Sunday, October 26, 2008
Well, bummer. This was going to be a really happy blog post about how nice of a day I just had. However, as I was moving my laptop from one room to another, so I could settle down and type all about my adventures, a power cord got caught in the doorway and my poor old dinosaur contraption of a computer went tumbling to the floor. It appears to be mostly functioning, although a wide blank band down the middle of the screen makes viewing a challenge at best. I’ve been struggling with this antique model, nursing it along like an adult child refusing to let their poor, sick old parent just get on with it and die, for some time now. I’m pretty certain that this is going to be the last straw – the pneumonia infection that’ll do in my bedridden PC. I’d kind of like to cry right now.
The purpose of that preface is twofold: primarily, I’d like to generate some outside sympathy. I feel pretty darn sorry for myself right now, and I’d like to feel as if someone else was sharing in my misery. Secondarily, it’s to apologize for the damper which has now been placed on what otherwise promised to be an upbeat entry.
To begin with, I’d like to explain what I’ve been up to lately. I haven’t been writing about my activities for a few reasons. I’ve finally found something to do that actually fills up my time and is fulfilling, two very important things which I’d quite honestly been missing previously. I’m continuing to go to the hospital in Mazate very regularly, and have been helping out around the clinic where I can. At the hospital, I’m making friends with new doctors all of the time (there seems to be a never ending supply of them, each one introducing themselves with all four names of their names – “Silvana Margarita Hurtado Garcia”, which makes remembering who in the world they all are an anti-Alzheimers brain exercise. I’ve developed a cheat-sheet with descriptions like “the bald guy with lots of nose hair,” “the fat sweaty really nice lady” and “Mr. Big Bushy mustache” to help me keep them all straight.)
On the 17th I very briefly met a very nice young lady doctor who invited me to do a “turno” – an overnight shift -with her the coming week. Even though I barely knew her at all – by chance, I ended up helping her do a hysterectomy on a woman with endometriosis, but that was all the contact we’d had – I agreed to come. By the time Tuesday rolled around I was somewhat regretting my decision. I was afraid it would be terribly awkward, sitting around the hospital trying to make conversation all night long with a woman I didn’t even know.
I went anyways, since I’d said I would, and couldn’t be happier that I talked myself into it. Doctora (Wendi) Estrada is a wonderfully sweet lady, just a few years older than I am, and not long out of medical school. She’s actually invited me to spend Día de los Muertos with her family in Xela this weekend, and I’m planning on going. I felt pretty much instantly comfortable working with her, and I was at the hospital for barely an hour before the surgeries started. We entered the operating room around 6 that evening and I didn’t leave until long after midnight. I started doing two cesareans with Dra. Estrada, then she switched out and one of the other on-call doctors, Dr. Delgado, came in and together we did two more. After that Dr. Javalois (yet another on-call surgeon) and I did an appendectomy. Finally, around 1 am, we got around to setting a broken bone on a boy who’d been waiting since we started pulling babies out of bellies.
One of the cesareans I did with Dr. Delgado really was a case study for me in what’s most lacking in heath care here. The doctors seem to be wonderful, well-educated and incredibly innovative. They are (at times) terribly limited in terms or supplies and diagnostic tools, yet they very clearly know exactly what they’re doing. Two weeks ago, for example, I watched a Whipple Procedure, one of the top most “major” surgeries a person can have. Technically, it’s called a pancreatoduodenectomy, and it consists of the removal of major parts of the stomach, the pancreas (total or partial) and the entire duodenum. It’s a curative response to a specific gastrointestinal adenocarcinoma (stomach cancer.) This surgery is such a big deal because it requires an enastomosis (simply put, reattaching the plumbing) of the stomach, bile duct and pancreas. Every time you have to totally sever a set of biological pipes and then totally reattach them, in hopes that they work well the next time you flush the toilet – er, eat some food, in this case – you’re taking a major risk. Unfortunately, plumber’s tape and that nasty stinky neon blue PVC pipe glue don’t do the trick here, and all sorts of outside organisms are given a chance to enter what should be a totally closed system. Fistulas, or, in non-doctor speak, giant gaping hole infections, are enemy number one in these cases. As one of the surgeons explained to me while we were in the operating room, the top of the list of riskiest surgeries is as follows:
1. Liver transplant
2. Whipple procedure
3. Heart transplant
That should give you an idea of how big of a deal it is. And yet, here we were in the dilapidated little Mazatenango National Hospital, elbows deep in intestine, sweating up a storm (since we’re only allowed to use the A/C every once in a while, to save on energy bills) and b.s. ing about everything from American politics to my boyfriend (everyone’s favorite topic of conversation, it seems). The doctors explained to me quite frankly that most American doctors would think it was crazy to do this surgery in these settings, but that they were quite confident that good surgical technique was the number one most important factor in making it a success, and they could supply that much. Sure enough, the woman is recovering just fine.
On the other hand, take the example of what happened during one of the C-sections with Dr. Delgado. This particular patient had been pushed ahead of several other waiting procedures when the fetal heart rate dropped dangerously low. We wrestled the little cabezon (they’ve got some great ways of modifying words in this language. “Cabeza” is head; the “-on” suffix means “very large,” so when you call a baby a “Cabezon” it means they’ve got a giant head. Spanish lesson of the day.) out of her mommy’s belly and could see right away that she had some problems. There were certain physical features which were not quite right, like the placement of her ears abnormally low on her head, and very large wide-set eyes. She didn’t cry out immediately, nor for the first several minutes of her life. The doctor told the waiting nurse to get her out of the surgery room and into the incubator, with oxygen and a fast-running IV, and to be quick about it. Not fully understanding what was going on, the nurse ambled out of the room with her charge, and the baby didn’t get much of the attention it needed until several minutes later when one of the other docs came in and took over.
It was evident very quickly that this little neonat needed to be admitted to the peds ICU, but that created a major inconvenience. The people responsible for getting her ready for admission, filling out the requisite paperwork, taking her over to the other ward, putting her on a respirator (which didn’t end up happening, actually, since there weren’t any available), and handing the case off to the on-call pediatrician were all the exact same people in charge of keeping the operating room functioning. This meant that admitting the patient would require a halt in the evening’s surgeries, which were already stacking up.
We closed up the mother and went to see how things were going with her daughter. Eventually mom was wheeled out and left in the middle of the operating room staging area, uncovered and shivering as she recovered from anesthesia, confused and uninformed about the status of her child. Meanwhile, the doctors worked to establish an umbilical IV and made phone calls around town attempting to locate a working respirator.
Generally speaking, I think that the place most in need of growth here is in nursing. A well-trained nurse would have understood that this baby needed special care, would have explained to the mother what was going on while the doctors ran around frantically, would have covered the patient following anesthesia. Clearly, too, we needed more than the people who were on hand, since the same nurses (not anesthesiologists) who are running the anesthesia machine all night have to also act as a neonate ICU team.
I’ve always thought that nurses have an important job, but now, working in an environment where good, knowledgeable and dedicated nurses are the minority that’s even more clear. Sadly, in Guatemala there’s no uniform training program, nurses are terribly underpaid and those who do take it on are horribly overworked. Most of the people providing direct patient care are “enfermeras auxiliares” or “paramedicos,” people who’ve completed a 10-month training program at a “nursing school.” However, there’s not a set accreditation program for these schools, and the amount of training varies wildly. Even then, there are not nearly enough of them to cover all of the jobs which need to be done.
Don’t get me wrong; there are certainly very good nurses who have years and years of experiences and are very dedicated to their job. However, there are also plenty of people who just don’t have the background to know what they’re doing or how to do it right. That’s not to imply that I do, either, but I have noticed serious deficiencies. I have a much greater appreciation now than I did before for the indispensible nature of our nurses at home.
Tuesday, October 28, 2008
As I write this I’m coming off of my insomniac’s hangover resulting from another night shift with Dra. Estrada. This time we got significantly less sleep than on my first turno. I started out doing a D&C, then a cesarean with Dra. Estrada, followed by an appendectomy with Dr. Javalois; warm-ups for what was to come. Around 9 pm we entered into surgery on a woman who’d been shot while selling ice cream in the park in Cuyotenango. Not a place I’ve ever been, and now a place I don’t have much desire to conocer. The bullet had entered on her left side mid-way down the ribcage, and angled sharply up to a final resting place below her right breast. Luckily it was pretty superficial by the time it reached her right side, and didn’t enter the thoracic cavity. Not that this little advantage mattered much; the bullet had managed to wreak havoc through her abdominal cavity. Dr. Javalois, Dra. Estrada and I spent nearly five hours digging through tripa (guts), tediously trying to first localize the major problems and then repair them. Lying on the table, before Javalois sliced in, her belly looked distended and tight. Sure enough, upon opening her up bloody fluid and coagulated blood gushed down her sides, soaking the drapes and our surgical gowns alike. (If you’re cringing right now, perhaps you understand why I haven’t been writing regular blogs about my experiences at the hospital. They’d all include similar descriptions – “…as I pulled my gauze pad away from the man’s gunshot wound, I was startled to see brain matter clumping to the bandage, looking like the offspring of old cottage cheese and a death certificate…”)
That dramatic beginning was indicative of the mess we’d jumped into. Lead had ripped through her liver, prompting a constant leak of blood which was nearly impossible to address. The liver has a texture similar to a waterlogged sponge, and putting hemostatic sutures (stitches designed to create pressure and stimulate clotting, to stop blood flow) is a tough proposition, since the tissue isn’t designed to hold tension like that. After we at least slowed the flow of blood from the liver we moved our way across the upper half of her abdomen, discovering a semi-vaporized pancreas which was removed after numerous unsuccessful attempts to cease its hemorrhaging. Zigzagging back across, we next encountered a leaky, multiply-perforated duodenum which needed mending. Going down a bit farther we learned that her left kidney hadn’t been spared from destruction, and also needed removing. (Which I found particularly disappointing, since the kidneys are my favorite organ, in case you were wondering.) Through all of this a mounting stench was permeating the OR, festering in the heat and causing us all to feel slightly nauseated. Sure enough, our next discovery was a perforated bowel, leaking fecal-esque material everywhere, and requiring a colostomy. Somewhere in there we removed her spleen, too, although I don’t honestly remember when.
We finally finished around two a.m. All of us were beat, and thanks be to God the cesarean that followed was quick and easy.
I made it to bed around 3:30, and didn’t waste much time dozing off. We got up around 7 for another cesarean, a breach baby with a huge head which we nearly popped off while trying to wrench it out of the uterus. (Don’t worry, that’s a joke, not a medical evaluation of the situation.)
Our gunshot wound patient died a few hours after we finished surgery, a fact which surprised absolutely no one. I feel terrible for her family, but also fortunate to have had such a fascinating and comprehensive surgical experience. I hope that doesn’t seem like a cold-hearted statement, because I certainly don’t intend it as such. However, the truth is that I barely even noticed the five hours flying by. I was totally engrossed in what we were doing, fascinated by Dr. Javalois’ skill and expertise (he worked for the military during the civil war, so he’s done this a time or two) and, as always while at the hospital, growing steadily in my excitement for being a doctor myself one day. Seriously, guys, it’s going to rock.
On another note, this weekend the sisters had a meeting in Retalheulu (just say Reu; no one actually knows how to pronounce that other crazy compilation of letters). On a coffee finca near(-ish) to the city they discovered a ruins site 20 years ago. The site, Takilik Abaj, is particularly cool because it’s a mix of Mayan and Olmec work, the only one of its kind known. It’s over 2,000 years old and still relatively un-discovered; archeologists are very actively researching and excavating. I rode with the sisters to Reu and then took a series of buses and pick-up trucks to the ruins while they were off discussing ecclesiastical matters. The weather was absolutely beautiful – it reminded me of one of those rare gems of an Oregon coast summer day in July, where all you want to do is grab a tractor inner tube and head for the Nestucca. I’ll put up pictures as soon as I get a chance to get them off of my camera.
