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Turistas

A brief update.  Still no pictures,this time just because the mere attempt to upload anything may bring down the entire internet for this city of 1,000,000 plus who probably need it for more important reasons.

Wendy and the girls arrived on Sunday morning and I got some great bear-hugs in the airport before being prompty dragged to Cinnabon.  We made it safely to Cochabamba on the 11:00am flight and met up with our friends, the Wolheters.  We relaxed at their place for the rest of the afternoon as the girls recovered from aout 36 hours of continuous travel.  We took a walk that eveningto a playground that was akin to a small Crossfit gym for kids in the middle of this hilly city.  My kids would run around for about 2 minutes, then lay down to recover from the altitude (somewhere around 7,000 feet), before picking themselves up to play some more.  They slept well that night.

Monday we travelled to Parqueo Pairumani, a mountain gorge with waterfalls and a fast moving (and very cold) stream that the kids played in for hours - we almost didn´t make the climb because Emma had wilted like a leaf of steamed spinach, but we took turns carrying her up the mountain on our shoulders, and the cool water quickly restored her to her normal, playful self.  Pictures are posted in my Facebook album "Pairumani."  

Tuesday we went to visit the giant Jesus statue overlooking the city.  It was apparently the tallest in the world (even taller than the well-known one in Rio), but rumor has it that Poland has built a bigger Jesus, much to the chagrin of the locals.  We took the yellow gondolas up the hill (Emma prefered this to the 1440 steps).  Jesus has a great view of the city.  You can even go up inside Jesus, but apparently only on weekends.  Later, the girls went out for a mani-pedi with the moms and I stayed home and babysat the boys (meaning I read, slept, blogged, sorted through my photos, browsed facebook, and ate some cookies).  The adults went out for traditional Bolivian fare on Tuesday night while the kids stayed back and watched Frozen... again.

Wednesday we packed the Land-Cruiser for our trip up the Andes and accross the Altiplano to LaPaz.  I played luggage-tetris on the roof before wrapping everything into a blue tarp burrito.  We then made a long, curvy, crowded drive topping out at 14,700 feet (Pike´s Peak in CO is 14,115 feet).  We took some of the most scenic potty breaks ever.  Emma and Tessa both resumed wilted-spinach posture, this time draped all over their longsuffering mother, who took it all like a champ.  No one vomited - thanks to God (who worked via a cocktail of dramamine, acetazolamide, benadryl, ibuprofen, caffeine, and Jame´s expert driving).  The second half of the drive was accross the arid Altiplano -  broad expanses of flat pastureland with flocks of sheep, cows, and llamas attended to by traditionally dressed Aymara women.  Towards the end, the snow-peaked tips of the mountains around LaPaz, including Illimani (21,122 feet).  We got a view of the city from the plane above (El Alto) before descending to LaPaz (12,000 feet) where we carried the luggage up four stories to our apartment for the week (that was a workout!).

OK, it´s Thursday now - time to take the fam up to Lake Titicaca (and no, I will never get the kids to stop laughing every time we say it).  Hasta luego!

The ones I didn't take

Why doesn't this blog have any pictures?

                Photography has long been my hobby – I used to take hundreds of photos at a time, even in the film era (what’s film?  The kids sometimes ask.).  Once things went digital, I would take thousands.  At first, I would mostly shoot landscapes – probably because I was shooting with a manual-focus, manual-metered camera and landscapes don’t tend to move all that much.  For the most part, I stayed away from people pictures much for this reason.  The best ones are candid, un-posed, and I simply couldn’t focus and meter fast enough to catch an unscripted expression worthy of an exposure.  Once I entered the autofocus, auto-metering, digital era, taking good photographs of people became much more feasible.

                And so I did – lots of them – especially on mission projects.  There were so many memories I wished to crystallize – unique faces bearing the full range of human emotion and experience, and largely without the option or even the propensity to conceal themselves with makeup or even contrived expressions.  Every eye, every wrinkle seemed to tell a story, the ethos of which I might capture if I took a picture or ten.  I would look back at these often, even hanging some on my walls at home.  Often, they would release a flood of memories, indistinct and mostly visceral, of the emotions, even the smells I had encountered.  The pictures I took appeared to be serving their purpose.

                After a few more projects, I noticed that I was taking fewer and fewer pictures.  I would get home and have a chance to page through them and would find myself disappointed – where were those faces so worthy of a LIFE magazine cover?  How was I to remember?  I even found myself swallowing my photographic pride and emailing other trip participants to get copies of the pictures they had taken. 

                Why was this happening?  The reason is likely multifactorial.  At a very simple level, my hands were always busy doing something else.  My mind was also distracted by all the other small tasks that needed to be done to keep a project moving.  I had little down-time to seek out the perfect shot.  I was also going places for the second and third time – the newness was waning and with it my shutterbug tendencies. 

                There were other reasons as well – I would discover, trip after less-photographed trip, that the quality of my memories was not fading as I had feared.  In fact, they were improving in ways.  Faces were replaced by people.  Story-laden wrinkles gave way to actual stories.  No longer a camera between us, the nature of my interactions with people deepened. 

                Psychologists refer to the Hawthorne effect – “a form of reactivity in which subjects modify an aspect of their behavior in response to the fact that they know that they are being studied.”  I’m sure you’ve seen it – smiles become forced, tears are not allowed to linger, and unacceptable emotions find a place to hide until the shutter snaps.  In short, the process of taking the photograph changes what is being photographed, sometimes completely eliminating it.  Sure, the person is still there, but the moment one had hoped to capture is gone without a trace.  The memory preserved is a shiny, plastic replica while the genuine article has begun to fade. 

There were many snapshots I had hoped to take on this project, but didn’t. 

-          The forlorn, lonely face of our young, pregnant patient before her appendectomy. 

-          The abject fear of a toddler being taken to the OR, to be sequentially replaced by exhaustion, resignation, trust, and calm as he is sung to sleep by the anthesia crew. 

-          The hilarious and uninhibited grin of a man under mild sedation as he tried to teach us Spanish during his hernia repair. 

-          The collective smiles and laughter of a sweaty ward of inpatients as they suffer through our Spanglish.

-          The tired yet willing faces of the OR instrument crew as they agreed to stay late “uno mas” time on behalf of a suffering patient.

-          The exhausted, yet satisfied repose of our Bolivian and North American volunteers as they sacrificed sleep and comfort to do what God called them to do, some for the first time in this capacity.

I didn’t take these snapshots, or maybe I did.  Much thanks to all of you who have helped in any way to make these memories.  Hopefully you’ve shared in them to some extent through the blog.  Better yet, consider coming along sometime.  Bring your camera, but don’t use it too much. 

Now the project is over, and I’m a tourist this week.  Let the cameras roll and the shutters fly.

-Matt

Uno mas

                It has been a very busy few days.  We ran out of internet credit on Tuesday and didn’t really get sustained access until returning to Santa Cruz last night (Friday).  Hence the infrequency of updates.  Now, there is so much to reflect and report upon that I don’t know where to start.   I guess I’ll give the story of a day that typifies these projects. 

                 Monday and Tuesday had gone quite well.  We had managed to pull off 10 major procedures in two days and had functioned quite well as a team right from the start.  Everyone knew their respective roles and embraced them, yet remained flexible enough to encourage and assist their teammates.  It was good, hard work, but the days were both long – we got back to the hotel around 8:00pm both times.  I knew that Wednesday would present a challenge as fatigue starts to set in, mosquito bites accumulate, intestinal issues become manifest, and the initial adrenaline rush starts to wane.  Additionally, we would have Yessica Pardo, a gynecologist from Santa Cruz joining us, hoping to do a few procedures of her own.  We would be hiring the services of Ulices, the local anesthesiologist (he has worked with us many times here and in Santa Rosa).  At the outset, the scheduled plan was to do at least 7 procedures and we had promised the local staff that we would try to finish by 5:00. 

                The team was somewhat Zombie-like at breakfast – but they were happy looking zombies and I decided to take the risk and caffeinate them.  Paola gave the team devotion with her ever improving English.  Franz, Yessica, and I pieced together a proposed OR schedule on the bus before running it past Klatt for his perusal – he made some valuable suggestions which might make things more efficient and keep us eager-beaver surgeons grounded in reality.  We pulled into the hospital grounds around 8:00 –a crowd was already starting to accumulate under the shade trees, under the entrance portico, at the door of our supply room, and in blue plastic chairs that made up the (very busy) optometry clinic. 

                Everyone went about their tasks without any need for instruction.  Dorothy and I rounded on the 4 or 5 inpatients that we had accumulated (mostly gallbladder resections and spinal anesthesia patients who stayed the night waiting to urinate).  The Anesthesia trio gathered their supplies for the day and made their first preop assessment.  Elaine (functioning as our circulator) packed the blue duffel with supplies for every OR contingency.  I would run back and forth from the OR to the supply room pulling suture and mesh for the day’s cases.  Things were running smoothly.

                In this flurry of activity preceding the day’s first case, I was frequently stopped by the waiting patients who would speak to me, unfortunately in Spanish.  Some were expressing thanks or asking questions about relatives who had undergone surgery and were back in the wards.  Others were asking to be seen in consult or to have surgery (our schedule was already more than filled for the week).  I would try patiently to sort out the difference, usually going to find one of our Bolivian team members to translate.  On more than one occasion, we would agree to see the patient in consult and make an attempt to wedge in “uno mas” operation into the already overflowing schedule.   My heart would get a bit heavy.  Faced with the reality of how quickly we can do safe work, I knew these concessions were likely to result either in a disappointed OR staff (working late hours in spite of our promised attempt at an early finish) or in a disappointed patient who’s operation may be postponed until next year. 

                The day got rolling and was moving along at the pace I had hoped for.  Hannah and Erica (CRNA) students have essentially turned Dr. Klatt into a 6-armed anesthesiologist, making for fast turnover between cases.  Dorothy functioned like a well-oiled machine in the recovery room/ ward allowing me to stay in the OR and move things along there.  (She become the talk of the whole hospital as she was able to demonstrate incredible patience,  compassion, and attention to detail throughout long days, in a 90 degree, 98% humidity room full of sweaty, needy patients.  She was a (very sweaty) sight to behold. 

                The procedures themselves were blessed with very little bleeding – Paola and Wesley (an intern from Brazil) both made for capable and enthusiastic first assistants who were able to anticipate my subsequent steps – open gallbladders were taking less than an hour and I was able to leave incision closure to them as both have demonstrated proficiency and increasing speed.  In the end, we would complete eight operations on two tables and have the last patient in the recovery room by 5:10pm.  It was the perfect day – we might even get to walk into San Carlos for ice-cream and enjoy some of the local culture.  Then…

                Uno mas

                “Doctor, can you come see a patient?” – It was the local obstetrician asking. 

                She is 17 years old.  14 weeks pregnant.  Feverish, nauseated, and in pain for the last 24 hours.  She had a long, forlorn face bereft of any “pregnancy weight.”  She could barely speak, but her dark, hollow eyes were themselves a plea for help.  Her husband and family had all left for their homes – at least 3 hours away by motorcycle.  They have cellphones, but live far beyond the edge of the grid.  They could not be reached.  I pressed gently on the right lower quadrant of her abdomen and the lethargic girl somehow managed the strength to recoil and push my hand away.  She had appendicitis.  The rest of her abdomen was soft, indicating that it had likely not ruptured yet.  She would need surgery, and soon.

                In Bolivia, it is almost unthinkable to take a minor to the operating room without consent from her parents, or to take a married woman without the participation of her husband in the decision making process.  Family is valued over autonomy, maybe even over safety.  I sought advice from the local hospital staff and from Franz and Yessica as the OR team (without even a hint of complaint) set up for the case (we had already packed up for the night).  We got approval from the hospital director, the local gynecologist, as well as myself – hopefully the family would be in agreement whenever they would arrive.  The patient herself consented, at least feeling the urgency if not quite understanding it.

                We made incision around 6:00pm.  The appendix was massive, gangrenous down to its base, but hadn’t ruptured.  Had it done so, she would have developed severe peritonitis for sure.  We had operated in time – tomorrow would have been a different story.  In the recovery room, she looked more comfortable immediately after anesthesia had worn off, although she was still weak and dehydrated.  She would continue to recover well.  Her family could still not be reached when we left on Friday afternoon.  Though she was feeling and looking better, I still couldn'tt provoke a smile as I am usually able to do with most our patients.  We gave her some food (families usually provide the food for the pateints) and turned her care over to the local staff before we boarded the bus.  We pray her family will return soon and that she will thrive through the remainder of her pregnancy. 

               The days on these projects can be long.  What should have been the shortest one turned out to be the longest.  I will confess to a moment of self-centered exasperation when confronted with that softly spoken "uno mas."  To be honest, they were the last words that I wanted to hear.  We were ten minutes from leaving for the day.  But that was when she was given to us.  Had we left for the hotel, the standard practice would have been to transfer the patient to Santa Cruz (they usually do not call us with many night-time emergencies).  This transfer however would likely not have been carried out without her family’s approval.  I think she would have gone septic by morning and lost the pregnancy at a minimum, maybe worse.   

Often times, the words we least want to hear are the ones we most need to.  Thank God for "uno mas." 

Expectations

I’ll start by quoting a song: 

              Novices have expectations
              because they think they should.
              Experts have their revelations
              Like they knew they would.

The name of the song is “Trouble”  (Artist: Over the Rhine, Album: Trumpet Child – Buy it, you’ll love it).  Now I don’t yet fancy myself an expert at this stuff, but I’m not a novice either.  Given the choice however, I felt duty bound to have at least some expectation of what we could do on Monday.  So call me a novice still. 

                If you read yesterday’s post, you know I went into Monday with the hope of pulling off five cases.  I don’t know why I thought this would be possible – on most my past projects we have not even made incision on the first case before lunch -  there are still machines to set up, supplies to organize and sterilize, processes to iron out, and all this with a new team, a language barrier.  Some of our team only arrived last night after 40 net hours of travel, including missed connections in Mexico and Peru.  We have 6 North Americans and 9 Bolivians [this includes our cook and our bus driver] – all this for a combined Surgical, Medical, and Optometry project.  I should be happy just to fix one or two navels. 

                We arrived at the hospital to see quite a crowd gathering.  The lobby already smells of sweat and sounds like a collective toddler melt-down.  The line goes far out the door.  Today will be all about multi-tasking for me as I try to see a bulk of the week’s surgical consults, fill out the schedule, and also make sure the first cases get going safely and that everyone else is settling into their roles (some of which have yet to be defined).  It helps that this is project #3 for Dr. Klatt (anesthesia) and #2 for Dorothy (preop/ postop nurse) – they are proactive, organized, and flexible.  Dorothy’s sister Elaine is here on her first project and really helped glue processes together as combined ciruclator and patient communicator of our needs to the local staff (I think she secretly speaks Spanish). 

                It’s late, so I’ll cut to the chase (no surgical pun intended).  I’m not sure how it happened but I’m pretty sure who was behind it.  We managed to pull off five cases (two open gallbladders, two hernias, and a large scalp mass/ cyst) with the first case starting at 10:00am.  Between them, I managed to see 20 consults.  None of them spoke English and I still don’t speak Spanish.  The Clinic team (with two Bolivian doctors – Franz and Alex) saw ~60 patients.  Most of them also received integrated health counselling and spiritual support and encouragement as well.  The eye team did 55 exams, including giving them  their glasses.  And everyone even ate lunch.  The patients are doing well so far and the team is in very good spirits, especially given how hard they worked.  Everyone is primed for tomorrow (and I’m pretty sure they’re all in bed too). 

                Feel free to read my previous posts about project Mondays.  They usually make inefficiency an art form and always manage to bring me to my knees.  I proactively went there today.  I’ll admit to feeling a bit of pressure and isolation on this project – this is my first one as sole surgeon, and it’s my smallest team yet.  Should I really try to do so much on the first day?  How many operations should we schedule for the week?  How hard can/ should the team work?  How hard and late will the local staff work before they go on strike?  What if we take on too much and have to break promises to patients who have waited months for their operation?  I’ll admit to both fear and guilt in even having expecations.  I gave this over to God this morning – His message back came out of Psalm 28:13-14

     “I believe that I shall look upon the goodness of the Lord in the land of the living!
      Wait for the Lord; be strong, and let your heart take courage; wait for the Lord.”

When something is repeated in Scripture, it is usually to highlight both its importance as well as our tendency to overlook it.  What was repeated this time?  “Wait for the Lord.”  But I’m a surgeon.  I hate waiting.  Waiting is time wasted.  Waiting is inefficiency.  The one place I almost never go at work or on project is called the “waiting room” – I do not belong there.  But there it is – “Wait for the Lord.”  It was as if He was telling me to make Him my expectation. 

                He made good on this message – both to me and to everyone else.  Any slow-downs were reflexively taken as opportunities to do something else productive or to enjoy a relaxed word or smile with our patients, their families, or our co-laborers.  And everything got done.  We set our expectations on God showing up and He did just that, cloaked of course in the garb of our patients, co-laborers, and the agape-space between them. 

Now bring on Tuesday.  Hasta Manana.