Today is Sat. Dec. 16th, I worked yesterday for the first time since returning home from Boca Raton on Wednesday. I had thought I was completely over the mild cold I returned from Honduras with, but it still lingered slightly as I felt fatigued all day at work. Luckily it was a fairly stress-free day of 2 total knee replacements and 3 D+C/ablations. I had hoped to do this entry on Thursday but ….. argh…… again the WordPress “autosave” somehow locked up and the site was frozen for the last 30 minutes I was writing. This had happened once before on my iPad and I thought that now writing on my MacBook this would not happen again but ….. I looked into how to disable “autosave” and it was so complicated I eventually gave up. I Will look into it again when I have finished up my Honduras “series”. I pulled up my Peacock account on the computer and will watch Chelsea-Sheffield while I write. Sheffield is in last place so hopefully, Chelsea will not embarrass themselves. The announcer said that it is a chance for Chelsea to “stop the rot” of their disappointing season. I just heard a sigh behind me and saw that Fifa had snuggled onto my office couch to “watch” the match with me.
In case someone is reading today’s blog and missed the earlier ones here are the names of the charities. NuestrosPequenosHermanos: NPHUS.org and OneWorldSurgery.org
I had another nice night’s sleep and noticed it was wet in the courtyard when I went for my morning coffee and Clif bar. The sky was dramatic but it would clear and be sunny as every day of the mission would be. The interior highlands of Honduras’ wet season is from May to October.
I got an early start on my 1/2 mile walk to work since again I wanted to be able to set up my room, see my patient, and do a nerve block in time to get into the room by 7am. I was scheduled to do anesthesia for some arm and shoulder surgeries today. Marcia and Theresa were each supervising one CRNA a piece in the other 2 rooms. Marcia wanted to learn more nerve blocks from Theresa and I was happy to let them do them all except that I wanted to have Theresa teach me to do infraclavicular blocks if one of my patients needed one.
My first patient was having shoulder surgery so they did a modified supraclavicular/interscalene block (as a true interscalene causes 100% of diaphragm paralysis but supraclavicular only 30%). In my practice, I do interscalenes for all shoulders (unless they have severe COPD), who receive general anesthesia for the surgery, as we don’t use Exparel (that lasts 2-3 days) and if we do get a patient who is bothered by the diaphragm issue it will resolve in at most 12 hours with the block.
Despite being given 2mg of versed (midazolam) as sedation for the block the patient was VERY uncomfortable and kept moving. Eventually, the block was completed and I took the patient into the operating room. After the usual placement of monitors and pre-oxygenation with a mask I injected Propofol to induce general anesthesia but after a minute or 2, the patient was still awake, despite also receiving inhaled sevoflurane. Looking at the site of the IV that had been placed by the pre-op nurses we saw that it was infiltrated. And, of course, being a shoulder case we had only one arm to work with. I asked the OR nurse to find one of the free anesthesiologists and she came and started an IV while I masked the patient. I was planning to place an LMA but as we worked on getting an IV in the patient a woman walked into the room and asked if “the patient will be having general anesthesia for the procedure”, I told her that yes the patient was “asleep” and as soon as we had an iv I would place an LMA. She then said the patient would need to be “paralyzed” and I asked if she was requesting the patient be intubated, she said yes if that was needed for the patient to be “paralyzed”. I had no idea who this person was. The surgery was scheduled for Dr. Anand Murthi and I guessed that maybe she was an ortho resident or PA he had brought with him on the mission (again…. we never received a list of the people on the mission, their roles, etc. ). After she and Anand had gone outside to scrub I asked the surgical tech who she was and he said she was “another surgeon” but he hadn’t worked with her. Once again I was confused as this meant that there were 3 arm surgeons here but there were only cases scheduled for Dr. Anand and Dr. Moddaber (Los Angeles).
The mission seemed hugely overstaffed with 2 leg surgeons, 3 arm surgeons as well as the local Dr. Merlin and his orthopedic surgery fellow, and the local eye surgeon with just 3 operating rooms. There was also ANOTHER surgeon there the first few days who I never met but apparently “helped” in some cases. I had initially been scheduled to work with Anand on Tuesday and Monday afternoon I had made an effort and found him seeing patients in the clinic to introduce myself and ask about his first case for the next day.
Anand was from Baltimore (so of course the first question to a doctor is … “at Hopkins?”, the answer was no) and he worked at Memorial Hospital. It is located right next to the Johns Hopkins University undergrad campus (on the calm northern edge of the city, not the deadly downtown area where the medical school is). I told him I had returned there a year ago for my 35th reunion and Charles Village was looking much more upscale than in the 1980s. I didn’t mention the guy in my fraternity who used to climb over the fence at Memorial Hospital to collect Nitrous Oxide canisters for parties… 😉
Anand had brought a teenage boy with him on the trip and they were also always with a woman and I assumed it was his family. After a few days, I learned that the boy was his nephew but it was not until after the OR on Wednesday that it became clear that the woman was another surgeon, Caroline, from Florida who was a colleague of Anand’s. I never learned if she used to practice with him or had trained with him, etc.
I talked to his nephew a few days later, he had his 16th birthday on the trip and we got cake. Both of his parents (and most of his other relatives) were doctors in Maryland.
After the “misunderstanding” about “paralysis” I asked Theresa to talk to Caroline and make clear that as all the patients were getting excellent nerve blocks their limbs were “paralyzed” and we could use LMAs to administer general anesthesia without giving muscle relaxants and intubating. After that, everything was fine in the room for the rest of the day, except that Anand played Country Music…. really? There are many people who dislike Country music and raunchy Hip-hop so I don’t approve when surgeons play these. Everyone can tolerate classic rock, pop, jazz, classical…..
As I mentioned earlier, I was interested in having Theresa teach me to do ultrasound-guided infraclavicular blocks. I had done infraclavicular blocks very rarely years ago but that was before ultrasound guidance and they always seemed too close to the lungs for my comfort. For hand and arm surgery I always use supraclavicular blocks, but because of the 30% chance of phrenic nerve blockage (to the diaphragm) and as Theresa uses Exparel with a very long duration the infraclavicular is safer, especially for patients with compromised respiratory function.
All of the upper extremity surgeries could have been done under just sedation but as there was the language barrier and no propofol infusion tubing it was easier to just do a light general anesthetic with LMAs (laryngeal mask airway, a breathing device that sits in the back of the mouth with the patient breathing on their own, versus an endotracheal tube). Speaking of language barriers, it was nice finally on Wednesday to work in an operating room with US surgeons speaking English. On Tuesday for the 8-hour case the surgeon, fellow, and our scrub tech (Cesar) all spoke Spanish so myself and Carrie (the circulating RN) had no idea what they were discussing the entire time. I did ask questions occasionally and Merlin was always happy to answer but it felt weird to not be privy to all the discussions about that very complex case.
Because I had been the late doctor the day before I got out early after everyone had lunch, another delicious meal of course in the clinic cafeteria. Yvonne (RN from L.A. who had been to NPH in Honduras before a few times) had mentioned that there was a nicer place to swim than “La Posa”, the smallish, stagnet-looking pond we had visited on our tour. We had been told that there were 4 dammed reservoirs on the property and I saw on Google Maps a very big one north of the hill to “La Roka” we had earlier climbed.
I copied the location from my photo at the top of the hike (the star) and saw that it would just be a little further hike. I contacted one of the local staff to ask if this was the place that Yvonne had mentioned (and where people jumped from cliffs into the water). She said that I could swim there but the place Yvonne was talking about was much closer and just past the farm. I checked Google Maps again and found the correct one and confirmed with her.
I labeled it “cliff pond”, not only was it much closer (only 1 mile from the Moscati) but a mostly flat path versus hiking up the hill to La Roka and then down to the bigger reservoir. I did not have a bathing suit since had not been told about any swimming potential but I did have my running compression shorts that I put on under my regular shorts. I also had no goggles but wasn’t sure it would be swimmable anyway. I headed out with just my water bottle and run belt for my phone but I did also bring my selfie stick/tripod. Again it was 80 and humid so I slathered myself with sunscreen and DEET. I planned to run a few miles, jump in the water to cool off, and then run a few more miles. It was very easy to find the way as Lucia had said to take the path just across the dirt road from the Cocina building.
After a half mile down this dirt path there was a gate with just a lanyard securing it and once through it was just not much further to where I could see water off to the left and found the dam.
It was the dry season and hadn’t rained recently so there was just a trickle over the dam falling about 40 feet down. I saw some cliffs across the river but there was NO WAY to safely walk across the dam. I later learned that people would swim across and then there was a path to climb to find a cliff to jump from but not something one could manage without a local guide. I didn’t see a “beachy” spot on the banks but I felt the long grass there and it was soft (not sharp) so it seemed a possible entry point. I had only run a little over a mile though so I went back to the path and continued my run. The path was very rocky and got steep so my pace was fairly slow in the hot sun.
I didn’t want to go too far though so I turned back and got to the dam area again after 2.6 miles of running. There was another nice “cove” in the river I passed that had a sandbar.
The water here seemed much clearer than at the small pond and the surface was clean as it was slowly flowing over the damn. I did a test of the footing and after the muddy/grassy bank, it went right down to a few feet deep and had a smooth solid bottom. The water was still a little muddy but that is typical of jungle rivers (like the one Alex and I had tubed down in the Ecuadoran jungle).
After the most important step… setting up the iPhone, I swam in comfortable at least 80-degree water. I swam to the rock and back twice and then across the river once for a total of just 10 minutes and 300 yards. If I had not been alone I would have loved to have kept swimming north to the cool sandbar I had run by earlier.
Here is my official Tarzan swim Movie! I edited out the part of me wrestling the Crocodile.
and a screenshot from the video, it was super quiet, really no birds or insects making noise. If you turn up the sound you can still hear my strokes all the way across.
After my swim, I realized it would have been smart to have brought at least a hand towel with me as I ended up having to use my shirt to wipe the mud/gravel off my feet before putting my socks and shoes back on. I had stopped my Garmin after the run to switch to swim mode and now put it back on run mode but I ran straight back to the Moscati center and saved that track to share with the rest of the people. It was exactly one mile. I also drew on the Ranch map and shared it with the group on WhatsApp along with my swim photo. I said that I would be working late on Thursday as had been out early on Wednesday but that I would love to swim again on Friday and would be happy to be a tour guide or lifeguard for anyone interested in going. A group of people did go there on Friday but they never shared the plan on WhatsApp or told me so I just ran on Friday.
After tracking the route back to Moscati I did another 1.5 miles of running to get an even 5 miles total done. On the path down to the hospital I saw my favorite horse with his head reaching through the barbed wire to get to some longer grass. I tore off some beyond his reach and fed it to him. I usually try to get a trail ride in on vacations but this was good enough.
Having gotten out of work so early I still had time to shower and rest in a hammock for an hour before dinner. I listened to John Prine and eventually actually dozed off to sleep.
There was a WhatsApp message that food servers were needed but as quickly as I was able to leap out of my hammock and get across the courtyard I was too late. I got to clean dishes and serving platters several times but never got to serve food. After my long run and swim, I was VERY happy they subbed in a piece of chicken for me (others got pork) because just rice and zucchini would have been a disappointment.
As soon as we lined up for dinner there was a huge amount of noise from the ceiling and we looked out at the courtyard to see a tropical downpour. But it only lasted 20 minutes and it was dry by the time I headed to bed.
Dr. Merlin gave a great talk about the health system (or lack thereof) in Honduras. There is a “national health insurance” but only 20% of the population is covered by it through their employers. Everyone else has to pay cash for everything, medications, clinic visits, and if one needs surgery must pay in advance for the cost of bandages, and implants, arrange for friends and relatives to donate blood, etc. Many rural people suffer and then die of completely treatable illnesses or injuries.
During Dr. Merlin’s 7-year orthopedic residency, 3 years were devoted to orthopedic trauma, he said 85% of it was from motorcycle accidents. Because of the huge amount of motorcycle and car accidents, shootings, drug abuse, and tropical diseases taking up almost all of Honduras’ limited medical resources very little is left over for “other stuff”. So treatment for things that would be considered urgent in the U.S. such as cancer, heart disease, or new diabetes ends up being delayed. Only one hospital in the country provides major oncology care. There is a 300-day wait to start treatment for breast cancer so it is all very advanced and likely fatal before treatment is started.