surgery!! :)

need surgery? on a budget? look no further than ecuador!

$250-$275 for a tubal ligation (compared to thousands in the u.s., especially expensive if you want it done laparoscopically, which many would argue - and I agree - is a waste of money as the surgery can be done "open" with a single tiny incision and minimal post-op pain, but that is an entirely different story)...

too expensive and still in need of contraception?
IUD - $35 (compared to $500 something in the U.S.)
Implanon - $145 (compared to $400-800 for insertion in the U.S.)

this morning I escaped 4 hour spanish class for a much better alternative. I went with Leah and Emma to observe minor surgeries at a local medical center - lucky me!! we are the only 3 who have gotten to see surgery this rotation, and though we were merely observing, and the morning consisted of just 4 tubal ligations (all 4 completed in less than an hour!), it was very interesting. 

 we changed into our loaner scrubs. Leah was in a massive pair of green scrubs and had a marked resemblance to a lettuce leaf. Emma and I both wore pale pink scrubs reminiscent of the mother baby unit, or maybe an easter bunny costume? what I'm getting at is that we looked good ;) especially when you added the scrub caps we wore as shoe covers because they were out of the shoe covers... make due with what you have; and boy do they ever take that to heart here, it is impressive!!

we entered the tiny OR and tried to stay out of the way while they prepped. the patient walked in and climbed onto the table - in contrast to the u.s. where patients are wheeled in on their designated beds and shifted to the OR bed... she lay wide awake and completely exposed (apparently respectful drapping of your patient is not a priority here), while the physician scrubbed in a far less than sterile manner. I had to hide my cringe and bite my tongue - this is his OR, his sterile technique, and his patient outcomes (which I would be very interested to learn about - rates of infection, tubal ligation failure, etc)...

the surgery began with the patient wide awake and the anaesthesia tech struggling to get prepped. the surgeon had already pulled the fallopian tubes into view when the first bit of sedative was given. the poor patient had been wincing and crying and sweating from the pain of the surgery thus far only with a little bit of local analgesic. we watched her heart rate and bp pick up on the monitor as he dug deeper into her pelvis. we were all relieved with the white sleepy milk was finally injected into her veins and she drifted off. 7 minutes later she was sterile, closed, and with the dressing in place, she was wheeled out of the room... 

the three of us gringas made to leave the room to allow for the turnover (cleaning). not necessary. we watched in dismay as one tray of surgical tools was dragged off the "sterile field" and another was set down in its place... the surgeon, wearing the same gown, simply replaced his own sterile gloves and his assistant did the same. no. way. the bed was not wiped down, the face mask for oxygen unchanged. is this allowed?!

the second patient was in the room moments after the first was wheeled away. 7 minutes later and they were asking for the 3rd patient... I was troubled by more than what I've already mentioned. importantly, when the medications were injected and the patients drifted off, their breathing was always compromised for a few minutes before anesthesia got the oxygen mask on and the O2 sats back up to normal... it stressed me out watching the saturation dropping from the high 90s to to the 70s...even 60s! it made me equally anxious the way they would recap needles, just asking for an accidental stick! I didn't like when the patients were clearly still awake and suffering, struggling against the arm restraints in reaction to the pain. I didn't agree when he explained to us, with the patient still awake, that because she was so fat he had to make a bigger incision. 

 it smelled familiar, like the ORs I love back home - oh how I welcome the smell of the cautery :) associated with the happiness of what I am excited to do for the rest of my life!! It sounded familiar enough, the bleep of the vitals monitor, the quiet conversation, the focus. but it looked so wrong. the sterile field hardly existing and the drapes tattered and faded. I glanced at the clock on the OR wall, it was stuck at 1 minute before 4 pm, the second hand twitching in time but moving nowhere... 

this is the 4th country where I have observed surgery and I thought it wonderful despite the many apparent shortcomings to eyes from a place so different. the thing is that my education has taught me to value evidence-based medicine, and as a result I couldnt help but correct each step of the surgery in my mind, making improvements in skill and efficiency as I have been taught at OHSU.

interestingly, the surgeon did the cutting and the identifying of vital structures, but nothing more. his female assistant, not a doctor or trainee, did all of the sewing. compared to my experiences in africa, this was impressive surgery. compared to the artists I observe and have the honor of assisting in the u.s., this was barbaric. oh the contrast, it is all relative I suppose.

what an interesting experience... and wow do I miss the inside of the OR.