Sunday March 10

We all slept late this morning... Well, to 8:30 or so ! We had another nice breakfast, but then learned that the water pump which gets water from the well across the street to the cistern on the roof is broken, so there is no water for bathing or flushing toilets or doing dishes. They have put a big tub if water near our bedrooms, and from that we transfer water into smaller tubs to bring into the shower. It's not great, but it works, and hopefully tomorrow the pump will be fixed. John and Nathan joined us around 11, and reported that everyone was doing well including the nightmare sigmoid volvulus from yesterday. Dimple was very pleased to hear that ! Readers with a weak stomach may want to skip to the next paragraph! I forgot to mention that in our late night dinner conversation last evening, we had come up with a new descriptive, based on our experience with abscesses here, and particularly the one Santiago operated on who is known to us as the Fountain of Youth. The term we coined is a "Vesuvial abscess"; in order to be called that, it has to meet the Knight criteria of spurting at least 6 cm in the air for at least 6 seconds and it must contain not less than 600 cc. Around 1pm Moses picked us up to take us to Kendeja, the RLJ resort on the beach. We had a lovely, relaxed afternoon which was well-deserved if I do say so myself. Tomorrow begins another week, which will be shortened by the fact that there are 2 holidays: Wednesday is Decoration Day, where families go out to decorate the graves of family members who have passed, and Friday celebrates the birthday of the first President of Liberia. We will work on Wednesday, but not on Friday as the President has invited us for brunch at 11am.

Saturday March 9

It's hard to believe that we are halfway through this trip. I think we have done well so far, and that we are making progress in terms of organization and planning. It isn't perfect by any means, but each time it seems better than the last, and I think that is the definition of progress. Santiago, John, and I are particularly excited today because we are planning to see Harriett, the 4 year old whom we operated on last March and removed the 9 lb. duplication cyst. As it turns out, one of the HEARTT pediatricians, Camille, has been in contact with Harriet's father (who wanted photos of what we removed) so we had a phone number. Wilfred called them the other day to say that we would like to see her perhaps on Saturday, and apparently they didn't understand because they showed up here at JFK the next day. The address we had for her was about 30 min away, but it turns out she has moved with her mother much further away, like a days drive. But they said they would stay in Monrovia until Saturday night or Sunday morning so they could see us, and hopefully that will be what happens. Santiago and John did an advancement flap on a lady with anal stenosis this morning. She had presented last year with rectal cancer, and Santiago did a local excision. Apparently she received some form of chemotherapy in the past year, and he was very excited to see her in the clinic last week since none of us expected she would still be alive. The stenosis appeared to be benign scarring rather than recurrent cancer, and here's hoping she will see us next year , After a quick lunch we got in the van with Wilfred and Camille, and went to see Harriet ! She is living with her grandmother quite close to the Executive Mansion, and we had no trouble finding the house. It was quite a celebration when we got out of the van, and Harriet looks beautiful ! I admit that I needed to pull up her shirt and look at the scar to be sure it was the same child, and it was! We attracted a gaggle of kids and others, and it really was fun and satisfying. As we headed back to the hospital, Santiago and discussed how we want to make a point of seeing patients from previous trips, because it is really a wonderful feeling to see that we have made a difference. We then came back to the hospital to operate on a 50 year old man with an acute abdomen who came to the hospital this morning. John and Nathan and I opened him to find the biggest sigmoid volvulus I have ever seen; I'm pleased to note that a sigmoid volvulus was out pre-op diagnosis also ! We resected his sigmoid, and tried to do a primary anastomosis, but it became clear that wasn't going to work so we did a Hartmann's. He is very slow waking up...we think in large part because of hypothermia...so I was able to get the Gaymar warming blanket working and we are warming him up. Because there is no ventilator available at JFK, we are staying him with him until he is awake enough to go back to the floor. Unfortunately it is Saturday night and we had plans for dinner at the Mamba Point Hotel followed by an expedition to Groovie's and possibly Deja Vu, but as I write it is 8:30pm and we are still here. We will do something tonight, but I'm not sure what ! As it turned out, our patient finally woke up enough to be transferred downstairs, and we went back to the bungalow around 11. In the meantime, John and Nathan went to Sajj with Moses the hospital driver to pick up some pizzas and other food; they arrived back shortly after we arrived, and we all had an excellent meal. After that no one was interested in going out, so we all went to bed.

Friday March 8

Today was another busy day. John and I did a 2 year old with a right inguinal hernia, followed by a friend of Barbu's with an umbilical hernia which we are hoping will be a One Day Surgery. Then we did almost bizarre case of a 40 year old man with a mass in his thigh for a year. He denied any pain, antecedent trauma, or systemic symptoms. An ultrasound showed a 20 cm mass which was mixed cystic and solid, and the radiologist suggested that it might be an abscess. That seemed unlikely to me since it wasn't particularly painful, it had been present for a year, and he had no fever or systemic symptoms. So we explored to find out what it was, and indeed it was an abscess...extending from halfway down his thigh to way up in his retroperitoneum. There were chunks of debris, leading. Us to think we were doing a pancreatic necrosectomy. We ended up putting 2 chest tubes in as drains. It was so much fun to see John so excited by the weirdness of the case !! We met up with Robert from the Eye Clinic and gave him the glasses and glucose test strips from Karen. It was very good to see him again, and we will try to have dinner next week. While we were doing all that, Santiago and Nathan did skin grafts on a little boy with thigh burns, and then a thyroidectomy. When they finished that, we went downstairs to check on our patients and then came home to change. We went back to the hospital to attend a long service and retirement ceremony for employees of JFK. Mr. Hne, the anesthetist, was being honored for 31 years of service, and sadly he will be retiring soon. It's amazing to think that he and many of the other honorees stayed around throughout the civil war years; it's hard to imagine what life was like in those times. He invited us to attend a couple of days ago, and it was easy to see that he was thrilled we were there. After that we came back here for dinner. We were thinking about going out with Wilfred to Sajj for karaoke or something, but I am dead tired. This morning I was a bit under the weather with a GI disturbance as well as aches and maybe a fever; I feel much better tonight, but I think I won't push things too far. We have one case scheduled for tomorrow morning, and then in the afternoon we are going to see Harriett !!

Thursday

It rained incredibly hard last night; the sound of it on the metal roof woke me, and confused me initially, but then I remembered the cause of the sound. John and Nathan came over to join us for breakfast; as usual they had already been to the hospital and reported that our patients were doing well. They also said that we would have 5 cases today as planned, because the parents of the 2 children on our schedule had come in last night and signed the consents. It is an interesting aspect of life here that nurses always get the consent rather than the surgeon; I will take a look tomorrow, but my guess is that the "consent" they sign is for an operation without particular consideration of the risks, benefits, or alternatives. Our first case was a 5 year old boy burned by hot water a few months ago, primarily on his left side. He developed severe scar contractures of his left shoulder, left elbow, left hip, and left knee. The hip had been released previously; today we released his shoulder and elbow, both of which had major webs. It took quite a while with Santiago, Nathan, and I trying to figure out how to use Z-pasties and the like to release the scars and allow return of normal movement. We were quite happy with the result when we were done; we plan to bring him back next week to do some skin grafting on his hip and thigh, and to release a contracture of his lower leg. While we were doing that, John assisted Dr Muvu with an above-knee amputation. Then John and I excised a breast mass and repaired an inguinal hernia while Santiago and Nathan took down and closed a colostomy. Just before we did the hernia Dr McDonald called to ask us to see a young man in the ED, and to talk about Rita. We went to the ED and saw the patient; he needed emergency surgery for strangulating bowel, so we got that process started through Mary. I went to see Dr McDonald in her office, and told her that I didn't think we could offer Rita anything; Rita is a young woman in her 20s who had a criminal abortion, and then seems to have developed a septic arthritis of her left hip complicated by a pathological fracture of the femoral neck. She was operated on twice by Dr Muvu, but now she needs more expert help than we can offer. While disappointed that we could not help, especially since Rita's father is a politician, I think Dr McDonald understood the rationale for us declining to operate. We then talked a little about the planned development of JFK, and that the re-establishment of JFK as a medical resource and academic center for Liberia was one of the lasting legacies that President Sirleaf would like to leave. Finally she expressed her sincere gratitude to us and all of our donors for the amazing amount of supplies we brought. Our last case was the hernia from the ED which John and I did; he had a loop of ileum stuck in the hernia which remained purple and flaccid after release, so we elected to resect it. It went well, and we finally finished around 7. After a stop at the dorm for our Internet fix, we came back o the bungalow for a great dinner of barracuda, couscous, and fresh salad. We had a wonderful discussion covering everything from JFK to pitstaches ( you really don't want to know about this concept dreamed up by Kenna!), and then off to an early bed after a long day.

Wednesday March 6

Today we had a big breakfast brought by Mrs Peabody, the head of dietary at JFK; I guess she is arranging for our meals, and she is doing a wonderful job ! After breakfast we went to the second floor ward to find our patients doing well, and then headed up to the OR. John and I did the first case which was an African hernia in Mr.Hne's uncle. It was huge, but reducible and we did a standard Bassini repair. He did well post-op, due I think in large part to the Marcaine which Dimple brought and which I injected. The next case was a 21 year old woman who had a huge cauliflower like mass on her left thigh. It was large enough that she was wrapping a kerchief around it ! None of us have any idea what it is, so a sample will go back for pathology. Santiago and Nathan and the intern whose name I cannot remember did that one. The last case was a skin graft on a 44 year old man man with a melanoma on his mid foot which had been excised a month ago. It was granulating well, but Dr. Kiiza was convinced that a skin graft was needed, so we did it. As we were leaving, we stopped by the 2nd floor to check on patients for the OR tomorrow. We found a couple and talked about them, and then out of the blue one of the nurses asked John about a young lady with a breast mass. It turned out that I saw her yesterday in clinic, but there is no way for me to know that she had been admitted other than to wander the floors and hope someone say something . That's part of the system problem here. For dinner we went to the Royal, which is all renovated. Very nice ! We are very busy on this trip, which is one reason that my postings are short. Perhaps things will settle down and I will write more later.

Tuesday March 5

There was some confusion this morning about what cases we were going to do, but it settled out when we learned that the woman with the cauliflower growth on her leg didn't get a bed apparently, so she won't be done today. Nathan and I did an orchidopexy on Jonathan which went well, and then we went down to the outpatient clinic. The. clinic is an amazing experience, in large part because it is ever clear why many of the patients have been referred to Surgery, if in fact they have. Many of them appear because they have aches and pains which they relate to a trauma; our standard for them is an X-ray and pain relief. This year Santiago brought a plastic bag filled with samples of Tylenol which he was giving out by the fistful ! He went up to do an EUA on a 10 year old boy with rectal trauma who had a diverting colostomy and now has a fistula. He might be ready for a decommissioning next week. When Santiago left, I took his place in the clinic and saw all sorts of interesting pathology including a woman with a spleen down to her pelvis; hopefully we will get her in soon for surgery. I also saw an older woman with chronic cholecystitis, which was interesting because I have never seen gallbladder disease here before, and today there were 2 in clinic. And I saw a 32 year old woman with several liver masses by ultrasound; I talked to Konneh and we sent her to the Chinese hospital for a CT scan. The problem is the the new Chinese hospital is about an 8 hour drive from here; they have spanking new facilities, including a CT scanner, but they have no specialist medical staff as of yet. After clinic and lunch, we came back to the OR for an emergency laparotomy on a 20 year old man. It seems he had been sick at home for 2 or 3 weeks; he saw an herbalist,to no avail. Apparently some of his friends told him he was being poisoned; they had no idea how right they were ! Santiago, John, and Nathan o Erased on him, and found a HUGE abscess, the contents of which virtually shot in the air when they got into it. They spent several hours peeling bowel apart, and eventually found the perforation, which they brought out as an ostomy. We have our fingers crossed. It really is astonishing that he could stay home for 2 weeks, unable to eat, virtually unable to move because of pain, before finally deciding to seek medical help. Raising awareness and expectations for the public is yet another hurdle in rebuilding the Liberian healthcare system. We came bak to the bungalow, showered, and then went to Sajj for a pleasant dinner. I never was able to connect to the Internet, so I will post this and yesterday tomorrow.

Monday march 4

Our first day of work on this trip, and it was a good one !! We went to the 2nd floor surgical ward at 8:30, and were introduced to a man with an acute abdomen who was looking very poor; my initial thought was that he had acutely ischemic or dead bowel. Dr Kiiza and Dr Konneh arrived soon after, and we all soon agreed that he needed an urgent laparotomy. We got that in the works, and then saw a few more patients before heading off to Grand Rounds....only to discover they were not on for today. But when we were there we met Dr. Bobo, one of the senior internists, who told me that he had heard from Adamah last week about the possible endoscopy unit, and he was extremely excited !! So Santiago and I went to the 3rd floor to meet with Dr. Bobo and Dr. Brisbane to discuss this possibility. Dr Brisbane is probably the most senior internist at JFK, and he is a remarkable man; he stayed at JFK during the civil war to keep it running as best he could, and he is a hero in the eyes of many. Interestingly, and perhaps not surprisingly, he is quite reluctant to talk about the war years, and takes little credit for the amazing work he did. In any case, the endoscopy deal is that a GI group in Evansville decided to upgrade their scopes, and so they have about 9 colonoscopes and 4 upper scopes which they would like to donate to JFK. In addition, one of the manufacturers has offered to donate a tower, which contains the video screen, the light source, and all of the electronics for endoscopy. Santiago and I had discussed earlier how we would need a physician champion to get this up and running, and we were extremely excited to have identified them this early in our visit. We will have more meetings about this project during this visit, and hopefully we can get it up and running in 6-9 months. Having it would definitely enhance the desired role of JFK as a referral center. After that we reclaimed Dimple's 3 bags of anesthesia supplies and went off to the OR. To say the reception that we received was joyous would be an understatement !! It was a wonderful,exciting moment that I will never forget ! Santiago and Nathan did a Hartmann's decommissioning as the first case. John and I were going to do the acute abdomen as the second case, but he coded and could not be resuscitated in the preop area; In a way I was glad we didn't subject him to an operation he was unlikely to survive. Then I went to the Admin building to get more of our supplies and met Dr McDonald just outside the ED; she asked me to come with her to see a VIP who had just arrived. He had been to JFK twice in the past week with the same complaint. It sounded to me and others that a leaking cerebral aneurysm was a definite possibility, so they got a UN helicopter to fly him to Ghana. Dewalt went to the airport and was able to get the bag we forgot, and that was another good addition to the day. Dimple went right to work with the anesthetists, and I could see that they were thrilled to have an anesthesiologist with them. She was impressed with what they could do with limited resources, and they were pleased with all the supplies she brought. Mr. Hne was also very happy to receive the pulse Oximeters, which will help make surgery safer at JFK; I also gave one to Mr Moore to use when he accompanied the VIP on the flight to Ghana. Kenna also fit in well, and I could see that she will have no problems working with the scrub techs and nurses. It was a great day in the OR, and that sets a wonderful tone for our visit .