Never give up in facing difficulties

It's a great day for me today. I was called up at 2:30am yesterday morning and later operated on a boy with typhoid peritonitis. I finally returned home at 1am this morning after assisting John with two laparotomies. I had worked almost twenty hours with only a short lunch break in between. But I am so excited that I can't stop writing this diary to share with you my happiness. I had done a PSARP (Posterior Sagittal Ano-Rectal Plasty, which is reconstructive surgery for an imperforated anus.) on a ten-month-old girl with imperforated anus and recto-vaginal fistula. The girl was brought to our hospital by her mother about two weeks ago from a place called Lofa, which is in the North of the country. It took them more than twelve hours journey to reach here. She had expected to have reconstruction surgery done. But we are supposed to only do emergency operations at Mamba Point. Besides, we do not have suitable instruments available and hence we had to turn her down. To prevent the ascending urinary infection, I performed a colostomy for her and referred her to the Mercy Ship (An American medical ship that comes to Liberia few times a year providing free reconstructive or cataract extraction surgeries). It took us a long time to receive a reply from Mercy Ship. There is no surgeon in Mercy Ship at the moment and we would have to wait until April for a reply. We faced a very difficult situation. It is impossible to discharge the girl home with a colostomy. Her mother could not look after the stoma in such adverse living conditions on her own. There would also be no supplies for the colostomy bag in the far North , which is much more barren even than Monrovia. The baby could die of all kinds of complications from the stoma. I so regretted that I might have done something wrong by creating the stoma for her. She had been fine for the last ten months without infection. She might continue to be well with the RV Fistula while waiting for the Mercy Ship. But now she has a bad prolapsed stoma. Or we can keep her here till April but that means a stay of two more months. It would be a great loss of our valuable bed spaces. I had once suggested operating here but John and others thought that it would be better waiting for Mercy Ship. They may have better facilities and expertise, but we don't have a concrete reply from them yet. This baby may not be accepted in April or they may not operate on her in April, as they need to wait for a Paediatric Surgeon who may come only once or twice a year. The best timing of reconstruction would be missed if delayed too long, as the newly formed anus needs to develop sensation to control continence, which is a procedure best performed at around six months of age. Technically, I thought we could manage such an operation here. I explained to the mother the options and their implications, the procedures, possible complications and consequences. We may not be the best choice but I had confidence that we could do it well. She wished us to operate here. If I decided to go ahead, I needed to have the timing right. I had to prepare how to handle any complications raised and how to best close the colostomy before I leave on 15 March. I struggled a lot. Is it in the best interest of the baby? Or am I finding reasons to operate? She only has one chance as the best result can only be achieved by the first operation. Can I make good use of this chance? Finally, I decided to operate. It was a smooth and successful operation. After watching the procedure, John was also convinced that it was a good decision to operate here. The procedure carries little risk. The operating anatomy is easily identified with the posterior approach. We can handle this well here although we need a lot of preparation and adjustments to our instruments. I am glad that my Paediatric Surgery training in London thirteen years ago has had its best application in Monrovia. I went to see the girl's mother who was waiting outside the operating theatre once the operation was finished. She was very happy and thanked me for my help. Her faith and gratefulness, I will never forget. The ward nurses were excited too. They came to the ICU to congratulate the mother and visit the girl. I told them we still have to wait for another ten days to know the final result. I am so happy not because of my success. I am happy because I think I have chosen the best alternative for the girl. Secondly, the staff had confidence in me. I remembered what Ian, the Australian anaesthetist had said to me, that the best place for reconstruction seems to be Mercy Ship but if I thought the best option for her would be operating here, he would support me. He could handle the anaesthetic risks. I discussed this with the MSF Medical Coordinator and the Field Coordinator beforehand and both of them supported my decision. The OT staff were happy that they could join me in the operation. I later took an opportunity to call my wife and my son, Andrew. I shared with them my happiness. I told Andrew not to withdraw in facing difficulties. He needs to identify his target and find means to solve the problems, and then he will succeed. Au Yiu Kai