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The Girl From Honduras

October 4, 2016

I have made a total of 10 medical missions over the years. I am fluent in Spanish so Latin countries were preferred. Each trip was for one to two weeks duration and I traveled to Honduras, the Dominican Republic, Colombia, Bolivia, and Mexico. Journals were kept.

It was necessary for me to bring a full set of surgical instruments and initially these were transported as my carry-on for the airplane. My trade tools were borrowed from the hospital operating room. Packing space was a premium. I tried to think of the most useful instruments and would also bring medications since these were always in short supply. With increased security concerns on later trips (after 9/11) the surgical equipment was handled with the general luggage. That always made me wonder if I could do my work once we arrived if the instruments did not. And then to have to face the operating room supervisor about lost instruments– well, we are talking in the range of about $50,000 or more.

Traveling by bus we arrive to an area, usually a rural part of the country, and set up. Sometimes this is an existing medical facility or perhaps an empty building. Local lay help is part of the team as well as medical personnel such as nurses. Our group also has its own lay help and paramedical personnel including a pharmacist. Sometimes there is a dentist. Other physicians from various specialties make up the remainder of the team.

 

On some trips we are also accompanied by military special forces that ride the bus and stay with us. Big guns but it shows the desperation felt in some areas. In a way it makes you feel like a celebrity. The local people are excited for the arrival of foreigners from far away. Instead of giving out candy or money, I gather children around me. I carry a book consisting of photos of my family, home, and countryside where I live. It includes a map so they can see from where we come with relation to their country. I have even been invited to come in and talk to the children in their schools.

The first full day is spent setting up the clinic. We will not begin operating for three or four days yet and the OR takes longer to be prepared. Members of our group were skilled in electrical, plumbing, or carpentry and building improvement. They did plumbing, ran wiring, and some construction so that after we leave an empty building can be used as the clinic over and over and provide a local medical facility. The military guys will not teach me how to shoot their guns. Well, I will not show them any surgery!

I feel pretty comfortable since I speak Spanish well. I help with directions and communication between our crew and the local community. My deficiencies will be noted later.

So patients are seen the first two or three days in the clinic and scheduled for surgery. There is exposure to diseases and conditions not seen in our country except in textbooks or perhaps going back to that one year spent at Charity Hospital in New Orleans for my medical internship. Some patients need additional preparation or outside exams prior to surgery. They are offered necessities such as dressing material and simple medications such as Tylenol or Pepto-Bismol. I try to explain things in lay Spanish terminology and some patients really stretched my knowledge of Spanish slang. I would like to share with you four of my best experiences.

This 23-year-old male comes in with an inguinal (groin) hernia. For me, an inguinal hernia is not a big operation. This patient tells me he is not employable with the hernia. He has a wife and two children. He traveled by bus for five hours to see me. His surgery was done using local anesthesia only and the next morning he was out the door on the 9 o’clock bus for the five hour trip to go home. He took a packet of 2 Tylenol in case he would need it.

Next, a 34-year-old gal needed her gallbladder out. Obviously, on a mission like this we do not have the capacity to do laparoscopic or minimally invasive surgery. So I made an incision below the right rib cage and performed an open gallbladder operation. The next day I went to the female ward to make rounds before starting my day. I looked around and saw my patient standing in the corner helping someone make their bed. Patients would bring blankets and sheets from home. Food was provided by families and much of this was fresh produce, and then the staples of rice and plaintains. I noted the same in the large metropolitan hospitals.

Anyway, I walked up to her and asked if she was hungry. She said yes. I asked her if she was having any pain. Her answer—“ Well, of course, I have pain– I just had surgery yesterday.” She probably went home to do the laundry for the family after I dismissed her the next day. I think she took a total of two Tylenol the first 24 hours and only because it was offered. Something as simple as Tylenol was not affordable for many of these patients. Thinking further about gallbladder surgery on these missions, my youngest patient for this procedure was 11 years old. That is another story.

Then there was the trip with my daughter, Kristin. She had just started college and had shown interest in the veterinary field. She wanted to go with dad on one of those missions. She wound up in the operating room as my first assistant. If I told her where to hold her hands and what to do she was good help. Her first surgery was one of the open gallbladder operations. After I had made the incision I took her hand with mine, feeling inside around all the internal organs. The next thing I know she goes to medical school, then finishes a family practice residency and a sports medicine fellowship. That was a favorite trip because she was with me. She just had her first baby September 1.

Now, I speak Spanish pretty well, right? I can talk with the local people and relate with my Latin colleagues on a professional level. So this 13-year-old girl is brought into the clinic by her grandmother. She has a hard lump the size of a medium orange in the lower third of her thigh. I felt this and knew immediately it was a bone tumor and was worried it was malignant. They were given a slip of paper to get an x-ray.

They returned two days later and after looking at the x-ray I saw that this was a benign tumor comparable to a mushroom growing on a narrow stalk off the main bone. I am not a bone cutter, but I am a good surgeon. This could be trimmed off, so to speak. I was smiling when I pointed to the bump on her thigh and told her and her grandmother we would take her to surgery and get rid of this. I was speaking about the benign tumor. I tried to keep it simple and on their level.

We did not have all the instruments needed. Looking around, one of the members of our group showed me his carpenter tools. Before the case, a small hammer and a chisel were cleaned and sterilized which allowed me to complete the procedure successfully. The carpenter and I were both beaming!

Later that day on postop rounds I found her crying and asked what was wrong. She said to me “Is it gone?” I nodded and said yes, playing the role as a confident American doctor. Through the blanket I touched the bulky dressing placed in the operating room after surgery. She began to cry again and said something about losing her leg. I asked her to lift up the blanket and when she saw both feet she smiled and wiggled her toes. This little girl and her grandmother thought I was going to amputate her leg.

The final episode is one of my favorites. A pretty 18-year-old girl comes in the clinic. When she was two years old she had the hair and scalp covering the entire top part of her head ripped out after her hair was caught in farm machinery. She had a bald area the size of a medium pancake. Surgeons and pathologists frequently compare things to food– whatever that means. So what I intend is a circle of bald scalp about 6 inches in diameter. Anyway, looking at her I said “Sorry, but I cannot do anything.” She turned to leave the clinic and began to cry. The “big” American doctor could or would not do anything for her.

One of the local Honduran nurses there had worked with me on previous trips. She came and punched me on the arm and said “Doctor, do you know what you just did. This little girl is considered damaged goods and will never get married. Can’t you do something for her?” So I walked outside the clinic and found her crying with the waiting crowd. We went back in and I began to play around with her scalp.

There is a layer of connective tissue that attaches the scalp to the skull. This allows the scalp to move around a bit. If this is divided the skin can actually be advanced one or 2 inches and has the capacity to stretch a bit more after that. I told her I could not close the entire deficit, but the deficit could be reduced to maybe one and a half inches. Yes, yes, yes, yes, yes!!! She beamed with hope.

So we go to the operating room where music was set up to make her comfortable. The procedure will be done entirely under local anesthesia. What I used would last 6 to 8 hours. Most of these patients require very low doses of any medication.

I did a circumferential injection all the way around the base of the scalp at ear level. After that I could start dividing the connections between the scalp and the bone and begin to slide the skin up over the top of the head. Starting at each end I put in a stitch that would dissolve after about a month. We would talk, laugh, and tell stories while waiting a little bit to allow the skin to stretch some. The entire procedure took about two hours. She was left with a silver dollar size deficit. Today, she wears her hair long and nobody knows. Three children now trail after this Girl from Honduras. And the procedure will delay the development of forehead wrinkles. She will look young longer.

These people are so grateful and compliant. Pain management is not known as a specialty here. To minimize swelling I asked the Girl from Honduras to sleep with her head up on three firm pillows for 10 days. I know this will be followed to the letter including 240 hours.

 

As I said before, none of what I did was life-saving, but much of what I did was life changing. We had to improvise. Sometimes MacGyver would have been proud. I learned that I can operate with my head, heart, and then a knife, fork, and spoon. So what if you lose the surgical instruments— except having to face the operating room supervisor!

Posted in Blog by jbosiljevac

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