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!

Liberian lessons

We have had a lot more time to do teaching on the wards in the past week. In addition to our morning lectures, Venee, Amir, and I have been taking time to do one on one teaching with the students. It was a lot of fun doing physical exam with them in the past few days. They are very bright and have rose to all the challenges we have thrown at them.
As I continue to work in Liberia, I am more and more amazed at the bond between families. The mother and child share so much in the first few months of life. The mothers come in wearing dresses, and the babies' outfits or blankets are made from the same piece of cloth. The mothers carry their babies on their backs in their lappas while they do their work.
We had a case of malarial hypersplenism, also known as tropical splenomegaly. It is a more chronic and less severe course. I am astounded by the all the different ways malaria can present.
I want to say thanks to everyone at UMass. There were so many people that chipped in to make this trip happen, from helping with forms to covering shifts.

A Long, Tough Day

Yesterday was a tough day.
It started with a baby with pneumonia. The baby was an 8 month old with some congenital animalies that had been admitted with pneumonia. He was in severe respiratory distress. We tried some medicines and suctioning, but he became apneic and bradycardic. We did CPR and brought him back, but he was still working so hard to breathe. My training has taught me that a malnourished, little baby is only going to be able to breathe for that long before he gets too tired. You recognize how much he would be helped by taking a break from all that work with mechanical ventilation, but we don't have the capacity for that yet. We used all the medicines available. I mixed and hung my very first aminophylline drip to try to open him up, kept him on the maximum amount of oxygen we are able to give with the compressors, but it was just too much for him.

Flag Day

Today was a holiday in Liberia, Flag Day. The hospital is running on a holiday schedule, which means We rounded in the morning, but no clinic in the afternoon.

It is funny how patients seem to come in with illnesses in themes- one day it seems to be all malaria, one day it is malnutrition, another day bronchiolitis. Today all our malaria patients decided they wanted to get better, collectively. We discharged a whole crew of happy kids. I am trying to attach some pictures to this blog of some of them, but the internet makes it SO slow. I think it might be quicker to print the pictures and send them in a corked bottle across the Atlantic for everyone to see.

I have done a lot of teaching about bronchiolitis in the past 2 days. There are no isolation rooms or blue gowns and masks to be had here, but we do encourage good hand washing. I have also been showing the mothers the benfits of normal saline and blue bulb suction. Even though I am in Africa, I can't escape RSV.

We have a few diagnostic puzzles on the floor. We have been limited because the xray machine has been down since we arrived, although we can do an ultrasound. We also have limited access to labs, and they don't have any labs on weekends or holidays, so we are trying to do our best with our brains, stethoscopes, and intermittent internet access.

Feeding time

Hopsitals of Hope has brough 4 monitors onto the Pediatric ward! They have attachments for oxygen saturations, blood pressure, and heart rate, and can even print an EKG. The staff was trained on them last week. We have a patient on the ward with bronchiolitis who was having some respiratory distress, so the nurses put him on the monitor. Shortly after, JFK had its first case of monitor-itis, where the family kept calling me over because they were concerned something was wrong with the baby. The reason for their concern was the blood pressure was coming up as "no reading" because the cuff was not attached to the monitor.
We are working hard on the malnutrition cases at JFK. We have done a lot of education with the medical students and the interns to use the WHO handbook and get these kids on feeding schedules. We have one little boy who is severely malnourished, even though he is 11 months old he only weighs 9 pounds, and has trouble tolerating feeds. He pulled out his NG tube this morning and his mother had gone home to get more clothes for him. Since it was Sunday and my schedule was a little lighter, I decided to feed him myself.
I lifted him out of the bed and he was like a bird, so fragile and light in my hands. As I snuggled him, instead of adorable baby chubby arms and legs, he seemed angular, as though every bone was making an impression on my arms. He reached up for the feeding syringe as though it was his favorite bottle, and he happily enjoyed every drop of his feed. Though there is more to do than I have time for in my short stay here, I am grateful for moments like these.

Free At Last

Today had an interesting start. We live in the doctors dorms, which is a JFK provided facility. It has a gate to our sleeping quarters, which is locked with a padlock. This morning we had a lock malfunction, and we were locked in. It is quite intersting to be unable to get out your door in the morning. Luckily we were planning to head to the wards early, so we had time to call security to let us out. It took him a few tries to break the lock open, but when he finally sawed it off the door, he started to shout "Free at last, free at last, thank God Almighty, free at last!"
There is an amazing group here right now called Hospitals for Hope. They are partnering with JFK to update lots of the wards and medical supplies. They are bringing in donated supplies from all over the world and working hard with the administration at JFK to make big changes at the hospital. I am in awe of all the good work they have done in the past week.

Quinine quinine everywhere

Or should I say mosquitoes, mosquitoes everywhere? There are mosquitoes all around-at the dorm, in the hospital, on or walk in between. And there is no shortage of severe malaria all around. Malaria is such an awful disease which can make a perfectly healthy child very sick in so many ways. There is cerebral malaria, complete with seizures and altered mental status, and children can be obtunded for days. The amazing part is when the kids get better, they just sit up and start eating, and then walk out the next day.
We have a very sad case in the NICU right now. The baby was born "depressed," meaning it dit not breathe spontaneously and was limp. He was put on oxygen, but when we arrived to see him, he began seizing. He seemed to have sustained some sort of birth injury, since he had a cephalohematoma. We gave him all the treatment we had available, and tried to do a head ultrasound, but did not have the right probe. The next day, he was floppy, and his pupils were fixed and dilated. We are all very sad for him.

Country Medicine

It is funny how time passes in Liberia. I feel like there is so much work to do everyday, but I can get caught up in one task. We are seeing quite a bit of malnourishment on the wards. The Peds team spent a good deal of time calculating, and then mixing, a formula for one of the babies out of ingredients we had on hand.
I gave a talk on nephrotic syndrome yesterday, which was really fun. I am going to try and do a journal club either this Friday or early next week. The medical students are very eager to learn and ask lots of great questions.
We have a case on the Wards of a girl with sickle who came in with malaria and pain crisis. She is the first patient I have ever seen in Liberia with sickle cell. Where are all the sicklers, we wonder.
I am learning so much every day about malaria, typhoid, malnutrition, and even some "country medicine," which is what they call Liberian home remedies.

The quiet after the storm

Today was the first real weekday of rounds. I met the medical students, and was reunited with the residents. We have a very large team, but lots of opportunity for teaching. We have many interesting cases on the wards right now, and a few diagnostic mysteries. Again, I long for some diagnostics and consultants, but I feel lucky to have my amazing pediatrics colleagues to consult with.
All of our patients who were "jerking" yesterday are improved today, and one even got discharged home from the ED because she was looking so good.
I am sorry for the lack of pictures thus far, but my camera battery died the second I landed in Monrovia. I am going to steal Amir's camera tomorrow, though. It would be really embarrassing to have my only picture on this Liberia blog to be of Worcester, MA.

The weekend

Today, I rounded on the Wards, ED, and NICU, then stopped for a lunch of jollof rice in the hospital cafeteria. I forgot how spicy Liberian food can be! I feel like I am back in the swing of things.
It is a wet rainy season here, and malaria and typhoid are rampant on the Wards. The Liberians are complaining because it is so cold (75-80 degrees) but when I am rounding in the hot crowded hospital with no breeze, I am glad for the slightly lower temperature.
It seemed that everyone was "jerking" today, which is what they call seizing. A few of the children were certainly jerking from severe cerebral malaria, a few from suspected meningitis, and one little girl had what looked like it may be early tetanus, but for her sake I hope it wasn't.
The wards are more crowded than I was here the last time. They have added more beds and cribs in every room. Right now we have more children than beds, even with the additional ones added.
The nurses greeted me warmly today and welcomed me back. They then promptly asked for hand sanitizer, which I consider a victory.

On the Ground

I have arrived! I made it, even though my flights gave me palpitations the whole time. I swear next time I am driving to JFK- it has to be quicker and less stressful. Luckily my connection was delayed as well and I made it to Brussels. That airport was a very clean and comfy place to have a layover.
I was able to meet up with Amir, the MD from Mt Sinai. I snoozed away most of both flights. I arrived in Liberia around 6 pm and drove to Monrovia with Alvin, an old friend from the last trip.
JFK looks as great as ever, though I was not able to take pictures because it was POURING RAIN. Ahh, the rainy season.
I am rounding on the wards tomorrow- I cannot believe I am back!

Takeoff

Farewell to Worcester! I am off to Monrovia. I had one minor last second camera glitch, but all was well with a new memory card. Right now I am at Logan, bags checked, through security. I am awaiting the boarding of the first small step of the long journey to Liberia. I am SO EXCITED to be going back! Keep your good vibes for ontime flights coming my way, and I will log on on the other side!

Packing...

I am trying to pack for my trip to Liberia. Once I put in the donated medical supplies, books, and clothes, I think I will have room for one pair of scrubs! Ahhh...not going to work in the Liberian heat.
I am getting so excited for my trip!