SM Mall, Baguio

When Katya and I needed to do some groceries we would walk or take a taxi to the SM mall. SM started out in 1958 as a department store in Manila that specialized in shoes, called “Shoe Mart”. In the 1970s they changed the name to “SM” and gradually expanded in the decades since. Now SM is one of the largest shopping mall chains in the world. The company went public in 1994 and grew to become the largest company listed on the Philippine Stock Exchange in terms of revenue. SM owns 46 shopping malls all over the Philippines and even branches in China. The Baguio SM Mall was opened in 2003, to the dismay of some prominent community leaders who lamented how it put a lot of mom-and-pop stores out of business.

The mall is a popular place to hang out. Within its bright, clean and air-conditioned interior you find the modern equivalent of the food stands you see on the street, selling chicharon (deep fried pork rinds), babingka (spongy rice cake), buko juice (young coconut water), and green mango with bagaoong (shrimp paste).

 

Another interesting finding was a counter called “Vape King”, right across from and indoor carosel and an electronics store selling large flat screen HDTVs. Vape King sells mini portable vaporizers for “herbs”. This obviously meant marijuana but they also sold packages of flavored tobacco to make it look legitimate. Vaporization is the process of heating dried cannabis leaves to a temperature just below combustion. It releases the resin in vapor form while avoiding the production of irritating, toxic and potentially carcinogenic combustion products. It does not produce smoke and minimizes any odors, and reportedly enhances the flavor of the weed.

Unlike my home state of Washington, marijuana is still illegal in the Philippines. In fact, they have some of the toughest marijuana laws in the world. The first time you get caught smoking you can be sent to rehab for six months. After the second time, you can be sent to jail for 6-12 years. If you get caught growing it, you face life imprisonment or the death penalty.

Despite that, the Philippines is second only to Mexico as the world’s largest producer of marijuana. The plant is not native; the seeds were first brought to the Philippines by American servicemen staying at Camp John Hay in Baguio and Sagada during the Vietnam war. They asked local farmers to plant it. Seventy percent of the country’s marijuana now is grown in the the Cordillera Highlands around Baguio. It’s not a hard decision for poor native farmers to switch from growing other crops to marijuana, since it obviously pays much better than vegetables. The plantations are hidden in the mountains in areas inaccessible by any vehicle, which make them difficult to find and eliminate. They are controlled by organized crime -- the narco-mafia -- and guarded by kids with AK-47s. The weed is carried out on foot trials and sold somewhere to the Japanese Yakuza, Chinese triads, and West African gangs, then smuggled into Japan, Canada, New Zealand, and Europe.

The Philippine Drug Enforcement Agency and Philippine National Police are fighting a fiece war on pot, constantly finding plantations and destroying plants. Earlier this month, they claimed to have destroyed 260,500 fully grown marijuana plants in an operation in Kibungan and Bakun towns north of Baguio. Curiously, no cultivator was arrested in the operation. Athough this seems to suggest that the PDEA is winning the war on pot, back in 2009 the PDEA had already declared victory in the Benguet province, declaring it "marijuana free". They accomplished this using programs that assisted farmers to switch to cultivating bees, silkworms, anthuriums, and the root crop yacon.

When people are vaporizing pot instead of smoking it in joints or out of a pipes made out of empty beer cans, that indicates to me they are moving up in the world. Indeed, the people that smoke it in Baguio are primarily professionals and college students. Students from the provinces where marijuana is grown are also often the ones transporting in to the city and selling it to help pay for their education.

The other favorite drug of abuse is “Shabu” or methamphetamine. I had suspected that this was a problem because during my first few days in Baguio I was suffering from a cold and went asking for pseudophedrine at three different pharmacies, but couldn’t find any. I think they have made it totally unavailable because of its use as a precursor in the manufacture of meth.

 

The SM grocery store at the mall has a large produce department with an amazing array of tropical fruits and vegetables, and about a dozen different varieties of rice. Along with eggplant, bitter melon, long string beans, carrots, and mushrooms, Katya and I picked up some santol, papaya, mangosteen, a small variety of banana, and of course, mangoes. There were others fruits that we didn't know the names of or how to eat but we bought them anyway just to try them.

The mangoes were incredibly sweet and ripe. The Canadians planned to bring home boxes of them. Unfortunately you aren't allowed to bring any into the United States. We also picked up some green mangoes for a green mango/papaya salad. Their “green” mangoes are similar what stores sell in the states as “ripe”.

Another useful thing to know is that you can change money at the SM customer service counter in the grocery.

A taxi line is conveniently located right outside the mall by the grocery store. People roll their carts right up to the taxi and an attendant helps you with your bags.

Diseases of Affluence, Diseases of Poverty

On the long, winding bus trip up to Baguio I was fortunate to sit across the aisle from Dr. Cannell, one of the two other anesthesiologists on the GO-MED team. He is an experienced missionista, so I was able to pick his brain for tips on dealing with the anesthetic challenges I was about to face. He passed me some of the handwritten notes he took last year. They included details on the types of cases, including information about the patients' co-existing diseases. As expected, filipino patients are shorter and smaller than North Americans, and never obese, which had implications for drug doses and selection of airway sizes. They were hardly ever on any medications, had no drug allergies, and rarely had had previous surgery. Severe tooth decay and undiagnosed, untreated high blood pressure are also common -- evidence of the limited exposure to health care that comes with poverty.

Another thing that he observed was that lot of patients suffered from asthma and chronic obstructive pulmonary disease. The air quality in Baguio and all the urban areas in the Philippines is awful. Pollution comes primarily from traffic and poorly maintained vehicles (mostly running diesel engines), plus numerous small fires used for cooking food and burning garbage. Cigarette smoking is also very common, especially among men. But Dr. Cannell also saw many non-smoking women from rural areas who also had severe COPD. He reasoned that a lifetime of cooking over open fires with poor ventilation was responsible. COPD is a condition characterized by destruction of the air sacs in the lungs which results in loss of elasticity of lung tissue and a decreased area available for gas exchange. Chronic inflammation of the airways produces asthma-like symptoms, and increased and retained pulmonary secretions. When these patients undergo major surgery they are at risk for bronchospasm and postoperative pneumonia. We would give them preoperative bronchodilators and steroids but sometimes their disease was so advanced that the benefit was minimal.

By the way, Filipinos are experts at grilling meat over open fires. You will see them cooking up skewered chicken on the street, including all the parts we normally throw out -- chicken feet, intestines, heads, and cubes of congealed blood -- on top of a grill made out of an old cooking oil can. While in Manila we even saw a man squatting by coals cleverly piled up in the gutter, grilling a thick fish steak. Our tour guides in Palawan would whip up a fire with glowing coals on the beach in no time, and cook up a feast of barbecued chicken, pork and fish for lunch. I think one of the secrets is to fan the coals with a hand fan woven from palm leaves.

Chicken heads and intestines on bamboo skewers, roasting over hot coals, Baguio Public Market.

There is a big difference between the disease patterns seen in poor countries compared to that seen in rich countries. In the United States we have an epidemic of obesity and its related conditions: type 2 diabetes, hypertension, obstructive sleep apnea, coronary artery disease, and cancer (breast, prostate, and colon). You can blame that on diet and behavior -- the increased consumption of meat and animal products, refined carbohydrates, and highly processed foods, plus an increasingly sedentary lifestyle. These “diseases of affluence” associate with each other because of common causes. Indeed, death in America is largely a food borne illness. In contrast, the list of diseases typical of poor countries include pneumonia and pulmonary disease, intestinal disease (due to nutritional inadequacy, obstruction and poor sanitation), parasitic diseases, metabolic and endocrine disease (other than diabetes), and diseases of pregnancy, plus many others.

As the economy of the Philippines continues to improve, its people are changing their eating habits. Fast food restaurants like Jollibee, Goldilocks, and Chow King are popping up all over to meet the desires of a growing young, urban population. (The median age in the Philippines is 23; in the United States, it is 37.) The diet is changing to resemble more of a western diet -- highly processed, prepackaged, convenient meals that are calorically dense but nutritionally poor. Diseases of affluence are predicted to become more prevalent in developing countries as diseases of poverty decline, longevity increases, and lifestyles change.

Photo by Katya Palladina.

Now back to the action at Baguio General Hospital. Our gynecologists, Dr. Young and Dr. Coll, performed surgery on a patient to remove a very large cystic ovarian mass. It was so big that the patient appeared to be carrying a full-term pregnancy. Using ultrasound, they calculated that it contained 8.3 liters of fluid. Afterwards, Dr. Young said that it was the largest cyst he had seen in over 30 years of practice. The patient had been living with it for two years. Obviously, the lack of access to health care results in patients not presenting for treatment until their disease has reached an advanced state.

Removal of the mass first required drainage of the fluid, then careful dissection away from surrounding tissues, including areas where it adhered to the bowel. The anesthetic concerns were primarily to monitor and keep up with blood loss and fluid requirements. The large mass could contribute to respiratory compromise when the patient is lying flat. Another concern was supine hypotensive syndrome, which is a drop in blood pressure that can occur when a patient in late pregnancy is lying flat on her back. The pregnant uterus, or in this case the mass, compresses the inferior vena cava, obstructing venous return from the lower extremities, resulting in low blood pressure and decreased cardiac output. This is especially true following induction of anesthesia (either general or regional), because of the vasodilation caused by anesthetic agents. This can be minimized by preloading the patient with IV fluids and placing the patient is slight left side down position, which helps relieve the obstruction.

Another issue was postoperative pain management. Because of concerns over opioid-induced respiratory depression, the nurses on the wards at BGH do not give any opioid analgesics such as morphine or oxycodone. Patients can only get Tylenol and ibuprofen after surgery, so we try to do everything we can to minimize their postoperative pain. Our anesthesia coordinator, Dr. Hoskin, came up with the idea of performing bilateral paravertebral blocks in patients who were going to have open abdominal procedures. The technique uses an injection of long-acting local anesthetic to anesthetize the nerves as they exit the low thoracic spine on their way to the abdomen. When placed immediately prior to surgery, the block reduces general anesthetic requirements, and can provide significant pain relief for about 24 hours. It's an elegant solution to the problem of pain management, and I was surprised how easy it was to pick up the technique after Dr. Hoskin demonstrated it to me.

Photo by Katya Palladina.

The mass turned out to be a dermoid cyst, which is a benign tumor originating from germ cells. The cells in a dermoid cyst are highly developed into mature tissues such as skin, hair, teeth, nails, and bone. It is not fetal tissue. And it is not to be confused with a parasitic twin that was enveloped by the patient before birth, known as fetus in fetu, which is an extremely rare condition. Some people don’t understand that though. Years ago I had a patient who insisted on having a spinal anesthetic so she could be totally awake for the removal of her small dermoid cyst. She wanted to see it as soon as it was removed, and even gave it a name and a proper burial.

[WARNING: Video contains graphic material. Do not watch it if you are at all squeamish!]

Removal of a Dermoid Cyst from Baby Seal Films on Vimeo.

Balut!

Balut, a Philippine Delicacy from Baby Seal Films on Vimeo.

On a stop during our bus ride up to Baguio, Katya and I found a food stand offering balut. Balut is a Philippine delicacy, a fertilized duck egg, boiled with the chick at about 17 days of development, and eaten in the shell. It is served with salt and/or a chili, garlic and vinegar.

The taste has been described as resembling liver, fatty and rich, not unlike foie gras!

Monday Morning at Baguio General Hospital

It's the beginning of our first day at Baguio General Hospital and tensions are a little high. The Canadians wanted to start on time! I half expected that things might be a little more relaxed on the mission, like we might even switch over to “Filipino Time”, meaning whatever happens, happens when it happens, typically around an hour later than you had planned.

I had to put together my anesthesia cart from scratch, picking through the supplies and our own pharmacy shelves for drugs. It was a simple metal rolling cart with three wheels that sometimes worked, and one that was frozen with rust, so it was a struggle to move it through the hallways. It didn’t roll as much as slide, and I would alternately try pulling and pushing to keep it going straight. Of course, I had overpacked it, trying not to forget anything I could possibly need, and things would fall off. Anesthesia is all about anticipating critical events which happen only one in a thousand times. It is best to be prepared for anything.

I performed a checklist on my anesthesia machine, an aged Ohmeda Modulus II Plus, which was literally rusting away. We were lucky to be able to secure the only two machines in the hospital that had working ventilators. Since the electrical system in the Philippines runs at 220 volts, we needed step-down transformers to run some the monitors we brought with us. A nurse told me that the first year she joined the mission, she destroyed a lot of equipment plugging in 110V machines into the 220V wall sockets. We taped over the accessory 220V outlets on the back of my Ohmeda Modulus II Plus to prevent anyone from accidentally plugging the 110V monitors into them.

Another issue was that there wasn’t a scavenging system on my machine. Scavenging vents the expired anesthetic gases into a waste system, rather than directly into the operating room environment. You need to do this because chronic exposure to anesthetic agents could have detrimental effects on the health of operating room personnel. For instance, nitrous oxide suppresses vitamin B12 activity and is linked to bone marrow suppression and reproductive difficulties. They didn’t know about this in bygone days of anesthesia and excess gases were vented directly into the room. Residents exposed to residual gases in their first days of their training would get a little sleepy, but supposedly would develop tolerance to the effects after a couple weeks. In modern hospitals scavenging is accomplished actively through a central vacuum system, but in Baguio we simply attached a hose to the breathing circuit and vented it out the window. Either way, the anesthetics, which are halogenated hydrocarbons, find their way to the upper atmosphere, where they not only contribute to the destruction of the ozone layer but also and act as powerful greenhouse gases.

Since there was no central oxygen pipeline system, our anesthesia machines worked off large oxygen H-cylinders placed in the corner of each room. One of the most critical pieces of equipment was the crescent wrench used to connect the oxygen gas line from the machine to the cylinder. It was always hanging in a prominent place in the hallway. If your oxygen runs out in the middle of the case you are going to need to get this in a hurry to switch over to a new tank. I almost started my first case with an empty tank. We replaced it at the last minute. Normally every machine is equipped with a small backup oxygen tank called an E-cylinder but none of our machines had them, so our margin of safety was significantly decreased.

The challenges I faced were nothing compared to what the BGH anesthesia residents have to deal with on a daily basis. Rachael, a first year resident who accompanied me in my room, told me that they usually work without any electronic monitoring -- no EKG, automated blood pressure cuff, or end-tidal CO2 or anesthetic gas monitors. Blood pressure is measured with a manual cuff and pulses are palpated. If a resident has a pulse oximeter, it is only because she bought it herself! As I mentioned before, only two anesthesia machines in the hospital have working ventilators, so they often ventilate by hand through an entire case.

If that isn’t bad enough, they work crazy hours -- 38 hour shifts on call (what they call “duty”), and are still assigned to work a room the following day. The operating room runs 24 hours a day of course. Common emergency procedures include appendectomies, open gallbladders (the equipment to do laparoscopic gallbladders is lacking), cesarean sections, decompressive craniectomies (for strokes), and laparotomies (usually for penetrating trauma). Saturday night is a big night for stabbings and gun shot wounds. Because of the constant demands of work, residents live at the hospital (thus the term “resident”), which charges them for room and board. That was how medical training used to be in the United States back in the day, before regulations to limit resident work hours were passed.

I definitely worked some long stretches during my training, working all night and catching 30 minute naps before morning rounds on what we lovingly called "The Dog Mat", a thin foam mattress we kept on the floor of a storage room on the cardiology ward. Residency programs justified that kind of treatment by saying that doctors needed to learn how to work effectively under pressure and while sleep deprived, and we weren't going to get the breadth of experience we needed if we didn't put in the hours. Today it all just sounds like an excuse for abusive labor practices to me. I am shocked at the conditions I put up with back then, but you don't bother complaining when you know it's only temporary.

In a way I envy the BGH residents’ training, because as technology continues to advance and make the delivery of anesthesia easier and safer in North America, I think we become so dependent on our machines that we start to lose our clinical skills. There is a relatively new device we use for airway management called the Glidescope, for instance, that uses a video camera for endotracheal intubation. A trained monkey can intubate with this thing, and when that secret gets out no one will need anesthesiologists anymore. But hasn't that always been the central problem with technology? Who needs to develop any skill to memorize anything when you always have access to the internet and Google, for instance. And writing cursive script has become a lost art. Kids these days don't know how to even read it anymore, but they can sure text with their thumbs like crazy!

[Photo credit to Katya Palladina]

Ating Tahanan: Our Home in Baguio

The mission volunteers all stayed at a place called Ating Tahanan, which is the Girl Scouts of the Philippines National Campsite and Training Center in Baguio. It was built back in the late 1950s in order to give the Girl Scouts a place to camp in a cooler climate during the hot summer months. The complex is comprised of a number of guesthouses as well as a couple centrally-located meeting and dining halls. I didn't expect such luxurious accommodations.

You might have noticed that in this picture of the Guesthouse they still have their Christmas lights up, at the end of January, including a lighted paról, or star-shaped Christmas lantern. It is an icon of Filipino Christmas. The Philippines celebrates the longest Christmas season in the world. It extends all the way up to Valentine's Day! (At least we saw plenty of Christmas decorations still up on Feb 14th.)

Katya and I checked into a large corner room on the upper floor of Guesthouse 1, a three-storey log cabin building which used to be owned by Senator Rogelio de la Rosa. The interiors of the rooms of Guesthouse 1 were covered with polished wood. On both the 1st and second floors is a central room with a stone fireplace and a full kitchen, which came in handy when we wanted to cook for ourselves.

Before he became a senator, de la Rosa and his wife Carlota (Delgado) de la Rosa were a popular acting couple who burst into stardom in the Filipino movies of the 1930s. Although the movie industry slowed down during WWII, de la Rosa became even more popular in the postwar era. By 1948 he was the highest paid Filipino movie actor.

Ating Tahanan is located on South Drive close to Camp John Hay. Although it’s in a park-like, wooded area, far above the crowded neighborhoods, you still wake up to a cacophony of crowing roosters and barking dogs, and occasionally to the smell of burning garbage. It took us about 20 minutes to walk to the hospital, and we would leave early to get there at 7AM. I had some close calls crossing streets on the way to work Traffic can be especially thick around the hospital and you can’t assume that people will stop for you even if you are at a crosswalk. Because Katya usually had to bring along a heavy tripod, camera bag, and laptop, we usually took a taxi which was easy to flag down on South Drive in the morning. The taxis are metered and it cost us between 53 to 57 pesos to get to the hospital. American country music is popular among taxi drivers in Baguio.

There are no traffic lights in Baguio. The ones that you do see there are derelict and missing lightbulbs -- evidence of past futile attempts at controlling the chaos. Despite that, the traffic keeps moving through the intersections and traffic circles. Filipinos are crazy drivers but follow a “give and take” philosophy which explains why you actually don’t see many accidents.

The showers at Ating Tahanan were a popular topic of conversation at breakfast. The Guesthouse used to have a central boiler, which exploded sometime last year. Instead of replacing it they installed small in-line electric hot water heaters in all the showers. To operate it you turn on the water and turn a dial to divert it through the heater and the shower head. Then you turn the heater on, and in a few minutes the water warms up. Although the dial on the heater has settings for "low", "medium", and "high", the only way to really get any warm at all is to turn it all the way to "high" and turn the flow way down. If the flow is too high you'll dilute the heat but if it is too low the heater will shut itself off, so it takes some fine tuning to get it right. Often I would enjoy a hot shower but when Katya would try it, the heater would shut off inexplicably and wouldn’t turn back on again. It took a little experience to get it to work reasonably well. People were also concerned that they would get electrocuted taking a shower with this thing on. Given the number of self-taught electricians in the Philippines, I think it was probably a valid concern.

Across from Ating Tahanan is a large vacant lot surrounded by a high metal fence. One of the taxi drivers told us that it used to be the site of the Hyatt Terraces Plaza. In 1990 Baguio was hit by a powerful earthquake that destroyed many building in the city and killed over a thousand people. The hotel collapsed, killing 80 employees and guests inside. My mother knew people who had died there, fellow classmates from St. Scholastica's College who were holding a reunion at the hotel.

I also remember the Plaza Terraces well because I traveled to the Baguio in 1989, and won about 40 USD at the hotel casino playing the slots. I also met with the psychic healer Reverend Gary Magno over coffee in the lobby. Magno practiced psychic surgery, which is a uniquely filipino phenomenon where the “healer” performs “surgery” with his bare hands on an awake patient to remove tumors and other pathological tissue. It makes a bit of a bloody mess but miraculously leaves no wounds or scars behind. Although we chatted a lot about his supernatural powers there, it is something you really needed to see to believe, so he invited us to his clinic in Manila, where we were able to videotape and photograph some of his “surgeries”.

In the 1980s, Baguio was a popular destination for foreigners looking for psychic surgery. American actor Andy Kaufman traveled there in 1984 for a six-week course of psychic surgery under Jun Labo, as a last resort in his fight against a rare large-cell carcinoma of the lung. He has been quoted as saying "If I'm gonna go, I'm gonna do the weirdest thing I can possibly do and just really flip people out." Since all conventional therapies had failed, he had nothing to lose by trying it. He died soon afterward of renal failure related to metastatic disease.

Interestingly, no one could give me a straight answer as to why the Hyatt Terraces Plaza was never rebuilt, or why nothing at all had been constructed on the vacant site in over 20 years. It’s beautiful property in a prime location. Some taxi drivers said that the ground was judged to be too "unstable". One mentioned that the Hyatt planned to build another casino there but faced resistance from moralistic Catholic leaders in the city. I finally got the answer I was looking for when someone told me that there were just too many ghosts there. In addition to being highly religious, Filipinos believe a lot of superstitions. Ghosts here are real.

Philippines: The Baguio Mission

I’m going to devote the next several posts to my recent trip to the Philippines. I rarely talk about my other life as a doctor here because this is primarily a sea kayaking blog. But today I think I’ll talk a bit about what it’s like working in an operating room as an anesthesiologist. In addition, I thought I would include some practical information about traveling in the Philippines for anyone interested in going there.

At the end of January 2013 I joined a Canadian medical mission to provide surgical care to indigent patients in the city of Baguio, in the mountains of Northern Luzon. The idea came from a nurse who I used to work with. She knew the mission founder and coordinator, another operating room nurse who works in the same hospital system. The organization is called Greater Outreach/Medical Education Destinations (GO-MED). I want to emphasize that GO-MED is not religious and its constitution explicitly states that the organization “shall remain free of any religious or political affiliation, and shall not engage in the promotion of any religion or any political party.” Although certain individual members may have volunteered for religious reasons, there are also many who are nonreligious and who simply act out of strong humanitarian values.

I volunteered last spring and they were thrilled to have me on board. I was basically paying a lot of money to take time off of my paying job to go do the same thing I did everyday but in  a third-world country for free. It actually turns out that a lot of medical professionals (doctors, nurses, and surgical technicians) love this kind of work and do it regularly. One nurse we met does two missions a year. Apparently in this business the people with such extensive experience are known as missionistas.

The Baguio mission turned out to be a good choice for a first mission. We set up at Baguio General Hospital, which is a teaching institution. Although Baguio is in the Philippines, it is in the mountains at 5280 ft, so the weather is much cooler than in the lowlands, maybe around 65 to 70 F during the day and down to 55 F at night. The accommodations were wonderful, and the hospital went out of their way to make sure we were comfortable and well fed. It wasn’t like we were living in nipa huts and going for days without showers.

Katya also volunteered to go as the official photographer. The group absolutely loved having a professional photographer around. Not only was she making everyone look really good, but was also posting on the GO-MED Facebook page everyday for all the friends and family back home. The patients signed a consent allowing photography for medical education, staff teaching, and publicity purposes. Some of pictures of them actually ended up on the GO-MED Facebook page. This is actually a big deal because in contrast to the Philippines (and probably everywhere else in the world) America is a highly litigious environment, and healthcare providers are also subject to privacy laws which mandate severe fines for the unauthorized release of Protected Health Information. Because of that, we in America all work in paranoid institutions that are ready at a moment’s notice to fire or discipline any employee perceived to act inappropriately. You wouldn’t even think of trying to post pictures from an operating room on Facebook in the United States, at least not without first consulting an attorney.

An operating room is obviously a privileged area due to issues surrounding patient safety, operational efficiency, and sterility as well as patient privacy. Katya was concerned about passing out at the sight of blood and open bellies, but she actually did fine, at least until she watched me perform a regional block. The sight of a long, thin needle sticking out of my patient’s back somehow made her a little lightheaded and she had to leave the room. Fainting at the sight of a medical procedure or venipuncture is common and hard to predict. It’s typically caused by a reflexive drop in heart rate and blood pressure known as vasovagal syncope. It’s more common in people with “needle phobia”. Ask any anesthesiologist about how many husbands/boyfriends they have seen pass out in a labor room at the sight of placement of a epidural catheter, for instance. The worst cases are the big, tough guys who don’t listen to warnings to sit down when they start to feel funny, but instead insist that they are OK. They go down hard. Among other reasons, that is why nurses will request that the patient’s family clear out of the delivery room as much as possible except for maybe one support person. A lot of people have difficulty understanding that we really don’t do these procedures for the benefit of spectators. It’s hard enough to take care of a labor patient -- we don’t suddenly want to have to call for help to deal with a family member passed out on the floor.

Now for a bit of a rant: I can’t help thinking also that the changes in healthcare we are experiencing at home is driving an interest in practicing medicine abroad. I personally have witnessed healthcare in this county become increasingly consolidated into large regional hospital systems, which are buying up all of the remaining independent physician practices, and which dictate in detail exactly how health care providers will practice. They give lip service to cost-containment while spending millions on unproven, not scientifically validated high technology in attempts to maintain "market share", and demand improved efficiency while burdening providers with ridiculous amounts of “paperwork” (now electronic), and force compliance with complex and draconian rules meant to improve quality indicators. I can tell you that, in contrast to working at home, it was a real pleasure to practice in a hospital that treated me a valuable asset and not a liability (someone who needs to be tightly controlled before he gets out of line) and which allowed me the independence to do the job I was trained to do in the best way I could given the challenge of limited resources. Within a day we set up two operating rooms out of the two dozen cardboard boxes of equipment we brought with us, and on Monday morning we were performing surgery. Despite not having worked together before, the efficiency was way better than I see at home, without sacrificing quality or safety. That says a lot about the teamwork we had, and sadly, also underscores that there are problems plaguing the system I usually work in. When doctors start to prefer working in a third world country for no pay over working in the United States, you know you have a serious problem!

After completing this mission I totally understand why someone would want to do more of them, and even get a little addicted to the lifestyle. It’s a great way to travel the world, meet and work along side locals, connect and travel with like-minded professionals who are a bit on the liberal side, and who are interested in social justice, enjoy teaching, and love practicing medicine enough to do it for free. The local people are extremely grateful for the skills you bring and the work you do. I can't think of a better antidote for professional burnout. You give, but you receive so much more in return. For one thing, you are given affirmation that you are a noble person, which you really are! It is only a toxic culture that has been telling you for most of your life, that you are essentially a selfish, greedy, and “rational” animal, repeatedly, until you believed it yourself.