A Salvadoran Surgical Tale

By now it’s no big secret, gracias a los powers of Facebook and the chambre monster, that I underwent a fairly routine surgical procedure here in El Salvador on November 24^th, the day before Thanksgiving. Thanks to my wonderful Peace Corps nurse, Irma; my deft surgeon, Dr. Alvarez; the attentive nursing staff at the Hospital de la Mujer; and the love, prayers and support of my family and friends, I was able to make a complete and speedy recovery.

***READER BEWARE*** This blog post will recount the details of my appendectomy from initial symptoms to post-op. If guts, gore and semi-gruesome details aren’t your cup of tea, you might want to skip this entry.

Appendectomy

The week leading up to Thanksgiving 2010, like most years, was a hectic one. Instead of busily planning my menu, testing recipes and searching out the perfect bird, this year I was more than occupied pairing Peace Corps Volunteers and Embassy Family Hosts for Thanksgiving and finalizing the last minute details of our volunteer bar party on Black Friday.

By Tuesday, most things were in order; all volunteers had Thanksgiving Embassy Families, even the difficult to place vegans, but I still had a few emails to send out. As absurd as this next statement may seem, it’s very true and very common. The cables connecting my town to the internet were stolen over the weekend, (thieves then sell the cables for great financial gain )leaving us Lisliqueños completely disconnected. With no other option, I packed up my trusty MacBook and charger, hopped on the bus and settled in for the hour and a half bus ride down to Santa Rosa.

On the ride into town I was rather lethargic, in hindsight even more so than normal. My body had already begun defending itself. After a bit of a nap I woke up slightly refreshed in Santa Rosa. A week earlier, my fellow NLUers and I discovered that Pollo Campestre, an inexplicably popular fast food chicken restaurant, has free wireless internet service. Connectivity was enough for these gringos to change their hangout from the BK Lounge to Pollo Campestre. In no time I had my portable office comfortably setup in a booth and started tackling my internet to-do list fueled by hot, fresh, brewed coffee. Such a treat. What? You mean to tell me brewed coffee isn’t a luxury good?

Soon enough my friends and PC colleagues, Brian and Erica, joined me. While eating lunch, we chatted and caught up on the latest chambre. Amid the stories and updates, Erica commented on how little of my salad lunch I ate, a completely abnormal occurrence for me as a Lifetime Member of the Clean Plate Club. I chalked it up to a bit of a tummy ache, most likely induced by too many cups of real coffee. In actuality, though, the bacteria attacking my appendix were beginning to wreak havoc.

With a successfully completed to-do list and the afternoon quickly dwindling away, it was time to hop my trusty 374 home. At this point, I was beginning to feel nauseous, very bloated and a little feverish. The unpleasant feelings intensified quickly and were joined by stomach pains. As I wriggled myself into a position where I didn’t feel like I’d lose what little of my lunch I ate out the window, I cursed my decision to have a salad, an often culprit of amoeba transmission. Based on previous experiences, I was positive I had contracted amoebas and was about to begin the unpleasant side effects. I prayed and tensed my entire body as the bus jostled me homeward. For those of you lucky enough to have experienced amoebic dysentery, you fully understand my divine pleas. I have done many embarrassing things in El Salvador, but I have yet to poop my pants and wasn’t yet ready to resign to the lowest of lows, no matter how bad the pain. Yes, I am fully aware of how gross that is, but I am also aware, based on casual research and anecdotal evidence, that 60% of all PCVs wish Depends were standard issue in their medical kits.

By some divine intervention, I was able to waddle gingerly to my house, hastily unlock the two bolts on the front door, run up the stairs, unlock two more bolts and sprint into the bathroom. Just in the nick of time. As this point I, a very risk averse person, was willing to bet large sums of money on the fact that I had little bugs in my belly.

With the idea of amoebas stuck in my head and in my belly, I began the usual at home care regimen until I could get in to see a doctor presumably the next morning. It was about 5PM then, only twelve hours to the first bus out. I could make it, no problem. This wasn’t my first amoebic rodeo, after all.

I busied myself as much as I could in my nauseous state, picking out and folding clothes to pack for Thanksgiving and the bar party, checking over my to-do list one last time and BBMing Mom and Dad. As not to worry my parents, I told them that I was feeling a little under the weather, probably just something I ate, definitely nothing serious. Around 7PM, my stomach pains began intensifying, not unbearable, and the vomiting began. I thought to myself, no worries, this is the standard procedure. By this point in my Peace Corps service, I know how my body reacts to amoebas: nausea, slight fever, followed by diarrhea and ending with two bouts of vomiting.

After my first vom sess, I laid down to try to relax, puke guacal at my side in case I couldn’t make it to the bathroom, and watched Pretty Woman. Halfway through the movie, my stomach pains were incredible and the vomiting hadn’t subsided. The pains weren’t localized to my right side, so the thought of appendicitis never crossed my mind. I transferred my movie screening to the floor of the bathroom (yes, I am aware of how pathetic that is) and fully appreciated having a nicely tiled, clean bathroom with flush toilet.

By round number five of vomiting and increased stomach pain, I began to give in to the fact that I might have something seriously wrong. I consulted my Peace Corps Medical Manual and WebMD on my Blackberry and diagnosed myself with an array of diseases include pancreatitis and bleeding ulcers. Never in my expert prognoses did I identify appendicitis.

Finally around midnight, with much guilt about the inconsiderate late hour, I called our emergency Peace Corps Medical Officer line. Irma, our beloved nurse who in recent months has been terribly overworked as our only full time PCMO, answered the phone. With the pain audible in my voice, I told Irma of my symptoms. She was very concerned and immediately thought of a possible appendicitis. Her main question was, is the pain on the right side of my stomach? At that point, I still couldn’t localize the pain. Without the pain localized, my symptoms seemed more like an intestinal infection. Irma told me to get myself to the hospital in San Miguel first thing in the morning for tests and that she’d be calling periodically to check on me.

Around 1AM, I wasn’t feeling any better when Irma called, yet the pain hadn’t localized either. I tried to hydrate as best as I could with water and oral rehydration salts, but kept vomiting faster than I could consume. At 1:30AM I started to get scared seeing as I live alone and so far from the nearest hospital. Instead of getting myself worked up, I decided to pack my bag and see how I felt afterward. It would be something productive to do to pass the time and at least I’d be ready to go.

Honestly, I have absolutely no idea what was going through my head when I packed my duffle, but I had my party dress, high heels, a bathing suit, seersucker shorts and about five polo shirts. Basically, the most random and useless array of clothing I could gather. I was smart enough, though, to pack my computer, phone chargers and wallet.

2AM came around, the pain was excruciating and I started to get panicky. I decided I needed to call someone I know with a car to beg them to drive me to the San Miguel hospital two and a half hours away. The first person I called was Don Felipe, a member of my cooperative. Unfortunately, Don Felipe lives in a rather remote community and his cell phone had no signal. The next person I called was Dr. Carlos, the head doctor at Lislique’s Unidad de Salud. Of course I felt awful calling people at such a ridiculous hour, but I figured he’d understand. He is a doctor after all. Much to my utter shock, he picked up and hung up his cell phone three times in a row. In desperation I sent a text message, explaining it was an emergency and to please call me back as soon as possible.

At this point, I didn’t know who else to call. The doctor wasn’t answering my text message and I was racking my brain for people I know with transport. Finally, I remembered that Fatima’s, my running partner, dad had a truck. I called her mother’s cell phone number and was incredibly relieved when she answered. Naturally I apologized for calling at 2AM and explained the situation. I didn’t even have to ask, Lola offered to have her husband drive me to the hospital. She told me he’d be over in ten minutes.

Leaving my house in a complete disaster, I grabbed my duffle, locked my door, vomited once more and was on my way to the hospital by 2:30AM.

To say that the ride was rough is a complete understatement. My ambulance was in actuality a small Toyota pick-up at least as old as I am. The first thirty minutes of my 150-minute venture was on a completely unpaved, very uneven and hilly dirt road. All the jostling and jolting intensified the pain so much that I cried a bit. Thankfully the majority of the ride was on paved, albeit not too smooth, roads. I was able to sleep fifteen minutes here and fifteen minutes there between finding comfortable positions.

Irma called me around 3:30AM to check on me and I told her of how I had become scared, the pain intensified, and was en route to the hospital. She then called the hospital to inform them of my arrival and ensured me that everything would be in place once we arrived.

A little before 5AM, we finally arrived at San Miguel’s very new, lovely private hospital. No other patients were in the entire emergency department, as far as I could tell, and as Irma promised, the nurse and doctor were awaiting my arrival. Thankfully I was able to make the entire ride without vomiting, but as soon as I stepped foot in the hospital, I was shuffling as quickly as I could to the nearest bathroom to expel pure bile. The nurse followed me in the restroom to make some observations on my bodily fluids. Extreme dehydration, duly noted.

Feeling much relieved, I was escorted to my exam room where the doctor sat down with me right away. She took my vitals as well as blood, urine and feces samples before performing a full body exam. When she began prodding at my stomach I was near tears again and she was fairly sure that I had appendicitis. The doctor then administered my banana bag via IV, told me she was just waiting on my lab results and on the arrival of the radiologist before sending me for an ultrasound to confirm her hypothesis.

While waiting for my test results, Irma called me to update me on the situation, to tell me to make sure to have them call her as soon as I am in radiology, and under no circumstances allow them to admit me, give me water or food, or even think about operating on me. This particular hospital, though authorized by Peace Corps to perform diagnostic tests and exams, is not authorized for operations.

At this point, I called my parents to inform them of what was going on, obviously causing panic, but trying to reassure them that everything was fine. My mother wanted to hop on a flight right away, my father remained his stoic emotion-internalizing self, while my poor sister was left to handle them both. I owe you big time, Dana.

Soon after, I was wheel chaired to radiology, where the ultra sound quickly confirmed that my appendix was in fact inflamed, but thankfully hadn’t ruptured. I was immediately on the phone with Irma who told me I was being transferred to a hospital in San Salvador and that one of our PC drivers, Gerardo, was already on his way eastbound. In order to save precious time, the plan was to have the hospital ambulance drive me westbound and to meet Gerardo somewhere in the vicinity of San Vicente.

I was taken back to the ER exam room to be given an antibiotic shot to prevent my appendix from rupturing on the two and a half hour ride to San Salvador and rest until the ambulance was ready to leave. In true slow Salvo fashion, Gerardo arrived at the hospital before the ambulance was even ready. Gerardo helped to gather my things and reports and we were quickly on our way.

Gerardo, a Peace Corps driver for nearly fifteen years and notorious for reaching destinations in record time, assured me he’d have me at the hospital in no time. I told him how much I appreciated him, especially being woken up at 4:30AM by Irma to come pick me up and the fact that he brought the brand new Toyota Prado Landcruiser, but to please drive algo suave. Puke guacal between my legs, I braced myself and we were San Salvador bound.

The drive into the capital started at 8AM, meaning it was now sufficiently late for me to make phone calls to my fellow PCVs to cover my responsibilities for Thanksgiving and Black Friday. By the time we arrived in San Salvador, Brock was picking up the wine for Thanksgiving dinner, Isabel was briefed on all the bar party details, and I was able to convince my mother to hold off on flying down until we had more details of my prognosis.

At 10:30AM, Gerardo and I arrived at the Hospital de la Mujer and I was immediately admitted. Irma had called in advance, the hospital was awaiting my arrival and the surgeon was on call. Before I even finished my admission paper work, Irma was rubbing my back, assuring me everything would be ok and making sure the hospital staff was making my case a priority. Irma is an efficient angel.

I was quickly wheel chaired up to my very nice, private hospital room complete with cable, internet and a Lay-Z-Boy recliner. The nurse instructed me to strip down and dress in the latest in hospital couture, a lovely floral pattern gown. The surgeon, Dr. Alvarez, was in immediately, performed a physical exam, and because I wasn’t in apparent excruciating pain, he decided to re-run all my exams. (Note to self: cry next time.) At this point, I hadn’t eaten or drunk anything in nearly twenty-four hours that wasn’t otherwise expelled, so the nurses hooked me up to another IV and took more blood.

My blood test came back, while I was waiting my turn in radiology, with a highly elevated white cell count. With that information, Irma started making phone calls and making sure I was put on priority for my ultrasound. I talked with my parents once again, updating them of the situation and assuring and reassuring my mom I was under excellent care. The truth of the matter is I was getting arguably the best care of my life. I was at the nicest private hospital in the country, I had Irma by my side advocating on my behalf, and my surgeon completed his surgical residency in the US, not to mention he removed the appendix of one of my colleagues two weeks prior.

Dr. Alvarez and Irma were with me during the ultrasound as not to waste any time with reading printouts of the exam. By this point, it seemed pretty imminent to me that my appendix was coming out and I was really starting to feel nervous. Some how, though, I still managed to keep it together. The ultrasound quickly showed an extremely inflamed appendix and then, with a very concerned voice, the radiologist said, “Hay liquido libre,” meaning there was free floating liquid in my abdominal cavity. My appendix had ruptured. My blood work indicated that the bacteria hadn’t yet entered my bloodstream, so time was of the essence to prevent going septic.

From that point, things moved very quickly. Dr. Alvarez ordered the OR to be prepped, he himself went to change from his very fancy suit, and I was wheeled upstairs for preparation. Irma had to make several phone calls to Peace Corps Washington to get my surgery authorized, I called my parents to let them know I was going in for surgery within the hour, and I had to write consent for Irma to call my parents afterwards and disclose my medical information. My dad is my healthcare proxy, but in an emergency situation where said legal documents aren’t readily at hand, written consent is used.

The nurses, all dressed in very adorable tailored scrubs, came in to take me to surgery. Irma, though her son was arriving at the airport from the States, stayed with me, reassured me that everything would be fine and that she’d be in touch with my parents.

Dr. Alvarez came to speak with me once more before going under general anesthesia. We discussed my options in terms of surgical techniques and decided that a traditional incision would be the way to go. The benefits of laparoscopy weren’t overwhelming, and the traditional method was more conservative with time. At this point, I asked him if he wouldn’t mind taking a photo of the appendix for me. He looked back at my as though that were the most ludicrous request anyone could make. “¿Por que querias una foto?” I explained that I had a natural curiosity to see what he was cutting out of my body, and also that two of my good friends are in medical school and would love to see it, too. Dr. Alvarez chuckled a bit and said, “Está bien.”

Once in the operating room, the anesthesiologist went straight to work, attempting to practice his English with me. Right as the juices started working, I remember the last concern I had was if I would be able to run in the Freezer 5k race that I had signed up for the previous week. For some reason, I was very concerned with being able to run and the doctors just laughed. There was no chance I’d be ready to run in three and a half weeks.

About an hour later, I woke up in the recovery room very groggy. To be honest, I don’t remember much other than speaking with the nurses in Spanish, insisting that they talk more quietly and getting angry with them for teasingly accusing me of dying my hair. Apparently I kept rambling on and on in Spanish about running in the 5k, about how I wouldn’t get to eat Thanksgiving dinner and how I needed to get to the bar party on Friday. At some point they told me I needed to callerme, rolled me over and gave me a shot right in my butt! Once in my hospital room, I just kept asking if Irma called my mom.

Irma later told me that my operation took about fifteen to twenty minutes longer than normal, and that even she started to get worried. She told me she paced and prayed in the waiting room until Dr. Alvarez came out and told her all was well. The reason my operation took so long was that my appendix was far larger than the surgeon had anticipated, about ten centimeters in length and of abnormally large girth, and that he had to increase the size of my incision by a centimeter in order to get it out. He estimated that I had been symptomatic with appendicitis for at least three days. Case and point of when a high pain threshold is not a good thing.

A couple hours after I returned to my room I was coherent enough to talk to my family. We all felt a great sense of relief, and I was able to rest comfortably after a few more butt shots of painkillers. Eventually Dr. Alvarez came to check in on me, back in his very dapper suit. He showed me the photos of my appendix he took on his iPhone, which he later emailed to me. Awesomely gross.

Twenty-four hours after my initial feelings of panic I was comfortably resting after a successful appendectomy. The longest day of my life was finally over.

I spent a total of three nights in the hospital, missed Thanksgiving dinner and enjoyed the bar party vicariously through phone calls and text messages from my friends. I was fortunate enough to have visits from Peace Corps friends and to spend “Thanksgiving Dinner” with my family via G-chat.

Now, El Salvador and I have a very unique symbiotic relationship with lots of give and take. I just never thought it’d literally take a piece of me.