Rick Bodor, MD UCSD department of Surgery
Welcome to one of the greatest of surgical experiences any resident (or any faculty, for that matter) can have. The Interface program is one place where you really feel you are changing lives. The people are grateful, the pathology is impressive, and the feeling of fulfillment is maximized. At UCSD, we historically have been able to go about 3-4 times per year, per resident. It is a great learning experience for all, and very helpful to many children in Mexico who otherwise would not be helped.
Things to do before you go:
1) Read up on the common procedures you will see, both in the preop clinic, and in the operating room (evaluation and treatment protocols for CL, CLP, CL Nose, CL scar revisions, Hand deformities, Syndactyly, Polydactyly, burn scar revisions, bone grafting, skin grafting, pharyngeal flap, etc.
2) Bring several overviews (texts, articles, etc.) that may help with the techniques, anatomy, etc.
3) Bring your camera, for both the fun, the outings, the website, and the patients' photos....
4) Bring your passport
5) Bring your ID
6) Bring your scrubs
7) Bring your walking shoes
8) Bring your Spanish (via translator, booklet, or knowledge, if able)
9) Bring your medical students (if there are some interested....make sure Cathy Mayo, or others in charge approve.
10) Bring your special equipment that you may need (Loupes, special gloves if your are allergic, tons of bacitracin ointment, special gauzes, sutures, etc. if there are types you like specifically)
11) Arrange your travel (go with the group - best, or if needed, you may drive to Mexicali -but make sure you know the exact place of the hospital, the time the group will be there, how you will get into Mexico, where you will park, etc.)
12) Bring your enthusiasm for the unique, and difficult conditons that may be found in Mexico in the ORs of the poorest hospitals. We have had blackouts for hours (bring flashlight?), food problems occasionally (bring your specialized drinks, if you wish), etc. A bit of extras never hurts to have around (toilet paper, one dollar bills, etc.).
13)Cell phones with US accounts do not typically work in Mexico, so either arrange the upgrade, or enjoy the quiet of not being accessible.
14). Before you go, be SURE that all your UCSD responsibilities with patients are taken care of, and all attendings are aware of your arrangements.
15) The "out of town" resident in Mexico should ensure that there still is a "covering" fellow in town. Typically, the in town resident rounds, and works extra hard to cover all the fires. Attendings are usually quite understanding of the resident, if they are aware of the thinned fellows- level support. On the day the fellow returns (often a night return Saturday) the fellow in-town has rounded already, and covers that day. Checkouts occur that night, with the in-town resident covering most often -if that is the most rested resident. The next day, the resident back from Mexico has slept, and covers home base, as before.
16) Already be arranging the "follow-up resident" visit for the next week. This historically has been the Junior resident, or some years, an alternating visit has been the case (Mexicali). Be on the lookout for any medical students who may speak Spanish who may be able to help on this follow-up visit.
Things to understand when there, in Mexico:
1) Be respectful of the people, hosts, and Mexico colleague surgeons. Many of them have been doing these surgeries far longer than you have. Even when you are tired, remember, they are most thankful that you have come, so be a team player, and be gracious.
2) Be careful of the foods that you eat: your Americanized GI flora is not typically the same as your Mexican hosts', so you may have problems with anything that is raw, and anything that has been in contact with water that is not bottled (fresh vegetables and salads rinsed in water, tap water drinks, etc.).
3) Take advantage of your resident status (you work hard, but you probably have first "dibs" on all cases...even if an attending will wish the same case: they can be a co-surgeon with you. You will learn much, so don't be afraid to ask for help, and work on the cases of your choice.
4) Remember: you will need to be careful on these operations: we have been led into potentially dangerous areas by occasionally incomplete H&Ps (midline scull "scar revisions" being set up for simple revisions, with nobody realizing the patient had midline scull fractures there, a post head injury coma and seizure history, and dangerous adhesions potentially adherent deeply into the superior sagital sinus. Had we not "re-asked" more detailed history on these and other preop patients, aggressive surgical procedures could have been quite dangerous in that remote operative setting. Any complications in the red cross hospitals of Mexico could be devastating to an international program like Interface. Use your OWN careful judgement to ensure you are doing the right thing.
5) Also remember: tell (via translators) the patients the permanent implications (and complicatins) of your surgeries. It is THEIR lives that you are alter-ing forever. That pharangeal flap patient may wish to know that there may be implications for potentially difficult future intubations for them. That scar revision patient may wish to know the recurrance rate of keloids, or the importance of not "suntanning" onto the scar post operatively. They may wish to know the early signs of in infection....and why they are being given their antibiotics and ointments. I make sure that the patients have a good written paper (often with diagrams) to give to their personal medical record files, future doctors seeing them, etc. The Interface chart also needs the basic record to be complete for the future surgeons who may need to operate in your operative site.
6) The follow-up time table is important to mention to all the patients as soon as possible, and make sure that the recovery room nurses know to put it all in writing to each patient anticipating a return visit that next week.. It may also be posted in the clinic recovery room, so patients will know that they can come back to an Interface doctor if there are any complications. Also mention to all "chronic" patients the fact that we DO return twice yearly. Pinpoint with Cathy the planned dates (or clarify the process of how to "follow-up") for those "multiple stage" operative patients to fully understand their follow-up options.
7) If you are late the next follow-up (one week post op) because of car trouble or something....make sure that you know the phone number of the hospital to where you are scheduled to go so the word can get out as to when you will arrive...there are families who have travelled for days for your visit, and they should not be left without alternatives in case you are not there (but: best of all BE THERE.....many are counting on you).
8) Take your camera to the follow-up visits as well. for medical as well as social reasons.
9) Photo not only the operations, but also the associated names and the op-notes....for the best, most complete records of the patients. They are all deserving of a "real"medical record, as best as is possible given the circumstances. The UCSD resident file of photos is one of the best records available for patients operated on, if needed to be accessed.
10). Make sure that you remind the other surgeons (those who will NOT be taking OUT those tiny sutures next week, on those screaming babies) to use ABSORBABLE SUTURES wherever possible. We all know the negative skin implications of the absorbable suture (inflammatory skin responses, etc.), but many of these patients may never return....and if they do, the trauma of the "picking at sutures" event for many is not worth the less traumatic stressor of having absorbable sutures. Of course, if the patient is willing, then the absorbables may also be removed the following week....electively. The resident MUST remind the other surgeons of this (if you value your sanity the next week, and have enough pity for those poor frightened babies you will have to see 7 days post-op).
10) Make sure that the Interface group (of nurses, etc.) are taking enough Polysporin packets, Chromic sutures, etc. that you may need. This is a work in progress, so input your part to Cathy Mayo or similar such program organizers.
11) On the follow-up (one day out, as well as one week out), you will be alone. You may need to bring a translator, or hire one (I once gave the reporter covering our work there 30 dollars for her time helping me translate, when I was desperate during my one week follow-up). Make sure you know where to send your "complications" patients, if you find some.
12) Make sure that you have enough equipment to cover your post-op visit complications, whether it is the POD#1 visit, or the Post week 1 visit. Make sure, specifically, that you don't lack enough:
Q-Tips, polysporin, dressings, suture scissors, scalpels, Loupes, alcohol wipes to clean equipment between patients, hand wash, gloves, PENLIGHTS, tongue depressors, etc. All will fit into an important bag of "Interface follow-up" stuff that you should arrange -and bring with you- before you round on follow-ups...each time.