Healing the Children in El Salvador

     I was not sure what to expect. The Presbyterian Hospital Main Operating Room is all I have ever known in my nursing career of four years. I knew practices and standards would be different. I knew that there would be a lot of improvising. That was all I knew of El Salvador: diversity. The severity of it I was about to find out….The entire team met up first thing Sunday morning. There were 12 of us: 2 surgeons ,2 anesthesiologists ,2 scrub nurses , 1 circulator , 1 medical student/anesthesia technician, 1 nurse interpreter , 2 recovery room nurses , and of course Bobbye, the trip administrator. These 11 people would be my family for the week.
     When we got to the hospital the waiting area was packed. There were even people lingering outside in the courtyard. …   First thing first: figure out which specialty gets which room. Technically, LDP has four operating rooms but one of those rooms is used for deliveries. Dr. Carcomo had assigned general surgery to the room with a better overhead light (nicknamed the “Starship Enterprise” for is size and shape) and the ENT surgery room had the instrument washing sink in it….There was a lot of equipment switching for the first couple hours until finally, the equipment found its way to the correct specialty and plugged into working electrical sockets.
     More often than not the group ate dinner together. It certainly created a sense of camaraderie and bonding. The team worked really well together. I had expected more tension and “all-business” attitudes but was pleasantly surprised at how well we got along. That unity helped make the week go by smoothly and joyously.
     On Monday morning we slept in because our bus could not pick us up until 8 o’clock in the morning. Bobbye had arranged government transportation for us for the week. This made me feel much more secure to go between the hospital and the hotel. Monday morning though, the driver was about two hours late—something about the contract or gas or both. I felt so terrible for our patients. Some of them had gotten to the hospital as early as 5:00 am! At least all of them were present when we arrived and each child already had their IV started. As far as I know, none of the families complained about the wait. There may have been some questions and concerns but all the families stayed. In the States, the families would have left and maybe threatened a lawsuit!
     The general team only had three surgeries to do. There were two sets of instruments we brought with us from the States. After each surgery I washed, dried, and wrapped the used set. Then I gave that set to Hilda—the Salvadorian nurse—to be sterilized while we did surgery with the other set. That set would then be ready for the following case. After the third surgery both sets were given to be flashed for the following day. The last patient for both teams was discharged from PACU around 4:30 pm.
     On Tuesday, our bus picked us up at 6:45 am. We had four surgeries scheduled for the day…I also taught Jessie how to scrub in to surgery—how to wash her hands and stay sterile at least. There was a limited supply of gowns and gloves so I could not teach her how to glove and gown herself or set up, but she was able to see more of what Dr. Linda was doing and help retract. After the first case I showed Jessie how to wash, dry, and wrap the instruments. Kay gave us an indicator to place with the set. When I saw the results, I wished she had not.
     The outer tape and the inner sterilizer tape changed on all of our sets. The indicators, however, never reached more than half way to the acceptable on the strip…The biggest culture shock for me involved the lack of regulations and standards. The autoclave did not get hot enough to kill worms and the staff simply continued on with surgery like nothing was wrong. The staff asked us to save the disposable cautery pencils we brought with us. They would soak them in a bacterialcidal solution and reuse them over and over.
     Wednesday was our busiest day. We did six cases total. Since there were only two sets of instruments, we spent some time waiting for them to be turned over. Eventually we put together a third set from the hospital’s instruments…Thursday was our slowest day. The general team was done before lunch time. So while Dr. Linda saw potential patients for Friday, I inventoried the remaining supplies. One of the doctors at the hospital, Dr. Riviera, scrubbed in to the surgeries with us on Thursday and Friday. He was a big help, although he may have slowed us down a bit because we were teaching him during the surgeries and he did not always understand our English.
     Friday was our final day. We did five simple cases and were done by lunch time. Our last two cases were difficult. They were both patients who Dr. Linda had not screened on Sunday—technically speaking “add-ons.” The second to last child needed a cyst removed. The general surgeon at a sister hospital, the surgeon who would follow up with all of our patients, brought to our attention the possibility that this patient may have a tuberculosis infection. It was the only specimen that we sent off for pathology. There was no lab in the hospital. It had to literally be “sent off.” I am still unsure of the outcome.
     Then the last patient was HIV positive. We actually knew this and had decided to do this surgery last because we were so uncertain of the sterility of the instruments. We did not want to pass inadvertently pass on the virus to another child. I realized later that we should have taken more precautions to kill microorganisms on the instruments we used on the patient with HIV because of the immunocompromised condition of the child.
     There are many things I would have done differently that week. But many things could not have been done better. This week changed my views on healthcare: it helped me to be more flexible, taught me to improvise, and showed me how to do things without advanced technology. All in all though—some things were very familiar. There were patients misunderstanding what time they needed to arrive at the hospital. There were parents wondering why they could not feed their child a big breakfast the morning of their surgery. And of course, there was dealing with noncompliance. Maybe things were not do different after all.

Jaren Gravagne, RN, BSN, CNOR is a third generation surgical nurse and currently is the General Surgery and Kidney Transplant Coordinator in the Operating Room. In addition to general surgery and kidney transplants, she also specializes in pediatric surgery and Wound VACs. She is currently training for her first half marathon and plans to keep running as long as possible. Her goal in life is to visit at least one country from every continent—except maybe Antarctica (it’s too cold!). In her spare time, she loves to experiment with gluten-free cooking and baking. Jaren lives in Albuquerque, New Mexico with her husband Anthony. She served with Healing the Children on a pediatric surgical mission in Santiage Texacuangos, El Salvador from February 27 through March 6, 2010. 75 children received surgery and medical care from the mulitdicipinary team.