Tuesday, July 30, 2013

Last week for group 3

After a weekend in the jungle, our group was refreshed and ready for our final week in Cochabamba. 

Monday, from Brett;
Today was a day full of kids. Sick and well kids. I find myself really drawn to pediatrics because a child in a room can really brighten your day. They can be really sick or hurt and still smile at simple things like a finger puppet. One thing that really stands about pediatrics here is that it is all about education. The parents need to be educated on what to feed their children especially. I also appreciated how upfront the doctors were about overweight children. They called things how they were and would tell the parents if their child was overweight or 'Gordo'. I was shocked how many parents give their kids coke instead of milk and was especially surprised to see this in an obese 8 month old. I got done earlier in the morning and decided to go play with one of the boys in the burn clinic. I could only make him smile once, which just about broke my heart. It was even more difficult because he wanted something but I had no clue what he was saying in Spanish. Situations like that make the language barrier just an annoyance. It's amazing how much I  can understand from one doc appointment and then entirely miss what the problem was with the child in the next appointment. I wish I could have been more fluent in Spanish before this trip, but I have definitely been motivated to work on my language skills. My afternoon consisted of observing pediatric nutrition lessons from a specialist. I learned that 20 years ago, about 60% of all children born in Bolivia would die before age 1 due to malnutrition. They have come a long way since that and all children under 5 receive free prescriptions and vitamins. The best part of peds is definitely the fact that all children act similar no matter where they are from and you can make them laugh doing the same things.

Friday, July 19, 2013

Primera Semana para Groupo 3

Perspective From Brett Fornell:
Our first week has been all about getting oriented to the town and to our shadowing experiences. Juana had been such a blessing to us and has been like a mom, tour guide, chef, and more. I can definitely understand Spanish better than I can speak and this week I have tried to learn more medical Spanish. It has been exhausting trying to comprehend and speak with the doctors and nurses. I have enjoyed the Latin American tradition of 'siestas' and think I could move here just to be able to take a siesta every day. I have spent time in the burn clinic and have fallen in love with the kids. The procedures are performed in a hot room and the dead skin is taken off while the kids are mildly sedated. I also saw a skin graft where skin was taken from the patients back and side to be used on his legs. On one of the days this week I made the journey to Clinica Americana Boliviana, another hospital, and was able to see a breast reduction. The plastic surgeon was very meticulous and made sure he was matching the size of each breast. 

The food here has been excellent but my favorite meal has been when Juana made Stromboli and homemade juices. We are eating like kings and queens here. Lets just say iIt is a good thing we are walking everywhere. 

Spanish-English Misinterpretation of the Week: In my Spanglish, I asked Juana If we could practice interviewing in Spanish with her and she thought I meant practice procedures such as breast reduction on her. It was quite humorous. 

View from our apartment:


Tuesday, July 16, 2013

Planes, trains, and automobiles.

Hola! We are the last group of the summer headed to Cochabamba to start our rotation-Drew, Brett, Kasey, and Brett.  After venturing around Peru, we finally crossed into Bolivia. Copacabana was the first stop in Bolivia where we rode in swan paddle boats, got caught in a snow storm, and ate quinoa pudding for desert. After two days, we hopped on a bus to La Paz. The bus ride was supposed to be an hour but our Spanish comprehension may have been lacking since it took 4 hours. Next stop: Cochabamba. In the La Paz bus terminal we wandered around trying to find our departure gate, which was a wild goose chase. Finally, the Bolivar bus pulled out of the station and within fifteen minutes, our bus was in an vehicle collision. We arrived to our wonderful apartment in Cochabamba at 4:00 AM. We are so grateful to start this journey and can't wait to learn along the way. Juana, our Bolivian house mom who will be taking care of us, has been so kind to us this far and took us to the hospital today. We're able to see the BCI clinic and some of the patients. Tomorrow will be the start of our shadowing experiences and we couldn't be more ready and excited. More to come!

Sunday, July 14, 2013

Round 2 Final Week

The project is over. We did our damage, and pulled wisdom from our respective experiences, hopefully. As always, the weeks fly by too quickly but here's how our last week went.

We started our last week upon our return from the jungles. Unfortunately, the workload was fairly light so I did not soak up as much at clinic as I had hoped in my final week here. We continued to see rinoplasties, hysterectomies, laparoscopic cholecysectomies, and such. However, Tuesday was the first day a doctor invited me to scrub in. I had been happy enough watching from the sidelines, but participating in an open cholecysectomy made my experience this week. For obvious reasons, my responsibilities were limited to holding tools. Nevertheless, I feel like this invitation was some form of acceptance after 4 weeks of simply observing. Having just reached this point, I wish we could stick around longer.

Our final day in clinic was Wednesday due to travel plans. Will and I decided to find Dr. Wallace and shadow him our last day here. In hindsight, I wish we had reached him sooner because we only tapped the surface of experiences and insight from Dr. Wallace. I was introduced to ultrasound and finally began to orient myself with the equipment. Ultrasound seems to require a good sense of three dimensional imagination, an understanding of physics, and knowledge of how the tool works. Otherwise, it is very difficult to read the images. We saw several pregnant patients, ovarian cysts, and normal imaging angles of the gallbladder, pancreas, and uterus.

Apart from some basic introduction to the equipment, Dr. Wallace also shared the history of his clinic. He moved to Bolivia some 25 years ago because his wife decided to work there. They started a small clinic in a hotel that his wife's parents owned. The hospital grew from a back room in a hotel with three employees (including Dr. Wallace, his wife, and a nurse) to the entire hotel with a fully functional operating floor and over 40 staff members. The growth of the clinic was the result of Dr. Wallace's desire to better serve his community and the interest of other local medical doctors who saw the potential of his project. In addition, Dr. Wallace was initially a pediatrician. He became an expert in ultrasound after he saw the need for it in his clinic, which brings me to a final point that Dr. Wallace shared with us about pursuing a medical education.

Dr. Wallace laid out an outline for us of how to study. Perhaps the most important wisdom he shared with us (which he wished he had found out sooner himself) was that a student must know what he is looking for in order to get the most out of his education. He gave himself as an example. When he first started learning ultrasound, he read the books and took the courses. He soon came to discover, however, that teachers and courses tend to push certain agendas, products, or simply teach what is easiest. Dr. Wallace had his own questions and he soon saw the redundancy in many of his courses. He realized that he could save himself hours of work and pursue his education with much more efficiency by asking his own questions and actively engaging himself in the learning process. He became his own teacher and searched for answers himself.

The main point, know what you're looking for. Ask the questions and do some research yourself. You learn much more this way because the questions are yours. The research is goal oriented from things you want to know. Anyway, that was Dr. Wallace's soap box, and I plan to put his advice to good use.

After Wednesday, we took the part of traveling hobos and have been on the road since then. Thursday, Nicole(squared), Will(squared), Maggie, Carolyne, Juana, Sandra, and I traveled to Copacabana. We visited the ancient sites of Incans on Lake Titicaca and nearly walked ourselves to exhaustion. The lake was vast, the skies were clear, the uphills were treacherous, but I enjoyed every minute. Afterward, Nicole, Will(squared), and I traveled to La Paz for the final day before my flight out of Bolivia. We enjoyed each others company walking around the city, sharing some brews, and meeting fellow travelers. I ended my stay in Bolivia in the highest beer spa in the world. Basically a bathtub, a fire underneath, and people pouring cold beer on your back as you steam in the chilly La Paz night. 2 AM rolled around and I made my way to the La Paz airport. Now I am here, in Bogota with a 14 hour layover thinking back on all the events of the past month. I cannot express how lucky I was to grab this spot and make the trip. I lost a few things, but gained so much more... cliche, AND true. I look forward to discovering how this experience will influence my future decisions as a medical student and doctor.

Monday, July 8, 2013

Round 2 Week 3

Week 3 has come to a close. We started our week coming off a visit to the Cristo. I am recounting the week as I look out toward that behemoth of a rock statue from Cindy's apartment halfway across the city.
I found a local church with my compadre, Will Pryor last Sunday. It was my first experience in a Mormon church. The congregation was incredibly friendly. Many came up to greet us, however, I still relied on Will for most of the translating. My listening abilities have always lagged behind my ability to speak Spanish, and this was no exception.  Just when I thought I was getting a handle on the language, I realize how much more I have to learn as I failed to follow the reverend's sermon.
The rest of the week was dedicated to gaining more medical exposure. Several nights, Will and I stayed in the American clinic until 11 PM. We've been told that the Concha, the neighborhood surrounding the Clinica, is very dangerous at night. However, we have grown comfortable enough with the city to grab radio taxis back in the evening when it gets dark. One evening we were pressed to jog back without a taxi, and we still made it back safely. Nevertheless, I still hesitate to make walking from the Clinica an option during the evening... day-time, no problem.
Anyway, back to the medicine. The week continued to have its fair share of plastic surgeries. Nose jobs take the cake. The procedure seems to be associated with a status statement as some doctors have told me. Several new procedures were scheduled this week, but Will and I continued to get great exposure to laparoscopic cholecysectomies, rhinoplasties, and cesarean sections. Appendectomies (which I found out can also be done laparoscopically... go figure) made their appearance this week. I observed one surgeon repair hemorrhoids. One young patient had an orchidotomy (an elegant euphemism for dropping testicles). Another patient had a perineal abscess repaired (ask me about the process if you ever care enough to know, also very interesting!). Several hysterectomies were performed. One of which removed a tumor. But when discussing tumor removal, the one I saw compares very dimly to what my friends Will Royster and Nicole Haghaasdfjbasdkj saw while in Viedma (see their blog).
Despite blood, fecal accidents, and some surgical instruments inspired by the SAW-series, I have discovered that lack of anesthetics makes me most uncomfortable in the surgery room. Until this week, I have found surgeries procedural and painless. Yet, it was one of the smallest surgical procedures that I found most disturbing. A patient came in with a dislocated distal phalanges in his thumb. The patient was provided lidocaine for the first 20 minutes, but he was not unconscious. Every prick and push was accentuated with a painful groan or scream. The experience only underlines what I hear from Nicole and Will and past groups who have spent time in the Burn Clinic where children are under sedated, lack pain killers, face debridement and amputations and the painful process of recovery.
All in all, this experience is wonderful. I may be lacking the limited resources and painful stories found in the Burn Clinic, but I am still having to swim in unfamiliar waters. While I am improving my Spanish, I am still interacting with people I barely understand. I am seeing surgeries with much more ease than I would experience in the States. I am also experiencing an amount of independence in traveling and city living that could land me in serious trouble if I make stupid mistakes. I know that I'm becoming a better person from this.
A quick blurb on our weekend Chapare adventure. Six hours of beautiful Amazonian forest, rivers, waterfalls, and cliffs. Jumped off a cascade several times only after Nicole and our guide, Ghino, did so. Rappelled down a cliff for the first time. Stayed in a hostal for the first time. Got lost and nearly exhausted funds that would have stranded us in Villa Tunari. And finally took a last minute, God-send, taxi trufi back to Cochabamba during a rainy night with several near collisions head-on with 18 wheelers. Great bonding time, great spiritual refresher, and no regrets. Planning to finish up this last week with a light dose of AWESOME.

Viedma: Week 3

Week 3 was our most routine thus far - Will was in the burn surgeries for the first two hours every morning while Nicole was observing and assisting in the Microbiology/Infectious Diseases department.  When a natural break in the surgeries occurs midway through the morning, we switch and Will goes to the children's rooms to observe burn aftercare.  It is significant to us that the actual burn surgeries are becoming routine - we're better able to participate in the burn operations as well as pay attention to the finer points of the reconstructive surgeries.

Nicole: I've been able to participate in the burn surgeries as thoroughly as the residents they train in the hospital - cleaning and debriding wounds, and re-wrapping them.  I also participated in culture-work with the Microbiology Department testing antibiotic sensitivity.  The parasitologist is very enthusiastic to teach, and shows me every egg, larva, and nematode that she finds in various biological samples.  I toured the Pathology Department with a visiting French student - we held various organs and tumors that had been removed for analysis, and observed their slide preparation.

Will: As my time in the burn clinic has gone on, Dr. Romero has started to allow me more freedom in the OR. He will request that I scrub in with him when we have extensive cases and will allow me to practice what I have seen for the past two weeks on patients. There are patients with full thickness burns that cover all 4 of their extremities. In order to keep the children under anesthesia for as little time as possible, I join Drs. Romero and Quiroga and will debride, clean, redress, and place skin grafts under their supervision. However, I am still trusted with a certain level of autonomy with the patients that I will not be privileged with until my surgical residency.

On Thursday, we followed Dr. Montano through his high-risk obstetric surgeries, while Will Pryor and Jon Chu observed in the burn clinic.   Nicole almost passed out observing her first natural birth.  We also observed a Cesarian on a woman who was 32 weeks pregnant with pre-eclampsia.  The child weighed 2.5lbs and has a 50% chance of survival.  There were a few other natural births and a D&C, but the incredible sight was the oophorectomy.  The woman was 16 years old, 90lbs, with 2 children and a husband.  Her belly was distended as if she were 4 to 5 months pregnant, but once opened up, the distention was revealed to be a 6.8kg ( ~15lb) ovary which had stretched with its tumor.  The entire surgery took 15 minutes from first incision, because the tumor was entirely encapsulated in the ovary and only required cutting two vessels to remove in its entirety.  Dr. Montano says it is the largest tumor he's ever removed, but that the other surgeon had removed an 8kg (~18lb) tumor just the previous week.  It honestly looked like a 15lb turkey, but with fimbrae.

Friday was our night in the Infant-Maternal Emergency OR.  It was a slower night, several natural births that went very well and a few D&Cs.  Later in the evening, we were able to observe an emergent pediatric surgery. There was a 4 month old infant with hydrocephaly that need a shunt placed. We saw the CT scans of his brain that showed drastically enlarged ventricles. The pediatric surgeon started by opening the scalp and drilling a hole in the skull with the scalpel. He then made  a small incision in the abdomen for the shunt to drain. He then used what is basically a Teflon tipped metal straw to guide the plastic tubing for the shunt from the scalp, behind the ear, down the neck, over the rib cage, and into the abdomen. Finally, the surgeon inserted the shunt into the ventricle, checked the flow, and finished placing the drain in the abdomen. From open to close the procedure took only one hour.  As he intends to do this post-residency - Will is geeking out the entire hour.

The weekends have been very thoroughly enjoyed by all - last weekend we all struggled up the 1400+ steps to the Cristo de la Concordia which perches above Cochabamba, and this past weekend we visited Villa Tunari in the Chapare region of the Bolivian Amazon.  There was an animal sanctuary with various food-stealing monkeys and a fantastic 6 hour trek through a local valley, as guided by a friend of our host family.  The path was wide enough for one person, steep, challenging, and beautiful.  We hiked up to a small waterfall (3-5m) with a pool deep enough for jumping off and then moved to a second waterfall (18-20m) which we rappelled down.  The clumsy gringas and gringos struggled to walk down Amazonian rocks for another hour and a half, surrounded by the most lush, verdant scenery and clear water you can imagine.  It didn't look real, and the pictures will never do it justice. 


Saturday, June 29, 2013

Cochabamba.... week 2 (aka how to climb two thousands steps without dying...)

This week has been an absolutely amazing one, as we continue to wander around the City of Eternal Spring and become better acquainted with its citizens.  Becoming more familiar with the hospital system at the Clinica Americana Boliviana, we were able to witness more surgeries than we had in the previous week.  These surgeries varied from simple skin grafts to massive sub-dermal liposuction.  In retrospect, it is clear to see that there is a wide gap between what we see at the Clinica and what must be happening at the Viedma Hospital.  With all these experiences at the Clinica, I can not help but wonder if what we are experiencing is only a skewed view of the Bolivian healthcare system.  After all, one can only imagine the expense required to have a massive liposuction in a country where the average worker only makes B150 (~$21) per MONTH!  Consider, also, that the average antibiotic and cough syrup combined costs B125 (~$17).  While this is relatively cheap for Americans, given the favorable exchange rate, it is a crippling cost for a family where everyone must work just to make ends meet.   Nevertheless, the indomitable spirit and optimism of the Cochabambian people is insatiable.  It is a lesson that each of us can and should learn from when faced with daily trials and opposition.

When you look out at the Cochabambian skyline you are surrounded by beautiful mountains and small villas that extend up as far as the tree line.  Lately the weather has been cold enough to allow pure white snow to cap the tallest of these peaks, providing an ample contrast to the beautiful flowers and lush palm trees that intermingle with the wide variety of man-made structures.  There is so much good in the world that at times it can be practically overwhelming.  Despite difficulties with the language and expressing oneself in it, smiles and stumbling through it always proves to bring a smile to the most tired nurse.  Although we may only be rising second years and, thus, unable to provide as much help as maybe a fourth year resident, in many respects our constant presence is enough.  One of the goals of the program is not only to provide service where needed, but to also build bridges and increase the goodwill that exists between all parties.  Every time we witness a c-section or witness a physician listen to the heart rate of an elderly patient, both parties synergistically benefit in what could only be described as pure magic.  While at times it is easy to only see the negative around us, only through a positive and persistent perspective are we able to accomplish the mission that we have accepted.  Every day more doors are opening; you just have to be willing to take the first step and walk through them.