Posts filed under ‘Esperanca’
For this global health elective, I was fortunate enough to go back to the same hospital in Nicaragua as I went to last year. One of our OBGYN attendings, does multiple international surgical missions each year. We went to Jinotega, Nicaragua with one Kaiser Permanente San Francisco anesthesiologist last year for one week and did GYN surgery with a program called Avodec. This year, she was able to coordinate though the same program to bring two OBGYN attendings, two anesthesiologists and two GYN residents. We had two ORs and were able to see/operate on double the number of patients we had last year. We flew out on a red-eye Friday after work, set up the ORs and organized our 6 boxes of supplies/equipment on Saturday, and began our triage on Sunday. We did H&Ps and full pre-op exams on over 100 patients, working in two rooms. Monday, we began operating and operated all day for the remainder of the week. We completed mostly vaginal surgery with only three abdominal ovarian cystectomies. Our patients stayed in one ward of the hospital with Avodec hired MDs and RNs and we saw our patients in both the morning and evening. We also worked with several of the Jinotegan Urologists and Gynecologists- having them scrub into cases and having them do some of procedures for education. It was a tiring but very rewarding experience. The patients were in such need of surgery and so appreciative for their care. It was motivating and inspiring.
Esperança April 2013
This was the moment I had been waiting since I was an intern. I had heard of all the wonderful abroad opportunities’ Kaiser Residents had participated, but the site that spoke most to me was the Esperança site in Jinotega, Nicaragua. My proctor, Dr Diane Sklar, had already participated in eight missions with the group between Nicaragua and Bolivia. I first heard about her trips when I was an intern, and I was fortunate to have the opportunity to join the family and connections that had been previously created there, now as PGY-3. This trip was going to introduce many exciting new changes and opportunities, as we were bringing double the medical group and equipment from previous years, we were expecting double the patients waiting for consults.
The day after we arrived to Nicaragua we walked into the hospital where over eighty consults were awaiting us in a large waiting room. Women from all over the country had come to be seen by “la brigada” the moniker they had placed on medical groups traveling through the country. With smiles and hope we saw women who had traveled as much as a whole day from Honduras and around Nicaragua to get to this small town of Jinotega surrounded by mountains located two hours north of Managua. The focus of our trip was on urogynecology conditions, and we saw women who had suffered from urinary incontinence and pelvic prolapse at times for more then twenty years. The most interesting case was of a woman who was only in her forties, but had suffered for over two decades from a complicated 5cm rectovaginal fistula likely acquired during child birth. Confined to an abusive home in the mountains, she gained enough courage to seek medical help from the volunteers for Esperança this year. The day we met her we were touched by her personal story and the extent of her condition. Her stoic nature was inspiring despite the effect this problem had on her quality of life. This story and others were added to our list of surgeries we were planning on performing over the next five days.
We had twenty seven patients we scheduled for surgeries including: colpocleisis, vaginal hysterectomies with vaginal vault suspensions, tension free tape suspensions, exploratory laparotomies for pelvic masses, cystoscopy and finally the rectovaginal fistula repair. Over the course of that week, more consults arrived and by the end of trip we had set a record total for consults seen at one hundred patients!
Despite bringing two attendings, Dr Sklar and Dr Kayser both from Kaiser Northern California sites, and two residents on the trip, we were unsure if we would have two surgical rooms to perform. That did not stop the resourceful nature of our volunteers in Nicaragua. One room was converted to two operating spaces and prior local nurses and scrub technicians from past trips had volunteered their time to help this group again which helped make the week run smoothly despite the space challenges. A total of seventy-eight procedures were performed over those five days, and all were performed with spinal anesthesia and without complications of any kind.
The women were so grateful at all time points of their care, with little complaints even on postoperative day 1 with grins showcasing their gratitude. Many hugs and kisses were spent during rounds as these women physically communicated their appreciation to their team of doctors and nurses.
The relationships I made with the patients were memorable but also all the new friends I had found in the volunteers and local doctors working at the hospital in Jinotega. Their selfless hospitality made me feel welcomed as a new member of this small medical family and their personal time dedicated to showing us around and having meals with us will always be cherished.
What I gained the most from this trip was regaining the humility that had strongly veered me to the field of medicine. The humble nature of this town, people and organization reminded me once again why I had chosen the field I was in. I regained a sense of inner peace and was more appreciative for all the advances and technologies that I had back here at home. My perspective on the medical field and medical system is broader and I feel it will make me a better and more patient physician for when I’m challenged by our modern tribulations.
I now understand why Dr Sklar does this every year, I couldn’t imagine not being part of similar missions in the future, not only for my sense of self but also for all the lives of women who’s quality of life can be drastically improved by hours volunteered to making their life better. This has been one of the highlights of my residency and career thus far!
Upon arrival at the airport in Managua, we were warmly greeted with a big sign and everlasting hospitality. We stayed in Jinotega, a small town in the mountains two hours north of Managua.
The next morning we saw over 40 patients in clinic and scheduled many of them for surgeries including exploratory laparotomies for newly diagnosed pelvic masses, hysterectomies, surgery for prolapse as well as incontinence procedures. We wasted no time and started the surgeries on our first day. I was challenged clinically in ways I’ve never considered. Limited by resources, we had to think about what materials were necessary so we could be as strategic as possible with the limited equipment we had. We often found ourselves improvising throughout the procedures and our time in clinic. Scant light, limited suture supply, minimal suction, and with basic instruments I quickly became thankful for all the materials we easily take for granted as surgeons in the U.S. “We simply do the best we can with what we have,” Dr. Sklar, my mentor, often reminded me throughout the trip, one time when the lights and power in the operating room went out in the middle of a doing a hysterectomy.
The patients are forever memorable. For all the major procedures we used spinal anesthesia and out of almost 40 surgeries completed on this 10-day mission, there were no pain issues. I can still vividly recall the smiles on their faces as they lined up in the late evening after we had finished a full day of surgery so that we could evaluate them in the clinic. Women who traveled 6-8 hours by several bus routes were quick to wrap their arms around us and embrace us with gratitude and a warm welcome to their community. Their smiles persisted immediately postoperative and every morning as we rounded on the patients. I will never forget their smiles.
Despite the language barrier and the cultural differences, I was able to form relationships with the people in the community. The little children whose mothers worked in the clinic spent hours there and were quick to befriend us. At any given break, I ran to play with the kids. They taught me games and songs and seeing them day after day it was impossible to not become attached. The local physicians ate lunch with us daily and we shared personal stories, cultural experiences, and clinical advice. It was impossible to not notice that despite how little they have as far as monetary things they are spiritually complete. I was envious of the sense of community and love that is disappearing in the major cities in the U.S.
One night we took a stroll around the village to learn more about the city and people of San Rafael del Norte, which is where the hospital was situated. We walked up a hill to the town’s cathedral. It was simple yet magnificent and we enjoyed one of their ceremonies. As I looked around the church it was striking to witness how these people are full of so much love and happiness. They hold each others hands in church, walk in the streets late at night, children play soccer outside at all hours, all the doors to their houses are wide open all day so as to welcome neighbors, couples walk holding hands, and everyone is smiling.
On the last day of our trip everyone involved in the mission and clinic threw us a celebratory dinner. Over 40 people attended and the room was full of warmth and appreciation both on behalf of the local physicians who worked with us, the ancillary staff, and me and the other two visiting physicians. Being privileged to be a part of a smaller medical mission with only two other physicians, I was able to be involved first hand in leading a medical mission. I learned that to make the most of a medical mission it is important to: 1) be flexible, 2) be willing to work with the local staff and 3) remember that you are a visitor…culturally and professionally. I am forever thankful to Dr. Diane Sklar for being a role model and taking me under her wing as she showed me the ropes to spearhead a medical mission. A flame has been ignited within me to be involved in more medical missions in the future as a new passion in me has surfaced.