Scrubbin' into South America

           I have been asked by some of our readers, why I haven’t blogged about my medical volunteer yet.  The reason being that, honestly, there was not much to talk about in the beginning of this trip.  But I finally feel like I have had enough of a worthwhile experience to share.  We’ve also had a lot to write about with weekend adventures that had time-consuming blog posts. Here is my opportunity to finally let you guys know what I have been up to in the clinics and hospitals around Cusco and my new volunteer project in Guatemala.  I am going organize this blog by first explaining to you the process of my volunteering from when I first got to Cusco to what I am doing now.  Then I want to give you case-by-case patient observations and interactions.

           

            First of all, I want explain the things I wanted to get out of my traveling/volunteering experience. I want to improve my Spanish and my ability to communicate with a Spanish-speaking patient.  Second, I want to get some hands on experience and help the less fortunate with health care.  The success of these goals, like any healthcare student, would revolve around my Spanish and also my ability to build rapport with the doctors.  

Clinica San Juan
de Dios

When I first got to Cusco I was told that the clinic I was supposed to be working in had some issues filing the paperwork that cleared me to work in the clinic.  This clinic, Centro De Salud de Ttio, was right around the corner from our home and had a high patient load and cheap cost.  Perfect! I thought. But I was told by our coordinator to be patient because, in Peru, things do not happen overnight.  So in the meanwhile I spent my first week working at another clinic; San Juan de Dios.  This private clinic was a bus ride away and it had a second floor dedicated to paraplegic and mentally disabled children.   Upon arrival of my first day and orientation it was a way nicer clinic than I had imagined but I was promised that there was enough of a patient load that doctors would need help.  I spent this first day following a doctor but she was not very happy about it.  The rest of the days that week I spent doing paperwork with no patients walking in the clinic.  I came to the understanding that the volunteering they were in need of was spending time with the disabled children upstairs.  While this is a great way to volunteer, it was not what I had set out to accomplish on this trip.  I finished up that week and set sights on other opportunities for the next week.  After talking to my volunteer coordinator she was scrambled to find somewhere in the city for me to go.  I knew from talking to other medical volunteers that there were plenty of opportunities in the city.  It was obvious that the IFRE Peru medical volunteer program still had a lot to be desired in its growth.  I was slightly disheartened from the false promises I received before coming to Peru, but I was and still am, determined to enjoy and make this experience everything it can be. 

The next week I was set up to go to an orphanage for mentally disabled children called Casa de las Estrellas.  The orphanage had funding from a company in Spain but lost it two years ago when their economy began to crash.  These kids have since then been without basic check ups for two years and were glad to accept me into the house.  My job was to give all the kids a check up and physical examination as a prescreening to see if any of them needed to go to the hospital for further medical attention.  There were about forty kids in the orphanage so this was an all week project.  I had to take two busses to get to the far end of Cusco to find the orphanage.  Everyday I was happily and overwhelmingly greeted with cold, slobbery hands and hugs from numerous children.  The excitement and love was so overwhelming that I didn’t mind all the germs I was inevitably receiving. There were four house-moms that showed up to care for the children everyday and a small Peruvian cook.  The sight of a bigger man such as myself was a rarity for them and in turn excited them.  One by one with the help of a house mom I checked the children out.  Pathologies included what you would expect from an orphanage - dermatitis and lots of it.  Although dermatitis is self-limiting, I had some creams to distribute anyway.  Other than warts, scratches, and irritated noses from constant nose picking, these kids were very well cared for.  

           

The next week was pretty low key for us with Thanksgiving; I spent the week waiting to hear back from our coordinator for other opportunities and going to the orphanage, Casa Hogar, with Sarah.  The kids there are not as well cared for so I spent that week, with the help of Sarah, cleaning faces, ears, and skin infections.  One day one of the girls fell over the couch and cut her forehead open and proceeded to bleed everywhere.  That was a moment of excitement until we cleaned her up and stopped her bleeding only to find a tiny, shallow cut. It was a bit of a relief because she cried and bled as if she punctured her skull. 

It wasn’t until after Thanksgiving that our coordinator asked a friend of hers who happened to be the CEO of a private hospital, Clinica Paredes, for a personal favor in having me intern in his hospital.  I met with him the next day where he asked me what my goals where.  He then granted me access to follow him and any doctor with their patients and even to observe in the operating room.  This was better than any opportunity that I had come across yet.  I was introduced to the operating room manager, Lilly, and we exchanged phone numbers so that I could contact her about the surgery schedule.  I followed the doctor with a couple patients but most of my time was spent in the operating room observing and even assisting in surgeries.  I meet other doctors in the area, two of which where bosses of the biggest hospital in Cusco called Seguro Hospital.  These doctors took a liking to me an invited me to come and shadow surgeries in their hospital.  They gave me their cell phone numbers and told me to call anytime I was in the hospital.

Clinica Paredes is a small hospital with two operating rooms.  Seguro Hospital is a modern three-story multi-winged hospital similar to the ones you find in the States.   Everything in Seguro was decorated in dark tile and not the typical all-white you see in the hospital settings back home.  My first experience there involved me walking around until I found the doctor I was phoning.  I finally found him with his head poked out of a restricted operating room entrance ushering me in a tossing me scrubs.  Within thirty minutes of my first day there I was scrubbed into a surgery, (But more on that later).  For majority of the weeks in Cusco I spent my time at Clinica Paredes and only spent a handful of times at Seguro. 

The only picture I have of Seguro Hospital.  Peak through the fence.

Clinica Salud de Ttio

It was January by the time I got the call from my coordinator saying that the papers had finally gone through and that I was clear to go to Centro De Salud de Ttio, the clinic I was supposed to be volunteering at the whole time.   I worked there in the topico or emergency department.  People come in for triage and then are directed towards the separate departments as needed.  There are also patients that come in for wound care, injections, sutures, nail removals, suture removals, ect. This is where topico came in.  I was immediately used in helping treat the patients that came through the door.   I went to the topico clinic for my last three weeks in Cusco.   My experiences in these clinics and hospitals have ranged from observing patient interactions, seeing patients on my own, performing small clinical procedures, observing surgeries, and scrubbing into and assisting in surgeries.   Of all these experiences there are a few that I would like to share.  Here are my patient interactions in a case-by-case presentation as I remember them:

Scrub station in Paredes
(Picture of Jesus
guiding surgeon above) 

Ayahuasca:  The first patient I followed at Clinica Paredes was the typical backpacker living in a hostel.  He was there with is brother complaining of continuous vomiting with blood and stomach pain which are both typical symptoms that most people have after consuming Ayahuasca.  Its believed to be part of the cleansing process.  I watched an endoscope go into his esophagus and stomach looking for longitudinal tears that would produce the blood in his vomit.  It turned out that he had tears at his gastroesophageal junction, which is called Mallory Weiss syndrome. 

Clavicle Fracture:  The very first surgery I observed in Clinica Paredes was a clavicle fracture due to a car accident.  The first thing I noticed about Peruvian surgeries is that if the procedure is done under general anesthesia there is no local anesthesia administered before the surgery.  This makes for a very painful post-op.  The small Peruvian trauma surgeon did the best he could to distract the displaced collarbone and realign it into anatomical position. After forty minutes of struggling, he set the bone as best as he could and screwed a plate across the fracture line.  It was better than nothing, as the doctor said. 

Paredes Operating
Room

Humerus Fracture:  Trauma surgeries are the most interesting surgeries to me.  One day a trauma surgeon bumped his case up because he needed to fix this lady’s humerus.  It had taken her over a week to get to Cusco after a car wreck that occurred in a village near the jungle.  Her body had begun to heal itself by the time of the surgery.  There was formation of new bone beginning to grow and soft tissues had been swollen and contracted around the fracture.  These factors made the surgery a bit difficult in trying to realign the bone into anatomical position.  The doctor had to re-break the humerus and try to re align it, battling soft tissue contractions. To make the operation even more difficult the only surgical plates they had were huge.  The doctor screwed a plate over the fracture line and into the bone to hold it in place and checked the movement.   Elevation and flexion at the shoulder joint were limited but the bone was in better alignment.  The thing I had to take away from this operation is that she was better off after the surgery than before – regardless of the resources that could have been available for a better outcome. 

OBGYN surgeries:  I had the opportunity to observe a couple types of OBGYN surgeries.  I wanted to be exposed to all different kinds of medicine and surgeries so, when the opportunity arose, I felt as if I was obligated to observe.  I first saw a caesarian section.  The mildly entangled umbilical cord and enlarged placenta had complicated the pregnancy and the doctors decided the baby had to come out.  I had never seen such urgency, force, and precision by two old ladies in my life.  They got that baby out of there in less than fifteen minutes.  Then the doctors showed the father the umbilical cord and placenta to reinforce their diagnosis and need to perform the caesarian section.  I got to see another C-section the next week as well but the procedure was calmer with the same successful outcome.  The second type of surgery I observed was a vaginal reconstruction.  With hemostats coming out of there in every direction, cuts and sutures being placed deep and superficial, I don’t know why anyone would undergo that procedure and that’s all I have to say about that.  The last type of OBGYN procedure I observed was an ovarian cyst removal and hysterectomy.  This was a very interesting procedure to be able to see the female reproductive organs exposed.   I also got to see what a cystic ovary looked like when the doctor removed it from the patient.

 Fracture Friday: This was the end of my second week at Clinica Paredes and I had met a lot of the regular doctors and nurses in the hospital by that point.  This particular Friday morning we had a surgery scheduled for a fractured wrist (distal radius).   The only problem was that the patient was late for the surgery. The trauma surgeon and I were talking while we were waiting.  He wanted to practice his English with me and I my Spanish with him as we exchanged our medical backgrounds and difference in North American and South American medical education.  The patient finally showed up and it was then that the OR manager, Lilly, told me that I would be scrubbing in on the surgery to help the doctor with his case.  Typically, the doctors show up with an assistant to scrub in and help but I realized he did not have anyone else with him and he requested for my help.  It felt good to scrub into a case again, except in a different country and in a different language.   My orthopedic rotation at Temple left me confident to help this doctor with his wrist surgery.  There were times during the surgery when I didn’t fully understand what he would say to me but I would assisted with whatever I thought would help him visualize and reset the bone.   A mild communication barrier was not enough for the doctor and I to successfully reset and screw in a plate to hold the patients radius in place.  I assisted mostly by holding the bone and plate in place while the doctor drilled and screwed.  We switched roles when it came time to close up the wrist, he handed me the suture and asked me if I had done this before.  I confidently said yes and accepted the chance to show my skills.  With a beautifully closed up wrist and my first scrubbed in case abroad finished, my day could have been complete right then. 

            The second surgery of the day was equally as interesting.  A young girl was in a car wreck a few days earlier and suffered a fractured jaw.  The fracture line was a vertical break just to the right of her chin.  The doctor I just finished the radial fracture with talked to the doctor about to perform the surgery and he also decided that he would use me to scrub in and assist in his surgery.   We had a quick conversation about who I was during the prep of the surgery and then we were in action.  The doctor made his incision inside the lower lip along the jaw line and exposed the fracture right away.  He wrapped a wire around the teeth across the fracture line and twisted the wire creating tension and closing the fracture together.  He then screwed a plate into the jawbone across the fracture line holding it in place.  He left the wire wrapped around the teeth and then looked to me to close the incision.  Again, I confidently accepted the suture remembering that suturing any part of the body is the same concept.   Even thought I have never put sutures in a mouth before, or a wrist, until that day.  I sutured up the incision in the girls mouth and my Friday was a complete success.  I had scrubbed into, assisted, and closed two very interesting cases. 

Total Hip Replacement:  Due to my month long orthopedics rotation at Temple University Hospital this surgery was no stranger to me.  In fact my first hip surgery I ever scrubbed into during that month was a four-hour surgery disarticulating the hip joint of a two hundred and forty pound ex boxer.  The experience I had in Cusco only involved me observing.  The procedure was the same but the way they went about it was completely different.  For example, in the States we used “space suits” which is essentially an all-sterile hood that has a clear plastic window and a fan inside to keep you from overheating.  This is used for increased protection since the surgery involves a lot of hammering and joint manipulation where there can be blood, tissue, and fluid splatter.  In Cusco they had the surgical cap and mask with no eye protection unless the doctor wore glasses.  In fact blood did get splattered on a couple of the doctors faces even though they turned away every time someone was doing the manipulations or hammering.  Another big difference that I observed was that the prosthesis representative for the surgery did a lot of the actual surgical placement of the new hip.  This is different in the States because the representative does not assist in the surgery and just tells the doctor the sizes of the different prosthesis and answers any questions during the process.   Despite the differences the patient had the same outcome of a newly replaced hip. 

Plastics:  My first day at the biggest hospital in Cusco, Seguro, was hectic and great at the same time.  I called the anesthesiologist who worked at the hospital and he tried to explain to me where to meet him.  It is hard enough to follow a doctor talking in person but on the phone it was near impossible to understand what he was saying plus he abruptly hung up the phone when he was done talking - which was understandable since he was in surgery but not necessary since anesthesiologists just kind of hang out during the procedure.  Anyway, I wandered around the hospital until I finally got some help and saw Dr. Tapia hanging out of a restricted entry door and waved me over.  I was then thrown some scrubs and rushed back into the main outpatient surgery floor.  I walked in on the end of what looked like a nose job being finished up but I wasn’t sure exactly what was done.  I talked to the doctors for a bit and it was established that I was to scrub into and help the doctor on the next surgery.  Which was in fact a rhinoplasty or nose job.  I got the opportunity to assist in two rhinoplasty’s that day.   Peru does their elective surgeries under local anesthesia, NOT general anesthesia, which means the patient is awake and conscious.  I assisted in placing the cartilage while the doctor sutured it in place and I also hammered as the doctor held the osteotome to remove bone and cartilage from the bridge of the patients nose.  The experience was very educational: I now fully understand the rhinoplasty procedure and I again don’t know why anyone in his or her right mind would undergo such a surgery.  Either way I left with a new life experience and was very happy about it.

            I also observed a breast augmentation and a liposuction surgery at the private hospital Parades.  I’ll spare the details and just say these were also procedures that left me with a new understanding for the human desire for a “perfect body”.   Again, I do not understand why anyone would want to undergo such a procedure. 

(1) Expose Tendon

Podiatry:  I was excited to finally observe a Podiatric case.  I asked the doctor if I could assist, considering it is my specialty in the United States, but he had an assistant that worked with him full time so it wasn’t necessary for me to be scrubbed into the surgery.  Either way I was happy to see what the doctor was going to do.  To spare a long and lengthy worded explanation of the surgery so I will just say that he transferred a tendon in the foot from one location to another to assist in lifting the foot since the original muscle responsible for that action was not functioning.  The surgery was necessary for a normal walking pattern.   This is a very interesting surgery and I was excited to witness how the doctors in Peru do it differently.

(2) Split Tendon

(3) Transfer Tendon

(4) Closed up 

(5) Post Op Cast

Abdominal Surgery:  I observed two different abdominal surgeries, which were firsts for me. It was interesting to see what that part of the body looked like outside of my anatomy cadaver lab.  The first surgery I saw was an open gall bladder removal due to cholelithiasis or gallstones.  It was crazy to see gallstones that were a little bit smaller than golf ball sized come out of a human body.  The second type of surgery was an open gastrointestinal surgery due to scar tissue constriction along the intestinal tract from a previous appendix infection and surgical removal.  I saw the entire small intestines removed from the abdomen and inspected foot-by-foot.  The doctor carefully cut away any scar tissue causing constrictions to the bowel, which was a tedious process.  There was a section of the bowel that was too scared and constricted to salvage and was removed.  The two ends of the bowel were reattached and the surgery was complete.  After my orthopedic rotations I knew the skeleton of the body was resilient but after watching the intestines being manipulated as they were during this surgery I feel like I walked away with a new understanding of the resiliency of the human body in general. 

Topico:  As I explained earlier, there were mainly basic procedures performed in topico.  There were two patients I helped whose stories I would like to share.  The first patient I would like to share was a young female who came to the clinic with a scarf pressed to her head.  After quick questioning the nurse was obviously upset that she had not come in earlier.  She explained that she was at a discoteca the previous night and someone had smashed a large bottle on top of her head.  We examined her to find a deep laceration (probably to the bone) that was about five centimeters in length.  I got to do the whole procedure of injecting anesthesia, cleaning out the wound, and throwing the sutures to close up her head.  That was the first time I had closed up a head wound like that and I was happy with the result and confident in the uneventful healing of her wound. 

            The second patient was a middle-aged man who came to the clinic with his hand wrapped.  He explained that he cut his hand in a machine doing construction work.  He unwrapped his right hand to expose two deep cuts to the ring and pinky finger.  The cuts were on the backside of the fingers at the last joint crease and were deep to the bone.  He had cut the extensor tendon of both fingers and was not able to extend them.  The nurse and I explained to him that he would need further surgery to repair the tendons in both his fingers.  He did not have a lot of money and was at the clinic now because he wouldn’t be able to afford a surgery at the hospital in the first place.   He understood his risk and told us he would go back to get his fingers fixed if he had the money in the future, but he wanted us to fix him for now.  Again, I had the whole procedure to myself and took great care in administering anesthesia, and thoroughly cleaning the open wounds.  Only the remaining joint capsule and soft tissues on the palm side of his hand were keeping his fingers attached.   I took the time to carefully sew his fingers back together and wrap him up to be sent on his way.  As I put his fingers back together I notice other scars on both his hands and knew that this wasn’t his first time in a doctor’s office getting his hands fixed.  Hopefully he is taking better care of his hands now.

Endoscopy

Finally I want to tell you what I am doing now that I have arrived at my volunteer program in Guatemala.  The program here is less interactive because there are three medical schools here and a lot of the clinics are not open to have foreign volunteers because they already have enough medical students around in the first place.  That being said, I am shadowing a gastroenterologist at the local public hospital, Hospital National Dr. Rodolfo Robles.  My responsibilities are strictly observing the doctor/patient interactions.  Every Tuesday the doctor performs endoscopies and I observe five to seven procedures.  The doctor speaks English and is very open to teach.  He has had me give a couple presentations on different diseases so far.  I do not know what my future volunteer will be like for the remainder of the time here, but I am learning what I can and trying to make the best of the situation at hand.  I know I will most likely not have the same hands-on experience I had in Peru but medicine is an ever-growing and educational field and I will learn and soak up as much as I can in the time I have here in Xela, Guatemala.                              

Patients line up every morning

Anesthesiologist carries his medications
in the same tackle box that I have at the lake.