Home Fulfilled

I think this may be my first morning entry.  Not that it has any significance-I just was having technical issues with my electronics due to an electrical surge!  Nonetheless I'm back online now in preparation for my final day here.

What a machete can do to an arm..

Yesterday was a good one.  I had an 18yo kid who was a 'rogue' (aka thief in Liberia) who made a very poor decision in trying to rob someone's home.  They attacked him with a machete cutting his wrist very badly and tearing his tendons.  He somehow escaped and made it to the hospital-better than the alternative.  Generally speaking if a rogue is caught he/she can be killed on the spot by the people, so I guess having your arm almost chopped off and making it out alive is not too bad.  I spent the morning putting him back together.  When I got to the OR we were almost ready to start on time, but now it was the pharmacist who was late and delayed us!  No need to get into too much detail with this one-I've reiterated this concept previously...

Spent the morning reconstructing his wrist.

I was however pleased to see that when I arrived, my man Babu had returned to spend some more time with me!  He scrubbed with me during the case and was very helpful.  After we finished up he even came with me to the ER to see some consults.  It was pretty ironic when I think about it; the last time I was here I had a similar case of an older woman who had been attacked with a machete by a rogue who was robbing her home and I had to fix her wrist.  Now this rogue met his match and someone fought back at him with a machete!  The Universe's karma I guess.  After the case and seeing some patients, Babu and I went to have lunch.  He said he'll come in to help me should I have anymore cases on my last day.

National Police ready to go!

During the afternoon/evening I met up with Lydia who is the Minister for Gender, Children & Social Justice and toured her office.  Her driver picked me up and took me through downtown which was my first time going since I've been here.  I remembered everything just like it was the last time I was here; many of the places still looked exactly the same.  Afterwards we made our way back to her home, but got stuck in lots of traffic as we approached the NEC (National Elections Commission) Building.  National Guards were detouring traffic such that no one could pass directly in front of the building.  Everyone was anxiously awaiting the announcement of the preliminary results scheduled at 5pm.  We were stuck in gridlock traffic around 4:40pm and people were walking amongst the cars anxiously waiting, pacing through the streets.  As we approached the detour point by the NEC, you could see the police in riot gear ready for anything-it was a pretty intense sight.  Lydia was in the back seat telling the driver to hurry up and get past the traffic-that was actually pretty funny.

The announcement over the radio came just before 6pm.

Happy kid at the Transit House!

We finally made it to Lydia's where we were taking in all the preliminary info and having my favorite Liberian dish finally-cassava leaf & soup!  That was the one dish that I was really looking forward to having before  leaving.  After we winded down at the house we went over to the Marpu Transit House that Lydia runs.  It houses kids who were given up by their parents or are rape victims or come from various malignant social circumstances.  Some of them have physical or mental disabilities as well.  She was sharing many of the success stories with me of adoption for some of the kids or how they've grown up and productively assimilated into society.  It's really great work that she's doing here and she is to be commended.  Imagine what the destitute looks like in a country that's the 4th poorest in the world-that's who she works with most of the time and she's turned people's lives around!

Casava Leaf!

I felt fulfilled by the time I got home. Ready for my last day...

Cancelled Cases

Armed guards were all over-couldn't get too close.

The week is flying by already and it seems that things are starting to wind down.  Today was relatively light around the town following the election.  The ballots are being brought to the National Elections Center which is right across the street from me and there are so many armed military guards right outside.  I wanted to go around and take pictures, but I didn't want any drama so I mostly stared around.  Sounds like there weren't too many issues at the polls and things moved along relatively well.  Some of the people were telling me that some polls closed even with people still in line who didn't get to cast their vote which caused some commotion.  Overall though it seemed uneventful.

Today at the hospital everyone is doing well on rounds.  Many of the patients are still in the hospital and usually will stay there a couple of weeks until their incisions are all healed because the risk of infection when they leave is pretty high.  It's interesting here that most patients aren't eager to get out of the hospital because many of them have better food and a place to sleep more so than they do at home.  I can only imagine how that would go over back in the States!

Overall it was another frustrating day in the OR.  The first patient was up and ready to go before 8am and I was a hopeful that we could start actually on time today, but then reality hit again-the staff came in late and it wasn't until after 9am that the patient was in the room.  It wasn't until the patient was on the table that the anesthesiologist asks the patient the last time that he had eaten...the patient had a bowl of soup this morning!  Case cancelled....
The frustrations, albeit expected, are beginning to mount and I'm making note of everything so I know what to address at the end of the week during my debriefing with the HEARTT team.  The second case had been canceled a few times and was next up, but we had to wait until General Surgery finished 2 of their cases before we could proceed with mine.  They can only do one case at a time under general anesthesia so its another source for delay with only one anesthesia machine working.  I had the driver take me back to the hotel where I did some work on the computer.  When they called me back saying that they were ready for my next case I went back to hospital to find that our patient had been canceled!  The anesthesiologist cancelled the case once the patient was on the table and his blood pressure had become erratic.  2 cases cancelled today on the table.

I went back to the hotel for the second time a bit disgruntled at another frustrating day.  I spent the rest of the day working on a presentation that I'm planning to give to the team I'm recruiting already for the next trip.  It's a bit unpredictable how efficient I can be working alone especially when relying on so many other folks of varying work ethic.  I'm planning to bring my own team next time and have the more chronic complex cases set up for me when we return.  We'll be able to do the acute emergent cases more efficiently as well.

Looking forward to the next couple of days as I'm sure there's still good work and planning to be done.  Not going to let the frustrations hamstring the primary focus. 

Election Day!!

All the campaigning and rallying has come to an end as of midnight on Sunday. There was much activity all over with the streets teeming of voters in support of their party.  So many people are looking forward to change and continued progress of this country-the 4th poorest in the world.  Liberia has been still recovering in almost every aspect of its existence after being fraught with civil war during the last 2 decades of the 20th century.  Under the past 12 years of leadership by the current President there has been so much growth and change for the better-Liberians are extremely passionate about continuing that trajectory.  Yesterday you could feel the quiet excitement everywhere-all the signs and campaign posters/billboards had been taken down at midnight Sunday.  To an outsider unaware you'd think it was just a routine quiet Sunday even though it was a regular working day.  And now today-election day!  It's a holiday and no one is working.  Again its very quiet around as people make their way to the respective polls to cast their vote.  Results should be announced within 2 weeks-hopefully the peace and serenity is maintained as the people come to know the outcomes and the candidates that will most likely enter the runoff (which is pretty much guaranteed).  I can't say I've ever been in another country during the time of their elections, but it's quite remarkable to see the fervor and pride the people here have in their democratic process! Everyone I've met or seen is deeply vested and understands that their vote really does count.  I can't say I've experienced the same back in the states. 

Yesterday at work was ok.  I attended morning rounds with the General Surgery Department to review all the patients that had been admitted over the weekend.  I observed as the residents presented to the attendings and were pimped for information during their presentations.  I was chuckling in my head the whole time.  Not at the residents, some of which seemed quite erudite, but the attendings who appeared to be doing much more pimping than normal in the face of their visiting guest...nonetheless it was a good didactic session for everyone.  Quite Socratic indeed!  Over the weekend there were some accidents with all of the campaigning, but unfortunately there wasn't anything for me to do as they all were bad traffic accidents with no survivors.

After I took in rounds it was time to head up to the OR to find that we were delayed.  Not because of nursing or lack of instrumentation and proper equipment.  We had no anesthesiologist.  All the surgeons were sitting around while they were complaining that this was the routine.  They were saying that now I've been here a week and things are starting to return to the modus operandi...
The anesthesiologist arrived and we were able to get moving.  During one of the cases I found myself in a bit of a precarious position as I didn't agree with the management of a patient that my colleague was working on.  As I mentioned earlier, I have to keep focused on the small victories and teaching as much as I can so that we all can learn together and do the best by the patient.  I think I was able to do that this time, but man was it hard!!!  Despite the tardy start, we were able to move pretty swiftly through cases until the elevator  that brings patients to the OR broke!!  Was a bit of a bummer because I was hoping to keep up the momentum and finish up the pending work.  This week is going to fly by-and I lose an operative day today with the holiday.  Hoping that the elevator is fixed by week's end.

I had a date tonite with Amie for dinner!  She was really excited to go to her favorite spot and was dressed beautifully!  We were able to catch up even more than before and she was showing me all the pictures of her family-man that girl loves selfies!!  She has 6 other siblings with 7 nieces and nephews.  It's great to see how they all are so supportive of her.  She was telling me how hard it is sometimes to stay happy and optimistic, but with her family and friends' support it sustains her.  She's grown into a remarkable young lady- I'm proud of her.                 

Today I plan to stay low key as the elections are going on.  Sounds like it's going to be a tight race.  May God bless Liberia on this day!!

Rest...

First week back has been great.  While being here certainly can be just as, if not more, taxing and draining than back in the states, there is a degree of serenity for me as I move into the weekend.  Friday was rather light and I only did 2 procedures-both below knee amputations, one being a revision.  Dr. Muvu scrubbed in with me for the first time this week and it was good being back in the OR with him.  We work well together and are both open to learn from each other in our own ways.  I had my laptop with me and I was able to show him some of the complex cases from New York that he was interested in and we discussed patients together.  He expressed interest in visiting to which I extended an open invitation.  We chatted about a lot of things including how things were around here during the Ebola outbreak a couple of years ago.  He told me that the entire hospital shut down for approximately 2-3 months during that time and thousands of people died who didn't even have the virus.  Many died of other causes (heart attacks, trauma, cholera, or other ailments) simply because they couldn't get any treatment secondary to the hospital closure-sounds like it was a chaotic time.  The overall death toll reported he said was not all secondary to ebola, but inclusive of all etiologies.  Pretty interesting fact.

Almost every car & truck was packed like this.

Barracuda is actually a tasty fish!

I was done by early afternoon and got back to hotel with the plan to ensconce myself in my room over the course of the coming weekend-at least Friday and Saturday-with the incumbent election processions.  Tuesday is election day and all of the candidates for President (over 20!) will be rallying in the streets.  I was advised to lay low and avoid going out into the streets which I had no problem with-I was able rest Friday and today.  As I sat in the cafe looking out of the window across the street there were so many people up and down the streets-cars and trucks teeming with supporters of the different parties.  I haven't received any calls about any major traumas so it appears that things have remained relatively civil.  Will see what the ER looks like on Monday, but I'm hopeful it stays that way.

I spent most of the day resting and talking with the hotel owner who seems to be a very nice Lebanese gentleman who's been in Liberia for 36 years.  It's pretty cool to hear him speaking Liberian English to the workers here!  He offered me barracuda for dinner which was amazing.  Sunday I have plans to attend church with Lydia and a luncheon with her brother and friends-looking forward to having some good Liberian soul food!  Glad to have some down time and recharge for next week...

"Send For The Next Patient!!!"

I don't even know where to start with my blog entry this evening.  What a day, what a day!!  Much much more eventful and productive.  I didn't get too much rest last night-I woke up even more focused and determined to make up for yesterday.  I arrived to the hospital and first made sure that everyone on the service was doing ok and there were no overnight issues.  When I got up to the OR today everyone had a bit more pep in their step and seemed a bit more focused than yesterday which I certainly was pleased about.  I think some of the conversations I had yesterday reverberated back to the right ears...

First case of the day.

By 8:30am we had the first patient on the table and by 9am I was prepped and asking for the scalpel-one small win!  It was the kid from yesterday that we had to cancel-he was nervous as would be expected, this being his second time in the operating room.  I can only imagine the feeling he must have looking up and having a foreign doctor trying to comfort him through a time like this-let alone operating on him.  He was a tough little kid I could tell.  I had my hand on his shoulder while he was trying to hold back tears as the anesthesiologist was placing the spinal anesthetic, shivering on the table.  Once we were underway with surgery everything went very well and we were finished in about an hour to everyone's astonishment.  They were actually taking pictures of the surgical incision after I had finished because they were impressed with the meticulous closure!  While it's rather mundane and routine for me, it was a big deal to them so I took the time to show them how and why it's important.  That was one of my goals for the day-try to teach and engage in a way that continued to spark their curiosity and enthusiasm so that they would want to see even more and hence be more productive!!!  AND IT WORKED!!! Another small victory! "Send for the next patient!!"

The waterhose is badly 'kinked!'

The next patient came in early this morning after being struck by a car and had dislocated his knee.  He had a gross deformity and minimal pulses in his foot and needed to come up to the OR to reduce his knee back into alignment-a closed reduction.  When I told the staff that this case in particular needed to come up now and bump the others, no one seemed to understand why.  I pulled up his xray and reviewed it with them explaining how the artery behind his knee was kinked like a water hose, preventing blood flow to his leg and how popping his knee back into position would "unkink" the water hose and allow his blood to flow.  Understood!  Once the patient got to the operating room I let them feel the normal bounding pulse in his normal leg and then the significantly diminished 'kinked' pulses in the dislocated extremity.  Once we sedated and relaxed him, I showed the scrub tech how to hold and pull the leg while I guided him and let him feel the knee pop back into position which was audible for everyone to actually hear!  Then once we stabilized him in a cast I let them feel the foot so they could feel the water flow again!! 

Another small victory!  "Send for the next patient!!"

Babu came to see me on his vacation!!!

Between the next case I got another surprise.  Babu stopped by during his vacation time off!!  He was one of my favorite scrub techs who taught me so much about Liberian culture-words, food, even dance moves!  He was the one that actually gave me the name 'Balah' which was one of the first things he said to me when he saw me.  He heard that I had been asking about him since my arrival, but everyone said that he would be on vacation for one month, but was still in Monrovia.  Once he heard that I was in the country he came up to the hospital.  And get this....he wanted to scrub into the next case with me!!  I was so glad that he was there too because the next case was 2-in-1.  The 15yo kid who had both a fractured femur and tibia.  This case also went very smoothly as Babu and I worked just as well together as I remembered while we listened to my old Liberian music mix in the background that they had made for me during my last visit!  I'm looking forward to learning some of the newer dance moves before I leave!

The day moved extremely efficient and everyone was involved and learning and having fun, and most importantly doing a good service for our patients.  I ended up ordering pizza for everyone which they THOROUGHLY enjoyed.  I'm hoping that we can keep up the good work in the remaining days.

The way to a tech's heart: teach them and give them pizza!!!

I had to move the remaining cases to tomorrow's schedule because I had to run to the Liberian Medical & Dental Council for a board interview to obtain my official Liberian medical license-exciting.  Things went well during the credentialing interview and I was able to get approved which means I'll be back for sure!!

My evening ended pretty interestingly.  I got called into the ER to see a sweet young girl who had an unfortunate accident injuring her femur.  Initially she was seen by the 'country doctor' who had placed some dirt on her leg as a treatment with a wrap.  After xrays revealed a fracture that would certainly require surgery, she elected to return to the bush doctor for treatment even following a long discussion of risks and alternatives.  I'm hoping that she finds the care that's best for her.  I mentioned before some of the frustration that comes with situations like this.  I just try and do the best that I can for patients and educate them appropriately so that they can make the most informed decision they can.  You can't help everyone which sometimes is a source of consternation for me when you're so passionate about trying to do so...

As I was walking out of the ER there was a crowd gathered around a car that was carrying a man in the trunk that had just been struck by a car and was DOA.  As I walked amidst the crowd and up to trunk to see if there was anything I could do, there were silent stares and sobs as I simply genuflected and nodded my condolences-there was nothing I could do.  They took man away in the car to their family.  The hospital driver and I were driving home shortly after when we came across another unanticipated finding-a school bus rammed into the middle of a compound's concrete wall!  We stopped to check out the scene which had recently been cleared out from what bystanders were saying.  I'm sure we may have passed some people on their way to the hospital or I may hear about some new patients/injuries in the morning.  You can't make this stuff up-just as soon as you think a great day's work is done and you're riding high, the next wave of chaos is right behind it.

Hoping no one was hurt.  I may hear about this in the morning...

Despite the unexpected ending to an otherwise very efficient and productive day, my spirits remain high and invigorated because we helped some good patients and people learned new things that they were excited about.  It's great reminder that I'm not only here to help people by doing surgeries.  I can be just as, if not more effective as a teacher and inspirer...Another small victory..."Send for the next patient!!"

Slow Day-Great Night!

Today was rather frustrating.  I arrived early to the OR for an 8am start.  Then 8:30 rolled around.  Then 9am came and went.  The patient finally gets to the operating theatre and then the staff notifies me that they can't find the equipment I need to do the surgery!  Needless to say we had to cancel the case...

Pretty light morning in the OR

The second patient was not stable for surgery.

And that was my morning.

I used the rest of the day to meet with the CMO of the hospital and chat about a few things.  I also was able to speak with the head nurse in the OR to make sure that we are as efficient as possible moving forward so as to optimize the time we have to work together.  I had to pick out my instrumentation specifically down to the screws that I'm going to use so that they can have it ready for tomorrow's cases.  Hoping that tomorrow is a better day for surgery.  I also met with one of the general surgeons Dr. Atem about what role I could play in the didactics of their surgical training and am scheduled to give some orthopaedic lectures during my time here.

The highlight of my day was dinner with old and new friends!  Masmina took me to this new place where we surprised my old friend Lydia who used to be a HEARRT coordinator.  She was so surprised and it was great to see her after all this time-she looks just the same as I remember!  We all sat and were chatting it up about life and having a great time.  Then Masmina's mom and her friend joined us along with the HEEART head coordinator Theresa.  It ended up being a great time with great friends and great laughs!! 

My old buddy Lydia looking great!!

Short entry today-going to try and get some rest for tomorrow and pray for a more productive and orderly day.

Why I'm Here...

With my circadian rhythm still off balance, I found myself wide awake just lying in bed at 430am staring at the ceiling.  I knew I wouldn't be able to fall back asleep so I used the opportunity to meditate and get my mind prepared for the day.  After my morning exercise in the room I made my way down to the hotel restaurant to grab breakfast-omelet, yogurt and fruit.  It seems there aren't many people here at the hotel presently as I have yet to see any folks floating around other than the workers. By now word has spread about my visit and everyone has been extremely friendly and cordial.

The hospital driver picked me up and we were on our way.  So much to see in the short 7 minute drive-people setting up their goods for daily sale, the workers hailing taxis using the silent hand gestures for which neighborhood they were headed to, some kids headed to school-a bustling morning.  As we make our way past several motorbikes carrying more than their recommended alottment of passengers, I see the back gate to the hospital.  Passing through the campus there were so many people waiting outside at the patient registration post for the clinic.  Several of them were looking into the truck as we drove past, smiling and nodding their head-a proverbial "welcome back."

I went into the hospital which is currently getting a much needed exterior facelift with renovations and passed through what was the old ER entrance.  I could remember all the times that I made my way through that corridor passing by so many injured patients who were waiting to be seen.  Some waiting for their families to bring money so that they could be registered to be seen. Some waiting for money to be treated after they'd used much of their money just to be registered. Some that never made it at all.  Walking onto the ward the first time I had the recollection of so many memories from each room.  I could remember each patient that I treated and the bed that they were in-so many rooms, but one in particular that stood out... 
Towards the end of the hallway in the day room the nurses and staff were doing their interdisciplinary rounds and from around the corner the first person I see-Dr. Muvu!!!  My old partner!  Was so good to see him-especially so unexpected like that.  Generally a very quiet and reticent man, in that moment he opened up and let out a loud boast and greeting as we embraced each other.  I think even the nurses and everyone who saw us were a bit surprised at the seemingly adolescent jovial banter we shared!  He looks exactly the same as I remember-I think the brother has found the African fountain of youth!  It may be in Rwanda!  We immediately went to make rounds on the patients that he wanted to me see: a 35yo man who had been in a bad motorbike accident almost 4 months ago with complete gangrene of his leg in need of an amputation. A 27yo man who also was involved in an RTA (acronym from the first blog) and had multiple fracture-dislocations of his foot which had undergone surgery and pins that needed to be removed. A 9yo child who had been struck by a car one week ago and has a bad fracture of his distal femur involving the growth plate.  A 15yo kid who came in last night after being hit by a car with fractures of both his femur and tibia shafts.  The list can go on and on.  Certainly not much has changed regarding the volume and types of injuries that are seen here.

Reunited with the 'Church'

Muvu proceeded to give me the tour and re-orientation of the wards as we made our way up and down the stairwell to each floor.  Lots of faces that I hadn't seen before and some familiar ones-I didn't quite remember everyone's name, but I knew that I had worked with them before if they ran up to give me a hug!  Down in the OR there were a few familiar faces and some new ones who I had the pleasure of meeting.  I walked around and wanted to see "the Church" and the operating rooms where so much was ingrained in my mental hard drive.  The place was just as austere as I remembered-not much equipment. The old storage room I had organized had nothing in it.  Flies in the OR.  T.I.A....

Very austere recovery room.

I told them which cases I'd like to get done, but we had a bit of a delay when one of the staff members told us that they could not do any surgery today because there was no sterile gauze.  It doesn't take long being here that you realize how blessed we are to live and work in a healthcare system in America that, even with its discrepancies, has resources readily available and abound.  I was almost unable to do surgery because of a lack of gauze!  Fortunately after a short, nice talk with administration, we were able to get the supplies.  While they were preparing for the first case Muvu and I headed down to the orthopedic clinic which was in a different location from where I remember.  We walked through the maternity hospital where many patients were waiting in the dark because of no electricity in the building.  Once we arrived he introduced me to a couple of patients who he wanted me to evaluate.  One was a very nice young gentleman who had been dealing with chronic bilateral hip pain.  His joints were completely obliterated from what looked to be tuberculosis.  He needs both of his hip replaced, but I don't have any equipment for it here and there's no orthopedic surgeon in the country that would otherwise be able to do it.  I took his information and will keep in touch with him and plan to bring equipment hopefully during my next visit.  He was comforted to have met me and at least know that there is a solution to his problem, but I was chagrined to know that my hands were tied and I was unable to help him at the moment.

While we were seeing patients in the dark with little air circulation I asked Muvu if he had any information on the whereabouts or happenings of Amie.  He looked at me and grabbed his phone to make a call.  He handed me the phone and it was her!!!  Turns out that her mom runs a tire shop at a gas station that he frequents so he actually sees her often and had her number-how fortuitous was that!!!  She was sooooo surprised to hear that I was back in Liberia and she couldn't stop rejoicing, as was I.  We made plans to see each other as Muvu stood by smiling.

It was time for the first surgery which was an above knee amputation for the patient with the gangrenous leg.  I felt like it was my first test as everyone was in the room watching me operate.  With no tourniquet available I had to move extremely swiftly and efficiently so as not to lose much blood.  I must admit I've gotten a little spoiled working back home where things like adherence to sterile technique and sharp, up-to-date surgical equipment are part of quotidian life, but you quickly adapt to the environment.  I didn't even have a handle to hold the scalpel blade-I had to use a clamp.  No power saw to cut the bone-only a dull hand saw.  I think I got my workout for the day just trying get through the patient's thick bone and was breaking a sweat!  All the while performing the operation leaning over because the surgical table wouldn't elevate. T.I.A....
By the end of the day I was only able to get through 2 cases.  Things don't run very efficiently, but I'm going to try and do as much as I can to help as many people as possible.  The second case went smoothly other than the electricity and light going out during the procedure so I had to do majority of it under a flashlight from someone's phone.

Why I'm here...

After the first surgery as I sat in the room adjacent to the OR getting my head around what the next couple of weeks is going to look like I hear someone call out my name, "Dr. Forsh!"  IT WAS AMIE!!!!!!!!!!  She had gotten dressed and took a cab straight to the hospital after our phone call and was roaming around the campus trying to find were I was when someone told her I was in the OR.  Right then and there my trip was made!!!  I bolted out of the chair I was sitting in and gave her a hug so big it almost knocked both of us over!  She wouldn't let me go.  It was the best surprise I'd gotten in a very long time!  Everyone had heard about her and a couple of people were actually there when she was in the hospital after her accident.  We sat, laughed and loved as she updated me on her family and life.  She actually works at her mom's tire shop and helps her out as she can with the business.  She unfortunately has been unable to use her prosthetic legs as she's outgrown them and needs some new ones which I'm going to try and help get for her.  Everyone was taking pictures with her like she was a celebrity-even those who didn't really know her!  She was all smiles and jokes.  Times like this and people like her remind me of why I chose this field.  Her determination, joy for life and happiness epitomize so much of what is good in all of us-we just have to choose to tap into and harness it regardless of our circumstances.  This little girl lost both of her legs, but she dances everyday...
So we certainly have a date now-I asked her what her favorite restaurant here is and we're planning to go there this weekend. 

My day was finished and the hospital driver took me back to the hotel.  The crate with all of my instruments and implants had finally arrived from New York.  Now my job will be to see what I have to help fix the other kids I met earlier later in the week...

Day 1-not bad. Not too bad at all.