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Alan M. Reznik, M.D., M.B.A.
This year I was asked to join a medical mission to Tarija, Bolivia. It was an orthopedic team sponsored by Esperança, a medical mission charity that organizes trips to Spanish speaking countries in the Third World. In February of 2014, I met the team at Miami International Airport for the red eye flight to La Paz the capital of Bolivia on our way down to the much smaller city of Tarija. The population is about 100,000 and the city was clean although poor by any standards. When we arrived Father Michael, a local priest met us. He is an American that moved there almost 30 years ago. He wears many hats and he was also connected with a special school for the deaf. He had a small dorm at his church for deaf girls. Many of these girls, age seven and up, did not know there were other deaf children before they got there. They had little or no language skills because they were not taught sign language. The story by itself was very moving and the girls could not be sweeter.
As it turns out, the deaf girl’s schooling and care was tied directly to our mission. One of the teachers and caregivers for the deaf girls had severe rheumatoid arthritis. Dr. Sachs, my former mentor from my fellowship in San Diego and the mission leader for this trip, replaced her knees two years ago on another mission trip. It was the first time bilateral knees were done in Bolivia. She is less than five feet tall so the knees were tiny. At first, only one knee was planned. When it became clear that doing only one knee would not allow her to walk, the second was contemplated pending how the first one went. The timing was tight and in order to get the second knee done in time, the second knee prosthesis was flown in from La Paz and arrived during the procedure for the first knee.
The story was moving on many levels. First, the Father (Padre) had to give her a wheelchair a few years earlier because her legs were so contracted she could not walk. This stopped her from working. After her knees were replaced, she was able to walk and she started to care for the deaf girls again. In Judaism there is an expression, “When you save a life you save the world.” It means that when you do something to change someone’s life you never know how many other lives you have changed as a result. Here, the one act of replacing her knees and allowing her to walk again has changed many deaf girls’ lives already and it will change many more in the future.
After passing through a rather unfriendly customs (America is not favored by the Bolivian government at this time), a layover in Santa Cruz, and completing all the flights, Monday was a planned clinic day. The Esparanca team had a large number of patients waiting in the hall when we arrived. We shared two translators; the Padre was one of them. I had to use some of my limited high school Spanish to get by.
Some patients did not need surgery and some surgeries that were needed we just did not have the equipment to do. If we decided to do an injection, the patient had to leave the hospital and go to the pharmacy to buy the cortisone and then come back with it for the injection. By the end of the Monday clinic, we had seen over 50 patients and set up 20 surgeries. Even with the wait and the trips to the pharmacy, the patients were extremely grateful to be seen.
Tuesday was the big day in the operating room. As in Haiti, the OR is a mixture of old, very old and a trace of new equipment. Sterility is at a much lower standard than at home and many things are reused that we would throw away. They process the equipment with Cydex for a faster turnaround. (Cydex is an extremely effective disinfectant but considered toxic in prolonged exposure for the staff using it here in the states so it is no longer used in our operating rooms.) They wash and reuse the plastic tubing (something we never do here) and as expected, there is no pump or special drapes. They use non-waterproof drapes for everything. As anticipated from experience on other similar trips, the first two cases took a huge amount of energy to get going.
As in many ORs, (even at home), there is always one nurse that knows everything about everything and without her nothing happens. Lytia, “Lity” is the “nurse” from Esparansca, the organization that runs these missions as well as many others. She does not work for the hospital; she is completely self-trained in the OR (not a real nurse) yet, she knows the hospital the best, so she is a true gift to everyone here. All of the anesthesia given by our group in the hospital in Tarija was a combination of local blocks, sedation and spinals. The oxygen flow and anesthesia machines were not trustworthy enough to venture a true general anesthesia. In the OR, every once in awhile the oxygen would go off, an alarm would sound, you would hear some yelling in Spanish in the back room and it would go back on a few minutes later. This is something that happened just often enough to give us pause when we considered a true general anesthetic for a patient.
After the two bigger open cases – a tibial plateau fracture and femoral osteotomy for a knee deformity valgus from polio (that she contracted because she was not vaccinated about 30 years ago) we set up to do our first knee scope. There were lots of interesting issues. I spent a lot of time organizing the equipment (much of it was from different companies so the scope and the sheaths did not match). We prepped and draped the leg only to find the nurse had reorganized everything so the scopes, trochars and sheaths were separating in to neat rows of each and unmatched again. The scope’s camera had to be covered in a cloth (since they are not sterilized the way we do it here). The monitor (an old cathode ray tube color TV) was not hooked up to the camera. Once we got going, it turned out that 3 of the 4 scopes were not usable. The lenses were so scratched you could not see at all. Some of the equipment had some other quirks we needed to work through. For example, on the only working scope, one of the two ports for fluid was stuck open. It turns out it was stuck in the open position, but internally it was closed so no fluid flowed through it. It took a long time to figure out what was preventing the fluid from flowing before we switched ports. Needless to say, after nearly four times longer than normal to do the case in the states, it went well and the patient was happy. The good news was we worked out the kinks and things improved greatly after that first run.
With a number of the kinks out in the open, Wednesday was planned to be a longer day. Now that we all knew the OR better and they knew us, things went much more smoothly. Still in many ways, the cases were more ambitious and we had a much bigger schedule. Because the cautery was not always working, we had to use a tourniquet for almost all the leg cases. One twelve year old had a contracted leg after a fracture and we had to do an Achilles lengthening to get his foot back to neutral. Before the surgery, his tendon was so tight he could not walk. I did my first of three open ACL’s using my own original ACL set I brought with me from nearly 25 years ago. It was a very different, old school way of doing it but surprisingly doable in this setting. I have to admit it gave me a renewed insight into the way we do it now. One baby had a congenital focal loss of the limb with no ankle, no forefoot, no heel and only one, large useless toe with a small one attached to the side. The mother wanted the useless toes removed so a prosthesis could be fitted to her leg and allow her to walk. We had set it up, but the father refused. So, the baby did not come in for surgery. That was the one disappointment of the trip.
As an aside, the food has been good and plentiful. We did have to avoid the water, any fresh salad, ice and anything washed with just tap water. Street vendor food was out of the question, no matter how good it looked. The water system was not great and although our hosts could tolerate it well, we were far more likely to get sick. Being careful and following some of the Padre’s advice (sometimes a little too late), we did go out each night and were treated to a nice meal. The team meals were a really nice way to get to know everyone and our hosts.
We were at an altitude of 6000 feet, so being thirsty was the norm. I was drinking bottled water whenever I could, and still felt very dry. So it was fortuitous that this was Bolivia’s wine country and the local wines were very tasty. I already had more than my norm for a month by Tuesday (for those who don’t know how little I drink in a month, I had much less than two glasses over three days). After Tuesday, another half glass was in the cards with dinner. One night, we were introduced to red wine and Fanta. Strange looking in the red wine, it floats on top of the orange Fanta making it look like an upside down Tequila Sunrise. Citrus, sweetness and bubbles, surprisingly not bad at all…
One funny thing to share…Louis is our driver who takes the seven of us to the hospital each day. He seems to favor Ray and me. He drives one of the truck-like SUV’s with pop-up-sideways seats in the way back. He says, “No doctor, you go here .” He was very specific about it. Dr. Sachs said, “It’s no use arguing with him, he gets insulted if we do otherwise.” It was just the way Louis wanted it, and that was that. So, we just sat where he said we should and smiled.
The people have a tougher life, so they tend to be less prone to infections in the OR then we are. They survived a lot of stuff as kids-better genes or just more exposure in general? They also have some weird diseases that we never see here in the U.S., like Chagas. It is a parasite that lodges in the heart and intestines. (Chagas Disease is named after the Brazilian physician, Carlos Chagas, who discovered the disease in 1909.) It is caused by the parasite, Trypanosoma cruzi, which is transmitted to animals and people by insect vectors and is found only in the Americas, mainly in rural areas of Latin America where poverty is widespread. I operated on one lady who had it. You would never know it. Interestingly, the disease can attack the heart in a way that if you treat it too late, the heart wall can fail just by killing the parasites that have made the heart’s wall their home. So many people, by necessity, go untreated.
By Wednesday night, I had a new nickname, Dr. Bisturi – the reason is that I had tried all week to learn the Spanish names for a lot of the surgical instruments. The one I most frequently messed up each day was when I said, “Bisuri” instead of “Bisturi” – so they finally wrote on the white board in the operating room, “Surgeon: Dr.Bisturi.” So, I became known as Dr. “Knife.” (Dr. Scalpel)
Still all the surgeries, after a few fits and starts, went very well. We are limited in what we could do, yet I was able to do a number of basic arthroscopic surgeries, as a “left knee specialist.” This and Dr. Bisturi became a big “chiste” pronounced chees-te (“joke” in Spanish) in the OR. The way the OR was set up and the limited plugs it had, made it much harder to do a left than a right knee. Not to mention, that you have to use your left hand more since you stand on the left side of the table as you face a bent knee. Of course, as it turned out, just by chance all the ACL’s were left and all but one of the knee scopes I did were also left. Gladly, the last case planned for Friday was a 14 year old with a dislocating patella and it was a right knee. Dr. Craig Stevenson seemed to get only the right knees to do. That made each of us, left and right specialists and equally invaluable as members of the team. The shoulders I did were mostly right. Of course at home most of the shoulders and knees I did my first week back were the right side. Go figure…
By Friday, we had done twenty surgeries in 4 days and saw more than 2 ½ times that number in the clinic the first day. During the week, one of us saw patients every day as we rotated responsibilities. The Padre became a patient too, by requesting that I inject his “bum knee” from an old sports injury before we left. After hearing about our team, even a former, well-known political leader of Bolivia made arrangements to see Dr. Sachs as well. Travel home was uneventful. A great trip, all and all.
Shirvinda Wijesekera, M.D.
Medical Mission to the Dominican Republic
Shirvinda A. Wijesekera, MD completed medical missions in the Dominican Republic in 2018 and in early 2019 where he was part of a medical team operating on spine deformities and other spine disorders.
Dr. Wijesekera- OR
Alan M. Reznik, M.D., M.B.A.
Hello from Haiti Sunday 12-18-11:
Arrived yesterday at the hospital at 5:30 p.m. after a very long day of traveling. Unpacked the medical supplies we brought, met the son of Dr. Mellon (the Mellons opened the hospital after being inspired by Albert Schweitzer). His stepfather William Larmier Mellon gave up banking and started medical school at age 41, in 1941, to devote the rest of his life to the poorest of the poor in Haiti in a town called Deschapelles.
One of my teachers at Yale had already visited here in 1970 as I found others did before. Dr. Steve Stein has been back many times since. Last time, he had no orthopedic help and with the increase in motorbikes, there are a lot of fractures; the main reason I am here.
Today, we climbed a small mountain at 5:15am to see the sunrise. At the top, there is a tree that has importance to the locals. The people carry a rock to the top and leave it to heal the sick or resolve their troubles. From there, you can see the mountains on one side and the river valley to the other. From the heights, we can see the water tower at the hospital far below. It was a site to see.
Once back from the climb, we had breakfast of spicy eggs and toast then off to the hospital for the tour. This is our orientation day and we are not on call. There are a number of areas in the hospital: maternity, medicine, pediatrics, surgery, orthopedics, therapy, lab, and operating rooms. The areas are small and very crowded by any standards. The cholera tents had been taken down already and those patients are not kept here now. There still is cholera but they move them out quickly. It is hard to believe that Haiti had no cholera until the recent outbreak. Cholera was brought to Haiti by an infected UN worker. They never had a case before. Now they will never be completely rid of it.
Once on the ward, there were quite a few fractures and we will be caring for them starting tomorrow. A lot to absorb! And, I don't speak Creole.
All is well, meeting very interesting people from all over with great life stories. Tomorrow promises to be a challenging day.
Alan M. Reznik, M.D., M.B.A.
Friday, December 23, 2011, late p.m.:
Last night the hospital had a staff Xmas party. There were around 70 people including the majority of the doctors and the seven visiting MDs. There was great Haitian music, a small dance performance from the staff (three couples), one person sang a song about Jesus that was dotted with some methodically-placed pauses that accented the song in a way that I cannot explain and the crowd loved, another did a stand-up comedy routine, there was a little dance music and we exchanged gifts with the staff by drawing numbers. I received a wall clock. The "alumni house" we are staying at needed a new one so the staff was very happy when we hung it up for them. There was fun all around and this time it was all in French. I smiled and nodded a lot. There was a "Pinch me, am I dreaming?" moment when I was standing outside the back of the small house, "ky sis," house six, on the hospital campus. Standing there with my rum and Coke (by the way the rum is supposed to be the best in the world in Haiti according to the NY Times), looking up at very bright and clean view of Orion in the night sky. It was so crisp and defined since the hospital and the very small compound has its own power generators making it the only light around for many many miles. The Haitian music played, there was dancing in the open room off the back patio and I thought, "Just how did I get here?" It was a dream-like scene, and I was overcome by a warm feeling inside. The stars here are so very bright, I wished it was the same night sky everywhere.
Today, there were three orthopedic cases, three hysterectomies, and a complex bowel colostomy closure in only two operating rooms. We ran out of time and I had to cancel two other cases. Then a nineteen month old came into clinic, the last patient of the day, with a displaced supracondylar elbow fracture. We did it as an emergency case. The baby did fine. The story is funny for other reasons. I will save that for when I return.
We are on call for the full weekend, and I have 4 other cases to do, but there is no time.
We will have to see what happens.
Best to all for a happy holiday!!
Alan M. Reznik, M.D., M.B.A.
Last e-mail from Haiti:
On the weekend, we had a few traumas, another open tibia fracture and at least one fetal death. By the 26th of December there was a clinic to cover as well as a number of cases left over from the weekend of call. There was an acetabulum fracture (the socket of the hip was broken) and a newly discovered pelvic fracture. It was newly discovered in that the patient had been in the ER/holding area (so called ‘SOB’) for at least three days with a facial injury and an ulna fracture but was unable to walk. He needed a pelvic film and it just had not been done until late Sunday. With a good amount of work to do, we were all pumped up to make the most of the day. The reality is we had already taxed the system and OR staff to its limits. Without running the autoclave on the weekend, there were no more drapes or gowns left. The drills were not sterile and there was no plan to process the materials we would need until the schedule was reviewed in the morning. With the untreated open book pelvic fracture, there were four orthopedic cases to do, there were a number OB/GYN cases to do as well. There was a man with a soccer ball sized mass (our guess was about 8 pounds in weight) on his back. He had been in the hospital since the first Monday of our visit. He had been losing blood every day and needed the mass removed. His blood count was dropping all week and he was waiting for family to give blood and to be cleared for surgery. He was on our list to be done, but we had all but written off his case by now as undoable given the circumstances.
After rounds we went to the OR and found one of the rooms was taken by ophthalmology cases. Losing a room to another service at the hospital was a real surprise. It was something we had not even considered. We had become so absorbed in the work that we assumed we had all the operating time to ourselves. Nonetheless, we agreed to start with some of the orthopedic cases in the other room. After the first two, we convinced the staff to let Dr. Stein and Dr. Blount take on the back mass. They then successfully removed the mass. On mid day rounds there was one nice high point. The patient with the pelvic fracture, after being unable to get up for at least three days, asked if he could get up with the fixator on. Once given the okay, his family got him up. He sat on the edge of the bed only 2 hours post op and said he has no pain. It has not ceased to amaze me how little pain meds these patients need and how quickly they get up by themselves or with the help of their family. Early in the week I was greeted in the hall at 7:00am by one of the hip fracture patients, only 18 hours after surgery. He was a spry, smiling, tall elderly gentleman wearing only an open long sleeve shirt and BVDs, sporting a hip dressing walking up the long hospital hallway using a walker by himself. The other hip fracture patient of the week was moving his leg freely within hours of the repair and up with two family members also within 24 hours of his surgery all without narcotic pain meds.
At the end of the day we completed one of the biggest cases of the week and several others. That night was our last time on the wards. We said goodbye to the patients, wrote down instructions for post op care in the charts and I gave out my last pieces of gum to the pediatric patients. Still to be completed, there was one last patient to see. After fixing his femur with a sign nail and the prior application of the external fixator for the ankle fracture, his hand had not been repaired. He was last on the list and we just ran out of time. He could not speak English but his face said it all.
Dr Blout, one of our team members at the Pediatric Surgery Ward and our patients.
A quote from Albert Schweitzer in the Courtyard.
Me in from of our home away from home: The Alumni House
The first sunrise of the trip, at the top of a mountain overlooking the hospital.
The guest pick up car with a picture of the prosthetic center; amputees on the left and new legs on the right.
Dislocated Knee in the x-ray above reduced with an External fixator.
Shirvinda Wijesekera, M.D.
Volunteering in Vietnam: Offering More with Less
When I received an invitation to join a medical mission trip to Vietnam I felt honored and privileged. I arrived in Vietnam not sure of what I would find. I did know that the goal was to provide spine treatment to the needy in Vietnam who were struggling with spinal deformities like scoliosis and other spine disorders. These patients had very few choices and options. At home in the States, we would never have allowed these deformities to progress to the magnitude they had.
The weather was warm and balmy, a far cry from the cold of Connecticut in December. The hospital too was out of a story, lacking privacy and modern equipment. Patients and their families slept in hammocks, cots, and makeshift stretchers. However, like home, the patients were warm and friendly. I have found volunteering to be a deeply rewarding experience. While we brought with us our expertise and what equipment we could carry, working with less would be the rule.
Most of the cases that I treated were children with terrible spinal deformities. We don’t often come across such profound deformities here in the States, as we thankfully have a system that can provide care to patients before it gets to these levels of severity. The work was challenging, but gratifying. It began with adjusting to deal with austerity of the operating room. Lighting was basic, and surgical tools were scarce. Fortunately we were able to bring with us some tools, and implants to make things safer and more effective. The operating room table was one out of history book, but it served its purpose and I was able to offer relief to those who had suffered the effects of spinal deformity, trauma, and tumors.
One of the most gratifying aspects was to treat the children with severe scoliosis. Many had their lives changed from physical limitation and social isolation. Without us, they would have been ostracized from their community and would have languished on the sidelines of life. We were able to correct the deformities, and the children found a new beginning with their “straightened” spine. They recovered from surgery, while their mothers slept in a hammock beside them. Even pain medication proved to be a limited tool, but the patients and their families were supportive and a testament to their spirit. After the surgical correction, the patients and their families were profoundly grateful and eager to return to their villages and communities with new hopes and dreams of contributing to their worlds.
I believe that volunteering overseas has been one of the most valuable aspects of my career. While the work is challenging, and the time away from home and practice is not easy, the rewards for these patients and myself are spectacular.