9 December 2009

A couple months ago, Dr. Guerrero called me on a Friday afternoon. Dr. Guerrero is a general surgeon that works in the Gotera Hospital, the hospital closest to the clinic where we work. I got to know Dr. Guerrero after he admitted a few of our patients from the clinic. I told him that I wanted to be a general surgeon like him after medical school, and we immediately hit it off.

This Friday, Dr. Guerrero called to tell me that he would be performing an operation tomorrow in the capital, and I was invited to tag along. I was thrilled and told him I would be on the next bus to Gotera. Two hours later, I arrived at the Gotera hospital as he was finishing his shift in the emergency department.

Dr. Guerrero lives in San Miguel, the largest city in the eastern part of the country and an hour drive from Gotera. We drove to his house and arrived by 6. I met his family, had a glorious dinner, and we were asleep by nine. The next morning we left at six for the capital.

Dr. Guerrero has a private surgical practice and also works in the public health system. He was operating on a private patient this morning in a private clinic. We arrived to the capital around nine and pulled up to the clinic shortly thereafter. The private clinic appeared nothing like the public hospital. The most noticeable difference was the utter lack of patients. My experience thus far in the public health system is that wherever you go, there are already 20 patients waiting in front of you. This private clinic was clean and tranquil.

Shortly after arriving, I introduced myself to the patient, and we changed into our scrubs. Dr. Guerrero was going to remove the patient’s gallbladder laparoscopically, which means he was going to make 3 tiny incisions and operate by using cameras. Laparoscopic surgery is ubiquitous in the United States. The surgery was performed without incident. I was thrilled to be in the operating room again and had a great time.

I have probably seen 20 gallbladders removed in the States. It was interesting to see the same operation in a developing country. Because we were in a private clinic the operation was nearly identical to what I had seen before. The operating theatre was smaller and the equipment was older, but it was essentially the same. Like I said, it was awesome to be back in the operating room. It reminded me how much I want to be a surgeon. After the operation we went out to eat with the anesthesiologist at Biggest, the Salvadorian equivalent to McDonald’s. Three hours later we were back in San Miguel.

Once we got back to Dr. Guerrero’s house he told me that he had to work that same evening and was wondering if I wanted to tag along. I said yes, we had a quick bite to eat, and went to the hospital.

Dr. Guerreo was pulling an all night shift in a social security hospital. This is a hospital somewhere between private and public, and as such it had elements of both. While it was very crowded, the hospital, Dr. Guerrero had access to the medicines he needed and could perform the tests he needed to make a diagnosis. Within minutes of arriving, we raced to another operating room where a surgeon had already begun an operation. He was removing the gallbladder of a woman. Although this was the same surgery that he performed in the private hospital, this operation was a bit different.

The operating room was the size of a large closet with concrete walls. The sterilized instruments were wrapped in old newspaper. The gallbladder was removed through an open incision. Unlike the three small incisions required to remove a gallbladder with laparoscopes, this open procedure required a 15 centimeter incision made across this woman’s abdomen. I had never seen a gallbladder removed in this way in the United States. In fact, there is clear evidence that open removal of a gallbladder is a significantly more morbid operation than with laparoscopes. You need a very good reason to perform this procedure openly in the States. But here in San Miguel, there was no other option. As always, I was thrilled to be in the operating room, but it was difficult to think about how much pain this woman will have and how much greater her risk of infection is because she was poorer.

The lack of laparoscopic procedures in this country is a result of a lack of equipment but also a lack of surgical training. Dr. Guerrero had to go to Europe to get his laparoscopic training. One of my career goals is to practice surgery in a developing country like El Salvador. I see a great need for a well-trained surgeon in a place like this. Besides the opportunity to help a lot of patients, I would also have the opportunity to bring the benefits of laparoscopic surgery.

--Bela