Although I joke about the travails of travel and the challenges faced working in a particular country, you should not think for a moment that I would change any of it. While most, if not all, the challenges revolve around navigating foreign bureaucracies, it is all part of the experience of doing what we do. Moreover, it helps us appreciate more the actual work being done; standing side by side with our foreign colleagues, providing a level of care/expertise and equipment that might not otherwise be available. At the end of the day, this is about the patients, not any of us, or the unyielding customs officer, or the hospital director napping at his desk.
With each succeeding mission I marvel at the care, compassion and dedication of those medical professionals who are patient focused each and every day – despite the distractions. This mission was no exception and, given the distractions, the success was that much sweeter. We were able to accomplish what we wanted and provide our local colleagues the equipment, training and support that they requested and that we promised.
We had two missions going at the same time; Chuck Durkee stayed in Managua and worked with Dr. Olivares, a pediatric urologist (as is Chuck). They handled many complex cases for which Chuck’s assistance and guidance were essential. Moreover, given that this was Chuck’s third time working with Dr. Olivares, he was able to provide follow-up on previous training he provided. Indeed, Chuck remarked that since he was here last October, Dr. Olivares has performed more skin graft procedures that Chuck showed him, more times in the last year than he had done himself. The cases basically fall into three types (on an overlapping continuum), and all the cases here are congenital (hereditary). I think it is important to explain them in greater detail than normal so you get a sense for the complexity (as if operating on children wasn’t complex enough).
Less complex cases where our doctors are able to show local doctors different techniques or refinements to their existing techniques.
- Two hypospadias (a congenital condition where the opening of the penis does not come out to the tip of the glans but opens somewhere along the shaft). Occurs in about 1 per 300 boys. 4 days post op the repairs on the two boys looked great.
Management of complications of patients previously operated upon.
- In one case, a 3 year old girl had a single kidney. He repaired it, but the repair failed, and she was now draining through a tube in her side. Her blockage was both by the kidney and the bladder. We re-explored the kidney, found the blockage, and hooked her back up. It was a very difficult surgery as there had been a severe infection after the first surgery and everything was scarred. She did well and was sent home after three days. When we return, we will fix the blockage by the bladder and she should be fine.
- A baby with ureteroceles (a peculiar congenital blockage of the ureter where the ureter enters into a blocked “bubble” in the bladder rather than directly into the bladder as is normally the case). Dr. O had punctured the bubble to get better drainage, an accepted technique, but now there was massive backing up, or reflux, from the bladder to the kidney. We opened the bladder, took out the bubble, narrowed the ureter (it was about 5 times normal diameter) and hooked it back in. The goal is for it to remain unblocked, without reflux.
Management of rare complex anomalies for which Dr. O requested help.
- A 14 day old infant had mild heart and lung problems. He had a normal appearing penis but on the top of the penis was a small opening leaking urine. He had only one kidney. Right above the penis on the lower abdomen was a round area of thin skin without muscle beneath it. We did a cystoscopy and found: two urethras, one through the penis, one through the small draining opening. They joined together at the level of the prostate. When we entered the prostate area, going deeper we found two openings, each which lead to a separate bladder. There was only one kidney (the left) but it drained into the right bladder. The area of thin skin ballooned up like a water balloon. This is the rarest variant of a rare problem, called covered bladder exstrophy, occurring one per several 100,000 live births. The duplicated bladders make it even rarer. These patients leak continuously until corrective surgery. But, since there is no blockage, and the single kidney is functioning well, it can be safely corrected at a later age.
- 3 year old girl with a bladder exstrophy (the bladder is open to the skin and drains continuously). There is no skin, muscle or bone in the midline and the bladder is not a sphere, but just a simple round structure sitting on the surface. Dr. O had not done these repairs before. An orthopedic surgeon cut through the pelvic bones so we could bring the pelvic bones together in the middle– –a significant procedure in and of itself. We rolled the bladder back into a sphere and closed her abdominal wall, put her vagina in the correct location as it was too far anteriorly placed, reconstructed her genitalia, created a new urethra. As a result, we believe she will be continent. Finally, we created a belly button, since she did not have one. She was doing great on the first day post-surgery.
- The same day we examined a 3 year old boy, never operated upon, who urinated from his anus. We found a second opening right at his anus in the 12 o’clock position (bet you never thought of your anus as a clock). We put the scope up and entered into his bladder. He had a normal penis but the urethra was too narrow to pass a scope through. We passed a wire through it and found where it located into the urethra coming from the anus. We will slowly stretch up his penis urethra to normal size by placing progressively larger catheters each week and can then close the urethra to the anus.
- 3 year old girl who had a balloon like structure coming out of her urethra into the vaginal opening. It was an ureterocele and Dr. Olivares incised it with scissors 6 months earlier. She still had partial blockage of the kidneys and reflux, or backing up. We explored and found she had 4 ureters, not two. One ureter (from the right) went into the ureterocele, and one ureter (from the left) went down her urethra to the vaginal opening. She also had big pockets or pouches (diverticuli) on each side of her bladder. We took out the ureterocele, removed the pockets, cut off the lower part of the left and right ureters described above, sewed them into the sides of the other two ureters and hooked the other two ureters back into her bladder. The end-result is the bladder will not reflux or be blocked. Surgery went extremely well but was quite a ride, since the x-rays available are much less detailed than what we use in the U.S. Therefore, we are forced to make educated guesses about what is going on and to be prepared for a number of surprises.
While Chuck worked in Managua, Brian Keuer and a small team headed north to Jinotega to work at the regional hospital with Dr. Montenegro, a local urologist. Courtney Desmond Keuer acted as interpreter (and quickly proved herself to be the most valuable member of the team by far), Bob Wadman, our mister-fix-it/utility player who always proves more than his worth on these trips, and myself (I leave you to judge). We came to Jinotega in February of 2013 to do a site visit and it became readily apparent that our services and equipment would be of great benefit. The Hospital is the largest in the province and serves about 800,000. Dr. Montenegro is a very gifted and dedicated urologist but lacks the equipment that would be readily available in any western hospital. Alas, this is not a western hospital. On our initial visit we promised Dr. Montenegro that we would bring the equipment she would need to do the most likely cases in Jinotega – cystoscopes, resectoscopes, cautery machine, light sources, cutting loops, camera and video among other things. Without this equipment, the most routine or diagnostic procedures, might necessitate a patient’s trip to Managua, almost 3 hours away (and even farther if coming from north of Jinotega). Throughout the week Brian and Dr. Montenegro did a variety of cases, including the following.
- 58 year old woman with a renal mass that had been present for several years causing severe stomach and flank pain. The doctors performed an open left radical nephrectomy (partial removal of the kidney) to remove the large tumor. The patient recovered well and was able to leave the hospital in 3 days.
- A 44 year old woman with recurrent urinary tract infections and a hydronephrotic (swollen) nonfunctioning left kidney. We performed the first laparoscopic radical nephrectomy at the hospital using equipment that had been at the hospital for some time but that we were able to assemble.
- A number of TURs(trans urethral resection of the prostate) which is the most common ailment seen and which would either necessitate the trip to Managua or result in an open, surgical procedure absent our equipment. TURs had not been performed in Jinotega by Dr. Montenegro, or anyone, prior to our arrival and Brian’s excellent training on our donated equipment.
- The first TUR that Dr. Montenegro did solo was a gentleman in his 50’s that had an indwelling catheter for at least two years which helped him void and empty his bladder. She was able to trim away excess prostate tissue and leave him without the discomfort of his catheter.
By the end of the week, Dr. Montenegro expressed that she began to feel more confident in handling the flexible and rigid cystoscope and in performing TURs. A number of TURs were scheduled in the coming weeks, so there is but little doubt that Dr. Montenegro will soon be more than proficient.Unfortunately, not all those who waited for treatment were treated. It was heartbreaking to have to turn away a gentleman from his kidney surgery due to a bad case of bronchitis. He had recurrent infections and pain from his kidney and had traveled 3 days from the forests near the border with Honduras for possible surgery. The decision was in his best interest as a major kidney operation and the anesthesia that it required would likely do him more harm than good at that particular time. We hope to be able to treat him on a subsequent trip.
Our medical mission is unique compared to those of other surgical missions with whom we are familiar. Our focus is on training and giving the equipment that they do not/cannot get on their own; we work with their staff, ensuring that they can continue after we leave. This is consistent with Knock’s mission of developing self-sustaining practices to assist the community. There is little doubt that training local doctors to doprocedures, and providing them with the necessary equipment, will have a positive and continuing impact long after we’ve left. While we certainly helped clear a backlog and handled cases that were particularly vexing, we were focused on treating a significant number of cases in tandem with the doctors so they would have the necessary training and skills to handle such cases after we left. As Dr. Montenegro remarked, the skills and willingness of Knock volunteers to undertake such a mission results in the betterment of the lives of millions of people who might need specialized urological procedures, and now have a urologist with advanced equipment and training to provide it.
I feel good about the mission because it fulfills a promise we made to Dr. Montenegro and the people of Jinotega on our first visit in February 2013.Tuesday I walked through the Children’s Hospital with Chuck and Dr. Olivares as they examined the patients they operated on the day before, including one discussed above. The little girl was doing well lying in bed with her parents sitting beside her. As Dr. Olivares talked to them the nervousness left their faces and they seemed somewhat relieved. In a country that doesn’t think too kindly of America, given our history with Nicaragua (a country of 6,000,000 – think about our fear of the Sandinistas and a communist takeover. Did this really pose a threat to us in the 1980s?), I wondered if this little girl would ever know that an American doctor helped perform her life saving/changing surgery. Her parents certainly would, and that made me further wonder if this would cause them to think differently about Americans or America? (not knowing how (or if) they felt about us to begin with). This, I believe, is what we should be doing. Missions like these, display the best of America and Americans, our compassion, our life saving skills and expertise, our world-class technology and limitless innovation. I’ve seen it first-hand with the doctors on this trip. Say what you will about the state of American healthcare (and I’ve got plenty but I’ll spare you), there is no question that US doctors are absolutely the best in the world. Although doctors from elsewhere are almost always welcome (with a few exceptions), the places we’ve visited have been clamoring for US doctors, as they too view them as the best of a very good lot. I’m proud and humbled to work with such dedicated individuals. It is largely because of them and the work they do, both here and abroad, that reminds me every day why we do what we do despite the (at the end of the day) really minor frustrations and inconveniences.
At a time when we hear a lot (from US politicians) about American Exceptionalism, you also hear it from non-Americans as the beneficiaries of American medical services, American technology and American compassion. It makes me wonder why we are so quick to bomb no matter the cost, and yet fail to realize the long-term harm we are doing both to ourselves and our “adversaries.” No better way to make today’s adversaries into tomorrow’s allies than through missions like these, student exchange programs and a host of others. Let others see us not through our ineffective (petty) government, but as compassionate, caring and talented individuals. How can we lead if we can’t get our own house in order? Can’t we, as Americans, do better than this? I certainly think we can, and this is why we will continue to organize Knock Foundation trips.
None of this would be possible without your kindness, generosity and support which goes to buy the much needed, life-saving equipment used on these missions and then donated to the host physicians/hospitals. We hope you will continue to support us in our efforts and consider joining us on one of our volunteer trips in the future (there is usually a non-medical component as well). To donate, I encourage you to go to the Knock website at http://www.knockfoundation.org and click on “Donate” (or you can simply send me a check made out to “Knock Foundation”). All of your donations are tax deductible.
Very truly yours,