Tuesday

Tuesday September 27

We met Moses in the OR at 8:30, and did 2 cases: he did a skin graft with Ly, and then a colostomy closure with me. I think everyone is very pleased to have Ly here, and to learn from him. I forgot to mention that last night before and during dinner at the Royal, he was mentioning some techniques that he uses, such as wound packing soaked with Flagyl and the use of honey to encourage wound granulation. He had a very interested and attentive audience ! The colostomy closure was a pretty miserable slog through a lot of adhesions, and since her previous chart could not be located, we had no idea either why the colostomy was done or how it was performed. It was located in the left lateral abdomen, and I would have thought it was a sigmoid colostomy...but it turned out to be a transverse loop. Eventually we figured it out, took it down, and did a resection and reanastomosis; there was moderate blood loss, but hopefully she will be fine.

After the OR we went to the Outpatient Clinic, where patients had been waiting since 8 AM or so. We saw an interesting collection of maladies, some surgical and others not, ranging from keloids to BPH, with a thigh abscess, an undescended testicle, and a mass of the left lobe of the thyroid mixed in. Hopefully we will operate on some, but it all depends on bed availability, and that is hard to work around. We are told that there are patients in the hospital for a long time awaiting surgery, and that they are kept "on bed" awaiting the surgeon's availability. It doesn't seem fair to either the patients waiting, or to the other surgeons, but I'm not sure how to fight it. It may turn out that there is more availability at Redemption.

An interesting anomaly in Liberian health care has come to our attention: Redemption Hospital, which is in Monrovia, is classified as a district hospital, and as such comes under the authority of the Ministry of Health. As a district hospital, patients are not charged any fees for services rendered there. On the other hand, JFK is a tertiary teaching hospital, and it's budget is part of the Executive Mansion; for some reason unclear to most of us, JFK is expected to pay it's own way for the most part, and thus it is forced to charge fees. The fee for evaluation in the ED was recently raised from 100 LD (about $1.50) to 600 LD ($9.00); this represents a large hurdle for most people in a society where 80% live on less than a dollar a day, and the unemployment rate approaches 75% . According to Adamah, Liberia is the second poorest nation in the world, ranking only above The Congo .

We then met up with Adamah and others in the dining room of the Maternity Hospital chatting about the possibility of HEARTT extending out to other hospitals in the Monrovia area including Redemption and ELWA. The medical director at ELWA is going to bring a patient to clinic on Thursday for me to evaluate; it sounds like she has a far advanced breast cancer and I doubt there is anything we can do about it.

Tonight I went out for dinner to a Chinese restaurant with Ly and 2 of his friends from Cambodia, both of whom are here with the UN. One works for UNICEF in Cambodia, and was sent here on an emergency 3 month mission to work in the refugee camps in spinach Liberia, populated by people escaping the recent violence in Cote d'Ivoire. His term is almost up, and they want him to stay for another 3 months, but understandably he says he can only handle another month. Liberia is a difficult place under the best of circumstances; I can't imagine what it would be like to reside in a refugee camp for 3 months. The other Cambodian works as a budget analyst for the UN peacekeeping force; he has been here for 2 years, and seems to have settled in. He drove us in a UN Land Cruiser, and seems quite at home dealing with Monrovia traffic. We had a nice mean and an interesting conversation before going to the grocery store and then home.