Tuesday March 1, 2011
My first three days in Bolivia have further opened my eyes to the realness of culture. Its hard to believe that in a world where one can be taking a medical exam in Chicago on Friday at 4 pm but arrive over 4,000 miles away less than 36 hours later that cultural difference are still capable of persisting, but it’s very real and it’s a nice surprise. While I love the American way of life, it’s refreshing to find that on a Sunday morning in Santa Cruz, Bolivia the streets are eerily empty, the stores are all closed aside from a few cafes and supermarkets, but the central plaza is filled with people of all ages sitting on park benches chatting and reading quietly to themselves. As I strolled the plaza I thought to myself, when was the last time that I had a day where nothing needed to be done? Where no textbook needed to be studied? No errand needed to be ran? No appointment scheduled? I sadly couldn’t recall. It certainly wasn’t a weekly occurrence. I thought this could be nice to spend the afternoon reading in the park. I found an open bench and opened my new free reading book- Cutting For Stone. I must have read the first 10 pages over and over again. I felt uncomfortable just sitting reading a book in a foreign country; there must be something to see, somewhere exciting to hit on the to-do list. But there wasn’t. So I convinced myself to sit and read for at least another half hour. It was refreshing.
The next morning I was eagerly awaiting my afternoon meeting at 3:00 and the patient neurology consult at 4:30. Finally, something to do! We arrived for the meeting a bit before 3 pm to find the doors to the clinic locked. We waited on the street for the next 30 minutes before being let-in by one of the receptionists. After another 20 minutes, the physician with whom our meeting was with finally arrived. However, he needed to see a patient first. We just sat and waited. It was now 4:30, still no meeting, but we had another appointment to be at. So we left, without the meeting. If that wasn’t frustrating to a timely American like myself, the afternoon just got better. We arrived about 10 minutes late to the neurology consult to discover that the patient was unsure how to get to the appointment so rather than call for directions, he just decided not to come. Therefore, the consult would be rescheduled for the following day. Two and a half hours after departing the house we had accomplished nothing. If I hadn’t been on vacation, forcing myself to embrace the culture and whatever came my way, this would have really irritated me. I learned that this is a common practice in Santa Cruz. Whether it be lunch dates with friends or business meetings, people come when they are ready and no one (but the Americans) seems to be frustrated or bothered by this lateness. I even asked one of the coordinators who had been there for months have you figured out what “late” means here? Meaning, if someone says 3pm does it mean 3:30, 3:45 or 5:00? She said it all depends and sometimes 3pm actually does mean 3:00 sharp. I think this is one cultural phenomenon that I am incapable of adopting. How does anything ever get done? It seems unfathomable in my mind, but it certainly must work for them. Imagining these exact same scenarios in the states makes me chuckle- the outcomes would have been very different.
The final cultural aspect I was bombarded with was on day number 3- Tuesday morning rounds at the hospital. We arrived a few minutes past the seven am start time and had to tip-toe quietly into the presentations that had already begun (see some things do start on time). It was a small room filled with rows of young people in white coats and what I inferred to be attendings in standard business attire. One resident presented his case and was promptly questioned and “pimped” by the chief at the front of the room. While the dialogue was completely in Spanish (so I wasn’t able to fully grasp the medicine), this meeting appeared to be extremely similar to rounds in the US. There were many doctors nodding off, some were eating their breakfast, others were coming and going and having side conversations about patients. Aside from the dialect I could have been right back at Loyola. The rounds on the ICU floor were also very similar to those that take place in the states. A resident presented the patient to their attending and was promptly instructed on how to improve. A small insight into how my third year might look. The discussion of patient care, the questions that needed to be answered, the medicines that should be dosed were all extremely similar. I sat in the lobby afterward trying to make sense of or take note of what my first few days had shown me. It took some time, but I realized that every country and every profession has their own culture and when you aren’t accustomed to it you feel uncomfortable and sometimes uncertain in how to act. While being at the hospital, I didn’t question my actions or my role. I struggled certainly with trying to understand the language, but I knew how to fit into the medicine culture. This was not so in my other adventures of the week. I also wonder at what point did I suddenly become comfortable with and accustomed to the culture that is medicine? Has it really only taken the past 18 months of medical school or did I learn this customs earlier in my life? If its true that I only learned them recently, then certainly it could be possible to adapt to a new culture or a new way of life in another country. I suppose there’s hope that I might one day be able to not feel uncomfortable without having a task at hand or be okay with a meeting that takes place 90 minutes after it was supposed to.
Saturday March 5, 2011
I'm now at the clinic and its more fun than the city of Santa Cruz, but it certainly comes with its challenges. Yesterday I saw a man who had come to the clinic in November and was diagnosed with kidney stones. He was sent on a consult with a nephrologist in Santa Cruz. For various complicated reasons between x-rays being lost, translation errors and not being able to reach the gentleman by phone he was told that he 100% needed surgery to remove the stones in early January, but he had returned to the clinic in March not aware of this. Can you imagine? I certainly cannot. Consistent painful, destructive kidney stones for four months! Obviously, all of us understood the importance that he needed to get this surgery as soon as possible. Well, the difficulty became that once we spoke to the Nephrologist he was able to see the patient that afternoon and potentially perform the surgery the next day. If not, then it was Carnivale and the nephrologists would be out of town for the following month. In the US you'd simply drive your car to the doctor have the necessary pre-operative tests at the hospital and be set for surgery; that was not the case here. Someone had to drive him to a nearby town (ie about 50 minutes from the clinic) for the xray and ultrasound and then we had to give him money and directions to take a bus to the doctor in Santa Cruz (another 90 minutes or so from that hospital). It was not the easiest plan to execute, but it was done. I don’t even want to think about what happens to individuals suffering from these ailments who are without an advocate from a clinic like this.
In the afternoons I have been traveling with Alice, a clinic coordinator and Maria, the clinic nurse, to the various towns that the clinic serves to help implement a new de-parasitization program. We spend the first few minutes presenting proper food handling and safety to avoid contaminated their food with parasites and then Maria discusses the importance of and the meaning of proper nutrition. We then proceeded to get the heights, weights and ages of all children who attended and provide them with albendazole and Vitamin A. On our last afternoon we treated over 80 kids in the afternoon ranging in age from three to fifteen. It was also Carnivale starting that weekend so the younger children were running around the school wearing homemade masks, painted on beards and banging on improvised drum sets. At the end of the afternoon I was beyond exhausted and ready to head back to the clinic for a cold shower and a nap when we were invited by one of the families to stay for dinner. I should have been elated and grateful, but instead I was irritated. I grudgingly (not visibly) drove to their home where they were preparing a homemade sopa for us. As we sat outdoors under a large collection of trees, dogs and roosters milling around us, listening to them discuss local politics and concerns my irritation quickly dissolved. Here I was a guest in their country and their home and I was being ungrateful because I wanted to what, sleep? Ordinarily being a conversationalist I tend to monopolize conversations in the states. However, with my fatigue and my sadly deteriorating Spanish skills I spent the next hour mainly listening to the conversation. It was a nice change. It was interesting to hear their thoughts and concerns. I feel blessed that these individuals had been willing to allow me to be part of their lives. Needless to say, it was a fulfilling day on so many levels.
Tuesday, March 22, 2011
Thursday, March 10, 2011
Chronicles of the DR
We arrived to the DR around 9 oclock local time and basically spent the first few hours of our visit waiting in various lines: $10 entry fee, immigration, baggage, customs and even a queue to leave the airport in the car because of an airport exit fee. I was rather convinced I would arrive to the DR to find that my baggage was still in Miami. Fortunately, this was not the case. My luggage actually arrived yesterday without me even though the American Airline peeps were resolute about my luggage needing to travel with me and this being the reason they would not allow me to fly standby. I was able to pick up my luggage from a rather shady storage area and we were on our way to ILAC. When I arrived several people expressed concern because they noticed my large suitcase I packed with ENT supplies arrived without me. I told them they should have opened the bag – I was inside the whole time. This received a few courtesy chuckles.
ILAC is located about 20 minutes from the airport and my first impressions of the grounds were very positive. It is very open with a courtyard in the center. There is also good security with a barbed fence and a guard dog – hopefully he will not need to pounce into action. There is wireless available so I have been able to email and even make a few calls. However, there is no air conditioning and Ill be sleeping under a mosquito net on a thin mattress – not to bad for roughing it in a developing country.
Breakfast starts at 6 am tomorrow followed by OR set up around 6:30 and the first case running at 7. This will be my first taste of surgical work in a developing nation and I am truly excited, though a bit nervous for the experience.
It's now day 2 of cases and I am completely exhausted. The fact that I have probably only slept about 7 hours total in the first two nights may be contributing. The first night I was unable to fall asleep not only because I slept for 10 hours the previous night but there were children and roosters making noises throughout the evening.
The days have been very full. We are waking up at 5:45, setting up the O.R.s by 630 and the first cases are starting by 7. Although the schedule only goes until 430 most cases have been going over. I am assisting with anesthesia for the T&A's which I like because there is quick turnover time and therefore more action for me. I have intubated more in the last 2 days then I did an entire month at Loyola. I feel myself becoming more comfortable, especially since I had never intubated a child before this trip. I have lost track of my overall record but I think I am about 60-70% success on the first try at this point. I really appreciate being involved in surgery because there is a real sense of accomplishment. You are part of a team that corrects a very practical problem to improve a patients life and more rarely save a patients life. I don't think there have been many life saving procedures here but we are certainly improving individual's quality of life. Patients are also very thankful and most have never undergone anesthesia or surgery before, unless they were treated by the medical mission last year.
We pick patients up in preop and as we walk them back to the OR there is clapping and cheering which is great fun. I am sure the patient feels famous for a brief moment.
We finished our last day of cases today and I am completely exhausted, still. We assigned one call night to each student and mine was last night. Although I had an uneventful night checking on the thyroidectomy cases (just changed an IV bag and emptied some drains), I still had to be up every two hours and I already had a sleep deficit. Nevertheless I made it through our final day in the OR without succumbing to death by exhaustion. I was even able to take a short nap tonight before we head out for dinner and drinks in Santiago. In total we completed 122 surgeries in 3 operating rooms over 4 days. The vast majority of cases were tonsilectomies and adenoidectomies but there were also thyroidectomies and 7 or 8 vascular procedures which take a much longer time to complete. Despite the hard work, the days have gone quickly and I have enjoyed gaining new experience in anesthesia.
Yesterday I had a “moment.” I saw in the eyes of several patients great trepidation about their pending surgery. I tried to place myself in their shoes – we walk them back into a strange room with several cumbersome machines and pieces of equipment, there is loud music blaring in the background and they are surrounded by doctors and nurses wearing masks and head gear speaking a language they don't understand. I felt very privileged to be part of the team that would help minimize their fear and help get them through the process safely. I think I have chosen a field where I can really feel satisfied in my work. However, in some ways I felt our work was not sufficient. The majority of us had limited Spanish and without a translator around we were not able to effectively communicate encouraging and calming messages during induction and wake up, though I think I did a better job preparing patients and walking them through the steps when I had a translator to work with in preop. Even so, I would have liked to better convey a soothing, calming message just prior surgery.
We had a couple close calls of nearly completing the wrong procedure on the wrong patient. There are several factors contributing to these near mistakes. First, the language barrier. Many patient have multiple, very similar names and because most of us don't speak the language all that well this sets up a high risk situation. Second, we are trying to treat as many patients as possible so the turnover time is very fast. Although we are trying to keep things very similar to the way things operate at Loyola there were times when we did not do a time out to ensure correct patient, correct procedure before first incision. I am thinking of speaking to Dr. Hotaling about attempting to implement the WHO surgical checklist during future trips to help avoid some of these difficulties though I am not sure of the feasibility/ challenges that may be associated with such action. One example where this checklist may have helped avoid confusion involves an incident where we completed a second priority operation when consent was for priority number one. A discussion was had with the family and in the end they were ok with both operations occurring at this time. I could tell that our thorough discussion of risks and benefits was something very foreign to the patients in the DR when receiving health care in their own country. This practice in our country has likely been greatly influenced by the legal climate in the US. Although I believe informed consent is important, there are times when one could argue informing patients of the 1 in a million risks that are associated with a surgery or anesthesia can cause more harm then good as a patient mentally prepares for an already very anxiety-provoking surgery.
Overall, I had a great time in the DR. I think I learned a great deal and this trip set a solid foundation for residency and future global health trips.
ILAC is located about 20 minutes from the airport and my first impressions of the grounds were very positive. It is very open with a courtyard in the center. There is also good security with a barbed fence and a guard dog – hopefully he will not need to pounce into action. There is wireless available so I have been able to email and even make a few calls. However, there is no air conditioning and Ill be sleeping under a mosquito net on a thin mattress – not to bad for roughing it in a developing country.
Breakfast starts at 6 am tomorrow followed by OR set up around 6:30 and the first case running at 7. This will be my first taste of surgical work in a developing nation and I am truly excited, though a bit nervous for the experience.
It's now day 2 of cases and I am completely exhausted. The fact that I have probably only slept about 7 hours total in the first two nights may be contributing. The first night I was unable to fall asleep not only because I slept for 10 hours the previous night but there were children and roosters making noises throughout the evening.
The days have been very full. We are waking up at 5:45, setting up the O.R.s by 630 and the first cases are starting by 7. Although the schedule only goes until 430 most cases have been going over. I am assisting with anesthesia for the T&A's which I like because there is quick turnover time and therefore more action for me. I have intubated more in the last 2 days then I did an entire month at Loyola. I feel myself becoming more comfortable, especially since I had never intubated a child before this trip. I have lost track of my overall record but I think I am about 60-70% success on the first try at this point. I really appreciate being involved in surgery because there is a real sense of accomplishment. You are part of a team that corrects a very practical problem to improve a patients life and more rarely save a patients life. I don't think there have been many life saving procedures here but we are certainly improving individual's quality of life. Patients are also very thankful and most have never undergone anesthesia or surgery before, unless they were treated by the medical mission last year.
We pick patients up in preop and as we walk them back to the OR there is clapping and cheering which is great fun. I am sure the patient feels famous for a brief moment.
We finished our last day of cases today and I am completely exhausted, still. We assigned one call night to each student and mine was last night. Although I had an uneventful night checking on the thyroidectomy cases (just changed an IV bag and emptied some drains), I still had to be up every two hours and I already had a sleep deficit. Nevertheless I made it through our final day in the OR without succumbing to death by exhaustion. I was even able to take a short nap tonight before we head out for dinner and drinks in Santiago. In total we completed 122 surgeries in 3 operating rooms over 4 days. The vast majority of cases were tonsilectomies and adenoidectomies but there were also thyroidectomies and 7 or 8 vascular procedures which take a much longer time to complete. Despite the hard work, the days have gone quickly and I have enjoyed gaining new experience in anesthesia.
Yesterday I had a “moment.” I saw in the eyes of several patients great trepidation about their pending surgery. I tried to place myself in their shoes – we walk them back into a strange room with several cumbersome machines and pieces of equipment, there is loud music blaring in the background and they are surrounded by doctors and nurses wearing masks and head gear speaking a language they don't understand. I felt very privileged to be part of the team that would help minimize their fear and help get them through the process safely. I think I have chosen a field where I can really feel satisfied in my work. However, in some ways I felt our work was not sufficient. The majority of us had limited Spanish and without a translator around we were not able to effectively communicate encouraging and calming messages during induction and wake up, though I think I did a better job preparing patients and walking them through the steps when I had a translator to work with in preop. Even so, I would have liked to better convey a soothing, calming message just prior surgery.
We had a couple close calls of nearly completing the wrong procedure on the wrong patient. There are several factors contributing to these near mistakes. First, the language barrier. Many patient have multiple, very similar names and because most of us don't speak the language all that well this sets up a high risk situation. Second, we are trying to treat as many patients as possible so the turnover time is very fast. Although we are trying to keep things very similar to the way things operate at Loyola there were times when we did not do a time out to ensure correct patient, correct procedure before first incision. I am thinking of speaking to Dr. Hotaling about attempting to implement the WHO surgical checklist during future trips to help avoid some of these difficulties though I am not sure of the feasibility/ challenges that may be associated with such action. One example where this checklist may have helped avoid confusion involves an incident where we completed a second priority operation when consent was for priority number one. A discussion was had with the family and in the end they were ok with both operations occurring at this time. I could tell that our thorough discussion of risks and benefits was something very foreign to the patients in the DR when receiving health care in their own country. This practice in our country has likely been greatly influenced by the legal climate in the US. Although I believe informed consent is important, there are times when one could argue informing patients of the 1 in a million risks that are associated with a surgery or anesthesia can cause more harm then good as a patient mentally prepares for an already very anxiety-provoking surgery.
Overall, I had a great time in the DR. I think I learned a great deal and this trip set a solid foundation for residency and future global health trips.
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