Day 4

I should apologize to the non-medical readers for putting in so much clinical detail on patients, but in addition to being something for you to read, this blog is going to serve as a resource for me in remembering the patients we have seen. So I need to put in the gory details!

Today was Outpatient Clinic day, so that is where we spent the morning seeing a remarkable variety of pathology. A surprising number of breast cases, including a middle aged woman with locally advanced cancer who is in pain and will have a mastectomy tomorrow for palliation. Afterwards, if she has the means, she can buy some oral chemotherapy and some tamoxifen, in the hope that the drugs to slow the progression of her cancer. It is an interesting, and perhaps bizarre, indication of the state of medicine in Liberia that all of this will be done without benefit of pathology, since there is no pathologist here. I know it is cancer, just from looking at it; nonetheless, my mind would prefer the certainty of a pathological diagnosis. We saw another younger woman in clinic who had a breast mass excised 2 years ago, and it was assumed to be benign; however she now has a mass in the area of the scar and palpable hard nodes in her axilla. This most likely represents recurrent breast cancer, but we don’t know for sure. She has the means to go to Ghana for further evaluation and treatment, and so that is what she will do.

On the wards today we saw two young patients in their early 30s with what appears to be squamous cell carcinoma of the anus. One is female, the other male, and both are far advanced. An attempt will be made to send them to Ghana for radiation therapy, but it is expensive and for each of them strictly palliative. The male has bilateral lower extremity edema and scrotal edema, most likely as a result of involvement of his inguinal nodes. His cancer has invaded the sphincter, so he is incontinent; the medicine residents are going to discuss the possibility of a diverting colostomy with him, just for hygiene and dignity purposes. They will also ask if he wants to make the trip to Ghana.

Other interesting patients in the clinic included a 7 year old girl with what looks like a hemangioma of her popliteal fossa; she will go to see Dr. Sherman at the Firestone Clinic; a couple of hernias; and a young girl about 19 with a large mass in her left breast and a couple of medium sized masses in her right breast. She had a left breast mass removed, but this has grown back. It is smooth like a giant juvenile fibroadenoma, but the recurrence makes me wonder about a phylloides tumor. Since we have no pathology, we will never know for sure, but if we can get her into the hospital for surgery before we leave, I will take many pictures of the whole and cut mass.

This afternoon we repaired an inguinal and an umbilical hernia is a 5 year old girl named Hannah. There is a Chinese pediatric surgeon here who watched the case and asked me a number of questions afterwards. I told him about Loupes, and he was quite excited !

This evening we saw a 7 year old boy in the ED who was moribund from dehydration when he came in; we were asked to see him because of a question of whether he could have a typhoid perforation. That seems unlikely, based on his softly distended abdomen. He was started on IV fluids, and his father was sent out to get ceftriaxone. That is the deal: patients or family are expected to supply any medicine which is needed, especially in the ED. There was no ceftriaxone in the hospital pharmacy, and at last report the father had been to 3 separate pharmacies attempting to purchase an adequate supply of the drug. The boy looks terribly undernourished in addition to being dehydrated; I wonder if there is something chronic going on in addition to whatever the acute process is. I suspect that tomorrow morning we will hear that he has died.

This evening James (Adaman) picked us up at the hospital and brought us back to the Guest House for dinner: Robert, Colleen, Senora, Dr. Steven Dahl, Georgette, and Adaman. We had a nice dinner : fish, vegetable and potatoes, and rice; Adaman told us stories of his life, and his mother’s life, when they were growing up. All four of her sons were in college in the USA when she was arrested following an unsuccessful attempt to overthrow President Doe in 1985. They were told that she had died, and did not learn until 6 months later that she was in fact still alive and in prison.

We have 5 cases to do tomorrow, so that should be interesting! Stay tuned for details !!