Final Days

This amazing trip is coming to an end. It is my last few days here in Liberia, and what an amazing ride. It has been filled with awesome experiences, frustrating politics, rewarding patient experiences, epic saves, and disappointing losses. There are several people I will always remember. Below is a pano of part of the main ED. Patients are crammed together in 3 large rooms. With close proximity, they become their own community, often helping translate English to English for each other and keeping each other honest about how many times they went poop, if they vomiting, or to remind the nurse if they are past due for a medication.

The nurses here have never seen nursing care in the US. They have no examples to go on. When I ask them to move faster, do more things at the same time, etc - they can only think that I'm asking them to go way above and beyond their peers... not make their way up to some standard. Despite this, they have worked very hard and are improving themselves because they believe in what we are trying to do and take pride in their work.

Liberian people are very kind, wonderful hosts. By nature they are social, conscientious, and grateful. I find it very hard to accept that they were in civil war for 15 years. Their customs are a mix of traditional African culture, and an interpretation of American culture as seen through music and television.

The elections for the second president following the war will be held on October 11 this year. As a result the various political parties are beginning to campaign and escalate the hype surrounding their candidates. The main parties in this race are the Unity Party (UP) including the current president Sirleaf, and the CDC party. The CDC by stereotype is primarily comprised of younger people with a lot of energy, interrupted education, and unemployment. There is a general uneasiness about how things will go with this group as the elections approach. You can google search the Liberian Observer to follow Liberian news surrounding the elections.

The PAs here have been patient with us as we push them to stretch their boundaries and continue their learning. I have made some excellent friends. I am hoping to bring a particular intern back to Stanford to shadow for 4-6 weeks once he completes his internship. He may be Liberia's first ever emergency physician. How often can one say they helped create a specialty in another country?

I fly home tomorrow evening and will get back into town on Monday afternoon. I will get to the airport 4 hours early as to not miss my flight. Oh yes, people have been there 2 hours early and missed their flight. Liberian security runs on Liberian time... even if there is only one flight that day.

I want to thank all of you for following my blog and sharing with me here in Liberia. Thanks for all the supportive emails. I miss home and can't wait to see you in a couple days!

Ben

Top 10 lessons / observations while in LIberia

Before I start, I want to acknowledge that there is a diverse audience reading this blog, and rather than writing one for medical colleagues and one for family / friends, the limited internet speed and access reminds me that I am lucky to write an online blog at all. Below are interesting observations while here in Liberia. This may sound a bit like a rant, and as unbiased as I try to be, I fear I fall short of being an anthropologist, standing idly by without trying to interfere with their surroundings. I also want to reiterate that I have a deep respect and appreciation for Liberians as they are wonderfully pleasant people who have been nothing but excellent hosts.

But, lets get on with it... here are some interesting observations.

10 - Island time

So maybe Africa is a very big island, but that doesn't stop the concept of island time in Liberia. From the slums to the ministry, any given watch universally runs about an our late, and in the afternoon, speeds up an hour early. For example, I am told by many of my expat friends that business or ministry meets scheduled to start at 8AM start receiving participants around 9:30. Around 10:30 people start getting unsettled and want a coffee break for 1/2 hour. They show up around 11:30 and shortly decide that it is close enough to lunch to recess. The 1PM sart time somehow extends to 2PM, followed again by a coffee break at 3:30PM. At 4:30PM, it is agreed that this is pretty close to the 5PM ending time, and who can accomplish anything in 1/2 hour? So, a 8 hour work day typically enjoys roughly 3 hours of dedicated attention. I was lucky enough to sit in on microbiology practical and learn how to perform blood films looking for malaria. The class was supposed to start at 8AM sharp. I was the only one in the building. I called the instructor to make sure I had the correct time. He said I wan't crazy, it was at 8AM, and he would be there at 9:30 and hope that 1/2 the class had arrived. I did the same.

9 - where did that building go?

The hospital is on a main road shared by several embassies, NGOs, and many UN operations. Despite the high-profile region of Sinkor, approx one out of five buildings are still burned, bombed out, and now provide wind coverage to squatters. I have asked several people, and nobody knows why these high-priced real estate locations are still vacant now for more than a decade. Are all the owners and their families dead, victims of civil war? Are the owners now enjoying the relative freedoms of the US, UK, South Africa? I'm not sure.

8 - handshake with a snap

This goes without muck explanation. The handshake here has some serious soul. It starts with a regular handshake, transitions to a slide, goes into a fist grip, then back to a handshake, and finishes with a snap of the middle fingers and a recoiling of the hand. Try it at home.

7 - supply and demand

Everyone knows that the price of things are based on supply and demand, and in many foreign countries, complicated by a skin tax (yes... white people pay more, no surprise, no problem - glad to do it). This phenomenon, however, isn't without its humor. For example, I can get a lobster dinner with wine on the coast for about $5, but a 2 gallon, green, cheep plastic garbage can may cost up to $22. WTF? Its always good for laughs.

6 - expat community

Liberia is one of the smaller countries in the world, approx 43,000 square miles. The community of visitors is even smaller. As such, I meet the same wonderful people again and again. Within 2 weeks of being here, I felt more familiar with this group than my high school class. A little community has developed here, complete with movie night, game night, and ah yes - trivia night.

5 - public restrooms

well... any wall, tree, bush, car, sleeping dog, or unsuspecting person not paying attention is a perfectly good thing to urinate on. Ah yeh, the men do this too. Enough said. I still havent gotten used to seing a business woman with her leather brief stucked under arms, squatting just off the road relieving herself. No judgement, just an observation.

4 - money in hand

Most of my pediatric patients are always carrying Liberty (cash) clutched in their hand. Apparently there is a belief that if they cary money as children then they will be rich as adults. I always joke with them and ask if this is my tip! They all laugh, and some even offer it. I joke with them, tickle them, and make sure they know I'm only kidding.

3 - tea parties

I have had the privilege to attend many meetings and meet many powerful people in this country. Many people are frustrated with the pace of accomplishing tasks, and the personal management skills of those involved. For example, some of my expat colleagues will hold a meeting with people trying to lead them through an exercise to arrive at certain conclusions and develop an action plan to accomplish their new goals. A little directed, I know, but apparently this is how development happens. I hear the analogy that sometimes meetings are like tea parties, people get dressed up, excitedly trade business cards, share meals and drinks, and at the end of a lot of time and expense, nothing actually got accomplished but a good time was had by all. When kids pretend tea parties, they similarly get all dressed up, sit down, go through great formality, but if you look closely, there is nothing in the cup and at the end of the day they are still hungry and need to eat something.

2 - issues of life and death

I've already explained that in order for any test to get done or medication to be administered, the family needs to come and post payment before a finger gests lifted. Really sick people will sit in their bed, alone and without family, for weeks. They slowly get worse, and eventually die. The second they die, family comes out of the woodwork and displays the most dramatic display of mourning I have ever seen! The small bill (devoid of medications or tests) is paid and the body prepared for an EXPENSIVE and elaborate funeral. Where were these people when the patient was still alive?

1 - Liberian English

This is by far my favorite! The official language is "english" with a twist, similar to the Caribbean, Haiti, Texas, etc. In addition to a unique pronunciation, it enjoys a distinct vernacular. When I talk to a patient, sometimes they look at me like I'm speaking German. My nurse will translate and say EXACTLY what I said, and even in a similar manner, and sudden the patient sighs and says, Ah yes... and then promptly replies. The nurse always starts with "He say...". I love it. Some examples are:

dizzy - eyes be rolling

urinating - peepee plenty

diarrhea - stomach running

fever - skin can be hot

seizures - body jerking

move over - dress small small

doing well - trying small small

hungry - gaping great

And it goes on.

Robertsport

Robertsport is a small fishing community, now famous as Liberia's first surfing spot, located just 10 miles south of the border of Sierra Leon (featured in the recent movie Blood Diamond). The region was first explored by the Portugese in the mid 15th century, and later on became the fist settlement of free American slaves in West Africa. Named Robertsport after Liberia's first president, Joseph Jenkins Roberts, it had the unfortunate early history of severe malaria and a high mortality rate. Multiple subsequent settlements along the coast had to be made prior to sustaining a thriving community.

Now Robertsport is a favorite among both locals and expats, featuring beautiful red beaches mostly free of feces and litter. Many of Africa's beaches are akin to large cat litter boxes but fortunately the best seem to be spared for recreation. Overall the drive from Monrovia can take anywhere from 3 to 5 hours depending on traffic. With gas approximately $5 a gallon, it can also quickly become an expensive endeavor. We had the good fortune, however, to make friends with both a 4X4 vehicle and subsidized gasoline. We enjoyed a bumpy yet roomy, airconditioned ride as opposed to what could have been an expensive logistical nightmare with a taxi. Thank you US tax payers!!

The outskirts of the main city quickly give way to lush jungle and open grasslands dotted with tall palms and canopied trees. This region used to be home to many large game, now mostly gone due to heavy hunting. Our neighbor to the South wasn't called the Ivory Coast for nothing.

Many streams and lakes enjoy the company of freshwater fishermen, equipped with the latest from the Field and Stream catalogue, a bamboo stick with a string and hook. I didn't have the heart to tell them that a significant proportion of them would later suffer from a parasite hosted in freshwater snails called Schistosomiasis. It is a leading cause of portal hypertension in the developing world.

Our journey brought us back to the populated street markets of Red Light. Again people were busy purchasing and trading the things they would need for this next week.

The construction changed to a plantation-style of metal sheeting similar to rural parts of Hawaii. Multiple families live together in smaller rooms divided by blankets and tarps. I know what you are thinking, and 1) no they do not routinely get vaccinated against tetanus, and 2) yes we see and treat acute cases of tetanus here in Liberia.

The ruins of buildings destroyed during the war are a constant reminder of the recent past. I would estimate that about one out of every five buildings we saw had heavy ammunition holes coursing through them and evidence of firebombs.

Finally we reach Nana' Lodge, a small collection of huts and canvas tents on platforms on the beach. This is a highly recommended spot for people to enjoy Robertsport.

After the long car trip I couldn't wait to kick back and enjoy the beach.

Our party of 6 was given the "executive VIP suite" which was actually beautifully constructed with local hardwood floors and wood plank walls and ceiling. Elevated by stilts, it is exactly what one would expect to see in old movies depicting British colonies in Africa. Needless to say we were quite comfortable.

Dinner is served every night for $10 per person, featuring chicken, crab, fish, and lobster all caught fresh in the morning. This hand-dug boat is typical for the ONLY fishing craft we have seen in Liberia.

The beaches were red with streaks of black, and the water was warmer than our showers. Overall this place was paradise!

This tree was legend to be the anchor point for the first explorers of Robertsport. I could imagine this given that it was the tallest tree along the coastline. The base of the root structure continued about 2 stories above the ground.

Sunday marked the third annual Liberian surfing competition. Several competitors, broken down by age class, competed for the title of Liberian surf champion. Surfing here is largely a post-war phenomenon and is becoming increasingly popular. The waves are ideal given its location on a cape. This creates a point break, with large waves smoothly running along the coast, often traveling for 15-20 minutes before breaking on the shore.

Smaller children would watch their parents or older siblings with envy - counting the days until they could compete in the under 15 category. I think Liberia will soon be known as a surfing destination! Well, maybe among West Africans.

We made it back to Monrovia without any casualties, sunburns, deadly snake bites, or car accidents. The entire trip cost us about $60 each, including an amazing seafood dinner and drinks over the weekend. I can't wait to come back!

UN-organized patient transfer to Ghana

About 2 weeks ago I had a VIP patient that suffered an inferior wall MI. Fortunately, because he was well connected, we were able to get aspirin, plavix, lovenox, and keep him connected to the one monitor we have in the hospital. His was the first EKG I've been able to get in the past 3 weeks. Its amazing what social status will get you in a hospital. I wish this didn't translate to home but it is just as prevalent.

Because we didn't have the capabilities to perform a formal

echocardiogram or angiogram, he needed to be transferred. Arrangements had been made 3 prior times, all cancelled for one reason or another. This time it looked like the trip was actually going to happen. I arrived 30 minutes late as to not be 2 hours early (Liberian time) which worked out perfectly. Our ride was another hour fashionably late. We made it to the airport just in time to catch a United Nations (UN) flight to Accra, Ghana. Fortunately we had an uneventful flight, and my only doctorly duties included denying my patient a cup of coffee and insisted that he didn't have sugar with his herbal tea. I'd say I earned my keep. It was able to bring on board a defibrillator, liters of IV fluids, medications, and needles. Last time I took a flight I wasn't able to cary toenail clippers! These rules were of course waived when I told them that I was a doctor on a special patient transport.

Accra is a much larger city than Monrovia, complete with well designed and paved streets, large city buildings with modern materials, and the most horrible traffic in West Africa. Unannounced to me an ambulance had been arranged to pick us up at the airport. Mind you my patient has been up and running around the hospital for a week now and is more stable than many people walking on the street. Because he was the patient, he had to climb in the back of the ambulance, which was actually a Land cruiser with a bed in the back instead of the seats. Being the doctor, I uncomfortably climbed in the back with patient and sat with all the luggage. To my surprise, he turned on the lights and sirens and began driving like a bat out of hell, barely missing the hundreds of cards, motorbikes, and pedestrians that dare to stand in our way. At times we were on the sidewalk and going the wrong way down traffic. I told the ambulance driver that this was dangerous and highly unnecessary, to which he replied, "you pay, I get through traffic. Why else take an ambulance?" True to his word, the 1 hour trip would have easily taken 5 hours otherwise. I leaned over to my patient, by now with a look of terror on his face, and kindly pointed out that we were 10X more likely to die in this ambulance as a result of a car crash than he would of another heart attack.

When the dust settled and the coach stopped moving, I opened my eyes and we were at the doorstep of the Korle Bu Teaching Hospital. This is one of the larger teaching hospitals in West Africa, and is similar to many county hospitals in the US. It had a more modern looking area with clean grounds and no overt signs of prior struggle or shelling. We were taken into a room at the National Cardiothoracic Center. Our guide barged in on one of the unsuspecting cardiologists to introduce me, to which I apologized and introduced myself. I learned that they could perform an echo and angiogram, but not place a stent. They could perform a bypass graft if needed. I could see this leading to another trip to the US.

After dropping off my patient, I had a more sane return trip to the airport. I ate a chicken sandwich and coke while waiting for my return flight to Monrovia. I slept the entire way. I had told my driver to be there 1 hour earlier than I actually needed (remember Liberian time), and to my pleasant surprise, he arrived an hour late, right on time.

Marathon

Liberia hosted its first ever marathon, a growing trend throughout Africa. There was also a 10k run that we were planning on running in, that is of course until we were volunteered to do medical for the race. Athletes from all around Northern Africa came to compete for the $3,000 prize. The end point was SKD Stadium, named after the past president of Liberia Samuel K Doe.

We attended the orientation meeting, and after a 3 hour discussion about the logistics and contingency plans, several people raised their hands all with the same question, "what on earth is a marathon anyway?" Suddenly I realized that many of the people in attendance have never seen or heard of a marathon!

The racers started at 6AM in the dark, many wearing inappropriate shoes, or in some cases, no shoes at all. The roades are full of debris and man-eating potholes that I thought for sure there would be some significant orthopedic trauma. The sad thing is that we are the main hospital in town, and although we have X-ray, we have no casting material and only a few donated, padded aluminum splints to work with.

The day started out with a drizzle, and progressed to a downpour! Fortunately we had a little tent set up with a few supplies and rehydration solutions. There were printed guidelines for less than savvy providers to treat heat stroke and hypothermia. Hypothermia in Africa? They also gave us a blood pressure medication, and ibuprofen. The irony of this is that there is no indication I could imagine to give someone a blood pressure medication during a marathon, and ibuprofen can damage your kidneys in the setting of an endurance race and dehydration - both conditions common in a marathon. Many of the runners would come to the tent, say they didn't want to stay and instead finish the race, but wanted us to know that their feet hurt. I said, "OK, got it, your feet hurt but you want to finish the race... go get 'em!" and release them before one of my counterparts could start casting them or starting arduous paperwork.

As we are familiar with in the US, major events in Liberia are excellent political opportunities.

With a coming election, President Sirleaf donned her rain cap, and surrounded by guards in ties and trench coats, started down the 10K course for a photo-op with the couds. It was great to see her running in the rain alongside her people, supporting this awesome event for Liberia. Overall we had a great time, and got entirely soaked. I now have a "Monrovia marathon medical team" T-shirt to prove that I was there. During the orientation meeting, one of the local "ambulance" drivers wanted everyone to get a certificate to show their grandchildren years from now that they had participated in this historic day. They said that it was too late this year, but they would consider it for next time.

Case Series

In this post I wanted to write about some of the interesting cases I've seen thus far at JFK. I have am taking a ton of photos of interesting pathology (with permission) but these are mainly for teaching as apposed to "show and tell." I have a few, however, with no patient identifiers that I can share. The majority of the sick patients I see have severe or cerebral malaria. Their management is largely the same: IV quinine, broad spectrum antibiotics, IV fluids, glucose supplementation, gastric decompression and evacuation, airway positioning, and seizure control as needed. These patients typically either perk up quickly, or die. Many people have a misconception that the locals live with malaria and thus don't get sick from it. Give me 2 seconds of your time at JFK and I'll prove you wrong. They get very very sick, and often don't survive bad cases of it. I won't bore my healthcare colleagues with stories about malaria as they are often the same. Instead, I'll talk about some interesting diagnoses throughout my time here and the good saves.

Case 1: A 32 y/o man comes to the ED for right upper abdomen pain. He has a history of being Hep B SAg + (he has hepatitis B) and now has this mass in his abdomen. Other docs have looked at this, and assumed it was a tumor in his liver as a complication of his hepatitis. He was given some tylenol, and sent home. Several weeks later he comes to see me for more tylenol. His liver function tests are mildly elevated, but he is having blood in his urine. I'm able to convince the "radiology department" to let me use the ultrasound machine, and find that this guy has a largely unremarkable liver being pushed up on into his chest by a large tumor on his kidney! It has large vascular flow, and multiple smaller nodules as seen in this ultrasound. This could be a renal cell carcinoma, or other malignancy. There is very limited cancer care here in Liberia, but this tumor would likely be amiable to surgical resection. We don't have radiation therapy. I consulted a "surgeon" who looked at my scans and agreed that he would take out the kidney. He was to be seen in clinic on Thursday. I discharged the patient home to follow up in clinic with some pain medication. Unfortunately, he never left the ED because he could not pay his bill (approx $1.5o US). He missed his surgery clinic appointment, even though it was down the hall, and eventually was discharged home. I don't know if he ever made it to clinic.


Case 2: 2 patients are brought in by taxi after a high speed head on collision around 5:30 AM after drinking and driving. One patient was ejected from the vehicle. He had obvious skull trauma, GCS of 5, grunting and difficulty breathing, not responding to anything but pain, and posturing (an ominous neuro exam finding). He was essentially left for observation. I asked for medications to sedate him to intubate him. From the looks I got, you would have through I ordered a STAT sex-change operation in the ED. Instead, I intubated him through his nose while he was awake so I could take over breathing. This worked... and I'm glad, because once to took over breathing for him, he tired out and would have died on the spot. In the US we would never intubated a head trauma patient through the nose out of fear for causing further injury - but in this case I had no choice. We placed him in a cervical collar, elevated the head of his bed, and gave him some mannitol given by Stanford pharmacy. I made up a hypertonic saline gtt from sodium bicarb from my resuscitation bag I made and gave him 3% NS boluses. Given his history and likely prognosis - I was concerned that without decompression he would not survive. I asked if there was a surgeon who could perform burr holes, and offered to do so if nobody else could. A prominent local physician was called in, agreed with the assessment, and took the patient to the OR. In the OR, a basal skull fracture was noted, no burr holes were performed, and the patient was taken to the ICU. When I went to see him in the ICU, his nasotracheal tube was pulled way back, to the point I knew it was no longer in his throat and residing somewhere in the back of his mouth causing nothing but an airway obstruction. The nurse seemingly not concerned about this stated, "another doctor saw it and through it was too deep, so he pulled it back." I had to plug the end of the tube with my thumb and demonstrate he was breathing around it to prove it was dislodged. I was told that the surgeon on the service was not in control of the patient, and that the respiratory therapist saw the patient and through everything was OK. I advocated and tried my best to raise awareness, documented my concerns in the chart, found the on call MD and showed him, and recommended that he be re-intubated and offered to do so. This was refused, so I left my phone number in case there were any problems or if they wanted help. A few hours later the patient died of a respiratory arrest.

Case 3: A 1 and 1/2 year old child was brought to the ED and admitted by my HEARTT doctor colleague with fever and vomiting. The on call resident at the time diagnosed the patient with stomach infection, gave antibiotics and was about to sent the kid home. The HEARTT peds doc listened to the chest, pounded on it with her finger, and quickly became concerned about a chest infection. She got the XR noted below which showed a large accumulation of fluid taking over the entire side of her lung. We needed to drain the lung, because in the absence of heart failure, and in this setting, it was most likely a bacterial infection or tuberculosis as the cause. Both required drainage of the pus and analysis of the fluid to help guide further treatment. In the US, the child would receive sedation medication and likely have no memory of the event. This child had 2 people holding him down. After injecting local numbing medication, a plastic catheter was placed in the chest over a needle and 200ml (almost a can of coke) of yellow / green pus was drained out of his chest. He began coughing, a sign of a re-expanding lung. The next day his fever went away, his oxygen saturation improved, and his breathing quickly got better. After a course of antibiotics, he was able to be sent home playful and smiling. There was no sign of tuberculosis.



I'll post other interesting cases in the future. I'm seeing the full rang of tropical disease here! It has been a very educational experience thus far. While there are no formal learning opportunities here, I'm spending about 2 hours a day reading up on topics trying to educate myself on these conditions that prior I had only seen in text books.

Downtime

Despite our long and crazy days, we do get some time off. On Sunday we spent more time perusing the waterside markets and bartering with the vendors. I was able to do much of my shopping and was quite pleased with my negotiation skills. Example, "I'll give you $20 for the mask and $10 for the necklace," to which I would get a no. "OK, how about I just give you $30 for both of them." "Deal!" The things in town are overpriced compared to the surro

unding areas, but value is a relative thing and these people are the upper lower class of society. I consider it my own Liberian economic stimulus package. The masks represent various tribes in Liberia of which there are 16. The larger mask represents the Bassa tribe which inhabits the region that JFK hospital is.

Scorched from the blazing heat of the market, we walked the 4-5 blocks down the street to the famous Mamba Point Hotel, a local hotel and watering hole with things like champaign, cheesecake, salads, curly fries, and lobster soup. Although pricy, this place has become a favorite among expats for a taste of home (and free internet). Its not without coincidence that this hotel is literally down the street from the US Embassy. The view overlooks the ocean, unobstructed by the shanty huts below. At first I felt incredibly guilty for such indulgences when I am her in Africa to help support the poor, but 6 weeks is a long time and a little R and R is a necessary re-charge.

We spent the rest of the day at the Kendeja beach resort. This place is a little out of to

wn, but provides an excellent pool and clean beach free of feces and litter. The ocean curr

ent is incredibly strong, and many of people (locals and visitors alike) have been mercilessly swept out to sea. Next stop Antarctica.

Ok - back to work, playtime over.