I will start by attempting to summarize our work on these two weeks, since that is what we came to do. I am told we completed 63 surgical procedures. My count is more around 52, but they tell us 63 because they count things like a bilateral hernia repair as two procedures, or they will count an incidental appendectomy along with the hysterectomy with which it was performed. At least 20 of these were open cholecystectomies (gallbladder removal). There were also a number of hysterectomies (much thanks to Bill Leach) and hernias. The first week we operated like crazy since we had both general surgeons and gynecology scheduling cases in parallel. To schedule a case is to make a promise as these people (underresourced rural Bolivians) only have access to non-emergent surgical care for these two weeks out of the year. We operated past 8pm on three of the five days and the local hospital staff was gracious to stay so late and to work so hard to allow us to care for so many people. We pushed their electricity, water supply, and personnel resources to the brink, and maybe a little bit past it at times. The second week (general surgery only) was a bit more tame and we actually made it to dinner on time 3 out of 4 nights, not that any of us would go hungry. They fed us like pigs on this trip... Actually, they even fed us a pig. A whole one. He was kind of crispy.
If I tell one patient's story, I will tell you about a man I will call Jaime. With an ever- shrinking world, I have changed his name, though I'm pretty sure they don't have HIPPA down here (I think they call it Hee-Pah). Jaime is 40 years old. He walked into our consult room with a downward, avoidant countenance. He was with a much younger woman who we would later find to be his daughter. He was gently cradling his right lower abdomen. He didn't say much. When it came time to examine him, he asked that his family leave the room, a request not made by most of our patients. He then lifted his shirt and showed us why he was here. Jaime had a colostomy, or maybe an ileostomy - we couldn't quite tell. It was prolapsed by about two feet into a plastic grocery sac secured around it with a rubber band (For non-medical types, this means he had two feet of inside-out intestine protruding from his abdomen into a loose fitting Wal-Mart sac). You could tell by the way he cradled it that it was tender.
Jaime had been stabbed in a bar fight about 7 years ago, perforating his bowel and giving him peritonitis. Fortunately he was able to have life-saving surgery, but the colostomy was necessary to prevent ongoing infection. It could have been reversed a few months after surgery, but Jaime did not have the resources to pay for that procedure. He was likely not even been able to pay the bills from the first hospitalization, so the colostomy stayed. Over the years, the abdominal wall began to weaken and the bowel started to prolapse out further and further. In a country with a paucity of properly fitting colostomy bags, this is a big problem. He constantly smells of excrement and must use one hand to support the weight of the bowel to keep it from prolapsing further. Employment prospects are grim, social stigmatization a given. Moreover, Jaime's lifestyle (which had resulted in the bar fight in the first place) had resulted in estrangement from his family. Guilt and depression are as evident as his colostomy. In past years, however, he has reconnected with his daughter and ex-wife, and they have helped him make it to Santa Rosa in hopes of having his colostomy reversed.
Though we do not have all the details on his original procedure, it looks feasible to attempt a reversal. Even if scar tissue is severe, we could at least revise the stoma and fix the prolapse. The biggest risk is that the suture likes will leak. If this happens, we would need to reoperate and create the colostomy once again. We are hoping we can perform the procedure through a small incision around the colostomy and avoid re-opening his larger midline scar, but we must be prepared to do so if necessary. He signs the consent, seemingly out of resignation, though he clearly wants the operation. He has no questions. He barely makes eye contact. He doesn't even seem to have hope in a favorable outcome. Maybe he is afraid to. We will do his case on Monday so we can watch him closely afterwards.
Monday comes and we take Jaime to the OR. Jean puts him to sleep. He is connected to two cardiac monitors and three pulse oximeters, all this in hope that at least one of each will be functioning at any given time as we are operating during peak power usage and there are frequent surges or brief outages. I am able to reduce his prolapse once he is asleep, and for a brief moment, it actually looks like a "normal" colostomy. In the end, the
procedure goes quite well. We are able to complete it through the small incision as we had hoped and with minimal contamination of the wound from the intestinal contents (this operation has about a 30% infections rate). We are pleased. In the recovery room, I am able to guide Jaime's hand to the site where the colostomy had been. Though tender, he feels its absence and I think I may have seen the beginning of a groggy, hesitant smile.
I should mention that we have had somewhat of a translator shortage during the second week. James and Jenny have returned to Cochabamba, Elizabeth has nursing classes in Santa Cruz, and Yoko is with the clinic team in places where Butch and Sundance haven't even been. Francis is our only translator, and my Spanish is still apparently so poor that I cannot even ask how to find him without a translator. We later learn that one of his disappearances was while he was on the ward talking at length with Jaime. This is how we came to know much of his story. Francis encouraged Jaime to look at this event as a chance for a new beginning. Just as his colostomy was no longer visible, so also could his pervasive sense of guilt. He had already changed his ways of drunken carousing, but he had yet to live free of the shame which had accompanied that life. Now free from the sight and the smell of his colostomy, he could should also live free of that shame. He has been forgiven by his family, but needed to know that He has also been forgiven by his Creator and can and should learn to forgive himself... to live as a forgiven man.
In Matthew 8, Jesus is approached by a leper. This man too bore a physical ailment that symbolized a sense of shame and filth. He says "Lord, if you are willing you can make me clean." Jesus simply says "I am willing" as he reaches out and touches the man, not only healing him physically, but also showering unconditional approval on him from God Himself. But He is not finished. The statement of God's willingness to heal is followed by a charge, maybe even a command: "Be clean." The man was not to go on living like a leper. He was no longer to be isolated or ashamed. He was even to boldly approach the purveyors of clean and unclean and declare himself a new man, clean and unashamed. So too can and should Jaime live a new life of forgiveness and acceptance. He tells Francis he will do this. They talk and they pray together.
I love it when I cannot find Francis. He is usually doing something like this.
I have so much more to tell, but I would not be surprised if you have already stopped reading by now. Maybe if I find time, I can tell you of our pig-roast with the mayor, or possibly of lounging in a pool at sunset with Cher, Beyonce, and a Germam dairy farmer named Norman (you think I'm kidding, don't you).
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