Surgical mission work in Ecuador presents challenges, inspires creativity

When asking friends about their vacation to South America, one doesn’t expect stories about ear reconstructions, cleft lip and palate repairs, or accounts of people with severe burn scars finally getting treatment. But those are the memories that several UK physicians and residents brought back with them after a week of volunteer medical service with Medical Mission Ecuador (MME) last March. And while they weren’t typical vacation memories, each one was worth keeping and sharing.

Dr. Ashley Kerekes, serving her chief resident year in the UK division of Plastic Surgery, was among a group of 70 physicians and health care providers who made the journey to Ambato, Ecuador. The group was a mix of first-timers who, like Ashley, had never embarked on a medical mission trip, and regulars who’ve participated in previous MME visits to Ambato over the last 25 years or had done other mission work.

Participants included more than just Kentucky physicians. Off the top of her head, Dr. Kerekes recalled groups of providers from Alabama, North Dakota, Tennessee, and Arkansas, to name but a few. The providers included plastic surgeons, pediatric orthopedic surgeons, registered nurses, allied health personnel, primary care specialists, OB/GYN physicians, and opthalmologists.

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From Kentucky, in addition to herself and Dr. Henry Vasconez, MME co-founder and chief of the UK division of plastic surgery, there were three pediatric orthopedic surgeons from Shriner’s Hospital for Children – Drs. Henry Iwinski, Vishwas Talwalkar, and Scott Riley. Dr. Chris Montgomery, a faculty member with UK Anesthesiology, brought along two residents.  And, finally, Eric Miller, a physical therapy specialist at Shriner’s, joined the group. Miller brought casting, splints, prosthetic material and an amazing level of creativity, Kerekes commented.

“I’m really doing this!”

Although this was Dr. Kerekes’ first experience, she expected the hundreds of people waiting in line to see the doctors. What surprised her most was the equipment the MME team brought with them to Ecuador.

“I couldn’t believe how many wheelchairs that we brought along. Then I saw the numbers of families who needed them. People were bringing children on their backs to see us because the kids couldn’t walk,” Kerekes said. In several cases, the wheelchairs were adapted to the family’s specific needs because they live in remote areas of the region.

“When I got into medicine, I always pictured myself doing mission work. But it was quite another thing to be on a bus leaving Quito [Capital of Ecuador] with a whole medical team and realizing, ‘Oh my God, I really am doing this!’”

There was not much time at all to rest when they arrived at the hospital. She and the four plastic surgeons settled in that Sunday and began meeting people. Kerekes estimates that she examined about 40 patients in about eight hours, which was about what everyone else in her group did, if not more, she said. In the evening, the plastic surgery team reviewed cases, decided on the surgeries to perform that week, and divided the load.

In five days, Kerekes and Vasconez performed or assisted on about 20 surgical procedures. That figure doesn’t even count the number their fellow providers performed. The experience was “pretty intense” on a number of levels, particularly because Kerekes did not have access to the same level of technology that she’s accustomed to at UK.

On an hourly basis, she said, something would come up to challenge her skills as a plastic surgeon. It demanded a great deal of creativity and problem solving to achieve quality outcomes, she said.

“This is one of the things I love about being in plastic surgery. You really don’t need a lot of stuff. As long as you have the essential elements – sutures, scalpel, and your hands – you can do a great deal,” Kerekes said. She also credited the hospital staff for being such helpful collaborators throughout the week.

The mission work went beyond treating patients. Kerekes worked with medical students and surgical residents from Ecuador. “Sharing experiences with the residents and participating in the education of medical students was as rewarding as working with the patients.”

The medical students provided most of the translations between Kerekes and the patients. Without them, there would have been no way for the program to run efficiently. With the lines of people waiting for treatment, the students and staff played a vital role in getting people through and communicating instructions. The amount of pre-planning was clearly immense, Kerekes observed.

“We saw a lot of cleft lips and cleft palates. And we saw a lot of microtia,” she said.

Dr. Vasconez had told her to expect it.

A curious form of microtia

Microtia, a defect in which infants are born without the external formation of an ear, has an unusually high rate of incidence in the Quito area of Ecuador. Although it has been the subject of several research studies, there is no explanation why microtia occurs so much, said Vasconez.

Some wonder if a cause may have something to do with living in the higher elevation of the Andes Mountains.  The city of Ambato, which is roughly the size of metropolitan Lexington, is located within a valley at the highest elevations of the mountain range, about 2500 meters above sea level. Despite being near the equator, much of the landscape surrounding Ambato is forest-covered mountains and snow-capped peaks from distant volcanoes. One of those volcanoes, Tungurahua, is about 40 kilometers from Ambato and active. In fact, a small eruption occurred in late February just prior to MME’s arrival.

In addition to environmental factors, there are concerns that herbicides used to destroy coca plants in the country’s war against the illegal cocaine trade may have a toxic effect on the populace, Vasconez reported.

What is unusual is that most cases of microtia in the region are isolated to the ear alone.

“Generally, microtia is just one symptom of a much larger birth defect. Infants usually have an underdeveloped jawline and cheek that requires complex reconstruction. But in Ambato, the majority of microtia is just a damaged or missing external ear. So the procedure is most often ear reconstruction,” Vasconez said.

Medical Mission Ecuador – 25 years of growth

But the acute need for ear reconstruction, as well as other basic procedures, among the indigent population’s children is one of the motivating factors behind Dr. Vasconez establishing Medical MissionEcuador with his brother, Dr. Luis Vasconez, and his sister, Beatriz.

“Ambato is where our parents were born and raised and where my siblings and I were born. Returning every year to provide care is my way of giving back to my home in return for all they have given me,” Dr. Vasconez said. The annual MME mission has gained a lot of momentum in the last quarter century.

The first year, it was just Dr. Vasconez accompanied by a registered nurse and an anesthesiologist.   But since that first year, the program has grown to such an extent that it now attracts several dozen volunteers from the professional medical ranks. Many have been involved almost as long as Dr. Vasconez

A key to the successful growth of the MME, said Vasconez, is that the group returns to the same place every year. It’s important for follow-up and continuity of care. Some patients require several stages of surgery over time, so it’s important that they can rely on MME returning to finish work that it started. It is estimated that MME has treated over 10,000 patients and performed over 1,700 procedures since its inception. In 2016, the MME saw over 1,000 patients and provided approximately 120 procedures.

First time won’t be the last

Kerekes can recall the cases she worked on vividly. One that seemed to make the most profound impression was working with Dr. Vasconez on a burn scar release procedure. A patient had suffered severe burns from a fire many years ago. The flesh had healed, but the neck tissue had joined with the chin in such a way that the person was unable to lift their head. While the surgeons carefully released the person’s neck, Eric Miller fashioned a brace so that the patient wouldn’t contract back down.

Though the patient would require rehab therapy to strengthen his neck muscles, it was the first time in almost a decade that he could look up and out at his surroundings.

After this experience, Kerekes declared it would not be her last time in mission work.

“I’m not sure that I had any expectations when Dr. Vasconez invited me to go. But the experience is never what you anticipate. It changed my perspective as a surgeon,” Kerekes said. It’s a perspective which will continue to influence her work when she begins her professional practice months from now.