Wednesday March 15 and Thursday March 14

 This has been an interesting trip for me in a number of ways. Because Santiago couldn’t make it this time,  there are just the 2 residents and myself; as a result, they have done many cases as a pair, and many with Dr Mabanza. In turn, I have done several solo, snd I have had the opportunity to work with Liberian residents. I’m searching for the next Dr. Gbozee with a mind like a sponge, technically adept, and eager to learn. I’m not naming any names at this point, but I think have identified someone who has that potential.

On Wednesday Adamah arrived with his friend Dr. John McGill who is a urologist in Georgia at the same hospital as Adamah. He came with Adamah for a week to check it out; he was astonished by the urology equipment being used (old) and was pleasantly surprised when he met Dr. Ayun Cassell, the main urologist at JFK. I have known Ayun for several years as he went thru the general surgery training program at JFK and then after he came back from urology fellowship training in Senegal. Not too many years ago, it was difficult if not impossible for graduates of the University of Liberia medical school to obtain specialty surgical training outside of Liberia. A few years ago, while still a surgical resident, Ayun decided to go to the West African College of Surgeons meeting where he presented 3 papers on original research he had done at JFK. The incoming President of the College, a urologist in Dakar Senegal, was so impressed that he offered him a training position in Dakar on the spot!

Thursday was our final day of operating on this trip. We did more hernias of various types, a mastectomy, an an incisional biopsy of a neck mass among others. They all did well.

Last night we had our farewell dinner on the rooftop terrace of the Murex. It was great fun, tho a bit embarrassing for me when Masmina asked each person at the table(there were 15) to say something nice about me. You might have thought it was my wake ! In any case the coomentsxwere kind and most appreciated.

Monday and Tuesday

Yes, My apologies to readers: we are having internet problems and as a result my Monday-Tuesday post has been lost into space or someplace. I will try to recreate it.

Monday was a busy day: we arrived at the hospital at 8:45sm and returned to the hotel at 9pm. We did a variety of cases including hernias and thyroids and lumps of various types, but I want to tell you about one patient in particular. She is a 39 yo woman with a large but operable breast cancer. Ominously she had several large palpable axillary lymph nodes. Several aspects of her treatment were and will be dictated by what is available here. There is no radiation facility in Liberia; patients who need it must go to Ghana or India, and that obviously involves significant expense. Because of her circumstances she chose to have a mastectomy instead, and perhaps avoid the need for radiation. She would have probably benefited from a course of neo-adjuvant chemotherapy given before surgery, but without the ability to assess her for metastatic disease, it would be hard to advocate for that. Furthermore, an essential element in decisions about breast cancer treatment is the presence or absence of tumor hormone receptors; the pathology department here often lacks the solutions necessary to do those tests. So she was scheduled for a modified radical mastectomy(removal and f the breast and the axillary contents), and Dr. Mabanza asked me to take Dr. Kempe,one of the senior registrars, thru the procedure. Gaspar and Dr. Kempe did the first part of the procedure by removing the breast, and then I helped show them how to do an axillary dissection. As a side note, axillary dissection is disappearing from the common surgical procedure list due to improvements in technology, understanding of cancer behavior, and improved chemotherapy. I expect that in the next decade any surgery for breast cancer will become rare in well-resourced countries 

Tuesday we did more hernias: Gaspar and Paul did several inguinal hernias, and I did a large incisional hernia with Gaspar and Kempe. There are an increasing number of Liberian residents who are eager to scrub with us, and that is very gratifying. I’m 

Sunday March 12

 Waking up to go down and sit on the dock drinking coffee and looking out at serene Lake Piso was idyllic! It is a most beautiful setting, and helped recharge the batteries for Week 2. Breakfast included the usual yellow pineapple as well as white pineapple. The white variety has a different taste: more subtle, and with a hint of mango in it I think. Habib says it grows as an oblong fruit without the spines of yellow pineapple. Seeing one before it is cut is now my quest ! After breakfast we went for a boat ride out to the entrance to Lake Piso at the ocean. As I mentioned before, Lake Piso is a tidal lagoon with open access to the ocean at Robertsport. We passed the fishing fleet docked in Lake Piso; from there they go out into the ocean to cast their nets. Robertsport has nice beaches, and surf; it is the surfing hotspot for West Africa, and attracts an international crowd who come to ride the waves. Around noon Gaspar, Paul, and Mark went to the beach at Robertsport to swim and enjoy the sun. Dr Joshi and I chose to remain well shaded at the lake. Gaspar, who was born in Cubs and thought he was resistant to the burning effects of the sun, got significantly burned after maybe 2 hours. I was glad that I stayed in the shade!

For the drive back, I rode shotgun in the lead car, and I think that qualified as an adventure sport experience ! No harm occurred to person or vehicle, but there were several close calls! We arrived back at the hotel around 5pm. It was a great weekend, and we are very grateful to our friends at the Murex Hotel for making it happen. 

Saturday March 11

Today we planned to do 3 cases in the morning, and finish by noon so we could drive to a lake house near Robertsport which is owned by the family who owns the Murex Hotel, our home in Monrovia. The 3 cases were an anal fistulotomy, and abdominal wall mass, and a huge lipoma of the upper arm. We arrived at JFK at 9am, and by 11:30 we had done only the 15 minute fistulotomy. Yes i was quite frustrated, but there are some things that we just have to accept. The abdominal wall lipoma was quick; the arm lipoma was intramuscular, but came out more easily than I expected. We then went back to the hotel and we’re ready to leave by 3:30. We had the same EPS drivers who brought us from the airport, and was again a high speed siren enhanced jaw clenching 50 mile drive with about a third on dirt road, and the paved portion is rutted and potholed. I was riding shotgun in the 2nd car (of 2) when we passed thru some small community at high speed. A motorcyclist pulled over when he heard the siren of the first car, but apparently didn’t know we were coming as he turned into the middle of the road striking our front tire on my side. He wasn’t hurt and got right up, but he destroyed the tire. We had to stop to chsnge the tire, and soon a crowd gathered with a lot of yelling going on. They called the police; one came and after some time an agreement was reached in which we paid $40 to the motorcyclist for damage incurred, and $10 to the cop for his service. While the negotiations were going on, we were chatting pleasantly with a number of the young men who had gathered. There was never any threat of violence; it was just a lot of yelling, and another interesting experience in Liberia!

Thursday March 9 and Friday March 10

 Thursday was a limited day in that we had 5 patients scheduled but only 2 of them were admitted the previous day. No one seemed to know why they weren’t admitted; the likely reason was financial. JFK has once again announced that surgery while we are here will be at minimal cost, and that is a big attractant. The two cases we did were a thyroidectomy for goiter done by Dr Mabanza and Gaspar and one of the Liberian residents, and a colostomy decommissioning done by Paul and myself. The thyroid presented itself as something of a watershed moment for me. The thyroid is very vascular, and requires meticulous dissection and lighting a lot of small blood vessels. It also requires careful dissection of the recurrent laryngeal nerve which inner area the vocal cords; injury to this nerve can cause voice changes or worse. I decided that changes in my vision due to glaucoma in my left eye create more risk to the patient than I am willing to take, and therefore I won’t be doing any more thyroid surgery. Dr Mabanza was very understanding and did the case successfully with Gaspar. It pained me to accept this diminution in my skills, and made me feel older, but I know it was the right thing to do. Paul and I did the colostomy decommissioning with no trouble.

Friday was a busier day. Dr Mabanza and Paul did another thyroid while Gaspar and I removed a giant juvenile fibroadenoma from the breast of a 19 year old girl. Gaspar and I then replied a hernia in a 15 year old boy. After that Paul and I repaired a large incisional hernia in a large woman which was quite a struggle but in the end we were successful. Dr Joshi did a TAPP block on her do she woke up with no pain, which was awesome! While we were doing that, a 30 year old male was brought up from the floor for an exploratory laparotomy. He had been in a high speed car crash the day before, and had developed an acute abdomen. Gaspar joined to Liberian team in surgery, and they found that he had almost completely transected an area of small bowel. He also had a non-expanding retroperitoneal hematoma. They repaired his small bowel and had finished closing his abdomen when he became unstable and then precipitously crashed and coded. Resuscitation efforts failed and he was pronounced dead. It takes a lot of force to transect small bowel, and it was likely that the small bowel was crushed by the bottom of the steering wheel crushing bowel against the spinal column. That type of deceleration injury often causes injury to the thoracic aorta, and my best guess is that was the cause of his demise. We will never know since his parents took the body for immediate burial, which is a common practice here. Everyone involved was quite distraught as expected.

Tuesday March 7 and Wednesday March 8

       After a good night’s rest, we all felt recovered from the sad experience of yesterday, and we were ready to take on the new day. When we arrived at JFK it seemed like it was going to be a slow day, but as so often happens, it filled up quickly. Paul did a VP shunt with Dr. Doe on a child with severe hydrocephalus. Gaspar went to the Outpatient clinic and found a lot of patients who need surgery. I had to rein him in a bit by explaining that there was no way we are going to do 4 thyroids in a day!I think it was a valuable experience for him to see the variety of patients who show up to the surgical outpatient clinic. It ended being a busy day with more hernias. The hospital has announced that the usual charges for surgery are waived during our visit except for the cost of drugs; we are already seeing an influx of patients as a result.

    Wednesday is Decoration Day, a national holiday in which people remember their relatives who have passed by cleaning up and decorating their graves. We had a busy day working starting with a young woman in her 20s who had presumed appendicitis which ruptured about 3 weeks ago. I’m not sure why she stayed home, but she was brought in yesterday and we operated on her today. There was a lot of pus, and very difficult adhesions. In the course of dissecting an area of small intestine perforates so we had to repair that. The area of the appendix was encased in scar tissue; we eventually decided that further attempts to get to her appendix would likely cause more harm than good, so we put in drains and finished. It’s difficult to predict how she will do; time will tell. After that Gaspar did 2 appendectomies with Dr Mabanza and Dr Charles while Paul and I did a man with recurrent bilateral hernias. Repairing recurrent hernias is always a challenge because the tissue planes have often been ob.iterated by the previous surgery; additionally, we often don’t know what type of repair was made. This patient told us the his repairs were done years ago in Nimba County.and done at different times by different surgeons. The left side was large, and it was a difficult repair but we got it done. The other side was smaller and easier.

Tomorrow will be another busy day I suspect.

March 6 2023

     This is the first blog posting for the March 2023 trip. The team includes Dr Gaspar Barreto-Montero, a senior surgical resident at Waterbury Hospital, Dr Paul Fata, a junior resident, Dr Chandra Joshi, an anesthesiologist at the Lahey Hospital in MA who has come with us many times, and Dr Mark Germani a senior anesthesia resident at the Lahey. Dr Santiago Arrufat and Samantha Schoultz APRN who usually come on our March trips, we’re not able to join us this time much to my regret and theirs. Gaspar, Paul, and I left from JFK Airport on Saturday evening and met up with Chandra and Joshi in Brussels; from there we continued on the Monrovia, arriving at 8:30pm on Sunday night. Our ride into Monrovia was the first surprise of this trip: I expected that we would be net by Dixon and his bus, but instead we were directed to 2 SUVs whose drivers said that they would be taking us. We then had a high-speed, siren enhanced, get out of the road cuz we are coming thru ride to the Murex Hotel ! Our friends had pizza waiting for us, and we we quickly off to bed.

Monday morning we arrived at JFK with our 10 duffel bags of supplies to find that the elevators were once again out of service; fortunately there were several strong men pressed into service to bring them to the 4th floor Operating Suite. After Grand Rounds and greeting many friends, out operating day began with Gaspar fixing a hernia with one nod he Liberian trainees while Paul and I repaired bilateral hernias in a 20 year old male. Later on Gaspar and I removed a giant juvenile fibroadenoma from the breast of a 13 year old girl. The final case was a young boy who developed an esophageal structure after drinking lye. He was quite ill, and had been in the ICU. Dr Mabanza tried but after repeated looks and poking, he determined that the esophageal inlet was fused and there was no opening. The child developed difficulty breathing on emerging from anesthesia and then had a cardiac arrest. We attempted to resuscitate him but we were not successful. It was not a good end to our first day.