Quality--Standards of Care for medical mission trips

One of the great things about medical mission trips is that the record keeping is much less than our daily office or hospital lives.  In fact, on some clinic days, it is barely existent.  It feels great to not have a pile of paperwork staring you in the face at the end of the day.
We are changing that.
While we have no love of paperwork (just ask the nurses at my office), haphazard record keeping is not helping the patients we go to Haiti to serve.  We have a responsibility to our patients to document their care.  Turn it around.  If you were seeing a physician, and they kept no record of your condition or the medication they prescribed, would that be acceptable to you?
It is not acceptable to us.  It is tedious to document, but it is important.

This last trip, we started using a new encounter form that can document multiple visits, a problem list, medication list, and a photo.  We purchased a mobile printer  (Canon PIXMA iP100 Color Ink-jet printer)

 to print photos for those chart. We would like to work as the guinea pigs for developing a standard for medical mission groups working out of HCM  as well as other areas where we expand.
We will also audit a portion of the charts randomly for completeness and best practices.
If anyone knows of an easy way to do this electronically, I am all ears...We will be looking for low-cost portable electronic medical records as those would be ideal for our needs.

Starting with our next trip, we will require all applicants to submit current credentials, licensing, and each team member will apply for a specific role within the team (at least for the medical members).  All medical professionals will only be asked to function within their normal scope of practice on the trip.

Our name tags, starting next trip, will be issued as photo ID badges (we used ID badge-like name tags for this last trip, but no photos).

We have been working on a standardized formulary based on cost and appropriateness for the population we are serving.  We will develop standard dosing guides with recommendations for all medications within our formulary.

Finally, we will begin to offer at least two hours of medical education per trip on regionally specific conditions.  I will work to get those accredited for CME and CEU credits.

Our goal is to keep the standard of care on our mission trips as close as reasonably possible to the standard of care at home.  We welcome any suggestions in the comments here or on the facebook page.

Tuesday, May 15th, 2012--Trauma (Guesly 2 of 2)

Guesly:
I am walking back to the room with a nurse when I hear my name being called urgently outside. I once wrote that I have my own preferences for how I would like to practice medicine, but my previous trips to Haiti have taught me Haiti does not care about my preferences(No Guardrails), and I must expect the unexpected with every step.

I emerge from the hospital door in time to see a Haitian police truck rushing through the rocky courtyard maneuvering between the tree trunks. I know from my past experience that whatever can get the police stirred up and rushing headlong into the mission cannot be good! I have often seen Haitian police officers standing on the street or sitting underneath a tree like they do not have anything to do. Maybe I am being a little harsh, but that makes the sense of urgency they bring all the more alarming.  Once I get a closer look into the bed of the truck I see five people. They are bloody. Some were screaming, and others look to be in shock. Just as my thoughts are coming together, The driver screeches to a halt, raising a cloud of dust which quickly envelops the vehicle. As the dust settles I hear "Dokte! Dokte!" and I rush to the truck, calling for some of our team members to help.

My mind flashes back to earlier this morning when majority of our team traveled to La Croix, about 4 hours away from Fonds Parisien. I had assigned myself to remain behind as the lonesome physician, thinking La Croix would have a greater need for doctors while I managed the relatively peaceful clinic in Fonds Parisien.

But I do have help here. I have Erika, a nurse who has been to Haiti multiple times. My medical assistant Kari has also been here before. Another nurse Trish is on her first trip to Haiti. The McLaughlins are a husband and wife dentist and optometrist, both Haiti veterans. The other team members are several first-timers, students from Corban University: Esther, Amanda, Courtney, Margaret and Caitlin.

One of the policemen fills me in on the crash.  these five were riding in the back of a tap-tap when they were all ejected after a head-on collision about fifteen minutes away. Tap-taps are the the primary mode of transportation in Haiti, They often start as pickup truck with makeshift modifications like added benches for seat and a solid metal cage for cover. One tap-tap could be packed with more than twenty passengers in the back. Although they are often very brightly and festively painted.

Watching them pass by on my various trips to Haiti, I have often wondered if the riders realize how thin the line is that separates a normal ride from a death sentence.

Though there is a swirl of activity, and things appear chaotic, some things do not change no matter where we are.  We must work systematically.  Erika and I start to examine the passengers to determine who is most critically injured. Erika asks for anybody who can walk to get out of the truck. One woman with minor road burns, several superficial lacerations gets out. In the furthest part of the bed of the truck we both agree that a woman laying there needs our help first. She has respiratory distress, facial swelling, scalp laceration, severe road burn to both buttocks and hips, severe abdominal pain, and pelvic pain. Once we stabilize her pelvis, survey her for other injuries, and start IV fluids, we turn our attention to the next woman. She has no obvious head trauma, but is sitting up complaining of severe abdominal and pelvic pain. She does not want to be touched. Just like the previous patient we are concerned about pelvic fracture and internal , and know we need to get both of them to a hospital with a surgeon.  She has less severe road burns and laceration but complained when I examine her pelvis, hips and abdomen. Similar to the previous patient we stabilize her pelvis, complete our survey, and start IV fluids.
We move on to a male patient who obviously has a severe left leg injury. He is an older man possibly in his early fifties, older then the first two patients who appear to be  mid-twenties to early thirties. He sits quietly with his left leg below the knee completely internally rotated with his big toe touching the floor and his upper thigh and knee remaining in the neutral position. While several of the nurses help I cut his pants legs off and notice that he has a closed, unstable proximal tibia and fibula fracture with marked deformity and a distal tibia and fibula fracture without noticeable deformity. I work on placing a splint to stabilize his left leg while Trish and Erika fight with him to start IV fluid. It is strange how he does not fight, resist, or act like he is in pain when I am placing the splint  to his left leg, but he fights with two nurses because he did not want to be pricked by a needle.
Lastly, we turn our attention to the less severe injured of the five. There is an older woman in her late fifties to early sixties. At first glance, she had multiple large road burns. The burns start below both of her eyes and forehead which indicate that her face has struck and skidded on the rough, dusty road. Her arms are a mess of large burns extending from her elbow to her mid forearms, her mid thigh to her knees, and her lower legs. Looking at her toes, I notice that most of the skin has been rubbed off with the most involving the inner aspect of her right great toes. All are bleeding. She is quiet with glassy eyes, in shock and does not seem to know what was going on. With initial assessment and secondary assessment I do not notice any major head, lung, or internal injuries. Could this be a concussion or minor brain injury possibly?  She does not have any pain when I examine her head, neck, chest, abdomen, and pelvis.  She has severe pain with evaluation of her knees. Once she was stabilized we know that we need to get four of the patients to a hospital with a surgeon. 

When I arrived on campus few days ago, I notice that only one of the two donated ambulances was parked at the mission. I was told that one of the ambulances is in Port-au-Prince being fixed, and the other ambulance is not functional.  Yesterday, before the accident, one of our team members Jerry King who is an engineer and a mechanic from the Mennonite mission help fix the ambulance that has been parked at the mission for weeks.

With only one ambulance I know we will have to arrange all the patients to fit. Getting them to a hospital Port au-Prince would take us over an hour without traffic, but heading there in mid day traffic will be worse. I know I can not take the chance of leaving any patient behind as there would be no physician  to assess them if something goes wrong. After careful arrangement, we get all the patients to fit. Three of the patients are secured to gurney and one patient is secured to a seat with a seat belt. Erika and I jump into the back of the ambulance, and we  ask Amanda, a student from Corban college, to join us.  When the door closes, the ambulance driver takes off like a rocket, jolting all three of us against the side of the ambulance as we are not yet secured.  Unlike the United States where people usually recognize the importance of yielding to an ambulance siren , in Haiti there is no awareness from the other traffic as our driver attempts to pass other vehicles going over 70 miles per hour while avoiding potholes, other vehicles, pedestrians, and animals.  It is easier not to watch, and Erika and I are busy diving to hook back IV fluids that have come loose, aiding one of the patients who is vomiting, soothing the other patient who has just been vomited on, addressing wounds that restart bleeding. Through all this chaos, I have to keep strongly reprimanding the driver in Creole to slow down as I am afraid he will crash us, and what good would that do?
After an hour and a half of white-knuckle driving we make it to the hospital where I give report to a French trained physician. While the craziness of getting these patients to a hospital that is better equipped to handle trauma is important, what is even more gratifying is that we find a hospital that is willing to care for them. Teams before have had huge problems with that (Jeff's Story)  Haiti, must have a better solution! We need to continue to help improve the facility we have at Haitian Christian Mission to handle any situation. 

I am thankful for having the amazing team members: the trained medical personnel as well as all the Corban students who responded while we were dealing with this trauma and showed great teamwork and willingness to help.

Tuesday May 15th, 2012--Cholera (Guesly 1 of 2)

Guesly:
"Dokte! Mwen gen dyare pou twa jou ak paske se mwen tèlman fèb, mwen vle tonbe." Peering at me through sunken eyes, she is telling me she has had diarrhea for 3 days, and she is so weak that whenever she tries to walk or stand, she feels like she will pass out. I sit less then an arm's length away, looking at this frail woman as she struggles to climb onto the exam table. She is cachectic, wasted. Her face is a shriveled prune. Her skin has lost any semblance of its normal elasticity due to her severe dehydration. She is only forty-two, but I could have easily taken her for sixty. Haiti, with the punishing sun and heat of the physical climate and the punishing daily struggle for good food, clean water, and decent shelter of the economic climate, ages everybody before their time. Her dehydration from the diarrhea has magnified that effect. In contrast, I can tell by her clean, nicely pressed yellow dress that she must have put in much effort to look presentable. Regardless of how poor or sick people are in Haiti, they always wear their Sunday best to look clean when they see a doctor. 

Her eyes appear fixed on me as if reading my thoughts. She continues “I can barely leave  the twalet before I have to go back to it. It has taken tout enèji mwen, all my energy, to not just want to stay there.” I can't help realizing how close she is sitting to me as I think about cholera. Haiti has been battling cholera since it came in 2010 with a UN team after the January earthquake. Before that Haiti was cholera-free for more than 100 years. Haiti has its share of diseases, natural disasters, and civil unrest. Now Cholera is taking those wounds and rubbing salt into them. Cholera seems cruelly designed to take advantage of Haiti's weaknesses. It is caused by the bacterium Vibrio cholerae.  When someone drinks water contaminated by cholera, it thrives in the intestines where it makes a powerful toxin that causes the walls of the intestines to literally pump out water from the body. An untreated person can lose up to 20 liters of fluid in one day's time. Humans, on average, only have about 3 liters of fluid in their blood vessels, 15 liters of fluid outside their cells, and 40 liters in the entire body, so that kind of water loss is devastating and can be rapidly fatal, even in someone who was previously healthy and well-nourished. If any of the diarrhea makes it back into the water supply, the bacteria continue their spread. Haiti has very little of either sewage treatment or drinking water purification. It is not uncommon for one stream to find use as wash water, bath water, drinking water, and as a latrine. Haiti also has no shortage of weak, malnourished people. In some ways it is surprising Haiti stayed clear of it for so long. I look at my patient, it seems likely she is yet one more cholera victim.

I do not withdraw from her. She is looking to me for help.  I know that cholera is highly contagious, but I also know I must set aside any concern for my own health to minister to hers. Once my questioning is done I get up to examine her after taking necessary precautions. Everything I see confirms my suspicion.  This woman needs treatment and IV fluids.  Fortunately, Haiti has established centers for treating cholera victims, and we can send her there.  As I finish, I exit the room to ask one of the Haitian nurses for help in transferring this patient to the cholera camp.

Thursday, May 17, 2012--Hard Decisions

Sabine:
On Thursday I stay at Haitian Christian Mission with Dr. King while the other providers go to Port-au-Prince. We settle into what has become a typical clinic day.  Everyone is hustling to take care of the patients at the clinic, and I am seeing my share.  Just after lunch,  a mother enters the room with her 18 month old boy. He is sleeping comfortably in her arms, but the mother is crying. I look at her and say  "Bonswa, what's going on with  ti bebe today?"  She tells me that when she leaves him, he has fits of crying so hard he stops breathing for a few seconds. I examine the baby.  He does not appreciate being awakened and fights and cries to let me know it. He looks thin, but well, and I'm about to tell her about breath-holding spells when she says " Li pa manje!"
" He won't eat? Poukisa? Why?"
"Mwen pa genyen lajan pou mwen achte manje pou li."
She has no money to buy food. As she continues to cry, she tells me she has two children and is pregnant with the third one.  After the second child, she started using birth control pills but got pregnant anyway.
Her husband was killed in a car accident 3 months ago, and since then, she has been unable to care for her children. He was the sole provider for the family. For the past 3 months, she has been going from one family member's house to the next asking for shelter for just a few days so she and her children would not have to sleep in the streets.
Her family has no money. They can barely feed themselves and their children, so she has been too ashamed to ask them for food.
I ask her to wait outside by the benches near the pharmacy and ask Erika to make up a bottle for the baby, not knowing if he will even take the formula since he is one and a half years old. I leave to go find Betty Prophete, but she is not around. So I find Dr. Maxine  and I explain to him the situation. He asks to speak to the mother, and when he meets her, he goes into a room with her for what seems like forever. The mother and child disappear from the clinic for about an hour and she reemerges with a 6yr old as well. Erika goes to give the 18 month old the bottle and he starts to guzzle it down. The mother takes the bottle when it still has a little formula left,  and she shares it with the 6 yr old.  He quickly downs the remainder of the bottle.  That is when we start to realize the gravity of the situation. Erika takes another bottle and mixes powdered Gatorade and water for the 6yr old child, who immediately guzzles it.
By then, Erika, Jenny, Trish, Debbie, Kari, and other team members are raiding their personal food stashes to give to the mother to feed her children as well as donations of their own money.
I go to look for Betty again and this time I find her. I explain the situation.  She looks at me with for a moment and I can see the sadness gathering in her eyes. Then she says "The orphanage currently has 11 children and 2 adults living in a two bedroom house,  we are at capacity and simply cannot take any more children."
I say "What about a job? Can she work as a janitor here or do anything around here and can get paid so she can feed her children?"
"I have hired more than I need right now and cannot hire anyone else, but I think the Menonite community down the road may be hiring."
By the time I get back downstairs, $350 Haitian dollars, formula, and protein bars have been collected for the mother and her children.
I speak to her for a while as team members play with the 6 year old and carry the 1 year old around.  I tell her to use some of the money to pay the people she is staying with, so they will let her stay a little bit longer. Also, she should buy water and other goodies to sell so she can buy food for her children.
She  looks at me and begs me to go get Betty so that she may plead with her and maybe, just maybe, Betty will see how desperate she is and will decide to take the children. I tell her that I will,  and I immediately go get Betty. After seeing her children and speaking with her, Betty refers her to the Baptist orphanage the next town over, not knowing if they will take her children. Before the mother leaves, she finds me and says, " Mesi anpil for everything you have done for mwen. Di tout moun mesi anpil. Tell everyone thank you very much."
After this, I have the chance to speak with Dr. Maxine who is a compassionate man and an excellent physician. He looks at me and says, " You know, Sabine, everyday I complain about not having money and being poor because of the small salary I make here in Haiti. But being poor is a relative term. At least I am able to provide a shelter for my family and food every day for my children. I may have little but at least I have something in comparison to this mother. I have to remind myself every day that things are not as bad as they seem. I do not have much, but if we are unable to do anything for this mother I will give her what little money I have in my wallet." I look at him and ask at what point does a mother make the hard decision to give up her children? I have been exposed to this for little more than an hour, and I find their plight incredibly painful.  She has had to live every day with the pain of knowing that her children may die of starvation soon if something doesn't change. Could I give up a child to the orphanage to keep them alive? I can't imagine how strong and selfless she is being called upon to be.
As I fly back to my home, and am typing this on my iPad, I am remembering this family and reflecting on their situation which is so outside my own experience, but all too common in Haiti, I realize I don't know how the story ends.  I don't know if she was able to find a job at the Mennonite hospital or able to get her children  into the orphanage.  I don't know how they will survive.  All I know is that I will continue to pray for her and her children.

[Ed. note:  Sabine and all of us will continue to pray. We will also continue to act as we feel we must, to extract ourselves from our comfortable homes and comfortable lives as we work to minister to these people and this country. We will continue to bring these stories back so that all can see that these are not just abstract ideas but people with hope and fear, joy and sorrow and pain.  Thank you, Sabine, for bringing this woman and her children to us, that we may also pray for her.--Doug]

Tuesday, May 15, 2012--Will to Live

This morning the team splits into two groups, one team stays back at HCM and the other team goes to a village named Megret which is located in the mountains past Tomars. The team drives up the mountain for about thirty minutes up to Tomars, this was the farthest the vehicle can go before the journey continues on foot. They hike with duffles and bags of rice, each weighing over 40lbs. It takes 40 minutes on foot to reach the town. It is worth it. The team sees and treats many people, some quite ill. Everyone had a positive experience . The team staying behind in Fonds Parisien has a busy day. We treat a lot of sick individuals. there is one family that stands out . A woman carries a 4 year old girl into the clinic. The girl is her niece. We ask the aunt where the child's mother is, she informs us that her sister, the child's mother, has just died from cholera. The aunt says she has eight children of her own but could not let her niece die from cholera as well. The little girl does not have the typical cholera symptoms of intractable nausea and vomiting with high volume, watery diarrhea. She is, however, severely dehydrated. Dr. Taylor decides to start IV fluids on the patient to rehydrate her and also attempt to reintroduce food to see if her bowels will tolerate it. The aunt asks if she could run home to pick up her 8 month old and check on her other children while we care for the child. We tell her that should be no problem. The little girl does well, better than we had expected,so we decide to discharge her home with the aunt. While giving discharge instructions to the aunt, she tells me and the Haitian nurses that she arrived home to find her sister laying on a mat outside of the front door. Earlier, the hospital had told her that her sister was dead, but there she was, still alive, lying on the mat. She tells us her sister is bloated from the IV fluids, and very weak. She has lost the will to live. We do not accept this. She has to receive proper care. I tell the aunt he need to get her sister back to the hospital. We drive with her and her 8 month old along a dirt road. We have to stop and walk the last quarter of a mile up a rocky trail choked strewn with underbrush. I would never have found this on my own.
We arrive to find the woman lying in a puddle of urine.  The aunt ducks into her house, and 8X10 foot room without windows and places her 8 month old on the bed next to 4 other children.  "Gade.  Watch her."
She returns outside and addresses her sister.  "Sister, this dokte is here to take you to the lopital.  You need to get well to take care of your timoun."
The woman replies, barely above a whisper
"Kite mwen, Mwen vle mouri. Mwen pa vle ale nan lopital la."
"Non! Non! Non! We will not leave you, you will not die. I do not care if you don't want to go to the lopital.  You are going. Your opinion does not matter!"
She lifts her sister, struggling under the weight.  The woman does not resist.  The aunt carries her sister 100 feet without stopping to rest.  A neighbor who notices the commotion rushes out to help, and together they carry the woman back to our truck. The aunt leans in close and speaks sternly to her sister "You can not just give up! You cannot just leave your timoun without a manman!  They need their manman badly! I have 8 timoun of my own, and I cannot afford to take in your timoun. So you WILL go, and you WILL fight, and you WILL live! You are not ALLOWED to give up!"
As we drive her to the cholera clinic, I wonder how someone can choose to give up so easily, especially when children are involved.

Sunday, May 13, 2012---Day of Travel

I am sorry for the delay in uploading the first post. The Internet service has not been the best since arriving to Haiti.  Everyone and all the luggage made it to Haiti safely which is a first for the Oregon team. I am referring to the luggage and not the team members.  On Saturday after arriving we take a tour of the campus and then headed over to the orphanage to spend time with the children ( I really want to see Gigi and Magdala, my two favorite orphans), and meet the two new orphans- Esther, who is only a month and some weeks old and Naline, who is about 6yrs old. Gigi, of course, has now grown pretty attached to everyone except for me. She just starts crying when I hold her. I will keep going to see her until she gets comfortable  with me. On  Sunday morning we  go to church and then do a tour of Port au Prince. The church service is fun. We have to sing a song for the people on Sunday. It is a little unrehearsed but I think we do great. During the tour I am surprised to see a lot of the tent cities which were set up around the city gone and the parks cleaned. The rubble from the streets is even cleaned up. I hope this means that the country is finally trying to move forward from the horrible disaster. The students are experiencing a little culture shock but I think they are handling it pretty well. We unpack the suitcases on Sunday and set things up for the first mobile clinic which will be tomorrow in a town past Tomars. Sabine

I have now tasted real mango.  The so-called mangos in the states are a sad impostor compared to Haitian mangos, which are perfectly luscious.  Also new and lovely to me is the breadfruit.  This heavenly treat is fried and tastes like a plump crispy potato chip with a soft fluffy center.  Well worth the trip to Haiti itself. 

Aside from being fed well, we had plenty of work to do.  During the five days we worked, we performed 9 surgeries, delivered one baby boy (who went home in a bright yellow dress), performed 32 ultrasounds and saw 403 patients.   The surgeries were difficult.  Many fibroids in locations I hadn’t seen before.  One was a retroperitoneal fibroid approximately the size of a large cantaloupe unconnected to the uterus with the ureter coursing through it.  We had one advanced cervical cancer, one metastatic ovarian cancer with the ovarian masses retroperitonealized and unable to be resected. The majority of women wanted surgery to remove fibroids so they could get pregnant.  In the states, removing fibroids to preserve fertility can be tricky, even with blood products on hand, retractors to aid in visualization, suction and general anesthesia.  Imagine performing these surgeries without any of the above on women with the largest fibroids you’ve ever seen under a spinal.  I’ve worried about every one of these women after surgery, not knowing how they would recover after the long surgeries and more-than-comfortable blood losses.  But these women are so tough.  They won’t ask for medicine for pain unless they are asked if they are hurting.  They never complain or question, only express complete confidence in the “blancs” that have come to care for them.

Prenatal care is something that is foreign here.  Most women do not come to the hospital to have their children, so coming before the baby is born seems frivolous.  For these women, a check-up would involve a long trek and money they don’t have.  Osapo is trying to change that.  They are planning to build a maternity ward and are working to develop a standard protocol for prenatal visits.  Still, an obstacle is getting women to the clinic.  For this reason, they have started a midwife program to train lay midwives (already practicing—often for a number of years) about appropriate care for pregnant women and optimizing safety for delivering babies outside of the hospital. 

This hospital has changed the lives of many people here.  It was started by a Haitian doctor, who brought on a second Haitian doctor and a Haitian surgeon to run the clinic here.  The patients are asked to pay nominal amounts for consultations; therefore the cost of running the hospital is consistently short about $2000/month.  The doctors often don’t pay themselves to try to make ends meet, which makes it difficult to take care of their own families.  Their sacrifices are great, especially when the sense of futility creeps in.  More often than not, the need seems insurmountable and the progress scarce.   But the people here are grateful and progress has been found.  There has been a decrease in water-borne illnesses since building a sanitized watering system that is free to the community.  They have also built outhouses for most families and have educated them about hygiene and the importance of drinking sanitized water instead of water from the stream where animals defecate and people bathe. They have built a house for a family here that had seven people living in a space the size of a walk-in closet, with a roof so short that they couldn’t stand.  This family had a cholera outbreak which prompted the doctors to inspect their home.  After seeing it, they walked away with tears in their eyes and the mission to change the lives of this family.  The father calls his house a “Godsend” and gave the greatest gift a Haitian can give: a goat to the doctor who changed this man’s world.  A man who earned less than a dollar a month found a way to give the most expensive gift possible to express his deep gratitude for giving his family a new life.    

There are more stories like this here.  This hospital is special because it is run by physicians who came from poverty within this country, determined to improve the lives of the people in this rural community.  It would be so much easier for them to leave the country to make a comfortable living.  While some did for a short time, this country never left their hearts.  They found themselves drawn back to make it better, even at great personal cost.  I would consider it a privilege to come here again, and hope, like the doctors here that every little bit does make a difference.  As their motto says on the entry wall of the clinic: “We must be the change we hope to see in the world.”

Jana Allison, M.D., Ob/Gyn

Joplin, MO

The last two days, I was asked to give some immunology lectures.  This was the reason I was asked to come on the trip. I think this was probably the most nervous I had ever been prior to giving a seminar.  The seminar was for a group of residents at a hospital in Saint-Marc.  There were about 9 residents in attendance and all very interested in what I had to say.  Dr. Toussaint was my translator and confessed to some nerves as well.  Neither of us should have been.  It all went very well.  There were no translation issues and the residents had a lot of questions, some of them I couldn't answer on the spot, so I had a lot of work to do for the next day's lectures.  I was told that some of them were preparing to begin taking the US board exams so this was a great help for them.

I was also asked to spend some more time in the clinic this morning.  Mainly to take pictures of the team working. As non-medical personnel, any hospital experience is impressive, but this one was truly amazing.  I was able to take pictures of one of Elizabeth and Jana's surgeries. They all seem to be doing well and in great spirits and even though they don't always have the best of technology or medications they are successfully completing multiple surgeries every day.
 
Later on I watch Cole suture some large lacerations on an elderly woman who had fallen into a well.  Her daughter is with her and holds her hand.  Cole does his best to ensure her comfort, but still has to contend with the language barrier to convince the woman not to move her head while stitches.


In the evening we were taken on a hike through mountains by two OSAPO staff and we are greeted by adults and children of the surrounding areas.  The poverty here is very noticeable, but the spirit and joy so many of these people have in spite of the situations is inspiring.  I can see why so many people fall in love with this place and have been constantly thinking about what I can do to help on our next visit.

This entire experience has been amazing.  The physicians and staff of OSAPO are wonderful and have taken such care to make sure that we feel welcome. We are taken on a hike through mountains by two OSAPO staff and we are greeted by adults and children of the surrounding areas.  The poverty here is very noticeable, but the spirit and joy so many of these people have in spite of the situation is inspiring.