Colombia - June 8th, 2011

Colombia has been a different mission, to say the least.  First of all, we are anchored approximately 6 nautical miles off shore, so the boat ride to the BLZ (the boat landing zone, you remember) is about 45 minutes (we call it “the slow boat to China”).  The BLZ is located on a Colombian Navy base, which is a 10-minute bus ride from the MEDCAPS site.  The most remarkable thing about the bus ride is the presence of heavily armed police guards along the street – at least every 100 yards.  There are also armed military guards stationed in towers looking out over the streets.  At the MEDCAPS site, we have 900 Colombian military and security personnel, for our protection and for the protection of our patients.  Makes me feel scared and safe at the same time.

The high level of security is due to the fact that the area of Colombia we are in, called Tumaco, is one of the highest cocaine export areas in the world.  Cocaine eradication is THE topic of conversation down here.  There is a local group called the FARC that is very active in exporting cocaine.  They are apparently a violent group which actively resists the CNP (Colombian National Police) and the Colombian Navy. 

We had a lecture by one of the local toxicologists last night, which described the methods used to eradicate cocaine exportation, production, and farming.  The local authorities attack the process at each step.  The Colombian Navy is responsible for preventing exportation by boat.  The Navy has dozens of boats which are extremely fast and heavily armed, to chase down the exporters.  The Navy base where the BLZ is located is full of confiscated narcotrafficking boats (and even a submarine that was captured!), with the engines detached and the fuel tanks emptied – to be re-commissioned for good instead of evil.  To combat production, the CNP investigate local farmers and attempt to limit the sale of chlorhydrate which is mixed with coca to create inhalable cocaine (the most addictive form, apparently, and the cheapest to produce – so the farmers actually give this form away to people, in order to get them addicted to the more expensive crack or powder cocaine).  At the farming level, eradication is accomplished through aerial spraying of, essentially, Round-Up.  We’ve been told that the FARC try to shoot at the airplanes during this process.  For any coca plants that survive the pesticide, the CNP hires civilians (for $20 per day) to dig up the remaining plants by the roots.  This seems like a fairly easy task, except that the coca farmers (the FARC) plant IEDs and land mines in with their crops – so explosions and severe injuries of these workers are common.

Extremely unfortunately, we got to witness the results of one of these IEDs yesterday.  Approximately 20 miles away from the Navy base, one of the IEDs exploded and injured 4 Colombian civilians.  Three were only minor injuries, but the last patient, 21 years old, was closest to the explosion and seriously hurt.  The CNP requested the Comfort’s assistance in caring for these casualties.  Since the ship is designed for disaster response as well as humanitarian assistance, it was actually very easy to take these patients on.  The four patients were flown in by helo, and transported immediately to CASREC (our Casualty Receiving area).  I happened to be on board the ship yesterday, so I was a part of the “mascal” (mass casualty) response.  The most severely injured patient was taken immediately to the OR, where he underwent bilateral lower extremity amputations (one above the knee, one below the knee) and a left arm amputation.  He also has a fractured left femur and right forearm.  He is currently in the ICU and is certainly our most critically ill patient.  I started my MOOD call at 7pm last night and didn’t leave the ICU until almost midnight.  Once we had the patient stabilized, the true horror of the situation sunk in for me.  He is 21 years old, and had taken the job that day for less than $20.  In fact, he wasn’t even hired to dig up coca plants.  He was the “water boy” – the person charged with bringing water to the other workers.  Apparently, one of the workers missed a plant and asked our patient if he would quickly dig it up – and that’s when the IED went off.  The patient has been unconscious/ sedated since he arrived on the ship, and we don’t know his phone number, so his family has no idea where he is or if he’s even alive.  He does not yet know about his 3-limb amputation and serious injuries.  I came extremely close to tears when this all hit me last night.  I’m sure my military colleagues serving in Iraq and Afghanistan see this every day, unfortunately, but I wasn’t expecting it and it really sucks.  He does appear to be stabilizing and will go back to the OR for another surgery tomorrow.  After that, he will be air-evac’ed off the ship to a Colombian military hospital.  He has no medical insurance but reportedly the President of Colombia will be paying for his med-evac off the ship.  Also, according to reports, because he was acting as part of the CNP, he will be eligible for medical care and should even get prosthetic limbs once his wounds are healed.  But I can’t help but think he’s not going to consider that good news. 

Other than that incident, Colombia has been fairly quiet.  Because of the extremely long transit time to get to and from the MEDCAPS site, most of the providers only have 2-3 days on shore.  Although going on shore makes the time go by faster, most of us are not complaining.  The first boats leave at 5:30am (requiring a wake up time “in the fours” – which should be illegal in my book) and don’t get back until after 6pm usually.  The patients seem to be much sicker – and much poorer – here than in the other countries we’ve visited, so the clinic visits are longer and more challenging.  The air temperature is about the same as Ecuador or Peru (high 90s to low 100s), but the humidity here is about 90% and there is no breeze, so it feels much, much hotter.  There are lots more mosquitoes, so my first day back from the MEDCAPS site, I was covered in 6 coats of DEET and about 42,000 coats of Purell. 

That day, I also won the award for seeing the world’s grossest wound – a distinction I would gladly pass on to someone else.  The patient was 91 years old and lived alone.  He reported having “worms” about 20 years prior, which caused his left leg to swell massively (a condition called elephantiasis).  Because of the swelling, he got an infection in his leg, which he told me had been there for 20 years.  When he came to me, he was sitting in a wheelchair, and his leg was wrapped with a dressing.  From across the room I could smell the dead tissue and see the flies and gnats buzzing around and feasting on his skin.  The smell alone had me nauseous.  One of the nurses offered to help me change the dressing, otherwise I probably wouldn’t have considered it.  We both donned masks to help shield us from the smell.  As I peeled back his dressing, the full extent of his wound became clear.  His entire shin/ calf was necrotic and the most disgusting thing I have ever seen.  I literally started gagging behind my mask.  When I looked at my translator, she had turned away and was crying – I told her she could leave the room if she wanted.  We irrigated his leg with sterile water and the drainage we collected at the end was filthy – with pieces of skin, dirt, and flies floating in it.  We then re-dressed the wound, but not before taking several pictures – I’m sure you all can’t wait to see.  The patient was very grateful to have a clean dressing, but was less pleased when I told him I recommended amputation of the leg.  He said that another doctor had recommended that before, but that he was concerned that surgery might kill him.  I told him that yes, that was possible, as he is 91 years old, but that the infection eating his leg might kill him too.  In the end, he agreed to at least consult with a local surgeon to discuss amputation.  In the meantime, I gave him one month of strong antibiotics and a few extra dressings, along with strict instructions to clean the wound every day (instructions that I am 100% certain he will not follow).  When we got back to the ship that night, the story of my patient had already spread.  A colleague had taken pictures of me irrigating the wound, and those pictures had made their way around my department.  Someone mentioned that they had had a similar patient in Peru – to which an eyewitness quickly responded, “No, I saw that patient too.  Melissa’s was a thousand times worse.”  In the medical world, seeing and treating a disgusting medical condition inexplicably gains you a certain amount of respect and admiration from your peers.  Again, an honor I would rather not have had.

Believe it or not, I haven’t been out to the MEDCAP site since that day.  I head out again tomorrow and Saturday.  The physicians in Tumaco have all been on strike since March, so the local hospital here is being run by residents and medical students.  Specialists are especially lacking, so I have been asked to see about 20 oncology patients tomorrow.  I have no idea what to expect, but I am excited to be able to use some of my oncology knowledge out here.  I am, admittedly, a little intimidated about seeing 20 new cancer patients in one day – usually we see between 25-35 patients at the site, but they are not as complicated as your typical oncology patient.  Should be interesting.  The next day, we have a meeting arranged with some of the local physicians (some of whom are on strike, and some of the residents that are working the hospital).  The meeting is referred to as a “SMEE” – a subject matter expert exchange.  Typically, these SMEE’s are less of an exchange and more a passing of information from us to them, but they specifically requested an oncologist, so I’m heading out to answer any cancer-specific questions they may have.