Things I'll Miss

We land in about an hour, and though I will still have the baggage claim and a three hour drive before getting home, this project is essentially complete. It would be great to have a few days to sit at home and process the last couple of weeks, but it's back to work on Monday. I haven't yet determined whether or not I will find work to be more or less relaxing than the project. It will be nice to be the surgeon without also having to be the nurse, the tech, the pharmacist, the orderly, the medical director, the cruise director, and Jason Bourne. It will be nice to ask for instruments in English, though I will probably continue to ask for them in Spanish. It will be nice to order a medication without having to rummage through a suitcase to find it. It will be nice use sterile light handles once again, though I will probably forget to reach for them. It will be nice not to sweat like a professional wrestler, but I will miss having a person who's sole job is to wipe my forehead. It will be nice to have patient monitors that chirp at the appropriate times, and an air-conditoner that doesn't. It will be nice to have an organized medical records system, but I loathe the notes and dictations I must contribute to that system.

Though it is always nice to return to the amenities of life in the Midwestern United States, that is in part because I will again have that period of time when I don't take them for granted... when I realize that I don't need to depend on them since most the world can't and doesn't.

I will be glad to have a warm shower without the threat of 240 volts entering my hand from the shower knob. (I did tell the hotel manager about this, and he promptly fixed the problem by wrapping my shower knob with electrical tape).


I will be glad to flush my toilet paper down the toilet without risking a major public health disaster. It will be nice to brush my teeth with tap water again and to stop using Cipro as an after-dinner mint. I will probably take a break from orange Fanta (these trips amount to a more or less continuous oral glucose tolerance test). It will be nice to walk on a sidewalk, though I will kind of miss the livestock which populate the roadside (of course, it is deer season in our front yard, so all is not lost).


I can do without roosters crowing at 2am - though we ate chicken at least twice a day in a futile attempt to cut down on the noise.
I will enjoy eating with my family again, but will miss the daily breakfast with a group of young Bolivian doctors who are dedicating their lives to serving the poorest of the poor. I will miss wearing flip flops, though I'm sure everyone else is looking forward to my once again wearing shoes and socks. It'll be nice to call home from my cell phone or my office, but I'll miss the cute little lady with the "phone booth" at the corner vegetable market. It will be nice not to trip over 5 or 6 mangey dogs on the way to breakfast each morning, but I'll miss having the hotel puppy nibble playfully on my toes (many apologies for that rocking-chair incident, buddy).


I will kind of miss the quaint, bare-bulb lighting fixture of the hotel lobby, but I will not miss the lightbulb size bug that would at times hang from it.


I will miss Yoko, but not the beetles.

Indeed, it will be nice to return home, but I am becoming increasingly aware that I have a home away from home... an extended family that I never would have predicted. I count myself the richest man in the world, though I am leaving some of my riches behind in what they say is the poorest country in South America (and I am not even talking about the 6.6kg of unroasted coffee beans I was unable to bring back). I will cherish my memories, but I also know from experience that memories can be painfully short. Please, feel free to remind me from time to time.

Thanks for reading along. All apologies for any unsavory surgical details, borderline inappropriate humor, cultural insensitivities, and overindulgent verbosity. I covet your prayers as I seek out my next project. If you have interest in volunteering, I'd love to chat with you about it. Much thanks to those who trusted me to take them along... Jean, Bill, Stan, John, Lori, Sarah, and of course Wendy, Emma, and Tessa. Thanks also for those in Bolivia (Francis, Yoko, Reuben, Franz, Sorona, Paola, Sheila, Blanca, Elizabeth, James, Jenny, Ignacio) who served as God's instruments, oftentimes placed in my hand at the exact moment you were needed most. One could scarcely meet a more joyful group of people, though you have sacrificed much in faith that such joy would await you. It is truly humbling to work alongside you. I sincerely hope we will get to do this together again soon.

-MC

Location:Seat 30B

Bourne in Bolivia

I am admittedly a fan of the Bourne trilogy of action films starring Matt Damon. Sometimes when abroad, the reality of the narrow urban streets, the third-world traffic "patterns," and anxiety at customs & immigration starts to meld with my caffeine-warped dreams and I start to fancy myself another Jason Bourne (only less good looking, minus the Parkour and Jujitsu skills, and not exactly multi-lingual). Then I wake up and a guy named Francis picks me up in a minivan and drives me to the airport.

I have now left Bolivian airspace while our beloved anesthesia machine hides somewhere in a warehouse north of Santa Cruz. This was no small feat, as many forces conspired against us. The big blue case did not escape notice upon our arrival - it clearly had not been purchased at the duty free and the new Bolivian customs officials (all of them had been replaced 5 days before our arrival) felt it their duty to keep the behemoth under their watch. Though we were ultimately able to take it with us and use it on the project, I had to agree to bring it back home or pay a hefty duty, though the amount was never specified. They were clearly angling for a bribe, otherwise they would have opened the case, inspected its contents, and assessed its value. As it were, they knew it was valuable to us, which was all that mattered. Francis called their bluff. If they are not bluffing, I will either need to return with the machine, or stay with it.
Through the two weeks that follow, Francis repeatedly tried to negotiate via phone with customs. This resulted in many wasted cell-phone minutes, but never was a ransom named. We drove to Santa Cruz on Friday with hopes of going to the airport and negotiating a deal - the baggage fees alone to return it would be $200, so anything near that figure would be worth it. Unfortunately, it is a national Holiday in Bolivia and nearly everything (except the zoo) was closed - even the souvenir shops where locked up. We would have to wait until the morning of our departure to learn the fate of Dr. Dre (and Dr. Campbell for that matter). The zoo was quite nice, by the way.
We departed for the ViruViru airport at 5:45am hoping to beat the lines. Francis suggested curbside check-in to find out early on if my passport was flagged in any way. He had the big blue case along with our luggage - I do not know what exactly was packed in it. For all I know, it could be the machine, or it could be the massive haul of decorative pan-flutes the Mayor of Santa Rosa had given to us at our last barbecue. My passport scanned without any problems and I was given a boarding pass - so far, so good. Francis, wanting to make sure I would not get stopped further on, still thought it would be a good idea to go down to the customs office and make sure the machine could stay and that I could go. Even though international flights had already arrived and people were entering the country, the customs office was locked and gated - a sign read that they would not open until 10:00am because of the holiday (Holiday's apparently take precedence over things like national security or customs extortion). Our flight was to leave at 9:10. We would need to make a choice - either check the trunk and bring Dre home, or leave Dre with our Bolivian staff and hope I wouldn't get stopped later. We chose to leave the machine (or whatever Francis had packed in the case). I checked my other bags and we say our goodbyes to Francis. I hope to see him again soon, but home is on our minds. I not truly rest until the plane is in the air.
We clear security, or at least one round of it - didn't even have to take off our shoes. We then pass a set of duty free shops and flat screens playing 1980's music videos. Now more security stations, at least two more hand searches of my carry-on bag, much scrutiny of my passport (They always look sideways at my Burmese visa before finding the Bolvian one. Later, I realize the Burmese visa is indeed sideways). One official takes my picture, scans my passport, then starts shaking his head disapprovingly. I have a moment of internal panic, but I am able to channel my internal Jason Bourne and secrete some endogenous metoprolol. I try not to sweat, but I have been constantly doing so for two weeks - lost cause. Finally, it turns out that the guy was just frustrated with his slow computer (I think he purchased it at the Santa Rosa Internet cafe). He says "No problem" and waves me through. I am now home free, or at least in the duty-free, where I immediately start to shop for over-priced chocolate and feel pressured to buy cologne.
Trying to decide if Jason Bourne would prefer his chocolate bar with or without Brazil nuts (Bolivian Brazil nuts, mind you), I hear my name paged overhead. I've seen the movies. Overhead pages are never a good thing. I ask myself WWJBD (what would Jason Bourne do) as I approach the desk. I know the answer, but I am pretty sure a sudden flurry of MMA skills would be ill-advised. The man at the American Airlines desk informs me that I have dangerous-appearing items in my suitcase (darn panflutes) and that I need to accompany him downstairs for an inspection. As we walk down a dark, lonely staircase, I try to determine if this is the part where I get kidnapped or become an organ donor (this would only be just, since I have been removing others' organs for the past fortnight). We reach the ground level and I am hand an orange vest (don't chain-gangs wear these?) to wear out onto the Tarmac. A big muscular guy with a gun is standing there with my bags and I am told to open the small side pocket on my rolling duffel. Thankfully, he also has a bible and this makes him seem a little less threatening (though it is open to Judges which I recall being a fairly violent book). He pulls out a laryngoscope and I am asked to safely dismantle the threatening-looking device. I show them the empty battery case and try to explain in Spanglish that it is a flashlight for looking into people's throats. This involves making some explanatory gestures - I decide to demonstrate on my own larynx rather than on the man with the gun. He seems satisfied. I give him my orange vest and they walk me back up the stairs to the terminal. I return to the duty free and buy my chocolate - both with and without the Brazil nuts. We soon board the flight and I am safely nestled in seat 24F amongst a crowd of softly snoring elderly British bird-watching tourists. My adventure complete, I fall asleep and contemplate selling the movie rights (but only if I am played by Matt Damon).



- Posted using BlogPress

Location:Viru Viru

Swimming with the Stars

My earlier post was entitled "Embarassment of Riches" before I got sidetracked by a story about a colostomy. Apologies for the confusion. Ever read one of those books that are so long that you forget what it was about in the first place? It's kinda like that.

The old adage goes that it is more blessed to receive. The altruist in me wants to agree, but that would contradict another truism I have learned - that whenever one serves on one of these projects, one always manages to receive way more than he could ever hope to give. If it is more blessed to give, then why would God have us receive so much in spite of our best efforts to tilt the balance otherwise?

Well since the beginning of our trip, the town of Santa Rosa has not ceased to make us feel welcome. The mayor has a love for both ceremony and barbecue. His people just like to party.

On Wednesday, after a day of treating parasitic diseases in the village of Loma Alta (I think it means high mountain, but it is actually a flat pasture), we were invited by the people of the village to go swimming. Since that village doesn't have a pool, we would need to go further offroad to the next village where there apparently is a pool of some sort. Some of the team were not initially keen on the idea, but once the suggestion had been made, the idea of a party started to grow. The vice mayors of these villages got involved, and before you know it there is a formal meal and Gladys, the head nurse at the hospital, is packing her suit. If I have learned one thing on these trips it is that you never turn down an invitation because by the time the invitation is made, the meal has already been cooked. We took Francis' Land Cruiser (a 1992 named Methuseleh with a broken control rod), Reuben's truck (a 1986 with no speedometer), and a taxi out past Loma Alta and on to the village of Rincon. The pool, apparently nestled deep within an unlabeled dairy farm, was unfortunately closed as the owner had fallen ill. We then drove on into the "Zona Urbana" of Rincon (a cow was eating grass next to the sign) to a thatch-roofed restaurant where our tables awaited. We were treated to a pig-roast (again confirming that they started cooking the meal even before we had been invited to the party) and other traditional Bolivian fare. No wonder there are so many gallbladders to remove.


Thursday was our last operative day and the clinic team was back working at the main hospital. Dr. Franz gave a noontime lecture on diabetes and hypertension while we ate cheese empanadas and drank orange Fanta. He had run into an old friend from medical school who is apparently living on a nearby dairy farm with her parents and looking for a full time job. She worked with us in the clinic that day. Her name is Cher (her father was apparently a fan). She invited us to go swimming that afternoon in the pool at HER dairy farm (apparently, this is becoming a trend) and, of course, she had already baked a cake for the occasion. Since we had been unable to swim the night before with the village people, we decided to take Cher up on the offer.

Cher picks us up at the hotel Ochotu and we again drive out on a bumpy road into the seemingly eternal Bolivian pastureland. We soon turn at an unmarked barbed wire gate and drive past her fields of cows and calves.


She is apparently in charge of rearing the 80 or so calves while other siblings and in-laws attend to other farm duties. We park next to the farmhouse and are soon picking blackberries (or something similar) from a tree and start fawning over the calves (ironic, I know) as they chew grass and moo at us. Soon, the roosters get in on the action and make their presence known. I agree with Jean, their crowing sounds much more like "Por Favooooor!" than cockadoodle doo.



The milking machine is down and Cher's sister and brother in law are busy fixing it, but not too busy to show us the milking barn. They eventually get it up and running, which is a good thing since some of the cows looked a bit full (that, or they were bulls with duplicate parts and sizeable hernias). Another brother hooks the cows up to the machine after hosing off their udders. He has a tee shirt on that says "I love my job."

We eventually settle down by the pool, which is actually quite a nice blue tile-lined pool, though it is only filled about two feet deep at this point. Perfect for lounging around with toddlers, though. Francis has brought his super-cute 2 year old (she keeps grabbing for my toes) and Cher's daughter Beyonce is swimming with her father, Norman. Norman is a motorcycle adventurer from Germany who was six years into circumnavigating the globe on motorcycle when he fell in love with Cher and settled down in Santa Rosa. A fascinating free-spirit who speaks six languages and has personally modified his own motorcycle to handle everything from the Serengeti to Patagonia.



Yoko, our nutritionist is also along, so I can now honestly say I have sipped coffee, in a pool, at sunset, with the trio of Cher, Beyonce, and Yoko, as well as a motorcycle riding German dairy farmer named Norman - not what I expected on a Thursday afternoon in Bolivia. I even got a goodnight kiss from Beyonce as we left.

Evenings like this are one of the unexpected blessings I encounter on these trips. Every person was a new treasure to enjoy, with stories to hear and uncanny points of commonality to discover. Nothing was rushed.


The sunset was phenomenal. The cake was made with home-grown blackberries and fresh cream from the farm. We are sad to cut things short now, but we have a date with the mayor for yet another municipal celebration (and of course another barbecue).

- Posted using BlogPress

Location:somewhere south of Santa Rosa

Embarassment of Riches

Many obligatory apologies for my failure to update this blog as often as I had wished. Internet access has been spotty at best and we have had minimal time to even seek it out. To be honest, I am glad that I have not spent much time holed up in a sweaty Internet cafe (minus the cafe part, mind you) as I would have missed out on much of what I have been blessed to experience these two weeks. Starting this post from the balcony at the hotel Ochotu (though I doubt I will finish it there) on a cool, rainy morning. It is 5:30 and my bags are more or less packed. It is the first time that the weather has been cool, so of course this means we are leaving Santa Rosa today.

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).

Location:Santa Rosa del Sara and the Zona Urbana

The best laid plans

So, my plan for the weekend was to catch up on blogging, reliving last week one day at a time. But then there was this pool, my children, my wife, a bed, and a wandering Emu, and a coffee plantation... and here I am in the hotel lobby about to board Francis' 1992 Land Cruiser (aptly named Methuseleh) to head back to Santa Rosa where they have yet to discover WiFi. If we can manage to finish operating by 10pm this week, maybe I'll have a chance to catch up the blog then.

Said ciao to Wendy and the girls, the Wolheters and their boys this afternoon. It was wonderful to have them here this week, though I regret not seeing them more (I saw less of them here than I typically do in Manitowoc), yet proximity still means something. Emma was quite tearful as we departed and it wound up being contagious. Reuben (the big logistics guy) kind enough to steal the hotel's horse cart and give us (me and the kids) a ride to the gate to make saying goodbye a bit more fun - Emma was not fooled, but it was nice to have her cuddle in my lap for a few more minutes.

If I don't have the chance to expound, I will attempt to summarize our work so far (for week one). We did 33 operations, most of which were gallbladders (around 12), hysterectomies (7 or 8), a smattering of hernias, a c-section, an appendectomy, and a number of lipoma or cyst excisions (we did those under local). Turnover time between cases tends to be long as we have to be sure that the patients in recovery are being watched closely, their pain medicines drawn up and orders written, the instruments for the next case are sterilized, the sutures gathered, the patient located, the room cleaned, and we have to drink about 2 gallons of water to replace our own sweat losses.

We also squeeze in our consults between operations so we can make sure tomorrow will be just as busy. Bill was seeing consults almost constantly, stamping out PID with a smile. Jenny Wolheter, our friend from Cochabamba, did much of his translating while her husband James helped us commincate with the OR staff. We take lunch in shifts - lasts about 15 minutes, but at least the room is air- conditioned. We are one or two translators short, so we often scramble to find one or just use my Spanglish/ Gringlish and a lot of pointing. At the end of the day, we make rounds with the local physician who will be staying the night at the hospital and watching the inpatients. They don't usually take care of surgical patients here, so we have to do a lot of explaining when we write orders. We missed dinner pretty much every day but Monday, but the ladies at the La Tapera restaurant were kind enough to stay open and save some food for us.

The Clinic team had equally long days, often travelling off road for ~3 hours each way and setting up in insufferably hot villages to see ~100 patients, dispense meds, and screen patients for more serious illnesses and surgical diseases. Wendy and the girls went with them on Friday since the drive was shorter, but the heat was still a challenge for them - Emma just wilts. They still had fun making crafts and playing parachute with the Bolivian kids - there were many more of them in the village since school is let out for the event.

Alright. Methuseleh is idling and I have scored a cold Coca Cola from the hotel bar for the 1.5h drive back to Santa Rosa. My hotel room will be lonely, I fear. May blog more often after all.

-Ciao


- Posted using BlogPress

Location:Lobby at the Eco

Looney Lunes - 10/22/12

Woke up this morning to find out that cracking the window was a bad idea. Mosquitos have found their way into the room and we all have a few bites. I manage to sneak out of the room and set up the MacGuyver coffee maker - nothing like a cup of French Pressed, American-Roasted Nicaraguan to jump-start the Bolivian dawn (much thanks to Rich @ Culture Cafe for hooking me up).

Read in Matthew 4 about the temptations of Christ. Struck by how He resisted the temptation to take the path of least resistance, refusing to turn stones into bread. He fully embraced his humanity, part of which was a reliance upon God as his father to provide for him as he started his time of ministry. We certainly have not chosen the path of least resistance in coming here - I know today will be a challenge as first days always are.

We have breakfast at la Tapera, then head to the hospital. We are unable to get cases started right away - a myriad of small delays and trying to find supplies we had failed to locate last night. Then, the mayor has an opening ceremony of sorts in the hospital courtyard, a smattering of around 50 locals show up to welcome us and enjoy the free cheese empanadas - I had a few myself. Chances are I will need my own gallbladder removed before this project is over. We finally get rolling clinically around 10:00am.

First case is a reoperation on a lady who has already had a cholecystectomy, but apparently still has a remnant gallbladder remaining that has managed to re-accumulate stones - I have no idea how this happens - but we struggle through a tough dissection (much scar tissue) in dangerous territory. Case went well and the anesthesia machine worked well (as did Jean, our capable anesthetist). Next, Bill does the vaginal hysterectomy, complete with the. patient's son watching and asking a lot of questions (not sure I can do that to you, mom). The case takes a long time to get started for myriad reasons, then it takes a long time as the language barrier and lack of familiar instrumentation start to take their toll. Everyone is meeting everyone for the first time and roles are still being defined.

As the day drags on, my frustration starts to build. We have promised to fix a hernia and take off a large lipoma as well, but the consults keep coming and it becomes exhausting just confirming that we have adequate sterile instrumentation for the next procedure. I feel like I'm doing everything (but so is everyone else), yet nothing seems to get done, and the patients wait patiently, dutifully fasting as told. Stan winds up excising the lipoma on a table in the recovery room while I see consults and bird-dog the supply prep. We then manage to fix a hernia under local anesthetic on the secondary table in the OR while Bill finishes up the Hysterectomy. We see a few more consults (actually, Bill sees TONS of them - they are really hurting for good gynecologic care here and he is in much demand). Then, make rounds on our postops. The gallbladder patient is having a lot of pain and a low grade fever (we later find that lowland Bolivia IS a low-grade fever for most of the year). This has me nervous - we don't really have the capability of doing bile-duct reconstruction down here and I'm not in the mood to improvise. We check back one more time after dinner and she is doing better. We get to dinner around 8pm and debrief on what we feel is a successful day - pulling off four cases in the first day at a place where they haven't done any surgery since this time last year. We talk about ways to improve the process tomorrow - everyone has productive insight. Our clinic team (entirely Bolivian) saw about 100 patients as well.
Wendy says the girls were still travel-weary much of the day, and with the heat they spent a good part of the day back at the hotel. Thank God the AC was repaired. They have looked out for our safety too as our shower knob is now wrapped with an insulating layer of electrical tape. I enjoy a cold shower before hitting the sack.


- Posted using BlogPress

Location:Somewhere northeast of Yapacani

Mucho Overdue

Where to begin. The project has been a whirlwind (a very hot whirlwind) ever since we arrived in Bolivia. I'll try to hit some highlights. Apologies for not updating until now, but we have been so busy I have not yet had the chance to hit the Internet cafe. Now that we are resting for the weekend, it will be. good to get my thoughts down on "paper." Apologies in advance for any irrelevant or gruesome details. I will post in day by day entries - hope I can "catch up" before the weekend ends.

Sunday - managed to "clear" customs with some difficulty. Apparently, Bolivia replaced their entire customs staff five days prior to arrival. Any advance preparations on the part of our Bolivian staff were null and void. Bags and declaration lists were inspected and they threatened to hold Dr. DRE hostage unless I promise to bring him home. Conditional "promises" were made and we were at least able to take him to the project site, but further haggling over customs, tariffs, duties, and import "laws" must still take place. Prayers would be appreciated. Feels like we are being extorted for a bribe - not giving in yet.
Sunday afternoon we took the hot 3h drive to Santa Rosa, checked into the Hotel Ochotu (AC in every room, hot showers - more on that later, and a new balcony from which we can enjoy the sunrise and the perpetual rooster crows). We had a late lunch at the restaurant La Tapera - no frills, but we have Yoko, our own personal "health inspector" who makes sure our food and water are safe. Hoping to avoid giving Montezuma any opportunities to seek revenge this week. We then went up to the hospital to set up for Monday and even see some consults - a chance we didn't have in San Juan - it will be nice to "hit the ground running" on Monday since we only have Bill (Gyn) and Stan (Gen Surg) for one week. Looks like we've already got some gallbladders lined up for tomorrow. Bill gets to start out with a vaginal hysterectomy and colpoplasty on the local doctor's mom - noooooo pressure.
We set up the new anesthesia machine and everything seems to be working - at least for now. The AC in the OR works and we didn't have to risk electrocution to fix the lights this time. Francis manages to "fix" the patient monitors (for now) and we utilize way too much duct tape in an attempt to safely ventilate the overflow of the anesthetic gasses out the back window.
Made it back to the hotel and put the girls to sleep - they've had a long day and a half of travel, but did quite well. At this point, the cool of the evening is setting in, aided by the AC. I figure I'll take a warm shower to wash off my travel stink. In Bolivia, this involves flipping the breaker switch on a 230 volt circuit which is conveniently located, yes, in the shower. This goes well, but is followed by a warm, tingly feeling as I touch the steel shower knob - should have worn those rubber flip-flops after all. I let go and continue with my shower, but soon the lights go out, the water gets cold, the AC turns off, and the tingly feeling goes away. My apologies to the team - no AC tonight after all. It will now be a long, sweaty night at the Ochotu. Breakfast is at 6:30 (0530 Wisconsin time), it is 11pm. The roosters have already started and apparently everyone in Santa Rosa has a motorcycle.


- Posted using BlogPress

Location:Santa Rosa Del Sara, Bolivia

Up in the air

It's 5:00am. I usually don't sleep well on planes, but somehow have managed to do so. I was pleasantly awakened to the flight attendant offering me coffee and the pre-dawn orange over the Andes out my window. Emma's head is in my lap - she slept well too. Wendy and Tessa are still comatose in the row behind us. So far, the trip has been kind to us.



We checked in at O'Hare without much difficulty. We were able to take advantage of the extra baggage allowance on the American Airlines platinum card and check four extra bags. Thouugh they could have turned that down on some technicalities, the lady at the desk (Patricia, I believe) found a way to make it work (saved us hundreds), though we still had to pay extra for the heavy anesthesia machine. Later, we watched out the window as they loaded our luggage onto the conveyor belt leading to the plane. Apparently, bright orange duct-tape reading "This end up" means nothing to Chicago baggage handlers, and "Fragile!" (Fra-gee-lay... must be Italian) must mean "tip me over forcefully." Oh well, at least it's on the plane.

The girls slept pretty well on the flight from Miami to La Paz. Unfortunately, the altitude got to Tessa who made full use of her "motion discomfort" bag, and now that we are descending to Santa Cruz, the pressure is really hurting Emma's ears. Only about 30 minutes left in the air, then comes the adventure of clearing customs. I've never had problems in Bolivia, but then again I've never brought quite this much equipment - hoping we don't get hit with much duty on "Dr. DRE."

Not sure when this will post. Hoping to find WiFi at the airport (and hoping they don't charge quite as many pesos as they do in Chicago and Miami).




- Posted using BlogPress

Location:Somewhere East of La Paz

Packed and Ready

It's here. We leave this morning for about 26 hours of travel and tomorrow will be soaking up the sun in Santa Rosa del Sara - (a place so small it gets no props on the new iOS6 maps app). Tessa is so excited she couldn't fall asleep last night. I asked her why and she said she is looking forward to watching a movie on the miniature TV screens on the plane. Sadly, I had to inform her that we are flying American Airlines and we should be thankful enough if the seats are merely bolted down. She also says she wants to make new friends in Bolivia, but wishes she could take hers with her.

I can't think of anything else to pack, mostly because it would require throwing something else out. Last night, a bag of almonds were sacrificed in lieu of a bag of bladder catheters for example. We were really packed by about 8pm, but I remained restless as I often do the night before a trip. I don't think I've forgotten anything, yet I KNOW I've forgotten something. This anxiety is only kept at bay by endlessly searching for that something, and when that doesn't work, I make the requisite last-minute trip to WalMart for fluorescent orange duct tape, a pink umbrella, and a fresh bottle of Gaviscon.

Now it is morning and I've had a few good winks. The coffee is brewed and I am now clinging to the familiarity of my morning routine (except for the blogging, that is) - Bible, books, fireplace, couch, and trying to let the girls sleep as long as possible. Tomorrow we will wake up at 11,600 feet (LaPaz) and on Monday morning I'll be reconstructing the MacGyver coffee setup to caffeinate our team before setting up the OR. On one hand I feel unsettled, on another hand I'm looking forward to resuming what has become my routine away from my routine, and I am quite happy that I will be joined by my family.


Reflecting this morning on all that I have to be thankful for. The number of people who have contributed to this trip is astounding. 4H kids collecting vitamins, sales reps donating their stock, numerous people contributing towards the anesthesia machine (fully funded in one week!)... I have no hope of offering a comprehensive list. It is truly humbling to see the interest so many of you have taken in setting this project up for success. In a way, you will be with us as we care for patients and their families in Santa Rosa. Thank you.

If you have opportunity to pray today, we've got some specifics for you.
- Wendy has been feeling a bit under the weather, mostly fatigue.
- We have a LOT of luggage and we are hoping American Airlines does not try to bail themselves out of bankruptcy with overage charges.
- We have a heavy but delicate Anesthesia machine (now clearly labelled as fragile with lots of fluorescent orange duct tape) in search of a gentle baggage handler in Chicago (and for a TSA agent who can distinguish it from an explosive device)


- We have a small team with some noteworthy gaps (no nurses, no techs) that we are hoping can be filled with Bolivian volunteers.
- The lavish hotel Ochotu (with AC in every room) is filled with Oil Company employees, so we will be staying someplace else -AC tbd. Sounds petty, but temp is 90's during the day, overnight lows around 78 - it can really suck the energy out of the team.

Thanks again, everyone. We'll keep you posted as often as we can.


- Posted using BlogPress

Location:Manitowoc, WI

Dr. DRE is a bit... heavy 

     Much thanks to all who have given so far towards the purchase of the DRE-Medical portable anesthesia machine for our projects in Bolivia with Medical Ministry International (www.mmint.org).  Your generosity is truly astounding.  With the help of matching funds from the HFM medical staff and the fundraising assistance of HFM Fund Development, we are nearly at our goal!  Remember that any excess funds donated will still go towards supplies and medications on these projects as well as towards sholarship funds to assist RNs and Surg. Technologists wishing to go on future projects.  

 

    We are getting excited as the custom-made protective hard case for the machine has arrived (and not a moment too soon).  Unfortunately, the combination machine/ case weigh 85.5lbs - you could say that Dr. DRE has a bit of a weight problem.  It will cost a bit extra to take him down there, so some of the donated money may still go for that and other luggage overage as supply donations have been astounding.  We (DRE included) about 435 pounds of luggage (8 bags pushed to their limit), plus whatever our companions bring along.  Just back in January, I struggled to fill 2 suitcases with supplies.  This time we have 8 and they are packed to the gills.  So much thanks to all who have donated supplies, extra suitcases, vitamins, medications, Bibles, money, and instruments, and your thoughts and prayers for the project.  So many have stepped forward to help.  We are so blessed and we can't thank you enough.  

    Further donations can be sent, tax-deductible to HFM Fund Development, 2300 Western Ave, Manitowoc, WI 54220 - labelled "restricted funds - anesthesia machine." or call (920) 320-2011 and as for Erik Barber/ Fund Development. 

Dr. DRE and associates

    So. I’m about to head back to Bolvia (Santa Rosa del Sara, to be exact) in 10 days. I’ve been participating on surgical/ medical/ dental missions projects with Medical Ministry International (www.mmint.org) since 1997 as a premedical student. On most of these projects, volunteer Anesthesiologists/ Anesthetists manage to make-do with meager anesthesia equipment. In Bolivia, this has involved a very old anesthesia “machine” which actually consists of parts from different anesthesia machines transported in an Igloo cooler and held together by electrical tape/ duct tape and a certain amount of rust. It leaks – so bad that the patients aren’t fully asleep (and the surgeons aren’t fully awake).

Old Machine – trust me, it leaks.

      One of our participants (Jon Klatt, MD – Anesthesiologist at Holy Family Memorial in Manitowoc, WI) from our previous project (Colonia Japonesa de San Juan – January 2012) worked with this machine and felt moved to spearhead an effort to get a new anesthesia machine for our work in Bolivia. Jon hopes to return for future projects as do some of his colleagues at HFM. In fact, Jean Reindl, CRNA is coming along with me this time for her first surgical missions experience. I am so excited for her and thankful for her generous donation of her time and willingess to take on such an adventure.

     The machine costs about $10,600. Manufactured by a company called DRE, it is a bare-bones, durable, portable machine perfectly fit for the conditions in Bolivia – MMI does about one project a month in different towns/ cities accross the country – the machine goes with them. With the project coming so soon, Jon and his colleagues went ahead and obtained the machine so Jean could use it on this project. They purchased it on faith that we will be able to raise the funds to cover its cost – I am truly humbled by their generosity and enthusiasm for surgical missions in general and the people of Bolivia in particular. Judging by the age of the current setup, this machine is likely to see 30-40 years of use down there.

“Dr. DRE” – tough, efficient, no leaks

      In an exciting development, the Medical Staff at Holy Family Memorial, in a unanimous decision, voted to provide matching funds up to $5000 for the machine! That means any donations routed through HFM Fund Development for this machine are doubled, and they remain tax deductable! How do I give, you ask? You can send a check to:

HFM Fund Development
2300 Western Ave
Manitowoc, WI 54220

Put a note with the check that states “restricted funds for anesthesia machine”

     Any excess funds raised will stay in the fund and will go towards things like supply purchases or to create scholarships for Nurses and Surgical Techs wishing to go on a mission project. We’d greatly appreciate your assistance (any small amount helps) in helping to send the DRE machine (I think I’ll call it Dr. DRE) to Bolivia with us. I’ll send updates during the trip as often as the Santa Rosa internet access allows.

Saying Sayonara to San Juan

1/28/12

So, a few things have happened since my last post. As is often the case, these projects wind up, not down towards the end and so they did, at least for the surgical and dental teams. The clinic team found there work slow down a bit with fewer people coming to the Centre Salud in San Juan than had come to the remote village clinics from the prior week. The weather was cooler, but only because of the rains, and the locals tend to stay indoors when this happens.

For the surgical team, we did more and more cases each day, everything ranging from removing extra fingers and toes from children to a steady diet of hernias. Most the hernia repair were actually on women, who tend to do a lot of manual labor. This is opposite the proportion seen back home. Of course, when a man comes in for his repair, the hernia is massive and has obviously been put up with for years - either for lack of opportunity to have it fixed, inability to stop work for recovery, or the nearly axiomatic truth that guys just don't go to the doctor until there is obviously a problem (and even then wait for someone else to notice it too). All this has meant a bit less down time for reflection and journaling/ blogging.

Our evenings likewise have been filled with social engagements unlike last week. Wednesday was a formal dinner with the mayor, the entire city council, and other government officials. Being a Japanese colony, this meant sushi, though I am still unable to get a straight answer as to what was actually in that Maki roll. Bolivia has no coastline, draws much of its water from tributaries of the oh-so-clear Amazon, and nothing about is infrastructure says "flown in daily." In Cipro do we trust. The dinner was a wonderful honor, however, and so far, my only known souvenir from the evening is my copy of the municipal ordinance read in our honor... in its entirety... in Spanish. It is nice to know that our work here is done with the cooperation and blessing of both the local government and health authorities. Francis has gone out of his way to develop such cooperative relationships and I truly get the sense that this local government cares deeply for its neediest people (across linguistic, racial, and economic lines), though it is often helpless to help them given the limited resources available to them.

The next evening, we were invited to the home of Miyuki, our 18 year old translator who worked with the clinic team on the first week and with the dental team this past week. Her mother is the local public health doctor who has worked closely with the clinic team. Her father owns a farm about 20 minutes north of San Juan which means one thing. Bugs. I literally ran a gauntlet of massive June-bugs just getting into the house - those that didn't audibly crunch under my feet managed to jump up and swarm my torso while I ducked for cover and ran inside. We were treated to an evening of hanging out, sipping coke, and admiring Miyuki's art (truly incredible paintings) until the dinner was served. Her father came in from the backyard pond with a pan of fresh caught fish - Paku and Sirubi (I am 100% sure those are spelled wrong - don't even bother googling them) which was prepared 4 or 5 different ways, including as Sashimi. (By the way, does anyone know for sure if Cipro covers the typical South American freshwater parasites? If not, please email me immediately.).

Later in the evening, we met her grandfather, who is 94 years old. He move to the area in the early 1950's from Nagasaki, just as the community was being founded. We did the math and he would have been 26 or 27 when the atomic bomb was dropped on his city. Seven or eight years later he would travel by boat to an as-yet uncleared portion of the Amazon basin where life would somehow be better and provide more opportunities. He has done well with what was given him and has a beautiful family to show for it. I can only imagine the stories that he could tell.

Amidst hernia-fest and one gallbladder (I must have removed the rest of them the last time I was here), the last couple of days were spent trying to tie up loose ends. This means making sure that appropriate follow up is arranged for some of our more concerning patients and that proper goodbyes are said and appreciation shown for those who have helped us.

Oliver's wound will still require meticulous care and occasional washing out under anesthesia. He tells me that the dressing changes hurt a little less each day, though he still cries when we do them. We share a hug and some laughs each day after we are finished. His room by now is filled with the crafts he has made with the pipe cleaners and construction paper that team members have given him - the paper chain must be at least 15 feet long. Fran still lets him borrow her iPad every now and then - he is getting good at Fruit Ninja and Angry Birds and apparently likes U2 music (but did he have to play Joshua tree the morning we said goodbye? That is just not fair to anyone hoping to maintain their composure).

The boy with appendicitis also has an open wound (quite common when the infection is so severe) as well which could take weeks to months to heal. Still, he is alive, and I am etremely grateful each day when i hear him say "hasta manana." At one point we were not sure he would even have one. He left the hospital on our last day.

The local doctors and nurses at the Centre Salud are being very gracious to see all our patients in follow up, even housing some who still need wound care or antibiotics. Others came back to see me on Thursday or Friday for wound checks and to confirm that their groins are still supposed to hurt a bit. They are all so gracious.

On Friday, we did one last case and made our final rounds. We packed up all the surgical supplies into their suitcases and bins and loaded them onto the trucks. We ate lunch, then returned to the hotel where I took down my mosquito net, dismantled the MacGyver coffee apparatus, and weighed my bags - I am apparently bringing home as much weight in coffee beans as I took in medical supplies. We loaded the bus and made a relatively easy drive to Santa Cruz where we did our requisite souvenir shopping before having one last meal with our Bolivian team mates. We will miss them dearly. I hope to see and work with them again, however, possibly as soon as November. By the way, there are apparently Spanish words that sound similar but should not be confused at dinner: these include Salmonada (salmon) and Salmonella, Jamon (ham) and Jabon (soap), servilleta (napkin) and cerveza (beer). Please make note of this for your future travels.

Now as we are on a plane somewhere between Santa Cruz and Miami, I have time to reflect. I'll spare you most of those thoughts for now. I have divided my time in the air between reading, sleeping, prayer, and the obligatory perusal of SkyMall magazine. To bring things full-circle from my opening post, I will now list the ten things that would have been useful had we been able to order them on the way down:

10. 140x military zoom binoculars for bird-watching (there are some beautiful birds in Bolivia)

9. Litter Robot self-cleaning kitty litter box - we'll take 250 of them for the streets of San Juan

8. Sleep sound generator - the one without the barking dog setting

7. The always cool pillow

6. Digital Bark-Free Pro ultrasonic dog repellent machine.

5. Peeing Boy of Brussels statue and fountain (It belongs here, not Brussels)

4. Cheesy Friends forever jewelry - at least 25 of them

3. Green Bay Packer auto decal - NONE of the cars down here have them. so sad.

2. Heated lumbar support cushion - because everyone in Bolivia has a bad back it seems

1. Rosetta Stone software, Spanglish edition

Enough silliness. I am onto yet another page and should spare you the rest of my thoughts (but you didn't think I'd actually err of the side of brevity, did you?) They center predominantly around gratitude as they often do at such times, but not necessarily in the way one might think. Whereas I used to fly home grateful for and eagerly anticipating reunion with my creature comforts, I am now both grateful for and in spite of them. It is pretty much a cliche by now that in serving on a project such as this, one always receives more than he could ever give. Try as one might to avoid this, it is the inevitable result of service to a God who is Himself the giver of all givers, the multiplier of loaves and fishes (raw though they may be at times), and the producer of a harvest a hundred fold what was sown. I have come to embrace it, and almost to laugh when it happens. When have I ever ended a vacation with tears of joy and an overwhelming sense of gratitude for the people I have met along the way? When have I returned so much richer than when I left?

The stuff which we left and to which we now return is mere stuff, material, yet immaterial. It is that stuff which so often separates those of us who cling to it from those who might never have any of it, or at least very little. In seeking it, we so often find ourselves alone, or in very small and loathsome company. When we seek to give of it, or to relinquish it in order to give of ourselves, we learn that we are all needy. Then we find that our needs are met in ways we could not have imagined. Scripture tells us in different passages that Christ is the giver, that He is the gift, and even the unintended recipient of the gifts we might give. We have seen Him everywhere.

I have before me a customs form instructing me to list the estimated value of what I am returning home with. Were I to fill it out truthfully, it would result in much bewilderment from the customs officials and I would likely miss my connection to Chicago (not sure what denomination I would use anyways). Please do not tell them of my omission, at least not until around 8pm Central Time.

Thank you so much to all who have followed my verbose blog posts, who have prayed or supported the project, who have come with me or have sent loved ones. I am flattered by anyone who is still reading or who would entrust so much of their time, talent, and treasure to a rookie director with much still to learn. Pictures will come soon.

Ciao.

Sometimes, the power must go out

1/24/12

We returned to work yesterday after our weekend of rest and relaxation. We returned to San Juan and found it surprisingly cool. We ate dinner and went back to the hotel to settle in. The next day would be a light one, at least on paper. Just a hernia and a scheduled washout of the femoral osteomyelitis (bone infection) on the 12 year old boy that Dr. Henry had initially debrided last week, but which the boy (Oliver) has been struggling with for months. If the planets align correctly, we could even be finished by noon and help the clinic team. (Of course, the planets never quite line up as we wish them to, and to plan your day around it happening is ill advised. I'm not a follower of astrology anyways).

I stayed up later than I should have due to an ill-advised game of team Scrabble (but at least Abby and I won with some come-from-behind double word score brilliance). No worries, I have perfected the MacGyver method of morning coffee and had everything set up and ready to go at 5:18 sharp. Alarm chirped at 5:00, I hit snooze twice per routine, then plugged in my immersion water heater ($5.99 on amazon) and sunk it into my 20oz thermos filled with filtered water. In 4 minutes it would boil and be ready to pour over some coarse ground beans in my French-press equipped Nalgene bottle. It WOULD be ready to pour had everything not gone suddenly dark and silent. The fans all stopped too, and though my coffee water stopped heating up, the room itself became still and hot. Fearing that I had blown the hotel's fuse, I walked out into the courtyard and feigned ignorance. I would later find that the outage was city-wide, so I think I am off the hook.

There was enough natural light for us to get ready for work. The water heater in the men's shower had never taken advantage of available electricity anyways. We still managed a hot breakfast since the clinic kitchen runs on propane. The hospital has a generator, so the outage should not affect our work there either.

Francis had left the evening before on a run to Santa Cruz to get more supplies and medications. The clinic team had added another Bolivian physician as well as Scott and Julie in the dental room. All together, this put us in real crunch for interpreters and I still do not habla mucho Espanol. The hospital team would have only one; Sandra. She is an excellent interpreter and a hard worker (her English is excellent as she spent two years in Ohio), but has yet to learn how to be in five places at once.

The day started with the usual "Where the heck is our patient?" causing us to send for Oliver instead, thinking we would get his short leg debridement out of the way so he could head back to his room at the health center (he is staying there for daily IV antibiotics and painful, deep dressing changes) and eat. By the time he got there however, so had our other patient who had been promised a morning time. Moreover, the head Japanese nurse would not allow us to do any other operations after Oliver since his leg was infected and would somehow permanently contaminate the operating room (though this didn't seem to be an issue last week). We complied so as not to offend our hosts, but this would put poor Oliver into an indefinite holding pattern wherein he would sit alone on a wooden bench with no food or entertainment. Any further cases we would find would bump his back even further. We felt bad for him. He has been through so much and always with a smile (always except when we are changing his bandages, that is). We did end up finding another case too - a bilateral recurrent inguinal hernia that would take a few hours to do (recurrences always take longer) on a man who had travelled many hours to get to us.

The morning was definitely off to a slow start. In addition to tardy patients and haphazard diplomacy with head nurses, the local orthopedic surgeon asked me to see some of the Japanese patients that had come in through the night (the Japanese general surgeon is out of town for the week). They were both elderly patients with potentially acute abdomens and both appeared quite ill. One was a 74yo male with typhoid and an ileus, but thankfully no evidence of perforation. The other, a 93yo woman, emaciated and moaning, who had been vomiting blood and with an apparent bowel obstruction. She was quite anemic and was getting short of breath, a bad sign when it is due to a problem in the abdomen. Her son seemed bewildered and concerned. These would not be quick consultations and would sideline not only myself, but also Sandra. We would not be able to start our first case until 10:00.

We had numerous obstacles in getting things started. The OR is out of anesthesia papers and the office was locked, thus requiring our one interpreter to ask for the key. The oxygen tank was empty, requiring our one interpreter to find the one man with a wrench large enough to change it out for a new one. The other patients' families had questions, many questions, all of which would require our one interpreter to answer. And Oliver, poor hungry uncomfortable Oliver could only wait. Siesta (11:00 - 2:00) was now fast upon us too, meaning the rest of the hospital staff would disappear and it would get even more difficult to move things along. And still, Oliver would wait.

I was frustrated and I felt like others were frustrated with me. Better planning from the medical director could have prevented this. This shouldn't be happening now into our second week. I felt pulled in multiple directions, which required me to pull our interpreter in even more directions, which I could tell was frustrating to her as well. Scott, our dentist, had shown up to look for some equipment and asked if I was alright. Moved by his concern, but was my frustration so apparent? I must have been wearing it on my sleeve, which only frustrated me further. And as soon as I start to indulge in self-pity, there is the 93 year old woman suffering through what may be her last day, and there is Oliver.

Of course, Oliver is now grinning from ear to ear. He is sitting on the same bench, but now he is with Fran, one of our wonderful OR nurses from Winnipeg. They are laughing together as she teaches him to play video games on her iPad. He would learn quickly, and she would entrust her iPad to him and his dirty little fingers, unsupervised, for much of the afternoon. She would come by frequently to check on him, to re-charge the battery, to make sure he wasn't lonely, and to imbibe in his infectious smile (Oh, were that the only infectious part of him).

The best advice is usually the hardest to follow (otherwise, there would be no need to offer it). I recall my dad once telling me (during the years where I directed a summer camp, having every detail planned out down to the minute) that the whole purpose of my well-laid plans might be to serve people, but that those in greatest need would likely show up as an interruption. At that point a decision would need to be made; put your head down and serve the plan, or set it aside and serve the interruption for whom the plan was all along intended. Today, I would again learn this lesson. It was a frustrating day, but then again, how would we learn anything without such frustrations, such interruptions.

In Mark 5, Jesus is on his way to heal one person and is stopped in his tracks by an unscheduled consultation. The scripture says he felt the power drain out of him (He who even has an infinite supply of it). He was also likely being prodded along to get on with things and attend to the task at hand (that task itself another person in need). Jesus is God, but he was also human. He had the same decision to make, and he chose to stop and not only heal the woman, but also to take even more time and affirm her faith and speak into the life of one who had likely been long ostracized by her illness.

I have a feeling I will need to learn this lesson again at some point, but for now, Fran's small demonstration of Christ's love for Oliver serves as a crystal clear reminder that we are here for the blessed interruptions. It would empower me to return to the elderly woman and take time, as much as required, to explain her plight and console her already grieving son - she would die that night. I am sure I will need to learn this lesson again at some point, and at some point that may just require the power to go out once again.

Recharged, Relaxed, Ready

1/23/11

We have had a wonderful 48 hours of rest and relaxation here at the Amboro Eco-Resort. As I said yesterday, we deserve none of this, but are deeply thankful for our time here. It has been a wonderful way to welcome Scott (Zak, dentist) and Julie (Risse, dental hygienist) onto the team, giving them plenty of time to get to know the others. They are now chomping at the bit (bad for the teeth, ironically) to do some dental work. We were going to try and set up a village dental clinic today, but torrential rains early yesterday have most the roads unpassable.

Yesterday, we had the privilege (I promise, I had NOTHING to do with this) of visiting

a local organic coffee plantation. We took a tour where they walked us through the whole process from seedling selection, coffee tree cultivation, berry picking and peeling, bean drying and selection, and on up to roasting and drinking the stuff (still my favorite part). It was neat to see the different stages of growth. They manage not to use any pesticides (we have the itchy bites to prove it) and to preserve the rainforest canopy and still get quite a good crop. They are finding this even more profitable too. Even though. the plants' leaves are somewhat insect-eaten, the insects overall have a net positive contribution to the soil and ecosystem such that it results in a good harvest without spending money on chemicals and wasting time trying to "sterilize" the process of all things natural.

I had 2 or 3 espresso back at the shop - incredibly smooth pull by an expert barista. Did some wheeling and dealing and will be bringing home about 8+kg of unroasted beans (Mike and Michelle, you can start the bidding now).

The mountain scenery was beautiful, though I wish we could have stayed until sunset. The plantation is on one edge of the valley with cattle farms and jungle in the lowlands and cloud-blanketed mountains in the distance. I have posted pics on my Facebook page for those who care to see. What you will not find posted anywhere is any footage of Bolivian Karaoke. It never happened, I promise.

Swam lazily in the pool with the team this morning, then lounged around poolside until it was time for the all you can eat barbecue (though I passed on the tripe and grilled cow intestine). We head back to San Juan in about 2 hours, luckily the drive is short. The break has been long enough to fully relax, but I'm glad to get back to work in the morning. We will likely put in full days Tues thru Fri and head back to Santa Cruz on Saturday morning. This will likely leave little if any time to buy souvenirs and postcards, but I can't say I'm too broken up about that (of course I've been here before). If the rest of the team needs to shop or are nervous about missing the plane, we may end up heading back to Santa Cruz on Friday evening.

Guest Post from Jungle Gary

1/23/12

I do not have the heart to blog about all we have suffered over the last two days. We have been whisked away from our comfortable digs in San Juan and were forced to stay in a nearby "Eco Resort" what with animals walking around, tropical birds chirping all morning, and a swimming pool way too large to enjoy all of. And the all you can eat buffets... so much work! So, in an attempt not to arouse pity from those at home, I have asked Dr. Gary Schmidt to write a guest post regarding his experiences with the adventuresome clinic team. I have read it, and though he disses the surgery team (out of sheer envy, I am sure), I will post it nonetheless.

On a serious note, I have been so blessed to hear their stories at the end of the day. As Gary details, one is limited in what he can do to treat illnesses, especially chronic ones, in such deplorable conditions, in such poverty, and with such limited infrastructure. At times, the only medicine to be offered is a listening ear and a caring touch. Such caring, touching can get exhausting. Jesus Himself even felt the power drain out of Him (John 5:30) when touched by a hopeless sufferer, He with unlimited power to heal. Yet God has sustained the clinic team through long days of both physical, mental, and emotional exhaustion, such that they seem to get stronger with each passing day rather than tiring. That said, they are enjoying R&R at the Eco-resort quite a bit. None of us deserve such a break (especially when so many have no reprieve from their poverty and illness), but we can be thankful for it and use it to prepare us for the work ahead.

So, to see how the other half lives...

"Have clinic will travel.

Unlike the hospital based team, the clinic team were not able to walk to their locations, did not have air conditioning, sleep in to 6:00, and did not just see 2-5 patients a day. Our team is composed of Katie Henry, Janet Schmidt RN, Abby Getz, an RN from Indiana, Lynne Pendse, a recreational therapist from North Carolina, Francis, and Deborah, two physicians from Bolivia, 3-4 MMI volunteers from Bolivia, and myself, Gary.

Our days have consisted of traveling between 30 minutes to two hours in a cab of a pick up truck or the back of an ambulance over roads that are in worst shape than any in the US. Going sometimes only 5-10 miles an hour for an hour, and driving from one side of the road to the other in an attempt to do the impossible, to dodge the pot holes, dogs, cows, chickens and pigs. On two days we actually had clinic settings to workout of, but most of the time it was a school house or another available building. Much of time my office was a table set up outside a building either on a porch or in the yard which was only dirt (which becomes mud when it rains), sometimes under a tree or mosquito netting (so much for confidentiality and HIPAA). There were dogs, cats, chickens, and lizards invading our space or were we invading theirs. Luckily the alligators and anacondas stayed in their on water holes.

We traveled to communities that consisted of between 4 to 25 families. Seeing anywhere from 70 to 105 patients at the 1-4 communities we went to that day. We got there and blew the siren on the ambulance or rang the gong on the porch to let people know that we were there. Our pharmacy consisted of 7 boxes on the back of the pickup truck or set up on the porch of the building which contained medications that had been donated to MMI by organizations such as Holy Family Memorial.

The medications were used to treat diseases as simple as colds, sores, and fungal infections to as complex as leprosy and Dengue. Treating hypertension and diabetes is complicated because we can give them the medications for a month or two, but after that they won't have access to or be able to afford any follow up. And to only test we are able to do other than their vital signs is a blood sugar. Diabetes is not common and most of the blood pressures are low normal.

Their life is very simple and they survive in a climate where now temperatures are 95 F and the humidity is in the 90's. Their poverty is very obvious with living conditions that we may consider dismal. But they are happy and very appreciative of the any help we are able to give them.

We come back to the hotel (not air conditioned), tired, dirty, sometimes muddy, smelling of sweat and DEET, but very thankful that God has allowed us to help His people as He has instructed us to "go to all the world".

Romans 8:28

Roughing it

Roughing it

1/21/12

Sorry to take such a break from posting. Settling in often means becoming busier and more immersed in the work and people at hand. Though unique experiences abound, they become more numerous, and for some reason I felt less compelled to immediately blog about them. I am also enjoying hearing the experiences from our clinic team who have been out and about at increasingly remote and destitute locations. Stories of train-cart rides through the jungle to grass-hut villages replete with Dengue, anacondas, naked children, even a leper. Considering having one of that team write a guest-post as they are seeing and experiencing parts of Bolivia I have not seen (and might not get to anytime soon).

From a surgical standpoint, we have become busier and thus more efficient with each day. Dr. Henry got to do a number of orthopedic cases, especially on Weds thru Fri. Katie (his daughter) got to observe a femur nailing on a day off from her work in the clinic. I have been a hernia fixing machine, but have had a few different cases mixed in. Got to take out a suspiciously ovary that wound up being a teratoma (complete with hair and teeth... pretty cool). Had to do a hemorrhoid (I told him not to tell anyone, lest a reputation be built).

The most memorable case to date has been an appendectomy on a very sick 5 year old. While I was in working on a hernia, Dr. Pendse was called to the ER to evaluate him. He was listless. Had been sick for at least 2 weeks according to what we could make of the chart. He was barely conscious, heart racing, blood pressure too low, feverish, and his labs demonstrated an anemia shocking for a 5 year old. Dr. Pendse made the diagnosis of ruptured appendicitis based on the history he got from the kid's mom. He admitted him and hit him hard with fluids and antibiotics, trying to get him to make urine and to stabilize his blood pressure before we took him to surgery.

In the States, he would be at a specialized pediatric hospital, admitted to the ICU, and descended upon by a team of specialists (surgery, critical care, ID, hematology), would get a CT scan and likely an attempt to drain the abscess with a CT guided needle. He would get blood transfusions. He would get everything. None of these are options here. It is surgery or nothing, and surgery on a child in this condition is risky. We seldom see kids so sick.

We got him somewhat stabilized and brought him to the OR, offering the family what assurances we could. They would pray and so would we. We started. He bled tremendously from places that should not bleed. With limited lighting, limited retraction, and weak suction equipment, it was nearly impossible to tell where it was coming from. The infection was severe, but contained and we were able to clear it out and remove the appendix without too much difficulty. But the bleeding continued and seemingly from everywhere. We estimated it at about 20% of his already anemic blood volume. Jon (anesthesia) tried to keep up by pushing more and more fluid through his little IV. We extended our incision, but still could not find the source. We packed him tightly with gauze sponges, a maneuver from damage-control trauma surgery intended to slow the bleeding enough to give the blood time to clot on its own. But would it? We packed and we prayed. Each of us, silently, even as our hands worked.

It stopped. All of it.

We will never know where it came from or why. We washed him out and removed the gauze. We looked everywhere for bleeding and could find none. His heart slowed a bit and his pressure remained steady, no longer dropping. We closed and moved him to the ward, alive. At home, we would keep him asleep on a respirator in the PICU and do the breathing for him. At home, we would give him blood. My translator, Sandra, is a match and tried to donate, but it was late and the lab was not even open to run the necessary tests on the blood. He would have to make it through the night on his own, though his blood count was only a third of what it should be.

He was still listless in the morning, but he was alive. He will likely receive blood from a family member today if the tests are able to be run. He is most certainly not out of the woods yet. There is much infection and inflammation to fight and limited resources with which he can do that. God must sustain him.

Returned to see him later and he was actually standing up with the help of his mother. Though small, it is a sign of strength and we pray he will find more of it. Will try to keep everyone updated as to his progress.

Hurry up and wait

1/19/12

Things continue to progress well down here. We are definitely feeling a bit more at ease in our environment and are at least developing a rapport with the local staff. I was able to fix a hernia today with the local Bolivian surgeon so we could share techniques. Turns out, he lived in Bellefontaine, Ohio for about two years via some connection with the Mennonite Central Committee back in his college days. Small world indeed. Dr. Henry is doing a slew of orthopedic cases today with Dr. Nitabara, the local Othopedic surgeon and they are developing a good working relationship as well. Things like this bode well for future projects in this area and hopefully they will become more effective and efficient as a result.

During the frequent lulls in activity, the team has banded together and created a detailed inventory of all of MMI Bolivia's surgical supplies. A daunting task to organize and inventory 40 some suitcases of randomly sorted supplies, but now we can send it out to upcoming participants so they can gather supplies to fill the shortages. I give Jon Henry and Jon Klatt full credit for starting up the idea, but everyone pitched in and made short work of it.

I got to visit the local internet cafe last night and was also able to make a phone call to Wendy and the girls. It was fun, but the girls still are not very talkative with me on the phone. It was still fun to tell them I love them right as they were going to bed.

The day is winding down for most of the team. Dr. Henry is still in fixing a pelvic fracture, but the rest of the team has left the hospital. The clinic team is staying out in the bush tonight, or at least in a small school in some remote village I can't pronounce. They have to stretch their mosquito nets over school desks and lather up with DEET to avoid Dengue. Mosquitos haven't been to bad in San Juan.

-Matt

Getting into a groove:

It’s Wednesday and we are finally settling into somewhat of
a routine. Monday (read earlier posts)
was a flurry of activity and awkwardness as we tried to set up our supplies and
learn our boundaries here at the hospital.
It is a different arrangement working in a private Japanese hospital
than it was working in a Bolivian government hospital last year in Santa
Rosa. Here, we
are one set of guests treating yet another set of guests. The Japanese have more stringent customs and
we are trying hard to honor those, avoid offending our gracious hosts, but
still to get our work done in such a limited time.

To summarize, Monday we only did two operations – recurrent umbilical
hernia (myself) and repair of a tibial plateau fracture (Dr. Henry). Yesterday, we managed to do an orchiopexy and
rectal biopsy on an 11 month old (Dr. Pendse), release of congenital syndactyly
on a one year old (Dr. Henry), an inguinal hernia repair on a 74yo female
(myself), debridement of femoral osteomyelitis on a 12yo (Dr. Henry) while the
local staff did some procedures on their own. I have come to accept my low volume of general
surgical cases at this point as I am busy enough with directing things and
making sure Dr. Henry has a chance to squeeze in as much ortho as possible
during his only week here.

Today, we have a few hernias to fix (if the patients show
up), and Dr. Pendse has already done a circumcision for phimosis. I am seeing more consultations and trying to
defer elective gynecologic procedures to future projects which might have a
surgeon better equipped to do them.

We found out that Monday has been declared a national
holiday (it’s the Aymara new year). Though
neither the Japanese, the Americans, nor the bulk of Bolivians celebrate this,
the local Japanese hospital staff are planning on taking the day off
nonetheless. We have arranged to work
Saturday and they will grant us enough staff to do that. This means our weekend will be Sun-Mon
instead. We may get to make a road trip
to do some sightseeing – will see. There’s
not much to do in San Juan (other
than surgery and sit around and sweat a lot).

Will try to keep posted as often as possible. Thank you all much for your prayers and
support.

Project Update 1-17-12

Brief update on project start:

To make a long story short, our internet access is limited
(hopefully to be remedied soon). I’ve
typed up a long blog post on my ipad which I hope to post eventually, but it is
trapped there for lack of WiFi. I typed
up a longer post on a laptop to find out that it has sketchy power supply. Because I didn’t save it sooner, I lost a
page and a half and can’t get it back. I
took a break and did some reading as it’s been a very long day. Hold on a sec while I hit “save”…

Okay, back now on a recharged laptop battery. Hoping to post this sometime tomorrow
(Tuesday) if I can make it to the internet café with my thumb drive. Enough about technology (or lack thereof).

We made it to Bolivia safely and smoothly, cruised through
customs with the help of our well-connected hosts, and managed to score some
espresso AND bacon at the airport before the bus ride to Colonia Japonesa de
San Juan de Yapacani (from here on simply known as San Juan). San Juan and its hospital are essentially a
ghost town on Sunday, so we were not able to get in to do any setting up - just
a tour of the builings without really going inside any of the rooms. We spent most the day coping with the heat
(98.6F + stifling humidity), settling into our lavish rooms at the Residencial
Jordan hotel (not too shabby by Bolivian standards), and getting to know one
another. So far, being medical director
is going well because I have had nothing medical to direct.

For our first workday (Monday), we ate breakfast and I gave
a devotion out of John 1:16-18 (the God who came) and Mark 1:40-41 (the God who
was willing to touch). Clinic team then
boarded the buses for an off-site location about 45 minutes away while the
hospital team started to unpack and organize the equipment and OR and to see
some initial consultations. Just like
last year, I am struck by the need to think of EVERYTHING involved in the
process of getting a surgical patient all the way through consultation to
postoperative care. Quite a bit is
involved, 98% of which is NOT usually my responsibility at home and which now
IS suddenly my responsibility is here.
Somehow, we managed to get about 40 suitcases and crates of supplies
organized, see consultations on everything from Hirshprung’s disease to hernias
to congenital syndactyly, to assemble the anesthesia equipment, put together
instrument trays, sterilize them, and then get two operations done, all with
the use of a single interpreter (she’s now curled up in the fetal position, but
should be fine by tomorrow). Francis had
to head back to Santa Cruz for the afternoon to pick up supplies to fill some
glaring gaps in our supply list (things like retractors and scalpel blades)
which are in shorter supply than we had expected. The fact that we got any procedures done
(specifically a ventral hernia repair and a delayed repair of a bad tibial
plateau fracture) was somewhat miraculous.
Rather than being frustrated by the pace, I tried to stay positive and
productive as did the rest of the team.
Francis encouraged us to be flexible, patient, and cooperative with one
another - such encouragement paid immediate dividends for the surgical team.

The medical team had an equally busy day, but managed to see
87 patients between the three doctors.
Not bad considering they had the assemble the clinic from scratch on
site. I don’t know many other details as
we haven’t had much time to debrief. Our
work may remain somewhat separate for the next few days as each team has to gel
and work on process improvement to become more efficient. That means sleep, which is what is on tap
starting in about five minutes.

Miss everyone stateside. I am definitely a bit more “on-edge”
here than my usual happy-go lucky self, but that doesn’t mean it isn’t exactly
where I’m supposed to be. My meditation
this morning was out of John 3:30 - that He must become greater and I must
become less. Today felt like it was much
about becoming less. Now eagerly
awaiting the part where God becomes greater.

Battery is about to die again, as is my wakefulness. More to come soon, time and net access
permitting.

-Matt