Life is too short for bad wine!

Dear readers.
The past 2 weeks have been somewhat of a rollercoaster-ride and only now am I realizing how much of a toll 30 hour shifts every 3 days take.  Today I had my first vasovagal attack in surgery.  I have often enough experienced this when getting up to quickly from a lying or sitting position, or getting out of a hot-tub too fast, but I believe today was the first time in surgery, where I felt as if something dramatic was iminent. Therefore, when I asked if the airconditioning could be turned on, I was advised to sit down, and promptly my mask was taken off and I told that I was paper-white, i.e. very pale.  It was odd to experience this, as never before has surgery done this to me.  First feeling nausea, sweat, heat, unsteadiness, lack of concentration and even uneasiness in the stomach, as well as a feeling of general un-wellness.  After a bonbon, taking off my scrubs and some water, I was a lot better.  What exactly triggered it I'm not sure, but I was holding the laparoscopic camera quite unsteadily, and getting remarks of this.  I didn't have a coffee this morning.  I haven't been sleeping sufficiently, because of prolonged hours in the hospital, as well as having had quite the work-out at the gym yesterday.  So proabably a variety of factors accumulated to bring to a near vasovagal syncope for the first time.  After recuperating I entered another laparoscopic cholecystectomy and did fine.  Hopefully this was a one-time-only episode.

Later in the day I went with a friend to a bar close to the hospital, where students and residents (who don't have a shift) get together on friday afternoons.  I met some really nice people and had a couple of beers.  We spoke about this and that, yet mainly medicine, comparing Europe and Central America, learning how stark the contrasts between the two really are.  As the beer exited the pitchers, I was drawn to the dance-floor to be tought a few steps of merengue; a simple latin dance.  A bit of bachacha was thrown in, before me and my non-medical friend had to leave, for the sake of the hour.  Yet, this was a good time to leave, as we'd already had hour beers, had some good conversation, a couple of dances and it was nearing dinner-time.  We left happy and returned home to crack open a decent bottle of chilean merlot, to accompany the "dobladas" which were being prepared and filled with chicken.
This in when I said a few sentences, which I have conjured, after having heard some from various people:
-Life is exactly about what we've been doing tonight, i.e. having good conversation with nice people, a pint of beer, dancing, having good wine and good food.  Life is too short for bad wine; this is why I try to pick the better ones, without going bankrupt.  The thing with wines is that they are a question of price versus quality, this is something one always has to take into account.

These are just a few things that cross my mind, amidst what has being going on today.  Of course, one has to work, in order to have significant funds to enjoy these fruits of life, yet just like wine is a question of quality versus price, so is life.  What is life worth, if it is all spent on work and no play?  I believe if one can find a balance of professional and personal life, then one can attain true happiness.  However, if the balance is tipped too much towards one or the other, the equilibrium is lost.  Therefore, one must take care of not to work or study too much, as this will degrade life.  The same goes for living too much, as this might actually tip the equilibrium too much to the other side, resulting in loss of reality.  Balance is the way to go, not too much of anything, and neither too little.  Getting the balance right must therefore be our goal, in order to attain true peace of mind and thus happiness.

Don't panic!

Both Douglas Adams, in The Hitchhiker's Guide to the Galaxy, and a doctor friend of mine, who helped arrange my current elective at the Roosevelt Hospital in Guatemala City, Guatemala, said these ever-helpful words.  Don't Panic!  My friend said this several times, as well as "don't worry", when she took me to see the Roosevelt Hospital for the first time, the day before last Christmas.

I knew that I was going to a hospital, which would be different to the ones I've already been in, seen and trained in Europe, yet how different I did not know.  This quickly became apparent as we entered the area and then the hospital itself.

As with so many businesses and institutions here in Guatemala, everywhere there are armed guards, barbed-wire fences and walls, and a lot of people.  All of this a applies to Roosevelt.  On entering the area, a guard lets one in.  When walking from the car park, I could see the 5 storey building, which seemed about 50 years old.  When standing in front of the main entrance, the emergency ward is somewhat to the right, and to the left are first paediatrics and then further left, the maternity ward, everything else was right in front of me in the old main building.

When entering, one is encountered with a lot of people.  If early in the morning, there will be hundreds of people waiting in lines or sitting on benches, to have an appointment with a medical professional.  I was taken to the day-care hospital, where I've been for the past 2 weeks in elective surgery.  Everything was nicely decorated before Christmas, i.e. everything apart from the operating theatres.
Nothing was going on, as there were no elective surgeries because of Christmas holidays.  We said hi to the nurses, who were packing surgical equipment, cleaning equipment and beds, oiling tires of the beds and even painting the walls.  Yet, this ward didn't seem a lot different from old European hospitals, but then I found out, that this is probably one of the better kept areas.

When walking through other areas, the poverty and the deprived healthcare system became apparent.  Very old beds, little equipment, maintenance lacking, many patients in limited space, no isolation between patients in intensive care, whilst in the air a mixed scent of disinfectant and bacteria (mainly pseudomonas).  This isn't surprising in a hospital built 60 years ago, after the US Roosevelt era (hence the name) and the amount of patients which pass through per day.  The hospital has 800 beds, has all specialities, and seems very short of cash.

The real shock though came when entering the emergency departent (A&E / ER).  There, a long corridor from the aft to the front door is immediately apparent, and on one side are ophthalmology, X-rays, operating theatres and a shock room.  On the other side, rooms for patients.  Then in the middle of it all, people and more people.  Patients on stretchers or sitting on a bench between the stretchers, whilst awating further care.  In the inspection and treatment areas there are usually 3 patients at any given time, and a lot of residents and medical students.  Nurses are scarce.  I was thrown back decades when witnessing this area for the first time.  Coming from a background mixed of Northern and Western Europe, this seemed like something one sees in movies or documentaries.  I was somewhat taken aback.

Still, this was just my first impression, and still it didn't quite prepare me for my first shift.

Up to now, the surgery in the laparoscopic day care facility has been very good.  I think I can say that the surgeons here are competent and the equipment is good.  The operating theatres are not the newest, nor are the lights and operating tables, but they suffice.  The anaesthesia is also good, although they are somewhat lacking in equipment and drugs.  Still, they have what's necessary.  I've mostly witnessed cholescystectomies up to now, but also hernia repairs and some appendicectomies.  Then, in A & E (Accidents and Emergencies) things are somewhat different.

During a shift, the residents (and the medical students), mainly take care of the emergency ward and As & Es.  The shift starts after a normal day, continues until next morning, when the residents go back to their posts, usually not having slept the whole night.  Everything imaginable and unimaginable can be witnessed on the shifts.  A lot of acute abdomens come in, some needing surgery because of severe cholecystitis or appendicitis, as well as gun-shot wounds, sports accidents, fights and infections, just to mention a few.

My first shift consisted mainly of observing, as just about everything was new to me.  I encountered somewhat of a cultural shock whilst observing, trying to follow what was going on, as well as the way patient-doctor interactions were conducted.  A the day (and night wore on)  I got the chance to assist in a appendicectomy, then I observed a laparotomy after a gun-shot wound, which penetrated at least 4 organs, and then again another appendix was resected.  Also, lots of acute abdomens of all ages, gangrenic feet, cuts of various bodily parts being sewn, I saw a man who had been shot in the side, and had an entry and exit wound, which thankfully didn't penetrate his thorax, only the subcutis, as well some motor-vehicle accident victims.

All in all, I probably saw more in one evening, than I did during my 2 weeks of emergency medicine in Iceland.  Yet, despite the amount of patients, I am still not in the clear how things work.  There seems to be a sever lack of just about everything, except doctors.  The residents do the work-up, whilst the medical students do the work.  I did not see a qualified specialist on my first shift, yet the most senior residents take charge, and seem very competent.  However, the work-load on each residence seems immense, and the infrastructure is seriously lacking.  Medcine is scarce, space is little, there are no telephones nor computers, nurses are few and general infrastructure seems to be about 50 years old.

All this said, this was just my first shift, yet coming from Europe, this was a medical cultural shock.  At 3 in the morning I was shown a room where I could sleep until the next morning, and the bed with 2 pillows and a sheet was very welcoming, compared to what the patients had to endure downstairs in the ER.  Thanks to some sleep, the next morning wasn't that bad, yet I felt the drain when returning home.

After that shift, I told my instructor that I would not be doing shifts every 3 days like they do, as this would undoubtably be too much, taking into account that I do not know the system, do not speak the language well enough, and am definitely not yet accustomed to the practice of Guatemalan medicine, which truly is different from what I already know.

When thinking of this difference, it became apparent to me, that it is truly based on WHERE, rather than WHAT one learns.  Even though the medical community might have the same books, the same sources of knowledge and a similar academic background, this does not account for each country, or even each medical centre within a country, to offer the same standard of care.  It has become apparent to me, that even standard drugs are different depending on where one works, i.e. medicine is not just science, it is also culture, a culture based on where one practices and the resources, knowledge traditions, which reside there.

My next shift is in 3 days' time.  It will without doubt be another grand experience and a very informative one.  I will do my best to continue my comparisons and thoughts on my current elective in the coming weeks, and also try to travel back in time to the advent of Dr. Gunther von Bergweinstrom, which is actually a few internships ago.  Whilst comparing, I will not hesistate to go back in time and recollect some of my previous travels, which should have been documented at that time, yet connections and computers are not always available, and sometimes enjoying the ride is more important than documenting it :-).

Gallbladders!

So, it's been down to medical business for the past days.  I'm already in my second week, and still recuperating from a terrible cold, whilst the gastroenteritis has succumbed to ciprofloxacin.
Christmas and New Year's was somewhat different to what I've experienced before, yet it seems that universally there is lots of food and drink; for me probably a bit too much food...

But that's done and the fun is sort of over, and the reality of elective surgeries has arrived.  Last week was easy going, as the department slowly got ready after the Christmas holidays.  This week however is business as usual, and up to now it's all been cholecystectomies.  Yesterday I viewed 4 laparoscopic cholecystectomies.  Only one was a bit difficult, and the liver in that one was nodulous too, so biopsies were taken.  Today it was young ladies only, all under the age of 30.  Two gallbladders were removed without hassle, and then there was a semi-acute appendicitis as well.  After that it was administrational stuff and reading, however tomorrow it's all hernias and the day after that it's the first "turno", Spanish for shift.  That should be an interesting 30 hours at Hospital Roosevelt.

Today I learnt a few things, which are important for successful laparoscopic surgery:
1. Make sure that the CO2 canister contains gas, and is open.
2. Make sure that the light of the laparoscope is on.
3. Make sure that the port for the carbon dioxide is open, in order to insufflate the abdomen.

Keeping these in mind, among other basics, one can expect easier surgery :-)

I have not noticed a lot of differences between appendicectomy and cholecystectomy here, except that the organs being removed are not placed in a plastic bag, after having been resected, and before being pulled out through the skin.  Whether this is good, bad or just different, I don't know, but in one case such was performed, in quite an ingenious manner:
A sterile glove was taken, the proximal part of it (the wrist) was suture, and then cut.  Thus a latex bag was ready and was used instead of a ready-made bag.  Very simple, cheap and effective!

I'm looking forward to writing about my first "turno, which will take place in the Emergency Department, which is most certainly very different to all those I have seen before.

Dr. Gunther von Bergweinstrom goes English.

Dear friends, family and other readers all around the world.

This blog has now changed from Icelandic to English in order for me to reach to a wider audience, especially those who have not yet learnt the amazing Icelandic language :-).

To start with, an introduction might be appropriate.  I am a medical student from Iceland and am situated at this moment in Guatemala, doing an elective in general surgery, at Roosevelt Hospital in Guatemala City, the country's capital.  I have been several times abroad, and hitherto trained in hospitals in Iceland, Germany, The Netherlands, Spain and am now starting here in Guatemala.  The current internship/elective is part of a 3 month elective period, half of which will be spent here and the other half in Peru.

I will be using this blog as a future reference for myself, as a record of my foreign outings within medicine, but also to keep track and let non-Icelandic speaking friends know where and what I'm doing, as time does unfortunately not allow e-mails to all those I would like to write.  Most likely I will also be comparing different health-care systems between the countries I know, as well as writing about special cases or just how medical care in general differs to that in Europe.

I already had an introduction at the hospital on the day before Christmas and was received very warmly in the (ever so nicely decorated) department, where I'll be spending my elective.  I knew that I'd be entering a totally different medical world, compared to Europe, but I did not realize how much or in what way the difference would be.  This will become increasingly clear, as I will officially start on the 2nd of January 2014.

Jóladagur

Jóladagur er að kveldi kominn, ég er nokkurn veginn búinn að pakka fyrir ferðalag morgundagsins, og enn er nóg eftir af svínalæri gærkvöldsins; skv. ömmunni, þá verður það borðað alla vikuna...

En ég þarf ekki að áhyggjur af því að fá of mikið svínakjöt, því á morgun er ferðinni heitið til kærustu gestgjafa míns, sem býr í Huehuetenango, 279km héðan, sem þýðir 5klst rútuferð.  Þar verðum við fram yfir áramót, en verð að vera mættur stundvíslega á Roosevelt spítalann kl. 7:30 þann 2. jan n.k.

Dagurinn í dag var rólegur, enda allir frekar "þreyttir" eftir gærkvöldið.  Morgunmatur, sem samanstóð af afgöngum gærkvöldsins, var því snæddur um 11, með ömmunni, afanum, frænkunni, en frændinn sem drakk hvað mest í gærkvöldi, og var fyrstur í rúmið, var rokinn á skrifstofuna, og borðaði því ekki "morgunmat" fyrr en kl. 15.  Klukkustund síðar var síðan "hádegismatur", með sömu uppröðun og morgunmaturinn.  Sem betur fer var enginn formlegur kvöldmatur, því eina hreyfingin í dag var göngutúr um hverfið með hundinum Cheeky og eigendum hans.  Það verður áhugavert að sjá hvað bíður mín í Huehuetenango, bæði að borða og allt annað.

Jólahaldið hér er a.m.k. nokkurn veginn á enda, en á hádegi í og aftur kl. 18 óskuðu allir hvort öðru gleðilegra jóla um leið og flugeldar fóru á loft úti.  Á morgun halda flestir aftur til vinnu, á meðan ég og Gabriel höldum á vit ævintýranna.

Og talandi um ævintýri, þá var heimsóknin á spítalann á Þorláksmessu sú áhugaverðasta, en það var eins og að stíga inn í senu í bíómynd, sem sviðsett er á spítala í lok seinni heimsstyrjaldarinnar í Bandaríkjunum, því útlitið var slíkt innandyra (enda sennilega byggður um það leiti m.v. nafnið "Roosevelt").  Ég átti von á þetta yrði slæmt, en þó ekki alveg svona gamaldags og skítugt.  Hverju sem því líður, þá á þetta eftir að vera afar áhugaverð, en jafnframt öðruvísi og lærdómsrík spítaladvöl.

Öðruvísi Aðfangadagskvöld

Í kvöld sat ég ásamt fjölskyldunni og beið eftir að fólk mætti.  Allir voru seinir, sumir meira en aðrir.  Því var sett á borð nasl og snakk, skenkt víni í glös, og beðið eftir að allir mættu.  Á meðan var drukkið og naslað, hlustað á tónlist níunda og tíunda áratugsins í sjónvarps-/hljóðkerfinu, sem var búið að koma upp (engin jólalög), sem breyttist í latínó slagara, ballöður og epískt popp eftir því sem leið á.  Karlarnir drukku aðallega viskí á klaka, a.m.k. tvöfaldur í hvert glas, mikið af klaka og fyllt upp í með sódavatni.  Krakkarnir fengu kók á meðan dömurnar fengu vín.  Eins og gefur að skilja, leið ekki á löngu þar til helmingur samkomunnar var oðrinnokkuð ölvuð, en þá var komið að matnum, hver samanstóð aðallega af sérlega góðu svínalæri, alls konar meðlæti og víni eftir þörfum; en þörfum virtist mikil hjá karlmönnunum á svæðinu.  Þegar allir höfðu borðað, stóðu allt í einu flestir upp, krakkarnir hurfu inn í stofu að spila, einhverjir inn í eldhús að spjalla, karlarnir út í horn að reykja eða eitthvert annað á meðan ég sat eftir og spjallaði við gestgjafa minn.  Stutt var í miðnætti þegar fyrstu gestirnir þurftu að fara í annað boð, en á slaginu miðnætti byrjuðu allir að óska hvort öðru gleðileg jól, um leið og flugeldar fóru á loft um alla borg og allt í kring.  Skyndilega var himininn og umhverfið orðið reyk- og hljóðmettað, líkt og á nýársnótt á Íslandi.  Þetta varði í gott korter, áður en þeir sem enn voru með sjálfum sér, eða höfðu pláss, fóru að fá sér eftirrétt.  Engir pakkar voru opnaðir, nema þeir sem ég afhenti gestgjöfum mínum, auk ömmunni og afanum, en afinn var orðinn það drukkinn, að hann vissi svosum ekkert um gjöfina.  Amman, þrátt fyrir bága heilsu, þakkaði þó fyrir sig.  Eftir flugeldana tíndist fólk fljótt í burtu, og var tekist til við að ganga frá, þeir sem eftir voru.  Enn var heilt svínalæri og gífurlegt meðlæti eftir, sem verður víst borðað næstu daga (og byrjað verður aftur í fyrramálið að klára afganga...).
Þetta var því hin áhugaverðasta kvöldstund, hér á Aðfangadagskvöld í Guatemala-borg.  Heldur meira áfengi en á Íslandi, álíka mikill matur, mikil tónlist og m.a.s. Karíókí, þegar fólk var búið að drekka í sig kjarkinn, og engin jólalög þrátt fyrir árstímann.  Það verður áhugavert að sjá hve marga daga afgangarnir endast.

Það er aðfangadagskvöld, ég er staddur í Ciudad de Guatemala, úti heyrist sírenuvæl, hundar gelta og á neðri hæðinni er verið að blast-a eitís hittara (ásamt myndböndum) í einhverskonar vídeó-hljóðkerfi.  Ansi ólíkt því sem maður á að venjast á Íslandi, en afar áhugavert engu að síður.

Því datt mér í hug að starta þessu bloggi, sem ég stofnaði fyrir hina miklu reisu sumarið 2009 fram á sumarið 2010, þar sem mér tókst ekki að blogga, en mun eflaust rifja upp ýmislegt úr því og skiptanemadvölum mínum hingað og þangað um leið og ég rek núverandi ferðalag mitt um hina latnesku Ameríku.

Klukkan er rúmlega 18 hérna og fyrir 2 klst voru enn verslanir opnar og fólk á fullu að kaupa, redda, og jafnvel borða McDonalds og steikta kjúklingavængi., sem er einmitt það sem ég fékk í hádegismat í dag.
Í kvöld verða svo 2 risastór svínalæri borðuð. sem hefur tekið 2 daga að elda (með undirbúningi).  Það er því eins gott að skella sér í sturtu og klæða sig í betri fötum, því það verða 20 manns hér á eftir og 1 Íslendingur að snæða, drekka og sennilega syngja og skemmta sér langt fram á nótt eins og þetta lítur út þessa stundina.

Gleðileg jól frá Gvatemalaborg!  Feliz Navidad desde la Ciudad de Guatemala!