I have tried a bunch of different ways to record my thoughts and memories after a mission trip and none seems to capture the sum of the experience. This year I just tried to jot down incidents in a chronological fashion as they occurred. It is not that things didn’t happen at other times but these just stuck out for whatever reason.
It is not unusual for patients to come in with lab, x-rays or even ultrasounds and present them to the doctor as a folded up piece of paper. It is amazing how small they can fold a piece of paper with important information on it. One patient came in today with an ultrasound report from his study done in May of 2005. If patients want to have records they must keep them because no one else has access or the availability to get them in a timely fashion.
Tuesday
During the morning rush of consults there would normally be 50 to 100 people filling the waiting area. This morning, a young black man grabbed my arm and in perfect English asked if he could have a moment of my time. I was taken back by his English and said yes. He was an American from New York University in pursuit of his Masters in Pubic Health. He had been assigned to the hospital in Monte Plata as part of this Masters work. He was intrigued as what we were doing there and the fact that we all were volunteers. We had a nice visit and he was around the whole time we were in Monte Plata.
A 14 year old girl came in with her father because of a lump in her breast. She was quiet scared of course because of the size of the lump being 2 inches in diameter. It could be a cyst or possibly a fibroadenoma which is benign. I knew that but she didn’t. She needed to have an ultrasound to see which it was. I told the family that and they stated that there was a place in town to have that done. They left and returned the next morning with the ultrasound report. As I read it in Spanish I realized that the report was of the uterus and ovaries not of the breast. I felt terrible that they had gone to the expense of the ultrasound with none of the benefits. The girl responded that they had done an ultrasound of her breast as I had asked. They took the report back and in 30 minutes returned with the correct report showing a solid mass in her breast. She was scheduled for later in the project and was found to have a benign fibroadenoma.
A lady came in with an ultrasound in May that showed gallstones and another one in October with no evidence of stones. It’s hard to tell which was correct because the quality of the sonography is terrible. I chose not to operate since her symptoms were not compelling enough on there own to justify surgery. Most patients come in to see us because we are here and they think that they might need surgery. They are not referred to us by a doctor. So most are not angry when we say that they don’t need surgery like they would be in the states because those patients have been seen and sent to us by another doctor who thinks they need surgery. They are relieved and leave smiling.
Some things are the same over the world. I was examining a 54 year old man and I asked him to stand so I could check him and I heard a familiar sound. He promptly reached into his pocket and pulled his cell phone out, flipped it open and began talking to someone while I examined him.
A lady in her 70’s came in to see me because she was sure that she had a fishbone stuck in her throat from the day before. I was unable to convince her there wasn’t something there. The sensation comes from a scratch in the lining of the throat and takes 3 days to go away. I finally had to tell her we didn’t have the equipment to examine her throat. She was able to accept that more readily than the fact that there was nothing there.
A man in his 50’s came in bringing his father who had a hernia. He quite proudly presented me with a chest x-ray, electrocardiogram, and blood test results including CBC, liver test and HIV test all of which were normal. I then found out the son had taught in Boston and was accustomed to U.S. medical workups. I scheduled him for surgery and asked him how much those test had cost him. His reply was $1700 pesos. That is about $50 U.S. In the states that would have cost closer to $1000.
Wednesday
We started the day with 15 scheduled cases. This year we had two rooms to work with instead of the one larger room. In the past the larger room was made into a room with two OR beds. That would have been better this year with the staffing issues we had, but this hospital had smaller rooms and we could only get enough stuff in the room to have one OR bed and equipment. Fortunately, we did have available the second room which was their delivery room. All of their equipment and I put equipment in quotes, was moved across the hall into what was their labor room. So, they would labor and deliver in the same room. There was a delivery during the night and they wanted to add her to our schedule for a tubal today.
I saw a patient today with a recurrent hernia from Santa Domingo but he had severe hypertension. Normally we would send him to the clinic and tell him next year. Instead we had to get him some medicine and schedule him for next week if his BP was better. His son was the one who would be transporting the badly needed narcotic meds we need from Santa Domingo. They had not come in time for our project as promised and we were scrambling and using less effective alternatives to this point.
I seemed to be seeing more hemorrhoidal and breast problems than in years past. Maybe it is the city we are in or maybe it is the changing times here also.
I am frequently ask, “What kind of things do you see” but also “what can you not take care of”. Here is a partial list:
A 74 year old male with elevated BP, irregular heart beat, chest pain and a hernia (we referred him to Santana Hospital in the capital where they have a full service hospital and charity care available.)
An 8 year old boy with a retractile testis.
A 3 year old with a lump under her chin from a fall.
A patient with varicose veins.
An elderly male patient with urinary incontinence.
A young boy with a crooked arm from a fall that had not been set when he broke it years ago.
A patient with a large thyroid (I referred her to Dr S.’s project in March).
A patient with large hemorrhoids (we didn’t have any rectal instruments).
A patient with an anal fissure.
A young lady with bilateral mastodynia (painful breast from fibrocystic changes).
A patient with a parotid tumor in her neck.
A patient with a hypoglossal abscess in her neck.
You know you are on a mission trip when dealing with inexperienced staff in the OR when you ask for a right angle clamp and they look carefully at the instruments and ask how to tell the difference between a right angle and a left angle. That is an inside joke because those in surgery just know that there are not any left angle clamps.
Today was a long but productive day. I finished filling the surgery schedule except for 5 or 6 minor cases for next week. The hospital is a little different than most of the small hospitals in the country. It actually was a government building built in the late 1960’s by the dictator Trujillo. It was then converted to a hospital. The surgery and labor and delivery “suite” are on the second floor. That made it tough as we unpacked and set up. Carrying the anesthesia machines and beds and autoclave was hard work along with the oxygen canisters. Also the patient wards were not designed for a hospital. There is only one bathroom on the floor at the end of the hall. So a patient has to walk down the hall to go to the bathroom. Also the patients have to walk up and more importantly have to walk down the marble stair case to leave.
One of the down sides to a hospital in a building that is not a hospital much less one with good lighting and electricity all the time, comes with even the simplest jobs in our hospitals back home. Whenever they needed to start an IV on a baby which happens commonly due to dehydration, they would pull a cart into the hallway at the opening leading out to the roof. That was the place where the sunlight was brightest and you could see the best. We were asked to help start IV’s frequently since our anesthesia people are very skilled at that. It was still unnerving to hear the babies crying and screaming because they were being held down and poked by the mean Americanos. The empty marble hallways make the noise even more. And the moms usually were the ones holding the babies while we were putting the IV’s in.
After we returned to camp in the evening all was well until I was awakened at 11:30 pm to say that they had received a call because the patient we had done an open gall bladder surgery on earlier was having problems. I threw on clothes and we drove to the hospital. We had hired a guard to stay at the hospital during the night to protect our stuff from disappearing. We also hired a local nurse to take care of any of our patients. We try not to place a burden on the local hospital. C. called to tell A. that the patient was having blood pressure problems. Two of the anesthesias people a nurse and I arrived to find the patient with a blood pressure of 80/0 and the patient was short of breath. In the states this would herald a host of test and procedures. That is not a choice here. They had taken a folding metal chair and placed it under the mattress by the foot of the bed. The beds don’t have hydraulics or cranks to achieve that. She had also opened the IV up to run as fast as it could. She then stabilized slowly and we could remove the chair. We then decided on the rate to run the IV but realized we didn’t know how to calculate the drip rate since we all use pumps now days in the states. We concluded that it was either due to dehydration or related to pain medicine.
When we returned in the morning we found her sitting in that same folding metal chair, smiling with a toothless smile. She then got up, walked down the long hall to the bathroom. She then climbed down the stairs to go home less than 24 hours after having her gall bladder removed and being in shock post op. Things are just different here.
We were however called to the ER to help with an elderly lady who was bleeding profusely. As I arrived, I found an 80 year old lady with a cloth belt wrapped around her lower leg with blood pooled on the bed. I had Dr W. hold pressure above and below the wound and then we looked. She had severe varicose veins and one of the veins had eroded thru the skin. When he let up it gushed out. With the pressure reapplied we released the makeshift tourniquet and I placed a figure of 8 suture to close the open wound. She left a happy and relieved patient.
We actually did more surgeries today than on any day last week with fewer workers. That was because of doing more minor shorter cases per day than last week. We even finished by 3:45 pm because of the 3 no shows. I am afraid that they will show up tomorrow and want to be added on. You never know from day to day.
Today was a good day for me. I got to operate since two of the surgeons had left over the weekend. That is still what I enjoy and a whole lot more than administration and organization but somebody has to do it. I did 4 hernias, and open gall bladder, a tubal and an exam under anesthesia. I had missed operating last week. One of the cases was an exam under anesthesia. I had seen the 11 year old boy with his mother last week in the clinic. She brought him to see me because he couldn’t speak or eat because his tongue was tied. This is a condition where the attachment of the underside of the tongue is shortened. The child appeared happy but obviously mentally retarded. He also could not control his saliva and had to carry a towel with him at all times. I scheduled his surgery for today with a procedure that is not to difficult but life changing for the patients. To my distress, when I had him asleep I could now look into his mouth only to see normal findings. There was nothing I could do except wake him up and go to talk to his mother. I explained to his mother that he didn’t need surgery and then gave her a number for a referral to a pediatrician at Santa Hospital. Instead of being upset that I couldn’t help him, she was excited that he didn’t need surgery. Some times people come not for a cure but just for hope. I’m sure that some of them never go to the center, but they know that they could and sometimes that hope is enough to sustain them.
We seemed to have more illness this trip than usual. Most of it however was more upper respiratory in nature. It may have just been the close quarters and flu bugs going around here and back home. There were still some GI troubles but not very many cases.
Tuesday
A patient came in today and said he was a patient from out dental clinic and said through the interpreter that he had some sutures to be removed. That was unusual as they usually use dissolvable sutures that don’t need to be removed. I got a battery operated headlight and a number 3 knife handle (we didn’t have any tongue blades to hold his tongue back). As I peered into his almost toothless mouth, I couldn’t see any sutures but I did see something oblong and pink on his gum. As it turned out it was a watermelon jolly rancher. Oh well, some never learn.
The day started busy with a full schedule and a new mother who wanted to have a tubal ligation. We also had 2 patients show up with paperwork saying they were supposed to have surgery today but my list did not show them on the schedule. Also the local Gynecologist showed up and wanted to do a D&C. We didn’t have the anesthesia help but she did her own anesthesia and surgery and then did the patient who wanted a tubal ligation. B. was ahead of schedule so using the room caused no problems.
The schedule worked out well even though we worked later that we should have. The dinner at the came is timed to occur at 6:30 as a serving line. So if we are not there they usually wait for us. So everyone has to wait. You can do almost anything to the project participants, but you got to feed them on time. I would rather try err on the side of being finished a little early than late. We want the participants to come back next year. If we work then too hard they won’t, since for some of them this may be their only time off for the year.
I did have an unusual occurrence today. A 70 year old male came for his surgery, but about 12:30 pm he told us he changed his mind and decided not to have his umbilical hernia repaired. He wanted his money back and then left. We charge a nominal amount of pesos that goes to the local hospital for the use of their hospital. We did not turn anyone away if they could not pay the amount. We found that if we did not charge anything then the value of the service was seen in a similar fashion. They thought that it was not worth anything. So we gave his money back. I don’t know if it was because he had been there since 8 am or if he was scared or exactly what it was. He was really the only patient during the project that complained about the waiting that they all did.
Wednesday
My low back was a little tender today and I didn’t think too much of it until I helped lift a patient to the cart. She was large and I felt my back when I pulled. I hate to have a tender or sore back especially on the day we are to pack up and leave. We only have a half day scheduled and my back got better within a day or so.
We seemed to have more no shows this year than before. They were also clustered in the second week. Those people were scheduled last week and maybe it is because of an altered concept of the future. Maybe next week is just too long in the future to be concerned about. Mandie and Jason also tell us that Dominicans don’t plan for future events or sign up but just show up and then it is usually late.
Probably the best memory is the worst. I did a hernia surgery just before leaving the states. I explained to the patient in the recovery room that I was leaving the country on a mission trip and that she should come in to have her staples removed while I was gone and then see me in 2 weeks after I had come back. Of course we wrote the instructions down but she didn’t come in for staple removal until two weeks had past. The staples were sore and she told my PA that she was upset that I made her wait to have her staples removed after I returned from my “fishin’ trip”. So I guess misunderstandings can occur even when you speak the same language.
The brief summary of our activities reveals that we saw nearly 1200 patients all together. In surgery we did 149 surgeries and the dentists pulled over 400 teeth. The family practice clinic saw almost a thousand patients and gave out 2800 prescriptions. As well, 75 people heard and responded to the gospel message for the first time. While it is important to be able to track the number of people served, we who went we as much the recipients as those we went to care for.
The following is a list of the procedures we did during the two weeks: Ventral incisional hernia 1
Umbilical hernia over 5 y 3
Inguinal hernia over 5 y 17
Inguinal hernia under 5 y 9
Inguinal hernia recurrent 1
Ganglion cyst 4
Post partum tubal ligation 4
Removal of Ovaries 1
Circumcision 3
Abdominal Hysterectomy 2
Cholecystectomy 3
Tubal ligation 4
Breast Biopsy 3
Hydrocoelectomy 5
Repair of earlobe 2
Excision of hemorrhoid 1
Removal of toenail 2
D & C 1
Removal of extra digit 3
Excision of skin tag 6
Excision of lesion 1 cm 26
Excision of lesion 2 cm 9
Excision of lesion 3 cm 11
Excision of lesion 4 cm 6
Removal of IUD 2
Excision of Bartholin cyst 1
Posterior colporraphy 1
