Wrapping things up

            I’m sitting at terminal D5 at the Miami International Airport – we will soon return to an English speaking country.  We have already cleared customs – I will admit that this always comes as a relief nowadays.  I never know how to fill out the declaration forms any more.  Have I been in contact with any livestock?  I did ride a bus with a chicken just this morning, but I didn’t touch it, so I guess that depends on how strictly one interprets “contact.” Am I bringing any insects into the country?  Well, I haven’t showered since yesterday and I stayed at the Hotel Ochotu, so I’m pretty sure that’s a yes.  In the end, the customs official was in a very chipper mood and had no intention of checking me for head lice, nor did he care to confiscate any of the tampons that the team had hidden throughout my carry-on bags as a goodbye prank. 

The North American half of our team enjoyed one last meal together at the airport Cuban restaurant before heading to our separate gates.  We all expressed our hopes to do this again together soon – maybe even next year.  Now it’s time to find some good coffee if I am to have any chance of staying awake for the drive home from O’Hare.  We land around 11:15pm.

The last day in Santa Rosa is always somewhat of a blur and this one was no exception.  We have a half-day in the clinic and OR before breaking everything down and loading it onto Ruben’s truck and our bus.  We then been invited to a barbecue with the mayor at the local Karaoke bar/ Discotheque.  Some of the team (those here for the first time) are even heading for Santa Cruz for the day (~2.5h drive) to do some touring and shopping before heading back for the dinner.

Rounds went well.  Modesta looked like a million bucks (or roughly 6.91 million Bolivianos) and posed for a picture or two before heading home.  We actually discharged all but one patient – he will stay through the weekend before having his drains removed and heading home, but even he looked quite well.  After rounds, we had a smattering of minor cases that we had been putting off until the last day in order to make room for the more major procedures earlier in the week.  There are always a few of the hospital staff who file in with lipomas or cysts to remove, and they all enjoy helping out on each other’s procedures.  We even took some skin tags off the mayor (with a few of his staffers snapping selfies in the OR with him (awake) draped in the background (clearly no Bolivian equivalent to HIPPA yet), but not before he and I were interviewed for a Bolivian television spot out under the mango trees. 

We managed a decent siesta during the hot afternoon – it was dry, but was probably somewhere around 90 degrees and it was nice to laze around in an air-conditioned hotel room and pack our bags – we would depart at 5:00am Saturday morning.  Cleaned up with another 220 volt shower before heading over to the disco/ karaoke/ barbecue/ farewell ceremony.  The mayor and other officials presented certificates of gratitude to both the MMI team and to the local hospital staff for their efforts this week, then we did some salsa dancing (I do not suggest the gringo variety) while a variety of mammals roasted on the grill. 

As the evening wound down to a close, I tried to clear some space for a group photo – some of the Bolivian team was to head back to Santa Cruz that very night as they had classes the following morning.  I dragged some stacks of white plastic chairs across the dance floor as people started to line up and hand all their cameras to Gladys.  In the process, a chair dragged across my left big toe, slicing it open a bit.  I looked in vain for something to stanch the bleeding.  Every napkin I could find already had barbecue sauce on it.  All the wound care supplies were already tied down under tarps in the bed of Ruben’s pickup.  The bleeding continued – this was going to make for a very awkward group photo and everyone was now lined up, waiting on me.  If only I could find something clean, something absorbent.   I needed something, anything designed to absorb blood quickly so as to avoid awkward social situations.  Someone in the crowd sensed my need and discretely handed me a small, flat pink and white wrapper.  Faced with an apparent nation-wide shortage of tampons, I was given an alternative product, absorbent on one side, adhesive on the other.  I wrapped it snugly around my big toe and hemostasis was instantly achieved.  Clearly everything has its purpose.

We headed back to the hotel, finished packing, and said our goodbyes to the car heading back to Santa Cruz.  We ourselves left on the team bus at 0500 the following morning and pulled into our driveway about 24 hours later (and 60 degrees cooler).  Four hours later, two girls in their jammies pile into our bed with us and jockey for the warm spot between mom and dad.  Oblique winter sun breaks the crust off our eyes.  It is good to be home.  Much thanks for all your thoughts and prayers this past week. 

Losing Count

Losing Count

     I would like to extend a half-hearted apology to those who expected more frequent updates on all that is happening in Santa Rosa del Sara.  Alas, there has been so much happening in this metropolis of the Bolvian heartland and I have had precious little time or bandwith to record and share it all.  Even now, I only have time to put down these thoughts by waking earlier than the rest of our team (though the roosters of Santa Rosa have been up for a couple hours already).  It is already our last day – I can’t believe how fast a week can go.

    Now, I am the first to admit that I am no accountant.  I did carry a math minor for a few semesters, but dropped it like a bad habit after it took me an entire semester to “prove” that 1=1 (apparently, writing “duh” on an exam does not cut it at the college level).  Nonetheless, I do come from a numerically obsessed profession, which can be both a good thing and a bad thing.  Though we measure success in less concrete ways, at the end of the project I will still be able to tell you how many procedures we performed, how many consultations were seen, and how many prescriptions were written.   Though we can say that it’s “not about the numbers”, the numbers are, in the end, individual people, and it is indeed all about the people.  Each of them are a singularity of infinite importance, neither greater nor lesser in value or in substance than another.  On this particular project, God has chosen to shower His blessings upon us with both people and numbers, with both quantity and quality of interactions with both our patients and our partners in service.  It has been wonderful. 

     One specific application of numbers in the field of surgery is that of making sure that our “counts” are correct.  That is, we want to make sure that we finish an operation with same number of needles, scalpel blades, instruments, and gauze pads that we started it with.  This is a good idea due to the dangerous consequences of leaving something behind in a patient.  Though a healthy idea in the operating room, I would contend that there are other areas of life where neurotically keeping such counts is neither possible nor advisable.  Now I am very happy to say that we kept very good count of our instruments and supplies in the operating room, but I am equally happy to tell you that I have completely lost count of much more important things through our week here in Santa Rosa. 

    I have already lost count of how many operations we have done – I believe it is around 30 over the first four days – For a two surgeon, one week project, this will be a record pace so far as my own projects go.  Today will be a bit lighter as we will be packing up the anesthesia machine and most our supplies while repairing a hernia and removing some lipomas (small fatty tumors) under local anesthesia.  We were originally going to head back to Santa Cruz tonight for some sightseeing/ souvenir shopping, but the mayor of Santa Rosa has planned a barbecue for us and the hospital workers as well as an official ceremony at the downtown square.  I hope they don’t make me give a speech; all I can really do in Spanish is ask for a scalpel and tell you how many ibuprofen tablets one should take after I use said scalpel. 

     I have lost count of how many belly-laughs we have shared as a team.  Everyone has a great sense of humor and irony.  The language barrier, along with the often-embarassing moments that make up healthcare have provided plenty of fodder (as have my tampons).  Everyone has had a turn at being harassed by their teammates.  One would think the medical director (“Del Medico”) would be spared such harassment, but alas he has not. 

     I have also lost count of the number of times I have been encouraged by my teammates down here – not flattered or patronized, but truly encouraged.  Surgery in this environment can be quite easy one moment, and then can become an immense stress when a case gets difficult.  The lighting is poor, the equipment old and limited, and the ancillary resources are few with which to manage a complication should one occur.  It can get difficult to maintain one’s cool in a hot operating room with two cases going on at once. When I wear that frustration on my sleeve (I may have stamped my feet once or twice), the others have been quite forgiving and gracious with me.   Our helpers, whether they be our North American volunteers, our Bolivian volunteers, or the local hospital staff working unpaid overtime (and hence volunteers in their own right), have bent over backwards each time to enable me to complete the task at hand.  After a difficult case, I am offered words of encouragement, a drink of cold water, a five minute break, prayers of encouragement, and sometimes a mood-lifting laugh.    

     I’m sure the clinic team has also lost count of the number of patients they have treated, as well as the number of pot-holes they have had to drive Ruben’s 1984 Land-Cruiser through to get to their locations.  Long lines always await them followed by long hours in hot, humid exam rooms.  In spite of their daunting task, it is quite uplifting to hear about the amount of time they manage to spend listening to their patients. The chief complaint may only be a headache or arthritis, but instead of quickly moving on to the “more interesting” patient, they have taken the time to sit with, listen to, encourage, pray, and share the love of Christ with their patients.    Our translators have been instrumental parts not only the medical care, but also in our ability to personally connect with people whose lives are so different than our own. 

     I have lost track of how many times our wonderful recovery room nurses Dorothy and Freddie have gone back to check on our postop patients, even long after they have left the recovery room.  We did a component separation (huge hernia repair that involves separating out the muscle layers of the abdominal wall) the first day on a sweet little lady named Modesta (and by sweet I mean incredibly stubborn).  At first, we would ask her to take a deep breath (to prevent postoperative fevers and pneumonia) – she would just shake her braided head and say “no” – no discussion, no excuses, just “no.”  It has been a real joy to see Dorothy visit her a few times each day to attend to her needs and to see her soften up in response.  By Thursday, we were laughing about her “bad hair day” and were recruiting her to help on next year’s project. 

     We are told (and are tempted to try) to count our blessings.  I think this is so that we will appreciate them appropriately, though the temptation is often to formulate ways to pay them back or to “pay them forward.”  It is human nature to try and make sure that our “counts are correct.”  The reality is however, that I can never adequately pay anyone back for the blessings I have received.  Even the attempt serves to insult the giver, to spoil the gift, and to oblige the recipient towards reciprocation based in guilt rather than joy.  In the end, sometimes all we can and should say is a heart felt “Thank You” and to happily lose count of both what we have given and have been given.  So to the people and government of Santa Rosa, to the staff of Hospital Dr. Melchior Pinto Parada, to the bevy of Bolivian MMI staff and volunteers, and to everyone who came (or enabled us to come) from the States – Thank You.  I cannot ever hope to pay you back. 

A Day Under the Belt

11/3/2013
      I am finally lounging on my bed in the Hotel Ochotu after a whirlwind 36 hours of international travel.  I have reason to believe that I may be able to post this without having to brave the sweaty Santa Rosa internet café scene, so I am blogging off-line, on faith that I will find a wifi network somewhere before the end of the project.  Where to start?
      The day got off to a smooth start – we were actually finished packing the night before we left, so we enjoyed a relaxed morning reading, eating waffles with the girls, and watching the roofing contractors/ FEMA crew as they continue to make our house looks as close to a Bolivian construction zone as possible.  Lindsay and Dorothy arrived on-time and we kissed our girls goodbye, condemning them to a week of certain spoilage at the hands of their grandparents (Thanks, Mom & Dad).  We made good time to O’Hare and made it to Miami with only a few minor hiccups on the way.  We met up with Dr. Kong at MIA before boarding for Santa Cruz – only at 40 minute flight delay, but thankfully no international connections to make.
     Wendy and I both managed to get decent sleep on the plane and no one suffered from altitude sickness in La Paz, so we managed to land in Santa Cruz feeling (though not smelling) refreshed and ready to clear customs.  And this is where the fun begins.  Franz (Bolivian MMI doctor) and Jula (health department official) were there to meet us and, as usual, managed to arrange our own line through immigration – Visas were no problem at all.  The problem came when it was time to take our bags through customs.  They have you load your stuff onto carts, then randomly select about one in three carts for a hand search (everything else gets a free pass, I guess).  You press a little button, and if the light is green, you’re good to go.  Wendy’s light turned green.  Mine was red this time. 
      Now mind you, nothing in my bags is technically illegal, but Bolvian customs is always on the lookout for things that look like imports on which they can collect a duty.  If they get the idea that any of our things are meant for resale, they want their cut.  Worse yet, they want to impound such items while they take two or three days to figure out how much they can squeeze out of you – days we can’t afford to lose if they set their sights on something essential to our work.  Within my suitcases were bags and bags of sterile gloves, needles, syringes, surgical dressings, medicines and vitamins, as well as some non-medical items that have been requested (random stuff like soccer balls, peanut butter, chocolate chips, and tampons).  Which of these things, you ask, did junior customs official Lopez find most suspicious?  That’s right:

Tampons

     I’m not sure what is so suspicious about tampons (other than the fact that a 36yo male had about 150 of them in his suitcase), but the LADY didn’t even know what they were.  So there I am, with the rest of the customs line behind me, trying to explain tampons via pantomime to an armed, non-english speaking woman with no sense of humor.  I failed. 
“Are they candy?”
Um… no.
“Can you demonstrate?”
Um… no.
“How much are they worth?”
That depends…
      Eventually (after an HOUR) she decides that she will impound the 150 tampons, three soccer balls, 200 syringes, 100 needles, and 50 scalpel blades.  They keep my passport for a disturbing amount of time while filling out more paperwork (I read the little form on the plane twice, and NOWHERE did it say I had to declare my feminine hygiene products!)  before finally giving it back to Franz. (I am now probably registered with Interpol as an international tampon smuggler and am quite fearful of my next TSA inspection.)  I finally make it through to the coffee shop and join the rest of the team.   It was good to finally see a happy mix of new and familiar faces ready to board the bus for Santa Rosa. 
      We finally made the drive to Santa Rosa after a quick breakfast at the airport coffee shop.  Traffic was dense all the way through Montero, so it took us about 4h – we arrived around 1:30pm.  We went straight to lunch – a different restaurant than in years past, thankfully with more elbow room and fewer canines patrolling for scraps.  We then stopped briefly at the hotel to check in before heading to the hospital to see some pre-screened surgical patients – we saw 18 consults and scheduled 13 of them for surgery before heading back to the restaurant for dinner – made it back to the Hotel around 8:30pm It was a long day and the team maintained a good attitude through all the sleep deprivation and airport hassles.  It will be nice to have already seen so many pre-surgical patients before the first OR days starts. 
       Monday will start early with breakfast at 6:30 – the clinic team has a 2h drive on bad roads to reach their destination.  The OR team has 4 cases scheduled, including a massive hernia on a little old lady that will probably require a complex procedure called a component separation.  Dr. Stan does these often as part of his practice and I am looking forward to doing one with him.  We also expect to see a large number of consults through the day.  We seem to be running a special on hernias this year because they really got word out through the rural areas where the hard working folks have been working on enlarging their hernias through decades of dairy farming labor. 
     Tomorrow comes quickly.  We are trying to cram a lot into one week, so not sure how often I'll get to post.  Thanks for following along. 
-Matt

Gearing up to go!

     Just a short note here to let folks know that we are heading back to Santa Rosa del Sara, Bolivia in T-minus 18 hours. Just a short, one week MMI project this time. It will be my third time to Santa Rosa which has a special place in my heart as it was my first Bolivia project location (in 2010). I get to take Wendy with me again this time, but the girls are staying behind with my parents – So nice to have them in our neighborhood now. We are truly thankful for their help this week.
      I am excited about our team this time around. We are joined by Lindsay Lorenz, PA-C who lives here in the Manitowoc area and works in multiple emergency departments in Green Bay. She has surgical experience as well, having worked with us in my office in the past. She honestly has so many skills, I’m not sure where she will do the most good. We also have Dorothy Grossheim, RN from our Same-Day Surgery department here at Holy Family. She will fill a much-needed role in preparing patients for surgery and monitoring them afterwards. That rounds out the Wisconsin Contingent.
      We also have a West Coast part of our team. I’m excited to work again with Dr. Stanton Smith, another general surgeon practicing in Klamath Falls, OR. We worked together last year in Santa Rosa and had a great experience. Stan gets to bring his wife Valerie this time as a general helper. We will also be joined by “Freddie” Buhr, a recently retired nurse who has known Dr. Smith for quite some time and who has always wanted to go on a mission project.
      From Ohio, we will have Dr. Roberto Kong joining us again. Roberto is an anesthesiologist practicing in Dayton, Ohio (GO BUCKS!) and this will be our third Bolivia project together. He was with us in Santa Rosa in 2010 and in San Juan in 2012. He is an extremely compassionate, conscientious, and skilled anesthesiologist. I’ve seen his MacGyver skills in action, but he is probably looking forward to working with the new anesthesia machine HFM donated last year (I’m pretty sure he’s still bringing his duct-tape and chewing gum, though. Just in case…)
     A late registrant is Dr. Henry Bush, a family practice doc working in Puerto Rico. He will be working with our clinic outreach team out in some of the smaller outlying communities in Santa Rosa county.
     We are in the final packing stages right now – a mad dash of Suitcase Tetris as we try to push each bag right to the weight limit. I have managed NOT to lose my passport this time around and I think I have all the paperwork ready to go. Not bringing any heavy equipment this time, so that should make clearing customs a little less “Bourne-like” this time around.
We get to stay again in the “Hotel Ochotu” again this year – a cozy little enclave three blocks from the hospital and perpetually under construction. I recall them also having intermittent AC and electrifying showers. To prepare, we have decided to have our home’s roof re-done as we leave – we are now pre-accustomed to construction noise and shouting en-espanol late into the evening. Our electricity also goes out on occasion.
      Not sure how much I will get to blog while we are down there. We tend to work late into the evenings on short projects, and as of 2012 the hotel did not have internet. In fact, the only internet access in town was at a quaint little internet café downtown. It was basically a 100 degree phone booth with 8 workstations (486 PCs on dial-up), seven of which are occupied by sweaty gamers at all times. The place is named “Need for Speed,” which is more of a plea for help than anything. I am not sure if it will be available this year as I hear it is serving as the outsourced headquarters for Healthcare.gov. If I am unable to post from the project, I’ll try and journal anyways and then post them when I get back to the airport next Saturday.
      Well, I’ve gotta go. More packing to do and I’ve got a seven year old girl trying to use me as a jungle-gym which will make fir intolerskjnble typos and unredablk blgs.

     Hasta

Caution: Verbose rambling ahead

51 operations, countless consultations, and I haven't dictated a single chart in a fortnight. My transcription staff at home is likely fearing the dammed-up verbiage that awaits them upon my return. So if only for their benefit, I unleash the lingual catharsis below in hopes that come Monday my words will be few. Barb, the office bookie, is currently calculating the odds - they're not good.

Crowded airplanes are not necessarily the best environment to start processing through and eventful two weeks. I'd much rather have an unscheduled day, an easy chair, a pot of coffee (or three), and two growing girls vying for space in my lap (coffee spills notwithstanding). As it is, that is the plan for tomorrow. At present, I am content with the little bubble of personal space called seat 31D. Occasionally someone stops by to offer me coffee, tonic water, or a shrink-wrapped pastry. The iPod is on shuffle. Life could be worse.

I haven't had time to compile final numbers - I think we did about 51 operations and probably saw twice as many surgical consultations. Marie, Franz, Paola, and Sarona also saw countless medical patients in her tireless clinic work. Reuben was always checking vision and giving someone glasses, even while loading the truck on our last day (he kept one box of glasses out for as long as he could). Yoko managed to keep us fed, free from illness, and somehow to spend the quality time with our patients that we could not - listening, talking, counseling, and praying with them - I have no idea where she finds the time as she never seems rushed. She multiplies minutes like loaves and fishes. Francis was here and there doing a little of everything. Occasionally he would disappear to Santa Cruz attending to urgent matters and maybe seeing his family (a most urgent matter - he is away from them so much). When he is gone, one of his disciples fills in with ever increasing confidence, grace, English proficiency, compassion, and patience. Their growth in just over a year is astounding.

Jon was again a Godsend - I love that he made the decision to come a second time. As of yet, he and Wendy are the only gringos crazy enough to come with me a second time. I can't say enough about what a blessing it is to work with him both personally and professionally - safe, efficient, compassionate care... and he is downright hilarious (or maybe the anesthesia machine was leaking). He made teasing Brenda and Paola as much of an art form as providing state of the art general anesthesia in the Bolivian hinterlands.

Brenda - I wasn't quite sure what she was going to do when she signed up for the trip - I knew very little of her background at the time. Getting to know her was a a joy in itself - I am glad she came for both weeks (I think she will be too once she has a couple days to rest up). What would she do? Everything, really (except serve Jon breakfast). She was a sterile instrument processor, a central supply runner, a circulator, a scrub tech, a Spanglish pantomime translator, and managed to take the brunt of Klatt's teasing so the surgeon could do his work in peace. Her work ethic was amazing and durable - sure she got tired - but she continued to keep things going. She was the grease on every gear (flattering, I know) of our well-oiled machine. For all our complaints about inefficiency, we did more surgery in two weeks than I do in two months at home. I still can't believe there was only one of her. She was everywhere.

I guess gratitude is what is most on my mind right now. I have so much to be thankful for. These projects are intense. Stress, anxiety, fear, unertainty, fatigue, and frustration on one hand, but also joy, laughter, love, peace, gratitude, friendship, and trust on the other. The oscillation and contrast between them seems to heighten the experience and appreciation of each. Maybe this is true of life in general, but for some reason I seem to notice it more down there. I seldom work harder or have more fun than on these projects. I dare you to come with me.

I also thank you for reading along (if you are still with me). Writing these posts has become the way I process my experiences - they can get a little wacky or personal from time to time (maybe even most of the time). If you haven't had enough yet, feel free to ask me about the project. I've got 8.8 kilos of coffee beans in my carry-on - I'd be glad to share a pot of it with any of you if you've got the time.






- Posted using BlogPress

At Hand

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

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

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

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

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

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


- Posted using BlogPress

We've got problems

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

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

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

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


- Posted using BlogPress

Finding the plane

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

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

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

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


- Posted using BlogPress

Getting it in gear

Four days have gone by already - we are starting to hit our stride in the operating room and it's amazing how time flies when every moment is not one of frustration. We managed to get six procedures done on Tuesday: two gallbladders, a large thyroid, and three hernias. We were still frustrated by instrument and linen delays, so the six procedures kept us working until about 7:30pm and we still postponed two cases for the next day (maybe my expectations were a bit too high). I could sense tension between the instrument staff and our own team and this was only exacerbated by the language barrier and our poor understanding of their normal procedures. At the end of the day, I found Francis (he had been in Santa Cruz haggling with customs officials about an upcoming project) and had a chat with Vasilica, their head instrument tech. Found out they are down one autoclave and have to reprocess gowns and drapes in the same one as the instruments. It takes twice as long for the drapes to cool and dry and this slows down the instrument cooling time. They also have only six gowns - we will typically use three per operation. Result of conversation: We will borrow some gowns and drapes from the hospital in Santa Rosa (site of last November's project - about an hour's drive away).
Wednesday ran much more smoothly - we did seven cases (two gallbladders, a thyroid, three hernias, and a leg lipoma) and actually finished by 5pm. We didn't even have the gowns from Santa Rosa yet, but the second autoclave was back up and running and we started having the scrub tech (or whoever is functioning as such) go without a gown (gloves only) since they don't really have to "belly up" to the patient. This gave us gowns to cover two cases at once while some were still in the autoclave. We really didn't have to use many disposable supplies at all.
With the early finish, John, Jim, and Brenda walked up to the San Carlos square to get some ice cream. I saw a couple more consults with Marie and we watched the hospital staff play soccer. We actually made it back to the hotel before dark too.
Today, we did another seven procedures (three hernias, a goiter, a gallbladder, a facial debridement, and cutting and closing the web-space on a 1 year old with syndactly of his hand) and were finished by 4:30. Part of me regrets not scheduling more, but we never know how long we will have Ulysses, the local anesthesiologist. He has been more than willing to help, but he covers emergency cases in 5 or 6 towns and occasionally has to disappear for an appendectomy in Yapacani or a C-section in San Juan. Today we had him all day until 3:00, so we were able to run two tables the whole time.
I has been great to see the team gel both personally and with our work. We are also building better relationships with the local staff. Jim is really good at making small talk with the local staff and taking real interest in their background/ education/ training, etc. Brenda has been a huge help in the OR - she's taken charge of making sure the next case is ready to go, that the equipment and suture are ready, she has circulated (being the supply gopher while everyone else is scrubbed in), scrubbed cases, assisted procedures, functioned as an orderly, cleaned the room between cases, and all while receiving constant teasing from Dr. Klatt (please note: this NEVER happens in Manitowoc). Alas, she has not yet made us breakfast, but there is still one more week to go.
It has been a lot of fun scrubbing with the Bolivian docs Paola, Franz, and Sarona (a.k.a. Smurfette - Pitufina en espanol). Dr. Ricaldy, the local surgeon, has also scrubbed the bigger cases and Ulysses will even start a spinal, then scrub to assist on the larger hernia cases. There is a lot of Spanglish and laughter emanating from the OR as we all start to habla the same lingo.
Wendy has memorized the exact location of every stitch, needle, syringe, glove, dressing, drape, gown, drug, tube, or drain in the supply room. Since we have to wear a hot gown or change clothes to leave the OR area, she has been a big help in bringing us needed supplies on a moment's notice. All I have to do is buzz her on the walkie talkie and she will bring me exactly what I need right away. She assures me that this service is not available at home and that she will be hiding the walkie talkies upon my return. She has also been helping dispense and explain prescriptions and eyeglasses in the pharmacy which serves as a the main hub of activity for the team's various functions.
Between cases, I usually go over to the consult area with Marie (Nurse Practitioner from NC - and one who gives me stiff competition in the coffee-consumption department). She has usually found a few people with gallstones or hernias for me to see, and she usually has one curveball patient with an as-yet unintified parasitic disease. I hope me shrugging my shoulders helps her feel better. With very limited laboratory capabilities, we are often stuck referring the more worrisome cases to ID specialists down in Santa Cruz.
Well, one day left for week number one, then Jim, Marie, and Wendy head back to the US and it's just John, Brenda, and I as the only gringos left. Looking forward to another trip to the coffee plantation this weekend. (You can submit your orders via private message, but I can't make any promises).
- Posted using BlogPress

Donde esta el equipo?

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

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

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

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


- Posted using BlogPress

Location:San Carlos, Bolivia

Next to me

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




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

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


- Posted using BlogPress

Location:somewhere over South America

let's see if this works

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


hmm... wonder how a second photo will work:




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


- Posted using BlogPress

Location:Manitowoc, wi

Testing, Testing, Uno, Dos, Tres

Testing out the latest version of the blogging app I'll be using on our trip. I'll try to post a few pics of trip preparations to see how those work on each site.

About to embark on fourth MMI project in Bolivia dating back to late 2010. It has become a home away from home, complete with colleagues/ friends who are becoming more and more like family. I must confess that I am getting very excited for what lies ahead. Our team is small, but since this is a surgery-only project, I will get to work in the OR with the Bolivian MMI staff who are normally out at remote clinic sites. Wendy also gets to come sans kiddos. Though I will miss them dearly, it will be fun to have her undivided participation in the workings of the project.

Packing is always an adventure. Overwhelmed with all the donations of supplies we have received. So many people to thank, I shudder to leave anyone out. Someone suggested getting in touch with Ethicon/ MAP international who donated roughly $10,000 worth of suture alone. A number of others sold me medicines or supplies at a remarkably and consistently low price of $0. Still others drove well out of their way after scrounging up hernia mesh which is always much needed. Others donated leftover supplies - one man's trash is indeed another's treasure. Others helped with the time-consuming task of sorting through all that stuff (at one point my office had more needles and syringes than the Jersey shoreline). Others have donated funds for the anesthesia machine which we will again use to keep our patients safe and comfortable. Others simply ask and show interest in the project, offer their prayers and encouragement, and wish us good luck and God's blessings. Some give us vaccines on short notice. I could go on and on.

Now the kids are tucked in bed, as are Wendy's parents who will love and nurture them (a.k.a. spoil them rotten) this week in our absence. The bags are packed and will barely make weight. I have made the last neurotic trips to Walmart and Fleet Farm. I have lost, then found my passport (and along with it, my sanity). We pull out at 9:00 tomorrow morning and land in Santa Cruz roughly 24h later. Word has it the hotel has WiFi. Will plan on keeping you all updated.


- Posted using BlogPress

Location:Manitowoc, WI