Apologies for my failure to update my blog but only once during the project. I meant to write more often, but those plans were waylaid by a wonderful fortnight that simply left little time for blogging or for the reflection I find necessary in order to write a worthwhile post. Now that I am on an airplane seat flanked by two boring/ snoring businessmen, I have had time to think and get to the task at hand. I’m going to save a general overall project for another post – we’re still tabulating the statistics and getting feedback and stories from team members, so it’s not quite time for that yet.
In brief, I am told we performed 82 surgical procedures and saw well over a thousand medical, dental, and optometry patients. To be honest, it really didn’t seem like that much since things ran so smoothly. Many hands indeed made for short work, and short, efficient work makes for boring and uninspiring blog posts, so maybe that’s why I didn’t write very many. Now that I have some time to reflect, my mind turns not to the statistics, but to people, their stories, and still the greater story that encompasses us all. So pardon the verbosity about to ensue, but it’s a long flight and I’ve had some caffeine.
We were a few days into the project and had settled into our groove. All the moving pieces both inside and outside of the operating room were coming together – the fruit of an experienced and well-prepared team. It is also the product of a fairly predictable case-load of overdue elective surgical procedures on otherwise healthy patients. Years ago, in a different context, my dad once told me that while a well-organized plan is very important, the people God most needs us to serve will often present as interruptions to those plans. Sure enough, just as our well-oiled machine was hitting full-throttle, we started to get consults from the inpatient wards – sicker patients, diagnostic dilemmas, and heartbreaking stories that come from the poorest corners of a broken world. This time, the interruption came in the look of an unsmiling 14 year old boy. His name is Lazaro.
Laying on his right side, unable to hold back tears, his left hip was partially flexed and he was either unable to unwilling to move it. He had high fevers and a high “white count,” serving as sure signs of a severe infection somewhere. He was tender all over the left side of his body – his abdomen, his flank, his back, his hip, and his thigh, though nothing showed itself on the surface. He had already been on antibiotics for a couple of days without improvement. He was so frightened and in so much pain, one could not tell if the infection were in his abdomen (wrong side for appendicitis), his hip joint, or deep in his retroperitoneum (behind the abdominal cavity in an area that makes walking extremely painful). He would need an operation, but without a CT scan to guide us, it was hard to tell where one should cut. Lazaro was sick.
Lazaro was also poor. I’m not sure how far he had to travel to reach the hospital, but it was clear he was from the countryside (the “campo”), and I’m sure the journey was excruciating (he mostly came via motorcycle taxi on roads of mud and dirt). His grandfather heard surgery and worried about the cost – he could not even afford to continue the antibiotics. We were able to provide them and to reassure him they would not be charged for the operation. We booked him for an exploration the next morning.
Not only was Lazaro poor, but he was also lonely. He lives with his aging grandparents. His father is dead and his mother, likely struggling with severe mental illness, wants nothing to do with him. So while his tears and cries spoke of his physical pain, there was a deeper sadness in his eyes that spoke to an abandonment that his grandparents were unable to assuage. This was despair, or as Kierkegaard would say, “a sickness unto death.”
We took Lazaro to the operating room the next morning. Based on his exam, I decided to perform a retroperitoneal exploration through a small incision on the lower left side of his abdomen. If he had an abscess deep in the back of his abdomen, this would allow us to drain it without contaminating his abdominal cavity. When we were unable to find anything there, the same incision allowed me a good look into his abdomen, which also was quite normal. 0 for 2, but we at least had only made one small incision. With him under anesthesia, we got a good exam, but could feel nothing else to guide any further incisions. The exact location of his infection would remain a mystery for now, as I could not bring myself to create more wounds, pain, or suffering. We would keep him on antibiotics while waiting for the infection to declare itself, hopefully without spreading or doing irreparable damage.
His fevers subsided, but his pain did not. By Sunday, it became clear that his pain was centering in the area of his hip. We were able to get him to move his joint though, which argued against an infection within the joint itself. We made arrangements to use the hospital’s (ancient) ultrasound machine in the operating room the next day in hopes this would guide a targeted exploration through his thigh muscles.
Needless to say, Lazaro was not excited to see us. Though despondent and numb, it seemed the only thing that would animate him was his fear of another surgical procedure, but with his abuelo’s consent (and little bit of Versed), he reluctantly allowed us to take him. With him fully asleep, the ultrasound indeed showed us a poorly defined abnormality three inches deep into his hip musculature. We made our incision and probed deeply in that direction, but initially found nothing. This was frustrating. Too aggressive of an exploration can damage the muscles and tendons, prolonging his recovery or adversely affecting his gait long into the future. But missing the infection a second time was not an option as life and limb would eventually be in jeopardy. Stephanie, our 4th year surgery resident, saw something on ultrasound that I could not. She could my finger was glancing off the side of the target and challenged me to plunge a sharper instrument at a slightly deeper angle. She was right on. Pus flowed out of the wound (sorry for those with weak constitutions) as I broke up septations within a large abscess cavity. Thankfully, it appeared to spare the actual joint space. We washed him out with lots of sterile fluid and antibiotics before placing a dressing and taking him to the recovery room.
The hardest part for the doctors, finding the infection and getting it drained, was over. The hardest part for Lazaro, was now to begin. Damaged by infection, surgery, and days without significant movement, his muscles were in no mood to get moving. Though his fevers were gone and his wound looked good from day to day, he did not want to get out of bed for long and he would become paralyzed with fear even at the sight of me, not quite believing my reassurances of “no mas cirugia.” And while he would tell us that his pain was much better, the look on his face told us that he still suffered much. Lazaro needed to walk. He also needed a friend and encourager. But my white coat and my scalpel disqualified me.
This is where our large and varied team comes into play. Fearing that he might develop full-blown “gringophobia,” I dispatched Yoko, our Bolivian cook/ nutritionist/ evangelist/ and counsellor to spend the morning with Lazaro. Why Yoko? If you have to ask, then you have not had the privilege of meeting her. She personifies compassion and patience. She knows how to listen, then to encourage, then to challenge those who are hurting, whether they are our patients, their families, or even members of our own team. At first Lazaro was not pleased to have a visitor, but within an hour they were coloring together and she was reading him stories and listening to him talk about his interest in cars he someday would like to ride in. That afternoon, he got up and hobbled across the room to the bathroom.
The next day, I asked Michelle, our team’s physical therapist, to come and help Lazaro walk further. This required her to take a taxi from our clinic location half an hour away and would take her away from those duties for much of the afternoon, but she seemed to relish the opportunity when we told her his story. She also borrowed a cane from one of our own team members with hip problems of their own. They were glad to lend it, even if it would make their own day quite a bit more difficult. We had Yoko warm Lazaro up for a second visitor. Michelle wore a pink jacket rather than a white coat. Still, he did not seem excited to have yet another visitor, but he eventually complied and let her help him with his gait. By the time we were finished with the day’s operations, he had walked up and down the hall three times. Even still, he agreed to walk a few steps towards me so I could observe. It wasn’t a smile quite yet, but his mouth showed something new: determination. To make the moment perfect, the radio down the hall actually played the “Rocky” theme song right as he stood up from his wheelchair. (I promise I am NOT making that up.)
As we arrived at the hospital for what would be our last clinical day and entered the back hallway, the first thing we saw was Lazaro, walking, unassisted – no IV pole, no cane, no helper. And while he still limped, it was actually his other leg that had stiffened up a bit from bearing the load so much the day before. Now he was bearing his full weight on his infected leg, and he bore it well. Lazaro was alone in the hallway, but now his aloneness stood as a sign of victory rather than defeat, and it came as the fruit of loving encouragement rather than abandonment. Still, he tightens up with fear and anxiety when he sees me. Still, he does not smile when I beckon.
For me, one of the most challenging things about surgery, especially when children are involved, is that we often must inflict suffering in order to heal. The pain of a procedure almost always precedes its benefits, and children have a harder time understanding or believing this than do (most) adults. Moreover, the permission to operate is granted by parents or guardians often, over the objections of the patient himself. While this does not bother me from an ethical standpoint, it does come at a relational cost. It violates a trust, and this may hamper a patient’s willingness to cooperate with subsequent treatments or therapy. This is why surgeons need a team – others who have not violated that trust and can thus gain the patient’s active participation in their own healing. Were it not for Yoko, and then Michelle, Lazaro might still be lying in bed, wondering if he could ever walk or even if it would be worth it to try.
I never did see Lazaro smile, but others tell me they did. I’ll take it.