It’s been several weeks now and I am starting to get reaccustomed to the sparkling floors, giant-sized beds with a million buttons, T.V. sets in the ICU rooms and the ease of ordering labs, imaging studies and simply transfusing blood products without a family member to donate. But I am back. After all, this is the environment in which I trained. This is what I know. However, I’ll never forget the challenges that Bolivian healthcare professionals face each day and I know I could never do their job the way they do. I am so lucky to have availed an opportunity to experience the practice of medicine and surgery that does not exist in the United States – an incredible learning experience.
I was able to take elective time in my surgical critical care fellowship to travel to Bolivia. The Northwestern Trauma and Surgical Initiative (NTSI) is partnering with Bolivian surgeons and institutions in the recent years to facilitate improvements in the Bolivian trauma system through capacity building, research and training. As I have always had an interest in global surgery, I asked one of my mentors, Dr. Mamta Swaroop, an Assistant Professor of Surgery in the Division of Trauma and Critical Care and part of NTSI, about an elective rotation during my fellowship. She directed me towards her contacts in a high altitude Andean city, Potosi, once known for the abundant silver that came from “El Cerro Rico”. I met Dr. Jose Luis Gallardo, a Bolivian general surgeon who has been working in Potosi for more than 20 years. He arranged for me to rotate at two hospitals in Potosi: La Caja National de Salud and El Hospital Daniel Bracamonte.
I arrived in Potosi early in March of 2014 and participated in the 2nd Annual Bolivian Trauma Congress; I gave two oral presentations: The Acute Coagulopathy of Trauma and The Management of Infections in Trauma Patients. After the Congress, I spent the first two weeks at La Caja Nacional de Salud, a government funded hospital, which serves miners, policeman, teachers, and other municipal workers and their families. There are four general surgeons at La Caja, including Dr. Gallardo, who take “turno”, or call every fourth day. In a typical day, I would arrive at 7:30 AM, make rounds with the general surgeon of the day and see patients who were admitted overnight. I would then round in the intensive care unit and review cases with the intensivist. I would then head to the operating room for scheduled cases. Since there were few residents in the hospital, I had the opportunity to scrub general surgery, urological, neurosurgical and obstetrical cases. All the physicians on call for the day were served lunch and ate together at a table outside the kitchen. It was nice to see the camaraderie amongst pediatricians, gynecologists, anesthesiologists, surgeons and intensivists discussing challenging cases, chatting up politics and showing concern for each other’s family over soup, rice and the meat of the day. In the afternoon, I went to clinic to see preoperative and postoperative patients. Often times following clinic, there were emergency cases like appendectomies, cholecystectomies and exploratory laparotomies. I’d head home in the evening, heat up some tea, and read about what I had seen that day and about what was to come.
I spent the next two weeks in El Hospital Daniel Bracamonte, a public hospital supported by the Ministry of Health, which serves mainly the indigenous population. Six general surgeons take call every sixth day with general surgery residents. The days were similar but the pathology was quite different. There were more emergencies and traumas, and the diseases were more advanced as patients often waited for days, sometimes weeks before coming to the hospital.
As a young surgeon, it was amazing to see pathology and operative approaches that I would never see in the United States. I scrubbed open drainages of hepatic and pulmonary hydatid cysts and saw cases of TB peritonitis. There is no endoscopic retrograde cholangiopancreatography in Potosi, so I experienced open common bile duct explorations and T-tube placements. These procedures are rarely done these days and are only discussed in conference or read about in a textbook. I scrubbed many open cases, appendectomies and cholecystectomies, not commonly done in a general surgery residency these days because of laparoscopy. At El Hospital Daniel Bracamonte, we saw a sigmoid volvulus DAILY. I am not kidding! If they presented within three days and as their first occurrence, we’d place rectal tubes (no endoscopy) to decompress. Otherwise, they were taken to the operating room for a sigmoidectomy. The high altitude (4100 m) and prevalence of Chagas disease are responsible for the frequency of this pathology.
As a physician, it was worthwhile to see and experience medicine in a totally different environment. In both hospitals, physicians learn to care for patients with fewer resources. They order fewer labs and imaging and rely more on their clinical judgment, which is usually correct. In the intensive care unit, I’d say that the typical ventilated patient got one chest x-ray during their stay as daily morning chest x-rays simply did not change management. They never performed echocardiograms, obtained CT scans (one scanner in Potosi), MRIs or did invasive monitoring, like Swan-Ganz catheters as families couldn’t afford them and it hardly ever changed management. I saw many patients with advanced lung silicosis and pulmonary hypertension. Often these patients would come to the ICU with pneumonia and proceed into multiorgan system failure. The intensivist would frankly discuss the situation with their families and often the patients were taken home to die surrounded by their loved ones instead of having a long drawn-out ICU stay filled with tracheostomies, feeding tubes, dialysis and the sterility of the hospital.
It is difficult to translate what I saw in Bolivia into practice in the United States. It really is like comparing apples and oranges. There is an abundance of resources in our hospitals and likewise, more expectations from our health care consumers as well as our providers. The pathology is different and the surgical training is as well. The language, culture and values are distinct, and affect how we interact with our patients. I was humbled each day by the complexity, limited resources and by the local physicians and surgeon’s reliance on clinical judgement and improvisation in patient care. I return to the United States with perspective and appreciation for what we have and for what others do not. Besides picking up new surgical techniques and becoming more familiar than I ever want to be with twisted sigmoid colons, I will take home one important concept: A successful surgeon must be flexible and adapt to provide the best care for his or her patients. We must continue to read and learn new techniques. We must be ready for shifts in insurance coverage and compensation. We must be ready to work in a system that may restrict us and not allow us to order test X or have equipment Y. And we must do all of this while keeping the patients best interests at heart. I consider this concept of adaptability to be the most important learning point from my time in Bolivia.
Today, if you ask for another CT scan, HIDA scan or for an MRI in that pregnant woman with suspected appendicitis, you’ll get it. If you want X type of mesh, your favorite energy-based surgical device or the newest endoscopic stapler, you’ll get it. Or say you see that sweet, relatively fit, 90-year-old grandma in your office with an aortic aneurysm. If you want to fix it, no one can stop you. You may have to fight a bit, but in general, you can make it happen…
However, what would you do if in ten years that wasn’t case?
What if our future healthcare system restricted you in ways you couldn’t possibly imagine?
Would you adapt or would you quit?
I would like to thank the Feinberg School of Medicine Center for Global Health, my mentor, Dr. Swaroop, Dr. Jose Luis Gallardo and all the other health care providers in Bolivia that made this experience possible.
