Posts filed under ‘Bay Area Surgical Mission’
I was fortunate enough to participate in a surgical mission to Quito, Ecuador from April 19-27, 2013.
One of my favorite quotes is from Harun Yahya: ” I always wonder why birds stay in the same place when they can fly anywhere in the world. Then I ask myself the same question.”
Kaiser is a unique surgical residency program because residents at all levels are encouraged to participate in global health efforts. As a second year resident in the Department of Head and Neck Surgery (“HNS”), I was able to participate in a surgical mission this year through the support of my Department as well as Kaiser’s Global Health Program.
The HNS residency program provides the opportunity to develop a set of skills that can touch people’s lives in incredible ways. Few things are more gratifying than sharing our skillset as physicians and surgeons with people who are in need of surgical intervention but either cannot afford it or do not have access to the type of surgical expertise that is needed. Taking our efforts abroad is one of the ways we can give back and help people who otherwise would not be able to experience our resources and services.
One of the things that struck me was the incredible coordination of effort that was necessary to make our surgeries abroad possible. Our team spent countless hours planning, gathering supplies and equipment, packing, and ultimately transporting our entire operating room setup to Ecuador. We were responsible for bringing all the essentials that we might need from Anesthesia monitors to surgical tools to medications and surgical dressings. Our team from Kaiser, along with generous donations from several individuals, made this possible.
We arrived at our hotel in Quito around 2:00 a.m on Sunday morning. We stayed in the old town neighborhood, a historic region of the city and a draw for visitors because of its cultural beauty and the number of activities and notable sites concentrated in the area. We finally made it to bed around 3:00 a.m. and were up for breakfast at 6:30 a.m. – a beautiful spread of toast, fruit, and eggs. After eating, we boarded a large bus for the 45-minute ride to Hospital Padre Carollo, where we would be operating.
Hospital Padre Carollo is run by a foundation known as Tierra Nueva. Tierra Nueva is a large nonprofit organization founded by the late Father José Carollo. Father Carollo was a relentless advocate for the poor, and he began Tierra Nueva as a social services center for Quito’s poorest citizens. There is a beautiful saying posted on the front of the hospital that can be seen by all as they pass by – “ Un Canto A La Vida” – which means “A Song of Life” or “An Ode to Life.”
Our first day at the hospital was used to set up a busy pre-operative clinic and unpack our supplies. While the surgeons met countless patients and consented patients for surgery for the week, the OR staff organized our equipment and stocked the operating rooms that we would be using. Patients waited for hours as we addressed each surgical issue, screening candidates for thyroid surgery, parotid surgery, tonsillectomies and adenoidectomies, and ear surgery to name a few. At the end of a long day, the team was ready for food and rest. After the bus ride to the hotel, we had supper at a local restaurant where adventurous members of the team tried the local “qui”, or roast guinnea pig.
The surgeries began on Monday morning. It was inspiring to see our nursing staff and anest
esia colleagues set up the ORs and successfully cope with the limited supplies available to us. What an incredible job they did! Since the local surgical teams were operating at the same time, we were very conscientious to respect their OR rules and protocols. Things as simple as where we could and couldn’t wear scrubs and when our shoes had to be covered took adjustment but we soon fell into the flow.
Between cases, additional patients would arrive and we would evaluate them. A case that stands out in my mind was a young man who had a left sided nasal obstruction after suffering several blows to the face over a year before. He was jumped by robbers, who took his belongings and hit him in the face, fracturing his nasal bones and collapsing the left side of his nose. His nasal defect was obvious in looking at his outward appearance, but his real complaint was the difficulty he had in breathing. He reported that it was interfering with his sleep and making it challenging to be active. We signed him up for a septorhinoplasty to correct the nasal collapse, straighten his septum, and try to restore a more normal looking nose. The patient was thrilled that we would be able to help him.
The morning that the patient was scheduled to undergo surgery, we saw him in the hallway and he beckoned us aside. Via interpreter, he explained that his wife had been scheduled to undergo a hernia repair the day before but given the large volume of general surgery cases, her surgery had been postponed until today. The patient described how he wanted to be there for his wife after her surgery and as a result was willing to sacrifice his own procedure. He didn’t feel like he could proceed with his surgery and still be there to take care of his wife when she came out of the OR. We offered him surgery the following day – his wife would be discharged by that time and he could get the care he needed. Looking down, he described how his job would not allow him to miss another day. We discussed that it might be months or years before another Head and Neck Surgery team is able to return and see him. He nodded his head in understanding. He had made it all the way to the hospital, sought our care and surgical expertise, and eventually had to forgo the needed procedure. Unfortunately, there is only so much we can do to help.
My experience with this patient illustrates that there are indeed limitations to our outreach efforts. Many patients will go unseen secondary to issues with access and time from both the patients’ and the surgeons’ perspectives. While we do our best, there will always be the need for more health care services. I believe, however, that this should serve as motivation and not discouragement. My experiences in Ecuador leave me eagerly anticipating my next surgical mission trip. The experience has helped put my training and practice into perspective and I think it is an integral part of our training as residents. I would like to thank the Kaiser Global Health Foundation, all of my faculty mentors, and the volunteer team who participated for their support.
Posted by Ethan Handler, MD (a fourth year Head and Neck Surgery resident from Kaiser Permanente Oakland in while serving a global health elective in Daet, Philippines with Bay Area Surgical Mission).
We left for Manila around 11 pm on Feb 9th from SFO. Seventy large boxes overflowing with medical supplies accompanied us in the belly of the plane. This was the first of two flights, capped off with a four-hour bus drive over rugged terrain, through sparsely inhabited villages, stopping at the buried church for a quick photo op, to finally arrive at our destination, Daet, located within the Camirines Norte province. An active town of over 100,000 people, bubbling with life, overcrowded with hundreds of motorcycles jimmy rigged to decadent and colorful sidecars.
Our accommodations were very comfortable, located a few blocks from the windblown beach famous for kite surfing, and a few kilometers from the hospital. We arrived on a Saturday afternoon, Friday, a day that only existed in our minds.
Sunday morning we were awake and working, furiously unpacking supplies, setting up the two connecting operating rooms that would house a total of 4 OR tables. The local government was very generous to grant us use of their hospital for our mission. Unpacking was followed by a trip downstairs to evaluate the packed clinic for surgical candidates. Native Filipinos traveled from a variety of provinces, alerted to the medical mission by radio and television broadcasts. Three services were represented during this trip, Oto-HNS, General Surgery, and OB/GYN.
The majority of our head and neck cases were subtotal and hemi-thryoidectomies. There is no iodinated water supply in these far reaching areas and as a result there is a higher incidence of thyroid goiters and disease. In addition, a few thyrogloassal duct excisions were also performed. No mass was under 5 cm.
Right outside the OR doors was the designated “procedure room”, although in reality it was a hallway. The lighting for these cases was via heat lamps that doubled as warmers for the newborn infants. This was epidermal inclusion cyst heaven. Every conceivable place for EIC’s to grow, we found, and removed. The largest was a 10 cm mass on the posterior scalp, successfully excised without bursting.
Every patient was beyond thankful, gracious, and possessed incredible toughness. Even when offered, they would seldom take pain medication. The recovery area and patient rooms consisted of 85 degree, 100% humidity rooms with patients and their families crammed onto cots. Yet nobody complained. Their stoicism and strong will was an example for all of us, and a point to remember.
We operated full days, all week long. Our nights were packed with various hosted events sponsored by local organizations. Everyone was gracious. I feel blessed to have spent time with these people, inspired by their courage and resiliency, while forging lasting bonds with the group members. I’m always amazed and thankful as to how close you become with others when sharing in an experience such as this one. Without a doubt, I would go back in a heartbeat.
A few pictures are included below:
Posted by Lisa Ryujin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland reflecting on on her global health elective in Daet, Philippines with Bay Area Surgical Mission).
I came to the Philippines unsure about how I would feel about a trip concentrating on providing surgery. However, over the course of my time here, I have realized that providing these services to those who did not have the means sometimes meant changing lives. One of the residents and I would stay up late and discuss the ethics of the surgeries, making sure that we were supervised and performing the same roles that we had in the USA. We talked about the responsibility that we felt for our post operative outcomes and how important morning and evening rounds were in making sure our patients were well taken care of. My attending and I were talking about the ‘magical post operative day 2′ and how happy and pain free the patients were. They asked to take pictures with us and took the post operative medications with huge smiles. We also talked about how wonderful it was to work with the Filipino nurses an the familiarity of our own nurses. They worked together as a team, and at the end of the day, the patients always came first.
I’m so grateful that I was able to participate in such a wonderful group effort, it was a true pleasure, and I can’t wait to come back!
Yesterday was the hardest day of our mission. Our first case was a suspected endometrial cancer, and when we finished the surgery, we cut open the uterus and confirmed, but there was not time to stop, we had other cases waiting. The next case was a 26 week sized uterus who wanted a myomectomy to preserve her fertility, another hard case. Then, simple appearing ovarian cyst removal that ended up being ovarian cancer. We had to pause and think of our mission, do no harm, we had not consented her for a hysterectomy, and her spinal anesthesia was quickly running out. One of the local nurses ran out of the operating room to find the patient’s mother to ask for permission to take the uterus and the ovaries with the hope of low stage an cure. We waited as the patient got more uncomfortable. By the time the nurse came back to give us the permission, we had almost run out of anesthesia making the surgery impossible. The anesthesia crew was wonderful and put her under general anesthesia and we completed the case. The last case was difficult - 18 cm bilateral ovarian cysts. After a long day, we had to go round and I had to sit down with two patients and their families and tell them that they had cancer, with a translator, in a foreign context. It was one of the hardest days of residency and it and it made me respect and wish for our oncologists.
After the discussions with the families I rounded on the rest of the patients and took a shuttle home. It was a hard day and I fell asleep immediately.
This morning when I woke up and went to round before our surgical cases, I was amazed how wonderful they were doing. Even though it’s been exhausting, it’s been one of the best times I’ve had in medicine.
It was a long 14 hours from San Francisco to Manila, and then one and a half hours to Legaspi and then 4 hours by bus to Daet. It took two full days to set up the operating room and today we had our first day in the operating room. There are two operating tables per operating room, only one anesthesia machine. We have been operating side by side and since we operate in the pelvis, we have been doing our hysterectomies under spinal anesthesia. It isn’t that hard to get used to, we operate on cesarean sections while they are still awake, but it’s just another layer that makes operating here a little foreign. But it’s been incredible what we are able to offer and how wonderful the staff has been. All our efforts revolve solely around patient care, what an amazing experience to share with the fantastic Kaiser team!
There are so many reasons that residents are interested in participating in global health projects. I have wanted to be a part of the development of clinics, medical education and self sustainability of medical facilities that are coming into their own. I have also been interested in the way medicine is practiced around the world, the different expectations that patients have of their physicians, and how we can better deliver quality health care. I have always learned much more than I have taught, and it has given me insight to different parts of the world. Up until this trip to the Philippines, I have focused on facility and medical personnel development, and much less with patient care.
In the past I have been hesitant to go on a surgical ‘mission.’ I thought that most places, even rural places, have physicians that provide wonderful medical care, and by going in and doing surgeries in places where there were local surgeons, we would undermine their skills. I also believe, that as a surgeon, you are responsible for surgical complications, and with short surgical missions, we are unable to deal with the possible complications of our surgeries. During past (Vietnam and Kenya) medical trips, I have never declined to participate in a surgery when the local surgeons have requested assistance, but when I did participate, it was clear how key communication during surgery is. In Vietnam, the names of the surgical instruments were in French, so even when I asked for standard instruments, the scrub would look at me bewildered. We take so many things for granted in our operating rooms, our wonderful anesthesiologists and CRNAs, our circulators and nurses and EVS make our jobs run smoothly.
At the last Global Health Educational Consortium, in Montreal, there was a session on the ethics of surgical care abroad. I attended, as I was interested to see the latest updates, papers and innovations. The West African College of Surgeons made a plea for more surgical missions. They said that in the major cities, there was a large concentration of surgeons, but in the rural areas, there may be facilities, but no doctors to staff the operating rooms. A Rwandan surgeon stood up and reported that after the 1995 genocide in Rwanda, there were a total of 5 surgeons and 2 anesthesiologists left in the country, today, there are still only 30 surgeons and 12 anesthesiologist to serve a population of 11 million.
Organizations like BASM (Bay Area Surgical Mission) are able to provide free surgical procedures in a place where all surgeries are a fee for service. And organizations like Doctors without Borders and Relief International, are able to offer surgical services to places in crisis. This is a wonderful temporary solution while simultaneously working on medical education, community development and self sustainability.
I am grateful to be able to go on my first trip, solely dedicated to providing surgical care, with people from BASM. A team that I have worked with every day at Kaiser Permanente in Oakland, a team that I love and trust, it will be a fantastic (and exhausting) opportunity to focus on patient care together. I am so happy to have talked with these surgeons from Rwanda, who had expanded my understanding of needs in other countries.
We fly out tomorrow for a 3 day journey to our final destination in Daet, Philippines. More to come!
In January 2012, I was fortunate to participate in the Bay Area Surgical Mission(BASM) trip to the Philippines. I traveled with a 19 person team comprised of physicians, nurses, and technicians from Kaiser Permanente Medical Center in Oakland and Santa Clara, California. The mission was lead by Joshua A. Gottschall, MD, a former Pediatric Otolaryngologist with The Permanente Medical Group who is now based in Orlando, Florida with the Children’s Ear Nose and Throat Associates. Members of the Kaiser Oakland Head and Neck Surgery Department included Barry M. Rasgon, MD, Stephen V. Tornabene, MD, and me. Luke J. Schloegel MD, a former resident of the program and soon to be faculty member, also participated. There were two general surgeons in our group. We also joined forces with a team of Ophthalmologists from the capital city of Manila as well as volunteer nurses and interpreters from the area.
The mission drew individuals from a wide geographic area, with many traveling great distances through treacherous country roads and often stormy weather to be evaluated for the first time. We operated in two small community hospitals in the neighboring rural communities of Tigaon and Sagnay of the Camarines Sur province of the Philippines. Despite the challenges of limited resources and time, I learned that we could still deliver quality care. Flexibility, dedication, and teamwork proved more essential than the “modern” conveniences of adjustable operating tables and high-powered lighting. Over the course 6 days, were saw many patients. Of these, 40 received major operations and 97 minor operations. Otolaryngologic cases included thyroid lobectomy and primary cleft lip and palate repair. The ophthalmology group performed 146 cases of cataract and pterygium surgery.
Our mission trip accomplished the goal of treating an underserved population with otherwise limited access to medical care. Both personally and professionally, this was a kind of priceless experience that will enrich the practice of any physician. I would like to thank the Kaiser Permanente Global Health Program for their generous support of this truly inspirational trip.