Tuesday, February 19, 2013

February 19, 2013 Guest Blogger Dr. John Burgoyne


So, if I were to be a blogger, I guess this is how it would start:

Some of you may wonder what a medical mission trip is like.  Well, first let me say that they are all different, and so I can only tell you what MINE are like.

Before I go, there are some things that have to happen. Lots of them are taken care of for me by Teresa, who runs S.M.A.R.T.  (Surgical Medical Assistance Relief Teams). She is in Honduras, and she organizes the interactions with the local hospitals and government, including the purchase of necessary drugs and oxygen, volunteer local support staff, temporary licenses and hospital privileges, in-country transport, food, lodging and security (we travel with armed guards). She also keeps track of my patients, most of whom require four or more staged procedures, and makes sure they are there for us.

All I have to do is scrounge up donated medical and other supplies (including cosmetics for gifts for the nurses- VERY important), pack and go. Oh, and pay for your ticket and $1,000.

Teresa really feels a strong calling to be here and help the people, and is organized, forthright, outspoken, and willing to do whatever it takes. She is also a gun aficionado, owns about fifty guns, and usually carries a Glock on our trips.

Teresa is originally from Arkansas, more recently from Kansas City, and has been living full-time in Honduras for several years. She is about five years older than me, and about a foot shorter, with long hair that is up in a bun for our trips. She is a minister, and when not organizing medical missions, she works with orphanages, adoptions, and trying to save the gang members of Honduras. At times she teaches Bible classes in the gang prison (you can get a seven year sentence just for having a tattoo- but most of them are real criminals).

A couple of years ago she took me into the prison, where I removed a few bullets and drained a few abscesses from the ignored prison population.  As an aside, the prison itself was fascinating.  The government had found it expedient to simply put all the 18th Street Gang prisoners in one warehouse - like building. Inside, the Gang was in charge. They built partitions, ran a commissary, sat around watching TV or talking on their cell phones, or being entertained by the women who were allowed in for a small bribe. The guards stay out of it. The leader when I was there was Spider, a friendly and charismatic fellow, who had a bullet fragment in his forearm that I removed first, so that I could then work on lesser Gang members with more threatening problems. The power went out while I was working there, so we went out into the prison yard and worked in the dwindling sunlight. I finished under flashlight conditions. Spider later got out of prison.               

As is usual, this trip I left with my two daughters, Genevieve and Gabby, on the red-eye from Seattle to Houston on Wednesday night.  My goal is always to be asleep before we are off the ground- a very important skill I strongly endorse. After a three hour layover in Houston, we did the three hour jump to the Capitol, Tegucigalpa.  This time, we spent much of the layover looking for pants- Genevieve was wearing shorts, having spaced out the fact that in Honduras only prostitutes and confused American newbies wear shorts. This being her twelfth trip, she really knew better.  I wasn't all that worried, but she was.

The first thing you notice in Tegucigalpa is that the runway is a little short. They REALLY stomp on the brakes. Every time. Comforting. Passport control is also a pleasure, with more forms and stamping than you would need to get into Cuba. Oddly, the thing that irritates me is that they are sloppy with the visa they staple into the passport, and so it makes it messy in my pouch.  I hate that.

I should mention that I always wear a fanny pack when I travel. Partly because of my obsessive need to always have my passport attached to me. Well, let's be honest, my obsessive need to have ALL my stuff attached to me.  My kids have told me for years it is not acceptable.  I ignore them, but if someone with more clout objects, I will need to get a new system.

While waiting for my bags, I always run to the restroom, just because that is my last chance in Honduras to actually flush toilet paper. It is forbidden in our hotel. Turns out that having to throw toilet paper in the waste basket really annoys me. Sorry, TMI. (To much information)

We then exit into the sweltering heat and indescribable odor that is Tegucigalpa.  Teresa is there, and everyone is looking out for the tall gringo doctor in the orange shirt, which I always wear just for that reason. We hop into the truck, armed and dangerous, and head over to Popeye's Chicken for lunch. There, of course, they have an old man with a shot gun to make us feel safe.

At this point the girls and I met our companions for this trip- Alan, a Florida appellate judge, and his daughter Leah, who just finished college and is headed to Nashville to pursue a career in music. They have both been heavily involved in various missionary service projects, and are currently in the middle of a 7-week stint in Honduras doing a number of different things.  Alan was an EMT in a former life, and has been in the ORs with Teresa's groups quite a few times over the past 15 years. Even here, he runs several miles every morning (I am way too cowardly to venture out in the streets myself), and is lean and tan. Leah has long dark hair and big eyes, and the three girls look enough alike to be sisters.  Certainly the Hondurans can't tell them apart.

The ride to Choluteca is about 2-3 hours, depending on traffic. The road is a main north-south thoroughfare, meaning a two-lane highway with multiple washouts and tank-trap sized potholes, with slow moving semis and crazed Honduran drivers more than willing to try to squeeze down the middle, forcing everyone onto the shoulder, where present. Shiver.

Our driver is José.  José requires some explanation. Teresa met José in 1998, when she was down here after hurricane Mitch, which really devastated Honduras. At the time, José was a member of the elite national police (the Cobras), and was assigned to Teresa's protection detail. He caught her attention by finding and returning a LOT of money that fell out of her stuff in the truck.  Actually RETURNED it. Unheard-of.  Over the years he became her personal security guard, then essentially adopted son.  He is now an attorney, who works with the adoptions, among other things. A couple of years ago, he ran for Congress here.  Despite his legal work, he still comes on our missions (or "brigades" as the locals call them), drives, provides security, but most important, entertainment. He is rotund, happy, and hilarious. My girls think he is almost like a cartoon character. We love José Benavides.

On my last trip, José was driving the other car, and since Teresa's shoulder had been broken in a freak slip-and-fall at the grocery store, I was pressed into driving. I really prefer not to.  REALLY.  I am way too gringo to be comfortable on the Honduran roads.

We then arrive in Choluteca, a town of about 100,000, with the infrastructure for about 20,000. Of the three intersections with traffic lights, one is broken. We make a pit stop at our hotel, the Hotel Flamingo, run by some of my favorite people in the world. Sonya, although undergoing chemo for cancer, makes wonderful food, the rooms are clean, the compound is safe.  Their daughter, also Sonya, is in medical school in Tegucigalpa, having been inspired by the hundreds of mission team members who have stayed in her hotel over the years.

I should add here that I have three rules while in Honduras: Only drink what Teresa gives you, only eat what Teresa gives you, and only go where Teresa tells you.  I have never been sick, and never felt in any danger with those rules. Teresa knows everyone, from cabinet level ministers to gang leaders, and is well positioned to escape from most situations that could come up.

Then it is off to the Hospital Del Sur. When I first started coming to Honduras, they basically gave us a large room with an OR table. We had to supply all the other equipment and personnel, including anesthesia and nursing, sterilizing equipment, and, of course surgical instruments and supplies. Now, all we really need is me and my three suitcases of disposables and instruments. They supply me with nurses, anesthetists, recovery staff, gowns and drapes. It is really nice, and all these are unpaid  volunteers from the local hospital.

The nurses are great. They giggle incessantly, amused by the giant gringo who seems incapable of remembering the names of any instruments despite having done hundreds of cases here.  They are mostly very short and very round, and my daughters observed that I am like Willy Wonka surrounded by oompa loompas. They donate their time, all for love of the children- and a few make-up kits.

The anesthesia in Honduras is mostly provided not by MDs or nurses, but by anesthesia techs. They really work hard for us as well.

Despite the upgrade, it is still primitive. We have frequent power outages, water only about half the time, terrible lighting, no patient gowns (we wrap them in thread bare sheets). One memorable trip, the power went out during an emergency C-section in the adjoining room, and by far the best flashlight available was my Blackberry.  Literally. Shiver, shiver.

Triage is the first step. This trip, we did that in a truly sweltering hot-box of a room designed as a barracks-like dormitory. I am sure it was 110 degrees, and clearly 100% humidity. At this point it became
clear that I was to be overwhelmed. There were 26 patients who needed advanced-stage procedures- in other words patients I could simply NOT turn away, and three first stage patients who had each been turned away twice before, and two thyroid patients who really could not wait.  That made 31.  Translation: not much down time.

My ear patients and their families are like a fan club.  They all know each other, support each other, and make sure everyone knows when I will be back. I love them. They love me. 

Due to a combination of genetics and nutritional issues, the incidence of microtia is much higher in Latin America than in the US.   Microtia is a birth defect where the outer ear is missing or misshapen. Often the inner ear works, but since there is no good ear canal, they really can't hear from that ear. If they have one good ear, however, it is the missing ear that is the problem much more than the hearing  They have a special highly perjurative insult here for kids with the condition, and they really can't go to school. The reconstructive surgery takes multiple procedures, and they often look worse before they look better. The interesting thing is, once they have had their first procedure they generally WILL go to school.

The kids are SO sweet and SO cute and SO grateful.  As far as we can tell, I am currently the only MD who does the surgery in Honduras. Since to go to the US for the several procedures would be around $40,000 just for the medical bills, plus getting there, it is truly out-of-reach for Hondurans, whose average per capita income is $1600. Sometimes I have wondered if my time would be better spent on something more life-threatening, but this surgery is so life-CHANGING for these children that I have decided I should stick with it.

We started surgery about 6:30 Thursday night, and six cases later we were back to the hotel before 1:00 am, which was a major victory. Sonja sent over dinner, which was delicious.  Leah had the opportunity to scrub in on a thyroidectomy. That also included the opportunity to turn green and have to sit on the floor to recuperate. 

We then took quick showers and went to bed. The challenge for me at the hotel is that the bathroom is truly smaller than those in some campers I have visited, and the toilet area is certainly smaller than a port-a-potty.  And I am large.  Between the elbows and knees banging on the walls and doors, and the whole toilet-paper-in-the-waste-paper-basket issue, I am, to say the least, a little challenged.  The unheated water was refreshing, and I slept like the dead until about 7:00, when the dulcet tones of José yelling awakened me.

After a Sonja breakfast (hot cakes, ham, fruit, eggs, OJ, rice and beans), it was back to the hospital. First we had to see all the post ops from the night before, all of whom were doing great. There was also the obligatory photo op.  Katarine, who is now 12, is still trying to figure out how to smuggle herself to America in our suitcases.  She thinks the girls would be amazing big sisters. I can’t say that I disagree.

When we met Katarine, she was eight, VERY personable, and full of life and love. She was apparently unrestrainable, and tore open her chest incision dancing so it healed poorly and had to be re-done. Twice.  She has given me numerous gifts, mostly food and little painted wooden touristy things. Her mother is one of the chieftains of the Dr. John fan club, and organizes everything with the others. Often, if Katerine is discharged but we are still there the next day, she will show up in her finest confirmation-style dress for more photos. We love her.

Friday we did fourteen cases, including three first stage procedures. These procedures start with an incision in the chest, going down through the muscles and exposing the ribs. The place where the ribs attach to the sternum (breastbone) has some excellent cartilage, just there for the harvest. You have to be careful to separate the under surface of the ribs from the underlying tissue in order to avoid tearing the sac around the lungs (the pleura), or puncturing a lung.  Both of those things are considered "poor form". No one wants to lose style points. No problems encountered.

Anyway, once you have the cartilage, you need to whittle it into the correct three-dimensional shape for a frame, and then bury the frame up in the place where you are building the ear. People are always fascinated by the whole idea of making an ear out of a rib.  I explain that an ear is one thing, but if you are good, you can make a whole WOMAN out of a rib.

The cartilage heals to the skin, and on subsequent procedures I have to fold skin under to bring the ear out from the head, make an earlobe, and thin out the flap. In the USA, I would operate about every six weeks or so.  In Honduras, they have to wait for my next trip, so usually about six months. They are surprisingly patient with the long waits. I am used to Americans, for whom this kind of long-term process would be maddening.

Anyhow, we moved right along. All the rest were old friends of mine, some of whom needed major work, some minor.

The local medical director assigns a public service MD to help us, and she did ALL the paperwork for me.  All I did was operate, eat, and rest.  If only my practice at home were like that!  It is really a way to experience the pure joy of surgery, as long as you don't get upset by the little things, like the poor equipment and lighting.

Friday night's bathroom adventure was enhanced by towel forgetfulness (I had to be rescued), and then a small mishap. While doing my ballet act to simultaneously dry myself and avoid touching any surfaces (germ phobia), I slipped and caught my ankle on the lip of the shower. As it turns out, that edge was quite sharp, slashing my ankle in three places. Bloody mess.  Not being interested in infection, I broke out the first aid kit, cleansed and dressed the wounds. Doctor-speak for putting on a bandaid.  Actually three, in this case. Near death experience.  I'm really much better with other people's blood. Mine should stay INSIDE its vessels.

Saturday morning started with Sonja's famous French toast. Really more like a pastry, it is so sweet. Once again, all of the post-ops were doing well, even the three who had rib harvesting were only using Tylenol for pain. Everyone went home.

During rounds, Gabby started to feel woozy, and spent the morning sleeping in the anesthesia lounge. She woke up when the OB/Gyn guy asked the girls if they wanted to watch a procedure.  Turns out it was a D&C, and they were totally grossed out.

For me, the day consisted of nine procedures, all upper stages, and all of which went well. I had a little anxiety as the day wore on and supplies dwindled, but we made it to the end.  In fact, we finished by 6:00, earlier than on most trips. The grand total of cases for the trip was twenty-nine, the most ever.

We then went back to the hotel, and after dinner I unloaded and re-organized all of my stuff for about an hour while the girls watched TV, showered, and was in bed by 9:30, and in a coma by 9:32.

Sunday morning was the reverse trip, starting with a quick trip to see my patients from Saturday, more French toast along with eggs and tamales, then on the road for the trip back to Tegucigalpa.  The traffic was not as bad, but the potholes were even more annoying, since we had to slow down so often and so suddenly.

Leaving Honduras is typically inefficient.  There are three long lines to check in. The first is for anyone traveling with a minor, where they make sure that you have the notarized authorization to travel from the other parent. It is interesting to me that THIS is the point that they check for that. Why here?  It seems that checking before I left the USA, or perhaps on ENTERING Honduras would make more sense. In any case, that is the system.

Next is the standard airline check-in, same as at home. The third (and longest) line is to pay the airport tax, which also seems unnecessary - why not just add it to the ticket price and get it from the airlines, like everyplace else in the world?  It DOES give them the chance to staple a couple of other receipts to our boarding passes. They love that.

We always eat lunch at the airport McDonalds. Why McDonalds? Why not? One trip a less-compulsive/paranoid team member left her passport and ticket in her backpack slung on the back of her chair at this point, and someone managed to make off with it while she was sitting there. No problem, with Teresa there to pull strings, and with the US Embassy's assistance, she was able to get new documents and leave on a later flight- five DAYS later. Passports, wallet, tickets are all high on my list of things that do not leave my body.

This is not the end of the red tape. After lunch, it is back in line to have passport and papers checked by two separate people, three feet apart, then the usual security screen.

Finally, we get through to the boarding area. Of course, to actually board they have one person to take the ticket, a government agent to check the passport, an airport official to collect the tax receipt, and another place to hand check the bags of anyone who meets profiling criteria.

I always try to stay awake on the flight to Houston so that I will be tired enough to sleep to Seattle.  This trip I was lucky enough to have secured seats in the very last row, so reclining was not an option in any case. I perhaps didn't mention that one of the reasons I try to get to sleep so quickly on planes is that I am so cramped at 6'4" that I am just too uncomfortable if awake.

In Houston we traditionally enjoy the authentic cuisine of Panda Express. As usual, I had the choice between the one hour layover or the three and a half hour one. Having had some rather unpleasant near-misses (you have to clear customs in Houston), I have opted for the latter.

One more flight and we're back to Seattle at 11:45 pm, ninety-six hours after leaving, where we are met by my gorgeous girlfriend and delivered home. Good thing I don't have to be at work until 8:30 Monday morning!

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