I think this is day 10, but maybe it's 9 ?

Today is Outpatient Clinic day, but we are operating. First case was one of the Operating Theater porters, known as “The General”, who had a huge hernia that he wanted us to fix. Robert and I did it, and it was quite difficult because, as Moses said, it was an “African” hernia…a slider into the scrotum, etc. We did accomplish the repair, and he was ready to go home later in the afternoon, which is remarkable by JFK standards.

Robert has gone to the US Embassy to get his visa renewed so he can return to the USA. Colleen and I went to the Outpatient Clinic and saw several patients. The most depressing was Augustine, and 11 year old boy with a 10 cm mass in his proximal left thigh, palpable nodes above it, gross lymphedema of the leg, and palpable nodes in his right axilla. This is most suggestive of lymphoma, probably high grade as the mass first appeared only a few months ago. Some form of soft tissue sarcoma is another possibility, though the diffuse lymphadenopathy would seem to make lymphoma more likely. We ordered a CBC, and hope that he can be seen by pediatrics. It’s an interesting situation, in that they apparently could admit him and give him some cytotoxic treatment, but would be doing so without a tissue diagnosis, since there is no pathologist here to render one.

Now we are waiting to do a splenectomy on a 53 year old woman with an enlarged spleen for a year, and no response to the usual medical therapies for malaria and typhoid. She is anemic with a Hb of 10 and a platelet count of 66,000. The holdup has been arranging for blood. Prior to surgery, the patients need to either have a family member donate blood for them, or they need to buy blood from the blood bank. This woman’s husband bought 2 units, but the anesthetist wants 3 available. I’m not sure it is entirely necessary, but I also don’t want to be the bad guy if the patient were to bleed to death on the table. Apparently the husband has been contacted, and he is on the way to get money and then bring it back here to buy another unit of blood. Makes you think they should have an ATM machine at the blood bank, except that ATMs are just emerging technology here.

Update : The husband came and paid for a third unit of blood. Then the anesthetist said she would prefer to have the platelet count over 100K; I told her that 66K was fine, and I had done splenectomies at that platelet level before. Then the patient had been sent back to her floor. Someone was sent to get her, but returned saying that the patient had eaten. Colleen and I went down to the patient’s floor, and discovered that she had not eaten. So I went back up and told the anesthetists, and they said “oh, it’s already 1 PM…why don’t you do it tomorrow?” With that, I lost and rather forcefully exclaimed :”No, we are doing it today ! “ It seems that they respond better to force, since they responded to my outburst, and within about 10 minutes the patient was in the OR. Colleen and I did the splenectomy, and lost maybe 100 cc of blood. She received the 3 units of blood anyway, since they had been paid for already…Go figure ! We also did it with a rather modest collection of instruments by USA standards, which perhaps reaffirms Colleen’s original impression after our first day that “We are spoiled”.

Shortly after that I was interviewed by someone, and it was filmed, but I don’t really know if it was radio or TV. It was fun talking about what we are doing, and HEARTT, and the surgical needs of JFK Hospital. My feeling is that the first thing needed is a reliable electrical system so that they can have decent lights, and bring in new equipment as indicated. Apparently the hospital is not grounded, and it will cost $10,000 to do that; sounds to me like it would be a worthwhile investment! I am told that the hospital does have generators for use during power outages, but they do not go on automatically, and are only turned on if the outage is expected to be prolonged. Who determines that and how appears to be unknowable. Here’s an interesting story: about a month ago an Indian government minister came to visit Liberia to discover what they could do to help with healthcare. Unfortunately, that minister was in a car accident on the way into Monrovia from the airport, and he suffered a serious head injury. He was stabilized at JFK, and then flown to Ghana by UN helicopter for a CAT scan and treatment; apparently he has recovered well. So now the Indian government wants to give Liberia a CAT scanner for JFK Hospital. My first reaction is that they really need to solve the electrical situation first, since CAT scanners really don’t like voltage surges and power outages. Of course I don’t know the details, or whether anyone has mentioned that there are a lot of other things which are needed much more…but this is a common problem in the developing world, I believe. People in the USA and elsewhere donate with the best of intentions, but if they don’t know the needs or capabilities on the ground, much of that donation will go to waste. I am told that JFK Hospital has crates of equipment donated by Hospitals for Hope over the past 2 years, but it is all stored in a warehouse and not even catalogued yet. I believe that they have hired someone to catalog it, so who knows what will be found.

Tonight we had dinner at the Guest House with Senora, Robert, Colleen, James, and Venay, a pediatrician from Children’s in Boston who will be staying there to do a pediatric heme-onc fellowship starting in July. She has been here several times, and is currently here for 4 months as an attending for the Liberian and US residents. We had a great discussion about medicine here, and the changes we see are necessary, and how those changes can be encouraged. One of the main problems, as I see it, is a lack of accountability by doctors, nurses, and many others. They are so used to living and working under impossible conditions that in some ways many appear to be resigned to the idea that there is nothing they can do. So if the hospital is out of a drug which has been ordered, they just don’t give it, rather than probing or asking if there is an alternative which could be used. We mostly see death as a personal failure (“there must have been something that I didn’t think of or didn’t do which would have saved that person”). I think they see death as just another life lost , and treat it rather impersonally rather than the way we take it personally. Maybe this is part of their culture, but I think their recent history and civil war has a lot to do with it also.