Sunday March 17

As planned, we were at the hospital a bit earlier than usual, and we were able to use both OR rooms to do our cases. John and I did the mastectomy so that we can bring tissue back for pathology, and Santiago and Nathan did the 2 year old with a hernia. The OR staff was very kind and accommodating in not only making it easy for us to do these last cases on a Sunday morning, but even having people come in so that we could use both rooms and be done sooner. After the cases, we went downstairs to say goodbye to patients and staff, and as always that wasn't easy. We hope that our patients continue to make progress; I know that we will see some of them again, but hopefully not as patients at JFK. We went back to the bungalow to shower and change for our flight. Moses came early, so we decided to go to Sajj one more time for chicken bread and pizza (I think that was Nathan's idea !) Then we went off to the airport for our flight to Accra and then JFK in NYC. I think this was perhaps our most successful trip for a number of reasons. There is no doubt that our familiarity with the people at JFK, and their familiarity with us after many trips makes the relationship easier for everyone. We all have a reasonable idea about what to expect from the others; even though I do let my frustrations reach a boiling point, I do know in my heart that they are trying, and that they are improving each time. Another key reason for our success was having Dimple with us. Her presence is what allowed us to do more complex, riskier surgery, mainly because the anesthetists knew they had back-up. The other day I was talking with Mr. Hne about the splenectomy we brought back for bleeding. He told me that when the patients of Liberian surgeons have problems, the surgeons tend to stand there and not do much; he was impressed that with the splenectomy all of the members of our team pitched in to try to find equipment and solutions to the critical problems we were facing. I think that part of what we do is to display that sort of teamwork, and perhaps others see how effective it can be. Finally, without doubt, much of our success on this trip reflects the fact that we all got along very well, and there were absolutely no personality issues at all between us. Everyone contributed to the success of the trip by not only doing their job well, but by helping others do the same. Kenna is a spark of joy and laughter, whether entertaining us at the table or in the OR, or getting into a soccer game with the neighborhood kids as we walked home; in addition, she is an incredibly good Surgical Tech! Dimple was a rock: steady, determined, flexible when she needed to be, but she would not accept "we can't do that" for an answer to anesthesia issues. She is also witty, and fun, and a great team player. John and Nathan were wonderful about keeping us organized. I told them at the beginning that I wanted to stress organization and information on this trip, and they did a good job at it, given the limitations of the system. John's full-blooded enthusiasm for everything he does, and his desire to learn everything he can from each case, was an inspiration; Nathan settled right in to this new experience, and seemed right at home within a few days doing complicated cases and learning how to care for patients without any of our usual tools such as labs, xrays, etc. And he loved that chicken bread at Sajj ! Finally, Santiago is an exceptional surgeon, a superb physician, a warm and engaging personality, and a great friend; he is an amazing resource for this work, and I am honored that we can work as partners in Liberia. I will return in September with a different team, and then many of this team will be back next March.

Saturday March 16

This morning we did our last 2 cases for this trip: Nathan and I excised a rather large ulcerated lesion on a woman's flank, and John and Santiago fixed a hernia to removed lipomas on the same guy. Then we collected our duffel bags, and brought more supplies over here to the OR. After helping to organize them, John and Nathan went to Sajj to pick up pizzas to bring back for everyone. As we were having our pizza party, Keffla, the surgical intern, came up to tell us that the woman I had seen with a large but operable breast cancer had been admitted on Friday night. Somehow that bit of information didn't get passed on, despite our asking the nurses multiple times if she was " on bed". Anyway, she had eaten yesterday, so we opulent do her surgery then....but the OR staff graciously agreed to let us operate tomorrow morning (Sunday) before we leave in the afternoon. We will also do a hernia on the 2 year old son of one of the OR staff; he didn't tell us until late in the trip that it needed to be done, and it looked like it would need to wait till September, but he pushed us and that's fine. We came back to the bungalow to find it being set up for a party, and at 7 many of the OR staff, Dr McDonald, Dr Marshall, Mary, and all of the HEARTT people came over or food, drinks, and dancing with a DJ set up in the living room. Mrs Peabody and her staff did all the arranging, and it was a wonderful evening. Dr McDonald was very kind in her remarks thanking us for our contributions to JFK, and I responded with our thanks for being allowed to be part of the team. John tells me that after our 2 cases in the morning, we will have done a total of 42 operations on this trip. We have definitely had a more complex case mix, and we all feel very good about what we have accomplished.

Friday March 15

This morning we were invited to have breakfast with the President, and it was a special occasion as always. John and Nathan came here to the bungalow before we left for breakfast,mand reported that Abdul was alive and well ! Then we went to the President's house; besides the 6 of us, the other invitees were Camille Henry, a pediatrician, and Mike Scott and Joe Tunno, both ED residents as well as Dr. McDonald. I had the honor of sitting on the President's right; she asked about our surgical cases, and the state of JFK, and we had a good discussion around the table. Partway through Auntie Jenny came in, exclaiming " And how is our favorite surgeon?" , and came over to give me a big hug and a kiss ! Around 10am the President excused herself to go to work; today is a national holiday, but of course she works anyway. At some point in the discussion I mentioned that I would be back in September, and Aunt Jenny said " But you know you have to come in July ! Or did I let the cat out of the bag?" Dr. McDonald had said something at the retirement function we attended about the President wanting me to be here for Independence Day celebrations at the end of July. I pressed Aunt Jenny gently to explain, but she wouldn't say anything more than I should plan to be here for the July 22-28 week; I'm hoping that more details will follow. But I guess if the President asks you to attend, then the apprppriate thing to do is to attend ! After breakfast we came back here to change, and then went to the hospital. Obviously Abdul was my main interest, and happily he was looking pretty good. He had been transferred downstairs to the ward around 12:30, and said he was feeling better today. His breathing was better, and I am optimistic that he will make it now. Our other patients were all looking good, including the mastectomy from yesterday, and Victor was looking better. At noon we met with Dr. McDonald and Dr. Bobo to talk about the development of postgraduate education at JFK, and the development of surgery in particular. We had in interesting and wide-ranging discussion of needs and resources; for me, the top priorities would be getting a pathologist, and an anesthesiologist, and surgical staff, and developing critical care services such as ventilators, etc. we also had a good discussion about the proposed endoscopy unit, including the equipment needs, staffing and resources, etc. They are extremely enthusiastic about this possibility, and Santiago and I have committed to doing what we can to get the process moving. We then went to look at the proposed site on the first floor, across from where pediatrics used to be. In the afternoon we went down to Front St to the carving shops; I bought an ebony mask and a few other things. It was good having Dewalt with us to do some hard bargaining ! Then after dinner at Sajj we went out to the 704 club in Painesville to meet up with Persillar and many other OR staff or a night of dancing. Dewalt was also there, being very protective of us. At one point I went into the bar with Barbu, and one of the bartenders said "Hi Dr Knight !" He is a friend of Persillar's, and last September she brought him to see me with enlarged cervical nodes. I biopsied one, and it showed granulomas consistent with TB. He told me he is on TB medication and is doing well ! We came home around 11:30, tired and ready to sleep before our last day of surgery tomorrow.

Thursday March 14

Thursday March 14 For the first time on this trip, it was raining when we left the house after breakfast. Not a hard rain like during rainy season, but more than a mist. On this trip, our meals have been taken care of by Mrs. Peabody, Head of Dietary Services at JFK, and her staff, and they have done an excellent job. Mrs Peabody left Liberia during the Civil War, and lived in Michigan until 3 years ago when she decided to come back because "her country needed her". She still has children in the US whom she visits regularly, but she seems genuinely happy to have come back to make a contribution to post-war Liberia. We knew today was going to be a big day for cases, and indeed it has been. John and I did bilateral inguinal hernias in an 8 month old boy, and then did a radical mastectomy on a 60 yr old woman. We learned of her because her daughter approached us on Monday as we were leaving the hospital. Her mother had been seen in the Surgical Clinic last October, and had paid her fees for surgery, butt she could never get a bed. We told her to bring her mother to clinic on Tuesday, which she did, and we were able to get her a bed through Mary. It's a sad story, because her breast cancer was ulcerated and advanced; I have no idea what it looked like in October, but today it was a salvage mastectomy. Finally we did a man with a nodular mass above and in his umbilicus. Pre-op we suspected carcinomatosis, and I am quite certain we were right. We biopsied some tissue to take back for pathology. In the other room Santiago and Nathan brought back the boy with burn contractures of his left arm, which we had operated on last week, and his left leg.. The arm looked pretty good, and the Dimple graft looked like a complete take. He has significantly improved range of motion in both his arm and his leg, but now he will need regular PT to stretch the tendons and get to full range of motion. We hope he will get that here in Liberia, but like so many things, there are many hurdles to overcome. Then they did a 14 year old boy admitted yesterday with a tender mass on his right lower ribs, and post- prawn dial abdominal pain. He had an ultrasound showing a probable abscess on his ribs and stones in his gallbladder. They did a cholecystectomy, and then drained the abscess which appeared to be going up to his chest, suggesting an empyema. Between cases I saw several patients sent up from the clic for me to see. One was a 9 year old girl who was shot 3 years ago, and lately she has been having intermittent abdominal pain. Santiago sent her for a CT, which showed the bullet had gone through her lung and diaphragm, and was lodged in her liver. I explained to her grandmother, and then to her American sponsor by phone, that her pain was not likely related to the bullet, and there was no need to take it out. Furthermore taking it out would involve a big and dangerous operation, and that was not advisable. Everyone was ok with that. Then I saw a 32 year old woman whom I had seen in the clinic. She is jaundiced, and had a suspicious ultrasound; I sent her for a CT which shows many heterogenous masses throughout the liver, probably a multifilament hepatocellular carcinoma unfortunately there is nothing to be done for her; that was a difficult conversation to have in a room full of people when the patient and I hardly appeared to speak the same language. Persillar was kind enough to stay and translate, but I don't think the patient really understands her dire prognosis. Finally I saw a 12 year old boy who started having pain in his right hip last September. No trauma or obvious inciting event. He had an X-ray which appeared to show a cyst on his femoral head; subsequent X-rays including one today have shown destruction of the femoral head,Mao now there is none. Dr Muvu has declined to biopsy it, not knowing what he would get into; I felt the same. It is clearly not something which can be handled in Liberia. At his mothers urging I spoke to his aunt in Minneapolis, and suggested that perhaps she could find a pediatric orthopedic surgeon at the University of Minnesota who would take an interest in helping out. It's frustrating an disappointing to see some of these complex problems in young people, which would be a challenge at the best medical centers, going unsolved because of lack of access to care. I know it is just the way the world works, but that doesn't mean I accept it. I thought we were headed home for a quiet evening, but when we stopped by the 2nd floor we found Abdul, the splenectomy we did 2 days ago, looking rather bad. He was tachycardic and tachypneic, and we decided to take him back to the OR for suspected bleeding. He had a lot of old blood in his abdomen, but no active bleeding that we could find. Post-op we have been waiting for him to wake up enough to be extubated, but it has been a slow process. The major problem is that there are no ventilators, so someone having difficulty breathing post-op or any other time is in big trouble; all they can be given is oxygen by nasal cannula. Mr. Hne pointed out that there is an anesthesia machine with ventilator which is brand new, but it is reserved for the shunt room, where it has been used maybe 15 times in 2 years. We were ready to seize it by eminent domain, but now Abdul has been extubated and seems to be able to breathe on his own. It is 11:30 pm, and we are going to go home. Joseph (anesthetist) and Sara (O2 therapy) have agreed to stay with Abdul in the OR because he needs the oxygen concentration available here rather than what is available through the concentrator machine. We are hoping Abdul will be better in the morning.

Wednesday March 11

Wednesday March 13 Today was Decoration Day in Liberia, so we operated on a holiday schedule in the OR. The first case was Santiago and John resection a transverse colon cancer; Santiago had seen him in the clinic along with his barium enema, which showed a classic apple core. That went smoothly, but with it being a holiday, nothing moved fast today. I did announce to everyone that I was over my frustration from yesterday; I have now entered the final phase, which is acceptance, or perhaps resignation. The next patient was a woman I saw in the clinic with a huge spleen; since I did a huge spleen yesterday, it seemed only fair to let Santiago and Nathan do it. It wasn't as big as the one John and I did yesterday, but it was still a challenge ! The final case was supposed to be a liver abscess next to a sick gallbladder, but when we looked we found a pretty normal looking GB and no evidence externally of anything in his liver. He did have some momentum stuck down to the pre-pyloric region of his stomach suggesting a possible recent perforated ulcer, and I think that might be the reason for his pain. We will treat him for that and hope or the best. We made afternoon rounds, and we were particularly happy to see Victor smiling again now that his Foley and NG tube came out. He showed us some of his drawings, and he is quite an artist. We went to Taaj for dinner with 3 of the HEARTT people. One of the things that Santiago and I talked about was the joy of developing a patient base here. In thinking about the advantages of returning to the same place each time, I had never thought about that aspect, but it really is quite an experience to have patients know that we will be back in 6 months, and they seek us out. We has also decided that seeing former patients, like Harriet and Victor, is important and gratifying and fun, and we will definitely being making a point of doing it on future visits. One of the other wonderful pieces of news today was that Mr Hne, the chief anesthetist who is retiring, told me that he would be happy to come back to work when we visit ! That would be wonderful !

Tuesday March 12

An interesting day today, from many perspectives. On each trip I seem to have a day when my frustrations reach their peak; today was it for this trip. We made our usual rounds, and found that all of our patients were doing well, but the rounds were somewhat hectic and disorganized. We then went to the OR to discover that Presillar didn't know we had planned to do any cases today, because neither she nor Anthony had received a list. We gave them the list, and then it turned out that the Chinese ophthalmologist needed to use our room for general anesthesia for a child. We convinced them to let us start in the Ortho room, so Nathan and I did a cholecystectomy in there. Of interest, that was the first cholecystectomy I have done in Liberia. It was frustrating was that we didnt start till 10:30 or 11:00, and nothing moved easily throughout the day. Next case was a splenectomy for me and John, and a colostomy decommissioning for Santiago and Nathan. The spleen was HUGE, weighing 4.2 kg, ans extending from LUQ to pelvis and across the midline. It was really quite fun to do, mixed with the normal level of anxiety about bleeding, and boosted by John's quite understandable enthusiasm ! The frustration was that circulating nurse was out of the room more than in it, and that created numerous delays. For reasons that were unclear, we then had to wait about 2 hours to do the final case, which was another colostomy decommissioning in a young boy. Santiago and John did that fairly quickly, and then we all went to Sajj for dinner and to watch a football match on the TV there. Interspersed with cases during the day were several patients brought to the OR area from the OPD Clinic by the intern for me to evaluate, such as a woman with a large fungating skin cancer on her left flank, and another woman with a large breast cancer which is potentially treatable. They clearly both need surgery, but I have no idea how we will fit them in as we move into our final days. I spoke to Mary, our angel who somehow manages to solve all of our problems, and I know she will take care of things. I find it frustrating that there are so many in need of services, and yet sometimes it is so difficult to arrange to provide those services. That frustrates me, and then the delays in the OR, the lack of efficiency, and a host of other factors push me above my tolerance. As I mentioned, this happens just about every trip, and by tomorrow I will have settled into the final stage of the process, which is accepting that we can't change everything, and we can only do what we can do.

Monday March 11

The beginning of our second and last week on this trip. On rounds it was nice to see that the man who wouldn't wake up on Saturday night Is doing well.we sent several patients home, and then went to Grand Rounds where the Internal Medicine team presented statistics for the past year. One of the interesting ones was that sepsis has the highest case fatality rate of all; not surprising in view of the late stage at which many patients come to the hospital, and the rather modest resources available to treat them. Then to the OR where Santiago and I did surgery on Victor, a 12 year old boy who presented in early January with an acute abdomen. At surgery he was found to have perforations of his ileum and descending colon; the colon was repaired and the ileum brought out as a loop ileostomy. He got better, and in February had his ileostomy decommissioned by a visiting American surgeon. He went home, and came back a few days later with peritonitis. On March 1 Moses did another laparotomy, washed him out, found the ideal anastomosis had broken down, and gave him another ileostomy. We saw him first a few days ago when the intern showed us his wound was breaking down, and stool was coming out a small hole near the ostomy. We really didn't want to reoperate on him, but felt we had no choice. Today we found an abscess, with obstruction, and a fistula. We took it all apart, and resected the distal several feet of ileum and cecum. Knock on wood it went well ! Santiago and I like to do one case together each trip, because it reminds us of the old days when he was a resident, and it also reminds us of why we enjoy doing this work together. The next case was a thyroidectomy for goiter with John. I thought maybe we could get away with just taking out the huge left lobe and isthmus, but the right lobe was nodule and I knew the right thing to do was to take it as a subtotal. Then we were going to do a cholecystectomy, but we were told about a 9 year old boy named Alvin admitted today with abdominal pain and dissension, and positive for typhoid. He was looking quite sick, so Santiago and Nathan brought him to the OR for a laparotomy; they found a lot of fluid in his abdomen, and 2 distinct perforations. They were working away when he became unstable, and eventually coded. We tried to resuscitate him for about 45 minutes to no avail. It seems like we experience the death of a child on every trip, but it doesn't get any easier. I know it is part and parcel of the work we do, and that we have a lot more successes than failures, but it still hurts.