I recently returned from an eye-opening and humbling surgical mission trip to Jinotega, Nicaragua. Although I realize that I can never put into words the gravity of my experience, coupled with the need to impact and improve the lives of the people of Jinotega, I will attempt to briefly outline my experiences.
Each morning at 0645, our surgical team made the 4 block walk to the hospital from our hotel. Jinotega is known for its beautiful mountains and foggy mists, hence the nickname "City of Mists". As the mists evaporated around us, we passed schoolchildren dressed in immaculately pressed uniforms. All of the streets were old cobblestone, most in need of repair. Cars, mopeds and men on horseback shared the same street. We sidestepped an elderly "trash man" as he reached a gnarled arthritic hand to pick up yesterday's trash in a never ending task to clear the streets. Horns honked seemingly at random, and we could hear locals engaged in heated discussions regarding the upcoming presidential elections. Several trucks outfitted with loud speakers jarringly cut through the cool morning atmosphere with propaganda messages in support of the incumbent president. A delicious aroma of fried dough permeated the air as everyone geared up for the morning. The residents watched us quizzically as our white clad selves made our way to the hospital.
We walk into the front doors of the hospital, weaving our way through the thick crowd of vendors intent on selling their freshly baked goods. We pass through open air hallways filled with exotic plants, a meandering dog, a sleeping visitor, a confused man with a black eye and blood stains on his shirt. The clinic is housed inside the hospital, and lawn chairs are neatly lined up to accommodate the 50+ people waiting to be seen.
Upon entering the hallway to the OR, we knocked on the door to the locker room. Every door in the hospital is kept locked. A nurse opened the door and led us into a locker room that was the size of a broom closet, accommodating only three people at most. The bathroom was adjacent to the locker room, which turned into a dressing room of sorts. The bathroom was in disrepair, and visibly dirty. The hospital did not supply toilet paper for any of the bathrooms. When I asked our interpreter about this, she told me that the hospital administrators felt strongly that staff members should supply their own hygienic needs because they had more important things to spend money on. Surprisingly, even the patients were not supplied with toilet paper or linens. If a patient had no family, they lay upon bare, ripped and unclean mattresses. I witnessed many families offering food to patients that had no family. I found myself constantly amazed at the altruistic generosity displayed by the people of Jinotega.
When we started setting up for surgery, I was impressed with the efficiency of the staff. There was little conversation. There was no confusion. Everyone understood their role, and executed each role flawlessly.
It was only when we were setting up the second case that I had to remember where I was. The backtable cover used in the previous case became the bed linens for the OR table. The Stryker saw that we just used for the previous case was wiped down with alcohol and then introduced to the scrub nurse for the next case. The bovie, suction, saw blade and k-wires used in the previous case were saved and soaked in Cidex for the next case. Even the ET tube was soaked in Cidex.
Lap pads and prep sponges were saved and laundered. The sutures used were reprocessed and were dull. Syringes were saved and cleaned. Virtually nothing was thrown away.
The turnover times averaged 2 minutes. While the current patient was being wheeled out, the next patient was right outside of the OR. If there was no visible blood or tissue on the floor, it was not mopped. The backtables were not cleaned between cases. When I started to clean the backtable, the nurse put her hand on top of mine and shook her head. I looked around for our interpreter, and she quickly explained that the staff believed that cleaning the back table was unnecessary because it was going to be covered, and the staff did not want to waste the cleaning fluid.
We saw countless machete wounds. Some of them were pediatric patients that were helping their parents in the coffee farms and did not understand how to properly handle this tool. A few were the result of fighting. The most disheartening case was of a woman who had her hand cut off by her husband because he didn't like the way she prepared dinner that night.
We operated on patients with failed suicide attempts. We were asked to re-align bones, place ex-fixes, repair nerve injuries. When we arrived on Sunday, we held clinic. We saw around 90 patients and then decided which patients were in most need of surgery. From that point, we formulated a surgical schedule based on the needs of the patients and which resources we had available. As a general rule, we did not routinely accept "add-ons" because we could not adequately plan for them.
As our surgical team left the hospital one evening, a man rushed up to the surgeon I was walking with, pulled on his sleeve and begged him to look at his daughter's hand. I stopped and engaged in the conversation. The daughter, a 15 year old named Lucy, was suffering from a medial nerve injury as the result of a failed suicide attempt. Lucy had been active in AA for the past two years. She cut her left radial artery when she experienced a relapse and felt that her life could never be a happy one. Lucy was captivatingly beautiful; she was demure and kept her eyes to the floor when we talked to her. Our interpreter knew Lucy and filled me in on her history. Lucy had been the target of a gang initiation when she was 12. Lucy suffered from unspeakable horrors that I cannot put into words. The fact that she was enrolled in AA at the young age of 13 spoke for itself.
Our surgical schedule was full, and we didn't have room to accommodate Lucy's surgery. However, during our walk back to the hotel, the surgeon and I came up with a plan that was feasible. We conferred with the other surgeons and agreed to take her case on as the last case on our surgical schedule.
Lucy was wheeled into the OR, terrified and tearful. She had obvious trust issues, and was fighting the anesthesiologist with all 85 pounds of her body. I took her hand in mine, looked her in the eye and said, "Que esta a salvo": "You are safe". It broke my heart to see the hesitation in her young eyes, but she gripped my hand tightly and didn't release my gaze from hers until she was completely under. I said to the local surgeon standing beside Lucy's bed, "This girl has captured my heart. There is something about her...I can't explain it. She is special." Imagine my shock when the surgeon replied to me, "Yes, she is indeed special. This is my niece."
We made rounds the next day. I didn't expect to see Lucy; the hospital didn't typically keep ambulatory surgical patients overnight. When I was walking through the corridor during evening rounds, I turned my head and saw Lucy perched on a wheelchair in the doorway to her ward. She exclaimed, "Mi ANGEL!" According to the ward nurse, Lucy had refused to move from the doorway in anticipation of our arrival. I immediately went to her and gave her a big hug, fearing that I was crushing her small frame. Her smile was electrifying. She was pain free. She told me that she felt 'new' and said that she was excited about taking her upcoming exams; all the while laughing in between sentences. Lucy was simply...HAPPY.
This is the very reason I chose to go on a surgical mission trip. There is no way that I could have known that I would meet and provide care for a patient like Lucy. But her struggle, her challenges, and her courage will continue to envelop my thoughts long after the memories of my trip have floated away like the mists of Jinotega.
