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Monthly Archives: April 2013

At Hand

I should be packing my suitcase, but there is only one hour of daylight remaining and I would rather spend it in a hammock surrounded by bromeliads, date palms, and the birds that inhabit them. A quick look at my weather app tells me this opportunity will not be available upon my return to Wisconsin. After this, we have a mayoral dinner and he apparently has a tast for tapir, armadillo, and javalinas. So if Montezuma doesn’t get me, the PETA operatives might (please don’t tell them). By the time the sun rises tomorrow, we will be checking into the Aeropuerto. Hoping for a less harrowing experience this time, I have made sure all the laryngoscopes are in Jon’s suitcase.
( http://campbellexploratorysurgery.blogspot.com/2012/11/bourne-in-bolivia.html )

The last 24 hours have been truly remarkable. I can hardly find words, but those who know me know that this will not keep me from trying.

Yesterday morning, in this same hammock, I was reading Matthew and pondering what it means for the kingdom of heaven to be near, to be “at hand.” I’ll admit, I’m still feeling around the edges of that concept even as I try to be obedient to its implications. How does this mean I should pray? How does it mean my prayers might be answered? Alas, no epiphany; at least not before breakfast.
We soon piled into the back of Rueben’s truck (1985 Toyota Land Cruiser, sans seatbelts, speedometer, odometer, cup holder, muffler… you get the idea) and were headed to the Hospital – about a. 20 minute drive away. We had an ambitious day ahead of us. Did 4 cases Monday, 5 on Tuesday, why not 6 on Wednesday? And why not make them big ones (comparatively)? The day started as they have all started – slowly. Difficult to say why – it is always the sum of a million little things, none of which are worth the haste or rudeness it would take to overcome them. I have begun to accept that we will always do two operations before lunch, no matter how large or small they are, there will be two; no more, no less. They went well. Lunch was delicious as usual. This left four cases for the afternoon. So much for making it back to the hotel before dark.
First case of the afternoon was the largest of the day. A huge hernia, I had cringed upon seeing it in the consultation room the day before. She had her gallbladder out two years ago in Santa Cruz. Whatever they closed her facia with didn’t work, half her GI tract now living in a basketball-sized bulge drooping down over her right hip. No binder or girdle can contain it, she must constantly lean to her left when upright. I usually prefer to take on such cases earlier on in a project (more time for follow up) and when we have multiple surgeons (even if only so there is someone else to talk me out of it). But she has no other recourse and she is why we are here. The case takes a long time – much of her colon and small bowel are adherent to the walls of the hernia, making things tedious and a bit bloody. The mesh (polytetrofluoroethylene + polypropylene patch to repair the hole in her abdominal wall) went in well, though (much thanks to mesh donations from Dustin Willette with Atrium!) and we were able to move on to the last few cases (more gallbladders and some smaller hernias).
About an hour later, we receive word that her blood pressure is low. Really low. Certainly, it must be the cuff, or maybe the size of her arm (big). If she were bleeding, her heart would be racing (it wasn’t). We gave her more IV fluids and Franz kept checking and re-checking the BP. Different cuffs, other arm… still low. Really low. One liter of saline, then two – still low. Heart still not racing. We finish our cases – it’s now around 7:00pm. We have the lab personnel come in so we can check a blood count. It’s low. She has bled. She might still be bleeding internally, but her pressure is too low to put her back under anesthesia – just taking a look could prove deadly. She needs an ICU. We’re in San Carlos.
An hour or so later, she’s had more fluid and her pressure is stabilizing, not normal yet, but improving. It will be a few hours before even re-checking labs will be useful. We must wait. I feel powerless, but at least they have a blood bank if things get worse. We leave her in the hands of the on-call doctor and a straightforward plan: she will spend much of the night at her bedside with us on the other end of the phone. The weary team returns to the dark hotel. After a shorter, quieter dinner, I headed back to the room. I couldn’t sleep, so I started packing my suitcase (mostly souvenirs… also known as coffee) in case I wouldn’t have time later. Sure enough, a call came around 11:30. Pressure was lower. Could we come back in?

Pretty quickly, Franz, Paola, Jon, and I were piling into the back of Rueben’s truck. Mariela, a volunteer from previous projects, had come up from Santa Cruz that afternoon to bring us cookies and help out. Our day went too late for her to head back, so instead she came to the hospital with us as well. It was a cloudless night, cold, or maybe Reuben was just driving that fast. The red, half-moon was setting in the West over the mountains, the stars were brilliiant and inumerable. I prayed for our patient while I stared at them, knowing their distance, feeling small. Surrounded by the heavens, yet they seemed anything but near.
In spite of road blockades developing both to the East and West of us, we managed to make it to San Carlos in under 10 minutes. We weren’t the only ones making the unscheduled trip. The laboratory personnel and sterile processing staff had also come, just in case they were needed. They would sleep all night on hallway benches.
The lady was sick, really sick. Visibly swollen with the fluids she had received, her pressure was low, and now her heart truly was racing. A hemisphere away from my own ICU, there was not much I could do. Surgeons operate and give orders… that’s about it. She was too sick for an operation, and I don’t speak much Spansh, especially when tired or anxious. I felt quite small.
Around me however, an ICU started to form. Jon grabbed meds from the OR to temporarily support her blood pressure while starting a larger IV in her swollen arm (because this is what Anesthesiologists do). Mariela was able to translate the detail instructions we gave out (because that’s what she does). Paola placed a foley (urine) catheter. Franz knew where all the supplies were as he had been manning the ward all through the day. The Bolivian phlebotomist managed to find a vein in a swollen yet dehydrated arm (because that’s what they do). The blood count was low, but not beyond reach. The blood bank lady showed up with 2 units of cross matched blood – O positive – and the tubing to transfuse it. Jon hooked it up, and when it couldn’t drip in fast enough, manually pumped it in using a large syringe as a piston.
Sure enough, her pulse started to slow and strengthen. She became more arousable. Some urine even started dripping through her catheter – the kidneys were still working. The second unit now running in, it was now time to wait. Or to pray for her together, as Mariela would suggest. We found some unoccupied benches in a lonely hallway, together making our requests known in whichever tongue came most naturally. We could hear the beeps from the monitor echoing down the hall. Subtle differences in their pitch tell of the trend in her blood pressure and oxygen level – they were rising.
We returned to the ward and watched the second unit finish going in. Another half hour and she continued to stabilize. She was more awake and said she was feeling better. We put together a plan and Mariela communicated it to the hospital doctor and nurses. It was almost 2:00am. In spite of the blockade now backing up to San Carlos, we were still able to make it back to the hotel. Later that morning, she looked great. Her labs would show that the bleeding had indeed stopped (I will never know what bled, but I’m blaming the omentum) and that her kidneys had survived the adventure. She was hungry.

My day had started swinging in a hammock, my mind in an esoteric cloud of theories about how God might answer prayers from His heavens which are apparently near. By night, I was offering up real prayers from the bed of an ancient pickup truck while staring at stars which were billions of miles away in these nearby heavens. How would God answer?

It is not without reason that he calls us His body. When I needed knowledge to do what I could not technically do, he gave me Jon. When I needed tongues to speak, He gave me Mariela. When I needed safe transit amidst blockades, he gave me Reuben and at truck without a speedometer. When I needed to know I was not alone, he gave me dear friends to pray with, and it struck me that while I was sending prayers to Him, I was doing so WITH his very body, which was also the same body with which He chose to answer the prayer. How does He answer prayer? In person, then it would seem. And that is indeed heavenly… and near. Amen.

 
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Posted by on April 19, 2013 in Uncategorized

 

We’ve got problems

I’m tired. We did five more cases today and have promised another 10 or 12 (# is always changing) in our last two remaining days. The operating tables are too low, so my back hurts after about 10 hours of standing. The lights are never quite bright enough, so my eyes are tired as well. The patients’ families are always stopping me in the halls with questions… in Spanish no less. Each day, we spend almost all the daylight hours in the hospital, missing out on any opportunity to enjoy the beautiful weather this week. There seems to be more and more work to do with fewer and fewer people to do it. We lost Wendy on Saturday, Jim on Sunday, Elizabeth on Monday, Marie on Tuesday… It’s like a bad episode of Survivor. We’ve even been attacked by a hungry emu. You must feel really bad for me.

Meanwhile, families across the US grieve over loved ones lost or maimed in a senseless bombing in Boston. Half a million people live in forced labor camps in North Korea while their leader sells their rice to buy Plutonium. People across the Bolivian lowlands wait years to have their gallbladders removed, suffering pain after most their meals. One need not look far to put my petty little problems in perspective.

We have had a wonderful project so far. My sides are literally aching from laughing so hard with our team. It is a joy to serve alongside people who can do serious work without taking themselves too seriously. Laughing at ourselves (and the things we usually complain about) is one of the ways we have reacted to being confronted with so many people whose problems far outweigh our own. Such irony has actually helped us to ignore our own (small) discomforts and better enabled us to empathize with our patients down here. (Klatt) shared a video on YouTube (link below) that just about sums it up. I hope it lightens your mood (as it did ours).

http://m.youtube.com/watch?v=ybDKfGEw4aU

 
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Posted by on April 16, 2013 in Uncategorized

 

Walking the lines, finding the planes

It is Saturday morning. I am resting in Santa Cruz after dropping Wendy at Viru Viru for a long flight home to a still snowy upper Midwest. Francis’ two year old daughter, Melina, is snuggling next to me, not so secretly hopping for something more exciting to appear on the iPad screen. Her 6 year old sister has already put on a gymnastics performance for her distinguished audience and tutored me a bit in Spanish. We enjoyed a breakfast of huevos, queso, and jugo de manzana. Makes me miss my own ninas.
I will miss Wendy much this week – the whole team will. From a practical standpoint, she put her multi-tasking skills to good work and became an integral part of all the different aspects of our project. Her servant’s heart and smile were more infectious than the local protozoan could ever hope to be. It was wonderful to have her here again as she becomes a part of my Bolivian family as well. Personally, she has been a steady and durable companion, one who has walked the fine line between listening quietly in my moments of frustration and admonishing me to regain my focus when these frustrations prove to be born of selfishness, shortsightedness, or a lack of faith. Did I mention that I will miss her?

When one operates, whether it be on a stone-filled gallbladder or an orange-sized thyroid lobe, the difference between a smooth case or a bloody mess is often a matter of a fraction of millimeters. Organs are separated from adjacent tissue by fine planes where blood vessels are few and what one sees looks more or less as it is shown in the anatomy textbooks. Find that plane and the operation will proceed quickly, safely, and with almost no blood loss. The mood is light during such procedures. We can make small-talk, joke about each others’ Spanglish, discuss the next case. All is copacetic. Miss that plane by less than a millimeter however, and things are different. Bleeding ensues. Blood loss is generally frowned upon. First of all, it’s blood; we each only have so much of it to lose. Though stated as an axiom: “all bleeding stops eventually,” the truth is that I would prefer it to stop sooner rather than later, preferably right now, thank you. Bleeding also obscures one’s ability to see what is what. It is as if a child came and smeared red fingerpaint all over those nice, precisely illustrated anatomy textbooks I mentioned – except the paint is precious blood and I am the child. Frustration builds as one tries to find his way back into the correct plane – a good surgeon will be able to stay calm through this time – walking the line between haste and efficiency, between confidence and careless bravado. Sometimes, this is when a more experienced surgeon can be of great assistance, not by actually doing anything different, but simply by being there with the knowledge that he has been there and done that and that the bleeding did and will stop.

Similar planes are to be found in other aspects of these projects. Do I constantly push for process improvements/ increased efficiency, or do I “go with the flow” and adapt myself to the normal pace of San Carlos? After all, the more procedures we can do, the more people we can help. But we can also do so at the expense of the people we are serving with, and this must be taken into consideration as well.
Do we take on a long, difficult procedure – one with higher risk and reward? Or do we transfer them to the bigger city and instead do four or five simpler procedures where the outcomes are less in doubt? In doing so, I am showing a lack of faith and missing an opportunity to transform a life? If we take on the challenging case, are we turning away others and missing the opportunities to serve them? It is difficult sometimes to find the bloodless plane between faith and stupidity, between caution and doubt. Sometimes it seems this plane does not exist, just as it does in some operations. A good surgeon will calculate the risk, remain calm, and complete the operation, risks notwithstanding. As I have said, all bleeding stops… eventually. The surgeon who is not able to proceed in such scenarios – he will soon become paralyzed by the fear of even missing the plane in the first place. He will take on less and less risky procedures until he can do very little at all. And God forbid a lawyer ever get involved.
I think the same applies to our role as servants of God and our fellow human beings. I once thought faith was essentially trusting that God would always work out or correct the outcome of our misadventures to one that everyone would find acceptable. I can easily quote some Bible verses (out of context) to support this theory. Unfortunately, this theory falls apart quickly when real life gets messy. One’s vision is obscured. One’s confidence wavers. Will the bleeding really stop?
I am nowstarting to learn that faith is not the assurance of a particular outcome, but rather the assurance of God’s acceptance and partnership as we serve, even though the outcome of our service may remain an indefinite mystery. Two things are certain: we will mess up (probably more often than we’d like to admit) and God is still with us if we ask Him to be (which I do less often than I should). He wants us to serve in spite of the risks. He wants us to negotiate those planes. After all, He has infinite experience, as we know He can handle bleeding.

*Please note: No patients actually bled to death in the creation of this blog post. Everything is hemostatic in San Carlos.

 
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Posted by on April 13, 2013 in Uncategorized

 

Getting it in gear

Four days have gone by already – we are starting to hit our stride in the operating room and it’s amazing how time flies when every moment is not one of frustration. We managed to get six procedures done on Tuesday: two gallbladders, a large thyroid, and three hernias. We were still frustrated by instrument and linen delays, so the six procedures kept us working until about 7:30pm and we still postponed two cases for the next day (maybe my expectations were a bit too high). I could sense tension between the instrument staff and our own team and this was only exacerbated by the language barrier and our poor understanding of their normal procedures. At the end of the day, I found Francis (he had been in Santa Cruz haggling with customs officials about an upcoming project) and had a chat with Vasilica, their head instrument tech. Found out they are down one autoclave and have to reprocess gowns and drapes in the same one as the instruments. It takes twice as long for the drapes to cool and dry and this slows down the instrument cooling time. They also have only six gowns – we will typically use three per operation. Result of conversation: We will borrow some gowns and drapes from the hospital in Santa Rosa (site of last November’s project – about an hour’s drive away).
Wednesday ran much more smoothly – we did seven cases (two gallbladders, a thyroid, three hernias, and a leg lipoma) and actually finished by 5pm. We didn’t even have the gowns from Santa Rosa yet, but the second autoclave was back up and running and we started having the scrub tech (or whoever is functioning as such) go without a gown (gloves only) since they don’t really have to “belly up” to the patient. This gave us gowns to cover two cases at once while some were still in the autoclave. We really didn’t have to use many disposable supplies at all.
With the early finish, John, Jim, and Brenda walked up to the San Carlos square to get some ice cream. I saw a couple more consults with Marie and we watched the hospital staff play soccer. We actually made it back to the hotel before dark too.
Today, we did another seven procedures (three hernias, a goiter, a gallbladder, a facial debridement, and cutting and closing the web-space on a 1 year old with syndactly of his hand) and were finished by 4:30. Part of me regrets not scheduling more, but we never know how long we will have Ulysses, the local anesthesiologist. He has been more than willing to help, but he covers emergency cases in 5 or 6 towns and occasionally has to disappear for an appendectomy in Yapacani or a C-section in San Juan. Today we had him all day until 3:00, so we were able to run two tables the whole time.

I has been great to see the team gel both personally and with our work. We are also building better relationships with the local staff. Jim is really good at making small talk with the local staff and taking real interest in their background/ education/ training, etc. Brenda has been a huge help in the OR – she’s taken charge of making sure the next case is ready to go, that the equipment and suture are ready, she has circulated (being the supply gopher while everyone else is scrubbed in), scrubbed cases, assisted procedures, functioned as an orderly, cleaned the room between cases, and all while receiving constant teasing from Dr. Klatt (please note: this NEVER happens in Manitowoc). Alas, she has not yet made us breakfast, but there is still one more week to go.

It has been a lot of fun scrubbing with the Bolivian docs Paola, Franz, and Sarona (a.k.a. Smurfette – Pitufina en espanol). Dr. Ricaldy, the local surgeon, has also scrubbed the bigger cases and Ulysses will even start a spinal, then scrub to assist on the larger hernia cases. There is a lot of Spanglish and laughter emanating from the OR as we all start to habla the same lingo.

Wendy has memorized the exact location of every stitch, needle, syringe, glove, dressing, drape, gown, drug, tube, or drain in the supply room. Since we have to wear a hot gown or change clothes to leave the OR area, she has been a big help in bringing us needed supplies on a moment’s notice. All I have to do is buzz her on the walkie talkie and she will bring me exactly what I need right away. She assures me that this service is not available at home and that she will be hiding the walkie talkies upon my return. She has also been helping dispense and explain prescriptions and eyeglasses in the pharmacy which serves as a the main hub of activity for the team’s various functions.

Between cases, I usually go over to the consult area with Marie (Nurse Practitioner from NC – and one who gives me stiff competition in the coffee-consumption department). She has usually found a few people with gallstones or hernias for me to see, and she usually has one curveball patient with an as-yet unintified parasitic disease. I hope me shrugging my shoulders helps her feel better. With very limited laboratory capabilities, we are often stuck referring the more worrisome cases to ID specialists down in Santa Cruz.

Well, one day left for week number one, then Jim, Marie, and Wendy head back to the US and it’s just John, Brenda, and I as the only gringos left. Looking forward to another trip to the coffee plantation this weekend. (You can submit your orders via private message, but I can’t make any promises).

 
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Posted by on April 11, 2013 in Uncategorized

 

Donde esta el equipo?

Just a quick update on our doings so far… sorry, but don’t have the energy to write a long, detailed description. Afraid that would wind up reading like so many of my previous posts anyways.

No matter how many times I do this (directing my third project here in the past 15 months), I always seem to be surprised and caught off-guard by the inefficiencies in our process. We only managed to do two of our own operations on Monday – I guess I should be pleased since that included the entire unpacking process as well as seeing about 25 surgical consultations through the day.m We may have already booked as many cases as we can realistically do for the entire week. This at least gives me even more reason to turf anything gynecologic to the next guy (whoever he is, I hope he knows how to wield a speculum).
The end of the day got especially frustrating when we were asked to stay and help with an emergency case with the local surgeon (specifically, to do his anesthesia). As we were preparing for this, a woman in labor was falling to progress as well and we nearly bumped the emergency bowel case to do that, but then we heard a baby crying in the delivery room, so things must have come out alright. Jim (Sindard – surgeon) and John (Klatt – anesthesia) stayed and helped with the bowel case (a sigmoid volvulus from Chagas’ disease – a parasite spread by the kissing beetle) before finally making it back to the hotel around 9:00.

Today went a little better, but was still full of frustrations. They did not have our instruments (equipo) sterilized for the first two cases, so we didn’t get started until 9:30 or so. The cases themselves were not easy: the hernias are larger, the gallbladders are rotten, the goiters are larger and all the while the lights are too dim, the instruments too short or too dull, the gowns and drapes too few, and no one seems to habla the same lingo. Everyone is working very hard, both our team and the local staff, yet inefficiency and miscommunications seem to be a given. There is a fine line between pushing to move faster/ get more done and seeming unappreciative/ pushing people too hard. I pray people will forgive me when I cross it.
In the end, we managed to do seven cases (three hernias, three gallbladders, and a thyroid lobectomy). I am pleased with that, but I know we cannot even maintain that pace before we exhaust our supply (specifically drapes and gowns) or the local ancillary staff. Shoot, we might even be out of beds in the hospital already.

Tomorrow brings another day. We will be contacting our friends in Santa Rosa to see if they can lend us their gowns and drapes. I have promised the instrument processing/ laundry staff that we will try to let them off by 5:00pm (and I will confess some selfish interest in that goal as well). OK… gonna go for a walk with my super-helpful wife around the hotel grounds here. She really has been a godsend this week (though she informs me that I will NOT be allowed to radio commands to her in the walkie-talkie once we return home).

 
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Posted by on April 9, 2013 in Uncategorized

 

Next to me

There is a woman riding next to me on the plane, in seat 29E, sleeping soundly. This is wise of her, for it is an overnight flight and will ultimately land at the beginning of a long, hot day. I should do likewise, and maybe I will, but there are butterflies afloat somewhere along my upper GI tract, and the promise of the approaching beverage service, with gingerale to settle them is enough to keep me awake for now.

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This woman is now on her way to the other side of the world, where even the stars in the sky will not be the same as those seen from home. She has left her children behind in the care of her parents, maybe bearing both a twinge of regret and of relief, for in a sense they are both her calling and her constraint (as all callings are to some degree). She has left other things as well; familiar routines, friends in need, willing obligations, as well as the certainty of purpose such things bring.

Why? Could the man in 29D really deserve such company? Certainly not. But then again, can such trusting companionship ever be deserved? If not, at least it can be received with humble thanks, treasured and not taken for granted. That he must do. If he ever puts down his coffee and takes off his headphones, I will tell him this… how truly blessed he is to have such a companion along on his journey.

 
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Posted by on April 7, 2013 in Uncategorized

 

Let’s try this again

Previous blog post was supposed to include pictures, but the app basically deleted them. Gonna See if this works this time. br />
20130405-215806.jpg

hmm… wonder how a second photo will work:

20130405-220000.jpg

not too shabby. might stick with this app. wonder if I can copy paste to the other…

 
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Posted by on April 5, 2013 in Uncategorized