The Farm & BD Party at Sajj House

Ade Capitan is a prominent person in Liberian society, and the primary supporter of the HEARTT program here in Liberia. She is the owner of a favorite live music bar (Groovy's), a rubber farm, and several factories. As a very well connected person of means in Liberia, she is a fantastic resource and a constant help to us here in country. She invited us to her "farm" yesterday... come to find out it is a large rubber plantation with a spanish style plantation home. As the private driver carried us in the new Chevy SUV through the famous redlight district (not what you think... it's called red light because it has Liberia's only red
light) we were reminded of the object poverty of the region. Thestreets were lined with markets, broken cars and litter.

The Coca-Cola factory was on the outskirts of town, boasting a 15 foot tall plaster coke bottle. Ironic that likely 90% of the coke consumption is by expats. Large trucks stacked with people blast music into the streets as their matching T shirts encourage passer-byes to vote for their party in the up-coming elections.

Also along the main road is a large, eerie looking skeleton of a building. There are several stories surrounding its demise, ranging from incomplete construction decaying over time to burned reminents of the war. It was the national defense headquarters - so anything is possible.

When we arrived at the farm, we drove down what seemed like endless rows of rubber trees. A small school and community of huts supported the dozens of workers that cared for the trees. A paper mill and other factories were also on the property. The gates opened by private security revealed the rows of luxury cars with their drivers eagerly awaiting further orders. Inside the home was lavash furnishings and a fully staffed bar. Within minutes I was introduced to the most influential people in the country and armed with aged single malt scotch and a cigar. Not bad for a "farm." Many of the people there had been trained in the US or the UK, and had returned with a pasion to re-invest in their home country.

The following day was my birthday! It was a normal day at work, but then we hosted a joint birthday party for me and going away party for my co-resident. Many of our contacts from the "farm" came, as did our expat friends and nurse colleagues. We bought pizza for everyone. The owner of Sajj found out it was my birthday, and free of charge, had a huge cake made, decorated with local fruits. It was enough to literally feed the entire restaurant. The best part? Topped

with blazing fireworks! It is quite possibly the most interesting birthday I have ever had.

Follow up from Delta flight patient

So today I received an email from the first (and sicker of the two) patients I cared for on my flight to Africa. Here is what he had to say...

"Hi Doc, I sincerely thank you for the loving kindness you offered to me . My God,whose name is Jehovah will bless you for that prompt show of love. I am Felix Appiah, the one you attended to in the flight on August 14. My family extend their deepest appreciation to you. We won't forget you for the saving feat achieved.The wonderful aspect about it is the free of charge. In future, I will also show my gratefulness in a small way. I pray to God to guide you in your life saving profession so that you do great things to help many others. Ben, let me tell you briefly about the problem. I use to have similar feeling almost anytime I am in flight. It start from feeling difficult to breef and the need to take more cold water. In one ocassion , I went to the bathroom , put water on my head and wash my face several times and got okay after few minutes. I feel dehydrated panting for water, but I usually dont get enough, that is always the case. This does not happen to me except when travelling by air and got stranded for many hours. Well you may advise me on this problem. " I replied to him and gave him some advice. Things like this keep you going. Just thought it would be fun to give the follow up on the case.

Expatriates

An expatriate (or expat for short) is a personal residing in a country or culture that is not there own. There is no shortage of these in Liberia. Following the Liberian wars between 1990 and 2003, there was an influx of international relief aid. Now almost 8 years later, the country has progressed to the development stage to develop the political, economic, healthcare and agricultural foundation of the country. As a result, foreign governments, NGOs, and private industries have set up shop in Monrovia, bringing with them a potpourri of Americans, Europeans, Asians. The community is small enough, however, that it gives the vibe of a small college town where everybody knows each other. New people stand out and are quickly introduced into the group.


To support these people, a housing and entertainment industry has concurrently developed to meet their needs. Because supply and demand factors dictate prices, food is expensive, and a US style condo with 2 bedrooms with hot water and electricity can easily cost 3-5 thousand dollars per MONTH (that's right, US taxpayers).

The pleasant thing about these circumstances is that there is always something to do, and someone to do it with. So far I have hung out with people from every branch of the UN, EU, etc and people from Brazil, Switzerland, the UK, China, Japan, Sweden, France, Spain, Austria, etc. The common language... English.

Last night we went to a fantastic Indian restaurant for dinner (Tajj), drinks out on the water at A La Laguna on a pier overlooking the ocean during sunset. Next stop in the ocean - Antarctica. Went over to a friends house for bourbon, to another housewarming party with all the expats, and then with a group of Lebanese friends to one of their clubs for dancing. Overall cost for the entire night - $10. Drivers? Provided. Time home? 5:30AM. Thank God we weren't planning on rounding in the hospital the next morning.

The people here, Liberians and expats alike, are a genuinely friendly group of people.

Yesterday we went to the waterside market for shopping. It was fun to play the typical tourist and barter for masks, necklaces, etc. We also bought material to have bags, shirts, and dresses made as presents. Its amazing how much this place reminds me of Sri Lanka.



On the drive home we witnesses a pedestrian in dark clothing get struck by a car. He had visible blood and brain matter on the pavement and wasn't moving. Our intuition was to stop, get out of the car and help him to the hospital. There was a large crowd, and our driver recognized that this occurred outside one of the political party buildings. We were directed that the situation was dangerously unsafe, volatile, and could explode into a mob at any moment with fighting. In fact, if an American accidentally hits someone in their car, they are directed to speed away and go straight to the US embassy to straighten things out. Otherwise, they may be killed on the spot. It was a stark reminder in the middle of this fun day that Liberia is still recently post conflict and in the midst of development. One should always be aware of their surroundings and prepared with a contingency plan should things go sour.



We have a new pediatrics resident coming today - new people. Its my turn to play tour guide! Even though I have only been here for 1 week, I feel like I've been here for months!

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.

Matters of Life and Death

In the united states, we have a sophisticated system of prehospital emergency care and designated centers of excellence for the treatment of st
rokes, heart attacks, burns, children, and trauma
s. The acceptable miss rate for heart attacks has become 0%. As a result of our increasing expectation of flawlessness, we routinely spend around 5-10,000 dollars on emergency patients that we don't e
nd up finding any serios disease in... and they eventually go home to follow up with their primary care doctor. We order every test and image to keep things moving, and cast a wide net to help support our theory that we would have caught something serios had it existed.

The Emergency Room (yes I know Department is more PC... but this is truly a large room) in Liberia sees about 4-6 fatalities a shift, many of them children. Anyone over the age of 5 years old has to pay for medications and studies before anything will be done. Children <5 years are free. Could you imagine having a heart attack, forgetting your wallet, and slowly dying in your chair at the hospital unless someone else paid for you? Daily occurrence. The HEARTT doctors have brought many donated medications that the hospital can't charge fo

r in hopes we can give medications first, ask questions later for the truly sick people.

When it is clear that someone is about to die, we have to carefully weight the likelihood of that person surviving. Chronic disease? Probable underlying heart condition r

equiring ICU care following survival? If the person dies, their family must still pay the bill before the can claim the body and remove it from the hospital. This means that if you spend money on someone with little change of recovery, you could literally deprive the family their ability to bury their loved one.

On a lighter note, I had my interview with the Liberian Medical Board. I am now officially licensed to practice medicine in the country of Liberia with no expiration date. I'll get a card with my photo signed by the chairman of the board. I also had a patient today with the same last name (Constance). I had permission from her and her mother to take a photo together. I was joking around that maybe we were cousins! People got a laugh out of that.

My fellow HEARTT doctors have been excellent about introducing me to the expat community here in Liberia. We have gone out almost every night. When restaurants are just as expensive as groceries, it takes the guilt out of dinning out. There are several good places to eat, and an excellent bar in Mamba point called the Tides - sharing the name of my local bar in the hometown of Gig Harbor. Our local favorite is the Sajj House - excellent pizza and beer.

Life here is fun, interesting and full of surprises. One has to cultivate a positive mental attitude, and think of things "glass half full." Otherwise one would go crazy. I try to think about the patients we saved that would have died had we otherwise not been here, as apposed to the ones we couldn't save.

Ah well - more positive stuff in the future.

First Days

I was introduced to the hospital and the medical staff on my first day. I am only allowed to work as an observer and educator until my meeting with the Liberian Medical Board in a couple days. However it turns out there is a lot you can do without writing notes or orders.

We took the afternoon to go to the Water Street

Market - a series of crowded streets where everything you wanted (and didn't want) is for sale. Kids stroll the curb s

elling sun dried, salted fish. I found several lapas, or yards of cloth, to have made into bags and dresses for my wife by a local tailor. I reminded me of the markets in Sri Lanka.

The emergency department is based on the old British system... a medicine and a surgery side. We are invited to help and care for patients in both, but act as attendings and are responsible for the "medical" side. Patients on the surgical side will eventually be seen by another physician. If the nurses feel uncomfortable or can't get help, th

ey know where to find us.

The nursing staff and techs are fantastic - they are eager to help and care for their patients. Many of them are interested in learning. There is a small pharmacy clo

se to the ED with NSAIDs, seizure meds, antimalarial and antibiotic medications. We are able to place IVs, and give fluids from plastic containers similar to juice boxes. There is one ultrasound for the hospital and of limited access to the ED... I would KILL to have a small, pocket portable ultrasound. I truly would save lives. We can get plain films, and a handful of labs. To give you an estimate, a CXR is about $30, 1 liter of oxygen per hour about $3, and one tylenol tab about 15 cents.

Last night we rounded in the ED before going to bed, just to make sure everything was alright. To our sorrow we discovered one of the sick children was not breathing. She was still warm, but didn't have a pulse. Nobody knew how long she had been dead - not even the mother or nurse who was sitting less than 2 feet away. There are no monitors like in the US - just chest rise and skin color. We coded the 1 year old baby for about 30 minutes before pronouncing her dead. It was time to go home.

Today we helped during case presentation rounds with the medical students. They are a bright bunch, often dedicated to their education and the future of Liberian medicine. We are careful in how we critique an instruct - often being later interpreted by the medical staff here as being too kind and blind to poor presentations, etc. My personal feeling is that it is not our place to criticize, but to share and reinforce things that are working well.

Tonight some people are packing up to go home. One of the EM residents that I have not yet met (taking a small vacation prior to leaving to the states) and a psychiatry attending who may be coming back to work on the medical staff here long term. We are going out to an Indian restaurant called Taaj - a local favorite.

Tomorrow we will hopefully continue working on the trauma resuscitation room and kit, largely supported by Stanford! We are doing this in between patient care activities in hopes of improving their infrastructure to care for their sickest patients.

** The internet is really slow today - so I will add the photos later **

Getting here (black cloud day 1?)

My wonderful wife got up at the crack of dawn and dropped me off at SFO airport. Fortunately both bags were underweight and they didn't charge anything. I settled in for an uneventful flight to Atlanta. On arrival, I was amazed what an international hub concourse E was. In fact, I already felt like I was in another country... I simply couldn't identify which one. It was almost like being at the Olympics. At least the signage in Georgia is in English.

About 1/2 way over the Atlantic on our way to Accra, Ghana, an African gentleman laid down in the isle and curled up to take a nap. Curious. I've seen similar things before in other countries on the trains when people want to snooze despite the people and meal carts trying to pass. Other Africans, however, though this bizarre as well - so something was amiss.

The flight attendant tried to sit him up and help him back into his seat, and upon resurrection, he took a face dive towards first class. I was just talking 15 minutes prior with this flight attendant about my business in Liberia, so all he had to do was look my direction with a dubious grin and I got out of my seat to help. I saved him the "is there a doctor on board" PA announcement that we all cringe to hear.

They brought out the flight medical kit - quite well stocked I might add - and began evaluating this man. He was in his 50s, and stated he had not had anything to eat or drink during layover or during the entire flight. He had a rapid pulse and low BP. No medical history. I fed him some juice and water, and slowly helped him up. TIMBER! This was clearly not working.

I placed in IV and emptied an amp of D50 into a liter of NS... besides code drugs this was all that was available to me. I check his vital signs... improving... thank god. The medical kit had a very cool portable single lead monitor that you simply place on the patients chest. NSR.


About 2 hours of babysitting, re-checking vitals, and emptying all the fluids I had available to me into his IV, I removed his line and sat him up. He was now bright-eyed and bushy-tailed and sauntered off to his seat. Of course there is always paper work.

The nice flight attendants gave me a bottle of champagne to donate to the HEARTT residents social fund for later. Very generous.

About 2 hours into my nap, I feel a taping sensation on my shoulder. When I clear the fog out of my eyes I focus on yet another flight attendant with a quasi-panicked expression. "Are you the doctor? she asked. "The only other MD on the plane is a psychiatrist... could you help again?"

I found a small cluster of people fawning over my new patient in 21J, a middle aged African female with a similar condition. She was fortunately already in her seat and able to drink juice. This fixed her right up and I was able to return to my nap.

After a short stop in Ghana, we flew to Monrovia where our descent was met by a grounded fleet of UN helicopters, the kind you see on the Russian side of old WWII movies. We were the only jet on the tarmac. After climbing down the stairs in the humidity, we were ushered into a makeshift corral where I presented my paperwork for inspection. "Ahh, DOCTOR?" followed by my nod. "Go right through - no questions, please enjoy your stay." The only reward better than frequent flyer miles is no problems at customs when you are bringing a 50 tub of medications into the country.

So far the countryside reminds me a lot of Sri Lanka. I think the prior experience helped soften the culture shock of Liberia. I start tomorrow AM bright and early.

Thanks for reading - BBC