Transcript July 2014: Cochabamba, Bolivia

July 2014: Cochabamba, Bolivia
Kevin Kirkland and Kristin McCormick – M2s
KU School of Medicine-Wichita
The HoH Logo
Bolivia
Hospitals of Hope (Hospitales de Esperanza)
Vinto, Cochabamba, Bolivia
http://www.hospitalsofhope.org/
Personal Goals
Kevin:
Kristin:
• Utilize experience in Bolivia to build
an understanding of how surgeons
can provide much needed care for
patients in underserved communities
• Synthesize ideas for providing quality
healthcare to patients of all
backgrounds in a domestic,
underserved setting upon arrival back
home
• Work with hospital staff to learn
about the Bolivian healthcare system–
its strengths, challenges, and future
directions
• Participate in community outreach to
meet short-term community needs
• Practice Spanish in both a community
and medical setting
• Grow personally in faith, compassion,
and cultural sensitivity
• Have a unique adventure!
About Cochabamba:
• Seated in Cochabamba valley in the Andes mountains
• Population 1,938,401
(4th
largest in Bolivia)
• Was once part of the Incan empire– colonized by the Spanish in 1542
• Garci Ruiz de Orellana purchased the land from local tribal chiefs
• Climate: semi-arid, tropical days, cool nights
• Extended dry season May-October, rainy season November-March
• Racial demographics: Quechua/indigenous > mixed indigenous > Caucasoid (minority)
• Heavily agricultural and industrial economy
• Large metropolitan city connected to surrounding towns and cities:
• Quillacollo, Sacaba, Vinto, Colcapirhua, Tiquipaya, Cliza, Tarata, Punata
• US Sister cities: San Francisco, Miami
Official flag (above) and
coat of arms (below)
About Hospitals of Hope-Bolivia:
• Founded in 1998 as a small clinic
• Expanded in 2003 to a 32-bed, level 2 hospital
• Staffed primarily by Bolivians
• Approximately 900 patients seen per month
• Houses the only organized EMS system for the West side
of Cochabamba
• More than 35 square miles covered
The hospital, settled in the Andes, with one of its EMS vehicles
Overview of challenges
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(details on following slides)
Transportation
Government opposition of the hospital
Poverty of patients
Availability of physicians
Resources/education available to facilities
:
Challenge 1: Transportation
Observed Issues
Ideas for Improvement
• Construction on the roads near the hospital
• Arrange a hospital-run transport system for
patients only
• Transportation workers often go on strike
• Lack of laws about moving over for EMS
vehicles on the roads
• Lobby city government to increase awareness
about EMS vehicles/implement laws to allow
passage through traffic
Challenge 2: Government Opposition of the Hospital
Observed Issues
Ideas for Improvement
• The Bolivian federal government continues to
threaten the independently-run hospital
• Seeking governmental control
• Seek increased funding of hospital staff
salaries and care costs by private donors
• Patients are unaware of the low-cost services
provided and protest the “expensive” clinic
• Attempt to make an alliance with the Bolivian
government to keep the hospital independent
• Educate patients about cost of care
Challenge 3: Poverty of Patients
Observed Issues
Ideas for Improvement
• Patients seeking care at hospital often cannot
pay for tests or surgeries when needed
• Set policies of care which dictate a patient must
receive prompt treatment regardless of upfront
cost
• Those who need procedures must wait until
their family can find the money, impeding
their timely recovery
• Arrange an efficient billing system so that
patients can gradually pay their hospital debt
• Implement a scholarship program
• Encourage physicians to take on pro bono work
Challenge 4: Availability of Physicians
Observed Issues
• Several of the physicians work in other
hospitals
• The surgery & OB schedules are thus
particularly limited unless volunteer
physicians are in Bolivia
Ideas for Improvement
• Encourage physicians to take on only one job,
perhaps offering an increase in salary as
incentive
• Hire physicians whose contracts state they must
only work at HoH
• Recruit more volunteers to serve in Bolivia yearround
Challenge 5: Resources/Education Available to Facilities
Observed Issues
Ideas for Improvement
• Protocols set in the US for better patient
outcomes have not been passed on to
Bolivian healthcare workers (outside-HoH
site)
• Increase funding
• Particularly in a pediatric burn unit, the
protocols were attempted, but could not be
followed due to a lack of proper supplies
• Educate employees about newly
discovered/better strategies for improved
healing
• Implement a Continuing Medical Education
program for Bolivian healthcare staff
Profound Clinical Experience: Kevin
Two cirujanos (surgeons) allowed me to scrub in on my first international surgery, a laparoscopic
cholecystectomy. Acute cholecystitis has a high incidence in Bolivia, so this operation is performed often at HOH. In
spite of our language barrier, the surgeons were willing and excited to teach me and involve me in the operation.
Using a laparoscopic gallbladder grasper instrument while looking at the monitor, I put the gallbladder into a bag for
removal. Thankfully, I had the opportunity to practice suturing during my June rotation in cardiothoracic surgery; I
implemented this skill when the surgeons allowed me to help close the patient using an interrupted stitch technique
and instrument ties. The patient recovered well, and he and his wife were thankful for our help. This experience was
exhilarating. Providing surgical services in developing countries can alleviate suffering, prevent disease from
advancing, and in some cases, save lives.
Scrubbing in
Kevin and the Bolivian Cirujanos performing the cholecystectomy
Profound Clinical Experience: Kristin
The first patient we saw at Hospitals of Hope was a car accident victim. She had hit a tree and suffered a
subdural hematoma along with several more minor injuries. She was in a coma. Aside from the shock of seeing
my first-ever patient on life support, the Bolivian interns and staff explained to me that they had been weaning
their patient from her sedation once per day, to no avail– she remained in her comatose state.
As I surveyed this woman’s CT scans, I could not help but be distracted by the outdated machinery
surrounding her– yet she remained alive under the best care the HoH staff could provide. We were told her
family was anxiously waiting until they could raise the funds to send her to a more advanced hospital. Her
children held out hope that their mother could awaken if she was given better care.
A few days later, the other pieces of this tragic puzzle fell into place. Our patient, whose family was
unable to pay for more advanced care, died in the hospital. We found out she had purposefully run herself into
the tree in order to escape a hopeless situation.
Clinically, I was impacted because this story was a stark example of the fact that I will not always be able
to help every patient, nor does every patient wish to be helped. I was also reminded of how thankful I am to live
in a country with such advanced medical technology.
Profound Cultural Experience
Perhaps the following story could be considered a clinical experience, but the clinical aspects of our time in
Bolivia were deeply intertwined with the cultural. After morning rounds at the hospital, the volunteers often rode to
other parts of the city to minister with partner organizations. The most popular site was the pediatric burn unit at a
local teaching hospital. Sure, the volunteers all enjoyed the time with the children in the unit, but what we saw
there changed our perspective on health care for good.
Four rooms down a single hallway made up the burn unit, which was housed in a building far from the main
hospital, in the middle of a construction site. Each room housed children in different stages of healing, arranged
from newest wounds at the front of the building, to more advanced stages of recovery at the end of the hall. In the
US, we keep burned patients as far from virulent organisms as possible, which means minimal human contact during
recovery. However, in this Bolivian hospital, resources are scant, so several children occupy each room. Their parents
must work to pay their hospital bills, so the children spend their days with the toys, television, and nurses, trying to
recover. So starved were they for attention that they took to our meager offerings of broken Spanish and playing
with puzzles like it was Christmas.
After playing with as many children as possible, we left the unit completely devastated. We couldn’t pick
the children up and cuddle them, because their physical wounds had to be nursed. We couldn’t provide what they
needed to be safe, because most of their burns were due to in-home accidents where the only affordable
environment is a dangerous one. All we could do was pray, so we did. That day, we realized it will take far much
more than willing hands to bring healing to the world. It will take resources, it will take education, and it will take a
power far beyond that which humans can provide. Not a day goes by that we don’t think of the children in the burn
unit, and thank God for providing for us. We continue to ask Him to provide for them.
How will this experience affect your future as a professional?
• Future plans:
• Get married on December 20th, 2014
• Continue working in short-term missions opportunities whenever possible
• Attend conferences, do research, and pursue Master of Public Health degrees after our third year of medical school in
order to best serve patients of all ages, nations, and races
• Seek out mentor-mentee relationships with others who have served internationally
• Apply lessons from this experience to healthcare in a domestic setting
• Grow in discipleship of Jesus Christ in order to be equipped to serve others well
Exploring the Bolivian OR
Visiting the Christ of the Concords statue– the tallest Christ statue in the world, including the one in Rio de Janeiro, Brazil