Rounds, malaria and emergency care in Liberia

Its the end of my first week in Liberia and is has been quite a blur. Thanks to my colleague from the University of Chicago, I have been indoctrinated into the local culture at a running pace. I wanted to summarize a few interesting experiences.

One day we went to the pediatric room to followup on a few of our sick patients. I was pleased that we came during rounds. Their resident was teaching the medical students about common pediatric presentations - it could have been on the wards of Stanford. Many of the cases not surprisingly are malaria, or malaria related. Many of the children are more susceptible, and once infected, the weakened condition and anemia often leads to severe infection. I am also seeing cases of Typhoid, measles, and almost every other infection and tropical disease I ever read about in medical school.

Malaria here is diagnosed by blood smear. There are rapid tests available, but there is such a high false negative rate that we don't rely on it. Instead, a drop of blood is placed on a slide and then slid across to thin the layer. This is an actual photograph of one of my patients by placing the camera in the eyepiece of the microscope. The malaria parasites look like blue circles with a pink dot on the side ( like this O. )

This is me looking at malaria blood smears.

One of our projects has been trying to make a trauma room, stocked with supplies donated to HEARTT. We have found that when a sick person comes to the ED, we have to call the RT to get airway equipment (which they hide around the hospital and not in the ER), IV supplies and common code medications. If the patient cannot pay, they won't get hospital medications. Thus we have code medications that we donated so we don't have to wait for the copay before starting CPR. Here is a photo of our new trauma room with Dr. Hansoti and a few of the nurses. We taught the cleaner how to do CPR. (Patient not seen in this photo for privacy).

An ultrasound was donated by one of the HEARTT doctors for use at the hospital. It has been removed from the ER to help generate income for the hospital, and thus is not regularly at available for our use in the ED. If we are lucky, we are able to steal it some afternoons and do our own ultrasound rounds. Otherwise getting an ultrasound can take 2-3 days in the ER. Here Dr. Hansoti is performing a FAST exam on an infant unrestrained in a car accident. We discovered that the baby was bleeding internally (likely liver or spleen) and would require surgery. We were not able to get the ultrasound for 4 hours. We started transfusing blood anyway to help stabilize the child, but unfortunately they did not survive prior to getting surgery. (written permission to use photo from patient's mother on file)

We randomly met a group of medical librarians from U Mass here on a mission to build a medical library for the medical school. They took us out to lunch to discuss their project. Their driver took took us to the medical school and we were given a short tour. It was recently rebuilt by the Italians stands out against the backdrop of Liberia.


The lack of imaging, laboratory and equipment has pushed my clinical diagnosis and inventive skills. Often we treat people based on their risk factors and initial presentation, as well as concern for most lethal possibilities and then treat for all of them. In the photo below, we were called to the pediatric room to help get IV access in a sick child with malaria. The nurses and residents had tried for hours. We showed them how you could use a regular needle in the bone (called an intraosseous needle) to give medications, fluid and blood. He had one of the residents try, and used this as an opportunity to teach all the residents, nurses and medical students on the floor how to use this technique.

Despite all my heavy comments about the burden of disease here and the bad outcomes, many kids come in on death's door, and leave happy and playful. Here is Dr. Hansoti performing a final examination on a now healthy child ready to go home. These are some of the truly rewarding moments that balance the experience and validate our efforts here. (written permission for photo by mother on file)

Just behind the fence of the hospital compound is the beach community, a sprawl of shambles and corrugated metal rooftops. These are common living conditions here with no running water, electricity or sanitation. Water pumps have been placed throughout the country in high density areas, but his water is not clean for drinking and contaminated with heavy metals and cyanide from the gold mining process that stains the groundwater here. We are forbidden to travel South of the hospital - Caucasian travels can be somewhat of a target.

Saturday night and Sunday will be a fun day, an escape with the expats.