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.
Saturday, June 29, 2013
Round 2 Week 2
Week 2 has been much more productive. After our trip to Salar de Uyuni, we returned to the Clinica Americano Boliviano with fresh enthusiasm. Increasing familiarity with the hospital, the city, and the language has encouraged us to explore more and interact with more people. I keep an open mind because I find myself learning several topics simultaneously. Medicine, Spanish, and geography are all important, but I have placed the most emphasis on learning the language. While medicine and geography help, I find the most pleasure in connecting with others through language. I am making a feeble attempt at learning Quechua, the native language of Cochabamba and surrounding regions. The language is very difficult for several reasons. It is clearly not a Romanic language, the words share no similarity with English, and the texts I am learning from are all in Spanish. An ambitious goal, but I love the expression of pleasure that overcomes the locals as they hear me murder their language.
Within the hospital, my colleague and I have remained mostly on the operating floor. Surgeries typically start at 8:30 AM. There is no set schedule as the agenda written on the whiteboard changes on an hourly basis. I may try to gather more on the history of the clinic. So far, from what I gather, the Clinica Americano Boliviano was started about 25 years ago by American Dr. Tim Wallace. The clinic started as a small back-building off San Martin Street, but it has been growing over the years. Now, the clinic has expanded to a 5 story building with a courtyard and various offices behind it. Today, the hospital is staffed by about 80 doctors who come and go around the clock. All the doctors also have offices elsewhere.
When Will and I are not shadowing on the operating floor, we follow other doctors in their temporary offices or around the clinic. The Spanish remains the largest barrier. It is very tough to learn anything about medicine in the office because everything is conversation. There are a few small tests and procedures performed that remind me of first year. In that way, I am able to follow the doctors more closely. The operating room is an easier learning atmosphere. With some Spanish under our belt and first year anatomy relatively fresh in our minds, Will and I are able to follow the surgeries, understand particular methods, and learn proper protocol in the OR.
We are expected to compare American medicine with the practices here. My experience in American operating rooms, however, is limited. Interestingly enough, I am getting my introduction to surgical procedures from a Bolivian perspective. I will not be able to properly compare the two practices until future years in medical school. This is what I know, and this will be the standard by which I compare surgeries.
This week I shadowed a pediatrician and two traumatologists in their offices. I was able to view a few X-rays although I had difficulty analyzing them until the doctors relayed the problems through very strained very slow Spanish. In the OR, Will and I observed many operations. We saw several rhinoplasties, a skin graft, laparoscopic cholecystectomy, liposuction, several cesarean sections, and an open cholecystectomy. The gallbladder could not be removed, however, in the open procedure due to complications that neither Will nor I were able to understand in Spanish. From this week, we inferred that the American Clinic seems to place much emphasis on aesthetic plastic surgeries (although the skin graft and one rhinoplasty seemed to be reconstructive). Why this is so, we still need to ask. This demonstrates a noticeable difference with the burn clinic in Viedma hospital where children are in dire need for reconstructive surgery. Nevertheless, the doctors in Clinica Americana Boliviano are excellent and I am impressed repeatedly with the ease and precision that they operate.
As for our main contact, Dr. Wallace, we have not had much time to connect with him, but it is our intention to shadow him and learn a little bit about ultrasound in the coming weeks. I also wish to learn how a man such as Dr. Wallace finds a calling that places him thousands of miles from home to build a fully staffed clinic from scratch.
As a cap to the week, Will (squared), Nicole (squared), Maggie, Carolyne, and I trekked to the Cristo statue that looms over Cochabamba. After having acclimated over a couple of weeks, one would expect to climb the 2,000 stairs with more ease than we experienced today. We realized how long the hike would be after stopping to catch our breathe after the first 50 stairs. Regardless, the view is amazing, Cristo is large, and the snacks sold beneath his outstretched hands are incredibly refreshing. We opted to take the cable-cars back down. I look forward to what Cochabamba has to offer over the next couple of weeks as I continue to learn more Spanish... and maybe some Quechua.
Week 2 has been much more productive. After our trip to Salar de Uyuni, we returned to the Clinica Americano Boliviano with fresh enthusiasm. Increasing familiarity with the hospital, the city, and the language has encouraged us to explore more and interact with more people. I keep an open mind because I find myself learning several topics simultaneously. Medicine, Spanish, and geography are all important, but I have placed the most emphasis on learning the language. While medicine and geography help, I find the most pleasure in connecting with others through language. I am making a feeble attempt at learning Quechua, the native language of Cochabamba and surrounding regions. The language is very difficult for several reasons. It is clearly not a Romanic language, the words share no similarity with English, and the texts I am learning from are all in Spanish. An ambitious goal, but I love the expression of pleasure that overcomes the locals as they hear me murder their language.
Within the hospital, my colleague and I have remained mostly on the operating floor. Surgeries typically start at 8:30 AM. There is no set schedule as the agenda written on the whiteboard changes on an hourly basis. I may try to gather more on the history of the clinic. So far, from what I gather, the Clinica Americano Boliviano was started about 25 years ago by American Dr. Tim Wallace. The clinic started as a small back-building off San Martin Street, but it has been growing over the years. Now, the clinic has expanded to a 5 story building with a courtyard and various offices behind it. Today, the hospital is staffed by about 80 doctors who come and go around the clock. All the doctors also have offices elsewhere.
When Will and I are not shadowing on the operating floor, we follow other doctors in their temporary offices or around the clinic. The Spanish remains the largest barrier. It is very tough to learn anything about medicine in the office because everything is conversation. There are a few small tests and procedures performed that remind me of first year. In that way, I am able to follow the doctors more closely. The operating room is an easier learning atmosphere. With some Spanish under our belt and first year anatomy relatively fresh in our minds, Will and I are able to follow the surgeries, understand particular methods, and learn proper protocol in the OR.
We are expected to compare American medicine with the practices here. My experience in American operating rooms, however, is limited. Interestingly enough, I am getting my introduction to surgical procedures from a Bolivian perspective. I will not be able to properly compare the two practices until future years in medical school. This is what I know, and this will be the standard by which I compare surgeries.
This week I shadowed a pediatrician and two traumatologists in their offices. I was able to view a few X-rays although I had difficulty analyzing them until the doctors relayed the problems through very strained very slow Spanish. In the OR, Will and I observed many operations. We saw several rhinoplasties, a skin graft, laparoscopic cholecystectomy, liposuction, several cesarean sections, and an open cholecystectomy. The gallbladder could not be removed, however, in the open procedure due to complications that neither Will nor I were able to understand in Spanish. From this week, we inferred that the American Clinic seems to place much emphasis on aesthetic plastic surgeries (although the skin graft and one rhinoplasty seemed to be reconstructive). Why this is so, we still need to ask. This demonstrates a noticeable difference with the burn clinic in Viedma hospital where children are in dire need for reconstructive surgery. Nevertheless, the doctors in Clinica Americana Boliviano are excellent and I am impressed repeatedly with the ease and precision that they operate.
As for our main contact, Dr. Wallace, we have not had much time to connect with him, but it is our intention to shadow him and learn a little bit about ultrasound in the coming weeks. I also wish to learn how a man such as Dr. Wallace finds a calling that places him thousands of miles from home to build a fully staffed clinic from scratch.
As a cap to the week, Will (squared), Nicole (squared), Maggie, Carolyne, and I trekked to the Cristo statue that looms over Cochabamba. After having acclimated over a couple of weeks, one would expect to climb the 2,000 stairs with more ease than we experienced today. We realized how long the hike would be after stopping to catch our breathe after the first 50 stairs. Regardless, the view is amazing, Cristo is large, and the snacks sold beneath his outstretched hands are incredibly refreshing. We opted to take the cable-cars back down. I look forward to what Cochabamba has to offer over the next couple of weeks as I continue to learn more Spanish... and maybe some Quechua.
Thursday, June 27, 2013
Viedma: Week 2
We started Monday just as we had started all the other days last week. Nicole was observing in surgeries in the morning. Will was with the children in the clinic. In the afternoon Nicole went off to the pathology and microbiology department and Will went in to observe surgery. The surgeries were pretty straight forward, just cleaning and re-wrapping some wounds. Nicole saw Tuberculosis, Paratuberculosis, Giardia, and a hand full of other bacteria and parasites.
Tuesday was scheduled to have 6+ surgeries, but most were put off to later in the week after a 5 year old girl who had swallowed flaming checha (Bolivian moonshine) suddenly began vomiting blood and eventually died. She had been recovering at the clinic for over a week and the change in her condition took everyone by surprise. All possible resources were diverted to her, but after endoscopy and efforts to cauterize the ulcers in her esophagus failed, she passed away. This is the first patient that the clinic has lost in over 2 years and Dr. Romero is taking it very personally.
Wednesday was the first day both of us were allowed to scrub in on surgeries. Nicole scrubbed in on a 10 year old boy with second degree burns over approximately 35% of his body all on his front, from his face down to his feet. Will scrubbed in on the previous patients brother, who had burned both of his feet, hands, and his face. Both surgeries were very labor intensive each taking about 2 hours to finish. Everyone involved was drenched in sweat after each procedure. The OR stays at a constant 85 degrees and gets warmer under the OR lights due to burn patients inability to properly thermoregulate. There have been a few procedures that we had to stop in the middle of to apply electric blankets and hot water bottles to the patients because their body temperatures would drop despite the ambient heat in the room.
Thursday Nicole went back to pathology to learn from the parasitologist, visualizing different ameoba, larvae, and discussing diagnostic criteria. Will's only surgery for the day lasted 6 hours and required harvesting deeper skin from the adolescent's abdomen than is typically required for skin grafts. Sadly, this boy's burns were 3rd degree and deeper, which meant that the fresh skin also had to be. The last 2.5 hours of the surgery were exclusively suturing of the skin onto the boy's left hand. Once the procedure was completed, the improvement was incredible. Will is really looking forward to seeing the bandages come off in approximately 5 days.
Tuesday was scheduled to have 6+ surgeries, but most were put off to later in the week after a 5 year old girl who had swallowed flaming checha (Bolivian moonshine) suddenly began vomiting blood and eventually died. She had been recovering at the clinic for over a week and the change in her condition took everyone by surprise. All possible resources were diverted to her, but after endoscopy and efforts to cauterize the ulcers in her esophagus failed, she passed away. This is the first patient that the clinic has lost in over 2 years and Dr. Romero is taking it very personally.
Wednesday was the first day both of us were allowed to scrub in on surgeries. Nicole scrubbed in on a 10 year old boy with second degree burns over approximately 35% of his body all on his front, from his face down to his feet. Will scrubbed in on the previous patients brother, who had burned both of his feet, hands, and his face. Both surgeries were very labor intensive each taking about 2 hours to finish. Everyone involved was drenched in sweat after each procedure. The OR stays at a constant 85 degrees and gets warmer under the OR lights due to burn patients inability to properly thermoregulate. There have been a few procedures that we had to stop in the middle of to apply electric blankets and hot water bottles to the patients because their body temperatures would drop despite the ambient heat in the room.
Thursday Nicole went back to pathology to learn from the parasitologist, visualizing different ameoba, larvae, and discussing diagnostic criteria. Will's only surgery for the day lasted 6 hours and required harvesting deeper skin from the adolescent's abdomen than is typically required for skin grafts. Sadly, this boy's burns were 3rd degree and deeper, which meant that the fresh skin also had to be. The last 2.5 hours of the surgery were exclusively suturing of the skin onto the boy's left hand. Once the procedure was completed, the improvement was incredible. Will is really looking forward to seeing the bandages come off in approximately 5 days.
Sunday, June 23, 2013
Cochabamba: Week One (or how not to get run over by renegade truffis)
Cochabamba, Cochabamba, Cochabamba... What a city of paradoxes!
I am continually astounded how paradoxical life can be in this incredible city. One minute you are dodging taxis and street rubbish and the next minute you are surrounded by buildings and riches equivalent to anything in the States. Indeed it is an interesting setting to learn medicine and to, more importantly, learn about humanity in vivo.
When one considers American culture with its broad and blurred spectrum of socioeconomic classes, it can be a rude awaking to step into an environment such as exists in Cochabamba. Like many cultures of the world, Bolivian culture is extremely polarized. At the very tip are the richest of the rich, who live lives of unsurpassed opulence. This elite class is built on the foundation of the low class, the commoners, who in some way or another work to support the rich. It is this lower class in which we have the most exposure and for which our influence that the Clinica Americana Boliviano and the Viedma Burn Clinic has the most relevance.
During my first week working at the Clinica Americana Boliviano, I can honestly state that I have learned more about how to operate healthcare with limited resource than I could have ever from a library of literature written on the topic. There is simple not the time, nor the copious resources that are otherwise available in the States. However, if we assume the Bolivian perspective it is fair to wonder if some of what we as Americans do is simply excess, overkill. Now let me be clear that I am not talking about not ensuring sterility in the OR or cleanliness in the outpatient clinics. Both are very important, no matter where you go. However, it was not that long ago in the States that surgical gowns and clinic tables were dressed in heavy canvas that was washed and sterilized daily as they are still done here in Bolivia. While according to American standards of disposable plastic everything the idea of reusing anything seems purely heretical, in many regards the Bolivian idea seems the most sensible (assuming the levels of sterility are comparable).
While some Americans may scoff at reusable nature of the clothing, dressings, and clinic table coverings that exists in Bolivia, they will be more surprised to know the level of technology that exists from the outpatient clinic to the OR suite. Yes, I will concede, we are in a third-world country. However, if one compares an OR at the Clinica Americana Boliviano to an OR in the States, it becomes abundantly clear that the same basic structure exists in both. For example, the anesthesia machine in Clinica Americana Boliviano might be a decade or two older than one in the State, but it still allows the anesthesiologist to safely maintain a patient in an anesthetized state during an operation. Similarly, consider the operating table. Sure the operating table at the Clinica Americana Boliviano requires one to manually pump it higher or lower, but does it still do the job? The obvious answer is yes. In many respects it could even be argued that the older equipment used at the Clinica Americana Boliviano and elsewhere is better than that in the States. However, I have no desire to open the can-of-worms concerning the idea of planned-obsolescence which is so ubiquitous in the States these days.
Although Cochabamba may exist as a city of extreme paradoxes, the opportunity to serve and learn here is already a richly rewarding one. Every human life is precious, and the more I work around the Cochabambians the more I am reminded of this point. If only every person had an opportunity to see for themselves the lives of these humble, but happy people, perhaps many of the woes-of-the-first-world would be greatly diminished.
I am continually astounded how paradoxical life can be in this incredible city. One minute you are dodging taxis and street rubbish and the next minute you are surrounded by buildings and riches equivalent to anything in the States. Indeed it is an interesting setting to learn medicine and to, more importantly, learn about humanity in vivo.
When one considers American culture with its broad and blurred spectrum of socioeconomic classes, it can be a rude awaking to step into an environment such as exists in Cochabamba. Like many cultures of the world, Bolivian culture is extremely polarized. At the very tip are the richest of the rich, who live lives of unsurpassed opulence. This elite class is built on the foundation of the low class, the commoners, who in some way or another work to support the rich. It is this lower class in which we have the most exposure and for which our influence that the Clinica Americana Boliviano and the Viedma Burn Clinic has the most relevance.
During my first week working at the Clinica Americana Boliviano, I can honestly state that I have learned more about how to operate healthcare with limited resource than I could have ever from a library of literature written on the topic. There is simple not the time, nor the copious resources that are otherwise available in the States. However, if we assume the Bolivian perspective it is fair to wonder if some of what we as Americans do is simply excess, overkill. Now let me be clear that I am not talking about not ensuring sterility in the OR or cleanliness in the outpatient clinics. Both are very important, no matter where you go. However, it was not that long ago in the States that surgical gowns and clinic tables were dressed in heavy canvas that was washed and sterilized daily as they are still done here in Bolivia. While according to American standards of disposable plastic everything the idea of reusing anything seems purely heretical, in many regards the Bolivian idea seems the most sensible (assuming the levels of sterility are comparable).
While some Americans may scoff at reusable nature of the clothing, dressings, and clinic table coverings that exists in Bolivia, they will be more surprised to know the level of technology that exists from the outpatient clinic to the OR suite. Yes, I will concede, we are in a third-world country. However, if one compares an OR at the Clinica Americana Boliviano to an OR in the States, it becomes abundantly clear that the same basic structure exists in both. For example, the anesthesia machine in Clinica Americana Boliviano might be a decade or two older than one in the State, but it still allows the anesthesiologist to safely maintain a patient in an anesthetized state during an operation. Similarly, consider the operating table. Sure the operating table at the Clinica Americana Boliviano requires one to manually pump it higher or lower, but does it still do the job? The obvious answer is yes. In many respects it could even be argued that the older equipment used at the Clinica Americana Boliviano and elsewhere is better than that in the States. However, I have no desire to open the can-of-worms concerning the idea of planned-obsolescence which is so ubiquitous in the States these days.
Although Cochabamba may exist as a city of extreme paradoxes, the opportunity to serve and learn here is already a richly rewarding one. Every human life is precious, and the more I work around the Cochabambians the more I am reminded of this point. If only every person had an opportunity to see for themselves the lives of these humble, but happy people, perhaps many of the woes-of-the-first-world would be greatly diminished.
Week 1 - Viedma
It was an in-depth introductory week at Viedma, both as to the manner in which medicine is delivered and as to Latin American culture. After meeting critical personnel on Monday, we arrived at the clinic ready for surgery at 8am Tuesday and discovered a mariachi band setting up for Dr. Romero's 70th birthday party. It was explained to us that Bolivian culture values relationships above all else, and the clinic's head surgeon was being honored for his lifetime of service to Viedma and paternal relationship to all of it's patients. After speeches and cake, surgeries resumed as usual. We took the day to learn about the children present, and the way of Bolivian medical education.
Nicole: My lack of any prior Spanish has hindered me significantly in building relationships with the nursing staff and Bolivian medical residents. Any efforts on my part are met with encouragement, but the language barrier does prevent the transmission of specific details of burn care.
Will: Having been to Honduras on two prior medical trips before starting medical school, I had an exposure to medical Spanish that has helped both inside and outside the clinic.
In the rest of the week we've observed between 6 and 7 procedures every day, ranging from mild wound redressings to skin grafts and reconstructive surgery, in addition to the constant physical therapy and nutrition administration of the recovering patients. It is not uncommon for the two surgeons on hand to be called out of long procedures, such as wound debridement, for simple redressings and initial evaluations of new patients. The juggling of such responsibilities are facilitated by an experienced nursing staff and a simpler procedure room.
One of the more impressive procedures we witnessed was a reconstruction of an adolescent patient's left neck and ear. Will was present for the Z-plasty of her neck to remove fibrotic scar tissue which lasted 2.5 hours, and Nicole was present for the reconstruction of her ear from the mass of remaining tissue, which was an additional 2 hours. The procedure not only restored her range of motion, but was a day-to-night difference in the young girl's cosmetic appearance. Physical therapy was observed over the next two days.
Startling information for both of us was the fact that sedation for these incredibly painful burn injuries is only provided by the clinic for children under 5. Older patients must have medicine provided by the parents, at an extreme cost for these patient families.
Nicole: My lack of any prior Spanish has hindered me significantly in building relationships with the nursing staff and Bolivian medical residents. Any efforts on my part are met with encouragement, but the language barrier does prevent the transmission of specific details of burn care.
Will: Having been to Honduras on two prior medical trips before starting medical school, I had an exposure to medical Spanish that has helped both inside and outside the clinic.
In the rest of the week we've observed between 6 and 7 procedures every day, ranging from mild wound redressings to skin grafts and reconstructive surgery, in addition to the constant physical therapy and nutrition administration of the recovering patients. It is not uncommon for the two surgeons on hand to be called out of long procedures, such as wound debridement, for simple redressings and initial evaluations of new patients. The juggling of such responsibilities are facilitated by an experienced nursing staff and a simpler procedure room.
One of the more impressive procedures we witnessed was a reconstruction of an adolescent patient's left neck and ear. Will was present for the Z-plasty of her neck to remove fibrotic scar tissue which lasted 2.5 hours, and Nicole was present for the reconstruction of her ear from the mass of remaining tissue, which was an additional 2 hours. The procedure not only restored her range of motion, but was a day-to-night difference in the young girl's cosmetic appearance. Physical therapy was observed over the next two days.
Startling information for both of us was the fact that sedation for these incredibly painful burn injuries is only provided by the clinic for children under 5. Older patients must have medicine provided by the parents, at an extreme cost for these patient families.
MS4BCI Round 2
BCI Bolivia is the first trip I've made out of country alone. As such, this project has been a series of challenges and firsts for me. For instance, simply making my connecting flights was a challenge since I've never been accountable for myself in such a situation. The project provides much freedom, allowing students to engage in varying degrees with their experience. Our freedom here has challenged me to show more initiative.
My rookie travelling status, and novice medical and Spanish skills have made me hesitant in my interactions with others. However, Dr. Bynum and last year's gang of MS4BCI students forewarned about this feeling of ineptitude. Confronting my hesitation, I could either limit my interaction with the Clinica Americano Boliviano (where virtually nobody speaks English) or I could dive head in.
Of course I opted to not dive head in, however, neither was I discouraged from engaging with the clinic. Interacting with the staff has been the most difficult because I only understand a fraction of what I'm told. I discovered that I can speak Spanish much better than I can comprehend it. With that in mind, my first week has been an orientation. I have remained a little side-lined due to the difficulty in communication between the staff and me. This upcoming week, I plan to stay longer hours and get more exposure as I develop better language skills.
Nevertheless, Will P. and I witnessed a superficial parotidectomy last week. I was also able to shadow a trauma doctor and a gynecologist. My companions in the burn clinic seem to have had more exposure to medicine, but I believe this is because the burn clinic is familiar with MS4BCI and its goals. The American Clinic should become a great place to send students as the staff becomes more accustomed to our presence. The American Clinic also seems surprisingly sophisticated compared to descriptions about the limited resources in the burn clinic, but I shall remain uncertain until I visit the burn clinic the week after next.
Overall, our theme for the first week has been adjustment. The great thing about a project like MS4BCI is that we have to take charge. We have run into mis-communication and unexpected circumstances, but I believe this has hardened our determination to make this a great experience. We remain flexible and eager to learn. Because I am just getting my bearings, it is difficult to report on too much within the first week. I take this new week with more enthusiasm after a refreshing weekend trip to Salar de Uyuni. More to come and a more descriptive account next week!
Saturday, June 15, 2013
Rotation Number 2, Summer 2013
Our first team is finished up and still on their way back home but the second group of students are already on their way to Cochabamba. This is the place to keep up with all their experiences in the hospital and community. Here is the team for this rotation:
Nicole Haghshenas
Rising MS-II at the University of South Carolina School of Medicine
Undergraduate: College of Charleston
I have a B.S. and M.S. in Biological Sciences from USC with a concentration in Microbiology. I did research at MUSC for 3 years before starting med school, and in my free time perform on an improv team, kayak, and play soccer. I currently hope to go into pathology or infectious diseases.
Will Royster
Rising MS-II at the University of South Carolina School of Medicine
Undergraduate: University of South Carolina
I was born in Chicago, but raised in South Carolina. I graduated South Aiken High School in 2006 and then graduated from USC in Columbia with a BS in biology and a double minor in Chemistry and Psychology in 2010. I took some time off to do volunteer work as a nurse and pharmacy tech at the Free Medical Clinic in Columbia and went on two medical mission trips to Honduras to act as a nurse, translator, and pharmacy tech. I've worked as a server and bar tender at Villa Tronco, an Italian restaurant in Columbia since 2008. In my off time I traveled around the south east playing bass in a rock band. I'll graduate from USC-SoM in 2016 and plan on pursuing a career as a pediatric surgeon.
Jonathan Chu
Rising MS-II at the Medical University of South Carolina
Undergraduate: Duke University
I am a rising second year at MUSC. I graduated from Duke University class of 2011 with a major in Classical Studies Civilizations and minors in Chemistry and Biology. I am a Navy ensign with their Health Professions Scholarship Program. I plan to serve as a Navy doctor and hopefully connect with some Navy Special Warfare units along the way as a Dive Medical Officer.
Will Pryor
Rising MS-II at the Medical University of South Carolina
Undergraduate: Brigham Young University, Hawaii
I am originally from Columbia, South Carolina. I completed my undergraduate education at Brigham Young University Hawaii, majoring in Biochemistry. During my undergraduate education I took a two year leave of absence to serve a religious mission in Southern California, were I worked with Latinos and grew to love their various traditions and beliefs. I have traveled extensively throughout Europe, Asia, and the United States and enjoy the opportunity to learn from various cultures. I am presently interested in pursuing a career in Interventional Radiology, although I feel strongly that learning the basics of medicine in a global medical setting is essential to becoming a knowledgeable and effective physician. I look forward to learning and serving during my time in Bolivia.
Rising MS-II at the University of South Carolina School of Medicine
Undergraduate: College of Charleston
I have a B.S. and M.S. in Biological Sciences from USC with a concentration in Microbiology. I did research at MUSC for 3 years before starting med school, and in my free time perform on an improv team, kayak, and play soccer. I currently hope to go into pathology or infectious diseases.
Rising MS-II at the University of South Carolina School of Medicine
Undergraduate: University of South Carolina
I was born in Chicago, but raised in South Carolina. I graduated South Aiken High School in 2006 and then graduated from USC in Columbia with a BS in biology and a double minor in Chemistry and Psychology in 2010. I took some time off to do volunteer work as a nurse and pharmacy tech at the Free Medical Clinic in Columbia and went on two medical mission trips to Honduras to act as a nurse, translator, and pharmacy tech. I've worked as a server and bar tender at Villa Tronco, an Italian restaurant in Columbia since 2008. In my off time I traveled around the south east playing bass in a rock band. I'll graduate from USC-SoM in 2016 and plan on pursuing a career as a pediatric surgeon.
Rising MS-II at the Medical University of South Carolina
Undergraduate: Duke University
I am a rising second year at MUSC. I graduated from Duke University class of 2011 with a major in Classical Studies Civilizations and minors in Chemistry and Biology. I am a Navy ensign with their Health Professions Scholarship Program. I plan to serve as a Navy doctor and hopefully connect with some Navy Special Warfare units along the way as a Dive Medical Officer.
Rising MS-II at the Medical University of South Carolina
Undergraduate: Brigham Young University, Hawaii
I am originally from Columbia, South Carolina. I completed my undergraduate education at Brigham Young University Hawaii, majoring in Biochemistry. During my undergraduate education I took a two year leave of absence to serve a religious mission in Southern California, were I worked with Latinos and grew to love their various traditions and beliefs. I have traveled extensively throughout Europe, Asia, and the United States and enjoy the opportunity to learn from various cultures. I am presently interested in pursuing a career in Interventional Radiology, although I feel strongly that learning the basics of medicine in a global medical setting is essential to becoming a knowledgeable and effective physician. I look forward to learning and serving during my time in Bolivia.
Sunday, June 2, 2013
Blog #3: First week in the hospital and Toro Toro
We have now been in Cochabamba for over 2 weeks, and as you can see from Alex's post we have been fortunate to witness a lot of diverse pathology you wouldn't normally see in the US. In this blog, I would like to highlight my first week in the Burn Clinic OR, and then (on a lighter note) tell you about a trip that Alix, Alex and I took last weekend to a Bolivian national park called Toro Toro, just 5 hours south of Cochabamba. Forewarning, this blog will be a little bit graphic.
For our first rotations, Barb somewhat delegated what part of the hospital we would work in. It was decided that due to my quasi intelligible Spanish, I would start off in the Pediatric Burn OR, where nobody speaks a lick of English. Dr. Romero is the main doc in charge of the Burn Clinic... this is his domain. In fact, Dr. Romero started the clinic himself 20 years ago, recognizing that there was no such treatment center for children in all of the city.
A little bit about the types of burns we see in the pediatric burn unit. Surrounding Cochabamba is an expanse of very poor, very underserved homes that they refer to as "El Campo" (literally translates to the field). We have passed through this area on our various excursions. The living conditions are substandard, and many people from El Campo come to our hospital because it is free and public, instead of one of the other private hospitals in the city. Just as a side note, our hospital is a teaching hospital, so we constantly interact with medical students, interns, and residents.
The women in these areas are not allowed to use birth control of any kind (which one can easily buy from any pharmacy for cheap). In fact, I was told today that for these people, the use of birth control indicates promiscuity, and upon discovery can result in severe domestic violence from husbands. This means that these women often have LOTS of mouths to feed (could be more than 10!) and not a lot of time to supervise their children. Additionally, the substandard housing is such that one room suffices as kitchen/sleep/play area. Thus, at a very young age (let's say 6), children are left unattended to watch their brothers and sisters and cook for their families. They are constantly playing amongst the numerous dangers of the kitchen, and their real enemy in this case: hot water.
The majority of burns I saw in the clinic last week were from hot water. Most often, the children were playing in the kitchen unattended, grabbed pot handles, and dumped scalding hot water on themselves. Its a travesty to look into their deep brown eyes and think how much pain they have already endured, at no real fault of their own.
Moving onto the surgery itself. Sterility is attempted in the OR, and if it is maintained I do not know. No stainless steel scrubbed walls here. People walk in and out frequently. Blankets and saline solution are heated on radiators that are placed cumbersomely throughout the room. I don't mean to say that it is really that bad. There is still much of the necessary technology needed to give general anesthesia/heart moniters/etc. In fact, I was pleasantly surprised by how well equipped they seemed to be.
Most certainly, there is no lacking in experience of the doctors. I have been humbled and awed by their expertise and gentility with the children. They care so much for the welfare of their patients, that they work for pretty much nothing, spending hours each day performing surgery after surgery.
Watching them work was a lot like putting together a puzzle, literally and figuratively. For one thing, as I have already mentioned my spanish is not superb. For most days, I had no idea what was coming next, when all of a sudden they had taken out a skin grafting instrument (looks like a giant electric razor) that slices off a thin piece of skin from an unburned section of the body, that is then placed on the deeply burned part. And then there is the cheese grater.
We were told prior to departure about this instrument from our good friend Colin Kane. I believe he has detailed his experience with the cheese grater in his own blog. On my first day in the OR, I was pretty anxious about the appearance of the cheese grater. I sort of knew it was coming but I didn't know when. The second surgery of the day was a boy with a second degree burn on his arm. Dr. Romero wasn't operating, it was Dr. Juan Pablo, a plastic surgeon.
Dr. Juan Pablo is, I'm guessing, in his mid 30s, and is one of those people that just lights up the room. He started his career performing only aesthetic surgeries in Buenos Aires for 10 years. He told me, "You know, I do, the boobs?" And cupped his chest where they would be. He laughs and sings during surgery, making the somewhat dismal subject matter a little bit more bearable. He is totally charming, and the story of how he started working with Dr. Romero in the burn clinic is nothing short of inspirational. He told me that the salary he makes doing the surgeries in the burn clinic for a whole month equals what he would make doing 2 botox injections. But he knows its important, and he loves doing it.
Anyway, Dr. Juan Pablo took the cheese grater. Wanna know what it looks like? Go into your kitchen and open up the drawer that has your cheese grater. Thats what it looks like.
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| Picture of a cheese grater I got off of google images. Looks exactly like the instrument the Drs. use to grate off the necrotic skin from the children's burns. |
Yes, this is a little disturbing. But the theory behind it is that grating off the top layer of skin of a second degree burn helps with reperfusion, thus expediting the healing process of the skin. The doctors swear by it, and are convinced that it helps immensely. I'm pretty sure that this technique is not used in the US, but that certainly doesn't mean its ineffective.
Dr. Juan Pablo was grating away, and then looked up at me and said "Look, it's ensalada de nino! What do you think?" Of course I said something really dumb "Um........ preferisco ensalada de lechuga?"
His eyes lit up in a smile above his surgical mask and his infectious laughter erupted throughout the OR, making all 10 of us in the OR laugh too.
Meanwhile the boy lay in his sedated state, blissfully unaware of our morbid senses of humor, and he will never know it happened. Speckles of blood dotted his arm where Dr. JP had been grating away at his exposed flesh.
It may seem pretty disgusting that we were able to laugh at this obviously terrible situation, but how can you not, at least a little? These doctors, Dr. Romero, Dr. Juan Pablo, and their resident perform these burn surgeries like clockwork, one after another after another. They are desensitized to their job, just as we all will be one day as doctors, and it was just me as an outsider looking in that saw how puzzling it is to joke during such a situation. And, inevitably, by my 3rd day in the OR I was desensitized too.
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| Dr. Romero, Dr. Juan Pablo, and their resident working away in the OR. |
Moving on to Toro Toro. This national park is incredibly unique, and for future MS4BCIers, you are foolish to not take advantage of it. A simple 5 hour bus ride at night plopped us off in the sleepy town of Toro Toro. Of course, it didn't all go off without a hitch and once again we almost missed our bus. One of my favorite aspect of language barriers is well illustrated by our difficult departure.
We had gone through a tourist agency of sorts to arrange our plans for Toro Toro. We were to take a taxi to the bus, where some woman named Cynthia would meet us with our bus tickets. Once we got to the bus area, we looked around and saw like 30 buses, spread out over a couple of different streets. We had no idea which was ours, and it didn't help that whoever is in charge of the weather decided this would be a great time for it to be pouring rain. I called Cynthia, and she tried to tell me on the phone, in Spanish, the location of our bus.
I can't remember what she said, but the point is that I didn't understand. No matter how many times she gave me directions, no matter how simply she put it, there was no way for her to get her point across. We had reached the classic phenomenon of language barriers I call "the standstill". She had said what she needed to say. I had no idea what she said. We both sat in a tense silence for about 15 seconds, each pondering our next move.
She hung up on me.
In the end, of course, we found the bus when Alix had an epiphany about its location (not before I stepped into a big pile of Cochabambian mud trash in my open toed sandles). We made our way to Toro Toro.
The landscape of Toro Toro is stunning. Tectonic plates somehow pushed up the land into mountains creating these unique, scalloped humps.
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| Landscape of Toro Toro |
The caving experience was great, and actually quite dangerous, even for me (sorry mom). If you have been to a cave in the US, you know that they are highly protected. They have rules like, "No touching the stalagmites! No flash photography! Hey, don't go beyond that rope!"
Not in Bolivia. We had free range to do whatever we wanted, with no barriers, and again, the three of us and our tour guide were the only people in this enormous cave. At different points, they had set up ropes so that you could repel yourself down unclimbable and slippery rocks. That was about it. If I wanted to, I could have gone up to a stalagmite and given it a great big hug. (I didn't)
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| Cave pic. |
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| Blind Fish in the Cave. |
The town of Toro Toro is, like I said before, sleepy. Not a tourist town at all. I think there were 2 restaurants in the whole place, with lots of stray dogs and sheep. It was a nice departure from the craziness of Cochabamba.
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| Toro Toro |
The second day of adventures took us to what our guide called, the "grand canyon of Bolivia". All the blogs and trip advice we had read before coming to Toro Toro called it a "legit canyon", and indeed it was. Our guide led us all the way down to the bottom of the canyon, where we hiked around on the boulders and eventually got to a picturesque watering hole with tropical vegetation.... a paradise. We gleefully jumped off rocks into frigid water. Our ascent out of the cave was a combo of bouldering and rock climbing, which our guide ensured us he saved only for the young and strong, and not for the faint of heart.
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| Canyon. |
We left the next day with the sunrise, sad to leave the tranquil bubble of Toro Toro. It was an unforgettable trip.
Judy
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