We send three teams to
Guatemala each year: a Neurosurgery team “Project Shunt”
from the University of Michigan with Dr. Karin Muraszko as Team Medical Director;
a Pediatric Urology team from Michigan State University/Sparrow Hospital and
Cleveland Clinic with team leaders Dr. Donald Bartkowski and Dr. Jonathan Ross; and
a Pediatric Urology team from Indiana University/Riley Hospital with team leaders
Dr. Martin Kaefer and Dr. Scott Walker.
Dr. Ross from Cleveland Clinic sums it up well, ”There are so many wonderful aspects to our trips to Guatemala. There is of course the gratification of helping children whose parents are so grateful, and the opportunity to meet the special people of the Fundacion Pediatrica Guatemalteca who give so much of their time and energy throughout the year caring for these children. The tremendous camaraderie among our team and our counterparts in Guatemala makes the trips even more rewarding. We always feel a bit embarrassed when people praise the work we are doing, since for us it is so uplifting – doing work we love with people that share a common goal, in an exotic place with a different culture. The week for us is a chance to recharge our professional and spiritual batteries. We are truly honored to have the opportunity to take part in these missions and be allowed into the lives of the children we help care for in Guatemala.”
Our PediUro teams have
been traveling to Guatemala City since 2001. We knew we
were needed; according to our liaison, the Fundacion Guatemalteca Pediatrica, it was
the first time in many years that such services had been offered in the country.
We’re proud of the good work our team, made up of doctors from Michigan State
University/Sparrow Hospital and the Cleveland Clinic, did there. (Why the unusual
combination? Team leader Dr. Don Bartkowski of M.S.U. called on his friend
Dr. Jonathan Ross of the Cleveland Clinic to help him assemble the group.) .
This unique hybrid group makes for great camaraderie and friendly rivalry.
The team performs very sophisticated urologic surgeries not available in
In what has come to be
the classic scene, children and their families line up outside
the clinic many hours before it opens. Their patient determination to see the American
doctors touches the hearts of all our team members- it always does.
Dr. Bartkowski sees
his experience as a chance to practice medicine outside what
has become the normal context, “an environment emphasizing medical economics,
patient management control and changing medical insurance plans, where medical/
legal expectations are often beyond human performance, where ‘doing your best’ is
less than a minimum standard.” In Guatemala, our team gives medical services to the
children they see, and the children and their families give them boundless gratitude.
It was that simple--and it always is.
“I accepted this
invitation with the hope of rediscovering my desire to help those in
need, with only the satisfaction of helping in return,” Dr. Bartkowski says. “Little did
I know how powerful and rewarding that satisfaction would be.”
The team’s sponsor in Guatemala City is the Fundacion Pediatrica Guatemalteca. Surgical technician Edwin Visalden reported upon returning from one trip, “Each year that we have returned, they have made improvements, but this year was really surprising. There is a new clinic that is much more spacious and workable and they made upgrades at the hospital. They have also done something that was very pleasing to all of us. There is an area in Guatemala City that is a dump (literally): 4,000 families live there. They live off the garbage for both their income and their food. It is very sad to see. The Fundacion Pediatrica built a clinic and placed it right at the edge of the dump, so that these unfortunate people who cannot make the trip to the distant clinic, can have one available to them. It melted our hearts.”
Forming partnerships with
like-purposed organizations has always been a great source
of strength and efficiency for Healing the Children. One of our valuable links is that
with Project Shunt, the brainchild of Dr. Nicholas Boulis, an HTC medical trip veteran.
As a resident, he organized a group of neurosurgeons and anesthesiologists from the
University of Michigan to travel each year to Guatemala City to help children who
desperately need treatment for hydrocephalus and other neural tube defects.
That was in 1998; today, Dr. Boulis is on the staff at Cleveland Clinic but still travels
with the University of Michigan team.
Here are the words of his mentor…
For the past nine
years, members of the University of Michigan Departments of
Neurosurgery, Anesthesia, and Operating rooms have organized a trip to Guatemala
to perform neurosurgical procedures for indigent children. The out reach is titled
Project Shunt. Working with Healing the Children, as well as the Pediatric Foundation
of Guatemala, the group provided much needed neurosurgical care to children in
Guatemala. Guatemala is a country with an emerging middle class but with significant
disparity between the classes. The majority (52%) of the population is under 18.
Of Guatemala’s 5.4 million children, 83% live in severe poverty. Guatemala has one
of the highest incidences of spinal bifida because of dietary issues, genetic
predisposition and poor prenatal care.
During our latest
medical mission we performed 31 neurosurgical procedures including
repair of myelomeningoceles, untethering of spinal cords and surgical management of
hydrocephalus. For the first time, we successfully performed an endoscopic third
ventriculostomy to treat hydrocephalus. The team was comprised of three neurosurgeons, three anesthesiology faculty, one pediatrician, a pediatric intensivist, three neurosurgical residents, two anesthesia residents, eight nurses and three ancillary personnel/translators. In weeks leading up to a mission, we ship some 8 pallets of equipment and each team member brings a foot locker of medical equipment, including our sterilization units. Preparation for each trip begins as soon as the last trip has been completed. Fund raising is on going throughout the year and includes a sale of various handmade Guatemala goods that are purchased each year.
In addition to performing operations, the group provides teaching to other surgeons, nurses and parents. An important educational objective was to improve the quality of life for children with spinal bifida and train the health care professionals in state of the art management techniques. By developing an intermittent catheterization program and providing catheters to patients and their families, there has been a dramatic decrease in urosepsis and death among these patients.
Industry support has
been important and has allowed us to bring shunts to Guatemala.
In addition, medical supplies are both purchased and contributed by the University of
Michigan and various vendors. Significant contributions are also made by a variety
of individuals and friends of Project Shunt to assure that all expenses are met.
It was the goal of the
group to provide identical care to the children of Guatemala as
that received stateside at Mott Children’s Hospital at the University of Michigan. With
each trip, we create three operating rooms, almost from the ground up. Included in
this are supplies for both preoperative and post operative care. Aligning with the
Pediatric Foundation of Guatemala has been important and assures that each patient
gets adequate pre-operative screening and postoperative care.
The complexity of the cases has increased and it is now routine for us do some of the most challenging spina bifida cases such as diastomatomyelia or complex lipomas. By assembling such a complete team we have been fortunate to have few complications and some very rewarding successes. This is truly a team effort. We create a pediatric neurosurgical hospital for the week we are there. This includes the pre-operative clinic, the OR, the post operative care unit and the subsequent inpatient care. For each of the medical participants, it is very apparent that the experience reaffirms why they became health care professionals. The smiles on the children’s faces and the look of hope in the parent’s eyes help us understand the impact of this work and gives us inspiration to return yet again.
Karin M. Muraszko MD,
Julian T. Hoff Professor of Neurosurgery
Chair, Neurosurgery Department
Chief of Pediatric Neurosurgery
Medical Director Project Shunt
Although we are the
Michigan-Ohio Chapter, sometimes our reach extends beyond our
borders even here in the U.S. Dr. Martin Kaefer, Pediatric Urologist from Indiana
University/Riley Children’s Hospital, traveled with one of our teams to Lithuania in the
1990s. So in 2002, when he and colleague Dr. Scott Walker an anesthesiologist,
decided to lead their own teams to Guatemala, they called on us to help with the
logistics. We did and their multi-state teams with members from coast to coast and to
the north (New York, California and Minnesota) have traveled to Guatemala ever since.
Working with our liaison, Fundacion Pediatrica Guatemalteca, almost 200 children
have received life-altering surgeries and scores more have received non-surgical care.
The teams work side-by-side with Guatemalan surgeons, pediatricians and other
care-givers. This has allowed for educational opportunities and excellent post-operative
and follow-up care. Together with Dr. Kaefer’s sister, Dr. Maria Kaefer, the team
hopes to continue this important mission for many years to come.
The beauty and the
bonus are in the collaboration of Urology teams. This group travels
at opposite times as the PediUro team from Michigan and Ohio. They are able to
follow-up and each others cases and give the best of care to the Children of Guatemala.
Team Indy 2006: Dr. Martin Kaefer, pediatric urologist and team leader; Dr. Scott
Walker, anesthesiologist and team co-leader; Dr. Jordan Gitlin, Dr. Andrew Freedman,
Dr. Steve Lerman, pediatric urologists, Dr. Maria Kaefer, Family practitioner/
pediatrician; Dr. Stacy Kritzmire, anesthesiologist, Dr. Michelle Bowlen, Anesthesia
fellow, Angie Ebersole, Anna Pfister, Robin Merritt, Marjorie Pappaioanou, and
Mary Pierce, registered nurses.
Team Indy 2004: Dr. Martin Kaefer, pediatric urologist and team leader; Dr. Scott Walker, anesthesiologist and team co-leader; Dr. Jordan Gitlin and Dr. Rosalia Misseri, pediatric urologists, Dr. Maria Kaefer, Family practitioner/pediatrician; Dr. Morton Green, anesthesiologist, Angie Ebersole and Kathy Allen, registered nurses.
In the words of Dr. Ross, we had a great team again this year in Guatemala. We were able to help a lot of children and the week flew by as always. With each year we become more comfortable performing complicated surgery in this setting, and this year we were able to perform several complex bladder reconstructions in children with very difficult urological problems. Once again the mission was extremely interesting, gratifying and humbling. Being able to care for these children and their families is a unique privilege and the team always returns home with a new energy and sense of purpose.
PediUro 2006 Team members were: Dr. Donald Bartkowski, pediatric urologist and team director; Dr. Jonathan Ross, pediatric urologist and team Co-Director; Dr. Julie Niezgoda, anesthesiologist, pediatrician; Dr. Curt Carl and Dr. Marc Domsky, anesthesiologists; Dr. Marc Mitchell and Dr. Ryan Berglund, urology residents; Dr. Pilar Castro, anesthesiology resident; Kermit Day and Mary Pride, registered nurses; Kim Horn, Edwin Visalden, Shauna Lunato, and Hank Kraft, surgical technicians; Sara Schultz, medical student, translators, aide.
Sara Schultz, a medical student and veteran team member offers her reflections.
Throughout my life I have been fortunate enough to travel to a number of Spanish-speaking countries. My experiences began when I was16 years old, when I traveled to Paraguay for a summer to give vaccinations in the barrios of Asuncion. It was a summer filled with adventure, and it solidified my love for two things—Spanish and medicine. Since that initial trip I have participated in any opportunity that combined these two things. So when the opportunity arose to participate in a medical mission trip to Guatemala with a team of urological surgeons, I jumped at it. During my second year of medical school I was first offered the position as a Spanish translator and team aide. It was an amazing experience and provided me with countless opportunities to learn more about medicine, and of course Spanish. When I was asked to return the following year I was thrilled. However, my responsibilities had increased significantly. Now, I would function as the translator, preop nurse, PACU nurse, and the intern. I was somewhat intimidated by what lay ahead, but I knew it would be another amazing year in Guatemala.
The first day we arrived we traveled to the clinic where we would be working that year in order to unload supplies that we brought from the United States. Each year the team brings 98 percent of the materials we will need, including surgical instruments and medications. The second day is “clinic day”, during which we see and meet all of the children who may have surgery during the week. The children have been seen over the course of the year and are referred to the pediatric urologists on the team, Dr. Ross and Dr. Bartkowski. The families may wait an entire year for the week that we arrive. Despite the short amount of time we are there, we are able to accomplish many procedures for the children that local physicians are unable to perform due to lack of training, materials, and technology. During the clinic we also see follow-up patients; some who will need the second and third stages of procedures and others that just come to visit. Often these families travel for days from the countryside and mountains in order to reach Guatemala City and to attend the clinic. They typically wait overnight before the clinic day so that they are sure to be seen, because they know that the alternative could be waiting for an entire year longer. They patiently wait for hours and hours as we go through the rooms full of patients.
This year we saw 86 patients on the day of clinic. I am always amazed by their patience and gratitude; no one ever complains about the wait or leaves the clinic without being seen because they are tired of waiting. We evaluate the patients in order to see if they are surgical candidates or would be more appropriately medically managed. After we determine which children are eligible for surgery we triage the cases and schedule the most emergent and complex cases that we can perform given the equipment and timeframe. Some children are referred to the U.S. for surgery because the cases are too complicated and dangerous to perform. By the end of the day we have a tentative OR schedule, and the families are informed of the day and time they are to report to the clinic. This year we scheduled 25 cases to be completed over the five days. Some patients are required to have studies completed and to come to the clinic with the results to see if they can be added onto the schedule depending on the results.
Each child had a unique situation and affected me in a significant way. I think about the children often and miss them. I hope that they are all doing well, and I look forward to seeing them again. I could easily write about each and every patient, but then this paper would turn into a novel! However, I would like to share the story of one little girl in particular. Her name is Maria Elena (name changed for privacy) and she was nine years old at the time of her operation. Maria Elena had been seen by many doctors throughout Guatemala and had also been seen by multiple specialists when they were on medical missions from the US. She had been through several urological operations and also had a history of spina bifida. Despite multiple procedures Maria Elena was left with an ostomy in her abdomen that required her to wear diapers. This year she was having a critical operation: a bladder augmentation so that she would no longer have to use the diapers. This was a particularly exciting concept for Maria Elena, because she was a fully functional little girl who attended school, and with the success of the procedure, would no longer be embarrassed by her condition. She was extremely friendly and would often break into a HUGE grin during our conversations
Maria Elena had her operation on the first OR day (Monday) in case there were post-operative complications and so that she would have ample time to recover while the team was still in Guatemala. Her operation went well, but because of her history of spina bifida she was not able to have a caudal, and therefore no pain pump could be used. This made controlling her pain after surgery particularly challenging.
The next morning when we returned I started on rounds and checked Maria Elena first. She didn’t cry, but I knew she was in pain because she barely looked up at me and never gave me one of her characteristic smiles. We immediately gave her more pain medicine, though it was difficult to control completely because of her major surgery. But, Maria Elena had tremendous strength and determination. She would use her incentive spirometry everyday and attempted any task we suggested. On the day that she finally was able to get out of bed and take her first few steps her enormous smile was back and it was highly contagious! On the day Maria Elena left the hospital she was doing very well. She was excited by the fact that she would no longer need to wear a diaper and could begin to live the life of a normal nine year old child.
Providing service to underserved populations is very important to me. It is one of the reasons I wanted to go into medicine in the first place, and having the opportunity to participate in this medical mission to Guatemala has been therapeutic for me. During my first two years of medical school I began to question whether I belonged there. I lost sight of the ultimate goal and became overwhelmed by the books and tests. Going on this trip for the first time when I was in my second year helped me tremendously. It reminded me of what medicine is about and showed me that once I make it through certain steps I will be able to participate in patient care. It also provided me with a new perspective on how fortunate I am to train in the US and to live in a place where the most technologically advanced healthcare is available.Although I learned many important things about myself, the most important lessons I learned were about the human spirit. I experienced firsthand the tremendous love parents have for their children and the strength and courage that children embody. Of course this love and strength can be seen in patients here at home, but it is different in Guatemala and other developing countries. It’s amazing to see such selflessness in the midst of extreme poverty. The children also have a physical strength that is unlike what we typically encounter here in the U.S.. They smile through excruciating pain and live with conditions that we would not dream of. But what I find most interesting and inspiring is their attitude: they are polite, courteous, cooperative, and hopeful. Despite their fear, they listen and attempt to complete whatever tasks lie ahead of them without complaining. Perhaps it was their parents encouraging them – and occasionally yelling at them in Spanish – or perhaps they realized that this opportunity might be one of their last chances to be healed. Whatever it is that drives them, it’s catching, and it inspires me to work harder so that I can someday be a better doctor and take care of other patients in similar positions. I am grateful to have been a part of the Guatemalan team, and I look forward to returning for many years to come.
Medical student Nicola Fynn served as an aide and translator for an HTC medical team when it traveled to Guatemala in 2005 to evaluate and treat children suffering from urological ailments. She has written a fascinating account of her experiences.
Our PediUro 2005 team: Dr. Donald Bartkowski, pediatric urologist and team director; Dr. Jonathan Ross, pediatric urologist and Team Co-Director; Dr. Jeannette Potts, urologist, family practitioner; Dr. Joseph J. Kochan III, anesthesiologist; Dr. Julie Niezgoda, anesthesiologist, pediatrician; Dr. Marc Mitchell and Dr. Justin Albani, urology residents; Dr. Augusto Torres, anesthesiology resident; Kermit Day, Betty Siska, Gloria Oster, and Mary Kisting, registered nurses; Vicki Lynn Allison, Lori Lewis, Debra Simmons, and Hank Kraft, surgical technicians; Sara Schultz and Nicola Fynn, medical students, translators, aides
I am a third-year medical student joining this well-established group on what will be not only my first mission trip with this team but also my first trip to Guatemala. I am both excited and intimidated to be working with these fine people. I have traveled extensively in South America, and I expect that Guatemala will be similar in some ways. I have very little experience in urology or pediatrics, but I am looking forward to what I hope will become a rewarding challenge.
Welcome to Guatemala: The Clinic
We landed on a short tarmac with brakes on full and were surprised that customs simply waved us through with our trunks once we mentioned our work. It had not been so easy in previous years to get into the country with all of the instruments and medicines in tow. This year, we were fortunate enough to arrive just after two other members of our group who paved the way with customs for us. They were able to stop the investigation of materials just before the officials opened sterilized instruments. While all this was going on, another customs official sat back at the desk singing and playing guitar. Our hostess, Maria Jose, met us with a brilliant smile and we were off to the hotel to rest up for a day of clinic. Welcome to Guatemala.
Fortunately, Maria Jose knew to ask for rooms away from the pounding music of the nightclubs across the street. So we were bright-eyed and bushy-tailed as we hopped into the van after a quick café con leche and some platanos fritos. We stepped into the clinic to find a lobby packed full of concerned, hopeful parents and young, timid patients. The children ranged in age from weeks to 18 years old and had a variety of complaints from mild to severe. Each of our two surgeons took an exam room and a translator and began to see patients. More than 50 children hoping that urologic surgery might be the answer to their problems had been notified to come to the clinic that day. One after another, we examined their fistulas, hypospadias, stomas, and ureteral reflux. Then the family would leave the room with a red card designating them for surgery, a yellow card indicating a medical treatment, or a blue card referring them back to clinic.
At midday, the lobby was still packed, and it seemed we would never be able to see everyone in one day. It dawned on me sometime late in our long day of consults how mature these kids were. Some had been waiting patiently on Mom’s lap for almost 12 hours without whining or pouting, not to mention the time it might have taken for them to get here. The ever-present sense of entitlement, so common at home in the U.S., was completely lacking in this room full of Guatemalan families. In the end, we couldn’t help all of them, but we made plans to help more than half of those who came for consults with surgeries planned in the upcoming week.
Doctora Andrea Cruz, one of our gracious hostesses, spent the day with us making sure things went as smoothly as possible. Once everyone had been evaluated, Dr. Bartkowski and Dr. Ross retired upstairs with their residents to put thought into the week’s surgery schedule. What could they accomplish each day? Did they bring the necessary equipment for all the cases? Would there be time to followup after complicated cases? Once the surgery appointments were made and distributed to the waiting families, we dragged ourselves back to the hotel to recuperate.
Dinner at Kakao was fabulous. I had coconut chicken in mango sauce and tres leches to die for. The best part of the evening, however, was the dinner conversation which centered on religion and spirituality, jokes, and old stories. All in all, it was a wonderful opportunity to know these people and to come to know old friends better. The remainder of the team arrived on the late flight; now our group is 18 strong.
Sunday morning, our troop of 18 set off to set up the operating rooms at the hospitalito. The hospital was a two story building with cartoon characters freshly painted all over the walls. The lobby, two examining rooms, and the administrative offices were on the first floor. A ramp led to the second floor, where we found four nursing rooms with four children’s beds in each, a small post-op recovery area, and three little operating rooms.
We hauled boxes of stored materials up to the second floor ORs, unpacked them, created makeshift shelves, organized medications, and then stocked sutures and gloves. It was quite a while before it began to look like we could care for any patients. Only the scrub techs and nurses were able to recognize all of the equipment and put it in its correct place, so I wasn’t able to contribute much more than physical labor. I did, however, manage to help out a bit by alphabetizing our pharmacy shelf. Fortunately, some members of our group had both creative minds and electrical skills that enabled them to rig up lights and revitalize old equipment found in the storeroom.
We finished setting up in the early afternoon and had some time to experience a bit of Guatemala City before dinner. So, we spent a relaxing afternoon at the artesania market admiring local crafts and mentally preparing ourselves for the week ahead.
The Operating Room
Our first surgical case of the week took three times as long as planned and set the precedent for the week. This poor boy had six surgeries in one, and at a young age, he is already no stranger to the OR. He is a beautiful, intelligent boy, and you would never know unless he took down his pants and opened his diaper that he was born with severe exstrophy and that his pelvis is an anatomical mess. After twelve hours of surgery, Dr. Ross was able to bring down both his testicles, fix a hypospadias, close two fistulas, and place a suprapubic tube. With this first surgery, we also found out just how hot it can get under surgical lights in a windowless OR while draped in latex and plastic. The thermometer hit 86 degrees F despite a mobile AC unit and fans blowing our drapes and sutures around. It was more than worth the time and effort, however, when he awoke pleased with the results, and his parents couldn’t hold back their tears. We had the pleasure of his bright smile and insightful questions for the next few days as he recovered before going home. I couldn’t believe how patiently the next boy had waited with his mother all day and then graciously accepted the news that we would have to delay his surgery because of the length of the first case.
La Fundacion Pediatrica took us out for a late dinner once both operating rooms had finished. We learned more about their far-reaching activities, including dental clinics, food distribution, and surgical missions, and about their goals to expand. Ultimately, they want to build the first exclusively pediatric hospital in Guatemala, a challenging and admirable goal to be sure. Already, they have overcome great obstacles and succeeded in reaching children with hope and help. Despite our engaging dinner conversation, Dr. Ross was still deep in thought, pondering the young boy’s surgery, his recovery, and his future.
On day two of surgery, we began to encounter some technical challenges that shed light on the first-world privileges to which we’ve become accustomed. As it turns out, we did just fine without the special underwater bovie whose absence had caused some concern. Dr. Albani and Dr. Ross were able to improvise with some suture when it became apparent that we didn’t bring a stent grasper. The cystoscope also caused some worry when we found that most of the lenses were too large for the scopes. One of our scrub techs put his electrical skills to work and was able to get the light source up and running. All of these setbacks were eventually resolved without too much trouble, and the kids were able to receive the care they needed. The heat in the ORs was also much more tolerable once we had some music to keep our minds off the sweat tickling our backs – at least until one of the two electrical outlets in the room stopped working and the bovie and the fan took precedence over the radio. We never did find a good solution to the bothersome fact that the surgical light hung low over the operating table and our tall gringo surgeons were constantly hitting it with their heads. Another late night in the OR followed by a high protein dinner and deep sleep …
Later that week, I got to meet one of Hank’s (one of our surgical technicians) old friends. She was a patient on a previous mission, and her story is touching. Her father accidentally drove over her in his car when she was a toddler, and the accident had left her incontinent. She was twelve when she received her surgery and had only a second-grade education because her incontinence prevented her from going to school. With surgery, she became continent and was able to return to school. With Hank’s friendship, she was able to learn some English as well. The whole family makes an effort to visit him each year when the team goes to Guatemala, and I was touched to witness their reunion.
Another young boy came from a convent three hours outside Guatemala City. The nuns at the convent have started a program with the goal of feeding children who have failed to thrive. He fell into this unfortunate group of children after suffering a terrible accident as a child. His grandfather was holding him as a baby when someone shot his grandfather twice, inadvertently shooting him as well. His was one of the week’s simpler surgeries, but we hoped it would be the first step in helping him with the complex issues surrounding his incontinence. He limped in on crutches in the company of a nun and his mother, but when I think of him all I remember is his wide, easy smile. It seems that I won’t be able to leave Guatemala without each of these kids tugging on my heart strings and weighing on my mind.
Thoughts and Impressions
I left Guatemala much too soon for my liking but with the hope to return. All of the children and families I spoke with this week are already weighing on my mind, and I hope to learn that they are healing well. It’s clear that la Fundacion Pediatrica and Healing the Children have worked incredibly hard to provide care for these children who might otherwise be without hope and without help. Coming to Guatemala has reminded me of the people and causes that drew me to a career in medicine in the first place, and I hope that my future in medicine is full of similar opportunities to reach the underserved in any and all corners of the globe.