Colombia
August 2016
I looked at my watch.
It was 4:30 pm and it felt like clinic was starting to slow down. It had been a busy afternoon. We had a slight reprieve as a woman we had
tentatively scheduled earlier for the removal of a facial lesion had not
arrived. Although our workload and the
sunlight were abating, the equatorial heat somehow seemed to be worsening. (How does that happen??) The three promoters, "R", "I" and myself were quietly eyeing the refreshing water of the
river. Our newest physician, "R" added words to our daydreaming thoughts.
“The water looks amazing”. Then
his tone veered, at once illustrating his experience with rural life and his
innate intelligence. “I am fairly
certain there are alligators in there. You guys can jump in, but I am going to find
something safer, like a faucet. Has
anyone seen a faucet around here?” "I", sitting on the stoop in the sun, smiled. “I am going in. I KNOW there are alligators in there
(pointing to the expansive river), but they probably aren’t any around here
(indicating the small muddy shore). And
if there are…then maybe it was meant to be.
Maybe something bad is going to happen wherever I am and whatever I am
doing...so I might as well be cooled off.
I am definitely going in.”
His words hung in the air; a prelude to a wonderful conversation. Instead, it unknowingly ushered the entrance
of a gentleman seeking assistance. He
nimbly stepped onto the porch of our wooden clinic, lifted his shirt and
wondered if we would remove the fairly sizeable lipoma he was unabashedly
showing us. "R", just having
successfully completed his year of social service that followed medical school,
jumped up and began to guide a promotora, "C", through the gathering of
the equipment they would need. Although
he is ever eager to lend a hand, I smiled briefly thinking his current
motivation might have been influenced more by reptilian factors. He is quick, but I had never seen him move
that fast.
Just as they were starting their consultation, the woman
with the facial lesion decided the time was right. Wanting to reward the kind woman’s confidence
in us, we quietly accepted the delay in our planned swim. A recognized her, and she and I
began to make our preparations. We had seen the remaining patients and the time
was ideal for focusing without the pressure of a full waiting room. “Do you want to help her?”, I asked, hoping
my voice hid my concern. Any surgery to
the face has always caused me pause.
Even carefully done, this particular repair would have a high likelihood
of a very evident scar. "A" responded with an enthusiastic “si”, but I saw a brief flicker of doubt in her
eyes. Despite my effort, I am fairly
certain she saw the same in mine. Had we
been in the tertiary care facility I had left three days ago, this woman would
have been treated by a specialized surgeon in a sterile operating room. I was comfortable that we would do our best
to create a clean environment, but I knew we didn’t have formal training in
plastic surgery. So, my thoughts were
racing a bit. And it was still hot. The same specialized medical instruction that
increases my utility and efficiency within the US, is confining to my scope here. In Colombia, I am frequently reminded of my
limitations. I constantly feel the need
to keep learning and responsibly expanding my boundaries to keep being a useful
physician in very rural areas. I have had
wonderful mentorship to guide me, but at that moment, support felt pretty
distant. As I was feeling my worries
escalate, it was a mentor’s voice I heard kindly but bluntly reminding me, “is
there anyone in the immediate vicinity that has more training in this than you?”
Ok then. On we go.
"A" and I slowly gathered our needed equipment. (How was it not cooling down yet??) The familiarity of this preparation began to diminish
my nerves and I was able to collect some thoughts that seemed relevant. As we discussed our planned specific steps
for the procedure, I tried to gauge "A’s" comfort. We had worked together intermittently for
nearly 10 years. We first met in 2008
when I taught an introduction to childhood growth and development to her class
of promoters. Her intelligence and her courage
were instantly apparent. She asked
thoughtful questions and always seemed to be advocating for others. In the intervening years her attitude toward
learning has allowed her capacity as a healthcare provider to blossom. I was so pleased with her personal decision
to move away from some of her family to live and work with us in the bigger town where we teach. This choice and her continued dedication have
helped found and solidify our local clinic.
Additionally, this experience continues to foster her clinical and
leadership skills. Working together
trying to help this woman, I am very aware we are both a little out of our
element. We will lean on each other’s
learned skills and together apply them to a new scenario.
Although this facial repair was new for her, I saw that she
was ready and focused. With the fading natural light, I sat down, put on my
head-lamp, gently held the woman’s head and lit the area for "A". With her usual care and attention, "A" skillfully injected the lidocaine and prepared the sterile area. She then donned her sterile gloves and we
were ready to start. Nearly forehead to
forehead over the woman’s face, "A’s" steady hand gently circumscribed
the area with a scalpel. As with any
procedure, we were both focused intently on her cutting. In this particular case we were also being
mindful not to drip sweat onto the sterile field. Quite the romantic view of surgery. Guiding someone else through a procedure that
worried me was fascinating.
I was so impressed that "A" could have me watching her
every move and still function. I know
this is a hefty weight for learners, but at the same time, we have grown to a
point where this degree of supervision was more welcome, supportive and
empowering than impairing. Some of her
work was too deep, some too shallow, but she made careful corrections. We both knew the most challenging part was
going to be making sure we approximated the edges well, to decrease the
likelihood of a gaudy scar. She
confidently placed her first suture, but it didn’t quite sit as well as she
wanted. She removed it and started
again. This one was closer to perfect
than I could have done. It looked
great. The edges came together
wonderfully. I exhaled with relief. I hadn’t realized that I had been holding my
breath. I guess it was pretty loud. "A" looked at me and giggled at my
hugely grinning face. She had been more nervous than she had let on too. The remaining sutures fell into place leaving
a thin scar which we hoped would heal beautifully. We bandaged the area, provided pain
medication and prophylactic antibiotics.
The kind patient was pleased we were happy, but left quickly so that she
could finish her family’s dinner. Cleaning
was a quiet, celebratory ritual. We were
both smiling as we mopped the floor and scrubbed the instruments. We had overcome an obstacle and learned
together. We were both more prepared for
the next time.
By the time we wrapped up, the waiting room was empty and
dark. We checked in on "R" and "C". During the procedure "I" and a second promoter had entered their consult room to learn the
technique. The patient’s wife had come
to the clinic to help alleviate the gentleman’s stress. The challenging portion of the procedure was
complete and they were just finishing up the sutures. I felt the same emotion here too. People were laughing, sharing this private
moment. Some from relief, some from
accomplishment, some because they were excited to learn something new and
helpful. As she was still learning, "C" had watched "R" carefully, handing him equipment.
She had been mentally preparing for the day when another patient would
arrive with a lipoma and there would be no physician “in the immediate
vicinity.” She would be properly trained
and ready.
