Monrovia: conclusion (Spring 2010)

Posted by Rachel Ng, MD (a third year Internal Medicine resident from Kaiser Permanente, San Francisco  who served, in Spring 2010, a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

It’s been over a year since my return from Liberia. As I approach the end of my residency training, my Liberia trip will definitely be one of the unforgettable highlights of the past 3 years. Again, I am so thankful for the incredible opportunity and support from the Kaiser Global Health Program and Yale/Stanford Johnson and Johnson Global Health Scholars Program.  I hope that the medical students and residents reading this blog (and even non medical readers) will seriously consider doing an international elective, medical missions, or some kind of volunteering trip abroad that will truly enrich your practice as a clinician.  Thank you also to other current KP residents for sharing all of your memorable stories and experiences of times abroad.

Aerial view of Liberia

This will be my last official blog about my Liberia trip that took place during Spring 2010.   In my last entry, I left off at the part of my trip where my teammates and I had the honor to meet with Liberia President Ellen Johnson-Sirleaf.  Thereafter, we also briefly traveled off the beaten track to marvel at the beautiful land and seascape of Robertsport.

The final 2 weeks

So it was, energized and ready to head back to the hospital for the final 2 weeks of my trip.  Knowing that the remaining time will pass quickly, I treasured, even more so, each moment of working with the staff I have come to know dearly and of seeing the patients whose conditions were now more familiar to me despite not having the diagnostic tools so easily at my disposal as I would have back at home. My patient panel had grown to become a TB service with pleural effusion +/- chest tubes, advance liver disease, pneumonia, cellulitis, and HIV w/ a few presenting with kaposi’s…seemingly not a very good outlook.  And some patients inevitably died.  However by that time, I had come to terms with the limitations of what the system could provide.  And systems issues take time to change.  Thus in a setting of what I have termed “medical poverty” (vs. “medical abundance” whereby there is more than enough of the basic medical support in infrastructure, persons, and supplies to treat all general medical conditions)—and similar to what many other residents on the KP Global Health Blog have already noted on the theme of limitations and humility—there is the realization that the art of medicine goes so much more beyond simply offering curative treatment. How much more can be offered by compassion, a listening ear, and the human touch. Below are a few more anecdotes.

My first hospice patient

In the middle of the night, an old man was admitted onto the hospital ward, accompanied by his young son.  The patient had apparently not been eating well for the past week or so and was then very weak and confused. He had also stopped urinating for many days. Long story short, renal failure was suspected with major electrolyte abnormalities. No labs available. Hemodialysis did not exist.  Patient was treated under comfort measures only and passed away the next day.

Events are perhaps not as scary when it is expected and not a surprise. And somehow, I felt more at peace with his death than any other I had encountered up until then (though still, any patient’s death is never “easy to deal with”).   It led me to think how much good could potentially come out of a palliative care service/hospice at the hospital and community.  If we cannot cure them of their diseases, at least we can lessen their suffering and preserve their dignity at the end of life.

The prisoner’s pain

Only a few times in my training have I treated prisoners who were still serving their sentence, sometimes handcuffed, and under the watch of nearby guards as they come into the hospital for treatment. This patient came to the hospital with right upper quadrant abdominal pain and a known history of hepatitis C. He was treated for acute hepatitis. As he clinically improved, he however continued to complain of mild lingering pain despite pain medicines given. Upon further questioning, it turned out he did not want to return to prison and thus had hope to delay his discharge but complaining of pain.  Being such a subjective experience, he still very well could have had pain, but likely, it was another sort of pain he had—one related to the trauma and injustice he had experienced—per his account.  And thus, what I did offer was a listening ear to hear out his story and offering hope and comfort as best as one human being could offer to another fellow human being while in one of life’s troughs. Unfortunately for this prisoner, because he was clinically improved and his acute abdominal pain was resolved, he had to be discharged back to prison.

The NGO community

Every so often, the NGO community in Monrovia would come together at a chosen restaurant for a game night. A fee is paid by each participating group that ultimately goes to the winner’s charity/NGO of choice.  Typical of any city that has undergone unrest requiring UN involvement, the capital city was infiltrated with NGOs.  Within a 5 blocks radius around the hospital, there must have been at least over 30 NGO offices dotting every street corner.  During my time there, the Spain MSF (doctors without borders) announced their planned withdrawal from the country.  Often times, the hardest part after a country crisis is not the acute stabilization but instead, the long term rebuilding of a community/nation whereby it once again becomes self maintaining/self-sufficient.  Think of all the attention Haiti received after the earthquake.  Where do things stand now?

Acupuncture

Somewhat conspicuous in their operation around the hospital, was a group of medical professionals from China.  They came during a hospital development phase when medical teams from other countries came to help out. Of the different teams, they stayed behind and opened a clinic in the city offering treatments of acupuncture, moxibustion, and other traditional Chinese medicine remedies.  One of the doctors on that team gave an interesting grand rounds presentation on meridians and acupoints.  The speaker claimed that there were apparently over 600 diseases of internal medicine, pediatrics, ob/gyn, and ENT (ear, nose, throat) that could be treated with acupuncture! Of all places in the world, what a pleasant surprise to find the use of complementary/alternative medicine when traditional allopathic medicine can only offer so much.

Marshall Island

Another off the beaten track activity. My teammates and I ventured through near 2 hours of absurdly rugged dirt roads to the infamous Marshall Island.  Our interest in this place was based on a just-as-ridiculous mythical story of the “one arm ape” that lived one of the islands.  Scientists use to conduct animal experimentation on these islands. However, during the civil war, the scientists fled and the apes remained.  At this point, the story became a bit muddled for me. It was not clear whether the one arm ape came about due to a scientific experiment gone wrong or that the ape unfortunately caught a grenade-having mistaken it for food. Anyhow, fortunately we did not catch sight of any apes missing any limbs. They were quite huge—size of 2.5 to 3 average-sized man put together! I’m glad they were friendly.

Heading home

And finally, the bittersweet day of my departure from Liberia had arrived.

Some of my final thoughts that day as I remember and looking back at my journal entry that day:

1) Next project: think about how to start an adult chronic condition clinic there (for ongoing hypertension, stroke, diabetes patients)

2) Would love to start an inpatient rehab program

3) Maybe in the future…hospice/palliative care service?

Thank you to my teammates, local colleagues, to the patients and their families, and many new friends met along the way, for making my experience as enriching as it was and for helping me see the beauty, strength, and hope of the land and people despite all challenges.

Hope to see you sometime again, Liberia!

Kendeja Beach

Monrovia Week 4 (March 14-21, 2010)

Posted by Rachel Ng, MD (a third year Internal Medicine resident from Kaiser Permanente, San Francisco  who served, in Spring 2010, a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

This week, besides the usual clinical happenings with my colleagues and I back at the hospital with urgent pericardiocentesis, chest tube insertions, and code blues, there were several highlights also worth mentioning.

The President’s Dinner (Local newspaper article)

This was quite an honor and an unexpected event during my trip.  The President of Liberia (Madam President Sirleaf) invited all the HEARTT volunteers to the president’s house for a reception.  I felt almost a bit starstruck to meet her. Overall, it was a very enjoyable evening of conversation and hors d’oeurves by the poolside.  Though she had served in many high political and corporate positions and now acts as Liberia and Africa’s first female president, I was impressed with her down to earth mannerism and genuine concern for the reconstruction of her country in all aspects. 

Fufu

Also at the President’s house, I was introduced to a local staple food, fufu. I had read about this dish in the book The House at Sugar Beach, where the author described it more as a food eaten during time of starvation as it’s high in carbohydrate. Per a quick search on wikipedia, “variants of the name include foofoo, foufou, foutou. It is a staple food of West and Central Africa. It is a thick paste usually made by boiling starchy root vegetables in water and pounding with a mortar and pestle until the desired consistency is reached.”

“Fufu is actually originally from Ghana from the Asante ethnic group. Settlers and migrants from India, Togo and Ivory Coast discovered it and modified it in their accord. The original word is ‘fufuo’. The word means two things. (1) The color after it is prepared is usually white and white in Asante language (asante twi) is fufuoop (silent p). (2) The manner in which it was made. The process is called fu-fu (pounding) and that is why they came up with the name fufuo.”

It was definitely filling and distinct with a slight sour-vinegar taste to it. I’m not readily going to call it my favorite.

Robertsport 

Since the end of its civil war, Liberia has yet to attract much tourism.  Yet, if the tourism industry is to take flight, likely one of the top 3 places to visit (it already has its place in the Lonely Planet chapter on Liberia) will be Robertsport, a seaside village and former resort.  There still stand the ruins of what use to be a grand resort hotel.  Now, there are several motels by the beach attracting an ecclectic crowd every weekend.  My friends and I stayed at the NaNa’s lodge (eco friendly, Glamping —apparently a new term for glamorous camping). Liberia has beautiful beaches.  And the waves are incredible—if only I know how to surf! 

Every tent has an ocean view.

The staggeredly arranged glamping tents.

The best and freshest tasting fish I have ever tasted in my life! It was caught just that morning by the staff of the lodge and then prepared for lunch. Yum! 

After lunch, we packed ourselves back into the van and off for our return to Monrovia for another week of exciting work (but sadly also nearing the end of my trip)!  Thus ended our 30 hours excursion, nevertheless that was revitalizing, much needed, appreciated, and unforgettable!

March 7, 2010: Monrovia week 3

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

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Half way through the rotation—time is passing quickly!

Answers to last post’s images:
-CXR #1: miliary tuberculosis
-CXR #2: tuberculosis pneumonia. The film is rotated. There is pleural thickening vs. loculated pleural effusion on left lower lung field. And other gross abnormalities….?!

This past weekend was marked by coming and going of new volunteers. While our guys from the Hospitals of Hope left, we surprisingly received a team of surgeons along with a couple of emergency medicine residents. It was a great addition of much needed skills to help out with the many trauma, tumor, and infectious cases.

Meanwhile, midweek on March 10, 2010 was an observed holiday—Decoration Day. Much like Memorial Day in the U.S., this holiday was a time to remember the dead—the many people who had fallen during the war. Near downtown is a huge public cemetery.

The rest of the week continued to be challenging with lack of manpower, varied and new pathology including tetanus and ascaris, my patient panel with growing number of liver disease patients, etc. The x-ray situation continued to present many setbacks of patients unable to pay upfront for x-rays. Or else if they qualified for free xrays, then it was a matter of not being able to find the stamp of approval for their free x-rays (HIV patients receive free medical care under the Clinton Foundation, after their initial diagnosis and registration into the infectious disease clinic). Or else, pushbacks from technicians about not having enough films. Etc. etc. etc.

Let me say however that despite situations being grim, not all is lost, and really not as depressing and whiny as my blogs may be sounding. Despite not being to run successful codes here for now, there have still been many miraculous and beautiful moments. The gentleman whom I mentioned in my previous blog is about to be discharged, as well as the boy who came in with tetanus—originally so spastic as to resemble almost status epilepticus—now ready to go home and walking on his own. Healing and cures do occur.

And thus, another week went by. Over the weekend, I had some time to get to know more the land and people here. There is also almost a sense of renewed innocence in the city—one that comes from hope after the war? I have not heard much war stories from the people around me, but as I have read before, it was truly a time when “hell on earth” existed. If so, I can understand…who would want to retell and re-live that experience, even verbally. And so, Reconstruction continues.

This weekend also included a visit to the National Liberian Museum. I believe there is a small little blurb about it in the Lonely Planet chapter on Liberia. The exterior of the museum building was colonial appearing. However, as I stepped inside, I found a large room sparsely filled with scattered items. It was pretty sad at first sight. Nevertheless, my friends and I struck up a conversation with a tour guide who met us at the door. Systematically, he showed us significant wooden furniture pieces belong to the country’s past presidents. We also saw old currency—thin metal sticks of varying lengths, made from iron, bronze, or gold, twisted at both ends—used before the introduction of the Liberian paper dollar. I can’t imagine trying to carry those things around. Other items around the room included a very old flag (Monrovia used to be called Christopolos or “city of Christ” and the very first flag of Liberia was with a cross on it. Later the capital was changed to its present name, after US President Monroe.), masks, clothing, and couple of communication drum (back in the days before telecommunication existed, people were called to the town center via communication drums placed strategically at interval distances away from town and as one drummer hears the original drum sound, he would hit his drum, and so on).

(Communication drum)

At the very end of our tour, we had a nice little traditional African music concert with the xylophone and samba drum .

(President Tubman’s chair)

(Former equivalent of “passports” or ID cards—tiny wooden masks unique to each tribe)

(Wooden art portraying post-war reconciliation)

Home

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

4/18/10

I’m home now and back to work! Oh how I miss Liberia and my time there! I will continue to log on my Liberian experiences in the coming week(s), so stay tuned! It’s great to begin seeing and catching-up with some of you!

Meanwhile, some more photos and highlights…explanations and stories to come!

1) Meeting with the president:
http://www.liberianobserver.com/node/5302

2) Firestone rubber plantation

3) Liberia’s beautiful beaches

4) Guess what? Abnormal chest x-ray #1. Email me your guesses!

5) Guess again…abnormal chest x-ray #2 (not the same patient). Will post the answers in my next entry.

Of death and dying, ICU, and codes

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

3/28/10

The ICU on the medical ward is located in the middle of the single long hallway, directly across from the nursing station. The ICU has 5 beds total, 3 of which have monitors. One never forgets any first deaths: during medical school, in residency, and now in Liberia.

It was my 2nd week in Liberia when my colleague and I were curbsided by the ED intern, who asked us to evaluate a septic patient. The man presented with history of several days of abdominal pain. Other than that, we knew nothing else. Altered, dyspneic, and deteriorating in front of us. Agonal breathing, apenic, pulseless. ACLS started. Crash cart. Respiratory therapist called. Epinephrine 1mg iv x1. Pulse regained! Attempted intubation…unsucessful after multiple attempts. Continued ACLS protocol…must have been almost 1 hour+ of trying to resuscitate this young man. Finally called it. The wife was asked to return to the ED. When she heard the news, became hysterical, in shock, and began wailing uncontrollably and started singing a (mourning?) song.

If the patient survives even triage in the ED and makes it to the medical ward or ICU, the chance of survival still does not increase by much. Patients are given time to declare themselves, for which way their bodies have already determined to take despite us throwing antibiotics, fluids, diretics, and other medicines at them.

Overall, ICU is a challenging place. Mainly, the patients who have survived the ICU have been DKA patients. Mainly, the bottleneck is respiratory support. Thus, septic patients, severe CHF exacerbation, flash pulmonary edema, patients hang onto life only by the skin of their teeth if they can.

The many deaths I have encountered here have been incredibly frustrating and sad. Not only do I walk into rooms on my rounds, to find patients apenic and pulseless without any prior notification, but that even if a patient suddenly crashes, there seems to be a lack of urgency to do something about it. And even if CPR is started, the lack of resources (vasopressor, ventilator in the medical ICU) truly prevent a good attempt for resuscitating patients. Two observations of this common situation to comment upon: first, it appears that patients who are younger may tend to get more attention and resuscitated earlier. Otherwise, elderly, HIV, and stroke patients (high aspiration risk) are less able to fend for themselves, with poor reserves to begin with, and thus less attended to.

Here, there is no requirement or obligation to ask about a Code Status, compared to the common practice in the US. I have heard that in the UK and in Hong Kong, it is a similar practice. Patients are not asked, “would you like to be resuscitated and to what extent…with intubation and ventilation, with pressors, etc.” In the US, I question the ethics of resuscitating a person who is with irreversible altered mental status, end stage disease, or end-stage dementia so that they can live out the rest of their days on life support and be visited upon by their family members. Here, I initially noticed my urge to start ACLS, whether it was out of habit when seeing a crashing, apenic, or pulseless patient, or else it was out of the feeling that it was the only thing I could possibly DO. Generally, I think doctors hate sitting around and not being able to DO something to help their patients. And thus for so many of my patients that I feel helpless about, due to them presenting in such advance stages of their disease or else the medicine required does not exist, ACLS became my default for actually being able to perhaps do something for them, to prevent death. Yet, as I stepped back and thought more of my patient panel…strokes with major neuro deficits, HIV encephalitis, end-stage renal disease, end-stage heart failure patients, perhaps its more than ok to let them go. For sake of quality of life and not just for management of resources. Palliative care and hospice would be an amazing addition to patient care here.

Photos

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

3/15/10

1. wooden carving depicting reconciliation of the multiple ethnic tribes (the middle section of people embracing each other). The 3 warlords during the civil war embracing each other in the lower corner of the carving. (Liberia National Museum)

2. Traditional African instrument (will try to download the audio later on).

3. Me in downtown Monrovia (road paving under reconstruction)

4. typical patient room on medicine ward

5. map of liberia: Monrovia along the coastline. Names of the different counties throughout the country.

Week 2: part 2 of random thoughts

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

3/7/10

To admit or not to admit:
Clinic here is not necessarily too different than from clinic at home. However, if I order labs during the clinic visit, the patient needs to return the next day to bring me the result for review. I’m not sure if they need to pay twice.

In the US, for the most part, I have always considered care over cost. Thus if I think the information acquired from a test will help me in better managing the patient, then I just go ahead and order it. Here, I find myself debating and thinking two, three times whether a test is absolutely necessary as health care is so expensive here for most people.

Here, I feel like I have a higher threshold for sending people to the ED from the clinic or else to admit them to the ward. Example of people who walk into the clinic with systolic pressures of 80s to 90s. Maybe slightly dehydrated. Will they be okay with just a prescription of ORS? or should I send them to ED for IV rehydration? One of the good things about being here has been developing a heightened sensitivity for the “eyeball test” and clinical judgment based on just history and physical.

The medicine attending here reminded me that as a physician, he doesn’t think about the cost; if the patient needs the test or treatment, then go ahead and order it. As for the rest, leave it to social work to deal with.

I will take this advice with a grain of salt.

Sample fees:
CXR = 250 LD (liberian dollar)
Chem 4 (Na, K, Cl, Co2) = 600 LD
Clinic visit = 50 LD
ED triage =100 LD
Ward admission = 2500 LD
Ward deposit for treatment = 2000 LD

There is also a fee to pay to remove a body from the morgue when a patient dies. It is sad and ?unethical to hear (from my pediatrics colleagues) that some parents were advised by other parents to carry their sick child home when they are almost about to die, as to avoid the morgue fee.

Survival of the fittest:
I’m convinced Darwin/Spencer’s coined phrase of “survival of the fittest” exists here. And I’m grateful for it. Otherwise, my time here would be much sadder with a higher death rate. There must be some in-grain resilience that runs through the genes here. If the life expectancy in this country is so young, then anyone who’s passed that expected age essentially “passed the test”.

One success story—actually, a real miracle—is of a 70-something-year-old guy who presented to the ED in flash pulmonary edema, oxygen saturation at 33%. Extremely tachypneic and dyspneic. Diuresed him crazily, slapped on nitro, and actually survived the night with partial ambu-bagging and nonrebreather mask on 5L (that’s the max), satting at 55% to 65%. Still oriented. Day 2, O2 sat came up to 70s-80s. Day 3, O2 sat to 90%. …Amazing, something I’ll never quite wrap my head around unless the objective data I was getting was false, but still, quite a miraculous case. Now, 10 days later, will send him home soon with outpatient rehab. Yeah!

Week 2: a rough week (part 1)

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

3/7/10

Over the weekend, my colleagues and I were invited to attend the LMDA (Liberian Medical and Dental Association) at the Firestone Hospital. Yes, Firestone—as in the headquarter plantations of the US rubber tire company of the same name. We saw never-ending hectares of rubber trees being tapped for latex. I got to see some greener parts of the country outside of Monrovia. It was refreshing. I heard that upcountry land is even more beautiful.

Modes of transportation
I just realized that there are no traffic lights or stop signs anywhere in the city or from between the city to the airport. Thus, one always hope that cars would yield if one is trying to make a turn or else crossing a street by foot. The roads have significantly improved over the past 2 years already by being paved and with street lights installed. There are still many parts of downtown and smaller streets with pot-holes and unpaved areas. Motor vehicle accidents, similar to global statistics, is not uncommon and likely near #1 cause of death. 1 month ago, a public bus driving across town rammed into a gas tanker that was on the side of the road. The mass casualty caused chaos for the hospital ER. I think 1/2 of the busload survived. One unfortunate evening, had to ride in a semi-stationwagon-like taxis with 9 other people (3 in the front, 4 in the back, and 3 in the hatchback trunk—absolutely crazy). Apparently this happens also not uncommonly. I’m just glad I wasn’t one of the statistics.

My frustration with X-rays
This week has been one long mission on getting chest x-ray for my patients. First, the x-ray machine was not working. Then the x-ray machine was fixed but no films were available. My patient who had a pneumothorax, PNA, and pleural effusion, with chest tube was unable to get a CXR until almost 1 week later. Thank goodness he’s okay. Chasing after labs…also another similar story.

The rest of the week 1: a brief summary

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

3/7/10

Dear family and friends,

So the rest of the week breezed by quickly. On my first day of rounding with my team of interns and medical students, I learned that it was the last official day of school for the 3rd and 4th year students before they enter their 1 month study period prior to final exams in April. How disappointing! I barely got to know them and now they’re leaving the wards. However, a smaller team does have its advantages too, so I’m looking forward to working with my 1-2 interns for the rest of my time here.

A bit about the medical school: it appears to me there is only 1 medical school in the country. Studies and training were heavily disrupted by the war. Thus, the current class of interns consists of 13 doctors, but the 4th year class will be graduating close to 30 students and same with the 3rd year and so forth. After medical school graduation, internship at JFK requires 2 months rotation through medicine, surgery, ob/gyn, peds, ER, and other subspecialty. Then there is a several months period where they get further procedural/surgical training to prepare them for their time upcountry or in the bush, when they became the generalists who will head the clinic in the bushes. I’m not sure if this upcountry posting is required or not.

One of the reason I chose to work in Liberia was so that I could better communicate with my patients without a translator. For the most part, that has been the case. However, I’m sure there’s much more to learn.
(Medical) Liberian English:
-small small- can mean slowly or better
e.g. doc: “how are you feeling today?”
patient: “small small” = “I’m feeling a little better”

-Spot positive = HIV positive
-Koch’s disease = TB
-feeling hot = fever
-stomach running = diarrhea

The pathology is quite varied. Many malaria (the great mimcker here) cases as inpatient and OPD(clinic). Quinine is the 1st line drug used here. Almost everyone who comes in complaining of feeling “hot” gets a malaria smear and widal test (typhoid). Many new diagnosis of hypertension (high blood pressure) and diabetes.

Other cases seen thus far:
-pulmonary tuberculosis, abdominal tuberculosis, tetanus, pyomyositis, rhabdomyosarcoma, schizophrenia, pyelonephritis, pneumonia, bronchitis, congestive heart failure, liver cirrhosis, acute renal failure, oral candidiasis, kaposi’s sarcoma, diabetic ketoacidosis, flash pulmonary edema, urinary tract infection, hypertensive urgency/emergency, post-traumatic stress disorder, etc.

A lot of pleural effusion and ascites. Learned to put in a chest tube.

And a few even more interesting cases:
-persistent hiccup
-a girl who presented to clinic with h/o intermittent “barking like a dog”. Diagnosis made by referral doctor was rabies (but girl was bitten 10 years ago). My colleagues and I think it may be tic disorder/tourette’s syndrome.

The weather is very hot and humid here, even though the hospital is 2 blocks away from the coast. Occasionally there is a breeze that comes through. So many people are dehydrated, coming to clinic hypotensive or constipated that I’m mainly telling them they need to drink more water besides prescribing bisacodyl (the only laxative on the formulary). Even my CHF patient I’m telling them to drink more water.

Again, thanks for your prayers and encouragement. I’m very thankful to be happy, healthy, and safe. I’m still working on posting photos (I’ll have to shrink the files cause they are do big to upload).

Days 1-3

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

3/6/10

Day 1: Arrival
Exhausted from the long flight but as mentioned in my last post, arrived safely to the dorms. Also had many layovers en route, but did not get to leave the airport or see much of the land from aerial view since it was either dark or I was sitting in the aisle seat. When I arrived,the immigration officer only stamped my passport for a 30 days stay despite me having a 1 year visa. This was quite unexpected. However, later I found out that this has been the norm for most of my fellow volunteers since late last year. Hopefully, the extension will not be too difficult.

First impressions (from while waiting at the airport to arrival to the dorms):
-very hot and humid (it felt like 40 C)
-lots of UN vehicles and personnel on ground
-very beautiful sunset
-dangerous driving conditions

Slept very well that night.

Day 2: Getting to know the hospital and the people
I decided to immediately dive-in to get to know the system. Luckily, I did not suffer much significant jet lag. I was also fortunate to have a fellow internal medicine resident, also from California, to work with me for the 4 out of the 5.5 weeks that I will be in the country. Though the hospital was relatively big, I quickly found my way around places and soon met most all the attendings, resident, interns, medical students, and administrators.

The day started with morning report, where the post-call intern and PA gave a brief report of the overnight events, including deaths and new admissions. Then the 3rd year student presented the full H+P and impressions—or essentially the problem list. Thereafter there was the monthly grandrounds. The topic of that day was by the ophthalmology dept on ectropion and entropion.

In the afternoon, one of my colleague’s patient died of septic shock from an incarcerated umbilical hernia. Surgery wouldn’t take her to the OR beforehand because of her massive ascites. Overall, it sounded like all parties were limited to do much more for her.

The hospital tour: JFKMC is a good-sized hospital w/ 4 floors (out-patient dept, Med, Peds, Surgery, Ob-Gyn/OR/L+D), though not all areas are completely renovated and operational yet. OPD (out patient dept) is huge with separate areas for pediatrics, ob-gyn, surgery, and medicine. I heard from someone that 1000 patients are seen daily. There is also a surgery/trauma and medicine/peds emergency room.

The hospital was established in 1968 and was the country’s largest referral center up until the time of the civil war that took place between 1989 to 2003. The conflict took much toll on the hospital and now it’s still in recovery mode. It is still the major referral hospital for most of the local clinic and smaller hospitals in-town and up-country. There are maybe at least 10 other public/private hospitals in town?

Finally in the evening, I got to meet the rest of the HEARTT (http://www.heartt.net/) volunteers and learned to play a scrabble-related game called Banangram. Currently, I’m with 1 med resident, 1 peds attending, and 1 ER resident. They are really a great bunch, and I already like them a lot. Earlier in the month, there were also some ID attendings visiting. I heard that next month there will be a few more ER and pediatrics residents coming. This is exciting because I got the impression that not many people rotated through this place, but apparently HEARTT has volunteers from many other places in the US besides the J+J scholars program.

Day 3: Hospital Tour

The medicine ward is divided into 2 sides with 1 team on each side. Today, observed medicine rounds. DKA apparently is quite common here as the first presentation of a diabetic patient since routine labs and check ups are extremely rare. There is a lady in the ICU with a chronic hand ulcer and presenting with DKA. This is not necessarily anything new, but the degree of infection and ulcers/abscess/wounds people present with is mind-boggling at times. Why were they unable to come into the hospital earlier? Many people try “country” medicine first because it’s cheaper, thus one reason for the delay to coming to the hospital.

I will try to post some pictures soon (I think the photo files are too big and the internet is slow here).

Heard about hospital admission costs: (conversion rate 1USD = 70LD)
ED fees = 100 liberian dollars
Hospital admission: 2500LD (plus 2000LD in advance for meds and supplies)
ICU admission: 4500LD

Patients need to pay upfront before they can even enter the ED triage or wherever they need to go. There was a highly publicized case of a young man who was very ill, came to the ED, could not pay his triage fee, and was refused admission and literally DROPPED DEAD outside of the ED. The family refused to take the body away until the press came.

And once they are admitted, they have to pay their hospital fees before being discharged. If unable to pay the fee, then they can’t leave the hospital and continue to accrue further debt while they stay in the hospital. There is a lady who owes 34,000 LD, and I wonder when she’s ever going to leave. I hope the hospital social worker will be able to help in cancelling her debt.