Happy Halloween!

After spending so much time in medicine, whenever I see a skeleton around Halloween, I can't help by check the accuracy of the anatomy.

Image is Study of Skeletons by Leonardo da Vinci, c. 1510, in the public domain, from Wikipedia.

International Medicine

I loved every moment of the medical mission. Most of it, though, was a little bit self-serving. There is a question in philosophy whether an act can be truly altruistic. An act that may seem altruistic - donating to a non-profit, for example - gives the donor a sense of satisfaction or pleasure, and hence is not a purely altruistic act. In any case, instead of spending the week anesthetizing patients at the VA, I had the true privilege and opportunity to help kids in Guatemala who needed it. We made a difference in the lives of our 30-some patients. I loved it; it was so satisfying and fulfilling. We do a lot of volunteering and public service as high school students, medical students, undergraduates. But since residency, I haven't had the time or energy for something like this, and I missed it. It feels good, satiates some internal desire to give to someone who needs it. And now, I realize, I have a knowledge base and skill set that's truly useful, necessary, and uncommon.

But did we make a dramatic difference in the community? No, not at all. Communities need infrastructure, resources, physicians who will stay for the long haul. An international group that comes in for a week and then returns to our charmed lives changes things for individuals, but not communities. The people I admire most are those with the vision, resolve, and self-sacrifice to try to make the real lasting changes. One mentor I've worked with helped build a hospital in Rwanda; other anesthesiologists in the department have taught and trained anesthesiologists in other countries. Those are the foundations of real international medicine. What I did - no matter how great it was - was dabbling.

Nevertheless, I learned a lot and I grew a lot. In terms of medical knowledge, I broadened my experience of pediatric anesthesia, especially seeing pathology that would normally be treated much earlier on. I learned how to cope with older equipment, limited medications, a different environment. I began to learn about systems-issues when infrastructure, nursing, floor care, and pain management are limited. My Spanish improved. I cared for patients with medico-psycho-social problems, became aware of how culture affects care, gained an appreciation for the nonmedical issues - education, physical therapy, support systems, ethics - at play. My abilities, techniques, comfort, and confidence improved over the four days we operated. Our operating room teams worked smoother and more coherently with each case.

I am so grateful for this opportunity and would not hesitate to go on future medical missions if I am able. Although I wish I were the kind of mover and shaker that could really elicit change in a setting that needed it, I am content with being one of the players who changes lives of individuals, one at a time.

A Little Bit of Fun

We also had a few days of rest and relaxation on our mission trip. The whole group went to Antigua, a beautiful church-laden cobblestone town. We hiked up a volcano, stayed in a beautiful resort, and explored the old capital of Guatemala. Over the week, I got to know the medical team incredibly well. Everyone was so dedicated, motivated, and wonderful to work with. We worked long hours but no one complained. We improvised and made do with the resources we had; we played with the kids; we came together as a seamless team. It truly was a work hard play hard type of trip. In the end, I didn't feel like it was a vacation per se, but it was more fun than a regular week of work ever was. There is something magical about bonding in a different country with a group of people you wouldn't normally hang out with but a group of people brought together by a single unifying desire to care for children in need. I had such a great time and definitely want to incorporate international medicine in my future career if I can.

Culture and Language

Although I experience different patient populations working at different hospitals, the difference between patients at home and patient I saw in Guatemala was very striking. The children we treated in Guatemala seemed to me more independent, stoic, and hardy than those I remember from home. Part of it was an increase in the authority dynamic of medicine. I think the families, parents, and children in Guatemala viewed us in a particular light because we were physicians donating our time to an international medical mission. Families were passive; there was no argument or objection to our medical decision making. For example, if I felt that a 40kg 10 year old needed an IV start rather than an inhaled mask anesthetic, no one complained. None of our patients got any midazolam syrup, a common anti-anxiety premedication we give here, but very few of our patients had irreconcilable separation anxiety. Almost all the children we took to surgery were calm, understood what was going on, and acted a little older than their age. Even after surgery, the patients in Guatemala were stoic and hardy with regard to their pain. There was an understanding, an expectation that surgery would hurt, and they didn't need excessive coddling, treatment, or attention. When our physical therapist pushed the patients to do their exercises, the children did even though it hurt, something we don't always see in American kids.

I also got to practice my Spanish. Over the last several years, I've built up my medical vocabulary, but there are still gaping holes. Immersing myself in the local environment really gave me the opportunity to work on my communication, gain confidence, and learn. Our interpreters were so helpful, encouraging us to speak the language and build relationships with our patients. We also worked with physicians from Guatemala, and that dialogue was not only an opportunity for them to practice English, but also an enlightening experience in understanding medical delivery in a different country.

Scoliosis

Our biggest surgery on the medical mission was a 10 level spinal fusion from T4-L1 in a young teenage girl with adolescent idiopathic scoliosis. She had worn a brace for years with little improvement and was incredibly motivated to get the surgery. However, we had to be sure we could do it. Even small things we take for granted here in the states aren't readily available in Guatemala. For example, our operating bed was not designed for prone cases, that is cases where patients are positioned on their stomach. Working with our nurses and techs, we fashioned a prone operating table that would relieve pressure on her vital organs during this long 8 hour surgery. We did not have invasive arterial blood pressure monitoring. We had to confirm our access to a blood bank and ability to get blood for transfusion. We inquired about access to blood tests and the turnaround time; we ended up sending our blood draws by taxi to the nearest lab. We hammered out a plan for post-operative pain because a surgery this large was going to hurt. And in the end, we decided to proceed.

With all our preparation, the surgery went incredibly smoothly. Although it was a grueling 7-8 hours, we worked together as an amazing team. The surgeons worked incredibly efficiently, the nurses coordinated smoothly, and the Guatemalan physicians and staff assisted us with getting blood and sending our CBC tests. The result was so incredibly lifting for me. We tided the patient through her post-operative pain, and by the end of the week, she was walking down the hallway. All of us were so inspired to see the change we made in her life.

Image shown under GNU Free Documentation License, from Wikipedia.

Pediatric Nerve Blocks

One of the neat things we brought to Guatemala was an ultrasound machine and equipment for performing nerve blocks. Regional anesthetics or selective nerve blocks have a real advantage, especially in resource-poor environments. Our opiate availability was limited and once the patients went to the floor, the nursing ratio was not as high as we'd like. As our nerve blocks can last many hours, that would help our patients get rest that first night and begin physical therapy earlier. Since nearly all our surgeries were on the extremities, for many cases we would induce anesthesia, intubate the patient, and then do the nerve block. We mostly did popliteal, saphenous, femoral, and infraclavicular blocks as single shots (we could not manage catheters) and the results were excellent. For young children, we also did caudal blocks which are similar to single shot epidurals, allowing four hours of pain relief. The surgeons were wonderfully patient in letting us do these blocks.

We had to be careful though because we didn't have our normal emergency resources. If a patient had toxicity from too much local anesthetic, we didn't have the antidote, lipid emulsion. If we punctured the lung in an infraclavicular block, we would not have X-ray or chest tubes to diagnose or treat pneumothorax. In the same way, general anesthetics carry the risk of malignant hyperthermia and we did not have dantrolene for reversal. We carried a small supply of emergency drugs and had a defibrillator, but I was concerned about these rare emergencies. On our first day, we came up with plans for most emergencies, and luckily we did not have to use them.

Surgery

During the four surgical days on our medical mission, the entire group would have breakfast at the hotel together at 6:30 and then take shuttles to the hospital. The surgeons then made rounds on their post-operative patients while the anesthesiologists and nurses set up the operating rooms. When we were ready, we would meet the patient and parent in the pre-operative area. We adhered to standards at home; we made sure the surgeon initialed the operative site, double checked the procedure and consent, reviewed the plan with the parent. Unlike operations at home, we didn't pre-medicate the children with midazolam because we didn't have any. But surprisingly, the children tolerated the new and scary experience quite well. For the older and larger kids, we would start a pre-operative IV. For the others, we brought them back and induced inhaled anesthesia by mask. Common procedures included Achilles tenotomies, psoas muscle release, excision of extra digits, leg lengthening or shortening, osteotomies, and revision of prior surgeries. We used fentanyl and morphine as our opiates; we brought some ketorolac, acetaminophen, and ketamine as well. We were limited in our antiemetics so we only used them for older children and when necessary. Though the monitors and ventilators were old, we were able to do most of the things we needed with them. Unlike surgery at home, we didn't have good ways of warming the patient under anesthesia so the rooms were on the sweltering side. In fact, for one of the surgeries, the surgeons had rubbing alcohol poured down their back and clipped icepacks inside their gowns because it was so warm.

The post-anesthesia recovery unit was immediately outside the ORs, so close that we could stick our head outside the OR and check on our patients. We had 3 beds awaiting our patients. The PACU nurses took blood pressures manually and had a pulse ox but no EKG. Once the patient was awake, drank some jugo, and was comfortable, they were brought upstairs by orderlies to the pediatric ward.

We had anywhere from three to six cases in each room each day and operated until around 7pm. Even after the last surgery was finished, we hung around to do post-operative rounds and make sure that the last patients were discharged from PACU safely. Because everyone had to take the shuttles together back to the hotel, everyone worked together and waited around until the day's work was done. During the day, we'd have a delicious lunch provided by the hospital, and at the end of the day, we had dinner as a large group in the hotel before retiring for bed.

Clinic Day

The Sunday after arriving to Guatemala was our clinic day. Imagine a waiting room the size of a tennis court filled with over a hundred people. Children hunch over coloring books we brought, some having others color for them because their congenital hand deformity won't allow them to grip a crayon. They are here to see the surgeon about that club hand. The parents socialize, forming an ad hoc community, lamenting how hard it is for their bowlegged son to go to school or how expensive it is to buy a wheelchair. The doors to the smog-filled street are open and fans are going full blast because there is no air conditioning. Volunteers check patients in and call them up to see the surgeons in a makeshift examination room. Screens are set up to give some semblance of privacy as surgeons test range of motion, check gait, hold X-rays up to the fluorescent lights. An interpreter and scribe are assigned to each attending surgeon and the process moves quickly. The surgeons determine whether we can feasible intervene; sometimes, we don't have adequate equipment, facilities, or follow-up. But if the child is a candidate for surgery, they will either send them to get further X-rays or see us in our anesthesia closet. On their way to see us, nurses take their height, weight, and vital signs. Then in a quick 10-minute visit, I go through the medical, surgical, and birth histories, medications, allergies, anesthetic plan, preparations, and expectations. I carefully record the patient's information and file the chart - the surgical evaluation, my pre-op assessment, a photograph of the child, X-rays, and a contact information sheet - away carefully.

After we have seen about fifty children, we convene to discuss the cases. We are operating for four days and we want to fill the slots with the most high-impact cases. We have to decline some children - the surgery is too involved, the anesthetic is too risky, there are undiagnosed medical illnesses, or the child is running a sky-high temperature. But for most of the children, we slot into each day, trying to create a balanced schedule. After making the week's operative list, we go back down to the waiting room to all the eager faces.

Travel

The entire medical mission group flew together to Guatemala. We brought over 30 bags of equipment, almost 50lbs each, filled with surgical instruments, crutches, splints, a wheelchair, medical supplies, and anesthetic equipment. Although we got our controlled substances at the hospital we were volunteering at, we brought along all our other pharmaceuticals - from sevoflurane to emergency drugs to antiemetics to antibiotics. Getting these through customs always takes a little time; indeed, we arrived at the airport 3 hours before the flight and spent a while waiting when we arrived in La Aurora Airport in Guatemala City.

Although it felt a little silly bringing so much stuff, when I arrived at the hospital in Guatemala, I knew why. We were working at a small but adorable hospital only used for mission trips. Although it had large equipment like beds, operating tables, Mayo stands, cabinets, an autoclave, and ventilators, it didn't have too much more. We even brought disposable things like gloves, gowns, hats, and masks because we didn't want to use up local resources.

Each day, we climbed up four floors through the tiny, narrow, adorable hospital. There were three small operating rooms, and according to other group members who'd been on multiple missions, this place was luxurious. We quickly settled in, hanging shoe-racks on the walls to hold our supplies, testing the monitors and ventilator, hooking up the suction and electrocautery. Each ventilator was different, donated from American hospitals once they were obsolete. When I started residency, we had a few similar models so I wasn't completely lost, though over the last few years, Stanford has phased all these old-school Drager machines out.  I got to work, rummaging through our equipment, jerry-rigging and cobbling things together until I was satisfied. Although there was a small culture shock when I first walked in, when I got down to it, we had everything to deliver a smooth, safe, and stable anesthetic.

Images taken by me on the Operation Rainbow medical mission.

Operation Rainbow

I just returned from a medical mission to Guatemala with an organization called Operation Rainbow. It was an incredibly eye-opening and deeply moving experience. I was initially approached by our chief residents as the group was looking for an anesthesia resident to accompany them. The brigade of 26 volunteers included 4 surgeons, 3 anesthesiologists, 9 surgical staff (including circulators, scrub nurses, and sterile processing technicians), a physician assistant, orthopedic technicians, a physical therapist, a bioengineer, interpreters, and a medical student. We were going down to Guatemala City to work with a local pediatric foundation to provide orthopedic surgery to kids with a variety of deformities, from rickets to scoliosis to club hands to traumatic nonunions. I was thrilled to do it. One of the great things about anesthesiology is that even in residency, there is flexibility in the scheduling. I signed up hardly knowing what I was getting into.

Logo shown under Fair Use, from operationrainbow.org.

If I Had More Time...

Perhaps it is inherent to this time in life or stage in my career or my generation, but I never seem to have enough time. I have so many topics I want to blog about yet I struggle to find time to proofread the posts I publish. There are aspects of anesthesia I want to read more about but each evening, bedtime comes before I can pull up PubMed (it doesn't help that the government shutdown's tentacles have ensnared PubMed either). If I had more time, I'd reimmerse myself in philosophy, visit the library more often, write more poetry. I recently came across articles discussing the German Tank Problem and the Doomsday Argument, fascinating queries involving philosophy of science and mathematics, and it reminded me of a course I took on philosophy of physics. There was a time when I had the luxury of time to ponder on such thought experiments, and it feels a little sad now that my life has pared itself down to simplicity. I reassure myself that such is the reality of residency or perhaps this is the nature of most people at my stage in life. Each night, as I fall asleep, I resolve to make more time, more time to write, dance, read, learn, discuss, play, exercise, and work.

Liver

You can probably tell from the last few posts, and I promise this will be the final one about liver anesthesia, but I had a great time on the rotation. I only had two transplants, but they were rewarding and exhausting. The goals of anesthesia vary from case to case, and being a satisfied anesthesiologist is finding the cases whose goals resonate. In an outpatient surgery center, the goal is to expedite quick wake-ups, discharge, and turn-overs. In neurologic surgery, the goal is to select anesthetics that protect the brain and allow a quick neurologic exam at the end of the case. In liver transplants, the goal is to keep the patient alive. Those anesthesiologists who balk at real risk, who gravitate towards happy and healthy patients need not apply. But for me, the type of person who loves "big" cases, complex medical decision making, facility with procedures and their interpretation, the liver room is the place to be. I had a fabulous time with the challenge, and it gave me my moments of anxiety. But at the end of the rotation, I think I am a better anesthesiologist as a result. Hopefully, when I finally go out to find a job, I can incorporate cases like this because the challenge is thrilling.