Rollercoaster ride

     Sorry it's been so long since I have posted anything. We had major rain the past 3 days, which puts a big damper on my ability to access the wireless internet. Time is flying by here- today is my last weekday. I can't even think about leaving yet- there is just too much to be done.
     We have had some ups and downs this week, as always. The NICU has had some sad cases. We had a 4.6 kg infant delivered at 44 weeks with severe asphyxia. We also have an infant whose mother was in labor for 48 hours before she sought medical attention. These babies have such severe anoxia. One of them passed away last night, the other is in critical condition. The importance of maternal and child health supervision is evident everywhere you turn. Access to care is still a major issue here. And it is a hard, hard thing to be a baby in the developing world.
     We also have had some malnutrition admissions. One is a 3 month old girl who has a cleft palate. She is unable to breastfeed due to her cleft, and her mother cannot afford food. Breastfeeding failure is a major cause of malnutrition here because when mothers are unable to feed they often do not have another option. This poor little sweetheart just grabs your heart. She weighs four pounds, so she even infant clothes are baggy on her. She was really irritiable when she came in, but has improved after being fed. I went on a quest for a Huber nipple, which is a specialized nipple used to feed babies with cleft palate. As you can imagine, I was not successful. I could barely find a place that sold baby bottles at all. I am hoping Dr. Okoh can bring a few back from his trip to the states.
     We have had an interesting challenge on the wards this week. A few children from local orphanages have been brought in for various complaints. One of them has unbelievable splenomegaly, but nobody knows how long he has been that way or any family or medical history. The staff from the orphanage were interested to know if we would be interested in making field trips to see children at the orphanage for them. Apparently now they have 500 children they are taking care of.  If they had asked me before today, I would definitely have gone. Maybe next trip.
     We discharged one of the tetanus admissions this morning. He has been here the entire three weeks I have been here. He walked out of his room today(albeit stiffly) and said "I'm ready to go home." We all clapped for him- it is so good to see him well again. It is really uplifting to see a boy who was so sick walk out smiling today.
     Hopefully I will have internet access so I can publish some reflections before I leave.

Tryin' small

     Liberia is a place that never fails to challenge me. Sometimes the challenge is mental, sometimes emotional, almost always extreme. In Liberia, instead of saying someone is hanging in there, they say they are tryin' small.
     This was a brutal week. we lost two young girls. The first was the young girl who died of tetanus. The second was a lovely ten year old darling who died of respiratory arrest from pulmonary edema. The morning she died was one of the moments I was pushed by the demands of this place. I was trying to coordinate her care when she arrested. I ran to her bedside and she was breathless and pulseless. I started CPR, having the intern bag her while I did chest compressions. Ten seconds in we got a call that there was a critical infant born in the maternity ward.  Then I was informed that our baby with neonatal tetanus was having obstructive apnea from secretions and that her bedside suction wasn't functioning. Trying to triage 3 acutely ill patients while running the code and doing chest compresstions was an extraordinarily trying moment. I definitely prayed for grace. The intern had to step out and I gave a medical student a crash course in the proper seal and bagging technique. I gave another instructions on where to look for some suction supplies for the infant with tetanus. I did everything I could think of to save these children's lives. Two hours later, the babies were both doing well, and the girl had passed away. I was covered in sweat and saddened by the loss of a life ended too soon.
     There is always such inspiration here, though too. Last week I was called to the NICU to see a baby with birth asphyxia. She was seizing by the time I arrived. We gave her IV glucose and I ran around procuring her some phenobarbital to quiet her seizing brain. It took less than 10 minutes as I ran between hospital floors investigating emergency cabinets, but that is a long ten minutes. Every second of a seziure can seem like it is lasting for days. The baby began to breastfeed, slowly at first, but then increasingly well. She became more active and vigorous with each passing day. She was discharged home today with a happy mother. The NICU nurses asked if I was considering moving here, and told me I take good care of Liberia's babies. Hard to have dry eyes when you hear something like that.
      I have had the challenge of working as an attending here for the first time. Emmanuel has had other commitments for the past 2 weeks, so after the first half hour, I am leading rounds by myself. I had to switch gears fast from the medicine I am used to practicing to the resource limited setting. I have enjoyed the teaching immenselyand I have 8 medical students and 2 interns on my team. I also gave hospital wide Grand Rounds on Monday. I almost died when I opened the talk on my flashdrive and 1/4 of my slides hadn't been saved, but somehow I mustered through. I presented a tetanus case, and discussed the pathophysiology, current treatment recommendations, and public health issues of the disease. It led to a fascinating discussion between the Peds, OB, Internal Medicine, Surgery, and Anesthesia departments on the disease and management. It made me wish we sometimes had a forum like this back in the States!
       It is also my responsibility to give the students Friday afternoon lectures. I had prepared a talk on fluids and electrolytes, and one of the students was assigned to help me set up the projector and connect the power cords, etc. Since the projector was locked in Emmanuel's office, he had given me the key. I arrived ten minutes early to have ample time to set up. I was quite surprised to see the projector up and running. I asked the medical students if they had a spare key. Turns out they couldn't find the key (it being in my pocket) so they called the carpenter and had the doorknob and lock removed so they could set it up for me. Talk about overly enthusiastic medical students. I mean, you all know I love the nephron, fluids, and electrolytes, but busting down doors for my talk was a bit over the edge.  Luckily they have repaired the lock so I don't have to feel too guilty.
      I can't explain the passion I have for working here. It is brutal, it is hard. I have to work harder with sicker patients and less diagnostics and medications to treat them with. Yet I am always inspired by the strength of the patients, the beauty of the children, the community of families that rally around the family member in need. The people of Liberia know adversity, and that in the face of adversity, you cannot quit, but must keep trying, if only "small-small."

This never gets easier

We had our first loss on the Pediatric Ward since I have arrived. This never gets easier.
She was a beautiful 13 year old girl. She had an ulcer on her leg from a minor scrape from playing outside with friends. It was still there 3 weeks later when she arrived at the hospital with fever and malaise. We debrided her wound and started tetanus prophylaxis, but that night she began having lockjaw and spasms. We sedated her and continued therapy, and she did well for a few days.  But then she developed massive hemorrhage. I spent 7 straight hours at the bedside trying to stablize her with blood and frequent suctioning, but after a while we couldn't keep up with the hemorrhage and we lost her. We lost her in a heartbreaking and gruesome way. Her family was at her side the entire time, praying to save her, holding her hand, weeping. A free vaccine could have prevented all her pain, all of her suffering. A vaccine could have prevented a beautiful girl from dying too young.
This never gets easier.

The Other Side

Yesterday was an incredible day. They have built a new hospital in Tapita, in Nimba County, which is about a 9 hour drive from Monrovia, near the Ivory Coast. They asked the HEARTT director and the volunteers to come see it, and consider helping to staff it. Since it is the rainy seaason, the roads may or may not be passable, and there is no way of knowing. Since we are only here for a limited time, it was decided we should take a helicopter to ensure we could get there.
This was such an unbelievable ride. We were flown over much of Liberia, and we got to see a Liberia that is very different from the Liberia I know. About 5 minutes into the ride, the city (and almost all the roads) disappeared. All you could see was dense rainforest for miles and miles. Occasionally, there would be a small clearing with 4-5 huts. The green jungle rose and fell over the hills, some areas drenched in rain, some in sun, with the clear blue coast alongside. It was breathtaking.
When we arrived in Tapita, we were greeted by a group sent to welcome us. We were then escorted to the hospital. The town is a small, rural village, with most people living in huts and zinc houses, a few small stores and restaurants. The hospital was a gorgeous new sturcture, with very impressive facilites. At the hospital, we were met by the community health worker, the local chiefs, and local people who are involved with the hospital. They very formally greeted us in a receiving line and took us on a tour. During the tour, I was speaking to some local women about health care in the community. They have no working hospital, and the closest clinic is 6 miles away. They have a high disease burden, and most people cannot afford the fees of the clinic, so they do not go. One of the mothers told me: "It's terrible. Every 5 minutes you turn around, somebody's child is sick, somebody's child has died. It is too much." These women were amazing, kind and warm people. One of them asked me "Would you come to work in Tapita?" We talked for a while, about how there needs to be more than doctors, nurses, medicines, and equipment. But if all that was in place, I would be happy to work in such a nice hospital. I said: "I hope that all of these things come soon for you. I believe that children deserve to have someone to care for them. Children in Liberia, children in America, children everywhere. She held my gaze and said: "Now Doc, that thing is true." The power of that moment will be with me for a long time.
After the hospital meeting, we were escorted to lunch, which was a meat stew over rice with soda to drink. These people had so little, but were so proud to host us with what I am sure was a very expensive meal.
We could not stay long, but the people of Tapita made a big impression on me. I will not forget their warmth, their generosity, or their kindness. I hope HEARTT can work to help them soon.
When I arrived back at JFK, there was a lot to do. Two new infants in the NICU with respiratory distress, one began seizing an hour after birth. One of them was completely pale, I was worried he would go into hypovolemic shock at any moment. They are both stable today.
we have 2 patients with Tetanus on the wards, stable but on a heavy dose of sedatives.  We are trying to walk the balance of preventing spasms but not suppressing respirations. It is so hard to see children suffer from such a completely preventable disease.
I hope you are all well. Please keep the children of Liberia in your prayers.

Safe and Sound

I have arrived safe and sound in Liberia. The internet has been super spotty, so emailing and blogging has been tough.
The travel here went remarkably well- no delays on any of my flights, which is almost unheard of. As the plane was flying over Liberia, I was reminded what a beautiful and lush country it is. It is the rainy season so everything is green and blooming. I arrived in Monrovia to see all sorts of new changes. The airport has had a makeover, complete with shiny new tile, paint and airconditioning! I also almost fell off my seat when the road from the airport was paved. Lots of good stuff happening here.
I was so excited to start on the Wards yesterday. Emmanuel is a wonderful teacher. One of my interns was a third year medical student on Pediatrics my first trip. And one of my fourth year medical students was a 3rd year with me last year, so it was a great first day. It is so nice to be able to come back to the same site and see all the staff and nurses again. I was greeted everywhere with smiles, hugs, welcomes, and thank yous.
The Pedi Wards and NICU are not much changed. I wrote my first chemotherapy for a little girl with retinoblastoma, a tumor of the eye. We have 2 patients with retinoblastoma currently. It is quite heartbreaking to see them suffering from this disease. No matter how many times I come here, I am never less saddened by the injustice of the suffering of these children.
I am working hard and trying to get ready to cover Emmanuel when he goes, at which point I will be the only pediatrician in the country. Luckily there are some great emergency medicine folks here to keep me company. I am off to the hospital for now.

Last post at Work

Hey Everyone,
In case you haven't heard, I am returning to Liberia! I am so thankful to the folks at UMass who have supported this trip- I am so lucky to have such an amazing opportunity. To my family and friends, thanks as well. I will miss you all but I will be thinking of you all the time. I am BEYOND exciting to be going back!