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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