by Brian Woodcock, MD
The pulse oximeter reads 1%, and the heart rate is slowing. It’s 9:00 pm; I’m in an ER in an outside hospital in Guatemala City, on my own except for Cathy one of the Survival Flight nurses from the University of Michigan. The rest of the team is back at our hospital finishing the day’s cases. I am trying to intubate an eleven-month-old child who is postop from insertion of a ventriculo-peritoneal shunt, and who has severe respiratory difficulty from stridor due to a sub-glottic stenosis. Nobody speaks English and the baby’s mother is standing right behind me.
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Jackie Ramirez preparing to anesthetize one of the babies |
It is hot, I am sweaty, and I am nervous. We have just transported him from our hospital on the other side of the city because we have no ICU facilities there. The ER doctor thinks this baby needs to be tubed and I agree. We would have tubed him before transport but we had no sedation to give for the journey, and the thought of losing the tube in the back of the van we have for transport made me think he would be better breathing spontaneously. In spite of the stridor, he has been maintaining his saturation with a face mask. The 3.0 tube seemed to go OK, with mist in the tube and bilateral breath sounds, but then the sats fell. The baby looks blue, the pulse oximeter reads 1%, and the heart rate is so slow it sounds like an aeon between each heart beat. I know Dr. Tremper always says the pulse oximeter is inaccurate below 70% but somehow that does not make me feel any better. And I am thinking, ”What on earth am I doing here?”
What I am doing is Project Shunt, a medical mission to operate on children with neurosurgical problems in Guatemala. I look down with the laryngoscope again and find the tube is out, above the cords, it slips back through easily and the saturation and heart rate come back up quickly. The whole episode lasted about thirty seconds but I can tell that my recovery from the experience will take a lot longer, and a few beers may be involved.
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Brian Woodcock and Jackie Ramirez anesthesthetizing a child with marked hydrocephalus |
This is the third year that Project Shunt has taken a mission to Guatemala City to operate on children with neurosurgical problems. The project was initially the brainchild of one of the neurosurgical residents at the University of Michigan, Nick Boulis. The Michigan/Ohio Chapter of Healing the Children approached Nick in 1997 with a request for help dealing with neural tube defects and hydrocephalus in Guatemala. This region has one of the highest rates of neural tube defects in the world, due to poor prenatal nutrition and a scarcity of antenatal screening. There is also a dreadful shortage of neurosurgical capability in the country, there are extremely few neurosurgeons, and any treatment available is prohibitively expensive for the vast majority of these families.
After an exploratory trip by Nick Boulis and Judy Negele to establish how the facilities were in Guatemala City, a team has operated each fall for the past three years. The team was established as a collaboration between the University of Michigan Department of Neuro-surgery and Healing the Children. The Fundacion Pediatrica Guatemalteca, a nonprofit foundation for the care of underprivileged children, has served as a host for the project in Guatemala and has located the children needing help, provided the preop clinic facilities in Guatemala City and continues postop care after we have departed.
Judy Negele from the Department of Anesthesiology at the University of Michigan has been involved from the beginning, when she was still a CA-3 resident. The first anesthetics she administered, after graduating from her residency, were in Guatemala. And she still remembers her first patient well, a two month old with a 61 cm head circumference who’s head had to be supported off the head of the table to make intubation possible.
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Karen Muraszko, our head neurosurgeon and Judy Negele with one of the older children |
Judy has been responsible for gathering together the equipment required for anesthesia provision and ensuring all our supplies are shipped ahead of time or brought with us. She has also recruited the anesthesia team each year. In 1998, she went with a British anaesthetist, David Jones, who traveled from the UK for the mission. David subsequently spent a year at the University of Michigan as a Visiting Instructor in the Department of Anesthesiology. Last year, I joined the team and we also took a senior resident Chris Kreuzer. This year, Judy and I were joined by another senior resident Jackie Ramirez. The mission has been an excellent educational experience for the senior residents who have come with us. They have dealt with cases in circumstances completely outside their experience at the University of Michigan.
The hospital where we have operated for the past three years is an infectious disease/rehabilitation hospital for children. The Pediatric Foundation in Guatemala, which coordinates the Guatemalan end of setting up the Mission, rents the use of the operating rooms and a post operative ward for us. The hospital’s facilities are very basic. The hospital had two operating rooms, one of which was not much bigger than a closet. Looking at their OR log book, the rooms are normally only used for a few minor cases each week. The hospital is located in a very insalubrious area of the city, but the view from the front door includes a large volcano on the horizon.
There has been a change in Government in Guatemala since last year. Someone close to power has an interest in the Pediatric Infection and Rehabilitation Hospital. The head of the hospital has been replaced and the set up has been improved. The staff has been much more cooperative and helpful. The hospital is cleaner and smells fresher.
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Induction of anesthesia |
Many of the supplies we use are donated from charitable organizations in Detroit and Toledo that specialize in equipment for medical missions. They collect discarded and unwanted equipment from doctors and hospitals. Some supplies have been opened but not used, some are expired, and some are just unwanted. They collect some unusual equipment. Half the IV sets were made for use with an IV pump but work fine by gravity with the pump cassette hanging free. We learn quickly how spoiled we are at home.
Our flights and accommodations are paid for by Project Shunt. We also have to purchase a lot of the equipment and supplies that cannot be begged borrowed or stolen from other sources. Much of the effort in the year before each trip is spent in eliciting donations from various sources.
The operating room facilities were very basic and the wild life was plentiful. The team was liable to break out singing “La Cucaracha” whenever a cockroach was seen. One of the nurses, Jessie, felt a tickling sensation at the top of her leg, the tickle moved toward her butt. She danced around a lot. A large cockroach fell out of her pants and was promptly dispatched under foot. The most impressive thing was she dealt with the whole situation without breaking scrub! I would have run screaming from the building, with my pants around my ankles, if it had happened to me. Jessie spent the rest of the trip with the bottoms of here scrub pants taped up to prevent a repeat episode.
On the first day, we set up the ORs for anesthesia and surgery. All of our equipment, except for the anesthetic machines was brought from the US including our disposables, circuits, tubes, and IV setups. We had to rig up blue scavenging tubing to get the anesthetic gases out of the operating rooms, which had no AC, ventilation or windows. We Y-connected the machines in both rooms to tubing which we taped to the walls, through the ORs, through the scrub room, the recovery hallway and let it vent into the main hospital hallway.
We had an old Ohio Heidbrink kinet.o.meter anesthetic machine in one room and a Modulus in the second. Neither had a ventilator. Both had a pipeline attachment to an H oxygen cylinder with an E cylinder back up on the machine. There was no air or nitrous oxide available, therefore all cases, including the tiniest neonates, were done on 100% oxygen. Because of the absence of pipeline oxygen, we had to be constantly aware of the risk of running out of oxygen. Those unfamiliar to this risk had to be educated to the sound of the bosun’s whistle, which warns you that the O2 supply has died, and you need to do something NOW.
Nearly all the anesthetics were inhalational inductions with halothane, intubation deep. Maintenance consisted of spontaneous respiration with halothane, or isoflurane while the one bottle lasted. This technique sounds horrific and would not go down well with the examiners in the oral boards but it worked. The advice from old hands who have done missions before was to “keep it simple”. To use a single agent inhalational, spontaneous breathing technique in patients with hydrocephalus and raised intracranial pressure goes against everything I had been taught about neurosurgery. You would expect the respiratory depressant effect of the volatile agent to lead to raised carbon dioxide levels and increasing intracranial pressure. However, even the smallest babies soon established a regular breathing pattern and breathed themselves down to a normal CO2. We ran into very few problems with technique. Normally, you would not expect a neonate to breath spontaneously for 4 to 6 hours through a 3.0 or 3.5 endotracheal tube, particularly as they were often in the prone position. Some of the smaller kids having meningomyelocele repairs were liable to episodes of apnoea and they would be assisted by hand until they started again. We had 30 mg of morphine supplied by the Pediatric Foundation in Guatemala that we divided between the kids, but we noticed that more than a minimal dose in the smaller meningomyelocele repairs led to a prolonged recovery. We were not happy about sending children back to the ward from recovery until they were fully recovered. We had a spare pulse oximeter, which we could send to the floor but we were not convinced the nurses would know what to do if the saturation fell. It was kind of scary to be telling the parents, in Spanish, what to do if the pulse oximeter fell below 90%, and hoping for the best when we were not there. It was also difficult to obtain an extra oxygen cylinder for the ward. We had two syringes of thiopental which were split amongst a few of the older children who did not mind having an IV sited, with some assistance from EMLA cream to make it painless.
Monitoring was obtained with two ProPaq monitors, very kindly loaned by the manufacturer, and another ProPaq that we purchased. We had the capability for ECG, oximetry, NIBP and ETCO2. We could not monitor volatile levels but this was not a problem when right dose is enough. We simply titrated up and down according to the response of the patient. It takes you back to the days before pulse oximetry, end tidal carbon dioxide, and volatile monitoring when you have to use clinical skills to judge the depth of an anesthetic. Ah yes, the good old days when we used to treat the patient not the numbers...now don’t get me started!
Temperature control was not much of a problem because the room temperature approached 100°F as the day went on. Saran wrap was used but often had to be removed when the babies’ temperature rose too high. The absolute absence of any ventilation in the OR suite meant heat build up during the day. After boiling last year we brought fans to cool us, and placed them all around the ORs. It was still distressingly hot. The ORs are at their coolest first thing in the morning and are comfortable with the fans. The fans have to stay off during induction and awakening to avoid cooling the children. As the day goes on, the heat from the lights and equipment builds up. By 5:00 pm it is very hot, everyone is sweaty and tired. By 7:00 pm we are boiling, and by 9:00 pm we are dying and fit to be shot.
Our recovery area was the corridor immediately outside the OR. There was very little space; we had room for two trolleys big enough for any size of child and a baby bed with an overhead heater, which did not work. We had to supply oxygen from cylinders and were often reduced to Y-connecting two masks or nasal cannulae to one cylinder guessing how much oxygen was going down each limb. In spite of the hot temperatures we were working under, it was still easy for the smallest neonates to cool down in recovery. We found this was a main contributor to apneic spells and a giant old Bair Hugger that we brought from the US was put to good use. We had some ProPaq transport monitors, with ECG, BP and saturation capability, in recovery.
The preoperative clinic on our first working day was held at the clinic run by the Fundacion Pediatrica Guatemalteca. There were more than forty children, with their families, waiting to be seen. The Foundation had made sure it was known when we were arriving and had brought the children in to be seen. It was surprising to see how many of the meningomyeloceles patients were less than a week old. Those children were lucky to be born before we were coming. If you are born in the other 51 weeks of the year, you were out of luck.
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Hopeful parents who have brought their children for evaluation at our |
Judy usually evaluates all the patients with Matt Boulis, our pediatrician. Every year there are kids we have to turn down for various reasons, which can be difficult for all involved. The parents come with so much hope to see the “American doctors” and sometimes it is impossible to do the case. The first year one infant had a very large encephalocele that would allow no neck extension and intubation would have been impossible without a fiber-optic bronchoscope.
This year an 11 old girl came to be evaluated with a large posterior fossa brain tumor. She had been lost to follow up for nine months, she now had significant deficits and the tumor was too far progressed to allow us to operate with our surgical and anaesthetic limitations. Judy says after she finished examining and talking to her, her father picked her up and she looked into Judy’s eyes and said “me gusto mucho” (I like you a lot). Judy couldn’t hold back her tears, as she knew we could not do the surgery. Nine months earlier she would have been easily operable, now it was too late, even if she could have been brought to the States. This makes us realize how lucky we and our children are to be born in the US or Europe.
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One of the smaller babies, Roxanna, in recovery |
The children were gorgeous, cute as anything and mostly good during induction. A few simple phrases in Spanish were useful to reassure them and to tell them to take deep breaths or open their eyes. Unfortunately “ojos” and “ochos” are easily confused in Spanish and Matt Boulis, our pediatrician who worked recovery, was renowned for repeatedly telling the kids to “open your eights” instead of “open your eyes”. Intubation could be challenging in babies with hydrocephalus with an extreme head size. We sometimes had to support the head off the end of the table so the neck could be extended enough for intubation.
One 11 year old had an open lipomyelomeningocele untreated since birth. She had good leg function and was walking well (lucky not to have died from meningitis through all those years with an open spinal lesion). Interestingly, one of the cases last year turned out to be a Jehovah’s Witness. In the US this might have generated concerns about blood transfusion and whether the child should be made a ward of court to allow life saving transfusion if it should become necessary. In our situation it made no difference, we had no blood bank and no ability to get blood for transfusion, we relied on the good hemostasias of the surgeons and the ability of the children to tolerate a drop in hematocrit. Oh yes, and luck.
One of our patients last year was a 20-day-old baby with a cleft lip and palate, who also had hydro-cephalus. We shunted him but had to leave the cleft lip and palate untreated. If he is lucky, he will be seen by one of the Operation Smile missions which also visit Guatemala City under the auspices of the Guatemalan Pediatric Foundation.
The smallest baby we looked after in the past two years was a 4-day-old 1.8 kg with a meningomyelocele. He actually did very well and caused us no problems. As always, doing neonates for the first time in a while is scary, however, you soon get back in the saddle and even enjoy it. A 24 g IVs in thread like veins soon becomes the norm. There were however, a few patients who tested us severely on the IV front. Oh boy, did we sweat over some of those chubby babies with no veins? These were ‘must get’ IVs. We even had to resort to scalp veins after the ward nurses had blown all our options, because there was no possibility of putting in a central line.
One of the most distressing points this year was when we had to cancel a five month old child, Helen, who when we had first seen her on Sunday at the clinic had a right sided bronchitis. We gave her antibiotics and brought her back on Wednesday for her myelomeningocele repair and ventriculo-peritoneal shunt, unfortunately her bronchitis was worse. She was admitted and placed on IV antibiotics, but was no better on Thursday, and in no condition to withstand a possible five or six hour operation, breathing spontaneously, especially as we had no OR ventilator. We were also in a situation where if we ran into postoperative pneumonia or respiratory failure we simply had no facilities for management of those problems. There was no ICU, no pulse oximetry on the ward, no ability to give oxygen. It was our last day operating, so she would have to wait until the next neurosurgical group from the US came. We were told there was a good chance that a shunt could be placed by a local neurosurgeon in the meantime. Still, telling her mother that she could not be done was upsetting for all of us.
The pre and postop ward last year had a sign saying “Unidad de Cuidados Intensivos” (Intensive Care Unit) outside but had no sign of any ICU facilities such as monitors, ventilators or any equipment at all. An adjoining room had two old and grubby iron lungs against one wall, presumably from the old days of polio. These were clearly old, decrepit and unused for decades but were interesting to see. The ward was tiny and the beds were packed in tightly. This year we had a much cleaner and more spacious ward, and there were even cribs for the smaller kids.
The Guatemalan Pediatric Foundation is currently in the process of building a new, dedicated, facility of its own for surgery in Guatemala City. We were able to tour the site in its half-finished state. They have bought a very large house, stripped it out, and are in the process of fitting it with some excellent amenities. The building is bright and spacious. There is a small ER with beds for dealing with minor illnesses, e.g. rehydrating children with diarrhea. This would function work as our preoperative clinic. They have a second hand X-ray machine being installed that was donated by a hospital in the States.
There will be two or three ORs with 1st generation Narcomed machines, which will be a great improvement. There is a proper recovery area and 20 post op beds, but the amazing thing is every bed space has piped oxygen. What a luxury! No more Y-connections on H cylinders! There is even a four bed ICU with pediatric and adult ventilators. Kind of scary, at least before we had a reason for not doing massive cases requiring postop ventilation. But it will be great to know that the facilities are available and we shouldn’t need to transfer any critically ill kids out.
Each year we have one or two days to do a little sight seeing. Antigua the old colonial capital of Guatemala lies less than an hour’s drive away, up in the mountains. With out the heavy industry and pollution of Guatemala City and narrow streets lined with old colonial buildings this seems like another world. There is a large, elegant plaza with central fountains featuring four maidens with water pouring from their breasts. The plaza is full of people promenading in the evening before dinner, a prime spot for people watching. It is also a great place to buy hand made souvenirs from wandering vendors. The only problem is that to show any interest always results being surrounded by a flock of vendors.
Three volcanoes that can be seen at different points of the compass, their perfect conical forms towering over the city overshadow Antigua. The buildings in the streets mostly encroach directly onto the sidewalk, but once you enter past the room facing the street there is often a courtyard with a hidden garden in the center of the building.
Just like Ann Arbor there seems to be an increasing number of coffee shops and the number of Internet cafés is surprising. We stopped for coffee in one of the houses with a garden courtyard. The legend attached to the house was that the master of the household came home and found his wife and butler in a compromising position. Being a reasonable man he punished the butler by walling him up alive inside the house. This was just a story until 1976 when during renovations a cupboard inside a wall was discovered with a skeleton standing upright in it.
Next year we will be returning to Guatemala City, hopefully in the new facility. We are already thinking ahead. Serious preparation will start in the New Year. If you are interested in assisting with Project Shunt, with time, effort or especially money, then you can contact me (bwudcock@umich.edu), Judy Negele (jnegele@umich.edu), Nick Boulis (nboulis@umich.edu) or Andy Youkilis (youkilis@umich.edu). More pictures from the last two years trips can be seen at: