2018 Togo Blog

Dr. Cheatham and his family have been serving since 1986 on short-term medical mission trips through Samaritan's Purse & World Medical Mission, Inc. In August, I will be serving at Karolyn Kempton Memorial Christian Hospital / Hopital Baptiste Biblique (HBB) in Togo, West Africa. For those that are interested, I will be maintaining a blog detailing my experiences. Internet access may not always be reliable, but I will try to post interesting cases and photos on a daily basis. If you have questions about what we are encountering here, feel free to drop me an email.

August 18, 2018
After leaving Orlando yesterday and flying through Newark-Liberty International, I arrived in Lome, Togo around 2:30 PM. My two bags, full of much-needed antibiotics and other supplies for the hospital were some of the last bags off the plane. For quite a while, I wondered whether the bags had made the connection in Newark or whether they had been tampered with in transit, both of which has happened during previous trips to Africa. All was well this time and customs was a breeze. They initially wanted to examine the suitcase full of meropenem after x-raying it, but immediately waved us through once they heard it was for Hopital Baptiste Biblique (HBB). The drive to up to the hospital was similarly uneventful thanks to our driver. I am always amazed that there seem to be even more motorcycles on the road with each trip that we make. Donkeys used to everywhere, but I didn’t see a single one today. Now it is motorcycles carrying the driver and up to FOUR passengers plus cargo per motorcycle: boxes, bags, chickens, goats, cattle, sofas, bookcases, and even coffins are balanced on the handlebars and back. Cars, trucks, motorcycles, and pedestrians are all crowded onto narrow two-lane roads, each assuming they have the right-of-way. No wonder that motor vehicle crashes (road traffic accidents in African parlance) are such a common source of patients at HBB. In fact, we encountered a car vs. motorcycle crash about an hour from the hospital. No victims that we could see, but the car was severely damaged, and the motorcycle was off in the woods 50 yards away. We arrived at the HBB guesthouse around 5:30 PM. I unpacked and the antibiotics and other supplies were in the hospital within the hour. After a quick dinner and some reading, I turned in around 9:30 PM, hours earlier than my norm, but trying to make up for poor sleep on the overnight flight from Newark.

August 19, 2018
Wow! Is that what 8 ½ hours of sleep does for you? I awoke early, ate, and headed for the hospital for morning rounds. HBB is much as it was when I was last here 2 years ago. There are much-needed plans to rebuild and expand the hospital in the coming years as it is bursting at the seams. Patients will travel the 2-3 hours from Lome, bypassing other hospitals, in order to receive care at HBB. They come from neighboring countries as well. The HBB full-time missionary physician staff is seriously depleted right now with Dr. Russ Ebersole serving as both pediatrician and internal medicine physician and Dr. Tom Kendall serving as surgeon and hospital administrator. Dr. Mary Boggs is serving as a short-term surgeon until next Monday; it was great to catch up with Mary after meeting her at the Eastern Association for the Surgery of Trauma (EAST) meeting a few years ago. It was also great to see the physician assistants who have stepped into the gap of missing physicians at HBB over the past few months. I caught up with both Mary and Tom in the operating theatre. Tom caught me up to speed on how he runs the surgical service now and the three of us did a few dressing changes on patients under ketamine. Mary and I will be taking every other night call this week to give Tom some time to focus on hospital administration. We reviewed the operating schedule for this coming week and it looks busy. Tomorrow’s elective cases include a total hysterectomy and a modified radical mastectomy and split-thickness skin graft. The smell of necrosis that was immediately apparent upon walking into the hospital this morning was from a 18-year-old man that Mary and I took to the theatre after the dressing changes. He was involved in a road traffic accident in Ghana 9 days ago in which he from ejected from his car and thrown into the forest. He laid there for 3 days before he was found and taken to a hospital in Accra where his left upper arm laceration was closed. He then travelled the 5 hours from Ghana to Togo, arriving at HBB last night. Upon arrival, his left arm was mummified and necrotic. It was obvious that his humerus was fractured and his elbow dislocated. It appeared that he had developed compartment syndrome of the left arm with loss of perfusion of the distal limb. We performed a guillotine amputation of the left upper arm, removing the necrotic tissue, glass, stones, and maggots still in the wound while trying to preserve as much tissue as possible for future closure. We take for granted the ready availability of an organized EMS and trauma system back home. As we operated, Mary and I had to wonder whether his arm could have been saved had he received proper care earlier. We will take him back to the operating theatre tomorrow for further washout and debridement. As we finished, Russ brought us an abdominal x-ray of a 16-month-old who has never had a bowel movement without an enema. Almost certainly Hirschsprung’s Disease, we are resuscitating the child and will plan to perform a colostomy on him tomorrow.

August 20, 2018
We started the morning with a medical staff meeting and devotions. Tom Kendall and I started the day with a Caesarean section and bilateral tubal ligation. It was good to see how Tom does the procedure and refresh my memory as HBB's obstetrics ward was closed when I came in 2015 and there was an OB/GYN physician here when we came in 2016. Mary Boggs started her day with a modified radical mastectomy and axillary lymph node dissection for an infiltrating ductal carcinoma the size of a volleyball! Once Tom and I were finished with the C-section, I scrubbed in to provide an extra pair of hands on the mastectomy while Tom further debrided and changed the dressing on the young man who required a guillotine amputation yesterday. Tom and I then operated on the 16 month-old with probable Hirschsprung's Disease performing biopsies of the rectum, transition point, mid-colon, and appendix as well as a diverting colostomy and mucus fistula. His abdomen was 1/3 of its original size when we decompressed the colon. His mother was quite pleased. In addition to a few other dressing changes, we spent the afternoon in clinic seeing post-operative wounds and scheduling cases for this coming week including several hernias, a hysterectomy, and a radical nephrectomy. The surgical diversity in a mission hospital never ceases to amaze me. Once out of clinic, we were faced with an open radius fracture, facial trauma following a road traffic accident, and a middle-aged woman with an active upper GI bleed who has received 4 units of whole blood so far today. Mary and I performed an emergent EGD on her, ruling out esophageal varices and finding blood throughout the stomach. The available gastroscope was not great and the view of the stomach was already dark because of the blood. We briefly saw what appears to be a gastric tumor, but before we could confirm this, she became markedly hypotensive and we had to decompress her stomach and abort the EGD. As the surgeon on call tonight, I just rounded on her before turning in. Her blood pressure is much improved and she is awake and talking with her family. We will continue to resuscitate her this evening and likely attempt another EGD in the morning with a new gastroscope that was just sent out to HBB by Samaritan's Purse.

August 21, 2018
Internet access has been very poor the past day or two so I was unable to upload to the blog yesterday. Today it is much better which is a huge help. With the diversity of surgical problems one faces in a mission hospital, you become dependent upon looking things up online and emailing other surgeons around the world for ideas and suggestions. Duing rounds this morning, we discussed the best course of action for a young man who has developed severe osteomyelitis of his left shoulder and left hip. Both have multiple draining sinuses which we have opened and change the dresings on daily in the operaing theatre under Ketamine anesthesia. His pelvic x-ray shows a severe osteoclastic response of the left hip, acetabulum, and iliac wing. We are continuing to drain his infection, but are looking to how we can best give him a function left leg instead of a chronically flexed and infected left hip. Time to "phone a friend" and get some ideas from other surgeons. Unfortunately, the woman with the probable gastric tumor passed away during the night. Her family had discussed taking her home to pass when I spoke with them last night. We decided to attempt another EGD this morning with a new gastroscope as they wished to know whether she had cancer or not. For many patients here, they must make a financial decision between having surgery or not. The cost for an exploratory laparotomy is only $250-350, but that is a fortune for many patients. We would therefore likely not proceed and have the family incur a significant debt if we felt that the procedure would not change her prognosis. After rounds, Tom Kendall and I did a hysterectomy and bilateral salpingo-oophorectomy for fibroids. Her uterus was quite large and she was uncharacteristically obese for a Togolese woman. The procedure was prolonged due to her size, but went well. Mary Boggs knocked out several smaller cases while we were in the other room. Today is a Muslim holiday in Togo so several patients either cancelled or did not show up for their operations today. We only have one operation scheduled for this afternoon so we will see what comes in to triage. Even with the holiday, we are slated to complete almost 30 surgical procedures this week. HBB remains very busy with patients in every bed and some staying on the floor.

August 22, 2018
Today is, in theory, a non-operative day at HBB. Nevertheless, we still have six cases to do. Our first case this morning was a young woman who developed herpes zoster of the left chest and breast. She went to a local tribal doctor who applied a caustic substance to her left breast to treat her pain. She presented to HBB with full-thickness necrosis of the skin of the left breast sparing the nipple. Mary Boggs had previously debrided the necrotic skin and has been using negative pressure wound therapy to clean the wound up. We have debated split-thickness skin grafting vs. an attempt at primary closure in recent days and chose to try the latter. Mary raised superior and inferior mastectomy flaps this morning and we closed these over the breast tissue and around the nipple "island". The procedure went quite well and this will give her a much better cosmetic result than skin grafting. In addition to several other dressing changes under ketamine, we also debrided and applied a VAC to the young man with a traumatic amputation of the left arm this morning. The wound is cleaning up well. We are trying to preserve as much upper arm length as possible so that he can use it functionally. Our young 16 month-old boy with Hirschsprung's Disease (who looks like he is around 3 months due to his failure to thrive) is now a voracious eater! He is obviously trying to make up for lost time. His ostomy and mucus fistula swelling is decreasing. We are closely following a 2-year-old girl with the pediatric service who is jaundiced and has an obviously inflamed gallbladder on ultrasound. It is unclear as yet whether she has a biliary tract obstruction or whether she has been given some form of herbal medication with resultant liver toxicity. Tonight I am on call. We were presented with a 68 year old Fellani man who presented with a one-month history of abdominal pain that has become progressively worse with nausea and vomiting over the past two days. A firm mass was present in the right lower quadrant and he had rebound tenderness. We have just finished exploring his abdomen where we found an abdomen that was full of metastatic tumor. His cecum was encased in tumor resulting in a complete obstruction of his intestine. We attempted to find some colon that we could bypass to, but his abdomen was too involved and additional surgery would likely only commit his remaining days of life to being in the hospital. We closed his abdomen and have explained his dismal prognosis to his wife and son. They seem to understand, but I am sure that much has been lost in translation From English to French to Ewe (the local language) to Fellani (the patient's language). Walking back to the guesthouse, Mary and I were met by a large, black scorpion on the path. It is easy to forget that we are in the middle of what could be considered jungle. There are numerous birds, poisonous snakes, lizards, and toads that roam the compound. One can also hear monkeys howling off in the distance (in addition to the three monkeys that are pets of the missionary children here!).

August 23, 2018
The remainder of my night on call was uneventful. HBB remains very busy with every patient bed filled and patients on gurneys in the hallway. After we made morning ward rounds, Mary Boggs and I spent three and a half hours performing a modified radical mastectomy and axillary lymph node dissection on a young woman with a ulcerated breast cancer. Her tumor weighed approximately 15-20 pounds. She had spent years using her left arm to support the weight of her breast. This was one of the largest breast tumors I have ever seen and had numerous venous collaterals that took time to meticulously control. Her long thoracic nerve and thoracodorsal nerve were perhaps the most obvious that I have ever seen. While we operated in one room, Tom Kendall worked on our young man with osteomyelitis of the hip and pelvis, drilling the femur and greater trocanter to drain any pus that might be present. He found necrotic bone, but no obvious pus. After lunch, the three of us split up a variety of cases including bilateral inguinal hernias, a ventral hernia and lipoma excision, an exam under anesthesia for a fistula-in-ano, and multiple dressing changes. The 16-month-old with probable Hirschsprung's Disease continues to improve and has had his first ostomy output (which his mother is quite proud of). Our breast reconstruction from yesterday is also doing very well as is the hysterectomy from Tuesday.

August 24, 2018
Today was a busy day in the operating theatre. We started the day with a Caesarean section for breech presentation. Tom Kendall let me do this one, with him assisting, which was a good refresher. We delivered a healthy baby girl with a large umbilical hernia which we will need to repair at some point in the future. I then did a right inguinal hernia in an 11 year old boy that I had seen in clinic last Monday. He was very stoic as they put in his spinal anesthetic and never cried or even whimpered once. I hadn't done a pediatric hernia in some years; a high ligation of the hernia sac was all that was required. In the afternoon, Tom and I did a bilateral tubal ligation as a quick case before we did a few VAC changes under ketamine. As the surgeon on call, I saw two consults in the afternoon. The first was a patient with a massive inquinal hernia which had been present for 30 years. He had significant loss of abdominal domain. There was concern for a possible bowel obstruction as the source of his abdominal pain, but the intestinal contents of the hernia were moderately reducible. He also had a small, but reducible epigastric hernia which appeared to be causing him pain. His real problem, however, was a very large hepatoma of the liver. Liver disease is much more common here than in the U.S. His liver was largely replaced by the tumor which is no doubt his primary problem. We discussed this with the patient and family and the fact that we unfortunately have no treatment for him at this time. The second consult was an elderly diabetic male who presented with foot pain. He had an obvious puncture wound of the heel which was draining purulent, foul-smelling fluid and gas consistent with gangrene. He had no palpable pulses in either foot. We explained that amputation was almost certainly necessary. He asked that we do "everything possible" to save his foot. Amputation of the foot (if you have read my blogs from previous trips) is a death sentence for many patients here as they are unable to work in the fields plus their family must now care for them. There is rarely any way to find them a prosthesis and if they do ambulate, it is with crutches or a tree branch as a crutch. We placed him on broad-spectrum antibiotics with little hope that it would make a difference. We have scheduled him for debridement first thing in the morning. While this might seem to be an emergent procedure by U.S. standards, such cases are routine here and you try to preserve your operating room staff for true emergencies at night. The patient and family also need some time to come to the realization that amputation is the only way to save his life.

August 25, 2018
I only received one call during the night regarding the patient with the liver tumor. The staff was wondering when we were going to fix his 30-year-old inguinal hernia. Even in the absence of his liver tumor, we would still have not fixed his hernia as return of his intestinal contents to the abdominal cavity would likely not have been tolerated at all. He is, like many Africans, very thin with a small abdomen. Hernia repair would likely have resulted in significant respiratory issues and we have no mechanical ventilators or ICU here. As Mary and I made ward rounds this morning, his family was wheeling him out of the hospital to take him home. There is no hospice here; the missionary physicians here do what they can to provide patients with palliative care, but the volume of patients who could benefit from a formalized hospice team is quite large. There is a very successful HIV/AIDS team in the local community. Mary and I were able to discharge several of our post-operative patients from this week. They are all doing well for which we give thanks. Our probable Hirschsprung's patient is gaining weight rapidly as all he does is eat. His face is beginning to fill out and he is much more awake and alert than he was at the beginning of the week. It is very gratifying to to see his improvement. We took the elderly diabetic patient to the oeprating theatre this morning. His necrosis and gangrene is much more extensive than we had expected, but not surprisingly. We placed him in Dakin's dressings and will show the wound to the patient and family as we continue our discussions regarding the need for amputation.

August 26, 2018
Mary and I made ward rounds, completed several dressing changes, and changed a VAC dressing in the operating theatre under ketamine, all by 10 am. After a busy week with almost 30 operative cases, we have been able to discharge many patients in preparation for the coming week's operative schedule. Each of the remaining patients is doing very well. The sole exception is the young girl with severe liver dysfunction. Although her liver function tests continue to decrease, she is now pancytopenic and showing signs of cutaneous hemorrhage. We remain puzzled by what is causing her organ dysfunction. We are continuing to speak with the elderly diabetic male with a gangrenous foot. What had appeared to be potentially viable in the operating theatre yesterday is frankly necrotic today and will require further debridement. He remains hopeful that conservative management will save his foot, but this will not be the case. Mary will be departing to return home tomorrow leaving Tom, Zack Greenlee (our physician's assistant), and me to staff the surgical service. I am on-call today and as of this evening, the hospital appears to be very quiet...

August 27, 2018
Today is Surgery Clinic day at HBB, but we still had several operations to do this morning before heading to clinic. We changd the VAC dressing on the patient with the traumatic arm amputation and I was able to primarily close approximately 30% of the distal wound today. This will preserve an additional 10 cm or so of upper arm length which will help with his longterm functionality. We reapplied a VAC dressing and will hopefully be able to place a split thickness skin graft on the upper portion of the wound by the end of the week. In addition to two other VAC dressing changes, Mary and I operated on a patient with a massive right renal cyst. She had initially thought that she might be pregnant again, but a CT scan at another hospital showed a very large simple cyst of the kidney. We drained and marsupialized the cyst wall, packing it with omentum. Mary left me to close her abdomen while she ran back to the guesthouse to finish packing before heading to the airport at lunchtime. Just before lunch, I spoke again with the elderly man with the necrotic foot. We had a very good discussion, through Efrem (one of the Togolese physician assistants) in French. The patient eloquently explained that he has had a good life, has lived for 75 years, and is ready to die if need be. He would prefer to be home with his family and does not believe that amputation with significantly prolong or improve his life. He thanked us for attempting to save his foot (and life), but asked that he be discharged home to be with his family. In the afternoon, Tom, Zack, and I staffed clinic and scheduled a number of patients for surgery either this week or the next. The internet has been running slightly better today which has allowed us to at least read and reply to some emails. You forget how dependent we have become on the internet in our daily lives. Here in Togo, there is only one internet and cell carrier for the entire country. It is grossly overloaded and underequipped for the number of users and frequently crashes. I am on call again this evening and just returned from a consult for acute hemorrhoidal bleeding and rectal prolapse. It is not as bad as it might have been. We will see what the rest of the night brings.

August 28, 2018
We had a busy operative day today at HBB. Tom took one room while I took the other. Tom did a hysterectomy and pediatric hernia repair in the morning while I did a pediatric colostomy takedown and two VAC dressing changes. After lunch, we did a split-thickness skin graft to the penis, scrotum, and testicles in a patient who had developed Fournier's gangrene and undergone debridement at another hospital. He arrived here with exposed and granulating testicles that had retracted into the suprapubic tissues above his penis. After lunch, we saw several consults including a 35 year old male with an infected left molar who presented with Ludwig's Angina (infection tracking down the neck from an infected tooth). I have encountered this several times in previous trips to Africa (where there is no dental care to speak of), but this was clearly the worst case I have seen. The patient had a fluctuant mass with subcutaneous emphysema in the right neck and also the right shoulder. We took him to the operating theatre and opened the submandibular space first. This is the classic location for Ludwig's Angina. He had some selling there, but no obvious pus. We removed his infected molar and then turned our attention to the right lower neck and posterior triangle. On opening the neck, we were met by pus, necrotic tissue, and gas under pressure. We followed the infection medially where it tracked along the carotid sheath and down into the mediastinum on the left. We debrided whatever necrotic tissue we encountered. Without a CT scan, don't know the full extent of his infection an necrosis. We packed the neck and mediastinum and placed him on broad-spectrum antibiotics including Penicillin G, Clindamycin, Rocephin, and Flagyl. In the States, we would have kept him intubated and on a ventilator, which we don't have here. We therefore extubated him and took him out to the "Reanimation" (the recovery room) adjacent to the nurse's station. It became quickly clear that he was unable to maintain his airway without a continuous jaw-thrust manuever and could not clear his secretions. Our Canadian respiratory therapist, Chris Penny, did a great job working with him, but it became apparent that he was not going to improve. To avoid an airway death in the middle of the night, we returned him to theatre and performed an awake tracheostomy under local anesthesia. This was what he needed and he is now awake, alert, and maintaining excellent arterial oxygen saturations. If he is going to survive this infection, he will require numerous trips to the operating theatre so a tracheostomy will serve him well. The rest of the night on call was uneventful.

August 29, 2018 - I have not been able to upload to the blog for three days due to the erratic internet service.
Tom had to go to Lome (the capital) this morning so Zack and I covered the service. We returned last night's patient with Ludwig's Angina to the theatre and reexplored his neck and mediastinum. There did not appear to be any further pus draining which we were pleased to see. We repacked the wound and returned him to the HBB equivalent of the ICU. On physical examination this morning, he had some subcutaneous emphysema in the left chest wall. Chest x-ray does not show a pneumothorax. We are concerned that this may mean that his infection has spread deeply into the mediastinum. Hope fully, the antibiotics will make a difference. I was able to primarily close over half of the young man with the amputation's arm; we will place a skin graft on the upper portion of the arm on Friday. We also changed the VAC dressing on the young woman with advanced breast cancer that Mary performed a radical mastectomy on last week. She should be ready to skin graft Friday as well. As we only have one dermatome, and it needs to be sterilized between uses, we can only schedule a single skin graft a day if the dermatome is needed. We will plan to harvest a small skin graft with a Weck or Watson knife to close the amputation and use the dermatome for the breast skin graft. We take much for granted back home and are used to being able to do multiple similar procedures each day. Here, where you may only have one of a particular instrument, or limited supplies such as suture or Jackson-Pratt drains, you have to use the supplies sparingly always considering that you may need it for a future patient. Wednesday is normally a light day in the operating theatre. The OR staff was happy to be done by lunch as they are very excited that the hospital soccer (football) team is scheduled to play a rival team at 3 pm today. The afternoon today was very quiet, which allowed me to work on my September 7th General Surgery Grand Rounds on volunteering in Togo. This evening, we were sad to hear that the 2-year-old with severe liver dysfunction has died. Her liver function tests have continued to improve during the week, but her glucose has dropped consistent with liver failure, she has become severely neutropenic, and she has developed scattered hemorrhagic skin lesions. Russ Ebersole had sent viral cultures to Lome to rule out hemorrhagic fever yesterday, but the results have not returned as yet. Her mother is obviously distraught, but especially so as the family in Benin had wanted to hold a special animism ceremony to cure her. She elected to bring her daughter to Togo and HBB instead. The family told her before she left that it would be her fault if her child died by going to a hospital. There are layers of culture and tradition here, along with the severe limitations of diagnostic and pharmaceutical therapies, that we do not have to deal with in the U.S. It is comforting to recognize that without HBB and its staff, many more patients would die or suffer as a result of their injuries / illnesses.

August 30, 2018
I operated last night on an 11-month-old who presented just before midnight with an incarcerated right inguinal hernia. We were unable to reduce it, even with sedation, and took him to the operating theatre where his terminal ileum was incarcerated, edematous, and contused. I was able to reduce it by opening the internal ring significantly and then repairing it. We finished around 2:30 this morning and he is already looking better. Today is a busy operative day for HBB. I started the day with umbilical & suprapubic incisional hernias and bilateral large hydroceles while Tom did a massive right thyroid lobectomy and a thyroglossal duct cyst. As I was finishing my first case, the staff came in to report that a woman on the Maternity Ward was not progressing appropriately and they were sugggesting urgent Caesarean section. She has already lost her first pregnancy due to failure to progress. I performed my first solo C-section and delivered a healthy baby girl named "Yawa" for "Thursday". Interestingly, she will have the same birthdate as Kaitlin, my eldest daughter, who turns 25 today! This afternoon, we will be skin grafting the face of a woman who required radical debridement for infection, changing a VAC dressing on an infected inguinal hernia done in Lome, and reexploring the neck of the man with Ludwig's Angina. The variety of operative cases here is amazing. Tom Kendall and I have begun preliminary discussions about the possibility of an ORMC surgery resident rotation here at HBB.

August 31, 2018
Today is my last day at HBB. Friday is normally a clinic day, but we are trying to wrap up a number of patients with wounds that we have been treating over the past 2 weeks. I started the morning with a bilateral tube ligation and followed this with a split-thickness skin graft to the left breast in the young woman who required a radical mastectomy for probable breast cancer. Tom did a few VAC changes in the other room and then we joined up to re-explore the neck and mediastinum of the young man with Ludwig's Angina. His fever has broken overnight and he remains on Penicillin G, Clindamycin, and Rocephin. He is complaining of some right lower chest pain which we suspect is due to the almost certainly extensive inflammation in his mediastinum. He is tolerating his tracheostomy and beginning to take some liquids. We remain very worried about him as we have little else that we can offer him. We debrided some additional necrotic tissue and repacked his neck and mediastinum. Tom will return him to the operating theatre tomorrow. I then did a quick epigastric hernia that we had seen in clinic on Monday and followed this up with a split-thickness skin graft to the remaining upper arm wound on the 18 year old with traumatic amputation of the arm following a motor vehicle crash. He now has a functional left upper arm amputation stump that he should be able to use in his activities of daily living. The staff resterilized the dermatome so that we could do a second skin graft today; it was still steaming when it was brought into the room and we had to cool both the dermatome and mesher off with sterile water just to touch them! For both skin grafts, I used a trick that Tom had shown me using Dermabond to adhere the meshed skin grafts and prevent movement. It works very well and is much faster than suturing grafts in place. Just before lunch, Tom and I did an urgent Caesarean section. Eight cases done by lunchtime. The operating theatre staff was getting it done this morning! This afternoon, we saw the few clinic patients that Tom had not seen this morning between his cases.

September 1-2, 2018
I left HBB at 7:00 am and was driven to Lome by Kofi. We had a wonderful discussion of Togolese culture and family dynamics on the way to the airport. Air travel in Africa is always interesting. Checking in for a flight is usually a bit of a madhouse and you have to allow extra time due to long lines and customs. The same Ethiopian Airlines representative checked my ticket and passport three times from my arival at the airport to boarding the plane. My travel home was a bit more circuitous than my inbound trip from Newark to Lome. I was routed from Lome to Addis Ababa, Ethiopia to Dublin, Ireland to Washington, DC to Orlando. 10,695 miles and 36 hours of travel from HBB to home. Every flight was essentially on time and I arrived back home without any difficulty. It was great to get home to family. Overall, it was a very rewarding and trip and I certainly got more out of it than I gave. I look forward to sharing my experiences during Surgical Grand Rounds on September 7th at 8 am.