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.