July 2014: Cochabamba, Bolivia

Kevin Kirkland and Kristin McCormick – M2s

KU School of Medicine-Wichita

Hospitals of Hope (Hospitales de Esperanza)Vinto, Cochabamba, Bolivia

http://www.hospitalsofhope.org/

The HoH Logo

Bolivia

Personal Goals

Kevin:• 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

Kristin:• 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 (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

• Construction on the roads near the hospital

• Transportation workers often go on strike

• Lack of laws about moving over for EMS vehicles on the roads

Ideas for Improvement

• Arrange a hospital-run transport system for patients only

• 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

• The Bolivian federal government continues to threaten the independently-run hospital• Seeking governmental control

• Patients are unaware of the low-cost services provided and protest the “expensive” clinic

Ideas for Improvement

• Seek increased funding of hospital staff salaries and care costs by private donors

• Educate patients about cost of care

• Attempt to make an alliance with the Bolivian government to keep the hospital independent

Challenge 3: Poverty of Patients

Observed Issues

• Patients seeking care at hospital often cannot pay for tests or surgeries when needed

• Those who need procedures must wait until their family can find the money, impeding their timely recovery

Ideas for Improvement

• Set policies of care which dictate a patient must receive prompt treatment regardless of upfront cost

• 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 year-round

Challenge 5: Resources/Education Available to Facilities

Observed Issues

• Protocols set in the US for better patient outcomes have not been passed on to Bolivian healthcare workers (outside-HoH site)

• Particularly in a pediatric burn unit, the protocols were attempted, but could not be followed due to a lack of proper supplies

Ideas for Improvement

• Increase funding

• Educate employees about newly discovered/better strategies for improved healing

• Implement a Continuing Medical Education program for Bolivian healthcare staff

Profound Clinical Experience: KevinTwo 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 ExperiencePerhaps 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