Mexico 2013 Journal
This represents a bit of a deviation from my prior blogs in that I have only gone to the DR on projects with MMI in the past. We were asked to do a pilot project to Mexico as they had not had prior general surgery projects in Mexico for MMI. So, Here is a post about my experience to Mexico on a surgery project.
Saturday-
We didn’t have to leave until 10:55 AM so it was an easy morning to finish packing and go to the airport. There were 5 of us on the first flight to Houston. That gave us time to visit at the airport and go over our plans and ideas.
The first leg was an hour and a half and very uneventful. Unfortunately, we had a 6 hour wait until our next flight to Tuxtla. During that time we ate twice and saw the remainder of our group arrive. One from Michigan, one from Phoenix, two from Des Moines and two more from Wichita on a later flight.
The 2 and a half hour flight went quickly due to our anticipation. It is hard to believe you can be in a remote area in Central America in only 4 hours of flight time. The airport in Tuxtla is 45 minutes outside of town in a very remote area. So we boarded the 2 old 15 passenger vans to make the 45 minute trip in the dark to our hotel in the city. Customs in the airport was very simple with us being the only flight in at night. It is a new clean airport with lots of glass and 6 gates. The agents were very helpful. All bags arrived with minimal hassle and just one line to wait in getting our passport stamped.
Tuxtla Gutierrez is the capital of the state of Chiapas, Mexico. It is a town of 500,000, but is bigger than it was designed for. It doesn't have much tourism so dollars aren't taken anywhere. Mexican Pesos are the currency (not to be confused with Dominican Pesos). A dollar is equal to 13.07 pesos. It was almost 1 am by the time we reached the hotel. The hotel didn't look too good but was clean. Nice but simple.
Sunday-
We awoke at 6 am and cleaned up and walked about 4 blocks to Dan's 4th floor apartment to have breakfast of cereal and fruit and coffee. The town is fairly busy, but not on Sunday morning at 7. By 8 we were ready to take our caravan of vans and an open bed truck with a tarp on the road the 120 kilometers to Jaltenango la Paz. Unfortunately, the entire road was barely passable so the trip took 4 and a half hour. Yes, 4 and a half hours. They have had unusually heavy rains over the last 3 weeks on a daily basis. All the rivers and fields are full and the roads have suffered more than usual. This is now towards the end of the rainy season.
The main crop is corn but there are few flat fields like seen in Kansas. The hills, mountains, valleys and even the bar ditches are planted by hand and harvested the same way. We arrive in town around 12:30 pm. The town is also known as Angel Albino Corzo, named after a national hero, politician from the 1800's around their independence from France. The town seems very small but actually is over 25,000. No stop signs or traffic lights in the whole town. The hotel we are to stay at is even more Spartan than last nights. It has Wi-Fi but it doesn't work, somebody is coming tomorrow or Tuesday to check it out. Also, there is no hot water. Dan said they had both hot water and Wi-Fi last time he stayed there. They are going to have someone look into the problems soon, or so the translation went. The room barely has room to walk around the two full size beds and no closet, chest of drawers or place to unpack. So we live out of suitcases. The bathroom has a sink, toilet and shower, all together with no curtain or distinction between the shower and the rest of the small room, so the drain centrally placed in the floor drains the whole room which gets wet during the shower.
We went to a restaurant for lunch and took up the whole small place with our 15 people. We ordered off the menu and it took a while to cook that many meals with one cook. They have mostly traditional Mexican food with corn tacos, burritos quesadillas, etc. Not a very extensive menu.
We then drove to the hospital and spent an hour and a half figuring out the logistics of where to put what. The other surgeon and I then started about 3:30 seeing patients and saw them nonstop till around 7 PM. We did consults on 58 patients by the time they stopped coming. 5 were not candidates for us to do. All the patients had been prescreened by local doctors. They each had lab, X-rays, EKGs, and sonography when indicated. 23 of the patients had gallstones. Very few had the lumps and bumps that we normally see in the DR.
We apparently stepped on some toes politically today. Two municipalities are sponsoring our trip. One is here where the hospital is (Jaltenango); the other Monte Christi is 10-20 kilometers away and doesn't have a hospital so they partnered with Jaltenago to have us come. They were told that we would begin to see patients at 4. We were ready early and started at 3:30. So the local people were told to show up around 5 (since we start at 4?) and all the other communities patients were brought in by bus and got there early. So, by the time the locals showed up we were almost filled up with an unequal numbers being scheduled from Monte Christi. So, we had to add several to the already full schedule to make it fairer.
We went back to same cafe for dinner for more tacos, corn of course. Then a walk in the dark back the 8 blocks back to the hotel. Our room was warm and sticky. Of course the air conditioner didn't work, but by standing on the dresser (without the drawers), we were able to get it to work enough to make noise to crowd out the snoring, fireworks and cannons (celebrating Chiapas Independence from France in 1860's) and the early morning roosters. At least we had an air conditioner along with the ceiling fan, since those on the first floor only had a ceiling fan and no air conditioner.
Monday-
Awake early as usual to find no hot or warm water. It turns out they ran out of propane to heat the water. Also, the Internet didn't work because the modem was "broke". I was able to fix the modem (by unplugging and plugging it back in) but they had cancelled the DSL since the modem didn't work...
First day at the hospital was filled with new challenges and opportunities for growth on our part. We had 8 major cases scheduled to do and after several stutters at starting we began around 9 with the first case. Other issues prevented the second case from starting till 11:15. But even with all that we were able to finish by 5:30 or 6 PM. I did all the cases until the last one so The other surgeon could take care of the administrative and political stuff. We have 2 anesthesia providers so we could alternate between two OR tables in the same room. That allowed us to turn over very quickly. Also, we didn't have to stop to see clinic patients since we had seen all of them yesterday. This project had been designed as an exploratory or pilot project from the beginning since we had never been here before. All the participants were handpicked by The other surgeon and me (along with God). So out intent was not to do a bunch of cases. But, it is still hard to turn anyone away.
Back to another restaurant two doors down (owned by the same person) for dinner with a larger menu but not all things are available. With one waitress and 19 of us, we were not thru with dinner till 8:15 and then the walk home pretty much finishes most of off for the day.
The hot water was fixed but the Internet was not. The air conditioner had to be fixed again but worked to cool the room down ultimately. I am beginning to relax at bit (especially since we do have air conditioning and also that I am not in charge).
Well, the power to the hotel just went out for the whole hotel (16 rooms on 2 stories total). They say that the technician will be here in 30 minutes to hook up the generator, but the air conditioner won’t run on the generator. Glad I brought at least one flashlight. I didn't bring more because Dan says the power is more reliable than in the DR.... Might as well turn in.
Tuesday-
Awoke at my usual 5:30 and figured out the hot water system (the wrong handle controls hot). That helped a bunch. Cold showers are okay as long as they are brief, just not very relaxing. Walked to the restaurant for breakfast this morning and they have started serving a standard meal for all at breakfast and delivering a standard meal for lunch with way too much Mexican food for me. Evening meals are still chosen off the menu although they don't always have what is listed. Somewhat frustrating after trying figure out what each is in Spanish and deciding if I might like it, then it’s not available. All meals are big and come with corn tortillas and the refried beans are always black beans.
Then off to the hospital. Some of the Mexican staff takes the local Moto taxi since we are down to one van. The Moto taxis are 3 wheeled vehicles similar to rickshaws in Japan. It is open air with plastic covering for rainy days. I did the surgeries today with The other surgeon assisting. That allowed him more time for admin stuff. The president of Jaltenango showed up today and wanted everyone to come out for photo ops and speeches. I was busy so The other surgeon had the pleasure of going out to give an unexpected speech thru a translator. He hated that. We did 4 gallbladder surgeries, 2 inguinal hernia surgeries, 1 umbilical hernia repair and removed on lymph node on a young man that may have cancer or TB. I also took off a 6th toe on a 6 month old baby.
We finished the OR around 5:30 after an 8:30 start. The OR does have an air conditioner but it was not working properly and the rooms got so hot that we were drinking 8 to 12 ounces of water between each case to combat dehydration from sweating so much. While 85 degrees doesn't sound real hot, it is miserable with impervious gowns gloves hats and masks under the intense OR lights. It helps some that the OR overhead lights don't work and that I wear a head lamp on all the cases to be able to see.
One of the gallbladder surgery patients had some bleeding problems during the surgery. It made us realize the lack of back up and options we have here. We had no topical hemostatic agents like we have back home but also in the DR because of the warehouse of supplies that they have. There was also the constant strain to do more. We finally remembered that there will always be more patients and more difficult cases to do and that we can only do what we can.
It began to rain for the first time as we went to the restaurant and continued thru dinner. Being on many prior trips, I should have realized that the gentle rain meant that the laundry I dropped off this morning would not be ready as promised this evening, since drying involved hanging on a line without rain, even though it contained my sleep clothes. We had a Mariachi band show up after dinner to entertain us with music and also cake and dessert by two of the ladies from the hospital to celebrate Dan's daughters 18th birthday.
I walked back to the hotel in the rain under an umbrella. It provides time of reflections and relaxation. When we got back we found more governmental officials at the hotel waiting for us. They had missed the ceremony this morning and wanted to thank us personally. So more chit chat, photos and off to bed. This trip has not had much alone or decompression time.
Wednesday-
After waking at 5:15 and showering and getting ready for the day I have time for my devotion and journaling. Fortunately my roommate is also an early morning riser and we haven't had any early morning issues. The town is quiet at 6:50 when we walk to the restaurant to breakfast except for the roosters and dogs. Our room does have a flat screen mounted on the wall but we haven't even turned it on so I don’t know if it works. It’s all in Spanish anyway.
The restaurant asked yesterday what we liked on our pancakes. So we were eager to have pancakes today till they told us they couldn't find syrup. We take Wal-Mart and Dillon's for granted. Each morning in the restaurant we had a short devotional presented by one of the participants.
Since we had the political problems of not doing enough of the on municipalities’ cases, they decided to hire a Mexican surgeon to come for a day and do 5 gallbladder surgeries on people we had to turn away, but they need our anesthesia. Then they needed the other table and the anesthesia machine, etc, etc. etc. He used much larger incisions and didn't use cautery to do his cases. The patients in postop compared notes and noticed the differences in their incisions and pain levels. They then added 2 or 3 more cases for him as the day went on. That slowed us down a bit. All the miscommunication is a common thread here but also in the DR. Here they charge patients nominal fees for their surgery to get the patients to take ownership. The charges were 100 pesos for a minor surgery, 300 pesos for hernia repair and 500 for gallbladder surgery. (With the exchange of 13.07 pesos to the dollar that would be $8, $24 and $38 respectively.) If they didn't have any money they still got to have surgery. The amount collected just about paid the local surgeon.
I did most of the cases with The other surgeon's assistance. We did one epigastric hernia, a femoral hernia, an inguinal hernia and 3 gallbladder surgeries and were getting ready at 4 PM to start the last of 2 umbilical hernia surgeries when the power went out while I was closing an inguinal hernia surgery patient. It had flickered a couple of times during the day, but this time it was out for 30 minutes. They sent for a technician and he came after a bit. We had been on generator power all day because the sector of the city was without power. Being on the generator means that the air conditioner was only intermittent causing the OR temp to rise to the low 90"s. It was very draining physically for the whole crew. The instruments were marginal so that was a struggle as well. No having the right instrument and using what is available makes it more difficult.
Even thou the generator would come on it would stop again. So we stopped the schedule and cancelled the last 2 cases. They had been waiting all day without eating, but never complained. The local surgeon agreed to come back tomorrow and start a 7 am to finish his last 2 cases. We added ours on as well, but for Friday.
We walked to dinner for the 2 hour meal (waiting time plus eating time) of corn enchiladas, refried beans with guacamole salsa. After a brisk walk home we found our laundry all mixed together and still moist from the earlier rain. They forgot to clean our room. So we waited outside, then went into our room and tried to hang our clothes wherever we could. Then to sleep, not much time for anything else.
Thursday
After we walked to breakfast for another full meal we rode the van to the hospital. Our anesthesia provider who worked with the Mexican surgeon went in early to start at 7 am on his last 2 cases and we arrived around 8:15 as usual for us. The surgeon was upset that we didn't stay and finish last night as he was sure the technician was going to fix the generator. We were not that sure and didn't want to risk the patients having the surgery and not being to have electricity to finish the case. The surgeon showed up around 8:30. He said he overslept. So we were without our second anesthesia provider all morning. They finished their 2 gallbladder surgeries and then did a C Section.
The day started slow for us also since the generator was off last night they couldn't launder our scrubs as they had done before. It seems as one of the ladies took everything home to wash. We waited a bid and she returned with our clothes.
The cases were mostly routine with the gallbladder surgeries getting harder as the week goes on. Almost all of our cases were on females this year. We have very few males. It’s hard to tell why. All patients were prescreened by the local docs in the 2-3 weeks prior to our arrival. So everyone had lab, with coagulation studies, X-rays, EKGs and sonography where indicated. They had apparently rejected or turned away the high risk patients and also only sent major cases. We had very few minor surgeries. Very few patients were on medications or had medical co-morbidities.
We stretched the hospitals capacity with all our major surgeries and his majors and then 4 deliveries thru the day. So it was hard to keep moving until somebody left. The hospital only has two patient rooms with 6 beds each, a peds room with 2 cribs and 4 labor beds. Today I did 3 open gallbladder surgeries, 3 umbilical hernias, and 3 inguinal hernia surgeries. At times the OR would get hot (mid 80's) and we were exhausted but the time we finished at 6 pm. We did get a full meal at lunch delivered from the restaurant in a Styrofoam container with corn tortillas. I usually just ate the tortillas.
Since we were sponsored by local municipalities instead of churches, the spiritual focus was different. We still prayed over each patient in Preop area, but there wasn't a gospel presentation in the waiting room. The town has very few churches and that may be due to the influence of the native Mexicans culture as opposed to the Catholic Churches influences. The town was 23000 when surveyed 10 years ago but had grown in population since then. Most all streets are paved, but there are no stop signs or lights. The town sits down in a valley with beautiful mountains all around. The Mexicans are offended by being called third world but their sewer system is the same as the DR and the smell of burning trash is very familiar.
By the time we got to dinner we were all pretty tired. Eating late is hard but the walk home helps some. I was able to sleep well thru the night and awoke at 5 am for the start of the last day of the project.
Friday
Each morning I have awakened at 5 to 5:30 and gotten up to shower and get ready for the day. I have found a chair and table next to a window overlooking the street. It is all open air, so sunrise comes thru the window with a light fog and nice temperatures in the 60s. I have had time each morning for my devotional times and journal. I don't have to make extra time for exercise here since we walk to breakfast and to the hospital, which is nice.
One of our Mexican staff and tow of the participants were sick thru the night. One got IV fluids and meds and is going to stay at the hotel today. With such a small group, they will be missed. The hospital was very busy again today. We had scheduled 14 patients with mostly minor procedures and two umbilical hernia surgeries. All of our major cases had gone home today. The hospital only has 2 patient rooms, one for men and one for women with 6 in a room and a pediatric room with 2 cribs. On the other end of the hospital was the ER with 2 beds, and OB with 3 labor beds, the delivery suite and the OR. While we were there we put 2 OR beds in the OR and used the post op area for our supply room. Then we used the labor beds for Preop and occasional post op overflow.
Even thou we stressed the capacity of the hospital; we had much more cooperation and interaction with the local doctors, nursed and hospital staff. Our sponsorship was the local governmental agencies rather that a church as it is in the DR. They have provided our meals, transportation and housing. The Mexican MMI support staff has been Daniel, his 18 year old daughter, his 14 year old son, and Fernando who was a young man who translated for us and Sergio a Mexican physician from the north of Mexico. The rest of the help was from the local area.
We finished the OR schedule around 1:30 then we had our lunch (provided by the restaurant) and then packed up the supplies. We had a small ceremony by the local hospital director with photos and a gift of locally grown coffee for each of us. After going back to the hotel and checking out, we didn't leave Jaltenago until 4:30 in our caravan of vans and pickups. The 60 mile trip back to Tuxtla took 4 and a half hour!! The roads were largely impassable with wash outs, potholes and one lane segments. We made it to the Hotel Del Carmen in downtown Tuxtla Guterriez around 9 pm. For our three sick ones not much better, it was nice to have a clean, nice and cool room to sleep in.
Saturday
Very restful sleep last night. We awaken and went down to the hotel restaurant for breakfast. The group left at 9 am for the waterfall and shopping at San Christobal de Casa today. I chose to stay back for a day of relaxation and rest. The group returns at 4:30 and we were off to dinner in the evening. They had a good trip up a river into a canyon to see a 700 meter waterfall. They saw lots of animals, crocodiles, vultures and pelicans. They also had a time of tourist shopping. The dinner was to a traditional Mexican fare and was nice. After dinner we went back to the hotel and had a time of sharing and prayer.
The review of the trip showed that we did 59 consults. I did 38 surgeries of a total of 52 cases. The local hospital usually does around 5 surgeries a month. Another of our group got sick over the night but not too bad.
Sunday
We were up at 4:30 to be ready to leave at 5:45 to get to the airport (a 45 minute drive out of town). We got to the airport before it opened to check in. So that allowed us to sit in the airport until our 7:55 departure back to home.
It was a good trip to new places with old and new friends to help others in need and share the love of Jesus with all. The Apostle Paul reminds me in Philippians 4:11-12 that we must learn to be content. This trip helped me to re-focus on the joy that comes in spite of our conditions or circumstances.
