Pure Medicine

There are always new challenges with each mission, changes in regulations, new paperwork, one or another bump in the road and sometimes even a “Jersey  barrier” to make us work just a little bit harder to provide care to our patients.  This year, there are a few of these, some of which we were already aware of that have intensified, and some that just popped up out of the blue.

Expiration dates.  This is the “shoe covers” of 2015.  For anyone who has been on one of our missions in the past ten years or has heard me talk about them, they know what I mean.   We mostly use shoe covers in the U.S. to keep our shoes clean in the operating room—preventing blood or other items from soiling them.  In many instances, we have dedicated shoes that we only wear in surgery.  Here in Ecuador, there is an obsession with shoe covers and where they must be worn and where they must be removed.  There has not been much common sense in instituting this practice, and in several of the hospitals where we’ve worked, it seemed that patients were placed at greater risk of infection by us putting shoe covers on and off repeatedly without a nearby sink to wash our hands.  That means clean shoe covers, but nasty hands.  This has driven me crazy at times.

This year, the “expiration date” frenzy seems to be peaking.  Our hosts will acknowledge that in many cases, companies put an expiration date on items that really don’t warrant such a designation, but they do it for other reasons—perhaps to encourage turn-over and revenue, or in other cases because of sterility concerns, rather than issues of degradation of the item itself, as one might worry about with a medication.  The primary example I will mention is the oral airway.  This is a small plastic item that comes in many sizes and is put into the mouth of the patient during or at the end of surgery to keep the tongue out of the way and the airway open.  It’s not sterile.  It doesn’t change with time.  But the ones we had were in individual packaging that included an expiration date.  And the case that we have been drawing from for several years was thrown away because of these dates.  In the U.S., manufacturers are often now posting a “manufacture date” but no expiration date to avoid this issue.  Common sense.  Unfortunately, bureaucracy doesn’t often have any interest in common sense, but rather in creating rules and instituting rules, whether sensible or not.  We already knew about this one…It’s just worse this year.

We are working again at the “Social Security Hospital” in Latacunga, where we worked two years ago.  On our previous visit, we were easily able to coordinate our efforts with those of the hospital staff, and we were pleased with the level of cooperation.  So when advised that we’d be working there again, we were optimistic that we’d encounter a similar situation.  And for the most part, everything has gone very well.  But some new requests and requirements have surfaced, that are painfully reminiscent of the hassles we work around due to insurance and billing and prior authorization at home.  These are the sorts of things that we hope to leave behind when we embark on our surgical missions, but alas, it seems that the future holds the same hassles in Ecuador as at home.  By that, I’m referring to a number of surprise requests we’ve encountered over the past several days of operating.

First, we were asked to provide the lists of the patients along with diagnoses, planned procedures, as well as the surgeon who would be doing the procedure and the anesthesia staff.  This may sound like a reasonable request, but we were asked to provide all of this in Spanish.  Again, hardly unreasonable, but since our electronic medical record-keeping is in English, this would have to be done by hand, rather than just printing them the lists of the surgical schedule, as we have done normally in the past.  A little bit of back and forth with the administrators resulted in the compromise that we would provide the lists, as usual, and they would have their residents translate and input the information into the hospital system.  I also explained that the list was not always specific as to who would be doing minor procedures, since we all did those based on who was available.  They just asked that we provide a surgeon’s name.  Okay.  We could handle that.  Accuracy was apparently not an issue.

Next, on our second day, we were informed that some patients, who were “affiliated” with the hospital would also require detailed operative notes.  In Spanish.  Affiliated patients are those who are part of the Social Security system—anyone who works or whose parents work—entitling them to services provided by the government, including health care.  The hospital could get some reimbursement for providing their care, and in order to get the money, apparently more detailed records are required.  Again, while this seems like a reasonable request—and we used to dictate a note on all of the procedures in the early days of our missions—our surgeons are not fluent in Spanish, specifically the “surgical” Spanish that one would need to dictate an operative note. I also explained that these were not standard (since each case is very different, especially on the secondary and tertiary procedures done for cleft lip and palate), so providing a standard dictation was not possible.  Again, with some negotiations, we decided to provide a dictated note in English to the resident working on any given day, and he or she would provide a Spanish summary.  Since this only applied to between four and six patients, it was not a terribly formidable task, but it would have been nice to know this in advance, so that we could have been prepared with a recording device, for example.  No such luck.

These are observations, rather than complaints, since our job is to provide care in spite of a variety of challenges, and we always have to be flexible and accommodate the ever-changing world of healthcare in the developing world.  But when we head to Ecuador to provide care, one of the best aspects of the work is that our efforts are focused on delivery of care, rather than on the business of providing that care.  That’s what we leave behind.  The term “pure medicine” was thrown about at one point while discussing what we do here, and unfortunately, pure medicine is no longer the reality of our mission.  We must now deal with the challenges that our hosts face when they offer space and allow us to provide the care to their patients.  We are required to deal with their realities, things we’ve been struggling with at home for a long time, which are now spilling over to the developing world.  It will be interesting to continue to watch the evolution of Ecuadorean healthcare and adjusting the execution of our mission to meet the needs that arise in time.  It will no longer just be about fixing lips and palates and hands and burn scars…