Exodus, Dirt Peas and Sharing Tears

It's been a while since I last wrote because we've been very busy.  We've moved out of the old Maternity Center and into the renovated hospital (or "Europe" as the patients and staff call it). The move was not a minute too soon.  We've actually been waiting to move since I arrived here a few months ago.  The renovated facility is so much better than what we had.  Patients are no longer housed in wards but in rooms with 4 beds to a room.  At first some of the patients wanted to go back because they were used to being with a lot of other people and enjoyed the company.  They've gotten used to the luxuries of "Europe" now though.  The actual move was a sight to see.  We packed everyone up with their belongings and walked through the hospital compound to the renovated Memorial Center.  It looked like a group of refugees with all their things bundled up and placed on their heads or backs.  It was a bit disorganized and in my efforts to keep the orthopaedic patients organized I began leading the move and instructing the nurses where to put all of the patients (I really felt like Moses for a minute).  In order to get to the surgical ward on the 2nd floor the patients and their families had to take the elevator.  That took a lot of coaxing because none of them had ever been in an elevator before!  Many of them were terrified to go into the little room.  This was exacerbated when one of the 2 elevators got stuck with people in it. Fortunately it was 2 hospital maintenance workers and they remained calm, although the people outside the elevator panicked knowing people were trapped inside.

I've "adopted" a young girl, Yamah, and she has been having a hard time.  She comes from the interior and recently was brought to Monrovia to live with her Auntie and attend school.  Last month her Auntie's brother was killed by armed robbers.  Yamah's auntie left her with a cousin and went to see about her murdered brother.  Yamah was confused and left the house after some time to go find her auntie.  She's not used to all the traffic and was struck by a speeding truck.  She came into the hospital with a severely crushed leg.  I had to amputate it above the knee.  To make things worse she got infected and I've had to take her to the OR everyday to wash out her wound.  We don't have the proper labs or medicines so I've been using what's available but nothing seemed to work.  I decided to use honey and went to the market and found some "country honey."  I've been using that for the last fews days and the infection is resolving.  She has also been getting stronger.  She had a bout with malaria again, to make things worse, but I've treated her for that and she has improved.  She's a very shy 7 year old girl and she's very worried about the loss of her leg.  She speaks Kpele and for a long time none of us knew she could speak English.  We were surprised on day when after surgery she began speaking English under the influence of anesthesia.  She asked me not the put "rags on her foot" (she was asking me not to put the gauze around her stump).   Her family shows up very infrequently and so I've come to care about her a lot.  Some days she feels better than others and she talks more.  She's started moving herself around from her hospital bed to the stretcher or into a chair.  She's a very picky eater and half the time she won't eat the hospital food so I give her "small" money and the nurses go out and buy food that she'll eat.  I've also found protein drinks in the supermarket and I get her to drink one-a-day now.  She's introduced me to some new Liberian foods and she shared "dirt peas" (peanuts) with me the other day. I've started putting her in a wheelchair and taking her outside, which she enjoys.  We sit outside and talk and people come up to us and encourage her.  I was able to take her over to the Rehab Center the other day and introduce her to Josephine, the woman that runs the Rehab Center. They make "false legs" there and I thought it would be good for her to see one since she was constantly asking if she would ever walk again, if I would really make her a new leg, and if she "could wear slipper."  She looked afraid at first when she saw the prosthetic leg but I encouraged her to touch it and Josephine was very good with her. Today, she was mad at me because I traveled over the weekend to one of the counties bordering Guinea and didn't make it back today until late.  I asked one of the other surgeons to do her dressing change and when I arrived the nurses told me she was very upset and wouldn't eat because I hadn't come.   I took her outside and I think she forgave me.  She even asked me to take her back to see the "false legs" so I think she's been thinking about it ever since.  It takes a second to get hurt but years to heal wounds.  She'll heal but it will take time. 

I spent the weekend in Nimba County, one of the larger counties in the country.  The ministry of youth and sport was kicking off the All County Sports Meet to help unify the country through sport.  A football (soccer) match between Nimba and neighboring Grand Gedeh was the highlight.  This was significant because these 2 counties were engaged in war for many recent years.  The game was very exciting and it ended in a tie, which I think may have been a good thing.  People from both sides celebrated together.  I traveled there as part of the medical team from JFK.  I took along with me a physician assistant, Joe, and our driver Alvin.  The trip brought back a lot of memories for them and we talked a lot about the war times and what they had to do to survive.  Alvin told us how he was forced to flee into the interior and live in the bush for a month and a few days.  He told me how little boy soldiers would come up to him and say "big brotha, give me your shoes."  Many time the guns they carried were too heavy for them to really carry correctly but these child soldiers were dangerous and killed many people.  Alvin told us that he survived that ordeal with one slipper and a watch and he has those items packed away to this day as reminders of what he lived through.  I spoke with many other people and heard their stories of survival.  I also saw the consequences of war: devastated villages, impoverish people, and frightened children.  I also saw however, people happy to be at peace and longing for security and stability.  The opportunity for that is exciting and cause for celebration.  On part of the trip I found myself at a rally and cultural dance.  It was a lot of fun, and not just because I got the equivalent of a Liberian lap dance.  Ok an explanation is in order I know - "so what had happened was" one of the women began dancing in front of people, making the crowd laugh and the person she danced in front of share money.  She of course made her way over to me and danced and I shared my money with them and the crowd cheered. Later a frisky "Ole Ma" came over a danced in front of me too.  Her friends were chuckling as she did it and she made me laugh and the crowd laughed and then I dug in my pocket and pulled out money.  Her friends, the ones that had been snickering, led the cheer.  

This, too, is Liberia. 

Liberian Thanksgiving

Today we celebrated Liberian Thanksgiving and I've had a chance to think about all the things I'm thankful for.  I've had an amazing time the last two weeks:  I traveled to Sinoe county for a birthday celebration, rode in a helicopter for the first time, ate dinner at the Chinese Embassy, went to a local soccer game, and made two kids happy with simple coloring books and markers.  

Sinoe county is south of Monrovia and approximately an 8 hour ride over bad dirt roads.  The ride was worth it though because i got to see the country and meet people all along the way as we passed by the villages and made stops here and there.  Most villages are very basic and the houses are made out of clay and tin.  Greenville City is the hub of Sinoe County and is a sleepy little town that was settled by freed American slaves from primarly Mississippi and Alabama.  The architecture is remarkable and the connection between the American south and Sinoe is palpable.  I stayed in Sinoe 3 days and had a wonderful time.  I then got lucky and heard there was a UN helicopter flying back to Monrovia so I jumped on and made the trip back in 1 hour.  The views from the helicopter were amazing - the ocean was off to my left and the interior to my right.  We flew over some very isolated villages and it amazed me how people survive in such remote places.  

Back at the hospital we've almost completed our move to the renovated hospital.  Up until now we've be all working out of the Japanese hospital.  The Japanese hospital was built as a maternity ward and it is very cramped and in poor condition but was the only thing that survived the war.  The majority of the JFK Memorial hospital was looted and abandoned - we are working to restore it and we're making steady progress.  For the last two weeks I've been only performing emergency cases but we've had our fair share.  I've been able to discharge from the hospital over 75% of the patients that were on the wards when i first arrived.  Most of them had been in the hospital for many months because there was no one with the experience to take care of their difficult problems.  Currently we have three kids on the wards and they're very special to me.  Theresa is a young girl that has very bad bone infections that have caused her bones to break.  She's been in the hospital for over three months.  The other day I stopped in late and found her with a small piece of coloring book paper that she had colored in.  She became very excited when I told her she had done such a good job coloring it in and she told me she really liked coloring.  I decided to find a coloring book and markers for her and her roommate Prince.  I gave them the books and markers and wished them Happy Thanksgiving and they were so excited.  Actually Theresa had been crying because she had recently been moved by the nurses and her leg was hurting her.  It was great to see her smile like that when she saw her new book and markers.

Priceless...

A patient told me today that she was happy to see me because I encourage her.  She came in with a severe crush injury to her foot after being hit by a car while she was on the back of a motorbike. She required an amputation and that took a lot of convincing.  She was very scared, mostly because she works in the market and didn't know how she would manage to feed her family with one leg.  I had a meeting with the family and after multiple discussions was able to get everyone on the same page.  She showed me her surgical wound and showed me how well she is doing exercising her leg and she is really making great progress.  I've met with the rehabilitation people and we'll be fitting her with a "false leg (as we call it here)" once her stump heals.  It was nice to hear her tell me I encourage her and in turn she has encouraged me. And I have been reminded how important it is to encourage each other.

So Happy Thanksgiving!  (Liberian Thanksgiving!) 

And remember to encourage someone.  I'm sure you'll be encouraged too.   

Traffic scuffles, "African Man", 6 but 1, vacuum dressings and "private nursing

It's been another 2 weeks filled with life, Liberian life...  I've moved into a nice apartment on the 3rd floor of a building approximately 1 mile or so from the hospital.  It's a bit difficult to find if you don't know the area...you pass S.O.S clinic and a "No Lemon" ?!? sign then there is a dirt road on your left.  It looks like you need a Hummer to make it down the road because it is so uneven, but we make it in just about any type of vehicle regardless, as long as we take it slow.  I was joking with a Liberian friend that you have to pass No Lemon and take your first left, drive past 3 mud lakes (huge puddles), 1 naked baby (passed by him one morning) and a chicken standing in front of 2 shacks on your right.  When you see 5 stray dogs you take another left.  When you reach the next mud lake you'll see a red gate.  That's where I  live.  TGH apartments, Apt 19.  It's a great place...I have a balcony that overlooks the area including out over the ocean.   Every morning I wake up around 6:30 am, look out from my balcony over Liberia and thank God.  I've gotten into my routine - shower, eat some fruit for breakfast and then wait downstairs for my ride.  Alvin, a hospital driver, picks me up at 7:30.  Traffic is crazy by that time and we take Old Road to bypass much of it, but Old Road is no walk in the park, by that time it's filled with people rushing to market or kids going to school.  We stay on the horn so we can pass.  Old Road leads to Tubman Blvd and then we hit the heavy motor vehicle traffic.  At that hour there are some police directing traffic, as there are no stop signs or lights, and the 4 lane highway turns into 3 lanes going downtown and 1 going out.  

The other day, on our way to work we were moving slowly in traffic when a motorcyclist tried to squeeze past and scraped our car.  I was looking out the passenger window when it happened and before I knew what had really happened my driver, Alvin, jumped out yelling.  The motorcyclist sped off and Alvin ran after him.  We were in an area of major traffic and a few police were nearby.  I heard Alvin yell for the police to grab the motorcyclist but they didn't budge.  Alvin kept chase and remarkably caught up with the man as he tried to squeeze through another tighter spot.  Alvin picked up the back of the motorbike so the rear wheel didn't contact the ground and just kept spinning.  The man jumped off the bike and ran but of course Alvin caught him and then the police got involved.  The man was detained until he made arrangements to pay for the damages.  Dr. McDonald, the Hospital Administrator was also in the car and explained it this way, "Alvin's been driving here all throughout the war, so he's been through alot."  When he got in the car and we started back on our way I joked with him that I didn't realize he was that fast and that I didn't jump out because it wasn't my side (unwritten rule).  

Saturday I went into work for a half a day then went to a friend's for lunch.  My friend, Lydia, was cooking traditional Liberian food to celebrate one of her friends' birthday.  It was a small gathering; Ibrahim from UNICEF was celebrating his birthday.  He brought his colleague, a university professor from Sierre Leone.  Another friend, deputy minister of justice also came.  It was great fun.  The food was fantastic and the company interesting.  I listened intently to the discussion of Liberian politics and about the similarities between the culture in Liberia and Sierre Leone.  Throughout the conversation they would joke about the crazy behaviors of people in the region and summed it up by saying, "African Man," then laughing.   I also heard for the 2nd time what fantastic beaches Sierre Leone has and so I plan on taking a weekend trip.  

After dinner I went to hang with the other birthday girl, Camille (Peds resident from CHOP), and friends.  We went to La Noche and had dinner then went to  a nightclub DeJa Vu.  The music was great and I danced for hours (lost about 10 lbs).  

Sunday was tragic.  A man ran his car off the road into a crowd off people. I was called by an ER nurse to come to the hospital quickly.  I arrived and people would lying all over the place in the trauma room.  The ER docs, Emilie and Meera were already there and filled me in quickly.  2 had been brought in D.O.A.  One man was gasping for air, his pupils were blown and he died about a half hour later.  I started seeing patients and a few minutes later, I found Emilie and Meera performing CPR on a little girl.  Sadly, she didn't make it.  One man was complaining of a lot of pain  and was bleeding from his leg.  I threw a suture in his leg and stopped the bleeding.  Otherwise he was breathing heavily and was tachycardic.  He had a deformity of his right wrist and right leg that looked like old injuries but was relatively stable so I moved on to assess the other patients.  About a half hour later a nurse came running to tell me that he was getting agitated.  I went over to him and he was looking worse and sounding confused.  His breathing was more labored so we checked his vitals and he wasn't breathing properly and his O2 saturation was 70's and dropping.  We made a team decision to intubate him, which was an event to say the least, then we were able to hook him up to the only ventilator we have, after it shorted out the first time we plugged it in.  Emilie and Meera set up a drip to try to keep him sedated and we moved onto the other patients.  Just when it began to quiet another women came in unconscious with a severe laceration to her head.  Her pupils were also blown and she wasn't breathing on her own.  We were not able to resuscitate her.  6 people died in all.

The next day I came in and went directly to the trauma room.  I walked to the area where the intubated patient had been left and found that the bed was empty.  Usually that is a very bad sign so I asked a nurse what happened to that young man and she pointed to a man sitting in a makeshift wheelchair!  I couldn't believe it and if it wasn't for the deformities in his right wrist and leg i wouldn't have believed it was him.  I asked him, "What are you doing?!?"  He responded, "It's painin me, doc," pointing to different parts of his body.  He stood up!  I looked him over.  He walked.  The nurse told me that overnight he had woken up and pulled the tube out of his throat.  His vitals stabilized and he continued to improve up until then.  I saw him again about an hour later and his family was there.  I told them that he was a miracle, that he had almost died last night.  They told me that he had survived not only this but he had also survived the "Lutheran Church Massacre" and that is why he had the deformities on his wrist and leg.  I told them that it was clear then, "God wants him to live," and they agreed.  We all laughed and smiled and thanked God for but one miracle.  

6 deaths but 1 miracle.  One miracle is enough to remind me why I'm here.

The rest of the week has been relatively quiet.  I had a minor victory today when I was able to put together the first wound vac dressing on a patient.  Everyone thought I was crazy when I started stuffing sponges into an open infected wound then attached a tube to it and sealed with plastic.  I had to run around town to gather parts so that i could run a small vacuum machine to create the suction.  It then took me an hour to get it set up.  I had 5 young male patients looking over my shoulder and telling me I was doing good for them and that the vacuum was working.  They told me they would keep an eye on it and make sure it kept working properly throughout the night.  That's the Liberian equivalent of a private nurse.

I'll see how things are going tomorrow.  

And life goes on.  As Shannon, an elderly hospital driver, put it to me the other day when commenting on a confused driver puttering around in front of us nearly causing another accident,  "This is no time to be sufferin from indecision."  I like that.  It's a great saying and I've adopted it.  "No time to be sufferin from indecision."  Too much life to live. 

 

14 days

where do I begin...I have been here a total of 14 days and I've settled in, sort of...

My trip began from JFK in NYC.  Terri and I trekked out there with my bags to meet Dr. James Sirleaf and two other HEARTT volunteers, Bryan Mazzucco R.N. and Dr. Garvey, a general surgeon from Connecticut.  I had no problems with my bags and quickly realized after meeting my three travel partners that I was going to have a fun trip.

After saying a bittersweet goodbye to Terri, Bryan and I boarded our flight to Monrovia via Brussels.  Drs Sirleaf and Garvey would meet us on the other side of the Atlantic since they were taking a different flight through Accra, Ghana.  

We had a great flight, I even had the whole middle row to myself to stretch out and sleep (poor man's first class).  The only hiccup occurred when i woke up and looked on the in-flight monitor and noticed we were heading for Abidjan!  What!?!  I didn't know anything about going to Abdijan (Cote d'Ivoire).  Anyway, we quickly realized that we would make a brief stop there to pick up people before finally arriving in Monrovia.

The first think I noticed flying into Monrovia at night was how extremely dark it was.  I have never flown into a place that has such little light.  Electricity is still a commodity here and although I've been told there has been significant improvements, electricity is not ubiquitous and often goes out in many areas.

We landed without a hitch, and then we were met by a couple men that had been sent by Dr Sirleaf to pick us up.  We then met Dr. Garvey again outside of the airport.  We quickly packed up our things and jumped into the truck.  We took off and 2 seconds later we were pulling into a driveway.  We stopped in front of this building and the driver said we should get out.  We got out and I asked where we were and Dr. Garvey said that this was the VIP area and Dr Sirleaf was in there speaking with his mother, President Sirleaf.  We walked inside and were greeted by some important looking people and asked to sit down.  We sat for a while and talked about our flight experiences then Dr. Sirleaf came out.  He told us that the President was about to leave for the US for a meeting with President Obama and other leaders of state.  We could meet her before  she boarded her plane.  I was excited but felt unprepared.  I wasn't dressed appropriately to meet the President but he said it was fine.  Soon the President emerged from her meeting room and we all lined up.  Dr Sirleaf made the introductions and I said something stupid while everyone watched as we shook hands.  The funny thing was, I was going to prepare something in the off chance I would meet the President, I just didn't realize it would be within minutes off landing in Monrovia.  Oh well.

After she left we jumped into the truck and made our way from the airport to town.  The road is well paved but dark.  It took 40 minutes or so to make our way.  We arrived at the President's guest house (yeah) and quickly settled in.  My room had this really nice bed with a comforter designed with the Liberian flag.  

We grabbed something to eat (there are pictures of Madame President accepting an Award from President Bush Jr. in the dining room) and hit the sack.   

The next few days we stayed at the guest house, met Auntie Jennie and some of the other family members and began work at JFK Hospital.  The hospital is the main referral hospital in the country.  Liberia has over 3 million people and 1.2 million living in the city.  I've been told the city was only designed for a few hundred thousand but during the war people fled the interior and head either out of the country into neighboring countries such as Guinea, Cote d'Ivoire or Sierre Leone or to the city.  The influx of people is clearly evident by just looking out of the window of JFK Hospital to an are called, "Behind JFK."  "Behind JFK" is a shanty town set up during the war.  It is right on the beach and I can hear, see and smell it from my current apartment.  

When I left the guest house I moved into the "Chinese apartment."  The Chinese apt. is an apartment building built by the Chinese government for the Chinese health workers that are stationed at JFK.  They are friendly neighbors although none of them speak English and I can't say much more than hello in Chinese.  We smile a lot at each other though.

My apartment is nice but has it oddities...for example, the shower is just stuck on the wall next to the toilet and i have to aim it away from the toilet and stand in the corner literally up against the wall to take a shower.  Also I have an air conditioner, but everything is in chinese so I just keep pressing buttons until it either turns on or off.  And forget about the washer/dryer down the hall.  There are about 20 buttons on each machine, all labeled in Chinese.  Lucky for me, there is a nice woman, Ma Annie, that works at the medical dorm next door and she offered to do my laundry for me.  

The hospital is similar, in a sense, to what I experienced in Malawi.  The patients are housed in wards.  I recently took a census and we have 26 inpatients and about 6 patients in the ER awaiting either a bed for admission or xray.  Our xray machine is broken, so patients have to go to another small local hospital to get there xray.   This means there family has to pick them up and transport them, paying for the xray themselves, then bring them back.  If the family doesn't have the money $10 or so, the patient just lies in bed until they can get the money.  

There is a lot of death.  Resources are limited and patients die everyday due to various causes, acute abdomen, bleeds, unknown causes etc.  The ER is separated into Trauma/Surgery and Medicine.  They are packed and there is generally one physician there ( a HEARTT volunteer, ER resident from the states).  I make rounds in the Trauma ER daily, if not multiple times a day.  If not, many things go unnoticed and people suffer.  I recently stopped in by chance on my way out and found a 19 yr old girl lying in bed complaining of neck pain.  An xray had been taking and was read by the ER officers (sort of like a physician assistant) as negative.  She was given instructions to go home and do physical therapy.  Her mother was about to take her home.  I looked at her xray and quickly noticed she had a displaced fracture of C2.  I placed her into a brace/cast.  She cried when she realized she almost went home and could have easily moved her neck the wrong way and become paralyzed and died.  I wonder how many cases like this i miss in a day.

The first week I did some general surgery cases with Dr Garvey and learned that there is alot of bowel perforations here secondary to typhoid.  Tetanus is also a problem here, as is esophageal strictures in children after they mistakenly drink lye (used for making soap and put into random bottle the children mistake for milk).  The esophageal strictures are terrible because the kids just wast away...there is a child in the ER that has been there for weeks if not months. I saw him eating the other day.  He had 2 plates and a bowel of soup and I thought, man this kid is hungry, and I was initially excited to see him take a bite.  Then he vomited into the bowel and I realized he would chew and swallow and the food would back up in his esophagus until he vomited it up.  The bowel i thought was soup was his vomit basin.  Sites like this are heartbreaking. Difficulty is everywhere and it makes the work hard.  So you have to balance it out with other things.  

I had a great time hanging out with the guys.  We were well taken care of.  A couple of times we ate double meals (first at the guest house then asked over to the President's house where we ate again).  We went out  a number of nights to the local restaurants and lounges.  Most of the business are owned by Lebanese and there are a few really good restaurants with extensive menus.  

Over the first 2 weeks I've met so many people and they've all been given instructions to take care of me and have done so.  It's good to have so many friends here now.  I've met people at the US Embassy, the Chinese Ambassador and I went to church with the President and rode in the motorcade.  The motorcade is exciting and nerve-racking at the same time. There are a lot of men with machine guns and the motorcade drives at high speeds for security reasons.  We stop often though when the President sees people (particularly children along the rode).  It's quite amazing to see people's excitement to see her.  The crowds often sing and dance for her.  Anyway, church was a lot of fun.  The President introduced us and asked us to come up and say a few words!  Talk about being put on the spot.  The best part however, was when this 3 or 4 year old boy directed the choir.  We were able to catch it on video and plan on posting it on Youtube.  I'll let you know when we do.  It is great.  

A few days ago we were interviewed for the local press and an article was written about our work here.  http://www.liberianobserver.com/node/1973  It made the front page!  LOL!  Around the same time I was asked to be Chief of Orthopaedics and rebuild the ortho/trauma program.  Additionally I would be given an appointment to the medical school to help teach.  I am excited to add this to the list of jobs i have here.  I find the medical students bright and eager to learn.  Unfortunately, many of them have been in medical school for many more years than the scheduled program requires.  Due to lack of staff as a result of the war, it is not uncommon for them to have been in school 3-5 years beyond the 5 required years.  There simply is not enough qualified staff.  This was the case for the resident I am training.  Dr. George was in undergraduate for 9 years and medical school for 10 years due to the wars.  He has completed a year of internship and a year of residency and has a specific interest in orthopedics.  

Bryan, Dr Sirleaf and Garvey left a few days ago and it's quieted down socially.  In a short period of time we became good friends and I have a lot of good memories and jokes to tell.

Currently, there are 2 other volunteer physicians, Camille - a Peds resident from CHOP, and Meera - an ER resident from Brown.  There's also Diasmer, a Scott Fellow in administration, and Lisa - a social worker.  They are all very dedicated and inspirational and we do the best we can to support each other when times get tough as they inevitably do.

Well, that's all for now.  My Chinese apartment is calling me (yes, in chinese - don't ask me how i know it's calling me, I just do)