Humanitarian Medical Mission — A Cure for Burnout?

I had the opportunity recently to spend a week in Honduras doing humanitarian work, aka medical missionary work.  Like alternative medicine, this is something I had a lot of interest in during medical school but as time went on, never did as much of as I thought I might.  I spent a month during residency in a rural Mayan village in Guatemala and I went to Chile with the Air Force after their big earthquake in 2010, but that's about it.

This opportunity came up through the Making a Difference Foundation.  This foundation was started by CHG Healthcare, a local company here in Salt Lake City, one of this website's long-time sponsors, and the company behind locum tenens services you've heard of such as CompHealth, Weatherby, and Global Medical Staffing as well as locumstory.com.

Like many companies, including ours, CHG decided they wanted to do some good in the world.  They had been donating to other organizations for years but basically decided to bring their charitable mission in-house and the Making a Difference Foundation was born.  They've been lining up a half dozen humanitarian trips a year and invited me to come along on one and even offered to pay my program fee and airfare.  Yes, of course, they're hoping for a little publicity, but I told them that of course if I went on a humanitarian trip I was going to write about it on my blog.

I took a look at the dates, locations, needs, and opportunities and decided to go on a one-week medical mission to Honduras with them.  I had two conditions though:

1. I wanted to make sure they could actually use an emergency doctor.  Obviously different organizations go to different places with different needs.  If the purpose of the trip was to repair cleft palates, that probably wasn't the right trip for me.
2. I wanted my daughter Whitney to be able to go along and I wanted her to have something to do.  I didn't care if it was cleaning the floors and stocking the shelves, but I wanted her to have some meaningful work there.

I don't know that in the end that either of those conditions was really fulfilled all that well, but we still had a great experience and an enjoyable time.

Medical Mission Preparation

Showing up to work at the ED

Over the course of four or five months before the trip, there were a few things that needed to happen.  The Making A Difference Foundation partnered with A Broader View Volunteers to handle a lot of the details.  There was some paperwork to fill out.  There was a list of immunizations that were recommended, so we went to a travel medicine clinic.  I got my tetanus shot updated and we both took the oral, attenuated typhoid vaccine (which needs to be attenuated quite a bit more in my opinion given how ill I was the day after my first dose).  We also picked up some malaria pills.  I had to pay $15 for a background check.  I had to send them a copy of our passports and my medical license.  We had to buy Whitney some scrubs.  They also recommended we get some gifts for our host family.  And they recommended we bring “at least one bag of medical supplies” and provided a list of needed supplies including the following:

• Anesthesia — masks, breathing circuits, LMA’s, hyperinflation bags, epidural kits
• Casting Materials — undercast padding, plaster wrap, casting tape
• Drainage/Irrigation — irrigation trays, suction catheters, yankauers, wound evacuators
• Drapes — surgical, exam, single and drape packs
• Dressings — gauze pads/rolls, elastic, bandages, wound dressings, dressing kits, medical tape
• Electrodes — EKG/ECG, ESU, EMS, defibrillation, needles/blades
• Endo/Laparoscopic — staplers, trocars, obturators, graspers, dissectors
• Feeding — nasogastric tubes, enteral administration sets, gravity bags – NO SOLUTION
• Gloves — surgical and exam
• Gowns — surgical and patient
• Infant — bottles, newborn caps, diapers, birthing blankets
• IV — administration sets, IV catheters, winged infusion sets, epidural supplies, ext. sets
• Lab — specimen collection, vacutainers, test tubes/bottles, pipettes, culture media
• Medical Apparel — scrubs, masks, caps, shoe covers, aprons
• Mobility Aids — wheelchairs, crutches, walkers, canes
• Monitoring — leads, temp probes, BP cuffs, pulse ox/O2 sensors
• Needles/Syringes — all types and varieties, sharps disposal containers
• Nursing Aids — dressing aids, underpads, restraints, anti-embolism stockings, diapers
• OB/GYN — umbilical catheters, speculums, maternity briefs/pads, umbilical clamps
• Operating Room — surgical packs, table covers, surgical instruments, towels
• Orthopedic — post op boots/shoes, braces, slings, undercast padding, splints
• Ostomy — pouches/bags, barriers, stoma powder/deodorizer
• Personal Hygiene — body wash/shampoo, toothpaste, combs/brushes, washcloths (all unused)
• Respiratory — nasopharyngeal, ambu bags/resuscitators, nasal cannulas, endo/trach/bronchial tubes
• Skin Prep — alcohol pads, iodine applicators, soap, scrub brushes, lubricating jelly
• Sutures — all types and varieties, wound closure devices
• Urinary — catheters, catheter trays, drainage bags, skin prep items, specimen containers
• Medications including:
  • Hypertension: (enalapril, propranolol, atenolol, aspirin, hydrochlorothiazide)
  • Diabetes: (glibenclamide, metformin)
  • Epilepsy: (phenytoin, phenobarbital, phenotypic)
  • Migraine or headache: (migradorixina, avamigram)
  • Muscle aches: (doceplex, diclofenac, carbaflex, ultradoceplex, dexaneurobion, doloneurobion)
  • Pregnancy control: (prenatal and folic acid)
  • Constipation: (fiber)
  • Stomach: (ranitidine, neogel, famotidine, sertal compound)
  • Antitussives: (salbutamol spray 0.2% and beclomethasone spray 0.1.% tylenol)
  • Antibiotics: (ciprofloxacin, amoxicillin, tetracycline, dicloxacillin)
  • Fevers: (acetaminophen, ibuprofen)
  • Allergies: (diphenhydramine, allegra (fexofenadine), benadryl)
  • Injections: (thiamine, dipyrone, ampicillin, ceftreaxone, gentaminicin, lisagil sertal compound, alergil, novalgina, procainic penicillin, benzathilica, distilled water)
  • Cures: (povidine, gauze, clinical alcohol, hydrogen peroxide, bandaids, bandages, cotton) * Ophthalmic solution

I simply went to the two Emergency Department (ED) directors where I worked, gave them the list and took what they gave me.  Since I packed in about 20 minutes, I'm not really sure what I actually took down there, but it ended up being two large duffle bags of stuff.  I'm sure they threw half of it away, which is fine.  Take what's useful and leave the rest, right?

Whitney was in charge of gifts and I also went by the library and picked up a few books on Honduras to read on the plane.  It was a good thing we left early for the airport, as I discovered at the counter that I had brought an old, expired passport instead of my current one.  My neighbor ran my current one down to me and we checked in with four minutes to spare.

Medical Mission in Honduras

The Honduran flag has five stars on it, to signify that they are in the middle of the five main Central American countries (Guatemala, El Salvador, Honduras, Nicaragua, and Costa Rica) that many Central Americans would still like to see united.  (Apparently, Belize and Panama are always excluded from that list for some reason.)  Honduras is the second poorest country in Central America (behind Nicaragua) and has the second highest homicide rate in the world (behind El Salvador).

As we were arriving in Honduras, the front-page article in the newspaper was about how the US Embassy in the capital had been firebombed the day before.  All of the teachers and most of the health care workers in the country had already been on strike for a couple of weeks because they hadn't been paid in months and the government was talking about privatizing both industries.  While we were there, the Dole Fruit Company had dozens of its vehicles attacked, burned, and looted.  Most Americans are aware of the “caravans” showing up at the Southern border.  Guess where they all started?

Whitney shares a coke and a moment with a Garifuna boy

Honduran Medical System

Fortunately for us, we were hours away from the capital in a city on the Caribbean coast called La Ceiba.  The on-the-ground folks for A Broader View had arranged for us to assist and observe in the public hospital in this city of 3/4 of a million people.  There were several reasonably well-equipped private hospitals in town, but I was told that about 70% of the people in Honduras can only afford to go to the public hospital.  It was an interesting lesson in socialized medicine and two-tier health care systems.

Wrestling drunks in the ED, just like at home

There was obviously a fairly inefficient bureaucracy in place.  Given my prior military experience, I'm no stranger to large bureaucracies trying to run a health care system, but this was a whole other level.  This hospital had a supply budget the year before of about a million dollars.  Yes, just one million.  However, the administrator had only spent $200,000 for whatever reason.  So in classic bureaucratic “use it or lose it” fashion, the new budget was $200,000, leaving them woefully undersupplied.

This isn't a little rinky-dink hospital either.  There would be 30-50 people in the waiting room for the EDs (adult medicine, adult surgery, peds, gyn) every morning when I walked in.  It received ambulances with gunshot wounds to the head and multiple motorcycle accidents per day, patients were transferred there from outlying hospitals for a higher level of care, and it had inpatient pediatrics, medical and surgical wards, labor and delivery, and ICU.  Orthopedics, neurosurgery, gynecology, and general surgery were all available.

Despite this high-volume, high-acuity patient population, capabilities were severely limited compared to what you and I are used to.  I didn't see a computer in the entire facility.  Now, before you laud the elimination of EMRs from your practice, consider the difficulty of practicing without any old records and having to handwrite all your notes and orders.

There were no electronic x-rays, in fact, the only x-rays you could even get were hand x-rays due to the limitations of the machine.  That's right, they were running a trauma center without a functioning x-ray machine.  Forget bedside ultrasound.  Even radiology didn't have an ultrasound, only labor and delivery did.  So if you needed an x-ray, you wrote a prescription for it and gave it to the patient's family member.  They went out and raised the money for the x-ray, raised the money for an ambulance transport, and called the ambulance to come get the patient, take them to a radiology center (usually associated with the private hospitals) and bring them back for further care.  As you might expect, this process could take most of the day.

There was a CT scanner in the hospital, but due to limited parts (a filter of some kind that they only had one of) they only fired it up once or twice a week and batched any CTs they needed to do.  Any other CT scans were sent out.  Forget MRI.  Imagine being a neurosurgeon without an MRI.

If you need labs, the nurses would draw them and give the vial to the family.  If it was a lab that could be done at the hospital, they would take it to the lab and pay to have it done.  If it could not be done at the hospital, like a troponin, for instance, they took it to an outside lab, waited for it to be run, and returned with the results.

If the patient needed a splint or a cast or an operation and the hospital did not have the supplies needed to do it, the family was given a list of needed supplies (like OR drapes and towels) and sent out to purchase them and bring them back before the procedure would be done.  The suture cart had only 0 and 2-0 sutures.  Facial lac?  Yup, that got closed with 2-0.

Food, bedding, clothing, etc. were all provided by family members.  Needless to say, if you didn't have a family member you could be in a world of hurt here.  In order to deal with the reality of this inefficient bureaucracy, a black market had sprung up in kiosks outside the hospital selling most of the supplies a patient might need.  Capitalism to the rescue!

Whitney putting on her first cast

It was interesting that there was no shortage of labor.  Despite the strike, at any given moment there were dozens of workers in this ED.  Granted, most of them were nursing students and the hospital was primarily run by 22-23-year-old interns, but it was interesting that the largest expense in the hospital was not highly specialized labor like in the US, it was supplies.

The pathway to becoming a doctor starts at 16-17 with an 8 eight-year program.  60-70% of medical students are women.  There are six years of school followed by an intern year and then a social service year.  The social service year was required whether you went to the public medical school or one of the two private medical schools.  Your assignment came via a lottery, although if you scored a highly desirable position you might be able to exchange it for something you'd rather do.  Those who were sent into a bush village in Moskitania were simply out of luck.

Following those eight years, you were a generalist and could try to get a job or hang out a shingle if you like.  You could also apply to do a residency.  Both medicine and surgery are three-year residencies.  The interns were paid $220/month.  The social service docs made $300/month.  A resident would make closer to $1000/month and a typical attending would make $2000-3000/month.  Here's a video where I interviewed one of our hosting docs/translators, Dr. Annette Dyan.  She was just finishing up her social service year.

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It was interesting that the doctors knew what the patients needed, but they simply did not have it available.  For instance, there was one ventilator in the hospital.  So a key discussion on rounds each morning was who to put on the vent and who to take off the vent.  There was an option to transfer patients to the next larger city, but the family had to arrange and pay for the transfer.  They often chose not to, usually for financial reasons.  It was interesting to round each morning on a patient with a PCO2 of 110 who wasn't put on the ventilator until the fifth day of hospitalization.  I did her intubation without paralytics.  Despite a chip-shot view and a heavy dose of valium, it still proved fairly challenging.

The ingenuity of the staff was impressive.  For instance, instead of an EKG machine with little stickers that get thrown away each time, the EKG machine used suction cups.  It worked fine.  And clearly had been working fine for a long, long time given the state of the wires on the machine, all of which were covered in electrical tape by the time we left.  I watched a paracentesis done, quite effectively, with an 18 gauge needle, IV tubing, and a bucket.

It was appalling to compare the air-conditioned mall where you could watch the newest movies, buy motorcycles and big screen TVs and any cell phone you wanted to the state of the hospital.  It was really quite a testimony to me of the value of capitalism for solving problems.  On the other side of the political spectrum, it was also a testimony of what an inadequately funded Medicaid/county hospital system could look like.

 

Medical Tourism

Having done humanitarian work in the past, I know it often becomes what I call “medical tourism”.  There will always be an element of that.  As discussed in the previous section, just seeing how other doctors do things has value and is certainly interesting.  But the real goal of humanitarian work is usually to make a difference in the lives of those you are serving.  The problem is that medical tourism is relatively easy to arrange and do.  Making a real difference requires a lot more time and effort.

For instance, our group included five emergency doctors.  We went to assist in an ED in a country where emergency medicine doesn't exist.  There is a medical side and a surgical side.  90% of the time, there is no attending in the department at all, just the interns and perhaps a social service doc.  The internist rounds a couple of times a day and the surgeons come when called.

The arrangements of the trip were for the five of us to be in the ED for a few hours a day for five days.  But there were no US docs the week before and there weren't going to be any US docs the week after.  So how were they supposed to incorporate us into their system?  It was an impossible task.

It becomes even more impossible when you consider the language, cultural, and system knowledge barriers.  I mean, how many shifts does it take to get you up to speed in a new hospital in your country?  Now imagine that in another country.  I speak pretty good Spanish.  I studied it in high school, spent two years full-time as a missionary speaking mostly Spanish, minored in Spanish in college, worked as a Spanish translator in a clinic to help prepare for medical school, did a residency 40 miles from the Mexican border and have continued to speak Spanish every week of my career.  But I'm not a native speaker and many of the docs spoke even less than I did.

All Work and No Play is a pretty rare humanitarian project

The ideal experience for a medical mission would have been to have come down, been plugged right into their system—teaching, seeing patients, etc., have a translator who happened to be a physician who had worked in their system at your side the entire time, and then somehow magically been able to detach from the system, get on the plane and go home a few days later.  It just wasn't going to happen.

So I knew this particular experience was going to lean far more toward the medical tourism side than the “making a huge difference” side of the spectrum.  Having done an experience in Guatemala that was much closer to a medical mission, this wasn't a surprise to me from the very beginning.

A “medical tourism” trip is usually pretty short, is fairly vague on the medical work you will actually be doing, and usually focuses on some of the cultural and scenic experiences you will have.  The people running the trip usually have a significant focus on you having a good trip and getting the experience you are looking for.

If you are interested in avoiding being a medical tourist, here are five tips I have for you:

1. Go for a long time.  There is a reason that Doctors Without Borders requires a 6-month commitment from most of its doctors.  It just takes a long time to make a big difference.  It can't be done in a day or two.
2. Have a defined project.  My neighbor takes his general contracting company to an underdeveloped country every other year and builds them a building like a school or a library.  There is a very defined goal and it is clear when it is completed.  They take everything they need and leave their tools behind.  Many surgical specialties are capable of doing similar work, with perhaps the classic example being the repair of cleft lips and palates, but it is entirely possible to do something similar with vaccines, pulling teeth, or a deworming project.  Maybe it is teaching PALS or ATLS or ventilator management.  But it is much more likely with a short trip that you will make a difference by having a defined project rather than trying to “help in any way we can”.
3. Go multiple times.  It is pretty difficult to know how you can best help prior to sending qualified personnel who speak the local language and understand the local culture and medical system to check things out.  But a second, third, and tenth trip?  That is much easier to design to make a big difference.
4. Make sure you'll be plugged into the system.  As a doc, you're a specialized labor component.  If you want to be part of the system, you need to replace somebody when you arrive and someone needs to replace you when you leave.  If you're an “extra” component, you're going to find yourself doing a lot more observing and a lot less helping.  Sure, you did an appendectomy or a C-section today, but who's going to do it next week?
5. Forget yourself and go to work.  Don't focus on your “experience,” but instead on the best way to make a difference and you'll be more likely to have both a meaningful experience and make a difference.

You might find that you get some pushback when you tell people what you're doing.  This surprised me a bit.  It didn't come from the locals, who were either very grateful for our assistance or at least put on a good show of being grateful.  It came from people back home.  Apparently, some people find the idea of being a medical missionary as being racist or colonialist or something.  Here's an example of a tweet sent my way:

So be prepared for that.

A couple of parts of the experience that I was looking forward to was living with a host family and going out to a rural area.  Unfortunately, both of those portions of the program had been eliminated when I arrived.  We stayed in a hotel (air conditioning and a shower every night) and rode an air-conditioned bus to the air-conditioned hospital each day.  Medium-adventure at best there.  The “medical brigade” to a rural area was also canceled, in part due to the political unrest but mostly just due to the fact that the vaccines we were going to give there never arrived.

We did some touristy stuff too—a barbecue at the beach, a visit to a chocolate farm, and a snorkeling trip on the last day.  It was fun, of course, but not the main reason I went on the trip.  I think that's pretty typical for most week-long humanitarian trips.

We made some great friends, both with the people on the trip with us and our local hosts and translators.  It was amazing how close you can get to people in such a short time period.

 

Don't Forget Your Deduction

Remember that your travel expenses to do humanitarian work and donations are tax-deductible as long as it is run through a US 501(c)(3).  You can't deduct the value of your time, but you can deduct your airfare, program fees, mileage, etc.

 

Busting Physician Burnout

I think humanitarian work can be an excellent antidote to burnout.  Spending time in an underdeveloped country always makes you grateful for what you have.  Inserting yourself into their medical system makes you grateful for your wonderful job.

In my first shift home, we had a trauma patient come in.  How grateful I was to have an x-ray tech, a CT tech, experienced nurses, lab techs, and a respiratory therapist at my side to greet them!  An hour later, the patient had been given medications and I had results from CTs and x-rays and was ready to disposition the patient.  The nurses were complaining about not having baby wipes in the ED and having to call central supply for them.  I was just happy to have all the disposable gloves I wanted to use.

Doing some humanitarian work, even if it ends up being mostly medical tourism, is a great way to remind yourself of why you went into medicine in the first place.  You will probably find that just like you wrote on your admissions essay that you really do “like science and want to help people”.

=”2″ link=”dWt4h” via=”yes” ]Doing some humanitarian work…is a great way to remind yourself of why you went into medicine in the first place. You will probably find that just like you wrote on your admissions essay that you really do “like science and want to help people.”

Now, I can't say I have any significant amount of burnout from my clinical work.  It's hard to get burned out working eight, 8-hour, day/evening shifts a month.  If I have burnout from anything, it's from WCI work.  But I left my computer home on this trip and didn't do a thing with WCI for 8 1/2 days, the longest period I've gone since starting 8 years ago.  It sure was nice to have a siesta and not feel like I should be checking email, creating content, or promoting the business.

As mentioned earlier, one of the main reasons I went was to have a great shared experience with my daughter.  I wanted her to be exposed to a foreign culture and language, medicine (her expressed career interest), and economic hardship like she has never known.  I think it was a success in that regard and hopefully, she'll write up a column about her experience that we can publish soon.

What do you think?  Have you done humanitarian work?  Why or why not?  What tips do you have for someone considering a medical mission?  Comment below!