by Joseph Webster Jr., MD
I recently had the pleasure of joining a group, Healing the Children Michigan-Ohio, on their trip to Villavicencio, Colombia. This group was founded by oral and maxillofacial surgeons who seek out destinations in South America to perform reparative cleft, lip/cleft palate surgeries for the indigent population. Obviously, this type of repair requires multiple visits: 1) repair of cleft palate; 2) repair of nasal/alveolar/fistula; and 3) lip revision. Therefore, once a site has been chosen, it should be revisited at least once more for subsequent surgeries and follow-up. These trips are also educational for the local oral surgeons who at times assist and/or observe procedures to learn techniques. I was joining the group for their third visit, on April 19-27, 1997.
These sites have hospitals, doctors, residents, etc., and are well developed, although they lack certain luxuries which have become commonplace for American hospitals. For example, they have X-rays, CT scanners, pagers, etc., but lack modern monitoring like ETCO2 and FiO2, and efficient and dependable suctioning.
I had been to rural Guatemala in January of 1994 and January of 1995, for a month each a time. The first trip consisted of building a health care center, and on the second we built a recreational center. Both trips involved medical clinics (general care/pediatrics). When I say rural, I do mean R-U-R-A-L. We rode in buses, and on top of buses, through meandering dirt roads in the mountains to a site without electricity or running water. One learned how to enjoy Tang, peanut butter & jelly, potatoes and rice, warm cerveza, and weight loss. I knew that this trip to Colombia would be better since they had running water and electricity. Yet, I was still wary of the unknown, and political unrest. Also, the previous two trips were spent with individuals from my fraternity whom I knew and trusted well. This time, I knew only an RN from TBICU, and my Espanol was between none and poco.
With 439,733-square-miles, Colombia is the fourth largest country in Latin America and is about the size of California and Texas combined. It is located at the juncture between Central and South America. There are no distinct seasons in Colombia, but differing elevations offer a wide variety of temperatures. With such diversity in temperature, altitude, and rainfall, Colombia produces an incredible variety and abundance of vegetation and animal life. When Middle Eastern coffee seeds were brought to Colombia by Spanish missionaries, they found a perfect climate. Coffee has flourished ever since, becoming the country’s most important export crop (although drugs and Cuban cigars may someday surpass coffee). Drug-related violence has subsided considerably since the death of noted drug baron Pablo Escobar; however, there still exists senseless violence, roadblocks with searches, and events of which the government denies knowledge.
Colombia’s population of 34.9 million is growing, with Bogota being its largest city. Villavicencio has a population of 253,780, and 87% live in the city. The city has 11 hospitals/clinics, with 16 outlying sites for urgent care. It also has an airport and, although it is three hours into the mountains away from Bogota, has many of the luxuries of large cities (a sports complex, discotheques, restaurants, nice hotels, etc.). Violence is rare in Villavicencio and 'tranquil' is commonly used to describe this city.
Before I begin with the trip, let me quote the itinerary,“...Dr. Webster will depart from Detroit on Continental #1158 at 12:15 p.m., and connect in Newark on Continental #739, departing at 2:55 p.m., and will arrive in Bogota at 7:45 p.m. He will be met, stay overnight, and go on to Villavicencio on Sunday.” Of course, things didn’t happen this way. I arrived in Bogota and was not met. It was late and dark and most English speaking people were not around. I waited two hours for my contact, in which time I decided to change my $120 to pesos and ward off offers for a taxi. I called the hotel in Villavicencio but was informed that the group was still working at the hospital. Once it was obvious that my contact was not going to show, I had four options: 1) stay in the airport and go home on the next flight; 2) stay in Bogota overnight and try to reach my group in the morning; 3) rent a car and drive to Villavicencio; and 4) take a three-hour cab ride to Villavicencio.
Well, they would not let me stay in the airport so my first choice was negated. The only secure hotel I knew of in Bogota was Hotel Cosmos 100, at $200 per night. I was not particularly happy about this option. I guess I could have charged it. However, even in South America and unable to communicate well with the natives, I am still the cheapest person I know. A taxi driver who knew some English discussed my options with me and offered a cab ride to Villavicencio for $160. After bartering with the man and actually emptying my wallet and pockets to him, we lowered the price to $119.20 (all of my money). I walked around one last time (now 11:30 p.m.) looking for my contact, then loaded my luggage into the trunk of his cab. A friend of his rode with him in the front and his 4-year-old son rode in the back beside me. For the first hour, I thought I would be taken to some abandoned area and left without my luggage. After an hour of driving, I knew that things would be okay for four reasons: 1) we passed two road blocks without difficulty or harm; 2) I saw signs to Villavicencio suggesting we actually were going in the right direction; 3) the driver knew how to drive safely in Bogota and into the mountains (Thank God I did not rent a car because I surely would be dead right now); and finally, 4) the driver’s son fell asleep against my arm. I, therefore, joined him at that point and closed my eyes. Hours later I found myself at Hotel del Llano in Villavicencio, Colombia. Organizers from the group were waiting for word of my welfare from Bogota. I was quite upset but chose not to verbalize these feelings. I instead focused on the children whom I would meet the next morning.
On Sunday we started at 6:30 am; I had not been to the hospital yet, nor had I met any of the other members. The clinical team consisted of three oromaxillofacial surgeons, a plastic surgeon, a gastroenterologist, a staff anesthesiologist, three CRNAs, six RN’s, three volunteers, an oral and maxillofacial resident, and myself. The hospital loaned us four anesthesia machines. Three of the machines required manual ventilation and the fourth was the dreaded beast of all beasts, the true dark face of evil itself: the Siemens 900C ventilator. I soon discovered that the Siemens would be mine to use because the CRNAs did not want to deal with it and, as a resident, I needed the experience. Thanks.
That Sunday and Monday we worked long hours each day, starting at 6:30 a.m. and going till 9:00 and 10:00 p.m. Most cases were mask inductions with an occasional IV or IM induction for the courageous or the crying, respectively. Dr. Peterman, an anesthesiologist from Sinai and head of the cardiothoracic division, served as our staff and assisted with inductions, emergences, breaks, and lunches. I started slowly, mainly because of unfamiliarity with my surroundings and the machine. Things soon improved and the cases went well with short turnovers.
All extubations were done with the patient awake; to facilitate this, the surgeons soon learned the importance of timing. If I was told 15 minutes, then at 17 minutes somebody was moving. According to Dr. Webster’s unpublished pocket manual: bucking means movement of an operative field while surgery is still in progress; timing is the emergence of a patient after the designated finishing time. Timing is key.
The last case of the day in the plastics room was done by a CRNA, who actually anesthesized all the plastics cases, as the plastic surgeon was her husband. The patient was a burn victim from years past and his medical records from previous surgeries were not available. He also had a history of WPW and was medically treated. He was given succinylcholine for intubation. Two hours later he was extubated only to be reintubated. These events occurred again for a total of three intubations all because the patient was felt to be floppy (his twitches were present but his tetanus was not sustained). He remained weak for six- to seven-hours postoperatively before he could finally be extubated safely. We suspected his Dibucaine number was low.
Tuesday was a vacation day. We visited the center of Colombia where the monument Obelisco alto de Menequa stands. We also spent the day at a club with a swimming pool. It rained that day.
Wednesday was a great day. The Siemens died. We discovered that the hospital had just purchased an Ohmeda machine that they didn't know how to use. It was like I was given the keys to a Viper GTS Coupe. The rest of the week went smoothly and by the week's end we had performed 87 cases without loss of life or complications. Saturday was spent shopping and dining in Bogota. On Sunday we returned to the USA after attempting to miss both flights.
While at dinner Saturday night, some of the group were excited to leave while others were sad. Most wished we could have performed more cases, but when we looked back over the week, we had ran all the rooms late every day. As with all trips of this sort, the week is usually summarized with documents from the governor, thank yous, and speeches by the elder members of the group. One surgeon’s speech consisted of explaining that the kids we helped are on this earth for us, to allow us the chance to express our philanthropic side. We should feel happy for these children and embrace the opportunity they provide for us to share with them and with each other. We travel across the world to help ourselves by helping them.
Although I do not completely disagree with this theory, I think the reason why people make sacrifices like this is because of their need to give back. All our lives we strive to achieve rank, respect, financial security, status, and power. We live comfortably and have no feelings of guilt when we see the less fortunate because we feel we have earned it. Whether we have earned it or not isn't the issue. Every so often we should give back. This can be done via monetary gifts, or through giving of our skills and time. Reciprocity should be an important part of everyone’s outlook on life; I recommend that we should all, in some way or another, perform charitable or philanthropic activities. I will finish by quoting Dr. Peterman, “Most importantly, do what you need to do to make you happy.”