Uno mas

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

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

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

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

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

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

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

                Uno mas

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

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

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

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

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

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