SURGERY IN THE "DEVELOPING" WORLD

On Sunday April 5 I returned from an illuminating nine day trip to Guatemala in Central America.  The original plan was to only spend eight days down there but when the airline overbooked the return flight and offered a nice hotel, free meals, and first class service back to New Orleans along with a decent voucher in exchange for leaving one day later, three of the other trip participants and I volunteered.  The delay in returning allowed us such memorable extras as: A) Attending a millionaire's daughter's upscale birthday party complete with piles of ceviche, Guatemalan brews, margaritas, and dozens of fashionable young people doing shots and taking pictures with tiny cameras all to the rhythm of live music and professional dancers  B) Feeling the rumble of several earthquakes originating beneath the very volcano that we had been working near for a week  C) Heading down to the hotel restaurant already exhausted and content only to pile a room service tray with BBQ chicken sandwiches, fried calamari, fresh salad, a delightful assortment from the dessert buffet, and "muy muy onion rings!" (Thanks to a fellow flight-bump volunteer for providing that bit of Spanglish loveliness, hopefully the "jungle rot" on her arm will clear up ... at least the confused server was rewarded with a tip roughly equal to a day's pay courtesy of our airline-bestowed meal coupons)  All of the unexpected niceties of a daylong layover in Guatemala City lent the end of the experience a definite high note that sweetened the entire week, but I want to focus on what transpired before flight 444 was overbooked and four of us were sent on a wacky tangent adventure in the Guatemalan capital city.  We were, depending on your particular beliefs, literally on a mission from God.
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Helping Hands Medical Missions (HHMM) is a Catholic medical mission organization formed in 1996 that now runs missions for doctors, nurses, dentists, and other medical professionals and volunteers on three continents.  This year the mission returned to Escuintla, Guatemala for the 8th time to work on two fronts - running a community clinic in San Vicente de Pacaya near the active Pacaya Volcano and performing surgical procedures in the National Hospital at Amatitlan.  More than 30 missionaries comprised the Helping Hands team this year, the majority of whom were veterans of Escuintla or other mission trips around the world.  Due to my Spanish language skills, certainly rusty a year after returning from Peace Corps service in Ecuador but still vastly more developed than those of nearly all of the other missionaries, I was chosen to work as a translator for the surgical team working at the hospital in Amatitlan.

I was alerted before signing up that Helping Hands is a very Catholic organization, and www.hhmm.org does mention a few details including daily mass, prayers, meditation, spiritual discussions, and even sharing the faith with host community members through home visits (evangelization).  Anyone who knows me knows that organized religion is not typically my cup of tea, but in the interest of changing scenery and meeting new people in a setting where the shared activity is purportedly to selflessly help others less fortunate, I figured I would wrap up my typical skepticism and incredulity for the common good.  Did exposure to the steamy hardscrabble life of tropical, dirt-poor central Americans convert me?  Predictably, no, but the week did show me the meaning and power of faith in others and reminded me of how out of touch with true suffering and the realities of life many of us in modern America are. 

The week began with a day of travel and schedule mishaps followed by two days of getting situated at the mission sites and spiritual programming including mass, prayers, and an afternoon of evangelizing to some of the poorest of the poor near the clinic site in San Vicente at the foot of Volcan Pacaya, usually hidden in a combination of low clouds and smog.  Ask me what good it does to walk home to home praying for strangers, encouraging them to go to mass and giving away plastic rosaries when many are caked in dirt and don't even have shoes - you're asking the wrong person.  Add to this the fact that most of those evangelizing can barely speak a word of the local language and you'll get nothing but a confused look from me.  What can I say though?  Does it make me a hypocrite that I introduced myself to residents clearly in need of more than a rosary and a blessing as a member of a Catholic medical missionary there to work in the community and to share God's love with them?  These aren't easily answered questions.  I played the role I was asked to play as a translator and a participator in the mission I legitimately signed up for.  Whether I am a believer is less than central to the equation ... I looked at it in terms of whether those we were meeting with seemed to appreciate and enjoy some noticeable benefit from our visits and that much was not debatable.  After mounting anticipation, sleep deprivation, and mentioning of the life and deeds of a man supposedly born more than 2,000 years ago on the other side of the planet several of the missionaries were anxious to get started doing something, anything that felt productive.  Images of the stations of the cross, Jesus' sacrifice for our sins, the Eucharist, grown men in long robes carrying shiny chalices around in the sweltering heat and humidity, and well-fed white people making the sign of the cross over their chests while malnourished Guatemalans from the community wondered when and how they might be treated - characterized the first few days, perhaps leading one OB/GYN doctor from California to head back to the airport before he got caught up in any more of what he witnessed.  Oh well, a cot opened up on the floor of one of the men's sleeping rooms at the guarded hacienda compound where we spent our nights and the day we'd been waiting for drew near:  Monday, when the clinic and the operating rooms at the hospital would come to life and the principal way many of us were hoping to contribute would manifest itself in work that was more than self-congratulating and predominantly religiously exclusive.

The National Hospital at Amatitlan in Guatemala is not like the hospitals you may have visited in the United States.  Yes, the doctors and nurses wear scrubs when they work, and they wash their hands and take other precautions to protect the patients, but the overall bright and sanitized environment of a typical American hospital is not really mirrored there.  The place is built of concrete and cinder blocks, and seemingly the only spaces with air conditioning are the three operating rooms despite this being a tropical nation.  Broken windows grace the walls along open air courtyards between wards and fallen leaves mingle with dust on the floor just outside of where surgery takes place.  Patients who are aislado (isolated/quarantined) because of their contagious conditions are simply put in a part of the room at the far end, separated from the rest of the side-by-side beds by a low wall that doesn't even connect to the ceiling.  None of the isolated patients are isolated from each other...  Wandering through the pediatric ward, garish but well-meaning paintings of Winnie the Pooh and other characters lovingly scrawled on the cinder block walls peer down at the littlest citizens of the country in varying states of health and comfort on metal beds with worn mattresses.  There's a little girl who's been in the ward for ten days with her grandmother watching over her.  Kidney problems have caused her to swell up with fluids that she can't seem to pass out of her system.  "The doctors say she can't drink anything until she passes the fluid, but she's so thirsty," the woman tells me.  Moving on one sees a toddler complaining of his circumcision pains. "Me dueeeeleeeeee!" he cries.  It huuuurts.  A dark-haired baby lies on one small bed with a plastic half-bubble over its head.  Where are the nurses, the attendants, the doctors?  At least there are some parents (all women) watching the kids.  This is supposedly a much nicer hospital than the one the mission has worked at previously.

Surgery.  I've never worked in an operating room before and am a little nervous about how I'll handle the gore, but I'm helping an ear, nose, and throat doctor so most of the procedures are tonsillectomies and septoplasties - minor surgeries with a minimum of blood and Hollywood-style guts.  After the massive confusion of the first morning has passed (Now we know the hospital's rules for what passes as sterile clothing in the operating theater) patients start appearing in the hallway outside of the operating rooms.  Nobody has wrist bracelets to identify them.  Charts and records are in metal binders tossed from doctor to nurse to surgeon to volunteer to translator (me) and vice versa.  "What is he here for today?"  I ask a Guatemalan woman guarding her son on a gurney.
     "A hernia repair." 
     "Whoops, ok then, moving along."  Ok, here's the kid with the tonsils.  I ask the mother her child's age, weight, past surgical history, whether he or she suffers from asthma, allergies.  Maybe it's a teenage girl.  Is she or is there any chance that she's pregnant?  I introduce the anesthesiologist.  He's been doing this for twenty years, don't worry about a thing, he'll take very good care of Carla/Ernesto/Mayra/Tomasito/Lisbeth/etc., you can wait for your son/daughter over around the other corner ... now my attention is back to the patients.  I ask about their brothers and sisters, where they live, what they want to do when they grow up, do they have any pets, anything to keep their attention from the scary people around them wearing masks and not speaking their language and brandishing needles and sticky sensors and clamps for their fingers.  I explain that they'll be asleep during the operation, that we're going to put a mask on their face that smells a bit like plastic.  Oxygen will go through the tube, breathe deeply.  OK now they're putting an IV in your arm.  Keep breathing deeply.  You may feel some heat in your arm as the anesthesia goes in, you're doing great, everything is fine.  We'll take very good care of you.
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In seconds the patient is out cold.  I've never witnessed anything like it. One minute there's a person there talking to you, light reflecting in their eyes, maybe a little kid screaming for its mother.  The next minute they're dead weight, arms slumping down off of the operating table, eyes wide open but seeing nothing, a rag doll.  Very strange, where is the person, what happened to the soul?  I take down information about the case for the mission records while the surgeon works.  Blood gets slurped up through a suction tube.  What happens if that machine fails?  Or if the power goes out and the anesthesia machine stops?  So much of what goes on in here is contingent on other factors falling into place correctly.  Impressive that this hospital is so gracious about opening its doors and wards and patients to these foreigners with no real proof that the missionaries are competent professionals capable of doing a decent job.  We sometimes struggle to communicate the simplest concepts:  "We aren't going to bring this back to the States, so you can sterilize it and use it again."  "These hair covers and gowns are for you."  "Do you have any 3-0 sutures handy?"  "We need another 1000cc's of saline."  "Fentanyl, where is the Fentanyl?"  I'm learning the English words for the medical terms at the same time that I'm expected to relay the requests to the local staff, so confusion results until we all get the hang of working together.  Most of what is said is related through smiles, laughs, hugs, and gestures ... which is quite the fun way to get your point across when people's health is at stake!  Everyone on our team from the active surgical doctors and technicians to the volunteers to the scarce translators to the nurses working in the recovery room to manage flailing kids and groggy adults without knowing a word of Spanish, we all throw up our hands and learn to let go of any desire to control or predict the outcome of the day.  What happens will happen, and we're in their territory now.  Guatemalan time rules.  Where do these patients even come from?  Who is changing them into their gowns?  Does anybody know the order of the patients and who is bringing the next ones down?  No.  I don't know.  No.  No.  We don't know that.  One just has to laugh and marvel at how it somehow works out.  We show up at 7am after rising at the hacienda before light at 5:15, gather up our supplies, and through some unseen magical process patients appear and undergo surgery, are moved to the recovery room, and are eventually wheeled right out into the open air hallway and back to their wards to settle into uncomfortable beds beside gunshot victims and that beautiful 38 year old nun or the guitar player missing two fingers after an attack.  We can see them if we hunt them down individually and do just that after each long day, trying to find the patients we saw and make sure that they're doing alright, have the medicines they need to recover, and have their questions answered.  There are few people who can answer our questions though.

In the evenings when the Blue Bird school bus (redecorated to serve as Guatemalan mass transit vehicle of choice) returns us to the hacienda we pass through a massive sugarcane plantation and witness the reality of a worker's life through the windows and dusty road haze.  Men with machetes plodding along the fields of green cane, sometimes carrying irrigation pipes, sometimes lining up to get paid or to be hauled off to a far-flung corner of the property for work.  Giant trucks with even bigger cargo trailers piled with cut cane stalks towering fifteen or more feet above the road.  A refinery belching steam and smoke with the sweet reek of molasses and bicycles hanging up behind barbed wire, the workers' rides to and from home.  The plantation is a massive machine needing constant feeding of cane, sweat, diesel, and time.  None of what is produced here stays here, the bus driver tells us one day.  He worked for the plantation corporation for five years ... says that all of the sugar is exported in bulk to Europe and elsewhere.  The richness of the volcanic soil and the moistness of the tropical air and the muscles and effort of the Guatemalan people go into creating a product that none of the workers will ever enjoy personally, at least not from this plantation.  I'm reminded of Eduardo Galeano's book Open Veins of Latin America which I read while in the Peace Corps.  Hugo Chavez recently gifted a copy to President Obama, boosting sales on Amazon.com.  Well, good.  More people ought to be aware of the way Latin America has been commoditized over the centuries.  What of it?  We eat breakfast and dinner at a pavilion behind more chain link fencing with the protection of armed guards.  We're here as Catholic (some of us) missionaries with the goal of offering medical assistance and the word of Christ to the underprivileged of this country, is this kind of precaution necessary?  At night a guard with a shotgun sits in the chapel belltower.  As if we could be awakened at 3am by the sound of a protective shotgun blast ringing out among the mango trees?  Protection against whom?  You want some medicine, then go to the clinic!  Despite the truth of the cheerfulness and graciousness of the Guatemalan people we met, there is a tension here as in many developing nations between the power of the wealthy and the numbers of the poor. 

My memories of the mission are mostly good.  I would certainly like to participate again, despite the deficiencies in communication, planning and organization.  Negative associations were outweighed by the quality of character demonstrated by fellow participants and the impressive quantity of Guatemalans served by our work, despite the many hours spent in transit or at mass, meditating, or discussing faith among ourselves instead of good health practices among the obviously needier Guatemalans.  The clinic team saw more than 1,500 patients and performed exams, distributed medications, and did dental work on many hundreds of people who would have little chance to receive such treatment otherwise.  Our team at the hospital did about 70 surgeries and many minor consultations thanks to the doctors and other dedicated volunteers.  Hospital staff went out of their way to show their appreciation by hosting a luncheon on our final day featuring a DJ playing local hits, fresh flowers, and a scrumptious lunch catered by a restaurant in Guatemala City.  Plenty of classic Latin American pomp and circumstance was strutted about, including long-winded speeches and official introductions capped by the presentation of certificates of appreciation to the surgical team.  Apparently the clinic team also received a lovely party in San Vicente for its significant efforts.  It would have been great to get to know more members of the clinical team a bit better but the nature of the mission really split the work into two fronts that rarely met at times when the constituent parties weren't exhausted from long days and little rest.  That is, I suppose, why there was a post-mission crawfish boil hosted at one of the missionary's homes yesterday.  Good food, great friends, and lots of laughs and brews to celebrate the bonds we formed and strengthened in our service to others.  Many would have appreciated the opportunity to see more of the host country by visiting a volcano or a lake or hearing talks or presentations about the sugar cane production or other aspects of local life there, and unfortunately little to no attention was placed on providing experiences outside of medical work or spiritual devotion.  In several instances participants themselves created their own cultural experiences outside of the mission parameters and while these were rewarding to some, they failed in their exclusiveness and inapplicability to the entire mission team.  Many wondered what the point was of coming all the way to Guatemala and dealing with the added complication of a language barrier when there is plenty of need for free health care in underserved communities in the States.  Without the chance for real cultural immersion planned into the trip, participants sometimes felt rushed from the isolated religious compound of the hacienda to a private pavilion for meals and then to the microcosm of working in a fishbowl hospital or clinic setting without much chance to get to know the country or its people outside of a treatment scenario.  Perhaps Peace Corps spoiled me for travel, but I certainly felt as if eight days were not nearly enough to get the essence of Guatemala in such a limited manner.  Maybe on future trips Helping Hands Medical Missions can take a scalpel to its schedule and do some reconstructive surgery to improve the experience for participants and beneficiaries alike. 

If YOU think a similar experience could bring out the best in you or reignite your sense of adventure and service to God (or equivalent deity, etc.), by all means investigate whether participating on a mission trip would be a good choice for you.  Check out www.hhmm.org
Of course googling "Medical Missions" will lead you down a rabbit hole of dozens of other opportunities to serve in various capacities in locations all over the world.  Serve on a ship, on an island, high in the Andes or down in the steamy Amazon, in a city, town, village, or jungle clearing.  Whatever you do, don't forget to take your bible, a sense of humor, and a grain of salt.  Ciao for now.