation; they are given an estimate of what it will cost. So then they come back for their surgery, and the cost exceeds what they have pre-paid. They are ready for discharge from a medical standpoint, but now they are held in the hospital until they can pay more money to cover the excess charges. Of course most of them don’t have the money, so eventually, after a month or so, the hospital gives up and lets them go home. In the meantime, the hospital charges for board, meals, and medicine have been piling up. It seems like a no win situation for all parties.

On our tour of the hospital this morning we saw a woman in her 20s, 4 months pregnant, who was having seizures. It wasn’t clear to anyone if it was pre-eclampsia, or possibly cerebral malaria. This afternoon when we went back to the ward, she was being wheeled out having just died. Then we went to the pediatric floor to talk to one of the pediatricians; they were trying to resuscitate a newborn baby whom they think had a congenital heart abnormality; the resuscitation was unsuccessful and the baby died.

On a brighter note, we met with Dr. Moses, who is the senior surgical trainee, and we discussed some patients who need surgery. One man has a large mass on the back of his neck, which is probably a hemangioma with has spontaneously thrombosed; we will operate on him tomorrow. We also have a pediatric hernia to do tomorrow. Several other cases are waiting in the wings, so I think we will be quite busy.

Two of the medical residents(one from San Francisco, and one from UCLA I think) asked us to see a 32 year old man with abdominal bloating and pain in his upper stomach, and a palpable epigastric mass. They did an ultrasound with a portable machine, and we repeated it. I think the mass is a hepatoma (liver cancer). They had talked to his family, who wanted to take him from the hospital to go see a local healer (aka witch doctor); they were convinced to keep him in the hospital until we had seen him. I told one of the medical residents that the witch doctor was probably his best option now. One of the interesting aspects of this is that we don’t have many of the clinical tools which we normally use. We talked about doing an exploratory laparotomy to biopsy the mass, but there isn’t much point since there is no pathologist to make a diagnosis. In the end, we are forced to make clinical decisions based on much more uncertainty than we are used to, and that can be rather uncomfortable. Maybe it will get easier after a while, but I’m not sure.

This afternoon a group of us went in a minivan to tour the city, and to go to the site of the Hotel Ducor overlooking Monrovia. It is quite near the American Embassy on Mamba Point. It was a 5 star hotel before the war; now it is a shell, lived in by squatters, and patrolled by UN troops. It still offers quite a view of Monrovia. From there you have a nice view down Broad Street to the bridge which was fought over for months during the civil war. That bridge is a key access point into Monrovia.

Tonight many of us had dinner here at the Guest House; Aunt Jennie made food for us, I think, and it was quite pleasant. Most of us were too tired to go out after dinner, so it was an early night. Tomorrow is a national holiday …”Decoration Day”…where people go out to decorate the graves of their loved ones. Even though it is a holiday, the Hospital Administrator (Dr. McDonald) and the Chief Medical Officer (Dr. Brisbane) have given us permission to do surgery, and have arranged accordingly for staff.

I should note that Internet access is sketchy. There is wi-fi in the dormitory, but the speed is pretty slow. Last night after dinner Ben came over; he is a friend of Adaman’s who runs the telephone company. I think he might bring a wireless router over here for us to use, which would be nice !