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.