Hospital de la Familia – Alexander Rivero, MD

Written by Alexander Rivero, MD, PGY-4 at Kaiser Permanente Oakland Otolaryngology Program while on Global Health rotation at Hospital de la Familia in Nuevo Progreso, Guatemala in November 2016.

A known entity – this time, I was less nervous and more confident as we took our 12 plus hour journey from San Francisco to Nuevo Progreso, Guatemala. I felt empowered, sharing with my co-resident, Dr. Jonathan Lin, the ins-and-outs of the trip like when we would have a rest stop along the long way or to make sure and wear pants because they blast the air conditioning on the bus. We were greeted by the staff and locals with a small fireworks display as per custom and unloaded our bags quickly as we dawned our scrubs to start a planned clinic that same day. We immediately began signing several patients up for surgery the following day. As a senior resident on the trip, I was able to have first pick at the complex cases as well as provide guidance on OR planning and scheduling. The transition from spectator on my first trip to Hospital de la Familia (HDLF) to active learner and organizer this time was perhaps the most notable change for me. I quickly realized that two years ago I had taken for granted some crucial elements including detailed organizing, planning and communication between services. This time I felt it was important for me to learn to navigate the system and actively participate in this process given my previous experience and also being the only native Spanish speaker in the crew. We often times speak of residency as a place where one gets pulled in a thousand directions at once and our main job becomes prioritizing elements and assigning importance value to each request. This was especially true in Guatemala but interestingly felt more administrative than I was yet accustomed to. Learning to bridge this gap was both intellectually stimulating and emotionally challenging.

The Case… in Point

Prioritizing was not without its downfalls, however. I distinctly recall our second to last operative day. A nurse informed us at 5:30pm as we were completing our last case, that there was still a patient who had remained NPO (nothing by mouth) since the morning, awaiting her turn on the operating room table. Due to a scheduling error, we had not included this patient on the operative board for that day. My heart sunk, yet my immediate attention was turned onto resolving the issue. There was no time to think about how I felt. “We can perform her case now” I thought. This, however, meant that our limited Anesthesia and post anesthesia care nurses would be working late into the night. We were short staffed as it was.  “How about first thing tomorrow?” I thought. I looked at our list of patients already scheduled for the following day. We had a fully booked operative day. I went to discuss the matter with our attending surgeons and anesthesia staff. We remained short staffed due to some staff illness and were on a time crunch. Unfortunately, we made the decision to cancel one of our elective cases the following day to make space for our scheduling mishap. I moved slowly to the preoperative area where the patients were anxiously awaiting their operative turn the following day. “Lo siento- I’m sorry” and “disculpa – forgive me” followed every other word. I knew this patient was upset due to the cancellation. In the United States, I’m sure he would have been yelling at me and asking to file a formal complaint. But all that he said was “Do you think I can spend the night and leave in the morning? I don’t have a ride”. I blinked incessantly to hold back the tears filling my eyes as I assured him we had a bed and would provide him with a meal. That night, I went to my room to process the emotional shuffling in my head, one that my patients were physically going through. I could not bring myself to participate in the nightly OR planning meeting that day. I felt let down by the system. Let down by the inability to physically help someone – after all, as a physician and surgeon, that’s what I was trained to do. Let down by a mission team that “seemed not to care” – a thought which I later realized was grossly mistaken. Was I the only one here to help these patients? HDLF patients travel sometimes for 6 or more hours just to be seen and potentially have operations scheduled. It could not have been a bigger slap in the face to a patient to have them wait for hours to be seen, wait for several more hours to be seen by a specialist, then wait all night to be operated on the following day (all while fasting) only to be told, “Sorry, your operation has been cancelled”.

The Crux

So therein lays the dilemma of the administrative component of this trip. I became acutely aware of the ins-and-outs that I had so easily dismissed on my prior visit. Tough decisions were made daily (we were unable to offer surgery to three other patients due to case complexity –  a decision I made personally and had the burden of sharing with the patient alone as well).  I came to realize the importance of maintaining team unity through understanding of each member’s role. I later understood that the team wanted to perform the cancelled surgery but it would be unsafe given the short-staffed nature of our trip. Although these elements of the mission were more difficult to cope with, they were critical to my complete understanding of the process of care for underserved patients.

A Balance Struck   

Understanding the needs of the team and the needs of the community was critical for a successful trip. After all, we provided clinical care to over 200 patients in the Otolaryngology clinic and completed over 20 surgical interventions. Success can sometimes be so narrowly defined that one might lose sight of the forest for the trees. By cancelling the case, we were able to provide safe and successful care to the other patients as well as allow for team unity. This would foster further continuity of care by encouraging all staff to continue to participate in these missions. I remain hopeful that these learned skills of team communication and management of patient and provider expectations will continue to serve me in my career as a maturing Otolaryngologist.