Friday, July 31, 2009

It is hard to believe but we leave for home today. This has been a great experience. The people have been wonderful and eager to work long hours to help as many as possible. Yesterday was our last operating day. We did 5 cases, including removal of the large tumor from the back of the young woman's leg. Removing it left a large defect down to the muscle, but thanks to the dermatone donated by Laughlin Hospital we were able to do a skin graft. They have not had that capability in years.

Today is cloudy and about 75F. We are scheduled to take off at 6pm (2pm eastern) for a 9 hour trip to Brussels then on to Newark and Knoxville, arriving at 6 pm on Saturday. We want to thank everyone for their prayers, this trip was a great blessing.

Mark and Mary

Sunday, July 26, 2009

Mary with hysterectomy patient. She had a huge ovarian tumor.


Deaf ministry.

Large thyroid Goiter.

Today is Independence Day in Liberia, so today and tomorrow will be slow at the hospital. I have a full house in the surgical ward, with 9 patients. Six of them are post op prostate cases, and all are doing reasonably well. I have been a little stressed the last couple of days. Unfortunately, after a long and difficult operation to repair a large arteriovenous fistula and 20 cm pseudoaneurism, Mark William died about 4 hours post op. I could go into the many reasons this happened, but the bottom line is the case was too complex and long for the very limited resources that this small hospital or, for that matter, this country has available. Thanks for all the prayers; his family and I are grateful.

There are more challenging patients yet to come. The first is a young man I wrote about previously. He was born with a urinary bladder exstrophy (open to the skin). He has had a constant urine leak since his birth. I was able to consult with Dr. Bob Strimer and he contacted a pediatric urologist at Vanderbilt who recommended implanting the ureters into the sigmoid colon. Ideally this will keep him dry and continent. I am going to do this on Tuesday. The second it the 7 month old with the huge meningiocele arising from the back of the head at the base of the scull. To remove it, the baby will need general anesthesia and to be placed face down. The cyst will need to be removed and the dura (watertight covering for the nervous system) closed with meticulous sterile technique. If the baby gets an infection it will be difficult to survive.

Sterility, as in the lack of bacteria, is almost laughable if it were not so serious a problem here. Today, for instance, there was no sterile gauze in the hospital for dressing changes, a common problem. The techs in surgery have to cut and fold from rolls of gauze, package and then sterilize them in an autoclave that must be supervised and nursed along. They have had a new autoclave for 2 – 3 years, but it needs a triple phase circuit to power it and no one has wired it.

Mary scrubbing in...

The third patient is the lady with the large sarcoma on the back of her leg, who will also need general anesthesia, a wide excision and a skin graft. I am supposed to do this on Thursday and of course we are leaving on Friday. The fourth patient concern is a 37 year old I saw today, complaining of passing blood with her stool. On exam she has a large rectal cancer. In the states, she would receive chemo and radiation prior to surgery. It does not exist here. Surgically she would need removal of her anus and rectum, with placement of a permanent colostomy. I don’t think that is an option, even if I could pull it off surgically, which is possible, there are no colostomy devices (bags and such) available. I need to discuss this case with the local MDs to see what options there are at the two other hospitals. The larger one is JFK Hospital in Monrovia; it was built with funding from the US during Kennedy’s administration. The other is a small but better equipped hospital at the Firestone Rubber plant – the largest employer in Liberia, other than the UN. Both hospitals suffer from similar lack of supplies, personnel and equipment.

On a lighter note, we were able to borrow a car yesterday and had dinner at a local restaurant called Sajj. We had Hummus and fresh hot pita bread which was excellent, followed by a veggie pizza. Driving the streets of Monrovia is a challenge, there are no working traffic signals and the streets are crowded with people and vehicles. The drivers are really very courteous when you learn the local etiquette. When you need to enter traffic, just nose out and someone will stop for you. You should watch out for and stop for the pedestrians. We have found Liberia to be relatively safe and secure as long as you use common sense and don’t put yourself in areas known to have problems.

The sun was out for several hours today which is unusual and nice during rainy season. We went to Dan and Cheryl’s house for a wonderful lunch. They are here with Samaritan’s purse and plan to be here for 5 years. They have 4 young children. He is a helicopter pilot, flying the SP copter all over the country taking teams and supplies to remote areas. He also has to sling load supplies in and out (that’s when the load is carried under the aircraft in a net or basket). There are several other committed missionaries here, several we met work with the African Bible College and others with SIM based in Charlotte, North Carolina. Samaritan’s Purse has a large presence in Liberia; it is the second largest active project country. There is a wonderful staff here, led by Kendell and Bev Kauffeldt. Please check the Samaritan’s Purse website for info, it is impressive.

Keep up the prayers. We will be leaving Friday for home.
Mark and Mary

Weds. July 22

Ups and downs today. Last night we were able to get a vial of heparin in Monrovia. There was only one place that had it and it was 25 dollars US. Unfortunatly, we showed up to do the big aneurism case this morning and the anesthetist told me he was low on oxygen and would not be able to get any until tomorrow, so we postponed. We were able to remove a very large ovarian tumor today. I'll try to post pics tomorrow. We also did a huge thyroid goiter.

I may have mentioned there are only 4 residency trained surgeons and one urologist in the country, so things have started showing up at the clinic. I see prostate after prostate, but also unusual cases, like a large recurrent sarcoma on the back of a young woman's leg. This will require skin grafting. I also saw a 7 month old with a meningeocele coming off the back of his head, this is as big as his head.

Overall, more challenges than I can meet, but we are really enjoying it.

Mark and Mary

This is a sarcoma we removed from a young man the first week.

Tuesday July 21, 2009
The last couple of days have been busy during the day but quiet after 5. We have done more hysterectomies and 3 more prostatectomies. Every one seems to be doing well. Alvin the 14 yo with the large ulcers from TB is a real problem. Ultimately I decided that I didn’t want to do a radical operation on him, one he probably would not recover from. I let him go home today with his family. This photo is of Alvin and his mother Alice while in the TB hospital, I think in the only private room they had.

I continue to see new things. Yesterday a 32 yo man came to the clinic with a bladder exstrophy, that is a bladder that did not close during development and is open to the skin at the pubic bone. As you can imagine, this is a terrible problem that would be fixed in the US when a baby. He has lived with this his whole life, constantly spilling urine. I may tackle this. I talked to Dr. Strimer about it today and he is going to make some calls, but I have an idea how I might close it. Today I admitted a 38 yo named Mark William. Mark has a 12 cm pseudoaneurism of the left iliac artery with an arteriovenous fistula. This has caused him to develop heart failure and ascities. We are going to attempt a repair tomorrow, please pray for this surgery.
It just started raining. We have had some good weather during the days and the weather is cool by African standards (about 75-85).
Only 6 more operating days left, next Monday is independence day and is a holiday (so maybe a trauma case). More soon. Mark and Mary

Mary with childern at a local orphanage.

Sunday, July 19, 2009
Today began again with hospital rounds. I have 11 patients currently admitted. 1. Cabi is a 14 yo with hepatitis B; I removed her gall bladder on the 15th. She was discharged today. 2. Aletha is a 45 yo post cholecystectomy done on the 17th. 3. Naomi is a 47 yo post hysterectomy and removal of a giant ovarian cystadenoma done on the 17th. 4. Mary is a post hysterectomy done on the 17th. She doesn’t know her age but prob about 40. 5. Gbasen is a 38 yo with profound ascities and a prolapsed uterus. This is likely due to cirrhosis from hepatitis. I have removed 10 liters so far and placed her on diuretics, but I can’t tell much difference yet. 6. Jacob is a 52 yo post left thumb amputation which caused gangrene; he was 3 weeks from injury when he presented and the smell was impressive. Surgery was the 18th and dressing change today, so far so good. 7. Ben is a 23 yo post abscess drainage from tooth infection done on the 16th. 8. Alvin is a 14 yo with unbelievable pressure sores developed after becoming paraplegic from TB. He is here for wound management and nutrition. 9. Benjamin is a 78 yo with urinary obstruction due to enlarged prostate, surgery tomorrow. 10. J.W. is a 76 yo post prostatectomy done on the 16th. And 11. Blessing is a 5 day old with bilateral cleft lip/palate. We are working with her mother on feeding and care, as we believe she will be discarded by the family and village unless a strong bond develops. There is an opportunity for repair in a few months if she survives.
Today we went to church with the chief of Samaritan’s Purse compound; his wife is an interpreter for the deaf in her church and has developed an integrated school for them all the way through high school. The service was interesting, we arrived at 10:15, they had adult Sunday school until 11 in the main Sanctuary. Worship service started immediately after with 30 min of singing and clapping. Afterwards, Mary and I were introduced, and not hard to find as the only white faces in the crowd of about 400. The service was good and biblical, and David will like to know –it went to 2 pm. We went to lunch with our new friends and had a very good grilled fish. Fish is a major part of the diet at least in Monrovia and along the coast.
Not much else for today. Miss everyone. Mark and Mary

Saturday July 18, 2009
OK so I haven’t been faithful in keeping up this blog. Those who know me will not be surprised. It is a challenge to get home late, write, and then go to one of the missionary houses to get on a very slow internet service, so please excuse my delays.
Our first weekend was pretty quiet; we had a church service/devotional/prayer time at Keith Coleman’s house. Keith is a dentist in his 30’s that practiced for about 5 years in the Nashville area. Since that time, he and his family have served aboard the Mercy Ship, a mobile hospital which travels worldwide providing healthcare to desperate countries. The ship was here for about 3 years and Keith decided he would join with SIM and ELWA hospital and stay. Liberia only has a very few dentists and he is providing excellent care to the people of this area. Wednesday I helped him drain a large abscess from a young man’s face. Sunday afternoon we went to the TB hospital with an independent missionary Patricia Anglin from Mason Wisconsin. She runs an orphanage and does much for the children here. Her passion is for the special needs children. We went to the TB hospital to see a young man, 14 years old, who had developed Potts Disease (TB of the spine) and became paraplegic. Since that time he has developed huge bed sores. I have never seen any like it, with one hip completely exposed the thigh bone out of the socket. This desperate boy is ready to die; he is so tired of the struggle. Patty is looking for any possible help, so I agreed to evaluate him. In the states, he would need comprehensive care, best from a spinal cord rehab center. He needs orthopedic and plastic surgery. Here, I can offer an amputation of the worse leg, use the skin to try grafting the other ulcers and push nutritional improvement. Keep this situation in your prayers, I have moved him to ELWA, and am working with wound care and nutrition now. Patty’s web site is http://www.acresofhope.org/.

During this past week Mary and I have been able to help care for many different problems. Some have been inguinal hernias, pretty much like we deal with at home. More complex cases have included a 20+cm abdominal mass arising from an ovary on a 19 yo girl. This was a locally aggressive tumor which had involved both ovaries, the uterus, the bladder and was stuck to the colon. We were able to remove it but unfortunately required a hysterectomy. This will be devastating to her and her family, as her worth is in having children. We have done several other hysterectomies for huge uterine fibroids (benign tumors of the uterus which cause heavy bleeding and pain), two cholecystectomies (gall bladder removal), prostatectomy for obstruction (more scheduled), thyroidectomy for a large goiter (more scheduled), appendectomy for what appears to be typhoid, lymph node biopsy for probable TB and today we amputated the left thumb for gangrene for a 3 week old human bite. Surgery is just like at home except for – bad light, worse instruments, hodge podge of suture, and drapes with holes in them. The cautery machine works but we reuse the grounding pad and the wire has to be taped up to the top of the machine to keep it from faulting (shorting out).but the staff want to do right and the care is compassionate. The patients are tough and their immune systems must be superhuman. Pain medicine is minimal, the only by mouth pain medicine is extra strength Tylenol. Overall the patients do well and go home quickly. An average surgery costs the patient about $100 USD, a lot when you consider the average income is +/- 100 per month.

I do have the privilege to work with a Liberian physician who has self specialized in surgery. Dr. Queye like most of the 40 other physicians in Liberia (pop. 3.5 million), did an internship after medical school, and then went into practice. He works for ELWA and does most of the day to day surgery, and also has a clinic of his own. He is actually very good and sure with his hands. The Liberian medical school is getting back into full swing. This year they graduated a class of 4, but admitted 50 to start, so they should start getting to the population in about 5 years.

Today Dr. Sacra is going to give us a tour of Monrovia, tomorrow we are going to church with Monjue, the wife of the Samaritan’s Purse security chief. She works with the deaf and is developing a deaf ministry. Her church has about 40 deaf. It is a big problem here due to Malaria and the high fevers that are associated with the disease.
That’s all for now. Take care. Mark and Mary

Well we did actually make it to Liberia. I’m sorry we haven’t been able to get any info out before now but we don’t have internet or email connections at the guest house we are staying in. First I will give you a brief rundown on getting here and our first few days.

We left Knoxville on Tuesday on what should have been a 1:40 Cont. flight to Newark. Unfortunatly the flight would be delayed at least 2 hours due to storms in Houston (where the flight was coming from). This would cause a missed connection to Brussels, so our flight was changed to Delta to Atlanta to Brussels, making our arrival in plenty of time to connect to Monrovia. This worked out despite the 90 min wait in the plane in Knoxville due to storms in Atlanta. So all went well and our luggage made it with us to Liberia, including the anesthetic drugs. Customs was not a problem, in fact when we told them we were going to ELWA hospital, we bypassed the lines and went right out to the car and met our driver Samuel, a native Liberian working for Samaritans Purse. Samaritan’s Purse, World Medical Missions, is the organization that arranged the trip for us.
We arrived after dark, about 10:15, in the pouring rain. It was a 35 min drive to the ELWA compound were the hospital and our housing is located. Compound is really not the right word, it is a collection of buildings and houses covering about 100 acres along the beach outside of Monrovia’s suburbs. There are no active gates or walls. There is local hired security of sorts which patrol. ELWA stands for Eternal Love Wins Africa. They are staffed by missionaries from SIM (Serving In Missions). The house is run by another organization called the African Bible College or ABC for short. The African Bible College was destroyed during the war and has just recently reopened. Samaritans Purse has essentially funded its rebuilding and is supporting its efforts to become a leading college in Liberia. The ABC guesthouse is very comfortable. We have a bedroom with windows facing the beach, and have our own bathroom. Unfortunatly, no hot water. Im sure in the dry season that is no problem, as it is hot, but the rainy season is cool and the morning shower sure wakes us up.

Our first full day was orientation to both the Samaritans Purse projects and to the hospital. SP has a large presence here and is working with building projects, literacy, agriculture, nutrition and others. There is a group of girls here from South Carolina for the summer, going to several villages “in the bush” doing VBS for a week at a time. They are staying in the villages in tents, doing projects with the children. These girls are tough on the outside, with tender hearts. It is very humbling to be around all these people. At the ELWA hospital, we met Dr. Rick Sacra, a family practitioner, from Mass., that trained at the ETSU program in Bristol from 89 – 92. He has been in Liberia from 94 until now with only minimal breaks. He is one of two full time physicians, the other is Dr. Quayee a Liberian practitioner who does the majority of the surgery currently performed here. They limit most cases to below the waist, so spinal anesthesia can be used.

The hospital at first glance is a mess, it has been in disrepair and needs some basic maintainance, but as you begin to get to know the people working there, you become impressed with what they are doing with so little. It is a 50 bed hospital with small wards of male, female, pediatric, and OB/post partum patients. Since my arrival they have turned their conference room into a surgical ward with six beds. The patients I am seeing are prescreened and referred for evaluation. As I understand it , the path a patient takes is to first go to the nurse/PA clinic where most common things are taken care of, if there is increased complexity or if the patient desires they can then go to the doctors office (D.O.) for evaluation. Dr. Sacra deals with a multitude of medical problems including diabetes, hypertension, any manifestation of TB that you can think of, typhoid, etc, etc. He does this with minimal lab, a fair ultrasound machine, occasional plain x-ray, and a limited pharmacy. The patients must pay for their services, so it is important to keep costs down by carefully choosing what is done and considering what the patient will continue to do after the visit. We have already used and given one of the blood glucose kits that were donated by Allen Britton. We had a 36 yo patient with extreme weight loss over 4 months time that came to the clinic with a blood sugar over 400. He underwent teaching, was started on insulin and given the monitoring device. He will have close follow up, but the kit will keep him from having to make daily visits to the hospital, as his sugar is brought under control.

My second day will mirror most of the remaining time I think. Devotions are at 7:30 at the hospital chapel, followed by patient rounds or surgery. Rounds and clinic evaluations will be done between cases and in the afternoon if cases are completed. I already have several cases scheduled, including prostatectomies (which are going to be my most common case I think), hernia repairs, neck mass biopsy, removal of a baseball sized tumor in the groin area (sarcoma maybe?), and a pelvic mass (cystadenoma I hope). The first 3 cases I saw in clinic were 1. Large unilateral lymphadenopathy (TB?Lymphoma?), 2. Mylomenengiocele on 4 week old girl with spastic paraplegia, 3. Recurrent tumor L groin, baseball sized. This is going to be an interesting 3 weeks.

Prep Day

Well its the fifth and time is getting short. I am just figuring out this blog stuff and it takes me a lot of time just to follow the links to get in. Next, I will try photo importing.

Laughlin Hospital has very generously donated needed anesthesia drugs and some other supplies. Pray that they make it into country without problems.

My main communication will be by this blog and email, so keep in touch.

Mark and Mary

First Entre: Prep for Liberia

Mary and I have received info from World Medical Missions (WMM) and are getting documents together. As of now, we will leave from Knoxville on July 7 and return on Aug 1. I need to get busy and get everything turned in. More soon. Mark