Friday, October 21, 2016

A memorable afternoon

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 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.

As the last of the sky’s light faded, we finished cleaning the consult rooms and walked together to dinner.  We sat on a friend’s porch, eating and reliving the day.  We initially were pretty lively and laughing about memorable events that surprised us.  As the food came, we calmed a bit and spent time clarifying lingering clinical questions from the day.  Just as I was quietly beginning to wonder what challenges tomorrow would bring, "R" apparently still had a lingering doubt of his own.  He pulled the owner of the home aside and whispered wondering if she had heard of any alligators in the river recently.  Despite the darkness, I could feel "I" roll his eyes and heard his laughter bellow.  Sitting there, amidst the buzzing mosquitos, I felt so lucky to have been given this opportunity to be here.  As far away as home was, it felt pretty darned close.

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